recent study suggests that post-arrest patients with lactate >12 mM might benefit from TTM33 (as opposed to TTM36). some folks on twitter are getting excited about this, but the study has very weak methodology (#rantorial 1/4)
(study: ncbi.nlm.nih.gov/pubmed/31745738)
the post-hoc study stratifies post-arrest patients on the basis of lactate level (<7, 7-12, >12). TTM33 vs. TTM36 doesn't make a difference in *any* of three strata. the p-values aren't anywhere close to statistical significance (#rantorial 2/4)
a multivariable model is used to massage the p-value in the lactate >12mm sub-groups from 0.42 down to 0.005. that's an 85-fold decrease! I'm no statistician, but this seems pretty shady (how can you get p=0.005 from a small raw sample size of 4/31 patients?) (#rantorial 3/4)
summary: (1) start with post-hoc observational data (2) divide into 3 subgroups (3) apply multivariable modeling to all 3 subgroups, which drops p-value by 85x in one (4) reach broad conclusion
read the study & see what you think, but I'm not too impressed (#rantorial 4/4)
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how to place a consult: you MUST understand the five stages of consultant grief.
once you can understand this painful and natural process, requesting consults will make a LOT more sense
buckle up, it can be a little rough…
🧵 1/6…
stage 1: denial
- You dont need a consult.
- You called the wrong service.
- 18 years old? consult pediatrics
- I’m not actually on call now
- Everything’s fine, just walk it off…
stage 2: anger
- you should have consulted us earlier/later
- you should have checked this test before calling us
- you’re a terrible doctor/student/human being
this is much better than MINDS (which contained ~90% hypoactive), but probably still not ideal.
(at this point, does anyone actually think that haloperidol helps with hypoactive delirium ??)
other than dilution of the patient population by patients with hypoactive delirium (who are unlikely to benefit & might conceivably be harmed by over-sedation), the methodology seems pretty solid.
I think it's time for a difficult discussion, folks.
Let's talk about CSF lactate 🫣
CSF lactate has been shown to be *superior* to traditional CSF studies in sorting out viral vs. bacterial meningitis in several studies & meta-analyses...
a subset of patients with viral meningitis will initially have a *neutrophilic* pleocytosis.
this can lead to unnecessary admissions & antibiotics
some patients are subjected to repeat LPs 😩
a low CSF lactate could avoid all of this, allowing patients to go home from the ED
CSF lactate measurement is recommended in guidelines from the United Kingdom, Europe, and France.
(it's not recommended in the ID society of America guidelines, but they're from *2004* and require revisions)