fresh RCT on the effects of a continuous infusion of hypertonic saline for traumatic brain injury (#1/6) jamanetwork.com/journals/jama/…
patients were randomized to an infusion of 20% NaCl for 48 hours. as shown here, the infusion was successful at pushing sodium levels to the mid-150s, with nice separation between groups (#2/6)
initially, patients receiving hypertonic infusions had fewer episodes of ICP elevation. however, their brain cells adapted rapidly to the higher tonicity... so when the hypertonic was stopped they had *rebound* elevation of ICP (#3/6)
ultimately patients treated w/ hypertonic infusions needed *more* rescue therapies for ICP:
😬 trend towards more boluses of hypertonic therapy
😬 significantly greater use of hyperventilation
so routine induction of abnormal physiology probably caused more harm than good
there was no difference in the primary endpoint (functional outcome after six months). not surprising, given the number of factors affecting this endpoint. and also, the fact that ICP was monitored and *corrected* when things were really going sideways. (#5/6)
the negative results of this study were predicted & explained further in this blog from 2014. bottom line:
🤯 giving everybody hypertonic infusions like Oprah isn't good
🤯better to use boluses when truly needed, as a temporary bridge to another treatment emcrit.org/pulmcrit/hyper…
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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)