EUH Dressler Conference: What are the presentations of nonconvulsive status epilepticus?

The Bottom Line: Nonconvulsive status epilepticus (NCSE) refers to a group of highly heterogeneous clinical conditions lasting more than 30 minutes, in which continuous or recurrent electrographic seizure activity results in nonconvulsive clinical features. NCSE in adults represents a constellation of conditions producing ongoing ictal impairment with myriad clinical presentations (Fernandez-Torre et al, 2015).

  • seizure activity seen on electroencephalogram (EEG) without clinical findings associated with convulsive status epilepticus
  • changes in behavior and/or mental processes from baseline associated with continuous epileptiform discharges on EEG
  • subtypes
    • subtle status epilepticus
      • severely impaired mental status, with or without subtle motor movements
      • coma with or without subtle convulsive movements developing in patient with untreated or inadequately treated generalized convulsive status epilepticus
    • complex partial status epilepticus
      • characterized by agitation or confusion, nystagmus, or stereotypic motor activity (such as lip smacking or picking at items in air or on clothing)
      • National Institute for Health and Care Excellence (NICE) recommends use of “focal seizure” instead of partial complex seizure
    • absence status epilepticus
      • relatively benign form of status epilepticus identified by 3 hertz spike-wave discharges on EEG
      • characterized by behavioral arrest associated with generalized spike wave activity on EEG

(DynaMed Plus, 2017)

References: DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – 2017. Record No. 115329, Status epilepticus in adults; [updated 2017 Feb 06, cited 2017 July 20].

Fernandez-Torre JL, Kaplan PL, Hernandez-Hernandez ML. New understanding of nonconvulsive status epilepticus in adults: Treatment and challenges. Expert Review of Neurotherapeutics. 2015; 15(12):1455-73. doi:10.1586/14737175.2015.1115719.

Summary: NCSE is responsible for diverse clinical manifestations including altered mental state, abnormal and bizarre behavior, language disorders, perception disturbances and/or consciousness impairment. All these symptoms occur without overt tonic, clonic or tonic-clonic motor activity. Nevertheless, NCSE does not always imply absence of all motor activity. Subtle motor manifestations such as palpebral myoclonia, limb and oroalimentary automatisms, dystonic posturing, twitching of the face or limbs and rhythmic nystagmus may occur (Fernandez-Torre et al, 2015).

Because the presentation is pleomorphic, a high index of suspicion and knowledge of the precipitating clinical underpinnings are essential in making a prompt diagnosis and treatment plan. Electroencephalography (EEG) is a mandatory test and constitutes the cornerstone for diagnosis and classification. EEG interpretation may be difficult and requires clinical and electrophysiological expertise, particularly with comatose or critically ill patients in ICUs (Fernandez-Torre et al, 2015).

Posted in Background question, Diagnosis, EUH

EUH Morning Report: What is the ideal diuretic dosing strategy for diuretics in a patient admitted from home with acute decompensated HF and already on home diuretics?

The Bottom Line: In managing patients admitted with heart failure exacerbation, the DOSE trial confirmed that furosemide (Lasix) intermittent bolus is equivalent to continuous drip, making continuous drip management unnecessary in nearly all situations. Furthermore, symptoms were similar in high dose bolus furosemide compared to low dose bolus furosemide, with only marginal differences in creatinine change in high-dose vs. low-dose furosemide boluses. However, the high-dose bolus patients had greater daily weight loss (more than 1kg additional fluid weight lost per day) compared to low dose patients.

Clinicians may consider up to 2.5 times the patient’s home daily furosemide dose, converted to IV in their diuretic bolus dosing for admitted patients with heart failure exacerbations.

Reference: Felker GM, Lee KL, Bull DA, Redfield MM, et al. Diuretic strategies in patients with acute decompensated heart failure. NEJM. 2011 Mar 3; 364(9):797-805.

Summary:  Although loop diuretics are an essential component of therapy for acute decompensated heart failure, there have been few prospective data to guide decision-making regarding the use of these agents. In the DOSE trial, no significant differences were found in either the patients’ global assessment of symptoms or the change in the creatinine level from baseline to 72 hours when diuretic therapy was administered by means of boluses as compared with continuous infusion or with a low-dose strategy as compared to a high-dose strategy (Felker et al, 2011).

Bolus vs. continuous infusion:

  • No difference in serious adverse events (44% in each group)
  • More cases of ventricular tachycardia with boluses than with continuous infusions (7 vs. 4)
  • More cases of renal failure with continuous infusion than with bolus (11 vs. 8)
  • More cases of myocardial infarction with boluses (4 vs. 1)

*These findings are not consistent with prior, smaller studies suggesting that continuous infusion, as compared with boluses, is associated with a lesser degree of renal dysfunction and greater diuresis.

High-dose vs. low-dose strategy:

  • Fewer in the high-dose group had serious adverse event than in the low-dose group (38% vs. 50%)
  • More cases of ventricular tachycardia with low-dose strategy than with high-dose strategy (7 vs. 4)
  • More cases of renal failure with low-dose strategy (12 vs. 7)
  • More cases of myocardial infarction with low-dose strategy (4 vs. 1)

*These findings suggest that prior observations linking high-dose diuretics with poor outcomes may reflect the severity of the illness rather than a harmful effect of high doses.

It must be noted that this study used a continuous placebo infusion in the patients assigned to boluses. The authors admit that this feature of the study design may have served to increase the time the patients were supine, a position that has been shown to enhance diuresis (Felker et al, 2011, p. 803). Also, the bolus group tended to receive a higher dose of the diuretic than did the continuous-infusion group.

Posted in Applying evidence, EUH, Therapy

EUH Resident Report: What are the current guidelines for treating non-CAP pneumonia?

The Bottom Line: Treatment guidelines for hospital-acquired aspiration pneumonia

  • no definitive evidence to inform optimal antibiotic regimen
  • antibiotic choice typically based on setting and concern for anaerobic infection
  • treatment should be based on suspected pathogens
  • pathogenic role of anaerobes and need for coverage is unclear
    • options, with anaerobic coverage, include (dosing for adults with normal renal function)
      • piperacillin-tazobactam 4.5 g every 6 hours or
      • an antipseudomonal carbapenem, such as meropenem 1 g every 8 hours or
      • an antipseudomonal cephalosporin, such as cefepime 1-2 g every 8-12 hours plus metronidazole 500 mg IV every 8 hours
    • plus consideration of vancomycin 15 mg/kg every 12 hours (adjusted to troughs of 15-20 mcg/mL)
  • optimal duration of therapy for hospital-acquired aspiration pneumonia not determined but 7-8 day course is recommended for most patients with hospital-acquired pneumonia apart from those with infection with nonfermenting gram-negative bacilli, such as Pseudomonas spp.

(DynaMed Plus, 2015)

References: DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 116655, Aspiration pneumonia; [updated 2015 Aug 12, cited 2017 July 11.]

Kalil AC, Meteresky ML, Klompas M, Muscedere J, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clinical Infectious Diseases. 2016 Sep 1;63(5):e61-e111. doi:10.1093/cid/ciw353.

Summary:  The Infectious Diseases Society of America and the American Thoracic Society present the following recommendations in their 2016 clinical practice guidelines (Kalil et al, 2016):

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Posted in EUH, Therapy

EUH Hunt Conference: A review of RCT findings on thrombolytics for pulmonary embolsim

The Bottom Line: Thrombolysis may be considered in selected intermediate-risk PE patients who have evidence of RV dysfunction or myocardial damage or in PE who may be clinically worsening or not improving with anticoagulation, and/or based on patient values or physician experience. Clinical benefit-to-risk profile is likely better for younger (<65 y/o) patients.

Reference: Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014 Jun 18;311(23):2414-2421. doi.10.1001/jama.2014.5990.

Summary: A meta-analysis of RCT findings concluded that among patients with pulmonary embolism, including those who were hemodynamically stable with right ventricular dysfunction, thrombolytic therapy was associated with lower rates of all-cause mortality and increased risks of major bleeding and ICH. However, findings may not apply to patients with pulmonary embolism who are hemodynamically stable without right ventricular dysfunction (Chatterjee et al, 2014).

Below is a table summarizing the evidence presented in the referenced meta-analysis (table created by Dr. Dan Dressler).


*Net Clinical Benefit = lives saved compared with ICH events (weighted 0.75 events per death event), intermediate-risk patients


Posted in Background question, EUH, Therapy

EUH Dressler Conference: What is the most appropriate timeframe for administering IV fluids to patients with sepsis or septic shock?

The Bottom Line: The Surviving Sepsis Guideline states 30cc/kg within first 3 hours for sepsis or shock, as defined by new Sepsis definitions (Singer et al, 2016).

References: Leisman D, Wie B, Doerfler M, Bianculli A, et al. Association of fluid resuscitation initiation within 30 minutes of severe sepsis and septic shock recognition with reduced mortality and length of stay. Annals of Emergency Medicine. 2016 Sep;68(3):298-311. doi:10.1016./j.annemergmed.2016.02.044.

Seymour CW, Gesten F, Prescott HC, Friedrich ME, et al. Time to treatment and mortality during mandated emergency care for sepsis. NEJM. 2017 Jun 8;376(23):2235-2244. doi:10.1056/NEJMoa1703058.

Singer, M, Deutschman CS, Seymour CW. The Third International Consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.

Summary: While some of the recent data on timing of IVFs (Seymour et al, 2017) suggest that completion of the initial IVF bolus within the first 3 hours is not associated with mortality improvement compared to completion of the initial IVF bolus beyond 3 hours, other data (Leisman et al, 2016) suggest that the earlier initiation of IVFs (within the first 30 minutes) is associated with improved mortality and reduced hospital length of stay.

The current guidelines, as listed in DynaMed Plus, call for fluids within 3 hours.

Posted in EUH, Intern toolbox, Therapy

EUHM Resident Report: How to handle difficult patient situations?

Difficult encounters are estimated to represent 15 to 30 percent of family physician visits. Factors contributing to these difficult clinical encounters may be related to the physician, patient, situation, or a combination. Physicians can recognize these visits as challenging by acknowledging their feelings of angst or helplessness generated during the conversation. These encounters are also characterized by a disparity between the expectations, perceptions, or actions of the patient and physician

Cannarella Lorenzetti, R., Jacques, C., Donovan, C., Cottrell, S., & Buck, J. (n.d.). Managing difficult encounters: Understanding physician, patient, and situational factors. American Family Physician., 87(6), 419-425.

The patient and physician each bring a frame of reference and set of expectations to an office visit. Empathy helps the physician suspend judgment and foster a relationship in which he or she is perceived as a healer and ally, not just a service provider. Better health outcomes are achieved when the patient and physician have congruent beliefs about who is in control of necessary changes to improve health. A focused assessment may reveal underlying, potentially treatable mental or psychiatric conditions; a history of abuse; or difficult family or social situations

Posted in EUHMidtown | Tagged

VA Resident Report: What is the effectiveness of POEM for achalasia?

Available data suggests POEM is very effective in the relief of symptoms in patients with achalasia. However, POEM is associated with a very high incidence of pathologic reflux. The clinical sequalae of the increase in pathologic reflux are currently incompletely understood, but it is plausible that longer-term outcomes associated with POEM may demonstrate GERD complications such as stricture and/or Barrett esophagus

Shlottmann, F., Luckett, D., Fine, J., Shaheen, N., & Patti, M. (n.d.). Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis. Annals of Surgery., Annals of surgery. , 2017.

Esophageal achalasia is characterized by lack of peristalsis and by a lower esophageal sphincter (LES) which fails to relax appropriately in response to swallowing. Treatment is not curative, but aims to eliminate the outflow resistance caused by the nonrelaxing LES.  In 2010, Inoue et al54 described the results of a new endoscopic technique called per oral endoscopic myotomy (POEM) in 17 patients with esophageal achalasia. They described the endoscopic creation of a submucosal tunnel, which allowed a myotomy by the transection of the circular fibers of the distal esophagus.

Posted in VA | Tagged