Ep 110 - March 2018 Round Up

March 2018 Roundup: Evidence-Based Medicine and Exciting Announcements at St Emlyn's

Welcome to the Centeminine's podcast monthly roundup for March 2018! This post delves into key highlights from our blog, discussing critical topics in evidence-based medicine and sharing exciting upcoming events. Let's dive in!

Catching Up After Winter

As the harsh winter fades, we’re catching up with several important topics from March. Despite the seasonal lag, there's a lot happening in the world of evidence-based medicine. Our blog has been buzzing with insightful posts, and we encourage you to explore the rich content we have curated for you.

Exciting Upcoming Events

Before diving into March's blog posts, let's highlight some exciting events on the horizon. We are thrilled to announce St Emlyn's Live and the Teaching Course in Manchester. If you're planning your study leave for the next 12 months, these are opportunities you won't want to miss.

St Emlyn's Live

St Emlyn's Live is shaping up to be an unmissable event. Scheduled for October in Manchester, this event promises a blend of learning and fun, with the added bonus of Manchester's unique charm—where the sun always shines (psychologically and philosophically, if not literally). Check our website for more details and secure your spot. We’re putting immense effort into making this event exceptional, ensuring it’s worth both your time and money.

The Teaching Course in Manchester

Alongside St Emlyn's Live, we have our renowned Teaching Course in Manchester. As you consider your professional development for the year, keep in mind the benefits of attending a well-structured, impactful course like ours. We're confident you'll find it a valuable investment in your career.

Evidence-Based Medicine: The Great IV Fluid Debate

One of the standout topics in March has been the ongoing debate over IV fluids in critically ill patients. This subject stirs significant anxiety and diverse opinions across departments and even within the same hospital.

The Normal Saline vs. Balanced Fluids Debate

The crux of the debate revolves around whether to use normal saline or balanced fluids such as Hartmann's or Plasmalyte. The evidence to date has been mixed, leading to differing practices. Our colleagues down under published the SPLIT trial a few years ago, finding no significant difference, but the sample size at the time limited the conclusions.

Recent Trials in the New England Journal of Medicine

Recently, two significant trials published in the New England Journal of Medicine have shed more light on this issue. These trials investigated the effects of balanced crystalloid versus saline in critically ill patients and emergency department patients admitted to the wards.

Cluster Randomized Trials

The trials used a cluster randomized design, where units were randomized to administer either balanced crystalloid (lactated Ringer's or Plasmalyte) or saline for a period before crossing over. With over 15,000 participants in each study, the findings are quite robust.

Key Findings

The trials revealed a small but significant difference in major kidney events in the critical care group (14.3% vs. 15.4%), suggesting a potential benefit of balanced fluids. While the mortality difference was not as pronounced, these results could have important implications for global intensive care practices.

Practical Implications in Emergency Medicine

As emergency physicians, how do these findings influence our practice? Over the past few years, there's been a shift towards more frequent use of balanced solutions, driven by a sound physiological rationale. Although the exact clinical significance of hyperchloremic acidosis from saline remains debated, the pathophysiological argument for balanced fluids is compelling.

Local Practices and Preferences

In our practice, preferences vary. For instance, our neurointensive care unit favors saline for patients with specific neurological issues, as explained in a podcast with Dr. John Hell from Southampton. For general use, Hartmann's is often the go-to solution.

Teaching the Next Generation

We emphasize the importance of fluids in emergency medicine to our new doctors. With only four main treatments—oxygen, analgesia, antibiotics, and fluids—it’s crucial to administer fluids effectively. While the choice of fluid might not be critical initially, ensuring the right volume is given can make a significant difference.

The Teaching Course in Cape Town

Another highlight from March was the successful teaching course in Cape Town. This course will be replicated later this year in Manchester, offering an excellent opportunity for hands-on learning and professional growth.

Success in South Africa

The Cape Town course was a resounding success, providing valuable insights and skills to all participants. The feedback was overwhelmingly positive, highlighting the course's effectiveness and the enriching experience it provided.

Chris Weymouth’s Experience

Chris Weymouth, a UK-trained physician, shared his experience working in a rural South African hospital. His story underscores the importance of structured and well-supported international placements. Such experiences not only enhance clinical skills but also foster personal growth and resilience.

Cardiac Arrest: Predicting Outcomes with Pupil Responses

Our final major topic for March revolves around predicting outcomes in cardiac arrest, specifically through pupil responses. This topic, close to our hearts, is critical for making informed decisions during resuscitations.

The Study from France

A recent study from France, analyzing over 11,000 cardiac arrests, examined whether early pupil responses could predict outcomes. The findings were intriguing but not definitive.

Sensitivity and Specificity

The study found that the absence of a pupillary light reflex is a poor prognostic sign, but with only 72% sensitivity and 68.8% specificity, it’s not conclusive enough to base critical decisions on.

The Gray Areas in Resuscitation

Deciding when to stop resuscitation remains one of the most challenging aspects of emergency medicine. While some cases are clear-cut, many fall into a gray area, making it difficult to determine the right course of action.

ECPR and Prolonged Arrests

With emerging technologies like ECPR (Extracorporeal Cardiopulmonary Resuscitation) and reports of remarkable recoveries from prolonged arrests, the decision to stop becomes even more complex. In young patients with no prior morbidity, the stakes are even higher, and the decision requires careful consideration and often consultation with colleagues.

Upcoming Events and Final Thoughts

As we wrap up our March roundup, we look forward to several upcoming events and ongoing discussions. The St Emlyn's team will be speaking at the Retrieval Conference in Scotland in April, and we have a variety of summer events lined up.

Join Us at St Emlyn's Live

Don't forget to join us at St Emlyn's Live in October. This event promises to be a highlight of the year, offering a blend of cutting-edge medical insights and networking opportunities. Check our website for all the details and secure your spot today.

Stay Tuned for More

We'll be back in May with updates on April's posts and more engaging content. Until then, keep enjoying your emergency medicine practice, take care of yourselves and your patients, and stay connected with the St Emlyn's community.

Conclusion

March has been a month filled with significant developments in evidence-based medicine, exciting course announcements, and thought-provoking discussions. As always, our goal is to provide you with the best possible insights to enhance your practice and support your professional growth. Thank you for being part of the St Emlyn's community. We look forward to engaging with you through our blog, podcasts, and upcoming events.