Provider Response to Critical Action Values for Hypoglycemia in the Ambulatory Setting: a Retrospective Cohort Study

BackgroundThe blood glucose level triggering a critical action value (CAV) for hypoglycemia is not standardized, and associated outcomes are unknown.ObjectiveTo evaluate the clinical consequences of, and provider responses to, CAVs for hypoglycemia.DesignRetrospective cohort study at Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center between April 1, 2013, and January 31, 2017.ParticipantsPatients with an ambulatory serum glucose < 50 mg/dL. Point-of-care capillary glucose and whole blood glucose samples were excluded.Main MeasuresElectronic medical record (EMR) review for providers’ documented response to CAV, associated patient symptoms, and serious adverse events.Key ResultsWe analyzed 209 CAVs for hypoglycemia from 154 patients. The median age (IQR) was 59 years (46, 69), 89 (57.8%) were male, and 96 (62.3%) were black. Provider-to-patient contact occurred in 128 of 209 (61.2%) episodes, among which no documented etiology was observed for 81 of 128 (63.3%), no recommendations were provided in 32 of 128 (25.0%), and no patient-reported hypoglycemic symptoms were documented in 103 of 128 (80.5%). Serious adverse events were documented in 4 of 128 episodes (3.1%), two required glucagon administration, and three required an ED visit. Provider-to-patient contact was associated with the patient having malignant neoplasm (adjusted OR 3.63, p = 0.045) or a hypoglycemic disorder (adjusted OR 7.70, p = 0.018) and inversely associated with a longer time from specimen collection to EMR result (adjusted OR 0.90 per hour, p = 0.016).ConclusionsThere is inconsistent provider-to-patient contact following CAVs for hypoglycemia, and the etiology and symptoms of hypoglycemia were infrequently documented. There were few serious documented adverse events associated with hypoglycemia, although undocumented events may have occurred, and the incidence of serious adverse events in non-contacted patients remains unknown. These findings demonstrate a need to standardize provider response to CAVs for hypoglycemia. Decreasing the lag time between sample collection and laboratory result reporting may increase provider-to-patient contact.KEY WORDS: Hypoglycemia, Critical action value, Ambulatory, Glucose     

Percutaneous coronary intervention in octogenarians: 10-year experience from a primary percutaneous coronary intervention centre with off-site cardiothoracic support

OBJECTIVETo examine the trends in patient characteristics and clinical outcomes over a ten-year period and to analyse the predictors of mortality in octogenarians undergoing percutaneous coronary intervention (PCI) in our centre.METHODSA total of 782 consecutive octogenarians (aged 80 and above) were identified from a prospectively collected PCI database within our non-surgical, medium volume centre between 1st January 2007 and 31st December 2016. This represented 10.9% of all PCI procedures performed in our centre during this period. We evaluated the demographic and procedural characteristics of the cohort with respect to clinical outcomes (all-cause in-hospital and 1-year mortality, in-hospital complication rates, duration of hospital admission, coronary disease angiographic complexity and major co-morbidities). The cohort was further stratified into three chronological tertiles (January 2007 to July 2012, 261 cases; August 2012 to May 2015, 261 cases; June 2015 to December 2016, 260 cases) to assess for differences over time. Predictors of mortality were identified through a multivariate regression analysis.RESULTSThe number of octogenarians undergoing PCI increased nearly ten-fold over the studied period. Despite this, there were no significant differences in clinical outcomes or patient characteristics, except for the increased use of trans-radial vascular access [11.9% in first tertile vs. 73.2% in third tertile (P < 0.0001)]. The all-cause in-hospital (5.8% vs. 4.6% vs. 3.8%, P = 0.578) and 1-year mortality (12.4% vs. 12.5% vs. 14.4%, P = 0.746) remained constant in all three tertiles respectively. Six independent predictors of mortality were identified - increasing age [HR = 1.12 (1.03−1.22), P = 0.008], cardiogenic shock [HR = 16.40 (4.04–66.65), P < 0.0001], severe left ventricular impairment [HR = 3.52 (1.69−7.33), P = 0.001], peripheral vascular disease [HR = 2.73 (1.22−6.13), P = 0.015], diabetes [HR = 2.59 (1.30−5.17), P = 0.007] and low creatinine clearance [HR = 0.98 (0.96−1.00), P = 0.031]. CONCLUSIONThis contemporary observational study provides a useful insight into the real-world practice of PCI in octogenarians.

Although age is a major cardiovascular risk factor which has a marked impact on the prevalence of coronary artery disease (CAD) and cardiovascular mortality,^[1] there is a recognised reluctance in offering percutaneous coronary intervention (PCI) to octogenarians (≥ 80 years old),^[2] despite its proven benefit in this age group.^[3–5] As a result, an increasing number of octogenarians undergoing PCI is observed, reaching almost 10% of all PCI procedures performed in United Kingdom in the period 2008–2012.^[6]Despite the increasing demand for PCI in the octogenarians, this patient population remains under-represented in randomised trials or only a highly selected group is investigated.^[7,8] Emerging evidence shows that the survival advantage of invasive compared with non-invasive management appears to extend to patients with non-ST elevation myocardial infarction (NSTEMI) who are octogenarians,^[4,9] although predictably, mortality rates are higher in patients undergoing primary PCI for STEMI.^[10]In the absence of robust randomised clinical data on PCI treatment strategies for the octogenarians, observational studies remain valuable in providing insights to outcome and mortality trends. As a result, we aimed to evaluate the characteristics of our “real world” octogenarian patient population presenting over a ten-year period to a PCI centre with off-site cardiothoracic support in terms of demographics, the procedural and clinical outcomes, and any potential predictors of mortality.     

Challenging rescue of a 4 years old boy with H1N1 infection by extracorporeal membrane oxygenator: A case report

Introduction: World Health Organization announced on April 2009 a public health emergency of international concern caused by swine-origin influenza A (H1N1) virus. Acute respiratory distress syndrome (ARDS) has been reported to be the most devastating complications of this pathogen. Extracorporeal membrane oxygenator (ECMO) therapy for patients with H1N1 related ARDS has been described once all other therapeutic options have been exhausted. Here, we report the case of a child (German, male) with H1N1-associated fulminate respiratory and secondary hemodynamic deterioration who was rescued by initial emergent ECMO established through a dialysis catheter and subsequent switch to central cannulation following median sternotomy. This report highlights several important issues. First, it describes a successful use of a dialysis catheter for the establishment of a veno-venous ECMO in an emergency case by child. Second, it highlights the importance of a closely monitoring of clotting parameters during ECMO therapy and third, if severe respiratory failure is complicated by cardiogenic shock, veno-atrial ECMO support via median sternotomy should be considered as a viable treatment option without further delay.