- Email: [email protected]
High versus low-dose frequently administered nebulized albuterol in children with severe, acute asthma
one patients were randomized to esmolol therapy and 24 to verapamil. Of these, 31 had a new onset of dysrhythmia. The final heart rate in both groups dropped significantly; however, there was no statistical advantage to either therapy. The most interesting result is that seven of 14 esmolol patients with a new onset of dysrhythmia converted to sinus r h y t h m versus two of 17 for verapamil - a statistically significant difference. Both groups experienced a concomitant decline in blood pressure, occasionally requiring intervention, but the difference in statistical significance is not c o m m e n t e d on. One patient apparently developed p u l m o n a r y edema w i t h verapamil, although this is not explicitly stated. Overall, the study suffers from several deficiencies. Most notably, comparison of bolus therapy versus an IV drip compares dissimilar entities. Moreover, there is a lack of control group and relatively small numbers. However, the relative safety of esmolol therapy seems to be demonstrated, and perhaps more importantly, its effectiveness in converting atrial fibrillation/ flutter is strongly suggested.
James Vayda, MD hydroxyethyl starch; lactated Ringer's
C o m p a r i s o n of h y d r o x y e t h y l s t a r c h and l a c t a t e d R i n g e r ' s s o l u t i o n on h e m o d y n a m i c s a n d o x y g e n t r a n s p o r t of critically ill p a t i e n t s in p r o s p e c t i v e crossover s t u d i e s Hankeln K, Radel C, Beez M, et al Crit Care Med 17:133-135 Feb 1989
These authors compared the effects of lactated Ringer's (RL) and 10% hydroxyethyl starch (HES) on cardiac index (CI), left ventricular stroke work index (LVSWI), oxygen delivery {DO2) , oxygen c o n s u m p t i o n (VO2) , and pulmonary vascular resistance index (PVRI) in 15 critically ill patients. Ten patients were h y p o v o l e m i c either f r o m trauma or following extensive surgery, and five were in cardiogenic shock or were post c a r d i o p u l m o n a r y arrest. RL and HES were given to each patient during periods of hemodynamic instability or w h e n their cardiopulmonary status was suboptimal. A prospective, crossover design was used. Each agent was infused until the wedge pressure (WP) was 16 - 2 m m Hg in the trauma/postoperative group and 18 _+ 2 m m Hg in the cardiac patients. WP, CI, LVSWI, PVRI, DO2, and VO 2 were determined prior to the infusion, at the end of infusion, and 30 minutes following the infusion of each agent. These values then were compared by using the Student's t test and analysis of variance. P < .05 was considered significant. HES significantly increased CI, LVSWI, DO2, and VO 2 while RL infusions showed no significant i m p r o v e m e n t in these values. HES produced a significant decrease in PVRI while RL increased this value. The results of this study demon18:10 October 1989
strate that HES expands plasma volume, thereby improving CI, D O > and VO 2 and decreasing PVRI. RL, conversely, expands the interstitial water thereby having little effect on CI, DO2, and VO 2. This is an important study because increases in CI, DO2, and VO 2 and a decrease in PVRI have been shown to offer a more favorable prognosis in critically ill postoperative patients, provided these variables are maximized early and maintained throughout the early postoperative course.
Tim Hutchinson, MD albuterol, dosage, pediatric
High versus low-dose frequently a d m i n i s t e r e d n e b u l i z e d a l b u t e r o l in c h i l d r e n with severe, acute asthma Schuh S, Parkin P, Rajan A, et al Pediatrics 83:513-518 Apr 1989
A prospective, randomized study of 32 patients was performed to determine the safety and efficacy of high-dose versus low-dose frequently administered albuterol aerosols for treatment of children presenting to the emergency department with severe, acute asthma. Criteria for inclusion were clinical evidence of asthma, m i n i m u m of five years of age, FEV 1 less than 60% of predicted, and no concurrent cardiopulmonary disease. Parameters measured were heart rate, blood pressure, respiratory rate, FEVI, FVC, PEFR, WBC, and differential counts, serum potassium levels, serum albuterol levels, and serum theophylline levels. The initial dose of albuterol in all patients was 0.15 mg/kg. The 16 subjects in each group then received six additional doses (0.15 mg/kg for the high-dose group and 0.05 m g / k g for the low-dose group) at 20m i n u t e intervals. The decision to administer additional therapy (steroids or theophylline) or to admit the patient was made by an attending physician w h o was not involved in the study. There was no significant difference between the two groups with respect to age, duration of asthma, duration of the acute attack prior to arrival at the ED, medications taken at home, pretreatment albuterol levels, or in the severity of the attack. There also was no significant difference in the percent improvement of FEV u FVC, wheeze score, or vital signs following the initial dose. At the end of the study, FEV u FVC, and wheeze score were improved significantly more for the high-dose group versus the low-dose group. No statistically significant differences in vital signs, WBC or differential counts, or s e r u m p o t a s s i u m levels w e r e f o u n d b e t w e e n the groups. Post-treatment serum albuterol levels were higher (19.8 ng/mL vs 12.4 ng/mL) for the high- versus low-dose group, as were the incidence of the side effects of tremor {eight patients vs four patients) and vomiting (three patients vs one patient). These side effects were mild and the differing incidences were not statistically significant. Four patients in the high-dose and ten patients in the low-dose
Annals of EmergencyMedicine
1130/165
ABSTRACTS
group required admission. The authors concluded that frequent high doses of nebulized albuterol appear to be safe and effective for treatment of otherwise healthy children with severe acute asthma. They also concluded that the side effects of high-dose therapy are mild and temporary. Bruce Spears, MD ventricular tachycardia, wide complex
Wide QRS tachycardia adult
in t h e c o n s c i o u s
Steinman RT, Herrera C, Schuger CD, et al JAMA 261:1013-1016
Feb 17, 1989
The last ten years have seen a significant improvement in our understanding of wide complex tachycardia. This article addresses the relationship between hemodynamic stability and wide QRS tachycardia etiology. Twenty consecutive patients with wide complex tachycardia who were conscious, alert, and oriented were analyzed prospectively. Electrolyte imbalance, acute myocardial infarction, and drug reactions were excluded. Twelve-lead ECGs were obtained in 18 of the patients, r h y t h m strips in the remaining two. The following ECG criteria supported the diagnosis of ventricular tachycardia: atrioventricular dissociation, QRS duration greater than 0.14 s, left axis deviation, and Wellens' morphological criteria for the QRS complex. Following conversion to sinus rhythm, electrophysiologic testing was performed in 17 of the patients. Using both ECG criteria and electrophysiologic testing results, a diagnosis of ventricular tachycardia was made in 85% of the patients, supraventricular tachycardia in the remaining 15%. Interestingly, heart rate was noted and found to be more than 200 in two thirds of the patients with proven ventricular tachycardia. The authors strongly suggest that we avoid the pitfall of associating hemodynamic stability with less malignant rhythms. Furthermore, they point out that ventricular tachycardia is frequently much faster than the classic rate of 140. Robinson Nicholson, MD
laser, angioplasty, coronary artery disease
L a s e r a n g i o p l a s t y of t o t a l l y o c c l u d e d c o r o n a r y a r t e r i e s a n d vein grafts: P r e l i m i n a r y r e p o r t on a c u r r e n t t r i a l Foschi A, Myers G, Crick WF, et al Am J Cardiol 63:9F-13F
Apr 1989
This report is one of the first on the treatment of severe coronary artery disease with laser angioplasty. Percutane-
166/1131
ous transluminal coronary angioplasty (PTCA) has been used successfully in lieu of coronary artery bypass grafting (CABG) for symptomatic patients with severe stenosis of coronary arteries. However, totally occluded arteries or bypass grafts have remained as unsolved challenges for PTCA. Laser angioplasty appears to be a viable option for these patients. Three investigators have treated totally occluded coronary arteries and vein grafts in 34 patients with 36 coronary laser procedures with a recanalization rate of 92%. All lesions were refractory to medical therapy and PTCA. After recanalization is achieved, conventional PTCA is used to dilate the artery. The laser system is intended to be an adjunctive debulking procedure. There were no complications attributable to the laser. There were no thermal or mechanical vessel perforations, and no emboli or acute reclosures. However, the problem of restenosis remains, with three patients having reclosure of the recanalized arteries during the clinical trial. Occluded vein grafts account for one third of patients undergoing bypass surgery. Because the organized red clot preferentially absorbs the green argon laser light, laser angioplasty may be the best method for opening these grafts in the future. However, conventional PTCA should be adequate, quicker, and easier for subtotal occlusions. If the laser procedure is successful, the cost is much less than that of CABG and hospitalization may be shortened to two days. This trial was not a prospective, double-blind, randomized, controlled clinical investigation and will require further research. Mark Murphy, MD hypertension, nifedipine, clonidine
Oral n i f e d i p i n e v e r s u s oral c l o n i d i n e in t h e t r e a t m e n t of u r g e n t h y p e r t e n s i o n Jaker M, Atkin S, Soto M, et al Arch Intern Med 149:260-264 Feb 1989
This randomized, double-blind, prospective,study investigated the effectiveness of oral nifedipine or clonidine in lowering the blood pressure of hypertensive adults. Fiftyone patients (mean age, 48.2 years) with diastolic blood pressures of 129 m m Hg or more were treated with either 20 mg nifedipine or an initial dose of 0.2 mg clonidine followed by 0.1 mg hourly for up to six hours. Mean initial blood pressure on the nifedipine group was 210/130 mm Hg. All patients who received nifedipine experienced a reduction in diastolic blood pressure (DBP) of 20 m m Hg or more. Nifedipine reduced the DBP to less than 110 rnm Hg in 83% of the patients within 45 minutes and in 96% within 120 minutes. Thirty percent of the patients experienced a subsequent increase in DBP to more than 120 mm Hg by 150 minutes. No clinically significant side effects were noted in this patient population. In the clonidinetreated group, the mean initial blood pressure was 206/132 m m Hg. Clonidine reduced the DBP in 79% of patients to
Annals of Emergency Medicine
18:10 October 1989
James Vayda, MD hydroxyethyl starch; lactated Ringer's
C o m p a r i s o n of h y d r o x y e t h y l s t a r c h and l a c t a t e d R i n g e r ' s s o l u t i o n on h e m o d y n a m i c s a n d o x y g e n t r a n s p o r t of critically ill p a t i e n t s in p r o s p e c t i v e crossover s t u d i e s Hankeln K, Radel C, Beez M, et al Crit Care Med 17:133-135 Feb 1989
These authors compared the effects of lactated Ringer's (RL) and 10% hydroxyethyl starch (HES) on cardiac index (CI), left ventricular stroke work index (LVSWI), oxygen delivery {DO2) , oxygen c o n s u m p t i o n (VO2) , and pulmonary vascular resistance index (PVRI) in 15 critically ill patients. Ten patients were h y p o v o l e m i c either f r o m trauma or following extensive surgery, and five were in cardiogenic shock or were post c a r d i o p u l m o n a r y arrest. RL and HES were given to each patient during periods of hemodynamic instability or w h e n their cardiopulmonary status was suboptimal. A prospective, crossover design was used. Each agent was infused until the wedge pressure (WP) was 16 - 2 m m Hg in the trauma/postoperative group and 18 _+ 2 m m Hg in the cardiac patients. WP, CI, LVSWI, PVRI, DO2, and VO 2 were determined prior to the infusion, at the end of infusion, and 30 minutes following the infusion of each agent. These values then were compared by using the Student's t test and analysis of variance. P < .05 was considered significant. HES significantly increased CI, LVSWI, DO2, and VO 2 while RL infusions showed no significant i m p r o v e m e n t in these values. HES produced a significant decrease in PVRI while RL increased this value. The results of this study demon18:10 October 1989
strate that HES expands plasma volume, thereby improving CI, D O > and VO 2 and decreasing PVRI. RL, conversely, expands the interstitial water thereby having little effect on CI, DO2, and VO 2. This is an important study because increases in CI, DO2, and VO 2 and a decrease in PVRI have been shown to offer a more favorable prognosis in critically ill postoperative patients, provided these variables are maximized early and maintained throughout the early postoperative course.
Tim Hutchinson, MD albuterol, dosage, pediatric
High versus low-dose frequently a d m i n i s t e r e d n e b u l i z e d a l b u t e r o l in c h i l d r e n with severe, acute asthma Schuh S, Parkin P, Rajan A, et al Pediatrics 83:513-518 Apr 1989
A prospective, randomized study of 32 patients was performed to determine the safety and efficacy of high-dose versus low-dose frequently administered albuterol aerosols for treatment of children presenting to the emergency department with severe, acute asthma. Criteria for inclusion were clinical evidence of asthma, m i n i m u m of five years of age, FEV 1 less than 60% of predicted, and no concurrent cardiopulmonary disease. Parameters measured were heart rate, blood pressure, respiratory rate, FEVI, FVC, PEFR, WBC, and differential counts, serum potassium levels, serum albuterol levels, and serum theophylline levels. The initial dose of albuterol in all patients was 0.15 mg/kg. The 16 subjects in each group then received six additional doses (0.15 mg/kg for the high-dose group and 0.05 m g / k g for the low-dose group) at 20m i n u t e intervals. The decision to administer additional therapy (steroids or theophylline) or to admit the patient was made by an attending physician w h o was not involved in the study. There was no significant difference between the two groups with respect to age, duration of asthma, duration of the acute attack prior to arrival at the ED, medications taken at home, pretreatment albuterol levels, or in the severity of the attack. There also was no significant difference in the percent improvement of FEV u FVC, wheeze score, or vital signs following the initial dose. At the end of the study, FEV u FVC, and wheeze score were improved significantly more for the high-dose group versus the low-dose group. No statistically significant differences in vital signs, WBC or differential counts, or s e r u m p o t a s s i u m levels w e r e f o u n d b e t w e e n the groups. Post-treatment serum albuterol levels were higher (19.8 ng/mL vs 12.4 ng/mL) for the high- versus low-dose group, as were the incidence of the side effects of tremor {eight patients vs four patients) and vomiting (three patients vs one patient). These side effects were mild and the differing incidences were not statistically significant. Four patients in the high-dose and ten patients in the low-dose
Annals of EmergencyMedicine
1130/165
ABSTRACTS
group required admission. The authors concluded that frequent high doses of nebulized albuterol appear to be safe and effective for treatment of otherwise healthy children with severe acute asthma. They also concluded that the side effects of high-dose therapy are mild and temporary. Bruce Spears, MD ventricular tachycardia, wide complex
Wide QRS tachycardia adult
in t h e c o n s c i o u s
Steinman RT, Herrera C, Schuger CD, et al JAMA 261:1013-1016
Feb 17, 1989
The last ten years have seen a significant improvement in our understanding of wide complex tachycardia. This article addresses the relationship between hemodynamic stability and wide QRS tachycardia etiology. Twenty consecutive patients with wide complex tachycardia who were conscious, alert, and oriented were analyzed prospectively. Electrolyte imbalance, acute myocardial infarction, and drug reactions were excluded. Twelve-lead ECGs were obtained in 18 of the patients, r h y t h m strips in the remaining two. The following ECG criteria supported the diagnosis of ventricular tachycardia: atrioventricular dissociation, QRS duration greater than 0.14 s, left axis deviation, and Wellens' morphological criteria for the QRS complex. Following conversion to sinus rhythm, electrophysiologic testing was performed in 17 of the patients. Using both ECG criteria and electrophysiologic testing results, a diagnosis of ventricular tachycardia was made in 85% of the patients, supraventricular tachycardia in the remaining 15%. Interestingly, heart rate was noted and found to be more than 200 in two thirds of the patients with proven ventricular tachycardia. The authors strongly suggest that we avoid the pitfall of associating hemodynamic stability with less malignant rhythms. Furthermore, they point out that ventricular tachycardia is frequently much faster than the classic rate of 140. Robinson Nicholson, MD
laser, angioplasty, coronary artery disease
L a s e r a n g i o p l a s t y of t o t a l l y o c c l u d e d c o r o n a r y a r t e r i e s a n d vein grafts: P r e l i m i n a r y r e p o r t on a c u r r e n t t r i a l Foschi A, Myers G, Crick WF, et al Am J Cardiol 63:9F-13F
Apr 1989
This report is one of the first on the treatment of severe coronary artery disease with laser angioplasty. Percutane-
166/1131
ous transluminal coronary angioplasty (PTCA) has been used successfully in lieu of coronary artery bypass grafting (CABG) for symptomatic patients with severe stenosis of coronary arteries. However, totally occluded arteries or bypass grafts have remained as unsolved challenges for PTCA. Laser angioplasty appears to be a viable option for these patients. Three investigators have treated totally occluded coronary arteries and vein grafts in 34 patients with 36 coronary laser procedures with a recanalization rate of 92%. All lesions were refractory to medical therapy and PTCA. After recanalization is achieved, conventional PTCA is used to dilate the artery. The laser system is intended to be an adjunctive debulking procedure. There were no complications attributable to the laser. There were no thermal or mechanical vessel perforations, and no emboli or acute reclosures. However, the problem of restenosis remains, with three patients having reclosure of the recanalized arteries during the clinical trial. Occluded vein grafts account for one third of patients undergoing bypass surgery. Because the organized red clot preferentially absorbs the green argon laser light, laser angioplasty may be the best method for opening these grafts in the future. However, conventional PTCA should be adequate, quicker, and easier for subtotal occlusions. If the laser procedure is successful, the cost is much less than that of CABG and hospitalization may be shortened to two days. This trial was not a prospective, double-blind, randomized, controlled clinical investigation and will require further research. Mark Murphy, MD hypertension, nifedipine, clonidine
Oral n i f e d i p i n e v e r s u s oral c l o n i d i n e in t h e t r e a t m e n t of u r g e n t h y p e r t e n s i o n Jaker M, Atkin S, Soto M, et al Arch Intern Med 149:260-264 Feb 1989
This randomized, double-blind, prospective,study investigated the effectiveness of oral nifedipine or clonidine in lowering the blood pressure of hypertensive adults. Fiftyone patients (mean age, 48.2 years) with diastolic blood pressures of 129 m m Hg or more were treated with either 20 mg nifedipine or an initial dose of 0.2 mg clonidine followed by 0.1 mg hourly for up to six hours. Mean initial blood pressure on the nifedipine group was 210/130 mm Hg. All patients who received nifedipine experienced a reduction in diastolic blood pressure (DBP) of 20 m m Hg or more. Nifedipine reduced the DBP to less than 110 rnm Hg in 83% of the patients within 45 minutes and in 96% within 120 minutes. Thirty percent of the patients experienced a subsequent increase in DBP to more than 120 mm Hg by 150 minutes. No clinically significant side effects were noted in this patient population. In the clonidinetreated group, the mean initial blood pressure was 206/132 m m Hg. Clonidine reduced the DBP in 79% of patients to
Annals of Emergency Medicine
18:10 October 1989