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Characteristics of patients that do not initially respond to intravenous antihypertensives in the emergency department: subanalysis of the CLUE trial.

ABSTRACT: Hypertensive emergency has a high mortality risk and the treatment goal is to quickly lower blood pressure with intravenous (IV) medications. Characteristics that are associated with non-response to IV antihypertensives have not been identified. The objective is to identify patient characteristics associated with resistance to IV antihypertensives.This was a subanalysis of patients enrolled in the previously described comparative effectiveness trial of IV nicardipine vs. labetalol use in the emergency department (CLUE) study, a randomized trial of nicardipine vs. labetalol. Non-responders were defined as those patients who did not achieve target systolic blood pressure (SBP), as set by the treating physician, within thirty minutes of IV antihypertensive medication, +/- 20mmHg. Stepwise logistic regression was used to identify covariates associated with the measurement outcomes.CLUE enrolled 226 patients, 52.7% female, 76.4% black, mean age of 52.6±14.6 years, of whom 110 were treated with nicardipine and 116 with labetalol. The median (IQR) initial systolic blood pressure was 211mmHg (198, 226), 210 (200, 230), and 211mmHg (198, 226), for the total, non-responder, and responder cohorts, respectively (p-value=0.65, 95% CI [-5.8-11.3]). Twenty-nine were non-responders, 9 in the nicardipine and 20 in the labetalol group. In univariate analysis, several symptoms suggestive of end organ damage were associated with non-response. After multiple variable logistic regression (AUC = 0.72), treatment with labetalol (OR 2.7, 95% CI [1.1-6.7]), history of stroke (OR 5.4, 95% CI [1.6-18.5]), and being male (OR 3.3, 95% CI [1.4-8.1]) were associated with failure to achieve target blood pressure.Male gender and history of previous stroke are associated with difficult to control blood pressure.

SUBMITTER: Freiermuth CE

PROVIDER: S-EPMC4380379 | biostudies-literature | 2015 Mar

REPOSITORIES: biostudies-literature

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Characteristics of patients that do not initially respond to intravenous antihypertensives in the emergency department: subanalysis of the CLUE trial.

Freiermuth Caroline E CE Chandra Abhinav A Peacock W Frank WF

The western journal of emergency medicine 20150317 2

<h4>Introduction</h4>Hypertensive emergency has a high mortality risk and the treatment goal is to quickly lower blood pressure with intravenous (IV) medications. Characteristics that are associated with non-response to IV antihypertensives have not been identified. The objective is to identify patient characteristics associated with resistance to IV antihypertensives.<h4>Methods</h4>This was a subanalysis of patients enrolled in the previously described comparative effectiveness trial of IV nic ...[more]

PMID: 25834670

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Project description:ObjectiveTo compare the efficacy of Food and Drug Administration recommended dosing of nicardipine versus labetalol for the management of hypertensive patients with signs and/or symptoms (S/S) suggestive of end-organ damage (EOD).DesignSecondary analysis of the multicentre prospective, randomised CLUE trial.Setting13 academic emergency departments in the USA.ParticipantsEligible patients had two systolic blood pressure (SBP) measures ?180 mm Hg at least 10 min apart, no contraindications to nicardipine or labetalol and predefined S/S suggestive of EOD on arrival.InterventionsMedications were administered by continuous infusion (nicardipine) or repeat intravenous bolus (labetalol) for a study period of 30 min or until a specified target SBP ±20 mm Hg was achieved.Primary outcome measurePercentage of participants achieving a predefined target SBP range (TR) defined as an SBP within ±20 mm Hg as established by the treating physician.ResultsOf the 141 eligible patients, 49.6% received nicardipine, 51.7% were women and 81.6% were black. Mean age was 52.2±13.9 years. Median initial SBP did not differ in the nicardipine (210.5 (IQR 197-226) mm Hg) and labetalol (210 (200-226) mm Hg) groups (p=0.862). Nicardipine patients were more likely to have a history of diabetes (41.4% vs 25.7%, p=0.05) but there were no other historical, demographic or laboratory differences between groups. Within 30 min, nicardipine patients more often reached the target SBP range than those receiving labetalol (91.4% vs 76.1%, difference=15.3% (95% CI 3.5% to 27.3%); p=0.01). On multivariable modelling with adjustment for gender and clinical site, nicardipine patients were more likely to be in TR by 30 min than patients receiving labetalol (OR 3.65, 95% CI 1.31 to 10.18, C statistic=0.72).ConclusionsIn the setting of hypertension with suspected EOD, patients treated with nicardipine are more likely to reach prespecified SBP targets within 30 min than patients receiving labetalol.Clinical trial registrationNCT00765648, clinicaltrials.gov.

Project description:Study objectiveWe compare the efficacy and safety of intravenous lidocaine with that of hydromorphone for the treatment of acute abdominal pain in the emergency department (ED).MethodsThis was a randomized, double-blind, clinical trial conducted in 2 EDs in the Bronx, NY. Adults weighing 60 to 120 kg were randomized to receive 120 mg of intravenous lidocaine or 1 mg of intravenous hydromorphone. Thirty minutes after administration of the first dose of the study drug, participants were asked whether they needed a second dose of the investigational medication to which they were randomized. Patients were also stratified according to clinical suspicion of nephrolithiasis. The primary outcome was improvement in pain scores of 0 to 10 between baseline and 90 minutes. An important secondary outcome was need for "off-protocol" parenteral analgesics, including opioids and nonsteroidal anti-inflammatory drugs.ResultsWe enrolled 154 patients, of whom 77 received lidocaine and 77 received hydromorphone. By 90 minutes, patients randomized to lidocaine improved by a mean of 3.8 points on the 0-to-10 scale, whereas those randomized to hydromorphone improved by a mean of 5.0 points (mean difference 1.2; 95% confidence interval 0.3 to 2.2). Need for off-protocol "rescue" analgesics occurred for 39 of 77 lidocaine patients (51%) and 20 of 77 hydromorphone patients (26%) (difference 25%; 95% confidence interval 10% to 40%). Adverse events were comparable between groups. Among the subset of 22 patients with nephrolithiasis, lidocaine patients reported a mean improvement of 3.4 points on the pain scale, whereas hydromorphone patients reported a mean improvement of 6.4 points (mean difference 3.0; 95% confidence interval 0.5 to 5.5).ConclusionIntravenous hydromorphone was superior to intravenous lidocaine both for general abdominal pain and a subset of patients with nephrolithiasis. A majority of patients randomly allocated to lidocaine required additional analgesics.

Project description:BackgroundEmergency care is an essential part of a health system. Ecuador has recognized emergency medicine as a specialty and has two emergency medicine residency training programs. However, little has been published about emergency department characteristics and capabilities in Ecuador.ObjectiveWe described the characteristics and capabilities of emergency departments (EDs) in Quito, Ecuador, in 2017, using the National Emergency Department Inventory (NEDI) survey.MethodsThe 23-item survey included questions pertaining to ED characteristics, including: visit volume, physical and administrative structure, clinical capabilities, technological resources, and consult personnel availability. This study included all EDs in Quito operating 24 hours/day, 7 days/week, and serving all patients seeking care. One representative from each ED was asked to complete the survey based on calendar year 2017.FindingsThirty EDs met the inclusion criteria, and 26 completed the survey (87% response). The median number of ED beds was 17 (range 2-61). Median annual visit volume was 22,580 (range 1,680 to 129,676). All but two EDs provided care for both children and adults. Cardiac monitors were available in 88% of EDs, CT scanners in 68%, and rooms for respiratory isolation in 31%. Most EDs could manage patients with general medicine (92%), general surgery (92%), and gynecology (88%) emergencies 24/7. Fewer were able to provide hand surgery (45%) and dental (28%) care 24/7. Typical length of stay was 1-6 hours in 65% and >6 hours in 31% of EDs. Half of EDs reported operating at full capacity and 27% reported operating over their capacity. When compared to private EDs, government EDs (public and social security) had a higher mean number of visits per year (50,090 government vs. 13,968 private, p < 0.001), higher mean number of ED beds (36 government vs. 9 private, p = 0.002), and higher length of stay (58% of patient stays > 6 hours in government EDs vs. 86% of patient stays 1-6 hours in private EDs, p = 0.009).ConclusionsEDs in Quito varied widely with respect to annual visit volume, ability to treat different pathologies 24/7, and resources. Most EDs are functioning at or over capacity, and a substantial number have long lengths of stay. Further research and investment in emergency care could help increase the capacity and efficiency of EDs in Ecuador.

Project description:ImportanceMonitoring emergency care quality requires understanding which conditions benefit most from timely, quality emergency care.ObjectivesTo identify a set of emergency care-sensitive conditions (ECSCs) that are treated in most emergency departments (EDs), are associated with a spectrum of adult age groups, and represent common reasons for seeking emergency care and to provide benchmark national estimates of ECSC acute care utilization.Design, setting, and participantsA modified Delphi method was used to identify ECSCs. In a cross-sectional analysis, ECSC-associated visits by adults (aged ≥18 years) were identified based on International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes and analyzed with nationally representative data from the 2016 US Nationwide Emergency Department Sample. Data analysis was conducted from January 2018 to December 2018.Main outcomes and measuresIdentification of ECSCs and ECSC-associated ED utilization patterns, length of stay, and charges.ResultsAn expert panel rated 51 condition groups as emergency care sensitive. Emergency care-sensitive conditions represented 16 033 359 of 114 323 044 ED visits (14.0%) in 2016. On average, 8 535 261 of 17 886 220 ED admissions (47.7%) were attributed to ECSCs. The most common ECSC ED visits were for sepsis (1 716 004 [10.7%]), chronic obstructive pulmonary disease (1 273 319 [7.9%]), pneumonia (1 263 971 [7.9%]), asthma (970 829 [6.1%]), and heart failure (911 602 [5.7%]) but varied by age group. Median (interquartile range) length of stay for ECSC ED admissions was longer than non-ECSC ED admissions (3.2 [1.7-5.8] days vs 2.7 [1.4-4.9] days; P < .001). In 2016, median (interquartile range) ED charges per visit for ECSCs were $2736 ($1684-$4605) compared with $2179 ($1118-$4359) per visit for non-ECSC ED visits (P < .001).Conclusions and relevanceThis comprehensive list of ECSCs can be used to guide indicator development for pre-ED, intra-ED, and post-ED care and overall assessment of the adult, non-mental health, acute care system. Health care utilization and costs among patients with ECSCs are substantial and warrant future study of validation, variations in care, and outcomes associated with ECSCs.

Project description:In India, and many low-middle income countries (LMICs), emergency medicine (EM) remains a poorly defined specialty and an unregulated field of clinical practice. Recognition of the attitudes, understanding, and expectations of patients presenting to Indian EDs will be crucial to the continued development of EM as a specialty. This is a multicenter, prospective, cross sectional study of adult and pediatric patients presenting to the ED in three geographically distinct regions of India. Participants were surveyed about their expectations regarding the type of care that they expected to receive, previous treatment options they have utilized, basic understanding of ED operations, factors contributing to their decision to seek ED care, and basic demographic information. 779 patients were approached to participate in the study, of which 698 (90%) completed the survey. Common ways that patients reported learning about the ED were referral from another healthcare provider (45%) and recommendation by a family member (61%). Participants chose the ED was because they thought they would be seen quickly (89%), would receive acute pain management (45%), their regular outpatient care was closed (45%), or were sent by another doctor (45%). Patients expected to wait 0.3 hours (18 minutes) on average to see a doctor in the ED. Over 75% or patients expected to see a specialist consultant in the ED and 12% expected to see their personal physician. Eighty-five percent of patients were triaged as moderate or high acuity, and 74% of patients were admitted. This study found that ED in India is utilized by a population with an extremely high acuity of medical illness that attempts to access healthcare through multiple avenues. Patients most frequently visit the ED due to a referral from another healthcare provider or family member. Most patients are aware of the existence of the ED, though understanding of available services may be lacking. Future research should focus on community outreach and education initiatives on ED services.

Project description:BackgroundAcute asthma in children can be life-threatening and must be treated promptly in the emergency setting. Intravenous magnesium sulfate is recommended by various guidelines for cases of acute asthma that have not responded to first-line treatment with bronchodilators and steroids. The treatment has recently been shown to reduce the need for hospital admission for adults compared with placebo, but it is unclear whether it is equally effective for children.ObjectivesTo assess the safety and efficacy of intravenous magnesium sulfate (IV MgSO4) in children treated for acute asthma in the emergency department (ED).Search methodsWe identified studies by searching the Cochrane Airways Review Group Specialised Register up to 23 February 2016. We also searched ClinicalTrials.gov and reference lists of other reviews, and we contacted study authors to ask for additional information.Selection criteriaWe included randomised controlled trials of children treated in the ED for exacerbations of asthma if they compared any dose of IV MgSO4 with placebo.Data collection and analysisTwo review authors screened the results of the search and independently extracted data from studies meeting the inclusion criteria. We resolved disagreements through discussion and contacted study authors in cases of missing data and other uncertainties relating to the studies.We analysed dichotomous data as odds ratios and continuous data as mean differences, both using fixed-effect models. We assessed each study for risk of bias and rated the quality of evidence for each outcome with GRADE and presented the results in a 'Summary of findings' table. There was insufficient evidence to conduct the planned subgroup analyses.Main resultsFive studies (182 children) met the inclusion criteria, and four contributed data to at least one meta-analysis. The included studies were overall at low risk of bias, but our confidence in the evidence was generally low, mainly due to the small sample sizes. Treatment with IV MgSO4 reduced the odds of admission to hospital by 68% (odds ratio (OR) 0.32, 95% confidence interval (CI) 0.14 to 0.74; children = 115; studies = 3; I(2) = 63%). This result was based on data from just three studies including 115 children. Meta-analysis for the secondary outcomes was extremely limited by paucity of data. We performed meta-analysis for the outcome 'return to the emergency department within 48 hours', which showed a very imprecise effect estimate that was not statistically significant (OR 0.40, 95% CI 0.02 to 10.30; children = 85; studies = 2; I(2) = 0%). Side effects and adverse events were not consistently reported and meta-analysis was not possible, however few side effects or adverse events were reported.Authors' conclusionsIV MgSO4 may reduce the need for hospital admission in children presenting to the ED with moderate to severe exacerbations of asthma, but the evidence is extremely limited by the number and size of studies. Few side effects of the treatment were reported, but the data were extremely limited.

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Characteristics of patients that do not initially respond to intravenous antihypertensives in the emergency department: subanalysis of the CLUE trial.

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Characteristics of patients that do not initially respond to intravenous antihypertensives in the emergency department: subanalysis of the CLUE trial.

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