Journal Club Podcast for March 2022
Dr Bertha Wu Prof Peter Cameron Dr Myles Sri Ganeshan
Editor: Dr David McCreary
Welcome to this month’s journal club podcast. We are joined by Professor Peter Cameron, Academic Director for the Alfred Emergency and Trauma Centre, and Dr Myles Ganeshan, Alfred Research Fellow.
This month we reviewed three papers, covering a range of topics that are finally, not COVID related!
The first paper we reviewed looked at the effect of early intra-arrest transport and extracorporeal cardiopulmonary resuscitation on functional neurological outcome in refractory out of hospital cardiac arrests. This was a single centre, randomized control trial published in JAMA just last month in February 2022 by Belohlavek et al.
The second paper we reviewed looked at whether delivering low-intensity mental health outreach programs online prevents self-harm in adult outpatients who have suicidal ideation. It was also published in JAMA in February 2022 by Simon GE et al. Yes it’s a bit of a left-field study to cover in our journal club! But was an interesting read.
The last paper we reviewed looked at the effect of using bougie versus endotracheal tube with stylet on first pass successful tracheal intubation. It was published in JAMA in December 2021 by Driver BE et al.
PAPER 1: EFFECT OF INTRA-ARREST TRANSPORT, EXTRACORPOREAL CARDIOPULMONARY RESUSCITATION, AND IMMEDIATE INVASIVE ASSESSMENT AND TREATMENT ON FUNCTIONAL NEUROLOGICAL OUTCOME IN REFRACTORY OUT-OF-HOSPITAL CARDIAC ARREST
READ IT HERE
CLINICAL QUESTION:
In patients with witnessed refractory out-of-hospital cardiac arrest, does early intra-arrest transport, ECPR and invasive assessment and treatment improve outcomes compared with standard resuscitation?
DESIGN
Single centre, randomized clinical trial in Prague over 8 years – March 2013- October 2020.
POPULATION
Adults aged 18-25yrs receiving ongoing resus for witnessed OHCA of presumed cardiac etiology + received a minimum of 5 min of ACLS without ROSC + ECPR team was available at cardiac centre.
Planned sample size 285 → 256 participants enrolled.
INTERVENTION
Invasive strategy group (n=124) – mechanical compression initiated followed by intra-arrest transport to a cardiac centre for ECPR and immediate invasive assessment and treatment.
COMPARISON
Regular advanced cardiac life support continued on-site in the standard strategy group (n=132).
OUTCOMES
Participants were observed until death or day 180.
Primary outcome: survival with a good neurological outcome (using Cerebral Performance Scale CPC - defined as CPC 1-2 at 180 days
Secondary outcomes: neurological recovery at 30 days – no need for pharmacological or mechanical cardiac support for at least 24 hours
FINDINGS
256 patients were enrolled with all participants completing the trial. 31.5% in the invasive strategy group and 22% in the standard strategy group surviving to 180 days with good neurologic outcome. The difference of 9.5% was not found to be significant with p value of 0.09. At 30 days, neurologic recovery had occurred in 30.6% in the invasive strategy group, and in 18.2% in the standard strategy group; a statistically significant difference of 12.4% (p 0.02). Cardiac recovery had occurred in 43.5% and 34.1% respectively; again not a significant difference. Bleeding occurred more frequently in the invasive strategy group, occurring in 31% of the invasive strategy group vs 15% of the standard strategy group.
AUTHORS' CONCLUSIONS
Among patients with refractory OHCA, the bundle of early intra-arrest transport, ECPR, and invasive assessment and treatment did not significantly improve survival with neurologically favourable outcome at 180 days compared with standard resuscitation. However, they also concluded that the trial was possibly underpowered to detect a clinically relevant difference.
JOURNAL THOUGHTS CLUB
Previous studies like the ARREST study have shown that ECPR does improve survival. It was unfortunate that this study was underpowered to find a statistically significant difference in survival and neurologic outcome between the study groups. The power calculation required a 15% absolute difference between the groups – this is a big number to achieve with any intervention! Other factors like the crossover from intervention group to standard group having all survived, and having more patients with VF in the standard group vs more with asystole in the study group could have potentially confounded and skewed the data in favour of the standard group.
BOTTOM LINE
This paper will unlikely change our practice of offering ECPR to eligible patients at the Alfred.
PAPER 2: EFFECT OF OFFERING CARE MANAGEMENT OR ONLINE DIALECTICAL BEHAVIOUR THERAPY SKILLS TRAINING VS USUAL CARE ON SELF-HARM AMONG ADULT OUTPATIENTS WITH SUICIDAL IDEATION
READ IT HERE
CLINICAL QUESTION:
Can low-intensity outreach programs, based on effective clinical interventions but delivered primarily online, prevent self-harm or suicidal behaviour among outpatients reporting frequent suicidal ideation?
DESIGN
Pragmatic randomized clinical trial conducted at 4 US integrated health systems conducted from March 2015 to September 2018
POPULATION
Included outpatients reporting frequent suicidal thoughts identified using routine Patient Health Questionnaire depression screening at the 4 US integrated health systems.
Total of 18,882 patients were randomized over the course of 3 years when the trial was conducted.
INTERVENTION
Care management intervention (n=6230) that included systematic outreach and care
Skills training intervention (n=6227) which introduced 4 dialectical behaviour therapy skills (mindfulness, mindfulness or current emotion, opposite action, paced breathing)
Interventions were delivered Intervention up to 12mo, primarily through EMR online messaging to supplement ongoing mental health care.
COMPARISON
Usual care (n=6187)
OUTCOMES
Primary outcome: Time to first nonfatal or fatal self-harm; with non-fatal self-harm ascertained from health system records, and fatal self-harm ascertained from state mortality data.
Secondary outcome: included more severe self-harm (leading to death or hospitalization) and broader definition of self-harm (selected injuries and poisonings not originally coded as self-harm).
FINDINGS
Of the 18,644 patients recruited, only 31% of participants offered care management and 39% of those offered skills training actively engaged in intervention programs. Over the 18 months following randomization, a total of 540 participants had a self-harm event, with 45 deaths attributed to self-harm and 495 to non-fatal self-harm events. These self-harm events were contributed by 3.27% in care management and 3.92% in skills training and 3.27% in usual care.
Therefore the risk of fatal or non-fatal self-harm over 18 months was found not to differ significantly between the care management and usual care groups. However, the risk was significantly higher in the skills training group than in usual care.
AUTHORS' CONCLUSIONS
Among adults with frequent suicidal ideation, offering care management did not significantly reduce the risk of self-harm, and offering brief DBT skills training significantly increased the risk of self-harm compared with usual care. These findings do not support the implementation of the programs tested in this study.
JOURNAL CLUB THOUGHTS
This was a well-designed study in an area where research is scarce. In the COVID era where many things including healthcare are becoming virtual, this study does ask an important question of whether providing mental health care online works. The paper shows that it’s not a good idea, at least for the study population amongst patients with significant disorders of self. This group of patients rely on the human connection to heal – virtual medicine is more impersonal than face-to-face care and likely did not provide the human connection that they needed. This may explain why there was low engagement by participants in both groups. Furthermore, the short-term skills training provided in the study didn’t provide the full course of evidenced-based dialectical behavioural therapy. This probably explains why the skills training group in fact did worse in the study!
BOTTOM LINE
The study population poorly represents the patient population that presents to our ED. The study will not change our current practice.
PAPER 3: EFFECT OF USE OF A BOUGIE VS ENDOTRACHEAL TUBE WITH STYLET ON SUCCESSFUL INTUBATION ON THE FIRST ATTEMPT AMONGST CRITICALLY ILL PATIENTS UNDERGOING TRACHEAL INTUBATION
READ IT HERE
CLINICAL QUESTION:
In critically ill adult patients undergoing tracheal intubation, does the use of a tracheal tube introducer (“bougie”) increase the incidence of successful intubation on the first attempt, compared with the use of an endotracheal tube with stylet?
DESIGN
Multicentre, unblinded, pragmatic randomized clinical trial performed between April 2019 and February 2021.
POPULATION
1102 critically ill adults undergoing tracheal intubation with sedation and standard geometry blades in 7 Emergency Departments and 8 Intensive Care Units in the US.
INTERVENTION
Use of a bougie (n = 556)
ComparisonUse of endotracheal tube with stylet (n=546).
OUTCOMES
Primary outcome: single insertion of a laryngoscopy blade into the mouth and either a single insertion of a bougie followed by a single insertion of an ETT into the mouth or a single insertion of an ETT with stylet into the mouth.
Secondary outcome: incidence of severe hypoxaemia (defined as sats < 80%) during the interval between induction and 2 minutes post tracheal intubation.
FINDINGS
Successful intubation on the first attempt occurred in 80.4% in the bougie group and in 83% in the stylet group; risk difference -26% <95%ci -73 - 2.2; p value 0.27>. Therefore, successful intubation on the first attempt did not significantly differ between groups. This finding did not change when adjusted analysis and multiple sensitivity analysis, including one defining successful intubation on the first attempt based only on the number of laryngoscope insertions, was performed. These analyses also showed that the odds of successful intubation on the first attempt did not differ significantly between any of the subgroups, including among more experienced operators, patients with difficult airway characteristics, or when video laryngoscopy was used. For the secondary outcomes, 11% in the bougie group vs 8.8% in the stylet group experienced severe hypoxaemia.
Esophageal intubation, pneumothorax and injury to oral, glottic or thoracic structures had a low incidence in both study groups.
AUTHORS' CONCLUSION
Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.
JOURNAL CLUB THOUGHTS
This study showed around 80% first-pass success rates in both groups. This is much lower than what we generally expect to see in an ED population. The BEAM trial published in 2018 showed a first-pass success rate of 98% when a bougie was used – this is the number we expect and should aim for. The low success rate in the study is probably due to how they defined a successful first attempt. Previous studies have defined this as when the laryngoscope gets taken out of the mouth. In this study, it was defined as a single insertion of a laryngoscope blade into the mouth, and either a single insertion of a bougie followed by a single insertion of an ETT, or a single insertion of an ETT with stylet into the mouth.
The operators in this study had a wide range of experience – from resident physicians who never performed an ETT to attending physicians with thousands of prior intubations. The study showed that overall the use of a bougie did not significantly increase the incidence of first-pass intubation success. With effect modification analysis, this study also showed that the use of a bougie will unlikely increase the rate of successful intubation on the first attempt for operators who had performed a greater number of intubations, and those who commonly use ETT with a stylet.
BOTTOM LINE
Train and get comfortable with both methods. This has the best chance of getting you out of trouble when you encounter a difficult airway as there is no one-size-fits-all approach to the airway and it's good to have more options in your armamentarium.
REFERENCES
Belohlavek J, Smalcova J, Rob D, Franek O, Smid O, Pokorna M, et al. Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest. Jama. 2022;327(8):737–47.
Simon GE, Shortreed SM, Rossom RC, Beck A, Clarke GN, Whiteside U, et al. Effect of Offering Care Management or Online Dialectical Behavior Therapy Skills Training vs Usual Care on Self-harm Among Adult Outpatients With Suicidal Ideation. Jama. 2022;327(7):630–8.
Driver BE, Semler MW, Self WH, Ginde AA, Trent SA, Gandotra S, et al. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation. Jama. 2021;326(24):2488–97.
DR BERTHA WU
Emergency Registrar
MBBS, CCPU (eFAST, AAA, BELS). Emergency Medicine Advanced Trainee and Intensive Care Medicine Trainee in Melbourne, Australia. Particular interests in POCUS, medical education and health care in resource-poor settings. Twitter: @berthawu29
Comments