2 Minute Medicine Rewind May 14, 2018

Association of Clinical Outcomes With Surgical Repair of Hip Fracture vs Nonsurgical Management in Nursing Home Residents With Advanced Dementia

The decision to undergo surgical repair versus a palliative approach in the management of hip fracture in patients with advanced dementia is less clear in the setting of poor cognitive and functional status, and limited life expectancy. In this cohort study, investigators analyzed data from 3083 nursing home residents with advanced dementia and hip fracture in order to examine the effect of surgical repair on all-cause mortality. Of these patients, 2615 residents underwent surgical repair, while 468 did not. Compared to those who received surgical intervention, those who were managed nonsurgically were more often black, female, had a BMI lower than 18.5, had more pressure ulcers, and were totally dependent in activities of daily living. Researchers found that the median survival was 1.4 years in residents managed with surgery and 0.4 years in those managed nonsurgically, with surgically managed patients demonstrating significantly greater survival (HR 0.88, 95% CI 0.79 to 0.98). At 6 months of follow-up, researchers also found that nursing home residents who had surgery had less documented pain (29.0% vs. 30.9%) and fewer pressure ulcers (11.2% vs. 19.0%), but were more likely to require physical restraints (13.0% vs. 11.1%) and antipsychotic medication (29.5% vs. 20.4%). Analysis of patients who were ambulatory before the hip fracture showed that more of them were ambulatory at 6 months after surgery (10.7% vs. 4.8%), although it should be noted that 96.1% of residents who were ambulatory before their fracture received surgery. Overall, results from this study indicate that while surgical repair has a survival benefit for patients with advanced dementia, it is also associated with a higher risk of requiring antipsychotics and/or restraints. As such, the management of nursing home residents with advanced dementia should be driven by goals of care. This study is limited in that even though investigators adjusted for many factors, results could have been affected by unmeasured differences between residents managed surgically or nonsurgically. Secondary outcomes were also measured at a single time point rather than longitudinally.

Drug-eluting stents versus bare-metal stents in saphenous vein grafts: a double-blind, randomised trial

Stents form the current standard of care for percutaneous intervention (PCI). Approximately 20% of patients undergoing PCI have previously undergone coronary artery bypass graft (CABG) surgery. Currently, there is limited evidence in terms of outcomes for bare metal (BMS) versus drug-eluting stents (DES) in patients with saphenous vein grafts (SVGs) from CABG. In this randomized controlled study, 3482 patients with previous CABG undergoing PCI were randomized to receive either DES or BMS in order to study the effect of stent type on target vessel failure. Target vessel failure was defined as a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization. Upon carrying out an intention-to-treat analysis with the data from 292 individuals in the DES group and 305 from the BMS group, researchers found that at 12 months of follow-up, target vessel failure occurred in 17% of the DES group and 19% of the BMS group (HR 0.92, 95% CI 0.63 to 1.34, p=0.70). There were also no statistically significant differences in secondary outcomes including myocardial infarction, all-cause death, definite or probable stent thrombosis, or stroke. Results from this study therefore indicate that DES does not improve target vessel failure in patients with aortocoronary SVG failure compared to BMS. This has important implications given the higher cost of DES. Limitations of this study include the fact that nearly all study participants were men, and that interventionalists carrying out PCI procedures were not masked to the type of stent used.

Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery

Intravenous (IV) fluids are routinely administered perioperatively during abdominal surgery to correct for preoperative fasting and other causes of hypovolemia. Traditional IV fluid regimens administer up to 7 L of fluid, however, more restrictive fluid regimens may be beneficial in terms of reducing tissue edema and weight gain. In this randomized controlled trial, investigators randomized 3000 patients undergoing abdominal surgery to either a restrictive or liberal IV fluid regimen in order to study the effect of fluid regimen on disability-free survival up to 1 year after surgery. Results based on the 2983 individuals included in the intention-to-treat analysis showed that the median rate of fluid infusion was 6.5 ml/kg/hr in the restrictive fluid group (IQR 5.1 to 8.4) and 10.9 ml/kg/hr in the liberal fluid group (IQR 8.7 to 13.5). The rate of disability-free survival at 1 year was 81.9% in the restrictive fluid group and 82.3% in the liberal fluid group (HR 1.05, 95% CI 0.88 to 1.24, p=0.61). In terms of secondary outcomes, acute kidney injury (AKI) occurred more often in the restrictive fluid group (8.6% vs. 5.9%, p<0.001). The restrictive fluid regimen group also had higher rates of surgical-site infection (16.5% vs. 13.6%, p=0.02) and renal-replacement therapy (0.9% vs. 0.3%, p=0.048). There was no statistically significant difference in rate of septic complications or death (p=0.19). Overall, results indicate that although a liberal fluid therapy regimen may not affect disability-free survival, liberal fluid administration is safer for reasons such as preventing AKI or surgical-site infections.  This study was limited in that clinicians could not be blinded to the amount of IV fluid they were administering. The trial also controlled the administration of fluid during surgery and for the first 24 hours after surgery, however, later amounts of fluid administration were not controlled.

Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children

There are currently preprocedural fasting guidelines for children who require sedation in the emergency department (ED). These guidelines were developed with the aim of reducing the incidence of life-threatening pulmonary aspiration, with the American Society of Anesthesiologists (ASA) and American Academy of Pediatrics specifying a minimum fasting period of 2 hours for clear liquids, 4 hours for breast milk, 6 hours for infant formula, and 8 hours for solids containing meat of fatty foods. Adhering to these fasting guidelines, however, may delay treatment, and were developed for patients undergoing elective procedures. In this cohort study, investigators analyzed data on 6183 children that received sedation in the ED in order to study the effect of preprocedural fasting before sedation on the occurrence of pulmonary aspiration, any adverse event, serious adverse events, and vomiting.  Researchers found that while no pulmonary aspirations occurred, 11.6% of children (95% CI 10.8% to 12.4%) experienced an adverse event, where 5.1% (95% CI 4.6% to 5.7%) of children experienced vomiting and 5.5% (95% CI 5.0% to 6.1%) experienced oxygen desaturation. Serious adverse events occurred in 1.1% (95% CI 0.9% to 1.3%) of patients. When fasting duration was analyzed in relation to adverse events, results showed that each additional hour of fasting for solid food did not significantly decrease the odds of experiencing an adverse event (OR 1.00, 95% CI 0.98 to 1.02, p=0.91), vomiting (OR 1.00, 95% CI 0.97 to 1.03, p= 0.79), or a serious adverse event (OR 1.01, 95% CI 0.95 to 1.07, p=0.64). Similarly, additional hours of fasting for liquids did not significantly decrease the odds of experiencing an adverse event (OR 1.00, 95% CI 0.98 to 1.02, p=0.97), vomiting (OR 1.00, 95% CI 0.96 to 1.03, p=0.81), or a serious adverse event (OR 1.01, 95% CI 0.95 to 1.07, p=0.69). Taken together, results from this study suggest that strict adherence to preprocedural fasting guidelines does not significantly reduce the risk of experiencing adverse events in children undergoing sedation in the ED, and therefore, procedures should not be delayed for fasting. This study was limited in that only 1.8% of patients included in this study consumed solids within 2 hours of their sedation, making conclusions about shorter fasting durations difficult. Furthermore, ketamine alone was used more often in the patients who did not meet fasting guidelines recommendations for elective sedation. Further research is needed to study the effect of fasting on outcomes for sedations performed with other analgesics.

Cost-effectiveness of Electroconvulsive Therapy vs Pharmacotherapy/Psychotherapy for Treatment-Resistant Depression in the United States

Despite research demonstrating that electroconvulsive therapy (ECT) can be significantly more effective than pharmacotherapy in the treatment of depression, the use of this treatment modality continues to be low. The infrequent use of ECT may be due to stigma, uncertainty surrounding its indications, adverse effects, and perceived high cost. In this study, investigators built a decision analytic model integrating data on clinical efficacy, costs, and quality-of-life effects of ECT. Investigators simulated the clinical and economic effects of 7 different strategies: 1 strategy with no ECT available, and 6 strategies with 0 to 5 lines of treatment prior to ECT. Simulated patients entered the model at initiation of first-line treatment and then progressed through up to 9 treatment lines. Results of the model showed that over 4 years, ECT was projected to reduce the fraction of time with nonresponse of depression from 50.2% of life-years to 37.1% to 32.9% of life-years, with earlier ECT leading to better reductions. If the willingness-to-pay threshold was set to $100,000 per quality-adjusted life-year (QALY), third-line ECT was projected to be cost-effective with an incremental cost-effective ratio (ICER) of $54,000 per QALY, while first-line and second-line were not. Fourth, fifth, and sixth-line ECT offered fewer QALYs with a poorer ICER than other strategies, but were cost-effective compared to no ECT. Overall, results from this model indicate that offering ECT after failure of 2 lines of pharmacotherapy/psychotherapy would be most cost-effective, while offering ECT later would still be more cost-effective than offering no ECT. This study was limited in that models included simplifying assumptions; investigators, however, tried to make these assumptions conservative. The cost data used also included costs from over a decade ago, underlying the need for updated data to model current healthcare costs.

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