Aug 24, 2019
Author: Dave Saintsing
sleep is an independent risk factor for development of health
problems such as type 2 diabetes. A 2019 study, randomized
participants to 3 groups: 9 hours of sleep, 5 hours of sleep with
weekend catch-up sleep, and 5 hours of sleep without catch-up
sleep. In the sleep deprived (5 hour) groups, there was
significantly more insulin resistance, calorie intake, and weight
gain regardless of catch-up sleep.
- Tramadol is prescribed 25 million times a year
in the USA, usually to avoid prescribing traditional opiates such
as Percocet or Oxycodone. Tramadol has complex pharmacology in that
is is both an SNRI and mu-opiate agonist after metabolism in the
liver. The pharmacogenetics of this vary greatly between people.
Many people have rapid metabolism that will lead to increased
opiate effects. Other medications interfere with metabolism (such
as SSRI’s). A recent study demonstrated increased risk of
hypoglycemia in diabetics taking Tramadol. Use caution when
prescribing this drug.
- Sepsis resuscitation has traditionally been
gauged by following lactate levels on the presumption that
lactate is an adequate marker of organ perfusion. Unfortunately,
lactate levels are often elevated by medications and other health
conditions such as kidney or liver disease, making lactate an often
ineffective biomarker for perfusion. The Andromeda-Shock trial
compared using capillary refill to lactate as guides for
resuscitation with the primary endpoint of reducing 28-day
mortality. The capillary refill group had a 9% absolute risk
reduction in mortality, but this did not reach statistical
significance. However, capillary refill can be used as another data
point while resuscitating your septic patients.
should you start pressors for patients in septic shock? A 2019
study compared routine resuscitation (30cc/kg fluid bolus) to
initiation of norepinephrine with the first 30cc/kg crystalloid.
They found that the early pressor group had significantly more
“shock control” (MAP>65) at 6 hours, compared to the control
group. While there was a trend towards less mortality in the early
pressor group, it was not statistically significant. Keep an eye
out for more studies in this area!
recent study in JAMA found that 88% of deaths from sepsis were
unavoidable, due to severe chronic comorbidities. Remember that
patients will still die from septic shock despite your best efforts
and knowledge of the newest literature.
Depner CM, Melanson EL, Eckel
RH, Snell-Bergeon JK, Perreault L, Bergman BC, Higgins JA, Guerin
MK, Stothard ER, Morton SJ, Wright KP Jr. Curr Biol. 2019 Feb 11. pii: S0960-9822(19)30098-3. doi:
10.1016/j.cub.2019.01.069. [Epub ahead of print].
Fournier J, Azoulay L, Yin H,
Montastruc J, Suissa S. Tramadol Use and the Risk of
Hospitalization for Hypoglycemia in Patients With Noncancer
Pain. JAMA Intern
Hernández G, Ospina-Tascón GA,
Damiani LP, et al. Effect of a Resuscitation Strategy Targeting
Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day
Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK
Randomized Clinical Trial. JAMA. Published online February 17,
Permpikul C, Tongyoo S,
Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early
Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A
Randomized Trial. Am J Respir Crit Care Med. 2019 May
1;199(9):1097-1105. doi: 10.1164/rccm.201806-1034OC.
Rhee C, Jones TM, Hamad Y, et
al. Prevalence, Underlying Causes, and Preventability of
Sepsis-Associated Mortality in US Acute Care Hospitals.
JAMA Netw Open.
Published online February 15,
Summarized by Will
Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD
From CarePoint PA Academy,