MEDEST

A Storify report by: Anand Swaminathan @EMSwami  from #AAME14 #emconf

• Preamble:

Minimal change in therapeutic approach to APE over 40 years despite modern evidences.

In APE (Acute Pulmonary Edema), the first ten minutes of management dictate the course of the patient. This is where we can save a life.

• Pathophysiology

Cardiorenal model basis for use of furosemide is mechanistically flawed and outdated.

Cardiocirculatory model: peripheral vasoconstriction leads to decrease in  cardiac function.

Neurohormonal model: build on increased norepinephrine levels and renin-angiotensin-aldosterone system activation

Urban Legend #1 – Loop diuretics are 1st line therapy in treatment of APE

The Truth #1 – Loop diuretics are not recommended as 1st line treatment in APE

References:

• ACEP clinical policy http://1.usa.gov/JyiSSN  states aggressive diuretic monotherapy unlikely to be beneficial

• Good overview of APE treatment http://1.usa.gov/1koxlBf  – “diuretics are not the ideal 1st-line therapy for most patients

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Urban Legend #2 – Patients presenting with APE are volume overloaded

The Truth #2 – Most patients with APE are not fluid overloaded and thus, do not require diuresis. Vascular Congestions DOES NOT equal fluid overload

References:

• bit.ly/1gC5DMr  most pt w/ APE have incr cardiac filling pressure but minimal change in baseline/dry weight

• 1.usa.gov/1gC5HvQ  > 50% pt w/ APE had weight gain < 2 lbs on presentation

• bit.ly/1bO3DeU  Pulm edema results from fluid shifts not fluid gain

Urban Legend #3 – Loop diuretics are harmless in APE treatment so just give them

The Truth #3 – Loop diuretics are harmful early in the management of APE and should be withheld

References:

• Furosemide alone caused increased PCWP in first 20 minutes http://1.usa.gov/19C4Tmc 

• bit.ly/1aEzyyI  furosemide activates renin-angiotensin-aldosterone system + sympathetic nervous system

• 1.usa.gov/1gdZfKt  furosemide decr GFR (assoc w/ worse outcomes), cardiac output (up to 20%) and incr afterload

Urban Legend #4– Morphine should be part of the initial APE algorithm

The Truth #4– Morphine is harmful in APE and should be completely dropped from treatment algorithm

References:

• ADHERE analysis http://1.usa.gov/KAtOjL  morphine assoc w/ incr mech vent (15.4% vs 2.8), incr ICU admit + mortality

• Morphine in APE assoc w/ incr ICU admit (OR 3.08) and intubation (OR 5.04). Mechanistically flawed http://1.usa.gov/17t6M4X 

Bottom line:

Myths

• Loop diuretics are 1st line therapy in treatment of APE

• Patients presenting with APE are volume overloaded

• Loop diuretics are harmless in APE treatment so just give them

• Morphine should be part of the initial APE algorithm

Facts

• Loop diuretics are not recommended as 1st line treatment in APE

• Most patients with APE are not fluid overloaded and thus, do not require diuresis

• Loop diuretics are harmful in early phases of the management of APE and should be withheld

• There is no role for furosemide in the management of APE

• Morphine is harmful in APE and should be completely dropped from treatment algorithm

[View the story “Acute Pulmonary Edema” on Storify]

 

Tag:acute pulmonary edema, edema polmonare, edema polmonare acuto cardiogeno, emergency medicine, medicina d'urgenza

Il trattamento dell’edema polmonare acuto cardiogeno, a parte l’introduzione della Ventilazione non invasiva come trattamento di prima linea, nella sua parte farmacologica non ha subito alcun cambiamento da oltre 40 anni.

Nonostante i vecchi concetti fisiopatologici (sovraccarico di volume, modello cardio-renale) che ne erano ritenuti la base etio-patogenetica, siano stati completamente contraddeti dalle moderne evidenze (redistribuzione dei liquidi e modello neuro-ormonale), alcuni cardini della terapia medica tengono ancora conto dei vecchi e superati modelli fisiopatologici.

Quali sono le verità sulla fisiopatologia ed il trattamento dell’edema polmonare acuto?

Quali sono le leggende metropolitane che ancora popolano la nostra pratica quotidiana?

Leggete il report di questa breve twitter story ed alla fine avrete le idee molto più chiare:

Myths about the Treatment of Acute Pulmonary Edema.

by Anand Swaminathan @EMSwami

In APE (Acute Pulmonary Edema), the first ten minutes of management dictate the course of the patient. This is where we can save a life.

Urban Legend #1 – Loop diuretics are 1st line therapy in treatment of APE

References:

• ACEP clinical policy http://1.usa.gov/JyiSSN  states aggressive diuretic monotherapy unlikely to be beneficial

• Good overview of APE treatment http://1.usa.gov/1koxlBf  – “diuretics are not the ideal 1st-line therapy for most patients

The Truth #1 – Loop diuretics are not recommended as 1st line treatment in APE

Urban Legend #2 – Patients presenting with APE are volume overloaded

References:

• bit.ly/1gC5DMr  most pt w/ APE have incr cardiac filling pressure but minimal change in baseline/dry weight

• 1.usa.gov/1gC5HvQ  > 50% pt w/ APE had weight gain < 2 lbs on presentation

• bit.ly/1bO3DeU  Pulm edema results from fluid shifts not fluid gain

• Vascular Congestions DOES NOT equal fluid overload

The Truth #2 – Most patients with APE are not fluid overloaded and thus, do not require diuresis

Urban Legend #3 – Loop diuretics are harmless in APE treatment so just give them

References:

• Furosemide alone caused increased PCWP in first 20 minutes http://1.usa.gov/19C4Tmc 
• bit.ly/1aEzyyI  furosemide activates renin-angiotensin-aldosterone system + sympathetic nervous system
• 1.usa.gov/1gdZfKt  furosemide decr GFR (assoc w/ worse outcomes), cardiac output (up to 20%) and incr afterload

The Truth #3 – Loop diuretics are harmful early in the management of APE and should be withheld
Urban Legends bottom line – There is no role for furosemide in the management of APE

Bonus Urban Legend – Morphine should be part of the initial APE algorithm

References:

• ADHERE analysis http://1.usa.gov/KAtOjL  morphine assoc w/ incr mech vent (15.4% vs 2.8), incr ICU admit + mortality
• Morphine in APE assoc w/ incr ICU admit (OR 3.08) and intubation (OR 5.04). Mechanistically flawed http://1.usa.gov/17t6M4X 

The Truth – Morphine is harmful in APE and should be completely dropped from treatment algorithm

Bottom line:

Quello che davvero funziona, secondo evidenze e congruità fisiopatologica, nel trattamento d’emergenza dell’edema polmonare acuto è:

• Ventilazione non invasiva

• Nitrati ad alte dosi

Quello che è solo frutto di retaggio culturale e non ha attuale supporto di evidenze e di razionale fisiopatologico (e quindi potenzialmente dannoso) è:

• Furosemide

• Morfina (ndr. se non per aumentare la compliance alla NIV nel paziente agitato)

Quindi per la prossima volta che incontrate un Edema polmonare acuto,  in un paziente emodinamicamente “competente” (attentia al compenso emodinamico, lo shock cardiogeno è un’altra storia), che siate fuori  o dentro l’ospedale, proponiamo una scaletta mentale che possa guidare l’approccio in urgenza:

1. Diagnosi clinico-anamnestica

2. Conferma ecografica

3. Monitoraggio parametri vitali (NIBP, FC, FR, SaO2, EtCO2)

4. O2 ter (28-50%) tit. a SaO2 94-98%

5. Opzionale- Per i pazienti agitati o poco complianti alla NIV Fentanyl/Morfina per via intranasale

6. Inizio NIV (CPAP o BiPAP)

7. Monitoraggio ogni 3 min della PA

8. Accesso venoso periferico/ Prelievi ematici

9. Nitrosorbide 5 gm in 10 ml a boli di 2 ml (1 mg) titolandoli sulla PAS (ogni 3 min). Target PAS 130 mmHg

10. Controllo frequente delle variazioni dei parametri vitali (in particolare (FR, FC e NIBP) e decisioni clinico terapeutiche mirate in base ad esse

[View the story “Acute Pulmonary Edema” on Storify]

Tag:acute pulmonary edema, edema polmonare, edema polmonare acuto cardiogeno, emergency medicine, medicina d'urgenza