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Correspondence / American Journal of Emergency Medicine 32 (2014) 1534–1552
In the light of these data, we think that a person without any previous experience in the creation of IO route can successfully perform this practice, even in his/her first experience, provided that he/she properly reads or learns the practice. As a result of this study, which enlightened the use of IO route of administration, demonstrated the usefulness of IO route of administration, revealed the learning curve, and, in addition, aimed to minimize to complications due to the incremental use of IO route of administration, we think that the physicians without a previous experience in this practice can practically and safely create an IO route of administration after the eighth practice, after performing the first 3 or 4 practice under the supervision of experienced physicians.
Onur Polat, MD Ahmet Burak Oğuz, MD⁎ Ankara University School of Medicine Department of Emergency Medicine, Ankara, Turkey ⁎Corresponding author. Ankara University School of Medicine Emergency Department, Samanpazarı-Ankara, Turkey Tel.: +90 3125083030, +90 5062515022(mobile) fax: +90 3125083032 E-mail address: [email protected] Ayhan Cömert, MD Ankara University School of Medicine Department of Anatomy, Ankara, Turkey Arda Demirkan, MD Müge Günalp Ankara University School of Medicine Department of Emergency Medicine, Ankara, Turkey Eray Tüccar, MD Ankara University School of Medicine Department of Anatomy, Ankara, Turkey http://dx.doi.org/10.1016/j.ajem.2014.09.018
References [1] Leidel BA, Kirchhoff C, Bogner V, Stegmaier J, Mutschler W, Kanz KG, et al. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Saf Surg 2009;3: 24–5. [2] Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, et al. Adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122(Suppl 3):729–67. [3] Deakin CD, Nolan JP, Soar J, Sunde K, Koster RW, Smith GB, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2010;81:1305–52.
Hydration therapy: critical intervention in the ED to prevent stroke in evolution after acute ischemic stroke☆,☆☆
To the Editor, We read the original article by Lin et al [1] with great enthusiasm. The authors have revealed the role of simple hydration ☆ Conflict of interest: Nil. ☆☆ Sources of funding: Nil.
therapy to prevent stroke in evolution (SIE) after acute ischemic stroke (AIS), which was done according to World Health Organization hydration protocol 2005 for diarrhea. They have concluded that providing hydration therapy to patients who present with a blood urea nitrogen/creatinine (BUN/Cr) ratio greater than or equal to 15 after ischemic stroke may help prevent the development of SIE, and such prevention is likely to improve prognosis given that SIE is a key indicator of poor prognosis after stroke. But it required careful decision related to overhydration especially with hypotonic fluids in patients with larger infarct particularly on day 2 or 3, when chances of cerebral edema are more. Dehydration is a frequent clinical problem in emergency department (ED). It is a marker of poor prognosis in many clinical situations like pneumonia, myocardial infarction, etc. Recently, various studies have concluded that dehydration is also a marker of clinical deterioration in AIS [2,3]. It worsens SIE, as dehydration impairs cerebral oxygen delivery and worsens clinical outcome in patients with AIS. Previous studies have proven elevated BUN/Cr ratio as a marker of dehydration in ED [2,3]. Studies have revealed that caval index (respiratory variation in the diameter of inferior vena cava) can be a useful bedside marker to predict dehydration in ED patients, and they also demonstrated a good correlation between caval index with BUN/Cr ratio greater than 20 [4]. The present author in their previous study also showed dehydration (BUN/Cr ratio, ≥15) as an independent predictor of SIE. Patients of AIS with BUN/Cr ratio greater than or equal to 15 were 3.41-fold more likely to have SIE (P = .008), and they concluded that BUN/Cr may be novel predictor of SIE, potentially useful in EDs. Similarly, Shrock et al [5] also concluded in their study that elevated BUN/Cr ratio of greater than or equal to 15 (marker of dehydration) is marker of poor outcome in patients with acute ischemic stroke at 30 days. The present author also studied urine-specific gravity (another indicator of hydration status), which is more easily obtained as a predictor of neurologic deterioration in AIS and concluded that patients with a urine-specific gravity greater than or equal to 1.010 were 2.78 times more likely to develop SIE [3]. However, there are few limitations in the present study. The control groups are retrospective, hydration therapy was not strictly standardized, and they could not rule out the possibility that factors other than hydration affected the outcomes. Again, they did not assess longer term outcomes in the treated patients. Randomized controlled trial on larger scale is required to replicate the findings of this preliminary study and to find out the long-term outcome. Meera Ekka, MD Department of Emergency Medicine, All India Institute of Medical Sciences New Delhi, India Corresponding author. Department of Emergency Medicine All India Institute of Medical Sciences New Delhi, Aurobindo Marg, New Delhi, PIN-110049 India Tel.: +91 9868397048, 011 26864666 E-mail address: [email protected] Sashi Bhusan Lakra, MD Kailash Hospital and Heart Institute, Noida, Uttar Pradesh, India E-mail address: [email protected] Praveen Aggarwal, MD Nayer Jamshed, MD Department of Emergency Medicine, All India Institute of Medical Sciences New Delhi, India E-mail addresses: [email protected] [email protected] http://dx.doi.org/10.1016/j.ajem.2014.09.031
Correspondence / American Journal of Emergency Medicine 32 (2014) 1534–1552
In the light of these data, we think that a person without any previous experience in the creation of IO route can successfully perform this practice, even in his/her first experience, provided that he/she properly reads or learns the practice. As a result of this study, which enlightened the use of IO route of administration, demonstrated the usefulness of IO route of administration, revealed the learning curve, and, in addition, aimed to minimize to complications due to the incremental use of IO route of administration, we think that the physicians without a previous experience in this practice can practically and safely create an IO route of administration after the eighth practice, after performing the first 3 or 4 practice under the supervision of experienced physicians.
Onur Polat, MD Ahmet Burak Oğuz, MD⁎ Ankara University School of Medicine Department of Emergency Medicine, Ankara, Turkey ⁎Corresponding author. Ankara University School of Medicine Emergency Department, Samanpazarı-Ankara, Turkey Tel.: +90 3125083030, +90 5062515022(mobile) fax: +90 3125083032 E-mail address: [email protected] Ayhan Cömert, MD Ankara University School of Medicine Department of Anatomy, Ankara, Turkey Arda Demirkan, MD Müge Günalp Ankara University School of Medicine Department of Emergency Medicine, Ankara, Turkey Eray Tüccar, MD Ankara University School of Medicine Department of Anatomy, Ankara, Turkey http://dx.doi.org/10.1016/j.ajem.2014.09.018
References [1] Leidel BA, Kirchhoff C, Bogner V, Stegmaier J, Mutschler W, Kanz KG, et al. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Saf Surg 2009;3: 24–5. [2] Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, et al. Adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122(Suppl 3):729–67. [3] Deakin CD, Nolan JP, Soar J, Sunde K, Koster RW, Smith GB, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2010;81:1305–52.
Hydration therapy: critical intervention in the ED to prevent stroke in evolution after acute ischemic stroke☆,☆☆
To the Editor, We read the original article by Lin et al [1] with great enthusiasm. The authors have revealed the role of simple hydration ☆ Conflict of interest: Nil. ☆☆ Sources of funding: Nil.
therapy to prevent stroke in evolution (SIE) after acute ischemic stroke (AIS), which was done according to World Health Organization hydration protocol 2005 for diarrhea. They have concluded that providing hydration therapy to patients who present with a blood urea nitrogen/creatinine (BUN/Cr) ratio greater than or equal to 15 after ischemic stroke may help prevent the development of SIE, and such prevention is likely to improve prognosis given that SIE is a key indicator of poor prognosis after stroke. But it required careful decision related to overhydration especially with hypotonic fluids in patients with larger infarct particularly on day 2 or 3, when chances of cerebral edema are more. Dehydration is a frequent clinical problem in emergency department (ED). It is a marker of poor prognosis in many clinical situations like pneumonia, myocardial infarction, etc. Recently, various studies have concluded that dehydration is also a marker of clinical deterioration in AIS [2,3]. It worsens SIE, as dehydration impairs cerebral oxygen delivery and worsens clinical outcome in patients with AIS. Previous studies have proven elevated BUN/Cr ratio as a marker of dehydration in ED [2,3]. Studies have revealed that caval index (respiratory variation in the diameter of inferior vena cava) can be a useful bedside marker to predict dehydration in ED patients, and they also demonstrated a good correlation between caval index with BUN/Cr ratio greater than 20 [4]. The present author in their previous study also showed dehydration (BUN/Cr ratio, ≥15) as an independent predictor of SIE. Patients of AIS with BUN/Cr ratio greater than or equal to 15 were 3.41-fold more likely to have SIE (P = .008), and they concluded that BUN/Cr may be novel predictor of SIE, potentially useful in EDs. Similarly, Shrock et al [5] also concluded in their study that elevated BUN/Cr ratio of greater than or equal to 15 (marker of dehydration) is marker of poor outcome in patients with acute ischemic stroke at 30 days. The present author also studied urine-specific gravity (another indicator of hydration status), which is more easily obtained as a predictor of neurologic deterioration in AIS and concluded that patients with a urine-specific gravity greater than or equal to 1.010 were 2.78 times more likely to develop SIE [3]. However, there are few limitations in the present study. The control groups are retrospective, hydration therapy was not strictly standardized, and they could not rule out the possibility that factors other than hydration affected the outcomes. Again, they did not assess longer term outcomes in the treated patients. Randomized controlled trial on larger scale is required to replicate the findings of this preliminary study and to find out the long-term outcome. Meera Ekka, MD Department of Emergency Medicine, All India Institute of Medical Sciences New Delhi, India Corresponding author. Department of Emergency Medicine All India Institute of Medical Sciences New Delhi, Aurobindo Marg, New Delhi, PIN-110049 India Tel.: +91 9868397048, 011 26864666 E-mail address: [email protected] Sashi Bhusan Lakra, MD Kailash Hospital and Heart Institute, Noida, Uttar Pradesh, India E-mail address: [email protected] Praveen Aggarwal, MD Nayer Jamshed, MD Department of Emergency Medicine, All India Institute of Medical Sciences New Delhi, India E-mail addresses: [email protected] [email protected] http://dx.doi.org/10.1016/j.ajem.2014.09.031
