Friday 9 September 2016

Skin Glue to Secure ED Inserted Peripheral IV’s

Believe it or not, skin glue has been studied for securing central venous catheters, epidurals and arterial lines. I must have missed the memo...

Can we glue peripheral IV’s in the ED?

This randomized controlled trial out of Caboolture Hospital in Queensland tried to answer the question. They enrolled 360 adult patients in the ED who were thought to require admission to hospital. They excluded patients who were agitated or had a high likelihood of removing their IV’s.

A study nurse took down the existing IV dressing and patients were randomized to glue vs. standard care. The glue group got 1 drop of cyanoacrylate (Histoacryl) at the IV insertion site and 1 drop under the catheter hub.

The primary outcome was IV failure at 48 hours defined as dislodgement, occlusion, infection, or phlebitis.

Results? The glue group failed 17% of the time and standard care 27%. Thus an absolute difference of 10% or number needed to treat of 10. Not too bad.

Remember that this study enrolled all comers. It did not focus on the high risk IV’s and excluded agitated patients which probably would have demonstrated a greater treatment effect.

Of course no study is perfect and there were some limitations. In addition, small studies can’t make great claims about safety. Nevertheless, I imagine it should be fine.

I would encourage people to view the associated video referenced by the manuscript. It shows the gluing technique and demonstrates the strength of bond very soon after. To me, this seems to have face validity. Who needs evidence... they could have just shown me the video!

There are some questions that remain.

Is it cost effective? It may not be but if used indiscriminately. But perhaps a targeted approach would make it more so.

Can we use other forms of cyanoacrylate such as Dermabond? The authors used Hisoacryl which has a pretty clever dropper so other applicators may get different results.

What should we take away for now?

I think a common sense approach is warranted. Although not specifically studied, I would imagine that we could identify “at risk” IV’s and use glue when thought needed. We would need to ensure that downstream health care providers are aware the IV has been secured with glue and educate inpatient teams about removal. Once again, there is a handy glue removal video.

I would imagine we will get more real world ED experience and studies over time.

Is there nothing glue can’t do?  


Ibuprofen instead of antibiotics for UTI?

Do all women with uncomplicated UTI’s require antibiotics?

Apparently not.

Of course one would expect some UTI’s to resolve spontaneously. Otherwise the human species would have died out thousands of years ago! But in the era of antibiotics, should we adopt a watchful waiting approach?

This double-blind RCT recruited 494 women from one of 42 GP practices in Germany. They were randomized to either ibuprofen or a single dose of fosfomycin.

The primary endpoints were the number of courses of antibiotics and the total burden of symptoms on days 0 to 7.

Results? Two thirds of the ibuprofen group recovered with no antibiotics. Holy smokes!

But unfortunately, they did have higher burden of symptoms as reported on a non-intuitive scale. (To me, they looked pretty similar.) In addition, there were 5 cases of pyelonephritis in the ibuprofen group as compared to 1 in the fosfomycin group.

Urine cultures were positive in about 75% with a pretty low bar of >10² cfu/ml. So who knows if some women never had UTI’s in the first place. Placebo works pretty well for non-bacterial illness. (We know this from treatment of “otitis media” and the Pollyanna phenomenon.) However, I think it is reasonable to assume that many really did have bacterial cystitis.

Another concern is external validity. It is possible that the patients who present to a GP practice are less sick then those who come to the ED. Insert cynical comment here...

So what to do with this information?

There are probably some women with simple UTI symptoms that do not need antibiotics. They will recover just fine with symptomatic therapy. When and in whom to do this is the big question.

The authors suggest a shared decision making strategy with a possible prescription for delayed antibiotics if no improvement. I think this sounds reasonable with some caution.

I also find many doctors make a soft-call diagnosis of UTI and reach for the prescription pad. Perhaps we could wait and see before resorting to antibiotics.

Two thirds better with nothing… pretty impressive.


Thursday 8 September 2016

HEART Score vs. Gestalt for Diagnosing ACS in the ED?

Clinical decision instruments for sorting out chest pain are nothing new. The latest craze seems to be the HEART score. Who would have thought it helpful to consider the history, ECG, age, risk factors and troponin?

Ok, it seems to have face validity. But is it an improvement upon what we are currently doing? This is an essential question for any decision instrument.

This prospective cohort study out of the Netherlands compared the diagnostic accuracy of the HEART score vs. gestalt in 255 patients.

Results? A whopping 29% of patients had ACS (I think the Dutch have been eating too much cheese.) The HEART score and gestalt seemed to have similar diagnostic accuracy.

Has the HEART score suffered an MI?


To be fair, this study was underpowered and the trends favoured the HEART score. In addition, the doctors specifying their gestalt risk of ACS (low, intermediate, or high) also had to calculate the HEART score! The authors duly noted this and dubbed it possible “influencing bias.” No wonder there was no difference.

As Dr Jerry Hoffman has stated numerous times, clinical decision instruments tend to work poorly in complex disease processes. We are probably never going to come up with a simple and good quality rule that can replace the complexity & nuance of ED chest pain evaluation.

Perhaps the enthusiasm coming from the USA stems from the desire to have some objective quantitative measure charted to justify sending someone home? Shoooooo lawyer you!

Despite the enthusiasm on social media, I’ve never used the HEART score and I know I’m not alone.

Wait a second... history, ECG, age, risk factors and troponin? I take it back... I’ve been using it all the time without knowing! I'm so clever...


Visser A, Wolthuis A, Breedveld R, et al. HEART score and clinical gestalt have similar diagnostic accuracy for diagnosing ACS in an unselected population of patients with chest pain presenting to the ED. Emerg Med J 2015;32:595-600.

Is irrigation of cutaneous abscesses necessary?

It has been long held dogma that one should irrigate the abscess cavity after ED incision and drainage. But as these authors point out, there is no high quality evidence to support this practice.

Unfortunately, this is still the case.

This RCT was conducted in Fresno, California; better known as MRSA country. They enrolled 209 patients with all kinds of abscesses to irrigation vs. no irrigation. This pragmatic design allowed for packing and antibiotics at the discretion of the doctor.

The primary outcome was ‘further intervention’ as defined by repeat I&D, antibiotic change or abscess related hospital admission.

Results? No difference with 15% vs. 13% meeting the primary outcome in the irrigation vs. no irrigation group respectively.

So, we should stop irrigating abscesses!?

Unfortunately, the jury is still out...

This was a small underpowered study with heterogeneous patient population. I don’t think we can make conclusions about the larger pus pockets with lots of necrotic material.

The irrigation was pretty half hearted. This was not standardized and the authors suggest about 100ml was used. Therefore, it is not surprising that such a minor intervention resulted in no difference. Perhaps more aggressive efforts would have achieved better outcomes? Once again, who knows?

Usually randomization evens out the confounders, but for some reason the irrigation group got more packing. In addition, they got more antibiotics at 90% vs. 72% of the time! That’s a lot of antibiotics for cutaneous abscesses and certainly not reflective of my practice (low MRSA prevalence).

The determination of the primary outcome was by 30 day telephone interview. This is far from perfect and could have led to some miscalls. This is better known as non-differential misclassification that can dilute the results towards the null hypothesis. Put another way, this could have watered things down (no pun intended).

The Annals of EM editors capsule summary concludes, “Irrigation of abscesses appears unnecessary after incision and drainage.” I guess this all depends on how you interpret ‘appears.’

In summary, this was a small study that still leaves us with more questions than answers. It gets points for originality. Maybe it's right, but unfortunately we are still in a necrotic mess.


Chinnock, B, Hendy GW, Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success. Ann Emerg Med. 2016;67:379-383.