Deferral of Estimated Glomerular Filtration Rate Testing Before Contrast-Enhanced CT in Low-Risk Emergency Department Patients: Assessment of Safety and Impact on Throughput

OBJECTIVE

To assess the safety and utility of deferring estimated glomerular filtration rate (eGFR) testing before contrast-enhanced CT (CECT) in low-risk emergency department (ED) patients.

METHODS

A new question was added to CECT order screens, allowing ordering ED providers to defer eGFR testing in patients deemed low risk for contrast-induced acute kidney injury (AKI). Low risk was defined as no known chronic kidney disease (CKD) or risk factors for AKI or CKD. Patients on chronic dialysis were deemed low risk. The project included three phases: baseline, pilot (optional order question), and full implementation (required order question). Outcomes were operational throughput metrics of CECT order to protocol (O to P) and order to begin (O to B) times. As a balancing safety measure, the proportion of patients deemed to be "low risk" and subsequently found to have eGFR value less than 30 mL/min/1.73 m2 was reported.

RESULTS

A total of 16,446 CECT studies were included from four EDs. In the pilot phase, provider engagement rates with the question were low (5%-14%). After full implementation, median O to P time improved from 23.93 min at baseline to 13.02 (P < .0001) and median O to B time improved from 80.34 min to 76.48 (P = .0002). In 0.3% (2 of 646) studies, CECT was completed in patients categorized as low risk by the ED provider with subsequently resulted eGFR <30 mL/min/1.73 m2.

DISCUSSION

Upfront clinical risk assessment for AKI and CKD by ED providers can be used to safely defer eGFR testing and improve operational performance for patients requiring CECT.

A case report on the atypical presentation of Renal tuberculosis as emphysematous pyelonephritis

INTRODUCTION AND IMPORTANCE

Emphysematous pyelonephritis (EPN) is a severe acute necrotizing infection, that causes gas to build up in the collecting system, renal parenchyma, and perirenal tissues (Mahmood et al., 2020). Uncontrolled diabetes mellitus and urinary tract obstruction are the two main risk factors. We report the second case report of tuberculosis as a causative pathogen of EPN.

CASE PRESENTATION

In this case report, a 60-year-old lady with poorly controlled type 2 diabetes was admitted to the emergency room due to left flank pain, a low-grade temperature, nausea, and vomiting. Emphysematous Pyelonephritis was diagnosed based on gas seen in the renal parenchyma on a CECT scan (EPN). She underwent conservative management, including the insertion of a nephrostomy tube and antibiotics. There is no growth detected in the nephrostomy drain's culture. She underwent a simple nephrectomy after deciding that she had not improved clinically after receiving conservative treatment. A biopsy of the specimen revealed a tuberculosis abscess. She received the proper care and made clinical progress over the course of a six-month anti-TB medication regimen.

CLINICAL DISCUSSION

The majority of EPN patients are female (2:1) and diabetic (90 %) with a mean age of presentation of 55 years (El Rahman et al., 2011). The preferred method of diagnosis for EPN is CT (El Rahman et al., 2011). E. coli, Klebsiella, and Pseudomonas were the most prevalent species in many of the reported cases (Khaira et al., 2009). In contrast to prior investigations, we discovered a case of EPN caused by tuberculosis invasion.

CONCLUSION

An essential lesson to learn from such cases is the importance of considering genitourinary tuberculosis when emphysematous pyelonephritis does not improve with conservative treatment, especially in areas with a high tuberculosis endemicity.

Selective Non-operative Management of Patients with Abdominal Trauma-Is CECT Scan Mandatory?

CECT scan is considered essential for selective non-operative management (SNOM) of patients with abdominal trauma. However, CECT has its own hazards and limitations. We evaluated the safety and efficacy of selective non-operative management of patients with abdominal trauma without the mandatory use of CECT scan in a prospective study. Patients with peritonitis and ongoing intra-abdominal bleed were excluded. Consenting FAST positive, hemodynamically stable patients with blunt and penetrating abdominal trauma between 18 and 60 years of age were included and admitted for SNOM and detailed ultrasonography of the abdomen (in all) with or without CECT abdomen (selectively). Eighty-four patients with abdominal trauma were admitted during the study period. Twenty-two patients did not satisfy the inclusion criteria and 18 required immediate laparotomy based on primary survey. Remaining 44 patients were admitted for SNOM: mean ± SD age of these patients was 27 ± 8.7 years; 40 (89 %) were males. Thirty-five patients (79.54 %) sustained blunt trauma (RTI = 16, Fall = 16, others = 3) while nine patients (20.45 %) sustained penetrating trauma. SNOM without CECT was successful in 36 (81.82 %) patients. Five (11.36 %) patients underwent delayed emergency laparotomy based on clinical and detailed USG evaluation. CECT was not done in these patients. Three patients underwent CECT for various reasons; however, they were managed with SNOM. Thus, SNOM without abdominal CECT was successful in 36 (81.82 %) patients. SNOM failed in five patients but abdominal USG was sufficient. SNOM can be practised safely in patients of abdominal trauma with limited use of CECT scan.

Accuracy of Focused Assessment with Sonography for Trauma (FAST) in Blunt Trauma Abdomen-A Prospective Study

Focused assessment with sonography for trauma (FAST) is a limited ultrasound examination, primarily aimed at the identification of the presence of free intraperitoneal or pericardial fluid. In the context of blunt trauma abdomen (BTA), free fluid is usually due to hemorrhage, bowel contents, or both; contributes towards the timely diagnosis of potentially life-threatening hemorrhage; and is a decision-making tool to help determine the need for further evaluation or operative intervention. Fifty patients with blunt trauma abdomen were evaluated prospectively with FAST. The findings of FAST were compared with contrast-enhanced computed tomography (CECT), laparotomy, and autopsy. Any free fluid in the abdomen was presumed to be hemoperitoneum. Sonographic findings of intra-abdominal free fluid were confirmed by CECT, laparotomy, or autopsy wherever indicated. In comparing with CECT scan, FAST had a sensitivity, specificity, and accuracy of 77.27, 100, and 79.16 %, respectively, in the detection of free fluid. When compared with surgical findings, it had a sensitivity, specificity, and accuracy of 94.44, 50, and 90 %, respectively. The sensitivity of FAST was 75 % in determining free fluid in patients who died when compared with autopsy findings. Overall sensitivity, specificity, and accuracy of FAST were 80.43, 75 and 80 %, respectively, for the detection of free fluid in the abdomen. From this study, we can safely conclude that FAST is a rapid, reliable, and feasible investigation in patients with BTA, and it can be performed easily, safely, and quickly in the emergency room with a reasonable sensitivity, specificity, and accuracy. It helps in the initial triage of patients for assessing the need for urgent surgery.