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Cafferkey J, Ferguson A, Grahamslaw J, Oatey K, Norrie J, Lone N, Walsh T, Horner D, Appelboam A, Hall P, Skipworth R, Bell D, Rooney K, Shankar-Hari M, Corfield A, Gray A. Albumin versus balanced crystalloid for resuscitation in the treatment of sepsis: A protocol for a randomised controlled feasibility study, "ABC-Sepsis". J Intensive Care Soc 2023; 24:78-84. [PMID: 36860553 PMCID: PMC9157259 DOI: 10.1177/17511437221103692] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Patients presenting with suspected sepsis to secondary care often require fluid resuscitation to correct hypovolaemia and/or septic shock. Existing evidence signals, but does not demonstrate, a benefit for regimes including albumin over balanced crystalloid alone. However, interventions may be started too late, missing a critical resuscitation window. Methods ABC Sepsis is a currently recruiting randomised controlled feasibility trial comparing 5% human albumin solution (HAS) with balanced crystalloid for fluid resuscitation in patients with suspected sepsis. This multicentre trial is recruiting adult patients within 12 hours of presentation to secondary care with suspected community acquired sepsis, with a National Early Warning Score ≥5, who require intravenous fluid resuscitation. Participants are randomised to 5% HAS or balanced crystalloid as the sole resuscitation fluid for the first 6 hours. Objectives Primary objectives are feasibility of recruitment to the study and 30-day mortality between groups. Secondary objectives include in-hospital and 90-day mortality, adherence to trial protocol, quality of life measurement and secondary care costs. Discussion This trial aims to determine the feasibility of conducting a trial to address the current uncertainty around optimal fluid resuscitation of patients with suspected sepsis. Understanding the feasibility of delivering a definitive study will be dependent on how the study team are able to negotiate clinician choice, Emergency Department pressures and participant acceptability, as well as whether any clinical signal of benefit is detected.
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Affiliation(s)
- John Cafferkey
- Emergency Medicine Research Group
Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK
| | - Andrew Ferguson
- Emergency Medicine Research Group
Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK
| | - Julia Grahamslaw
- Emergency Medicine Research Group
Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit,
Usher Institute, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Department of Critical Care, Royal
Infirmary of Edinburgh, Usher Institute, University of
Edinburgh, Edinburgh, UK
| | - Nazir Lone
- Department of Critical Care, Royal
Infirmary of Edinburgh, Usher Institute, University of
Edinburgh, Edinburgh, UK
| | - Timothy Walsh
- Department of Critical Care, Royal
Infirmary of Edinburgh, Usher Institute, University of
Edinburgh, Edinburgh, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation
Trust, Salford, UK,Division of Infection, Immunity and
Respiratory Medicine, University of
Manchester, Manchester, UK
| | - Andy Appelboam
- Academic Department of Emergency
Medicine Exeter (ACADEMEx), Royal Devon and Exeter Hospital NHS
Foundation Trust, Exeter Devon
| | - Peter Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | | | - Derek Bell
- Department of Acute Medicine, Chelsea and Westminster
Campus, Imperial College London, London
| | | | - Manu Shankar-Hari
- The Queen’s Medical Research
Institute, Edinburgh BioQuarter, Centre for
Inflammation Research, University of Edinburgh, UK
| | - Alasdair Corfield
- Emergency Department, Royal Alexandra
Hospital, NHS Greater Glasgow and Clyde, UK
| | - Alasdair Gray
- Emergency Medicine Research Group
Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK,Acute Care Edinburgh, Centre for
Population and Health Sciences, Usher Institute, University of
Edinburgh, Edinburgh UK,Professor Alasdair Gray, Emergency Medicine
Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal
Infirmary of Edinburgh, Edinburgh EH16 4SA, UK.
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Green J, Ewings P, Appelboam A. PP23 Evaluation of pre-hospital use of a valsalva assist device (VAD) in the Emergency treatment of supraventricular tachycardia (SVT). A randomised controlled feasibility trial [EVADE]. Arch Emerg Med 2019. [DOI: 10.1136/emermed-2019-999abs.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundSupraventricular tachycardia (SVT) is a common heart rhythm disorder. The Valsalva Manoeuvre (VM) is a safe, internationally recommended, initial treatment, but has a low success rate in normal practice. Recent studies have shown much better cardioversion rates, approaching 50%, can be achieved using a postural modification (the modified VM) and a manometer controlled 40 mmHg strain. Successful cardioversion could avoid hospital conveyance and unpleasant treatments, such as adenosine. Routine use of a manometer is not practical out of hospital. Blowing on an empty syringe has been suggested as an alternative but is unreliable in providing correct and consistent pressures. A Valsalva Assist Device (VAD), designed to provide a 40 mmHg strain resistance has been developed. It is small, portable, can be packaged with instructions for the modified VM and if successful, may be left with the patient.MethodsWe conducted a pragmatic, randomised controlled feasibility trial, comparing VAD versus standard practice delivered VMs. All other aspects of care were according to SWASFT guidelines. Participants were followed up to ask their views on trial procedures.Interim results (month 5 of 6)23 volunteer Station Leads recruited 22 Study Clinicians from 27 ambulance stations. 29 patients were enrolled over 5 months, 19 in the last 2 months (the first 3 months included steady recruitment and setup). The later enrolment rate extrapolates to a presentation rate of approximately 220 eligible patients to SWASFT each year. Complete data sets were available in 100% of participants. When followed up, participants reported verbal consent to be widely acceptable, although SVT symptoms were substantially distracting for many during this process.ConclusionOur experience of recruitment and data collection suggest a definitive trial, using similar methodology, is possible, but the low occurrence rate may challenge feasibility. Consent taking methods may require refinement for a larger trial.
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FitzGerald I, Ewings P, Lang I, Appelboam A. Testing of a novel Valsalva Assist Device with supine and modified positions in healthy volunteers. Emerg Med J 2018; 36:27-31. [PMID: 30504456 DOI: 10.1136/emermed-2018-208004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/07/2018] [Accepted: 11/11/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND The Valsalva manoeuvre (VM) is used to treat supraventricular tachycardia (SVT) by inducing a vagal response (drop in HR). There is debate as to the best position in which to carry out the VM and how the strain should be delivered in practice. We aimed to compare vagal responses induced with supine and modified VMs using strains delivered with a standardised manometer or novel Valsalva Assist Device (VAD), a simple device to provide resistance to exhalation. METHODS We conducted a repeated measures randomised trial of four VMs (two supine VM and two modified VMs), in healthy adult volunteers, with strains delivered using an adapted sphygmomanometer (manometer) or a VAD. Changes in HR, pressure and duration of strain and adverse events were monitored and compared between the techniques and devices. The trial was approved by the University of Exeter Medical School Research ethics committee. RESULTS 75 healthy participants aged 19-55 years were recruited over a 4-month period. A mixed-effects linear regression showed the modified VM resulted in a 3.8 beats per min (bpm) greater drop in HR compared with the supine VM (p=0.002, 95% CI 2.2 to 5.4). VM strains produced by the VAD were of a similar pressure but of slightly shorter duration and resulted in a 1.9 bpm smaller drop in HR compared with the manometer (p=0.01, 95% CI 0.4 to 3.4). There were no differences in adverse events. CONCLUSIONS Modified VM was associated with a greater drop in HR than a supine VM with no increase in adverse events in healthy volunteers. The VAD can be used to safely generate the recommended VM strain pressure, but produced a smaller drop in HR compared with a manometer and requires modification to enable the recommended strain duration to be achieved consistently. TRIAL REGISTRATION NUMBER NCT03298880.
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Affiliation(s)
| | - Paul Ewings
- University of Exeter Medical School, Exeter, UK
| | - Iain Lang
- University of Exeter Medical School, Exeter, UK
| | - Andy Appelboam
- Academic Department of Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Homfray G, Palmer A, Grimsmo-Powney H, Appelboam A, Lloyd G. Procedural sedation of elderly patients by emergency physicians: a safety analysis of 740 patients. Br J Anaesth 2018; 121:1236-1241. [PMID: 30442250 DOI: 10.1016/j.bja.2018.07.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/18/2018] [Accepted: 07/26/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The elderly are perceived as a high-risk group for procedural sedation. Concern exists regarding the safety of sedation of this patient group by emergency physicians, particularly when using propofol. METHODS We analysed prospectively collected data on patients aged 75 yr or older undergoing sedation between October 2006 and March 2017 in the emergency department of a single centre. We used the World Society of Intravenous Anaesthesia International Sedation Task Force adverse event tool, stratifying identified adverse events according to consensus agreement. RESULTS Of 740 consecutive patients (median age 84 yr), 571 patients received propofol, 142 morphine and midazolam, and 27 other agents. We identified 19 sentinel events: 2 cases of hypoxia, 10 of apnoea (without hypoxaemia), 5 of hypotension, and 2 of both hypoxaemia and hypotension. We also identified 30 moderate, 41 minor, and 7 minimal risk adverse events. There were no adverse outcomes. CONCLUSIONS We observed safe sedation practice in this high-risk group of patients in this department. A sentinel adverse event rate of 2.6% including a hypoxaemia rate of 0.5%, with no adverse outcomes sets a benchmark for elderly sedation. We recommend quality pre-oxygenation, an initial propofol bolus of no more than 0.5 mg kg-1, and a robust training and governance framework.
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Affiliation(s)
- G Homfray
- Academic Department of Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - A Palmer
- Academic Department of Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - H Grimsmo-Powney
- Academic Department of Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - A Appelboam
- Academic Department of Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - G Lloyd
- Academic Department of Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
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Newstead B, Bradburn S, Appelboam A, Reuben A, Harris A, Hudson A, Jones L, McLauchlan C, Riou P, Jadav M, Lloyd G. Propofol for adult procedural sedation in a UK emergency department: safety profile in 1008 cases. Br J Anaesth 2013; 111:651-5. [DOI: 10.1093/bja/aet168] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Rawlingson A, Blackburn J, Tilley R, Appelboam R, Appelboam A. Implementing the Sepsis Resuscitation Bundle: Education Improves Antimicrobial Administration in the Emergency Department. J Infect 2011. [DOI: 10.1016/j.jinf.2011.04.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Appelboam A, Reuben AD, Benger JR, Beech F, Dutson J, Haig S, Higginson I, Klein JA, Roux SL, Saranga SSM, Taylor R, Vickery J, Powell RJ, Lloyd G. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. BMJ 2008; 337:a2428. [PMID: 19066257 PMCID: PMC2600962 DOI: 10.1136/bmj.a2428] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury. DESIGN Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care. SETTING Five emergency departments in southwest England. PARTICIPANTS 2127 adults and children presenting to the emergency department with acute elbow injury. INTERVENTION Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children. MAIN OUTCOME MEASURES Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days. RESULTS Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children. CONCLUSION The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.
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Affiliation(s)
- A Appelboam
- Emergency Department, Royal Devon and Exeter Foundation NHS Trust, Exeter EX2 5DW
| | - A D Reuben
- Emergency Department, Royal Devon and Exeter Foundation NHS Trust, Exeter EX2 5DW
| | - J R Benger
- Emergency Department, United Bristol Healthcare NHS Trust, Bristol BS2 8HW
| | - F Beech
- Emergency Department, Bath Royal United Hospital NHS Trust, Bath BA1 3NG
| | - J Dutson
- Emergency Department, Bristol Royal Infirmary, United Bristol Healthcare NHS Trust, Bristol BS1
| | - S Haig
- Emergency Department, Bath Royal United Hospital NHS Trust, Bath BA1 3NG
| | - I Higginson
- Emergency Department, United Bristol Healthcare NHS Trust, Bristol BS2 8HW
| | - J A Klein
- Emergency Department, Musgrove Park Hospital, Taunton and Somerset NHS Trust, Taunton TA1 5DA
| | - S Le Roux
- Emergency Department, Bristol Children’s Hospital, United Bristol Healthcare NHS Trust, Bristol BS3 8BJ
| | - S S M Saranga
- Emergency Department, Bristol Children’s Hospital, United Bristol Healthcare NHS Trust, Bristol BS3 8BJ
| | - R Taylor
- Emergency Department, Royal Devon and Exeter Foundation NHS Trust, Exeter EX2 5DW
| | - J Vickery
- Emergency Department, Royal Devon and Exeter Foundation NHS Trust, Exeter EX2 5DW
| | - R J Powell
- Research and Development Support Unit, Royal Devon and Exeter Foundation NHS Trust, Exeter EX2 5DW
| | - G Lloyd
- Emergency Department, Royal Devon and Exeter Foundation NHS Trust, Exeter EX2 5DW
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Appelboam A, McLauchlan CAJ, Murdoch J, MacIntyre PA. Delivery of local anaesthetic via a sternal catheter to reduce the pain caused by sternal fractures: first case series using the new technique. Emerg Med J 2007; 23:791-3. [PMID: 16988309 PMCID: PMC2653979 DOI: 10.1136/emj.2005.032169] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Sternal fractures cause considerable pain, and a proportion of patients require admission for analgesia. Local anaesthetic techniques have been used to reduce the pain from chest wall injuries and may reduce complications from these injuries. The use of a local anaesthetic delivered via a sternal catheter over a fractured sternum has been described in a patient whose pain was inadequately controlled with opiates. This technique was recently offered to patients in the emergency department at the Royal Devon and Exeter Hospital, Exeter, UK, and the experiences of patients and doctors are reported. Findings from this first case series suggest that the technique seems to be effective, well tolerated and acceptable to patients.
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Affiliation(s)
- A Appelboam
- Department of Emergency Medicine, Royal Devon and Exeter Hospital, Exeter, Devon EX2 5DW, UK.
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Moore AR, Appelboam A, Kawabata K, Da Silva JA, D'Cruz D, Gowland G, Willoughby DA. Destruction of articular cartilage by alpha 2 macroglobulin elastase complexes: role in rheumatoid arthritis. Ann Rheum Dis 1999; 58:109-13. [PMID: 10343526 PMCID: PMC1752824 DOI: 10.1136/ard.58.2.109] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Neutrophil elastase accounts for the ability of some fresh rheumatoid synovial fluids to degrade cartilage matrix in vitro. The aim of this study was to determine if enzyme activity could result from depletion of synovial fluid inhibitors or protection of the enzyme from inhibition. METHODS The ability of synovial fluids to inhibit porcine pancreatic elastase was investigated together with chemical pretreatments capable of inactivating alpha 1 protease inhibitor (alpha 1PI) or preventing formation of alpha 2 macroglobulin (alpha 2M) elastase complexes. Subsequently, complexes of human neutrophil elastase with alpha 2M were prepared and applied to frozen sections of cartilage. Proteoglycan loss was quantified by alcian blue staining and scanning and integrating microdensitometry. Parallel studies were carried out using a low molecular weight chromogenic elastase substrate. The effects of alpha 1PI and SF on these systems were investigated. Finally, synovial fluids were subjected to gel filtration and the fractions assayed for elastase activity. High molecular weight fractions were pooled, concentrated, and tested for their ability to degrade cartilage sections. RESULTS All synovial fluids reduced the activity of porcine pancreatic elastase, the inhibition mainly being attributable to alpha 1PI, whereas remaining activity resulted from complexes of elastase with alpha 2M. Complexes of human neutrophil elastase with alpha 2M were shown to cause proteoglycan degradation in frozen sections of human articular cartilage. Alpha 1PI prevented alpha 2M elastase complexes from degrading cartilage but not the chromogenic substrate. The data suggested that alpha 1PI does not inhibit elastase bound to alpha 2M but sterically hinders the complex. However, only one of five synovial fluids was able to completely block the actions of alpha 2M elastase complexes against cartilage. Gel filtration of rheumatoid synovial fluids showed elastase and cartilage degrading activity to be associated with fractions that contained alpha 2M, and not with fractions expected to contain free enzyme. CONCLUSIONS The data suggest that synovial fluid alpha 2M elastase complexes can degrade cartilage matrix in rheumatoid arthritis.
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Affiliation(s)
- A R Moore
- Department of Experimental Pathology, St Bartholomew's, London
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