Aims
Benzodiazepines have been used as safe anxiolytic drugs for decades and some authors have suggested they could be an alternative for morphine for treating acute cardiogenic pulmonary oedema ...(ACPE). We compared the efficacy and safety of midazolam and morphine in patients with ACPE.
Methods and results
A randomized, multicentre, open‐label, blinded endpoint clinical trial was performed in seven Spanish emergency departments (EDs). Patients >18 years old clinically diagnosed with ACPE and with dyspnoea and anxiety were randomized (1:1) at ED arrival to receive either intravenous midazolam or morphine. Efficacy was assessed by in‐hospital all‐cause mortality (primary endpoint). Safety was assessed through serious adverse event (SAE) reporting, and the composite endpoint included 30‐day mortality and SAE. Analyses were made on an intention‐to‐treat basis. The trial was stopped early after a planned interim analysis by the safety monitoring committee. At that time, 111 patients had been randomized: 55 to midazolam and 56 to morphine. There were no significant differences in the primary endpoint (in‐hospital mortality for midazolam vs. morphine 12.7% vs. 17.9%; risk ratioRR 0.71, 95% confidence interval CI 0.29–1.74; p = 0.60). SAE were less common with midazolam versus morphine (18.2% vs. 42.9%; RR 0.42, 95% CI 0.22–0.80; p = 0.007), as were the composite endpoint (23.6% vs. 44.6%; RR 0.53, 95% CI 0.30–0.92; p = 0.03).
Conclusion
Although the number of patients was too small to draw final conclusions and there were no significant differences in mortality between midazolam and morphine, a significantly higher rate of SAEs was found in the morphine group.
There were no significant differences in mortality between morphine and midazolam but the rate of serious adverse events was significantly higher in the morphine group, although the number of patients was too small to draw final conclusions.
The performance of blood biomarkers (mid-regional proadrenomedullin (MR-proADM), procalcitonin (PCT), C-reactive protein (CRP), and lactate) and clinical scores (Sequential Organ Failure Assessment ...(SOFA), National Early Warning Score (NEWS), and quick SOFA) was compared to identify patient populations at risk of delayed treatment initiation and disease progression after presenting to the emergency department (ED) with a suspected infection.
A prospective observational study across three EDs. Biomarker and clinical score values were calculated upon presentation and 72 h, and logistic and Cox regression used to assess the strength of association. Primary outcomes comprised of 28-day mortality prediction and delayed antibiotic administration or intensive care (ICU) admission, whilst secondary outcomes identified subsequent disease progression.
Six hundred eighty-four patients were enrolled with hospitalisation, ICU admission, and infection-related 28-day mortality rates of 72.8%, 3.4%, and 4.4%, respectively. MR-proADM and NEWS had the strongest association with hospitalisation and the requirement for antibiotic administration, whereas MR-proADM alone had the strongest association with ICU admission (OR 95% CI: 5.8 3.1 - 10.8) and mortality (HR 95% CI: 3.8 2.2 - 6.5). Patient subgroups with high MR-proADM concentrations (≥ 1.77 nmol/L) and low NEWS (< 5 points) values had significantly higher rates of ICU admission (8.1% vs 1.6%; p < 0.001), hospital readmission (18.9% vs. 5.9%; p < 0.001), infection-related mortality (13.5% vs. 0.2%; p < 0.001), and disease progression (29.7% vs. 4.9%; p < 0.001) than corresponding patients with low MR-proADM concentrations. ICU admission was delayed by 1.5 0.25 - 5.0 days in patients with high MR-proADM and low NEWS values compared to corresponding patients with high NEWS values, despite similar 28-day mortality rates (13.5% vs. 16.5%). Antibiotics were withheld in 17.4% of patients with high MR-proADM and low NEWS values, with higher subsequent rates of ICU admission (27.3% vs. 4.8%) and infection-related hospital readmission (54.5% vs. 14.3%) compared to those administered antibiotics during ED treatment.
Patients with low severity signs of infection but high MR-proADM concentrations had an increased likelihood of subsequent disease progression, delayed antibiotic administration or ICU admission. Appropriate triage decisions and the rapid use of antibiotics in patients with high MR-proADM concentrations may constitute initial steps in escalating or intensifying early treatment strategies.
Various oxygenization methods are used in the treatment of respiratory failure in acute heart failure. Occasionally, after patients are stabilized by these ventilation methods, some maintain a degree ...of dyspnea or hypoxemia which does not improve and is unrelated to deterioration in the functional class or the need to optimize pharmacological treatment. High-flow oxygen systems administered via nasal cannula that are connected to heated humidifiers (HFT) are a good alternative for oxygenation, given that they are easy to use and have few complications. We studied a series of 5 patients with acute heart failure due to acute pulmonary edema with stable dyspnea or hypoxemia following noninvasive ventilation. All the patients were successfully treated with HFT, showing clinical and gasometric improvement and no complications or technical failures. We report our experience and discuss different aspects related to this oxygenation system.
En el tratamiento de la insuficiencia respiratoria en la insuficiencia cardiaca aguda se utilizan diferentes métodos de oxigenación. En ocasiones los pacientes, tras ser estabilizados con dichos modos ventilatorios, mantienen un grado de disnea o hipoxemia que no mejora y no es atribuible a un empeoramiento del grado funcional o la necesidad de optimizar el tratamiento farmacológico. Los sistemas de alto flujo con interfase nasal con un calentador humidificador acoplado (AFHC) son una buena alternativa como método de oxigenación, de fácil aplicación y escasas complicaciones. Presentamos una serie de 5 pacientes con insuficiencia cardiaca aguda por edema agudo de pulmón con disnea o hipoxemia mantenidas tras la aplicación de ventilación no invasiva. Todos ellos fueron tratados con sistemas de AFHC de forma satisfactoria, con mejoría clínica y gasométrica, sin complicaciones ni fracasos de la técnica. Describimos nuestra experiencia y discutimos diversos aspectos relacionados con dicho sistema de oxigenación.
Resumen En el tratamiento de la insuficiencia respiratoria en la insuficiencia cardiaca aguda se utilizan diferentes métodos de oxigenación. En ocasiones los pacientes, tras ser estabilizados con ...dichos modos ventilatorios, mantienen un grado de disnea o hipoxemia que no mejora y no es atribuible a un empeoramiento del grado funcional o la necesidad de optimizar el tratamiento farmacológico. Los sistemas de alto flujo con interfase nasal con un calentador humidificador acoplado (AFHC) son una buena alternativa como método de oxigenación, de fácil aplicación y escasas complicaciones. Presentamos una serie de 5 pacientes con insuficiencia cardiaca aguda por edema agudo de pulmón con disnea o hipoxemia mantenidas tras la aplicación de ventilación no invasiva. Todos ellos fueron tratados con sistemas de AFHC de forma satisfactoria, con mejoría clínica y gasométrica, sin complicaciones ni fracasos de la técnica. Describimos nuestra experiencia y discutimos diversos aspectos relacionados con dicho sistema de oxigenación.
Various oxygenization methods are used in the treatment of respiratory failure in acute heart failure. Occasionally, after patients are stabilized by these ventilation methods, some maintain a degree ...of dyspnea or hypoxemia which does not improve and is unrelated to deterioration in the functional class or the need to optimize pharmacological treatment. High-flow oxygen systems administered via nasal cannula that are connected to heated humidifiers (HFT) are a good alternative for oxygenation, given that they are easy to use and have few complications. We studied a series of 5 patients with acute heart failure due to acute pulmonary edema with stable dyspnea or hypoxemia following noninvasive ventilation. All the patients were successfully treated with HFT, showing clinical and gasometric improvement and no complications or technical failures. We report our experience and discuss different aspects related to this oxygenation system.
The MIMO clinical trial showed that patients with acute cardiogenic pulmonary edema (ACPE) treated with midazolam had fewer serious adverse events than those treated with morphine. Atrial ...fibrillation (AF) is a common comorbidity in heart failure and affects patient's outcome.
The primary endpoint of this substudy is to know if AF modified the reduced risk of serious adverse events in the midazolam arm compared to morphine. The first secondary endpoint is to know if AF modified the reduced risk of serious adverse events or death at 30 days in the midazolam arm. The second secondary objective of this substudy is to analyze whether AF modified the reduced risk of midazolam against morphine on the total number of serious adverse events per patient.
We conducted a secondary analysis of the MIMO trial. Patients more than 18 years old clinically diagnosed with ACPE and with dyspnea and anxiety were randomized (1:1) at emergency department arrival to receive either intravenous midazolam or morphine.
In this post hoc analysis, we calculated the relative risk (RR) of serious adverse events in patients with and without AF. Calculating the Cochran-Mantel-Haenszel interaction test, we evaluated if AF modified the reduced risk of serious adverse events in the midazolam arm compared to morphine.
One hundred eleven patients (median = 78.9 years; IQR, 72.3-83.7; women, 52.2%) were randomized in the MIMO trial, 55 to receive midazolam and 56 to morphine. All randomized patients received the assigned drug and there were no losses to follow-up. Forty-four patients (39.6%) had AF. In the AF group, the RR for the incidence of serious adverse events in the midazolam versus morphine arm was 0.42 (95% CI, 0.14-1.3). In the group without AF, the RR was 0.46 (95% CI, 0.21-1). The presence of AF did not modify the reduced risk of serious adverse events in the midazolam arm compared with morphine ( P for interaction = 0.88).
This post hoc analysis of the MIMO trial suggests that the reduced risk of serious adverse events in the midazolam group compared to morphine is similar in patients with and without AF.
Varón de 28 años, que acude al servicio de urgencias de un hospital terciario tras haber
presentado cuadros breves repetidos de déficit neurológico focal recuperados
completamente, además de varios ...episodios de visión doble de una hora de duración.
El paciente no presenta antecedentes médicos o familiares relevantes. Refiere haber
presentado dolor cervical y occipital derecho desde hace dos semanas después de
dormir en un coche al acudir a un Gran Premio de Fórmula Uno. En las últimas semanas
ha presentado además múltiples accesos de tos. La exploración clínica del paciente
fue normal. El electrocardiograma, la radiografía de tórax y una tomografía computarizada
craneal realizadas no demostraron anomalías. Se realizó una exploración de
resonancia magnética en la que se observó una disección en la porción distal (V3) de
la arteria vertebral derecha. Se describe la utilidad de la realización de la resonancia
magnética en los servicios de urgencias en patología neurológica.
Objetivos: El objetivo es evaluar el perfil clínico y la evolución de los pacientes con edema agudo de pulmón (EAP) tratados con ventilación no invasiva (VNI) en un servicio de urgencias ...hospitalario (SUMH) y los factores asociados con el fracaso de la técnica y la mortalidad .
Método: Estudio observacional y prospectivo que incluyó a todos los pacientes atendidos en el SUMH por con EAP que precisaron VNI. Se analizaron los parámetros clínicos y gasométricos al ingreso y a los 60 minutos, el modo ventilatorio, destino, complicaciones, necesidad de intubación orotraqueal, y tiempo de permanencia en urgencias. Se calcularon el índice de comorbilidad de Charlson y el índice de Barthel (lB). Se evaluó la mortalidad en el SUH, durante el ingreso hospitalario y a los 7 y 21 días tras el alta. Resultados: Se estudió a 133 pacientes, 69 varones (51 %), la edad media fue de 76,2 ± 10,9 años. En el 60% se utilizó la presión positiva constante en la vía aérea (CPAP) como modo ventilatorio. Los parámetros clínicos y gasométricos mejoraron tras una hora de VNI. El tiempo de tratamiento de VNI fue 4,25 ± 2,54 horas. La sequedad de mucosas y el eritema facial fueron las complicaciones más frecuentes (69 y 50% respectivamente). La técnica fracasó en el 9,8% y la mortalidad en urgencias fue del 3%. No se identificaron factores de riesgo asociados a una mayor mortalidad. La modalidad ventilatoria no influyó en la mejoría c1ínico-gasométrica, mortalidad ni en el fracaso de la técnica. El 33,8% (45) de los pacientes ingresó en la unidad de corta estancia (UCE), 26,3% (35) en cardiología, 18,8% (25) en medicina interna y el 5,2% (7) de cuidados intensivos.
Conclusión: El uso precoz de la VNI en el EAP mejora de forma rápida los parámetros clínicos y gasométricos del paciente, con escasas complicaciones, y estancia en urgencia corta, sin influir el modo ventilatorio en la mortalidad y el fracaso de la técnica. Debería valorarse su incorporación en todos los SUH. Emergencias 2010;22:187-192
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