Risk of Acute Kidney Injury After Intravenous Contrast Media Administration
By Stefan Meyering, DO
Annals of Emergency Medicine 11/2016
Jeremiah S. Hinson, MD, PhD; Michael R. Ehmann, MD, MPH, MS; Derek M. Fine, MD; Elliot K. Fishman, MD, FACR; Matthew F. Toerper, BS; Richard E. Rothman, MD, PhD; Eili Y. Klein, MS, PhD
Contrast administration was not associated with increased incidence of acute kidney injury (contrast-induced nephropathy criteria odds ratio 0.96, 95% confidence interval 0.85 to 1.08; and Acute Kidney Injury Network/Kidney Disease Improving Global Outcomes criteria odds ratio 1.00, 95% confidence interval 0.87 to 1.16). The baseline sCr and GFR in the contrast-exposed group was lower and showed better renal function than the non-contrast group contributing to bias. Administration of intravenous crystalloids was associated with a lower probability of developing acute kidney injury although the study’s main outcome displayed the frequency of later acute kidney injury in 7,201 patients undergoing contrast-enhanced CT, 5,499 undergoing unenhanced CT, and 5,234 with no imaging did not differ (10.2% to 10.9%)
This study suggests fear of triggering acute kidney injury after intravenous contrast during ED CT is disproportionate to objective data
Using POCUS for Diagnosing Pneumonia
By Dr. Brandon Roe
Brief Patient Presentation
10 y/o M presenting with fever, productive cough, difficulty breathing for 5 days. On lung auscultation ronchi in the left base is noted.
Clinical Question – PICO
In patients presenting to the Emergency Department with signs or symptoms typical of pneumonia, can POCUS be used with a diagnostic accuracy that is non inferior to that of a chest x-ray for diagnosing pneumonia.
Samson, F., Gorostiza, I., González, A., Landa, M., Ruiz, L., & Grau, M. (2016). Prospective evaluation of clinical lung ultrasonography in the diagnosis of community-acquired pneumonia in a pediatric emergency department. European Journal of Emergency Medicine, 1. doi:10.1097/mej.0000000000000418 Level 2 evidence
Ye, X., Xiao, H., Chen, B., & Zhang, S. (2015). Accuracy of Lung Ultrasonography versus Chest Radiography for the Diagnosis of Adult Community-Acquired Pneumonia: Review of the Literature and Meta-Analysis. PLOS ONE PLoS ONE, 10(6). doi:10.1371/journal.pone.0130066 Level 3 evidence
Bourcier, J., Paquet, J., Seinger, M., Gallard, E., Redonnet, J., Cheddadi, F., . . . Geeraerts, T. (2014). Performance comparison of lung ultrasound and chest x-ray for the diagnosis of pneumonia in the ED. The American Journal of Emergency Medicine, 32(2), 115-118. doi:10.1016/j.ajem.2013.10.003 Level 3 evidence
Parlamento, S., Copetti, R., & Bartolomeo, S. D. (2009). Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED. The American Journal of Emergency Medicine, 27(4), 379-384. doi:10.1016/j.ajem.2008.03.009 Level 3 evidence
Does the literature answer the clinical question?
No, the data is not robust enough to answer the question of whether ultrasound is non inferior to CXR. Based on these studies, US is more sensitive than CXR however based on severe limitations of the studies it is difficult to justify replacing CXR with POCUS when evaluating for pneumonia. I believe that POCUS has a role in this workup however better quality studies need to be done to definitively say that POCUS is not inferior to CXR for the workup of pneumonia.
Does research reveal a POEM?
Based on this data, I do not believe that a POEM was found. Better quality studies need to be done before saying that ultrasound can be utilized in place of CXR to evaluate patients with signs/symptoms concerning for pneumonia.
I will continue to use lung ultrasound as a diagnostic tool but will not solely rely on it. If presented with a patient with signs/symptoms concerning for pneumonia I will either treat based on clinical suspicion or obtain a CXR if I am not certain. I will incorporate US into both the treatment and CXR group as an extra diagnostic tool.