Episode 17- The Emergency Medical Minute meets ER-Rx


 

Episode Summary:

In case you missed it, last week Dr. Nick Tsipis from the Emergency Medical Minute discussed a few rapid-fire ER topics with our host, Adis Keric. Check out the full episode here or on the Emergency Medical Minute podcast! 

*Correction to figures quoted on anticoagulation reversal pricing. High-dose Andexxa regimen maxes out around $60,000 and Kcentra maxes out at $6,000. So there is still a massive price difference, but not as high as quoted in the audio.

Show Notes:

Key Points:

The Emergency Medical Minute meets ER-Rx:
– The concept of “healthcare-associated” pneumonia (HCAP) is gone. Patients from nursing homes or long-term care facilities are not necessarily at higher risk of multi-drug resistant (MDR) pneumonias
– In the setting of community-acquired pneumonia (CAP), only patients who have prior respiratory isolation of MRSA or pseudomonas, or patients who have severe pneumonias along with recent hospitalization (within the past 90 days) AND received IV antibiotics during that stay will need MRSA and pseudomonal coverage. The rest can receive typical CAP antibiotics
– The Pain, Agitation, and Delirium (PAD) guidelines highly recommend “A-1” or “analgesia-first” sedation in mechanically-ventilated patients. This is ideally initiated as PRN bolus dosing with continuous infusions only started if PRN dosing fails. The guidelines also discuss the use of dexmedetomidine (Precedex) and propofol, and highly discourage the routine use of benzodiazepine agents for sedation due to worse patient outcomes
– Most centers continue to use KCentra over Andexxa for the reversal of bleeding due to direct oral anticoagulants (DOACS) such as apixaban and rivaroxaban. This is due to the significantly higher cost of Andexxa and KCentra’s proven efficacy in this scenario
– Remember the indications and contraindications of KCentra. In some scenarios (bleeding in the setting of elevated INR due to liver disease) there is controversy regarding the use of KCentra, and in most of these cases KCentra may not be indicated
ER-Rx Episode 17

References:

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. J Respir Crit Care Med. 2019; 200 (7): e45-67

Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 ;41(1): 263-306

Connolly SJ, Milling Jr., Eikelboom JW, et al. Andexanet alfa for acute major bleeding associated with Factor Xa inhibitors. N Engl J Med. 2016; 375:1131-41


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