Article

In reply: Confounding biases in the association between fentanyl use and hypotension after rapid sequence intubation

1694 Correspondence / American Journal of Emergency Medicine 36 (2018) 16931715

to categorical data and analyzed using a Fisher’s exact test, which com- putes an exact probability of the chi-square statistic in small samples and does not require adjustments.

The authors fully agree that despite setting out to answer an impor- tant question our study has limitations due to sample size. We are hope- ful that additional research will be conducted on the topic to help provide more generalizable clinical recommendations. Atrial fibrillation remains highly prevalent in patients both with and without HFrEF and having a multitude of options will help providers to be more equipped in the acute management.

Conflict of interest

No listed authors have any conflict of interest to the subject matter in this manuscript.

Sources of support

None.

R. Hirschy, PharmD

Loyola University Medical Center, 2160 S 1st Ave, Maywood,

IL 60153, United States Corresponding author at: Critical Care, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, United States.

E-mail address: [email protected].

Kimberly A. Ackerbauer, PharmD

Boston Medical Center, 1 Boston Medical Center Pl, Boston,

MA 02118, United States

Gary D. Peksa, PharmD Joshua M. DeMott, PharmD, MSc

Rush UniversityMedical Center, 1653 W. Congress Pkwy, Chicago,

IL 60612, United States

E. Paul O’Donnell, PharmD

Rush UniversityMedical Center, 1653 W. Congress Pkwy, Chicago, IL

60612, United States Midwestern University, College of Pharmacy, 555 31st St, Downers Grove, IL

60515, United States

Goldenberg IF, Lewis WR, Dias VC, Heywood JT, Pedersen WR. Intravenous diltiazem for the treatment of patients with atrial fibrillation or flutter and moderate to severe con- gestive heart failure. Am J Cardiol 1994;74(9):884-9 doi:0002-9149(94)90580-0 [pii].
  • Khatchi F, Nagaband S, Shuster J, Novak E, Joseph S. Treating rapid atrial fibrillation in acute decompensated heart failure: metoprolol and diltiazem are equally safe, yet metoprolol increases conversion to sinus rhythm. J Card Fail 2014;20(8):S41.
  • Moss AJ, Abrams J, Bigger T, et al. The effect of diltiazem on mortality and reinfarction after myocardial infarction. N Engl J Med 1988;319(7):385-92. https://doi.org/10. 1056/NEJM198808183190701.
  • Confounding biases in the association between fentanyl use and hypotension after rapid sequence intubation

    I read with great interest the article of Takahashi et al. in a recent issue of the journal [1]. The authors conducted a secondary analysis of data of emergency room airway management collected from a multicenter pro- spective study of 14 Japanese emergency departments and concluded that pretreatment with fentanyl in rapid sequence intubation was associ- ated with higher risks of post-intubation hypotension. The authors should be congratulated for performing a well-designed study in an important topic of emergent airway management [2,3]. In addition, the current em- phasis to minimize adverse events after Emergency airway management makes the topic very relevant in emergency medicine [4,5].

    Although the study of Takahashi et al. was well conducted, there are some questions regarding the study that needs to be clarified to further support the authors’ findings. First, it is not clear if the authors adjusted for the time taken to perform laryngoscope. Laryngoscope place- ment time is a very important factor contributing to hemodynamic chang- es during intubation. Second, opioids are often selected as an anesthetic for patients with poor left ventricular function. It would be important to perform a sensitivity analysis to exclude the contributing factor of selec- tion bias in the authors’ results. Lastly, transient hypotension is often com- mon and not considered important; I was curious to know if the authors measured the time that the patients were hypotensive as this is more like- ly a detrimental factor to patients’ health.

    I would welcome some comments to address the aforementioned issues as they were not discussed by the authors. This would help to further substantiate the findings of this important clinical study.

    Financial support

    17 June 2018

    None.

    Mark C. Kendall, M.D.

    https://doi.org/10.1016/j.ajem.2018.06.045

    References

    1. Hirschy R, Ackerbauer KA, Peksa GD, O’Donnell EP, DeMott JM. Metoprolol vs. diltiazem in the acute management of atrial fibrillation in patients with heart failure with reduced ejec- tion fraction. Am J Emerg Med 2018;2017. https://doi.org/10.1016/j.ajem.2018.04.062.
    2. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treat- ment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Devel- oped with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37(27):2129-200. https://doi.org/10.1093/eurheartj/ehw128.
    3. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management

      of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;62(16): e147-239. https://doi.org/10.1016/j.jacc.2013.05.019.

      Vamos M, Erath JW, Hohnloser SH. Digoxin-associated mortality: a systematic review and meta-analysis of the literature. Eur Heart J 2015;36(28):1831-8. https://doi.org/ 10.1093/eurheartj/ehv143.

    4. Lopes RD, Rordorf R, De Ferrari GM, et al. Digoxin and mortality in patients with atrial fibril- lation. J Am Coll Cardiol 2018;71(10):1063-74. https://doi.org/10.1016/j.jacc.2017.12.060.
    5. Wang ZMD, Zhang Rui MD, Chen Man-Tian MD, Wang Qun-Shan MD, Zhang Yi MD, Huang Xiao-Hong MD, Wang Jun MD, Yan Jian-Hua MD, Li Y-GM. Digoxin is associat- ed with increased all-cause mortality in patients with atrial fibrillation regardless of concomitant heart failure: a meta-analysis. J Cardiovasc Pharmacol 2015;66(3): 270-5. https://doi.org/10.1097/FJC.0000000000000274.

      Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, United States Corresponding author at: Department of Anesthesiology, Warren Alpert Medical School Brown University, 593 Eddy Street, Providence, RI

      02903, United States.

      E-mail address: [email protected].

      18 June 2018

      https://doi.org/10.1016/j.ajem.2018.07.017

      References

      Takahashi J, Goto T, Okamoto H, Hagiwara Y, Watase H, Shiga T, et al. Association of fentanyl use in rapid sequence intubation with post-intubation hypotension. Am J Emerg Med Mar 14 2018. https://doi.org/10.1016/j.ajem.2018.03.026 [pii: S0735- 6757(18)30217-1. Epub ahead of print].

    6. Kurahashi N, Komasawa N, Watanabe N, Minami T. Successful tracheal intubation with the McGRATH(TM) MAC during chest compression in a difficult airway patient. J Clin Anesth 2017;39:15-6.
    7. Pourmand A, Robinson C, Dorwart K, O’Connell F. Pre-oxygenation: implications in emergency airway management. Am J Emerg Med 2017;35:1177-83.

      Correspondence / American Journal of Emergency Medicine 36 (2018) 16931715

      Tachibana N, Niiyama Y, Yamakage M. Less postoperative sore throat after nasotracheal

      1695

      Takashi Shiga, MD, MPH

      intubation using a fiberoptic bronchoscope than using a Macintosh laryngoscope: a double-blind, randomized, controlled study. J Clin Anesth 2017;39:113-7.

      Jin JH, Xue FS, Liu YY, Li HX. Determining predictive value of preoperative tests for dif-

      ficult intubation. J Clin Anesth 2017;39:120-1.

      In reply: Confounding biases in the association between fentanyl use and hypotension after rapid sequence intubation

      Response

      We thank the authors’ for pointing out three issues in our study [1] –

      1) the time taken for laryngoscope placement, 2) physiological reserve as a potential confounder, and 3) duration of post-intubation hypotension. First, the time taken for laryngoscope placement was not measured be- cause its measurement by an independent observer is logistically difficult in this multicenter study. Thus, we did not adjust for the time taken for la- ryngoscope placement. While it is unclear if this factor is related to the ex- posure (i.e., the use of fentanyl) and therefore is unlikely to be a confounder of the causal inference, we adjusted for multiple attempts (>=3 attempts) in the multivariable models. This adjustment is likely to have addressed, at least partly, the authors’ concern. Second, the physio- logical reserve, such as left ventricular function, was not measured in the JEAN-2 study. As acknowledged in the Limitations section of the orig- inal article, this might have serve as potential confounder [1]. Nonethe- less, the multivariable models adjusted for age, indication, and sedatives, which should have accounted for some effect of this potential confounder. Lastly, similar to the first point, we did not measure the dura- tion of the adverse event or post-ED outcomes. These important out- comes shall be a focus of our future investigations. Regardless, the literature has demonstrated that transient hypotension is a risk factor of higher in-hospital mortality, longer intensive care length-of-stay [2-4], and more-severe injuries which require immediate operative and endovascular treatment in patients with trauma [5]. Therefore, post- intubation hypotension – even a transient episode – should be recognized as an important risk factor for worse outcomes after intubation in the ED, and should not be ignored.

      Conflict of interest statement

      The authors declare that there is no conflict of interest.

      Jin Takahashi, MD, MPH Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu,

      Chiba 279-0001, Japan

      Corresponding author.

      E-mail address: [email protected].

      Tadahiro Goto, MD, MPH Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street Boston, Suite 920, Boston, MA 02114, USA

      Hiroshi Okamoto, MD, MPH

      Center for Clinical Epidemiology, St. Luke’s International University,

      3-6 Tsukiji, Chuo, Tokyo 104-0045, Japan

      Yusuke Hagiwara, MD, MPH

      Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu,

      Tokyo 183-8561, Japan

      Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu,

      Chiba 279-0001, Japan Department of Emergency Medicine, International University of Health and Welfare, 1-4-3 Mita, Minato, Tokyo 108-8329, Japan

      Kohei Hasegawa, MD, MPH Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street Boston, Suite 920, Boston, MA 02114, USA

      Harvard Medical School, Boston, MA, USA

      6 July 2018

      https://doi.org/10.1016/j.ajem.2018.07.018

      References

      Takahashi J, Goto T, Okamoto H, Hagiwara Y, Watase H, Shiga T, et al. Association of fen- tanyl use in rapid sequence intubation with post-intubation hypotension. 2018 Mar 14. pii: S0735-6757(18)30217-1. doi: 10.1016/j.ajem.2018.03.026. [Epub ahead of print]

    8. Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of post-intubation hypotension during emergency airway management. J Crit Care 2012;27 [417.e9-13].
    9. Green RS, Edwards J, Sabri E, Fergusson D. Evaluation of the incidence, risk factors, and im- pact on patient outcomes of postintubation hemodynamic instability. Can J Emerg Med 2012;14:74-82.
    10. Smischney NJ, Demirci O, Diedrich DA, Barbara DW, Sandefur BJ, Trivedi S, et al. Inci- dence of and risk factors for post-intubation hypotension in the critical ill. Med Sci Mnit 2016;22:346-55.
    11. Seamon MJ, Feather C, Smith BP, Kulp H, Gaughan JP, Goldberg AJ. A just one drop: the

      significance of a single hypotensive blood pressure reading during trauma resuscita- tions. J Trauma 2010;68:1289-94.

      Red blood cell distribution width in sepsis

      We have recently read with great interest the article by Wang et al. en- titled “Red blood cell distribution width is associated with mortality in el- derly patients with sepsis” [1]. In this retrospective cohort study the authors evaluated elderly patients (>=65 years old) with a diagnosis of se- vere sepsis and/or septic shock according to the 2012 International Sepsis Definitions Conference criteria. The authors utilized the prior definition of sepsis and septic shock [2] and found that RDW was an independent pre- dictor of in-hospital mortality in elderly patients with sepsis. However, we wonder if using most recent terminology [3] in the inclusion criteria would have influences on the result of the study. Our second concern is about biomarkers. cardiac dysfunction is a consequence of severe sepsis and is characterized by impaired contractility, diastolic dysfunction, and reduced ejection fraction especially in elderly patients [4]. Therefore, ana- lyzing the value of biomarkers of cardiac dysfunction such as B-type natri- uretic peptide (BNP) and comparison of BNP with RDW would give valuable information for risk stratification of patients with sepsis.

      Funda Sungur Biteker, MD

      Yatagan State Hospital, Department of Infectious Diseases and Clinical

      Microbiology, Turkey

      Bulent Ozlek, M.D.* Eda Ozlek, M.D.

      Cem Cil Oguzhan Celik

      Mugla University, Faculty of Medicine, Department of Cardiology, Turkey

      *Corresponding author at: Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah. Haluk Ozsoy Cad., 48000 Mugla, Turkey. E-mail address: [email protected] (B. Ozlek).

      Hiroko Watase, MD, MPH

      Department of Radiology, University of Washington, 850 Republican Street

      Seattle, WA 98006, USA

      https://doi.org/10.1016/j.ajem.2018.01.024

      14 December 2017

    Leave a Reply

    Your email address will not be published. Required fields are marked *