PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.
This week's topics include complications of shoulder surgery, induction of labor, sepsis and death, and bag ventilation at intubation.
Program notes:
0:37 Induction of labor at 41 weeks
1:39 May be better to induce than to wait
2:40 Studies in pregnant women
3:16 Complications of shoulder surgery
4:16 Serious adverse events
5:21 Sepsis and death
6:24 Hospice qualifying condition on admission
7:24 Less than 5% preventable
9:15 Bag mask ventilation
10:10 1.5 million patients ventilated each year
11:15 End
Transcript:
Elizabeth Tracey: Just how big a problem is sepsis with regard to mortality?
Rick Lange, MD: Making intubation safer.
Elizabeth: When should labor be induced?
Rick: And the risk of re-operation after a shoulder replacement.
Elizabeth: That's what we're talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I'm Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on March 1, 2019.
Rick: And I'm Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I'm also Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, I'd like to turn first to the British Medical Journal Open Access and their research journal taking a look at labor induction. There's an awful lot of discussion about this with many women when they get to 41 weeks of gestation. Many people feel like that's too long. And so the question is what should we do? They took a look at 1,800+ low-risk women with uncomplicated singleton pregnancies, and they were randomized to either induction, that was half of them, or expectant management until 42 weeks of gestation. They said, "Okay, what about perinatal mortality, neonatal morbidity?" [and] all the other things that they take a look at after a child is born, and then what happens if we just do the expectant management?
This is the conclusion. It says this study could not show non-inferiority of expectant management compared with induction of labor in uncomplicated pregnancies at 41 weeks. Instead, there was a difference of 1.4% for adverse perinatal outcomes in favor of induction, and so this sort of, like, backwards way of saying, "Wow, maybe it's better to induce than to wait."
Rick: This is an issue for about 10% of women who carry their pregnancy up to 42 weeks. As you alluded to, the risk of perinatal death is increased after 42 weeks of pregnancy. Now the interesting thing about this particular study is they looked at a lot of different outcomes, but the outcome that really seemed to be different was the Apgar score at 5 minutes. And unfortunately, that's not closely associated with longer-term neurologic disability. I'm not sure that this definitively answers the question about whether there ought to be induction, but it certainly raises the issue that there's not any harm to it. Whether there's any benefit or not, I still think that's up for grabs, but the fact that there doesn't appear to be any increased harm is clear.
Elizabeth: I think that A) it's really good that they're doing these studies in pregnancy, which, of course, has been one of those sacrosanct populations for a really long time. So I'm glad to see that there's some kind of study that's going on with regard to this. The other thing that I think is interesting, at least from my perspective, is that pregnancy, gosh, you really want to get it over with. [LAUGHTER] If there's nothing bad about induction at 41 weeks, I think I would go ahead and be induced. In fact, I was.
Rick: Elizabeth, maybe later this year we can report on another study that's ongoing. It's a register-based, multicenter trial that, again, is going to compare induction at 41 weeks with expectant management, but it's going to look at a number of different risk factors. I suspect we'll be able to give our listeners more information over the coming year.
Elizabeth: Let's turn to one of yours. Which one? How about the shoulder surgery?
Rick: Yeah, Elizabeth. Let's talk about that. We know a lot about hip and knee replacements and what the outcome is and what's the likelihood that you may need another surgery, but there really wasn't a lot of data regarding that for shoulder surgery. So these authors looked at over 58,000 elective shoulder replacements over about a 20-year period. They were able to get the data from the Hospital Episode Statistics from the National Health Service in England. And what they discovered was when they looked at the lifetime risk of revision surgery, if you have an elective shoulder replacement, what's the likelihood you're going to need another one, is that for men 59 years and younger the risk was 1 in 4. That's pretty substantial. Compare that, for example, to a woman over the age of 85, where the risk of needing another surgery is about 1 in 37.
Now most of these shoulders weren't just wearing out, because in the younger men that needed to have shoulder revision surgery, it often occurred within the first 5 years after the shoulder was initially put in. This study also looked at other serious, adverse events and about 4.5% or 5% risk of having a serious complication the first 90 days after surgery. So I think this study is important because it helps inform patients about what the risks are, especially age-related, and to allow them to make informed decisions about whether they want to proceed with elective surgery or not.
Elizabeth: We neglected to mention which journal is this in?
Rick: This is in the British Medical Journal.
Elizabeth: I guess it's worth noting that shoulder surgery, as we've talked about before and that came as a total surprise to me, turns out to be incredibly common, especially as we age. So this is really a big problem.
Rick: There's been a rapid increase in the incidence of primary shoulder replacements. Part of that is due to the rapid adoption of new implant technologies. Without this kind of data, I think patients can't be informed about whether they ought to proceed with the surgery, because oftentimes they have pain, usually due to arthritis, and if they go, "I'll just have the shoulder replaced to relieve the pain and I'll be over with this." But this study indicates it may not be quite so simple.
Elizabeth: And maybe worth a trial of PT?
Rick: Absolutely.
Elizabeth: Okay. Let's turn, then, back to me. this time we're going to take a look in the JAMA Network Open journal looking at this issue of sepsis-associated mortality in U.S. acute care hospitals. This, of course, [is] a very big issue, this idea that somehow we need to prevent sepsis in all of these folks nationally was a U.S. surgeon general's initiative, what, a year ago or so we talked about it, I think. The question, "How big a problem is it, really?"
This study took a look at 568 patients who died in the hospital or were discharged to hospice and sepsis was present in 300 of those hospitalizations and was the immediate cause of death in 198 of those. They took a look at, "What else was there? Progressive cancer, heart failure." The most common underlying causes of death in the patients with sepsis were solid cancers, chronic heart disease, hematologic cancers, dementia, and chronic lung disease. And then these hospice-qualifying conditions were present on admission in 121 of the 300 sepsis-associated deaths.
And so, in this cohort from these six U.S. hospitals, sepsis was the most common immediate cause of death. However, most underlying causes of death were related to severe chronic comorbidities. And I think that's a really important point, because I think when we're trying to discern what's going on with regard to sepsis, does sepsis develop because we've got these underlying conditions that really don't have anything to do with sepsis as a proximate cause of death.
Rick: Elizabeth, I think you hit the nail on the head. And it is a significant issue because approximately 1.7 million adults in the U.S. each year develop sepsis, and this contributes to about 250,000 deaths. The perception is that most of these sepsis-associated deaths are preventable with better care. And this has, obviously, sparked numerous sepsis performance improvement initiatives in the hospitals, not only in the U.S., but around the world. But as this study suggests, less than 5% of the sepsis-related deaths were judged definitely or moderately likely preventable. We need further innovations in the prevention and care of underlying conditions that may be necessary before we reduce sepsis-associated deaths.
Elizabeth: Sepsis is present at the time of death, but the reason it's there is because of all of these other conditions that have progressed to that point. Then, to me, at least, that suggests that trying to prevent sepsis is probably not a terribly practical goal.
Rick: Elizabeth, you're right, because the most common comorbid conditions associated with were terminal diseases like cancer and chronic lung disease and chronic heart disease, so your point is very well taken.
Elizabeth: Okay, well, let's turn to your last one then.
Rick: This is in the New England Journal of Medicine, and it talks about making intubation safer. This is in critically ill adults. Intubation or putting a breathing tube in individuals is obviously meant to put them on a respirator to get them through this critically ill period. The most common complication associated with the intubation is actually low oxygen or hypoxemia. Now you say, "Well, why would that be because we're trying to improve the respiratory status of the patient?"
Before you intubate the patient, you give them the medications to actually induce them and to paralyze it to make it safer. Now when you do that, you administer those medications. They take about 60 seconds to work, and during that time, the patient can have a low oxygen saturation because they're not breathing. The question is can you make intubation safer by putting a bag mask on them and manually ventilating them? People have been reticent to do that because of concerns that that will actually cause people to aspirate, that is forcing air into the lungs and also into the GI tract will cause these patients to actually aspirate to make things worse.
So to study this, the authors looked at 401 patients that were enrolled in seven intensive care units in the United States. They were randomly assigned to undergo routine intubation with the medications I mentioned or to have the medications and then have the bag-mask ventilation just before the patients were intubated. What they found out was the patients that had the bag-mask ventilation as a part of the procedure were half as likely to develop severe hypoxemia, and by the way, they were not any more likely to have aspiration. So this is an excellent study that shows among critically ill adults undergoing tracheal intubation giving bag-mask ventilation prevents hypoxemia and does not increase the serious side effects of aspiration.
Elizabeth: Right, which, of course, is often pneumonia, so that is an important thing to try to avoid. I thought it was really interesting in the editorial where they said, "Isn't it great to take a look at these sacred cows, these things that have been instituted and practiced for a long time, and really develop the evidence base?"
Rick: Yep, and because more than 1.5 million patients undergo tracheal intubation each year in the United States, it's a big issue. You said the dogma was, "Don't do the bag-mask ventilation because they'll aspirate. It'll make things worse." Then somebody scratching their head said, "Well, that's interesting, but nobody has ever really looked at it. Let's look at it in a thorough and rigorous way." That's exactly what this study did.
Elizabeth: Let's talk about the technical feasibility of this because I'm not sure I've ever actually witnessed it. Is it hard to do?
Rick: It's actually very easy. I mean the patients get the same medications to get them ready for the elective intubation, but during the time period from when they get that to when the intubation is started, basically you just put a mask on and you ventilate them until they're fully relaxed, they're fully paralyzed, then you intubate them. So this is very easy to do.
Elizabeth: On that good news note, then, that's a look at this week's medical headlines from Texas Tech. I'm Elizabeth Tracey.
Rick: And I'm Rick Lange. Y'all listen up and make healthy choices.