Health
Early restrictive fluid management does not reduce mortality in sepsis-induced hypotension
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1. Early use of vasopressors combined with a conservative fluid resuscitation did not result in a mortality benefit over a liberal fluid resuscitation strategy.
2. Early use of vasopressors combined with conservative fluid resuscitation also did not result in significantly different adverse event outcomes compared to liberal fluid resuscitation.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Sepsis-induced hypotension often requires admission to the intensive care unit due to hemodynamic instability. Extravasation of intravascular volume into the third space often results in drops in blood pressure, as seen in sepsis-induced hypotension. Fluid resuscitation and the use of vasopressors have been pillars in its management, with the primary goal of maintaining adequate intravascular volume to provide effective circulation. For many patients, both strategies are employed. However, it is unclear whether the approach of initiating vasopressors earlier in the course with a conservative strategy of fluid resuscitation will lead to better mortality benefits when compared with the alternative of being liberal with fluid resuscitation prior to initiating vasopressors later in the course. This study compared these two approaches among adults presenting with sepsis-induced hypotension. The primary outcome of interest was whether one approach yielded a greater mortality benefit at 90-days after the initial event. Results of the study found that there was no difference in 90-day mortality outcome or secondary outcomes of interest between the two modalities. This study was limited in that it excluded patients with extreme volume contraction and those who received more than 3L of fluids in the prehospital setting. Therefore, the results of the study have limited generalizability.
Click to read the study in NEJM
In-Depth [randomized controlled trial]: This study was a multicenter, randomized controlled trial comparing the mortality benefit of two different approaches to managing sepsis-induced hypotension: i) early vasopressor use and conservative fluid management, and ii) liberal fluid resuscitation prior to initiating vasopressor use. All adults with septic-induced hypotension were eligible for the study. Participants with confounding features to the study question were excluded. Those who were screened more than four hours after meeting the criteria for refractory hypotension or more than 24 hours since the first presentation, those who received more than 3L of IV fluids, those who were volume overloaded, and those who were significantly volume contracted from non-sepsis causes. After applying the inclusion and exclusion criteria, 1,563 participants were assigned randomly in a 1:1 ratio to one of the two strategies. The primary outcome was all-cause mortality before discharge at 90 days after the inciting event. Secondary outcomes of interest focused on adverse effects, which included duration of time without ventilator use, renal-replacement therapy, vasopressor use, and discharge from the intensive care unit. Results of the study found that at 90 days, there was no significant difference in all-cause mortality between the two groups (estimated difference, -0.9%; 95% Confidence Interval [CI], -4.4 to 2.6; p=0.61). The secondary analysis found similar results of non-superiority between one strategy over another. In summary, this study suggests that there is no difference between the two approaches to sepsis-induced hypotension.
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Grande Prairie RCMP issued a warning Friday after it was revealed fentanyl linked to a deadly overdose was mixed with a chemical that doesn’t respond to naloxone treatment.
The drugs were initially seized on Feb. 28 after a fatal overdose, and this week, Health Canada reported back to Mounties that the fentanyl had been mixed with Bromazolam, which is a benzodiazepine.
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Mounties say this is the first recorded instance of Bromazolam in Alberta. The drug has previously been linked to nine fatal overdoses in New Brunswick in 2022.
The pills seized in Alberta were oval-shaped and stamped with “20” and “SS,” though Mounties say it can come in other forms.
Naloxone treatment, given in many cases of opioid toxicity, is not effective in reversing the effects of Bromazalam, Mounties said, and therefore, any fentanyl mixed with the benzodiazepine “would see a reduced effectiveness of naloxone, requiring the use of additional doses and may still result in a fatality.”
From January to November of last year, there were 1,706 opioid-related deaths in Alberta, and 57 linked to benzodiazepine, up from 1,375 and 43, respectively, in 2022.
Mounties say officers responded to about 1,100 opioid-related calls for service, last year with a third of those proving fatal. RCMP officers also used naloxone 67 times while in the field, a jump of nearly a third over the previous year.
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Health
CFIA continues surveillance for HPAI in cattle, while sticking with original name for disease – RealAgriculture
The Canada Food Inspection Agency will continue to refer to highly pathogenic avian influenza in cattle as HPAI in cattle, and not refer to it as bovine influenza A virus (BIAV), as suggested by the American Association of Bovine Practitioners earlier this month.
Dr. Martin Appelt, senior director for the Canadian Food Inspection Agency, in the interview below, says at this time Canada will stick with “HPAI in cattle” when referencing the disease that’s been confirmed in dairy cattle in multiple states in the U.S.
The CFIA’s naming policy is consistent with the agency’s U.S. counterparts’, as the U.S. Animal and Plant Health Inspection Service has also said it will continue referring to it as HPAI or H5N1.
Appelt explains how the CFIA is learning from the U.S. experience to-date, and how it is working with veterinarians across Canada to stay vigilant for signs of the disease in dairy and beef cattle.
As of April 19, there has not been a confirmed case of HPAI in cattle in Canada. Appelt says it’s too soon to say if an eventual positive case will significantly restrict animal movement, as is the case with positive poultry cases.
This is a major concern for the cattle industry, as beef cattle especially move north and south across the U.S. border by the thousands. Appelt says that CFIA will address an infection in each species differently in conjunction with how the disease is spread and the threat to neighbouring farms or livestock.
Currently, provincial dairy organizations have advised producers to postpone any non-essential tours of dairy barns, as a precaution, in addition to other biosecurity measures to reduce the risk of cattle contracting HPAI.
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Health
Toronto reports 2 more measles cases. Use our tool to check the spread in Canada – Toronto Star
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Canada has seen a concerning rise in measles cases in the first months of 2024.
By the third week of March, the country had already recorded more than three times the number of cases as all of last year. Canada had just 12 cases of measles in 2023, up from three in 2022.
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