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Displaying 1-10 letters out of 770 published

  1. Precision of paediatric weight estimates

    Editor,

    Skrobo and Kelleher rightly stress the importance of accurate, rapid weight estimation in children when the situation precludes actual measurement of their weight.[1] They also rightly emphasise the need for estimation tools to be validated locally.

    The CORKSCREW study convincingly demonstrates that the mean bias of weight estimates using the Luscombe formula (3xage+7) is much smaller than that for the old APLS formula (2xage+8). Interestingly, this was true for 1-5 year olds too, which suggests that it might be better to use the Luscombe formula in all children, rather than just in 6-12 year olds as recommended in the latest APLS manual.

    However, the authors have not provided any results for the precision of these methods, although they suggest that estimates should be within 15% of actual weight. The ISO standard for accuracy of measurement methods defines both trueness and precision.[2] Trueness is the closeness of agreement between the arithmetic mean of a large number of test results and the true or accepted reference value. This is what the CORKSCREW study has presented. Precision refers to the closeness of agreement between test results. It is quite easy for a method to have very good trueness (for example, using the median weight for a given age, as found on standard age -weight curves), but have such an imprecision that it is clinically useless. One commonly used method to describe trueness and precision is described by Bland Altman.[3] The bias reflects trueness, and the limits of agreement (LOA) reflect precision. For a given weight estimate, LOA indicate the range of actual weights within which 95% of subjects will fall.

    Of the published methods of paediatric weight estimation, age-based methods have the worst precision, deteriorating with increasing age.[4] We would be particularly wary of using age-based weight estimation in teenagers, as the range of weights for a given age is far too broad to allow meaningful estimates in individuals. In comparison, the Broselow tape is a very precise method in children, but not useful in over 10s.[5] Newer methods of estimation based on mid-arm circumference (MAC) appear to be at least as precise as the Broselow tape in older children and adolescents.[6,7]

    Of course, tape-based methods require the presence of the child, and age-based methods might still have a role to play during preparation for a child's arrival in the resuscitation room. A MAC tape could be readily available pre-hospital as well as in the emergency department, and useful when the condition of the patient precludes objective measurement of their weight.

    Sincerely, Giles N Cattermole Colin A Graham Timothy H Rainer

    References: [1] Skrobo D, Kelleher G. CORKSCREW 2013 CORK study of children's realistic estimation of weight. Emerg Med J 2015;32:32-5 [2] ISO 5725-1:1994. https://www.iso.org/obp/ui/#iso:std:iso:5725:-1:ed- 1:v1:en [3] Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986 Feb 8;1(8476):307-10. [4] Cattermole GN, Leung MPY, So HK, Mak PSK, Graham CA, Rainer TH. Age- based formulae to estimate children's weight in the emergency department. Emerg Med J 2011;28:390-6. [5] Cattermole GN, Leung PYM,Graham CA, Rainer TH. Too tall for the tape: the weight of schoolchildren who do not fit the Broselow tape. Emerg Med J 2014;31:541-544. [6] Cattermole GN, Leung PYM, Mak PSK, Graham CA, Rainer TH. Mid-arm circumference can be used to estimate children's weights. Resuscitation 2010;81:1105-10. [7] Abdel-Rahman SM, Ridge AL. An improved pediatric weight estimation strategy. Open Med Devices J 2012;4:87-97.

    Conflict of Interest:

    None declared

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  2. Increasing the use of the fascia iliaca compartment block for patients with a fractured neck of femur: a quality improvement project

    We read with interest the article by Rashid et al (1) documenting current UK practice with regards to hip fractures (HF) and regional analgesia (RA); only 44% of their respondents reported local use of RA for this indication. The two main reasons highlighted were lack of equipment availability and lack of staff training; they therefore suggest that an appropriate protocol, a "Hip Block Box", audit and staff training may improve RA utilisation. They also highlight the utility of the Fascia Iliaca Compartment Block (FICB) in an emergency department setting.

    Our local guidance advises the use of the FICB in all patients with HF unless contraindicated. An audit of 100 consecutive hip fracture presentations in 2012 demonstrated disappointing performance with only 40% managed appropriately. Following a local survey of clinicians, the main reasons cited for limited utilisation of the FICB were:

    1) Lack of familiarity with the technique

    2) Lack of awareness of the protocol

    3) Difficulty locating equipment

    These findings mirror those of Rashid et al (1).

    In order to address this we undertook an education programme with middle grade doctors in the department; they were then encouraged to disseminate their knowledge to the junior team. The survey identified that consultant awareness of, and familiarity with, the procedure was already adequate. A simplified dosing regime was developed in consultation with the anaesthetic team; this facilitated the introduction of a simplified protocol. We also introduced "Block Boxes" to relevant clinical areas containing all the equipment necessary to perform the block.

    The audit cycle was completed approximately a year later and demonstrated appropriate management in 76% of patients. This represents an absolute improvement of 36% and a relative improvement of 90%.

    Our local findings demonstrate the efficacy of simple changes in generating significant improvements in the management of this cohort of patients. The changes implemented mirror those advocated by Rashid et al and we lend our support both to their utility and to the ease with which they can be introduced.

    References

    1. Rashid A, Beswick E, Galitzine S, Fitton L. Regional analgesia in the emergency department for hip fractures: survey of current UK practice and its impact on services in a teaching hospital. Emerg Med J 2014;31(11):909-13; doi:10.1136/emermed-2013-202794

    Conflict of Interest:

    None declared

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  3. The intubating laryngeal mask airway: What is there not to like?

    I was interested to read the paper by Castle & Naguran describing use of the intubating laryngeal mask airway (iLMA) in an entrapped patient [1]. The authors might be interested to know that I have also used the iLMA in the treatment of trapped trauma patients [2][3], and their case bears striking similarities to the ones that I encountered. Their report provides further evidence of the efficacy of the iLMA in trapped trauma situations, both as a primary airway rescue device and as a bridge to tracheal intubation. Their report was encouraging, but I felt that there were a number of important questions left unanswered, and I would like to draw attention to these and offer some observations of my own.

    The first important issue concerns the use of drugs. The authors failed to say if an anaesthetic or sedative agent was used to assist with insertion of the iLMA, and whether or not a neuro-muscular blocking agent (NMBA) was used to facilitate intubation via the device. In my own small case series involving five hypoxaemic trapped trauma patients, four of the patients who went on to survive to discharge from hospital required the administration of a dose of midazolam to facilitate insertion of the iLMA, and the single patient who accepted the iLMA without the need for medication was the only non-survivor. Although it has been shown that there is no statistical difference in the success rates for intubation via the iLMA between chemically paralysed and non-paralysed patients [4], the incidence of reflex coughing is likely to be higher in non-paralysed individuals, and the possible implications of coughing in the presence of brain injury and raised intracranial pressure clearly need to be borne in mind. Consequently, I would be interested to know if any drugs were used.

    Secondly, although the SpO2 and EtCO2 readings suggested that there was a significant improvement in the casualty's condition after insertion of the device, we were not told if the patient went on to survive to discharge from hospital - an important test of the efficacy and safety of any prehospital intervention.

    Finally, the authors omitted to mention the size and type of ET tube that they used, and it would be interesting to know if the iLMA's dedicated atraumatic wire-reinforced tube was employed, or simply a standard ETT rotated through 180-degrees, as some authors have recommended [5].

    I agree with the authors that it is probably wise to leave the iLMA in situ during transportation to hospital, even when tracheal intubation via the iLMA has been undertaken in the prehospital phase, since manipulation to remove the device from around the tracheal tube could cause the tube to become accidentally dislodged. It should be noted, however, that when the iLMA is left in situ after intubation, the manufacturer recommends reducing the volume of air in the cuff of the iLMA by 50%. This reduces pressure on the hypopharyngeal mucosa with the aim of preventing possible ischaemic damage to tissues.

    Castle & Naguran report that the first attempt to intubate via the iLMA was unsuccessful, with resistance felt at the point where the ETT should have entered the larynx, but that a second attempt at intubation was successful after the iLMA was repositioned and forward traction applied. Early studies suggested that a learning curve of approximately twenty cases existed for proficiency in tracheal intubation via the iLMA [6]. However, subsequent refinements to the recommended insertion technique have managed to improve first-time intubation success rates significantly [7].

    The recommended technique for intubation via the iLMA is sometimes called the 'Chandy' manoeuvre, named after the UK anaesthetist, Dr Chandy Verghese. The first part of the Chandy manoeuvre involves grasping the iLMA by its handle and moving it back-and-forth in the sagittal plane while noting the rise-and-fall of the chest (tidal volume) together with the resistance to manual ventilation. This optimises ventilation through the device which occurs when the distal airway aperture in bowl of the mask is directly opposite the laryngeal inlet. The second part of the manoeuvre involves lifting the handle of the iLMA at 45% to the horizontal plane of the patient's chest. This helps to align the angled ramp at the distal end of the airway aperture with the longitudinal axis of the upper trachea, so facilitating direct and unhindered passage of the tip of the tube into the upper trachea. Use of the Chandy manoeuvre can be expected to improve first-time intubation rates with the iLMA to levels approaching 100%.

    Castle and Maguran's case report shows the potential value of the iLMA as a device for rapid control of the airway in the prehospital setting, particularly when there is restricted access to a trapped casualty. They also show the value of the device as a bridge to blind intubation of the trachea.

    I believe that the iLMA is a much underrated and underused supraglottic airway device which is particularly suitable in a trapped trauma situation where there is limited access to the casualty. Its benefits include:

    1. Insertion and ventilation can be achieved easily by persons with minimal training [8][9][10][11][12]

    2. Functions as an initial rescue airway device in its own right

    3. Laryngoscopy unnecessary

    4. Neutral alignment of head & neck is a pre-requisite for insertion, rendering manipulation of a potentially injured cervical spine unnecessary

    5. Insertion requires an interdental gap of only 20mm

    6. Neuromuscular blockade not essential for insertion of the iLMA or subsequent intubation via the device

    7. Can be introduced blindly with one hand from any position

    8. No need to insert a finger into patient's mouth

    9. Rigid airway tube resists occlusion by biting

    10. When the cuff is inflated, this provides protection of the airway from bleeding arising above

    11. Facilitates seamless progression to tracheal intubation

    12. Permits ventilation between and even during intubation attempts

    13. Available as a disposable single-use device.

    With regard to the iLMA as a suitable rescue ventilation device for prehospital trauma care, one is tempted to ask, 'What is there not to like?'

    Dr Andrew M Mason

    (Hon. President, Suffolk Accident Rescue Service, Ipswich, UK)

    REFERENCES:

    [1] Castle N, Naguran S. Reflection: on the use of the ILMA in an entrapped patient. Emerg Med J 2014; 31(12): 1014-1015

    [2] Mason AM. Use of the intubating laryngeal mask airway in pre- hospital care: a case report. Resuscitation 2001 Oct; 51(1): 91-5

    [3] Mason AM. Prehospital use of the intubating laryngeal mask airway in patients with severe polytrauma: a case series. Case Rep Med 2009; 2009:938531. doi: 10.1155/2009/938531. Available for free download at: http://www.hindawi.com/journals/crim/2009/938531/

    [4] Ambulkar R, Tan AYH, Chia NCH, Low TC. Comparison between use of neuromuscular blocking agent and placebo with the intubating laryngeal mask airway. Singapore Med J. 2008; 49(6): 462-465

    [5] Shah VR, Bhosale GP, Mehta T, Parikh GP. A comparison of conventional endotracheal tube with silicone wire-reinforced tracheal tube for intubation through intubating laryngeal mask airway. Saudi J Anaesth 2014; doi:10.4103/1658-354X.130702

    [6] Baskett PJF, Parr MJA, Nolan JP, et al. The intubating laryngeal mask. Results of a multicentre trial with experience of 500 cases. Anaesthesia 1998; 53(12): 1174-1179

    [7] Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use of the intubating LMA-Fastrach in 254 patients with difficult-to- manage airways. Anesthesiology 2001; 95(5): 1175-1181

    [8] Levitan RM, Ochroch EA, Stuart S, Hollander JE. Use of the intubating laryngeal mask airway by medical and nonmedical personnel. Am J Emerg Med 2000; 18(1): 12-16

    [9] Reeves MD, Skinner MW, Ginifer CJ. Evaluation of the intubating laryngeal mask airway used by occasional intubators in simulated trauma. Anaesth Intens Care 2004; 32(1): 73-76

    [10] Menzies R, Manj H. The intubating laryngeal mask: is there a role for paramedics. Emerg Med J 2007; 24(3): 198-199

    [11] Timmermann A, Russo SG, Crozier TA, et al. Laryngoscopic versus intubating LMA guided tracheal intubation by novice users - a manikin study. Resuscitation 2007; 73(3): 412-416

    [12] McCall MJ, Reeves M, Skinner M, Ginifer C, Myles P, Dalwood N. Paramedic tracheal intubation using the intubating laryngeal mask airway. Prehosp Emerg Care 2008; 12(1): 30-34.

    Conflict of Interest:

    AMM is a former adviser in prehospital care to both Intavent Direct and the Laryngeal Mask Company, former distributors of the iLMA. Opinions expressed are purely those of AMM who has no connection with the current distributor(s) and no financial interest in sales of the iLMA.

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  4. Thoracic ultrasound may be a solution

    I agree with the authors that using the guidelines may not avoid subdiaphragmatic viceral injuries. First, many underlying diseases could alter the thorax shape and the diaphragm position. Second, in patients using positive mechanical ventilation support, many different ventilatory strategies, such as lung recruitment strategy, can alter the diaphragm level. Moreover, among some special groups of patients, such as patients with severe chest wall burn injury, the surface markers are not easily identified. Therefore, I use thoracic ultrasound before placing a chest tube, even without a chest x ray film. Common diseases requiring a chest drainage, including pneumothorax, hemothorax, empyema, and massive pleural effusion, can be diagnosed by thoracic ultrasound. A quick look via thoracic ultrasound can also prevent medical error, including placing a drain in the wrong side or even in a different patient.

    Conflict of Interest:

    None declared

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  5. Zero numerators and the illusion of safety

    Kaye and Govier's case series of propofol sedation for DC cardioversion 1 provides a useful contribution to the relatively evidence-light area of Emergency Department (ED) sedation. I would, however, urge caution in their conclusion that propofol is a "safe" drug for the uses they describe.

    Safety is obviously relative but, in the grand scheme of things, their series of 111 patients is small. The statistical "rule of three"2 suggests that, in a series with a zero incidence of a particular complication, the upper limit of the 95% confidence interval for the rate of that complication is approximately equal to one in n/3. Therefore, in the population they sampled, the rate of sentinel complications could as high as 1:37.

    Although their paper adds useful further evidence of the utility of propofol for ED sedation, I would venture that few clinicians would consider a potential rate of CPR or death of 2.7% indicative of a "safe" sedation technique. Larger studies are needed, although I would agree wholeheartedly with their assertion that midazolam is far from the gold standard drug for these patients.

    REFERENCES 1. Kaye P, Govier M. Procedural sedation with propofol for emergency DC cardioversion. Emerg. Med. J. 2014 31:904-908; doi:10.1136/emermed-2013-202742
    2. Hanley JA, Lippman-Hand A. If nothing goes wrong, is everything alright?. JAMA 1983; 249 (13): 1743-5. doi:10.1001/jama.1983.03330370053031

    Conflict of Interest:

    None declared

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  6. Emergency Department ECMO and Echo - better together?

    As highlighted by Chou et al[1] it is becoming more evident that extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR) is feasible and compares well against conventional CPR. As technologies such as ECMO[2] and echocardiography (Echo),[3] previously limited to intensive care units and cardiology suites, become increasingly available in the Emergency Department (ED), it is important that we fully utilize the information and support they can provide to carefully select cardiac arrest patients for advanced ED resuscitation.

    The percentage of patients who leave hospital alive following CPR varies from 0% to 20% and has not significantly improved in the last 30 years.[4] The recently published CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion), a single center, prospective, observational study from Australia, assessed the CHEER protocol, developed for selected patients with refractory in-hospital and out-of-hospital cardiac arrest.[5] The protocol involved mechanical CPR, induction of intra-arrest therapeutic hypothermia, early commencement of veno-arterial ECMO, and early coronary angiography for patients with suspected coronary artery occlusion. ECMO was established in 24 (92%) of 26 eligible patients, with a median time from collapse until initiation of ECMO of 56 min. Return of spontaneous circulation was achieved in 25 (96%) patients. Survival to hospital discharge with full neurological recovery occurred in 14/26 (54%) patients. Another study from the United States recently reported similar survival rates; 13 of 24 (54%) patients survived to hospital discharge with an ECMO based CPR protocol. Seven of these patients were discharged without any neurological deficit.[6] While these early results show promise for this form of advanced ED resuscitation, caution is required before rolling out this technology for all cardiac arrest patients.

    Can our health care systems afford the increased requirement of intensive care bed-hours that such a policy would lead to? Can we select which patients are most likely to benefit from ED-ECMO?

    A meta-analysis of predictors of survival from out-of-hospital cardiac arrest in 2010 found that survival to hospital discharge was more likely among those witnessed by a bystander or emergency medical services (EMS), those who received bystander CPR, were found in a shockable rhythm (VF/VT), or achieved return of spontaneous circulation (ROSC).[4] A further meta-analysis in 2012 looked at the of detection of cardiac activity on echo to predict survival during cardiac arrest. Pooled data showed that as a predictor of ROSC during cardiac arrest, echo had a pooled sensitivity of 91.6%, and specificity was 80.0%;[7] promising, but not independently predictive of survival.

    Protocols including ED-ECMO are feasible and may be associated with a relatively high survival rate. The introduction of such protocols to emergency medicine should be encouraged, but must involve careful patient selection, optimizing survival benefit. This may involve bedside echo in the ED, as well as other demographic and clinically derived predictors of survival.

    1. Chou T.-H. An observational study of extracorporeal CPR for in- hospital cardiac arrest secondary to myocardial infarction. Emerg Med J 2014;31: 441-7.

    2. Shinar Z, Bellezzo J, Paradis N, et al. Emergency department initiation of cardiopulmonary bypass: a case report and review of the literature. J Emerg Med. 2012;43(1):83-6.

    3. Hayhurst C, Lebus C, Atkinson PR, et al. An evaluation of echo in life support (ELS): is it feasible? What does it add? Emerg Med J. 2011 Feb;28(2):119-21.

    4. Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation 2014. DOI: http://dx.doi.org/10.1016/j.resuscitation.2014.09.010.

    5. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta- analysis. ?Circ Cardiovasc Qual Outcomes 2010;3:63-81.

    6. Peigh G, Pitcher H, Cavarocchi N, Hirose H. Saving Life And Brain With Extracorporeal Cardiopulmonary Resuscitation (E-Cpr) Chest. 2014;146(4_MeetingAbstracts):722A. doi:10.1378/chest.1990723.

    7. Blyth L, Atkinson P, Gadd K, Lang E. Bedside Focused Echocardiography as Predictor of Survival in Cardiac Arrest Patients: A Systematic Review. Acad Emerg Med 2012;19: 1119-1126.

    Conflict of Interest:

    None declared

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  7. Just to clarify

    A number of comments have been made to me regarding this article since it was published. I would like to take this opportunity to clarify that the experiences described did not occur whilst working at North Tees University Hospital. This is where I currently work as a higher trainee in Emergency Medicine. I am keen that the contents of the correspondence address do not overshadow the key message of the article.

    Conflict of Interest:

    None declared

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  8. Lack of evidence to support use of D-dimer in pregnant women with a suspicion of pulmonary embolism

    The authors state that current evidence supports the use of a negative D-dimer to rule out a suspicion of pulmonary embolism (PE) in pregnancy. They show in Table 2 5 relevant studies to support their conclusion. However, the study of Damodaram was the only study that included patients with a clinical suspicion of venous thromboembolism, thus including pulmonary embolism. All other 4 studies included either healthy pregnant patients or patients with a clinical suspicion of deep vein thrombosis (DVT). Evidence found in healthy patients cannot be extrapolated to pregnant symptomatic patients. Performance of the D-dimer test should be tested in pregnant patients with a clinical suspicion of PE before any recommendation can be made. Since PE is still one of the leading causes of maternal death, ruling out this diagnosis accurately is imperative.

    Furthermore, in non-pregnant patients, use of D-dimer test as a stand -alone test is not supported. The authors state that the Wells score can be a useful tool in calculating pretest probability, as its categories remain relevant. However, this statement is not supported by evidence. The title of this BET may be interpreted as if a D-dimer test can be used as a stand-alone test. In non-pregnant patients with a high suspicion of PE (Wells score >4 points), the presence of PE is found to be 10%, despite a negative D-dimer (Wells, Thromb Haemost 2000). Therefore, the most important conclusion should be that there's a lack of good-quality evidence concerning the management of a clinical suspicion of PE in pregnancy.

    Conflict of Interest:

    None declared

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  9. The Psychological Effect of Ebola on ED Staff

    Now 11+ years since SARS, it would be interesting to repeat this study post Ebola... Are staff any better prepared for a highly contagious, fatal disease?

    Conflict of Interest:

    None declared

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  10. Sepsis Six: Are we doing the right thing?

    Dear Editor,

    The "Sepsis Six" resuscitation bundle is now common in UK hospitals, and endorsed by the College of Emergency Medicine, SIGN guidelines, and the Royal College of Physicians.1-3 However, the evidence behind it remains limited and must be re-evaluated as new data emerges - especially since the results of the PRoCESS and ARiSE trials on Early Goal Directed Therapy (EGDT) were published this year.4,5

    The paper supporting Sepsis Six was originally published in 2010 in this Journal, and remains (as far as we are aware) the only published evidence on Sepsis Six.6 We believe this trial is internally flawed, and unable to provide convincing evidence of the benefit of Sepsis Six.

    We have two main criticisms of this sepsis 6 trial - firstly, it is inconsistent. Given that two large randomised controlled trials this year have shown EGDT to have negligible effect on mortality, it is hard to interpret the results of this trial - which showed a relative risk reduction of 91% (mortality dropped from 90.3% without EGDT to 7.5% with it). Also, the subgroup of patients who were shocked shows internal inconsistencies. The worst performing group - with a staggering 97.1% mortality were the shocked patients who received Sepsis 6 - yet if they received EGDT alone, their mortality was 8%. However, the combination of Sepsis 6 and EGDT in shocked patients performed best of all - with a 4.7% mortality!

    It seems inconceivable that in septic shock Sepsis 6 would increase mortality to 97.1% if performed alone, but reduce it to 4.7% if performed in combination with EGDT (which we know from RCT data has a negligible effect).

    The only possible explanation is that of confounding effects - younger, fitter people were receiving EGDT and Sepsis 6- who had a low mortality rate and survived, and less fit people did not receive it This leads to our second criticism - lack of co-variate analysis. Although the authors comment on the difference in age between some of the cohorts, they did not perform a multivariate logistic regression (or similar) that could have included age, MEWS score, source of infection. Given the complexity and difference between the subgroups, it is impossible to compare them without covariate statistical analysis.

    It is very hard to draw causality from observational trials (and the authors do not try here), but given the significant problems with this trial, we do not feel it can be interpreted as supporting evidence for Sepsis 6 either.

    Although we do not aim to be unnecessary critical of what may be seen as 'common sense practice', we have three main concerns. Firstly, the claim that sepsis 6 in unlikely to be harmful is not a sufficient basis for it's continued use. 'Common sense' medicine has repeatedly been proven to be harmful on numerous occasions. Secondly, emergency departments and wards are busy and under huge time pressure, and protocols that might tie up staff for an hour or more must be scrutinised. Thirdly, sepsis 6 is likely to lead to the greater use of stat doses of antibiotics in any febrile patient, given the impetus to administer them within the first hour for any unconfirmed sepsis diagnosis. We do not know the long-term impact of this on antibiotic resistance - which is rapidly increasing.

    Sepsis 6 means well, but is unproven, and should be treated as such.

    Fergus Hamilton Bryony Lewis

    1. SIGN. Care of deteriorating patients: Guideline 139. 2014. Available at: http://www.sign.ac.uk/pdf/SIGN139.pdf. Accessed October 14, 2014.

    2. RCP. Acute Care Toolkit 9: Sepsis.; 2014.

    3. College of Emergency Medicine. Clinical Standards for Emergency Departments. 2013. Available at: http://www.collemergencymed.ac.uk/Shop- Floor/Clinical Standards. Accessed October 14, 2014.

    4. The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-Directed Resuscitation for Patients with Early Septic Shock. N. Engl. J. Med. 2014:141001063014008. doi:10.1056/NEJMoa1404380.

    5. Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock. N. Engl. J. Med. 2014;370(18):1683-93. doi:10.1056/NEJMoa1401602.

    6. Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg. Med. J. 2011;28(6):507-12. doi:10.1136/emj.2010.095067.

    Conflict of Interest:

    None declared

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