Elise's conference pearls from 1-17 (also sent via email)

From Study Guide:
1.  Neutropenic fever and rectal exams:  7th Edition Tintinalli does say digital rectal exam is relatively contraindicated in neutropenic patients, and should be withheld until after antibiotics are started.  It also says to pay attention to the oral exam, perianal exam and entry sites of IV catheters; areas of infection not commonly evaluated in non-neutropenic patients.
2.  Coagulopathy and paracentesis:  7th Edition Tintinalli also says to reverse coagulopathy and thrombocytopenia before doing paracentesis, so correct answer for the test, but probably not the correct answer in real life:
Hepatology. 2004 Aug;40(2):484-8.

Performance standards for therapeutic abdominal paracentesis.


Advanced Liver Diseases Study Group, Division of Gastroenterology and Hepatology and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.


Large-volume paracentesis, the preferred treatment for patients with symptomatic tense ascites due to cirrhosis, has traditionally been performed by physicians as an inpatient procedure. Our objectives were to determine (1) whether large-volume paracentesis could be performed safely and effectively by gastrointestinal endoscopy assistants and as an outpatient procedure, (2) whether the risk of bleeding was associated with either thrombocytopenia or prolongation of the prothrombin time, and (3) the resources used for large-volume paracentesis. Gastrointestinal endoscopy assistants performed 1,100 large-volume paracenteses in 628 patients, 513 of whom had cirrhosis of the liver. The preprocedure mean international normalized ratio for prothrombin time was 1.7 +/- 0.46 (range, 0.9-8.7; interquartile range, 1.4-2.2), and the mean platelet count was 50.4 x 10(3)/microL, (range, 19 x 10(3)/microL - 341 x 10(3)/microL; interquartile range, 42-56 x 10(3)/microL). Performance of 3 to 7 supervised paracenteses was required before competence was achieved. There were no significant procedure-related complications, even in patients with marked thrombocytopenia or prolongation in the prothrombin time. The mean duration of large-volume paracentesis was 97 +/- 24 minutes, and the mean volume of ascitic fluid removed was 8.7 +/- 2.8 L. In conclusion, large-volume paracentesis can be performed safely as an outpatient procedure by trained gastrointestinal endoscopy assistants. Ten supervised paracenteses would be optimal for training the operators carrying out the procedure. The practice guideline of the American Association for the Study of Liver Diseases which states that routine correction of prolonged prothrombin time or thrombocytopenia is not required is appropriate when experienced personnel carry out paracentesis.

3.  From GI Curbside Consult:  IV erythromcyin now well accepted pre-endoscopy, and probably better than NG in cleaning out upper GI tract to help with visualization:
Aliment Pharmacol Ther. 2011 Jul;34(2):166-71. doi: 10.1111/j.1365-2036.2011.04708.x. Epub 2011 May 25.

Meta-analysis: erythromycin before endoscopy for acute upper gastrointestinal bleeding.


Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China.



Studies evaluating the effect of erythromycin on patients with acute upper gastrointestinal bleeding (UGIB) had been reported, but the results were inconclusive.


To compare erythromycin with control in patients with acute UGIB by performing a meta-analysis.


Electronic databases including PubMed, EMBASE and the Cochrane Library, Science Citation Index, were searched to find relevant randomised controlled trials (RCTs). Two reviewers independently identified relevant trials evaluating the effect of erythromycin on patients with acute UGIB. Outcome measures were the incidence of empty stomach, need for second endoscopy, blood transfusion, length of hospital stay, endoscopic procedure time and mortality.


Four RCTs including 335 patients were identified. Meta-analysis demonstrated the incidence of empty stomach was significantly increased in patients receiving erythromycin (active group 69%, control group 37%, P<0.00001). The need for second endoscopy, amount of blood transfusion and the length of hospital stay were also significantly reduced (all P<0.05). A trend for shorter endoscopic procedure time and decreased mortality rate was observed.


Prophylactic erythromycin is useful for patients with upper gastrointestinal bleeding to decrease the amount of blood in the stomach and reduce the need for second endoscopy, amount of blood transfusion. It may shorten the length of hospital stay, but its effects on mortality need further larger trials to be confirmed.


4.  From Joint Peds/EM conference:  This is just a reiteration of an excellent point made during the discussion:  for healthy, self-limited new onset seizure in peds patient, NO emergency neuro-imaging needed unless: focal neuro deficit, prolonged altered state, fever, or focal seizure.  If the kid needs an emergent neuro-imaging study due to one of these reasons, MRI far preferable.  All kids will get EEG, try to arrange within 24 hours for improved predictive value, and EEG results will guide need for outpatient MRI.