The edition · Emergency & Critical Care
Release the tourniquet as the first tube fills: fewer haemolysed samples
A randomised trial of 790 emergency patients cut haemolysis by about a third with one change in phlebotomy technique. Also today: a lower blood pressure target in ventilated children, and the CT signs that precede death by neurological criteria.
The edition in brief
In the TOURNI-ED trial, 790 adult emergency patients of non-critical acuity had blood drawn with a cuff at 60 mm Hg; starting deflation as blood entered the first tube reduced haemolysed samples from 26.1% to 17.2% (absolute reduction 8.9 points, number needed to treat about 11). In the PRESSURE trial across 23 paediatric intensive care units, a permissive mean arterial pressure target above the fifth centile for age in 1,814 ventilated children on vasoactive drugs cut median noradrenaline-equivalent dose by 37.5% with no difference in the composite of 30-day mortality and ventilation duration, and no excess kidney replacement or adverse events. A meta-analysis of predictors of death by neurological criteria after non-traumatic brain injury found CT signs of severe mass effect after stroke (OR 3.14) and lower grey-white matter ratio after cardiac arrest most consistently associated, from limited data.
A permissive blood pressure target in ventilated children cut vasoactive drug use without worse outcomes
Consider a permissive MAP target just above the fifth centile for age in ventilated children on vasoactive drugs, guided by perfusion.
CT signs of mass effect and oedema most consistently preceded death by neurological criteria
Use CT signs of severe mass effect or diffuse oedema as a prompt for closer observation and earlier family conversations, not as a prognosis on their own.
After cardiac arrest, do not prognosticate in the first 72 hours
Delay neurological prognosis after cardiac arrest for at least 72 hours, and base it on several tests together.
Releasing the tourniquet as the first tube fills cut haemolysed emergency samples by a third
When drawing blood from stable emergency patients, start releasing the tourniquet as the first tube fills and keep stasis under a minute.
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