June 5, 2013

DynaMed EBM Journal Volume 8, Issue 23

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: June 5, 2013

Expiration Date: June 5, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company

James McLellan, PhD - Senior Medical Writer, DynaMed, Ipswich, Massachusetts, USA


Dr. Ehrlich, Dr. Fleming, Dr. McLellan, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 8, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 6, 2013. Term of approval is for one year from this date with the option of yearly renewal. Each weekly updated is approved for 0.25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1304158E


Last week 536 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 168 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

Delaying Tracheostomy May Reduce Unnecessary Procedures in Mechanically Ventilated Adults without Increasing Adverse Outcomes
Reference: JAMA 2013 May 22;309(20):2121, (level 2 [mid-level] evidence)

Tracheostomy is often performed in critically ill patients when their need for mechanical ventilation is expected to be prolonged. The optimal timing for tracheostomy is unclear, because it is based on an estimate of a patient’s ongoing ventilation requirements. However, performing the tracheostomy early (within the first week of ventilation) has become increasingly common. The TracMan trial was a large multicenter randomized trial that compared early vs. late tracheostomy in 909 patients admitted to critical care units in the United Kingdom.

Adult patients (mean age 64 years) who had been on mechanical ventilation for < 4 days and were expected to remain ventilated for at least 7 more days, were randomized to 1 of 2 tracheostomy protocols. In the early tracheostomy group, patients had the procedure within 4 days of the start of ventilation. In the late tracheostomy group, the procedure was delayed until at least 10 days and performed only if still clinically indicated. Patients were followed for 2 years.

A total of 91.9% received a tracheostomy in the early group (84.6% at < 4 days) while only 44.9% of late group had the procedure (p < 0.05). There were no significant differences in 30 day mortality (30.8% with early vs. 31.5% with late tracheostomy) or 2 year mortality (51% vs. 53.7%). The median stay in critical care was 13 days in each group. Tracheostomy-related complications (primarily bleeding requiring IV fluids or additional intervention) occurred in 5.5% vs. 7.8% in the subgroup of patients who had the procedure (5.1% vs. 3.6% overall). The trial was terminated early for futility (at 54% of planned enrollment) without a prespecified stopping rule.

These data suggest that a wait-and-see approach may help minimize unnecessary tracheostomies that do not improve clinical outcomes.

For more information, see the Mechanical ventilation topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

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