We are there for the good of the patient, not for the good of the protocol, not for the good of the medical director, and not for the good of the company.

- Rogue Medic

Should We Start Using a Glucose-Insulin-Potassium Cocktail

ResearchBlogging.org

For two weeks straight, JAMA released EMS-related papers that received a lot of attention from the media. A clear, irrefutable trend. :oops:

OK, this paper is just an early release of a paper that is only available online.

Those unfamiliar with research have been making the usual exaggerated claims that come from wishful thinking and not considering the possible harm from rushing to adopt a treatment based on weak evidence.

Should we rush to make this another standard treatment, that will become a Standard Of Care through inertia and tradition?

 

No.

 

Ignore the media.

There are some other things to consider. This study is examined clearly and thoroughly by a couple of very trustworthy doctors on their blogs.[1] [2]

For some different perspective, look at a graph of the numbers of patients involved and the tiny benefit –


Click on graphs to make them larger.

OK. We can ignore that the study was originally supposed to be large enough to produce statistically significant results – 15,450 people.

We can ignore that the resulting number of patients is only 6.7% of the original and that the error bars on the results are frequently much larger than the possible benefit of treatment.

Even looking at just the patients enrolled, the possible benefit loses significance after discharge.

Do we want a repeat of epinephrine?

Half a century of lack of survival benefit based on an unimportant surrogate endpoint. Is appeal to the Standard Of Care anything other than a logical fallacy?

We can provide a statistically significant benefit that disappears when you leave the hospital.

Even the authors do not make exaggerated claims.
 

Further studies are needed to assess the out-of-hospital use of GIK as therapy for patients with ACS.[3]

Maybe we should listen to the authors encouragement to not read too much into this study. Studies of 20,000 earlier patients did not show benefit. Further study is needed, not further hype.

Go read –

The IMMEDIATE trial: Should EMS give Glucose-Insulin-Potassium? by Dr. Brooks Walsh in Mill Hill Ave Command.

and

Glucose-Insulin-Potassium For MI? By Dr. Ryan Radecki in EM Literature of Note.

Footnotes:

[1] The IMMEDIATE trial: Should EMS give Glucose-Insulin-Potassium?
Mill Hill Ave Command
Wednesday, March 28, 2012
Article

[2] Glucose-Insulin-Potassium For MI?
EM Literature of Note
Friday, March 30, 2012
Dr. Ryan Radecki
Article

[3] Out-of-Hospital Administration of Intravenous Glucose-Insulin-Potassium in Patients With Suspected Acute Coronary Syndromes: The IMMEDIATE Randomized Controlled Trial.
Selker HP, Beshansky JR, Sheehan PR, Massaro JM, Griffith JL, D’Agostino RB, Ruthazer R, Atkins JM, Sayah AJ, Levy MK, Richards ME, Aufderheide TP, Braude DA, Pirrallo RG, Doyle DD, Frascone RJ, Kosiak DJ, Leaming JM, Van Gelder CM, Walter GP, Wayne MA, Woolard RH, Opie LH, Rackley CE, Apstein CS, Udelson JE.
JAMA. 2012 Mar 27. [Epub ahead of print]
PMID: 22452807 [PubMed - as supplied by publisher]

Free Full Text From JAMA

Selker HP, Beshansky JR, Sheehan PR, Massaro JM, Griffith JL, D’Agostino RB, Ruthazer R, Atkins JM, Sayah AJ, Levy MK, Richards ME, Aufderheide TP, Braude DA, Pirrallo RG, Doyle DD, Frascone RJ, Kosiak DJ, Leaming JM, Van Gelder CM, Walter GP, Wayne MA, Woolard RH, Opie LH, Rackley CE, Apstein CS, & Udelson JE (2012). Out-of-Hospital Administration of Intravenous Glucose-Insulin-Potassium in Patients With Suspected Acute Coronary Syndromes: The IMMEDIATE Randomized Controlled Trial. JAMA : the journal of the American Medical Association PMID: 22452807

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Comments

  1. Great post. Any research in EMS is exciting, and we should be enthused by it, and also enthused by the possibility of having found a new treatment (if it is effective), however like you say, this is something where there’s enough evidence to warrant further investigation, but enough doubt that we shouldn’t be rushing to implement it until further study is done. If it proves effective, great; if not, now we know. Everything in medicine merits review and scrutiny, and the last thing we need to do is implement anymore unfounded treatments into the “standard of care”.

  2. Rogue, thanks for covering this. I’ve been trying to find more tangible information on this study, and this helps tremendously.

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