Brian Levine, M.D., FACEP, FAAEM

Program Director, Emergency Medicine Residency, Christiana Care; Associate Professor, Department of Emergency Medicine, Jefferson Medical College

Publications

Immediate Stress Echocardiography for Low-Risk Chest Pain Patients in the Emergency Department: A Prospective Observational Cohort Study
Immediate Stress Echocardiography for Low-Risk Chest Pain Patients in the Emergency Department: A Prospective Observational Cohort Study
Jasani G, Papas M, Patel AJ, Jasani N, Levine B, Zhang Y, Marshall ES

J Emerg Med 2018 Feb;54(2):156-164

PMID: 29274930

Abstract

BACKGROUND: Evaluation and disposition of low-risk chest pain (CP) patients in the emergency department (ED) is time consuming and expensive. Low-risk CP often results in hospital admission to rule out myocardial infarction, which leads to additional costs and delays.
OBJECTIVE: Our aim was to assess whether an immediate exercise stress echocardiogram (IESE) in the ED will allow safe, efficient, and cost-effective evaluation and discharge of patients with low-risk CP.
METHODS: Low-risk CP patients (TIMI [Thrombolysis in Myocardial Infarction] score 0-1) presenting to the ED with normal electrocardiogram, no history of coronary artery disease, and negative troponin T received IESE. We followed these patients for major adverse cardiac events and compared them to a control cohort of similar-risk patients admitted with traditional care at 1 and 6 months.
RESULTS: We enrolled 216 patients, 117 IESE and 109 control. We obtained follow-up at 1 and 6 months in 94% of the IESE group and 88% in the control group. There was no difference in diagnostic catheterization or percutaneous coronary intervention between the 2 groups (6.0% and 1.7% vs. 6.4% and 1.8%; p = 0.89). Median time from triage to discharge was significantly shorter with IESE (572.6 min vs. 1466.0 min), resulting in significantly lower cost ($4380.50 vs. $6191.70). There were no adverse events related to IESE or early discharge.
CONCLUSIONS: In our study, IESE for low-risk CP patients presenting to the ED has the potential to be equally safe, more expeditious, and more cost effective than admission to an observation unit.
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High Single-dose Vancomycin Loading Is Not Associated With Increased Nephrotoxicity in Emergency Department Sepsis Patients
High Single-dose Vancomycin Loading Is Not Associated With Increased Nephrotoxicity in Emergency Department Sepsis Patients
Rosini JM, Davis JJ, Muenzer J, Levine BJ, Papas MA, Comer D, Arnold R

Acad Emerg Med 2016 Jun;23(6):744-6

PMID: 26850378

Abstract

OBJECTIVE: Vancomycin loading doses are recommended; however, the risk of nephrotoxicity with these doses is unknown. The primary objective of this study was to compare nephrotoxicity in emergency department (ED) sepsis patients who received vancomycin at high doses (>20 mg/kg) versus lower doses (≤20 mg/kg).
METHODS: A retrospective cohort study was performed in three academic EDs. Inclusion criteria were age ≥ 18 years, intravenous vancomycin order, and hospital admission. Exclusion criteria were no documented weight, hemodialysis-dependent, and inadequate serum creatinine (SCr) values for the measured outcome. Analyses compared the incidence of nephrotoxicity for patients who received vancomycin at high dose (>20 mg/kg) versus low dose (≤20 mg/kg).
RESULTS: A total of 2,131 consecutive patients prescribed vancomycin over 6 months were identified. Of these, 1,330 patients had three SCr values assessed for the primary outcome. High-dose initial vancomycin was associated with a significantly lower rate of nephrotoxicity (5.8% vs. 11.1%). After age, sex, and initial SCr were adjusted for, the risk of high-dose vancomycin compared to low-dose was decreased for the development of nephrotoxicity (relative risk = 0.60; 95% confidence interval = 0.44 to 0.82).
CONCLUSION: Initial dosing of vancomycin > 20 mg/kg was not associated with an increased rate of nephrotoxicity compared with lower doses. Findings from this study support compliance with initial weight-based vancomycin loading doses.
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Recidivism among ED super users after implementation of a pain protocol
Recidivism among ED super users after implementation of a pain protocol
Passarello B, Levy Z, Levine B, Papas M, Jasani N Am J Emerg Med 2015 Apr;33(4):584-6 PMID: 25601164
Abstract
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A randomized trial of loading vancomycin in the emergency department
A randomized trial of loading vancomycin in the emergency department
Rosini JM, Laughner J, Levine BJ, Papas MA, Reinhardt JF, Jasani NB

Ann Pharmacother 2015 Jan;49(1):6-13

PMID: 25358330

Abstract

BACKGROUND: Optimizing vancomycin dosing may help eradicate bacteria while avoiding resistance. The guidelines recommend loading doses; however, there are no data to demonstrate that this may result in a more rapid achievement of therapeutic troughs.
OBJECTIVE: To evaluate the percentage of troughs reaching therapeutic levels at 12, 24, and 36 hours following an initial vancomycin dose of 30 mg/kg compared with 15 mg/kg.
METHODS: This prospective, randomized study was performed in a community academic medical center. Patients who were to receive vancomycin in the emergency department were randomized to an initial traditional dose of 15 mg/kg or a 30-mg/kg loading dose followed by 15 mg/kg every 12 hours for 3 doses. Patients weighing >120 kg or with creatinine clearances <50 mL/min were excluded.
RESULTS: In total, 99 patients were enrolled; 12 hours after the initial dose of vancomycin, there was a significantly greater proportion of patients reaching target trough levels of 15 mg/L among the patients who received a loading dose as compared with a traditional dose (34% vs 3%, P < 0.01). This trend continued at 24 hours but was not statistically significant. At 36 hours, there was no difference in the percentage of patients reaching target levels between the 2 groups. No statistically significant difference in nephrotoxicity or adverse events among the 2 groups was demonstrated.
CONCLUSION: A loading dose of 30 mg/kg of vancomycin achieved a higher percentage of therapeutic levels at 12 hours when compared with the traditional dose of 15 mg/kg, without increased nephrotoxicity or adverse events.
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Ultrasound-guidance can reduce adverse events during femoral central venous cannulation
Ultrasound-guidance can reduce adverse events during femoral central venous cannulation
Powell JT, Mink JT, Nomura JT, Levine BJ, Jasani N, Nichols WL, Reed J, Sierzenski PR

J Emerg Med 2014 Apr;46(4):519-24

PMID: 24462032

Abstract

BACKGROUND: Ultrasound-guidance for internal jugular central venous cannulation (CVC) has become the recommended best practice and has been shown to improve placement success and reduce complications. There is a dearth of studies that evaluate emergency point-of-care ultrasound guidance of femoral CVC.
OBJECTIVE: Our aim was to determine if point-of-care ultrasound guidance for femoral CVC decreases adverse events and increases the likelihood of successful placement when compared with the landmark technique.
METHODS: We conducted an Institutional Review Board-approved, prospective, observational study of consecutive patients who required CVC. Physicians who performed CVC completed a standardized, web-based data sheet for a national CVC registry. We evaluated single-institution data regarding CVC site, ultrasound usage, CVC indication, and mechanical complications (e.g., pneumothorax, arterial puncture, failed access, catheter misdirection, and hematoma). The study period was between January 2006 and June 2010. Analysis using Pearson's χ(2) and Agresti-Coull binomial confidence intervals was performed; significance was defined as p < 0.05.
RESULTS: We evaluated data for 143 patients who had femoral CVC in our institution. Sixty CVCs (42%) were performed under ultrasound guidance, 83 (58%) via landmark technique (p = 0.0159); 3.3% of femoral central venous lines placed by ultrasound guidance had recorded adverse events compared with 9.6% for the landmark technique (p = 0.145). There was no statistically significant difference in complications between ultrasound-guidance and landmark techniques. Our data showed a trend toward decreased rates of arterial puncture and reduced cannulation attempts resulting in improved placement success.
CONCLUSIONS: Our experience shows that ultrasound guidance for femoral CVC might decrease complications and improve placement success, although we cannot recommend this approach without additional data. We recommend a larger study to further evaluate this technique.
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