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Zhang Y, Miller M, Buttfield A, Burns B, Lawrie K, Gaston J, Ferguson I. Alfentanil versus fentanyl for emergency department rapid sequence induction with ketamine: A-FAKT, a pilot randomized trial. Am J Emerg Med 2024; 84:25-32. [PMID: 39059038 DOI: 10.1016/j.ajem.2024.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 06/12/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Fentanyl is often administered during rapid sequence induction of anesthesia (RSI) in the emergency department (ED) to ameliorate the hypertensive response that may occur. Due to its more rapid onset, the use of alfentanil may be more consistent with both the onset time of the sedative and the commencement of laryngoscopy. As such, we compared the effect of alfentanil and fentanyl on post-induction hemodynamic changes when administered as part of a standardized induction regimen including ketamine and rocuronium in ED RSI. METHODS This was a double-blind pilot randomized controlled trial of adult patients requiring RSI in the ED of three urban Australian hospitals. Patients were randomized to receive either alfentanil or fentanyl in addition to ketamine and rocuronium for RSI. Non-invasive blood pressure and heart rate were measured immediately before and at two, four, and six minutes after induction. The primary outcome was the occurrence of at least one post-induction systolic blood pressure outside the pre-specified range of 100-160mmHg (with adjustment for patients with baseline hypertension). Secondary outcomes included hypertension, hypotension, hypoxia, first-pass intubation success, 30-day mortality, and the pattern of hemodynamic changes. RESULTS A total of 61 patients were included in the final analysis (31 in the alfentanil group and 30 in the fentanyl group). The primary outcome was met in 58% of the alfentanil group and 50% of the fentanyl group (difference 8%, 95% confidence interval: -17% to 33%). The 30-day mortality rate, first-pass success rate, and incidences of hypertension, hypotension, and hypoxia were similar between the groups. There were no significant differences in systolic blood pressure or heart rate between the groups at any of the measured time-points. CONCLUSION Alfentanil and fentanyl produced comparable post-induction hemodynamic changes when used as adjuncts to ketamine in ED RSI. Future studies could consider comparing different dosages of these opioids.
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Affiliation(s)
- Yichen Zhang
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, New South Wales, Australia.
| | - Matthew Miller
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Department of Anaesthesia, St George Hospital, Kogarah, New South Wales, Australia; St George and Sutherland Clinical Schools, University of New South Wales, Kogarah, New South Wales, Australia
| | - Alexander Buttfield
- Emergency Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Brian Burns
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Northern Beaches Hospital, Frenchs Forest, New South Wales, Australia; Faculty of Medicine & Health, University of Sydney, Camperdown, New South Wales, Australia; Macquarie Medical School, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Kimberley Lawrie
- Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - James Gaston
- Emergency Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Ian Ferguson
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, New South Wales, Australia; Aeromedical Operations, New South Wales Ambulance, Bankstown Aerodrome, New South Wales, Australia; Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
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Rowland BA, Motamedi V, Michard F, Saha AK, Khanna AK. Impact of continuous and wireless monitoring of vital signs on clinical outcomes: a propensity-matched observational study of surgical ward patients. Br J Anaesth 2024; 132:519-527. [PMID: 38135523 DOI: 10.1016/j.bja.2023.11.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Continuous and wireless vital sign monitoring is superior to intermittent monitoring in detecting vital sign abnormalities; however, the impact on clinical outcomes has not been established. METHODS We performed a propensity-matched analysis of data describing patients admitted to general surgical wards between January 2018 and December 2019 at a single, tertiary medical centre in the USA. The primary outcome was a composite of in-hospital mortality or ICU transfer during hospitalisation. Secondary outcomes were the odds of individual components of the primary outcome, and heart failure, myocardial infarction, acute kidney injury, and rapid response team activations. Data are presented as odds ratios (ORs) with 95% confidence intervals (CIs) and n (%). RESULTS We initially screened a population of 34,636 patients (mean age 58.3 (Range 18-101) yr, 16,456 (47.5%) women. After propensity matching, intermittent monitoring (n=12 345) was associated with increased risk of a composite of mortality or ICU admission (OR 3.42, 95% CI 3.19-3.67; P<0.001), and heart failure (OR 1.48, 95% CI 1.21-1.81; P<0.001), myocardial infarction (OR 3.87, 95% CI 2.71-5.71; P<0.001), and acute kidney injury (OR 1.32, 95% CI 1.09-1.57; P<0.001) compared with continuous wireless monitoring (n=7955). The odds of rapid response team intervention were similar in both groups (OR 0.86, 95% CI 0.79-1.06; P=0.726). CONCLUSIONS Patients who received continuous ward monitoring were less likely to die or be admitted to ICU than those who received intermittent monitoring. These findings should be confirmed in prospective randomised trials.
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Affiliation(s)
- Bradley A Rowland
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Vida Motamedi
- Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Anesthesiology, Vanderbilt School of Medicine, Nashville, TN, USA
| | | | - Amit K Saha
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA.
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Ma S, Lee J, Serban N, Yang S. Deep Attention Q-Network for Personalized Treatment Recommendation. PROCEEDINGS ... ICDM WORKSHOPS. IEEE INTERNATIONAL CONFERENCE ON DATA MINING 2023; 2023:329-337. [PMID: 38952485 PMCID: PMC11216720 DOI: 10.1109/icdmw60847.2023.00048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Tailoring treatment for severely ill patients is crucial yet challenging to achieve optimal healthcare outcomes. Recent advances in reinforcement learning offer promising personalized treatment recommendations. However, they often rely solely on a patient's current physiological state, which may not accurately represent the true health status of the patient. This limitation hampers policy learning and evaluation, undermining the effectiveness of the treatment. In this study, we propose Deep Attention Q-Network for personalized treatment recommendation, leveraging the Transformer architecture within a deep reinforcement learning framework to efficiently integrate historical observations of patients. We evaluated our proposed method on two real-world datasets: sepsis and acute hypotension patients, demonstrating its superiority over state-of-the-art methods. The source code for our model is available at https://github.com/stevenmsm/RL-ICU-DAQN.
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Götzinger F, Lauder L, Sharp ASP, Lang IM, Rosenkranz S, Konstantinides S, Edelman ER, Böhm M, Jaber W, Mahfoud F. Interventional therapies for pulmonary embolism. Nat Rev Cardiol 2023; 20:670-684. [PMID: 37173409 PMCID: PMC10180624 DOI: 10.1038/s41569-023-00876-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/15/2023]
Abstract
Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging. Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis or surgery; however, a range of percutaneous interventional technologies have been developed that are under investigation in patients with intermediate-high-risk or high-risk PE. These interventional technologies include catheter-directed thrombolysis (with or without ultrasound assistance), aspiration thrombectomy and combinations of the aforementioned principles. These interventional treatment options might lead to a more rapid improvement in right ventricular function and pulmonary and/or systemic haemodynamics in particular patients. However, evidence from randomized controlled trials on the safety and efficacy of these interventions compared with conservative therapies is lacking. In this Review, we discuss the underlying pathophysiology of PE, provide assistance with decision-making on patient selection and critically appraise the available clinical evidence on interventional, catheter-based approaches for PE treatment. Finally, we discuss future perspectives and unmet needs.
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Affiliation(s)
- Felix Götzinger
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Lucas Lauder
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
- Cardiff University, Cardiff, UK
| | - Irene M Lang
- Department of Cardiology, Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Stephan Rosenkranz
- Department of Cardiology - Internal Medicine III, Cologne University Heart Center, Cologne, Germany
- Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael Böhm
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Wissam Jaber
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Felix Mahfoud
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany.
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
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Stanton E, Gillenwater J, Pham TN, Sheckter CC. Temperature Derangement on Admission is Associated With Mortality in Burn Patients-A Nationwide Analysis and Opportunity for Improvement. J Burn Care Res 2023; 44:845-851. [PMID: 36335477 PMCID: PMC10321386 DOI: 10.1093/jbcr/irac168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Although single-institution studies have described the relationship between hypothermia, burn severity, and complications, there are no national estimates on how temperature on admission impacts hospital mortality. This study aims to evaluate the relationship between admission temperature and complications on a national scale to expose opportunities for improved outcomes. The US National Trauma Data Bank (NTDB) was analyzed between 2007 and 2018. Mortality was modeled using multivariable logistic regression including burn severity variables (% total burn surface area (TBSA), inhalation injury, emergency department (ED) temperature), demographics, and facility variables. Temperature was parsed into three categories: hypothermia (<36.0°C), euthermia (36.0-37.9°C), and hyperthermia (≥38.0°C). A total of 116,796 burn encounters were included of which 77.9% were euthermic, 20.6% were hypothermic and 1.45% were hyperthermic on admission. For every 1.0C drop in body temperature from 36.0°C, mortality increased by 5%. Both hypothermia and hyperthermia were independently associated with increased odds of mortality when controlling for age, gender, inhalation injury, number of comorbidities, and %TBSA burned (p < .001). All temperatures below 36.0°C were significantly associated with increased odds of mortality. Patients with ED temperatures between 32.5 and 33.5°C had the highest odds of mortality (22.0, 95% CI 15.6-31.0, p < .001). ED hypothermia and hyperthermia are independently associated with mortality even when controlling for known covariates associated with inpatient death. These findings underscore the importance of early warming interventions both at the prehospital stage and upon ED arrival. ED temperature could become a quality metric in benchmarking burn centers to improve mortality.
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Affiliation(s)
- Eloise Stanton
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, USA
| | - Justin Gillenwater
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, USA
| | - Tam N Pham
- Department of Surgery, University of Washington, Seattle, USA
| | - Clifford C Sheckter
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, USA
- Northern California Regional Burn Center, Santa Clara Valley Medical Center, Palo Alto,USA
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Focused Cardiac Ultrasound Training for Non-cardiologists: An Overview and Recommendations for a Lower Middle-Income Country. Crit Care Clin 2022; 38:827-837. [PMID: 36162913 DOI: 10.1016/j.ccc.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Poor outcomes among the critically ill in low- and middle-income countries (LMICs) have been attributed in part to the challenge of diagnostic delays caused by lack of skilled personnel. Focused cardiac ultrasound (FoCUS) by non-cardiologists may mitigate the shortage of echocardiography experts to perform emergency echocardiography at the point of care in these settings. It is however crucial that FoCUS training for non-cardiologists in LMICs be based on robust evidence to support training delivery if diagnostic accuracy is to be assured.
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Singer S, Pope H, Fuller BM, Gibson G. The safety and efficacy of push dose vasopressors in critically ill adults. Am J Emerg Med 2022; 61:137-142. [PMID: 36108346 DOI: 10.1016/j.ajem.2022.08.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 08/15/2022] [Accepted: 08/27/2022] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To evaluate practice patterns, efficacy, and safety of push dose pressors (PDP) in critically ill patients outside of the operating room (OR) at a large academic medical center. MATERIALS AND METHODS This was a single-center, retrospective cohort study (June 2018 to July 2020) conducted at a 1273-bed academic medical center. The primary outcome was efficacy, defined as a 25% increase in systolic blood pressure, and the cohort was analyzed according to PDP response (i.e. responders versus non-responders). A logistic regression model was used to assess predictors of response to PDPs. Safety outcomes included the incidence of hypertension, bradycardia, and tachycardia. RESULTS 1727 patients were included in the final analysis. The median doses of phenylephrine and epinephrine administered were 400 μg (IQR 200-888 μg) and 50 μg (IQR 20-100 μg). The primary outcome was achieved in 102 (71.8%) patients in the epinephrine group and 1140 (55.9%) of patients in the phenylephrine group. Adverse effects after PDP receipt were minimal, with the most common being hypertension in 6.6% and 13.4% of the phenylephrine and epinephrine groups respectively. CONCLUSIONS This study demonstrates that PDP phenylephrine and epinephrine are safe and efficacious in treating the acute hypotensive period.
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Affiliation(s)
- Sarah Singer
- Barnes-Jewish Hospital, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63110, United States of America.
| | - Hannah Pope
- Barnes-Jewish Hospital, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63110, United States of America
| | - Brian M Fuller
- Barnes-Jewish Hospital, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63110, United States of America
| | - Gabrielle Gibson
- Barnes-Jewish Hospital, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63110, United States of America
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8
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McPherson KL, Kovacic Scherrer NL, Hays WB, Greco AR, Garavaglia JM. A Review of Push-Dose Vasopressors in the Peri-operative and Critical Care Setting. J Pharm Pract 2022:8971900221096967. [PMID: 35459405 DOI: 10.1177/08971900221096967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
During hospitalization, the risk of hypotension and associated sequelae remain important considerations for patient outcomes. The use of push-dose vasopressors (PDP) outside of the operating room has increased in recent years to combat the negative effects of hypotension. This narrative review evaluates the utility of PDP in its traditional perioperative setting as well as in areas of increasing use such as the emergency department and intensive care unit. Articles evaluating PDP highlight successful increases in blood pressure with all agents but differ in rates of adverse events and most lack direct comparison of PDP agents in regard to safety and efficacy. Agents utilized as PDP, including epinephrine, phenylephrine, norepinephrine, vasopressin, and ephedrine vary in mechanism of action, onset of action, and duration of action. These variations in pharmacology along with published literature may lead to differences in the preferred PDP for various clinical scenarios. Many adverse events associated with PDP have been due to dosing errors highlighting the importance of education surrounding the use of these agents. Additional research is necessary to further elucidate the risks and benefits of PDP in clinical practice, and to determine which PDP is truly preferred. Careful consideration should be given when determining the appropriateness of this administration method of vasopressors in various clinical scenarios.
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Affiliation(s)
- Kaitlyn L McPherson
- Emergency Medicine Pharmacist, Department of Pharmacy, 20205Charleston Area Medical Center General Hospital, Charleston, WV, USA
| | | | - William B Hays
- Emergency Medicine Pharmacist, Department of Pharmacy, Indiana University Health West Hospital, Avon, IN, USA
| | - Alexandra R Greco
- Critical Care Pharmacist, Department of Pharmacy, WVU Medicine, Morgantown, WV, USA
| | - Jeffrey M Garavaglia
- Neurology Intensive Care Pharmacist, Department of Pharmacy, WVU Medicine, Morgantown, WV, USA
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Marler J, Howland R, Kimmons LA, Mohrien K, Vandigo JE, Jones GM. Safety of Propofol When Used for Rapid Sequence Intubation in Septic Patients: A Multicenter Cohort Study. Hosp Pharm 2022; 57:287-293. [PMID: 35601715 PMCID: PMC9117767 DOI: 10.1177/00185787211029547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose Septic patients are at risk for hypotension, and this risk may increase during rapid sequence intubation (RSI). Sedatives such as propofol must be used carefully due to its ability to reduce vascular sympathetic tone. Since the safety of propofol for RSI is not well described in sepsis, this was a study evaluating propofol and its effects on hemodynamics when used for RSI in a septic population. Materials and methods We conducted a multicenter, retrospective, cohort study of patients with sepsis or severe sepsis requiring sedation for RSI. Patients receiving a propofol bolus for RSI were compared to patients undergoing RSI without a propofol bolus. The safety profile of propofol was evaluated according to the rates of post-intubation hypotension and vasopressor utilization between groups. Results A total of 179 patients (79 propofol, 100 non-propofol) were evaluated. There were no differences in hypotension (81% vs 78%; P = .62) or vasopressor utilization between the propofol and non-propofol groups (43% vs 49%; P = .43). Patients in the non-propofol group had increased APACHE II scores and healthcare-associated infections. Conclusions In this cohort study, administration of propofol for RSI in patients with sepsis and severe sepsis did not increase incidence of hypotension or vasopressor use, but acute illness may have introduced provider selection bias causing less propofol use in the non-propofol group. Larger prospective studies are needed to better characterize the adverse hemodynamic effects of propofol, before propofol bolus doses for RSI can be considered for safe use in this population.
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Affiliation(s)
- Jacob Marler
- Methodist University Hospital, Memphis, TN, USA
- University of Tennessee Health Sciences Center, Memphis, TN, USA
| | | | - Lauren A. Kimmons
- Methodist University Hospital, Memphis, TN, USA
- University of Tennessee Health Sciences Center, Memphis, TN, USA
| | | | | | - G. Morgan Jones
- Methodist University Hospital, Memphis, TN, USA
- University of Tennessee Health Sciences Center, Memphis, TN, USA
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Eyeington CT, Canet E, Cutuli SL, Ancona P, Brown AJ, Jenkins E, Taylor DM, Eastwood GM, Bellomo R. COMBED: Rapid non-invasive Cardiac Output Monitoring Baseline assessment in adult Emergency Department patients with haemodynamic instability. Emerg Med Australas 2022; 34:528-538. [PMID: 34981648 DOI: 10.1111/1742-6723.13926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The application of rapid, non-operator-dependent, non-invasive cardiac output monitoring (COM) may provide early physiological information in ED patients with haemodynamic instability (HI). Our primary objective was to assess the feasibility of measuring pre-intervention (baseline) cardiac index (CI) and associated haemodynamic parameters. METHODS We performed a prospective observational study of adults shortly after presentation to the ED of a large university hospital with tachycardia or hypotension or both. We applied non-invasive COM for 5 min and recorded CI, mean arterial pressure (MAP), stroke volume index (SVI) and systemic vascular resistance index (SVRI). We assessed for differences between those presenting with hypotension or hypotension and tachycardia with tachycardia alone and between those with or without suspected infection. RESULTS We obtained haemodynamic parameters in 46 of 49 patients. In patients with hypotension or hypotension and tachycardia (n = 15) rather than tachycardia alone (n = 31), we observed a lower MAP (60.8 vs 87.7, P < 0.0001), CI (2.8 vs 3.9, P = 0.0167) and heart rate (85.5 vs 115.4, P < 0.0001). There was no difference in SVI (33.7 vs 33.4, P = 0.93) or SVRI (1970 vs 2088, P = 0.67). Patients with suspected infection had similar haemodynamic values except for a lower SVRI (1706 vs 2237, P = 0.011). CONCLUSIONS Rapid, non-operator-dependent, non-invasive COM was possible in >90% of ED patients presenting with HI. Compared with tachycardia alone, patients with hypotension had lower CI, MAP and heart rate, while those with suspected infection had a lower SVRI. This technology provides novel insights into the early state of the circulation in ED patients with HI.
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Affiliation(s)
- Christopher T Eyeington
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Division of Anaesthesia, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Emmanuel Canet
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Salvatore L Cutuli
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Paolo Ancona
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Alistair J Brown
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Emily Jenkins
- Department of Anaesthesia, Austin Hospital, Melbourne, Victoria, Australia
| | - David McD Taylor
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,ANZIC Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation Centre (DARE), Austin Hospital and The University of Melbourne, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,ANZIC Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation Centre (DARE), Austin Hospital and The University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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11
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van der Ster BJP, Kim YS, Westerhof BE, van Lieshout JJ. Central Hypovolemia Detection During Environmental Stress-A Role for Artificial Intelligence? Front Physiol 2021; 12:784413. [PMID: 34975538 PMCID: PMC8715014 DOI: 10.3389/fphys.2021.784413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/18/2021] [Indexed: 11/19/2022] Open
Abstract
The first step to exercise is preceded by the required assumption of the upright body position, which itself involves physical activity. The gravitational displacement of blood from the chest to the lower parts of the body elicits a fall in central blood volume (CBV), which corresponds to the fraction of thoracic blood volume directly available to the left ventricle. The reduction in CBV and stroke volume (SV) in response to postural stress, post-exercise, or to blood loss results in reduced left ventricular filling, which may manifest as orthostatic intolerance. When termination of exercise removes the leg muscle pump function, CBV is no longer maintained. The resulting imbalance between a reduced cardiac output (CO) and a still enhanced peripheral vascular conductance may provoke post-exercise hypotension (PEH). Instruments that quantify CBV are not readily available and to express which magnitude of the CBV in a healthy subject should remains difficult. In the physiological laboratory, the CBV can be modified by making use of postural stressors, such as lower body "negative" or sub-atmospheric pressure (LBNP) or passive head-up tilt (HUT), while quantifying relevant biomedical parameters of blood flow and oxygenation. Several approaches, such as wearable sensors and advanced machine-learning techniques, have been followed in an attempt to improve methodologies for better prediction of outcomes and to guide treatment in civil patients and on the battlefield. In the recent decade, efforts have been made to develop algorithms and apply artificial intelligence (AI) in the field of hemodynamic monitoring. Advances in quantifying and monitoring CBV during environmental stress from exercise to hemorrhage and understanding the analogy between postural stress and central hypovolemia during anesthesia offer great relevance for healthy subjects and clinical populations.
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Affiliation(s)
- Björn J. P. van der Ster
- Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Yu-Sok Kim
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Internal Medicine, Medisch Centrum Leeuwarden, Leeuwarden, Netherlands
| | - Berend E. Westerhof
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Pulmonary Medicine, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Johannes J. van Lieshout
- Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Laboratory for Clinical Cardiovascular Physiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Medical Research Council Versus Arthritis Centre for Musculoskeletal Ageing Research, Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, The Medical School, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, United Kingdom
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12
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Nam E, Fitter S, Moussavi K. Comparison of push-dose phenylephrine and epinephrine in the emergency department. Am J Emerg Med 2021; 52:43-49. [PMID: 34864289 DOI: 10.1016/j.ajem.2021.11.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/27/2021] [Accepted: 11/21/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There is limited evidence to support the efficacy and safety of push-dose vasopressor (PDP) use outside of the operating room (OR). Specifically, there are few head-to-head comparisons of different PDP in these settings. The purpose of this study was to compare the efficacy and safety of push-dose phenylephrine (PDP-PE) and epinephrine (PDP-E) in the Emergency Department (ED). METHODS This retrospective, single-center study evaluated adults given PDP-PE or PDP-E in the ED from May 2017 to November 2020. The primary outcome was a change in heart rate (HR). Secondary outcomes included changes in blood pressure, adverse effects, dosing errors, fluid and vasopressor requirements, ICU and hospital lengths of stay (LOS), and in-hospital mortality. RESULTS Ninety-six patients were included in the PDP-PE group and 39 patients in the PDP-E group. Median changes in HR were 0 [-7, 6] and - 2 [-15, 5] beats per minute (BPM) for PDP-PE and PDP-E, respectively (p = 0.138). PDP-E patients had a greater median increase in systolic blood pressure (SBP) (33 [24, 53] vs. 26 [8, 51] mmHg; p = 0.049). Dosing errors occurred more frequently in patients that received PDP-E (5/39 [12.8%] vs. 2/96 [2.1%]; p = 0.021). PDP-E patients more frequently received continuous epinephrine infusions before and after receiving PDP-E. There were no differences in adverse effects, fluid requirements, LOS, or mortality. CONCLUSION PDP-E provided a greater increase in SBP compared to PDP-PE. However, dosing errors occurred more frequently in those receiving PDP-E. Larger head-to-head studies are necessary to further evaluate the efficacy and safety of PDP-E and PDP-PE.
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Affiliation(s)
- Elizabeth Nam
- Clinical Pharmacist, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354, USA.
| | - Scott Fitter
- Clinical Pharmacy Specialist - Emergency Medicine, Loma Linda University Medical Center, Loma Linda University School of Pharmacy, 24745 Stewart St. Shryock Hall, Loma Linda, CA 92350, USA
| | - Kayvan Moussavi
- Faculty, Clinical Education, Providence St. Joseph of Orange, Department of Pharmacy Practice, College of Pharmacy, Marshall B. Ketchum University, 2575 Yorba Linda Blvd. Fullerton, CA 92831, USA.
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Bakhsh A, Alotaibi L. Push-Dose Pressors During Peri-intubation Hypotension in the Emergency Department: A Case Series. Clin Pract Cases Emerg Med 2021; 5:390-393. [PMID: 34813426 PMCID: PMC8610482 DOI: 10.5811/cpcem.2021.4.51161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/21/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Emergency physicians frequently encounter critically ill patients in circulatory shock requiring definitive airway procedures. Performing rapid sequence intubation in these patients without blood pressure correction has lethal complications. Questioning the efficacy and fearing side effects of push-dose pressors (PDP) has created an obstacle for their use in the emergency department (ED) setting. In this case series we describe the efficacy and side effects of PDP use during peri-intubation hypotension in the ED. CASE SERIES We included 11 patients receiving PDPs in this case series. The mean increase in systolic blood pressure was 41.3%, in diastolic blood pressure 44.3%, and in mean arterial pressure 35.1%. No adverse events were documented in this case series. CONCLUSION The use of push-dose pressors during peri-intubation hypotension may potentially improve hemodynamic status when used carefully in the ED.
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Affiliation(s)
- Abdullah Bakhsh
- The King Abdulaziz University, Department of Emergency Medicine, Jeddah, Saudi Arabia
| | - Leena Alotaibi
- The King Abdulaziz University, Faculty of Medicine, Jeddah, Saudi Arabia
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Taboada M, Baluja A, Park SH, Otero P, Gude C, Bolón A, Ferreiroa E, Tubio A, Cariñena A, Caruezo V, Alvarez J, Atanassoff PG. Complications during repeated tracheal intubation in the Intensive Care Unit. A prospective, observational study comparing the first intubation and the reintubation. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:384-391. [PMID: 34353767 DOI: 10.1016/j.redare.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 11/02/2020] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND GOAL OF THE STUDY The goal of the study was to compare the incidence of complications, technical difficulty of intubation and physiologic pre-intubation status between the first intubation and reintubation performed on the same patient in an ICU. MATERIALS AND METHODS The study was approved by the ethics committee of Galicia (Santiago-Lugo, code No. 2015-012). Due to the observational, noninterventional, and noninvasive design of this study, the need for written consent was waived by the ethics committee of Galicia. Patients requiring tracheal intubation and reintubation in the ICU were included in this prospective observational study. Main endpoint was to compare the incidence of complications, physiologic pre-intubation status, and the rate of technical difficulty of intubation between the first intubation and reintubation performed on the same patient in an ICU. RESULTS AND DISCUSSION 504 patients were intubated in our ICU during the study period, and 82 (16%) required reintubation. There was no difference between the first intubation and reintubation regarding number of total complication (35% vs 33%; P = ,86), hypotension (24% vs 24%; P = 1), hypoxia (26% vs 26%; P = 1), esophageal intubation (1% vs 1%; P = 1), and bronchoaspiration (2% vs 1%; P = ,86). Physiologic pre-intubation status and technical difficulty of intubation did not differ between the first intubation and reintubation. CONCLUSIONS In our ICU patients requiring tracheal reintubation, incidence of complications, physiologic pre-intubation status, and technical difficulty of intubation did not differ between the first intubation and reintubation.
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Affiliation(s)
- M Taboada
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain.
| | - A Baluja
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - S H Park
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - P Otero
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - C Gude
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - A Bolón
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - E Ferreiroa
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - A Tubio
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - A Cariñena
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - V Caruezo
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - J Alvarez
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
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Young TL. A narrative review of paracetamol-induced hypotension: Keeping the patient safe. Nurs Open 2021; 9:1589-1601. [PMID: 34102027 PMCID: PMC8994964 DOI: 10.1002/nop2.943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/01/2021] [Accepted: 04/28/2021] [Indexed: 12/21/2022] Open
Abstract
Aim To understand the prevalence and epidemiology of paracetamol‐induced hypotension and clinical implications for contemporaneous practice. Design Narrative review. Methods In May and June 2020, an open‐date literature search of English publications indexed in ProQuest, PubMed, and EBSCO was conducted with the search terms ‘acetaminophen’ and ‘hypotension’ and related search combinations (‘paracetamol’, ‘propacetamol’, ‘low blood pressure’, ‘fever’, ‘sepsis’, and ‘shock’) to identify peer‐reviewed publications of blood pressure changes after paracetamol administration in humans. Results A pattern of blood pressure reduction following the administration of paracetamol is demonstrated in the 27 studies included in this review. Haemodynamic intervention often followed persistent blood pressure reduction, and was greatest in febrile critically ill patients who received parenteral paracetamol.
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Affiliation(s)
- Tricia L Young
- Australia and Bairnsdale Regional Health Service, University of New England, Armadale, VIC, Australia
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Pre-hospital predictors of an adverse outcome among patients with dyspnoea as the main symptom assessed by pre-hospital emergency nurses - a retrospective observational study. BMC Emerg Med 2020; 20:89. [PMID: 33172409 PMCID: PMC7653705 DOI: 10.1186/s12873-020-00384-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/30/2020] [Indexed: 01/10/2023] Open
Abstract
Background Dyspnoea is one of the most common reasons for patients contacting emergency medical services (EMS). Pre-hospital Emergency Nurses (PENs) are independently responsible for advanced care and to meet these patients individual needs. Patients with dyspnoea constitute a complex group, with multiple different final diagnoses and with a high risk of death. This study aimed to describe on-scene factors associated with an increased risk of a time-sensitive final diagnosis and the risk of death. Methods A retrospective observational study including patients aged ≥16 years, presenting mainly with dyspnoea was conducted. Patients were identified thorough an EMS database, and were assessed by PENs in the south-western part of Sweden during January to December 2017. Of 7260 missions (9% of all primary missions), 6354 were included. Among those, 4587 patients were randomly selected in conjunction with adjusting for unique patients with single occasions. Data were manually collected through both EMS- and hospital records and final diagnoses were determined through the final diagnoses verified in hospital records. Analysis was performed using multiple logistic regression and multiple imputations. Results Among all unique patients with dyspnoea as the main symptom, 13% had a time-sensitive final diagnosis. The three most frequent final time-sensitive diagnoses were cardiac diseases (4.1% of all diagnoses), infectious/inflammatory diseases (2.6%), and vascular diseases (2.4%). A history of hypertension, renal disease, symptoms of pain, abnormal respiratory rate, impaired consciousness, a pathologic ECG and a short delay until call for EMS were associated with an increased risk of a time-sensitive final diagnosis. Among patients with time-sensitive diagnoses, approximately 27% died within 30 days. Increasing age, a history of renal disease, cancer, low systolic blood pressures, impaired consciousness and abnormal body temperature were associated with an increased risk of death. Conclusions Among patients with dyspnoea as the main symptom, age, previous medical history, deviating vital signs, ECG pattern, symptoms of pain, and a short delay until call for EMS are important factors to consider in the prehospital assessment of the combined risk of either having a time-sensitive diagnosis or death. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12873-020-00384-1.
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Bankhead-Kendall B, Teixeira P, Roward S, Ali S, Ryder A, Sahi S, Cardenas T, Aydelotte J, Coopwood B, Brown C. Narrow pulse pressure is independently associated with massive transfusion and emergent surgery in hemodynamically stable trauma patients. Am J Surg 2020; 220:1319-1322. [DOI: 10.1016/j.amjsurg.2020.06.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/01/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
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Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport. Prehosp Disaster Med 2020; 35:495-500. [PMID: 32698933 DOI: 10.1017/s1049023x20000886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency. METHODS This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement <90mmHg. A dose of 20mcg every two minutes, as needed, was allowed per protocol. The primary data source was the EMS electronic medical record. RESULTS Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals. CONCLUSION These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.
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Yun D, Choi Y, Lee SP, Park KW, Koo BK, Kim HS, Kim DK, Joo KW, Kim YS, Han SS. Blood Pressure and Renal Progression in Patients Undergoing Percutaneous Coronary Intervention. Am J Hypertens 2020; 33:676-684. [PMID: 32179915 DOI: 10.1093/ajh/hpaa046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 02/28/2020] [Accepted: 03/12/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND High blood pressure (BP) may impair renal function following percutaneous coronary intervention (PCI). However, the predictability of renal progression based on admission and discharge BP and BP threshold values remains unclear. METHODS A total of 8,176 adult patients who underwent PCI at Seoul National University Hospital from 2006 to 2016 were retrospectively analyzed. Renal progression was defined as a doubling of serum creatinine levels, ≥50% decrease of the estimated glomerular filtration rate, or development of end-stage renal disease. The risk of renal progression according to admission BP (any time) and discharge BP (8:00-10:00 am) was evaluated by multivariable Cox and additive generalized models with penalized splines. RESULTS During a median follow-up of 7 years (maximum: 13 years), 9.3% of patients (n = 758) reached renal progression. BP between admission and discharge showed a low correlation, and all BP parameters showed a nonlinear relationship with renal progression. Systolic BP at discharge (SBPd) was selected as the best predictor of renal progression because the delta for the Akaike information criterion from the baseline model to the model with BP parameters was the lowest. The risk of renal progression started to increase at SBPd ≥ 125 mm Hg. This increasing risk of renal progression with SBPd ≥ 125 mm Hg remained significant, despite adjusting for the competing risk of all-cause death. CONCLUSIONS High SBPd is associated with renal progression following PCI, particularly when it is ≥125 mm Hg. This can be used as a risk classification and potential target of renoprotective therapies.
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Affiliation(s)
- Donghwan Yun
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Division of Nephrology, Seoul National University Hospital, Seoul, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Division of Nephrology, Seoul National University Hospital, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Division of Nephrology, Seoul National University Hospital, Seoul, Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Division of Nephrology, Seoul National University Hospital, Seoul, Korea
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Black LP, Puskarich MA, Smotherman C, Miller T, Fernandez R, Guirgis FW. Time to vasopressor initiation and organ failure progression in early septic shock. J Am Coll Emerg Physicians Open 2020; 1:222-230. [PMID: 33000037 PMCID: PMC7493499 DOI: 10.1002/emp2.12060] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/26/2020] [Accepted: 03/13/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Research evaluating the relationship between vasopressor initiation timing and clinical outcomes is limited and conflicting. We investigated the association between time to vasopressors, worsening organ failure, and mortality in patients with septic shock. METHODS This was a retrospective study of patients with septic shock (2013-2016) within 24 hours of emergency department (ED) presentation. The primary outcome was worsening organ failure, defined as an increase in Sequential Organ Failure Assessment (SOFA) score ≥2 at 48 hours compared to baseline, or death within 48 hours. The secondary outcome was 28-day mortality. Time to vasopressor initiation was categorized into 6, 4-hour intervals from time of ED triage. Multiple logistic regression was used to identify predictors of worsening organ failure. RESULTS We analyzed data from 428 patients with septic shock. There were 152 patients with the composite primary outcome (SOFA increase ≥2 or death at 48 hours). Of these, 77 patients died in the first 48 hours and 75 patients had a SOFA increase ≥2. Compared to the patients who received vasopressors in the first 4 hours, those with the longest time to vasopressors (20-24 hours) had increased odds of developing worsening organ failure (odds ratios [OR] = 4.34, 95% confidence intervals [CI] = 1.47-12.79, P = 0.008). For all others, the association between vasopressor timing and worsening organ failure was non-significant. There was no association between time to vasopressor initiation and 28-day mortality. CONCLUSIONS Increased time to vasopressor initiation is an independent predictor of worsening organ failure for patients with vasopressor initiation delays >20 hours.
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Affiliation(s)
- Lauren Page Black
- Department of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFlorida
| | - Michael A. Puskarich
- Department of Emergency MedicineUniversity of MinnesotaMinneapolisMinnesota
- Hennepin County Medical CenterMinneapolisMinnesota
| | - Carmen Smotherman
- Center for Data SolutionsUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFlorida
| | - Taylor Miller
- Department of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFlorida
| | - Rosemarie Fernandez
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFlorida
- Center for Experiential Learning and SimulationUniversity of Florida College of MedicineGainesvilleFlorida
| | - Faheem W. Guirgis
- Department of Emergency MedicineUniversity of Florida College of Medicine‐JacksonvilleJacksonvilleFlorida
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Factors Affecting Mortality in Patients Admitted to the Hospital by Emergency Physicians despite Disagreement with Other Specialties. Emerg Med Int 2020; 2020:2173691. [PMID: 32257444 PMCID: PMC7094204 DOI: 10.1155/2020/2173691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 11/27/2019] [Accepted: 02/11/2020] [Indexed: 11/25/2022] Open
Abstract
Background Emergency physicians (EPs) face critical admission decisions, and their judgments are questioned in some developing systems. This study aims to define the factors affecting mortality in patients admitted to the hospital by EPs against in-service departments' decision and evaluate EPs' admission diagnosis with final discharge diagnosis. Methods This is a retrospective analysis of prospectively collected data of ten consecutive years (2008–2017) of an emergency department of a university medical center. Adult patients (≥18 years-old) who were admitted to the hospital by EPs against in-service departments' decision were enrolled in the study. Significant factors affecting mortality were defined by the backward logistic regression model. Results 369 consecutive patients were studied, and 195 (52.8%) were males. The mean (SD) age was 65.5 (17.3) years. The logistic regression model showed that significant factors affecting mortality were intubation (p < 0.0001), low systolic blood pressure (p = 0.006), increased age (p = 0.013), and having a comorbidity (p = 0.024). There was no significant difference between EPs' primary admission diagnosis and patient's final primary diagnosis at the time of disposition from the admitted departments (McNemar–Bowker test, p = 0.45). 96% of the primary admission diagnoses of EPs were correct. Conclusions Intubation, low systolic blood pressure on presentation, increased age, and having a comorbidity increased the mortality. EPs admission diagnoses were highly correlated with the final diagnosis. EPs make difficult admission decisions with high accuracy, if needed.
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Abstract
Introduction: The knowledge of the etiology and associated mortality of undifferentiated shock in the emergency department (ED) is limited. We aimed to describe the etiology-based proportions and incidence rates (IR) of shock, as well as the associated mortality in the ED. Methods: Population-based cohort study at a University Hospital ED in Denmark from January 1, 2000, to December 31, 2011. Patients aged ≥18 years living in the ED-catchment area (N = 225,000) with a first-time ED presentation with shock (n = 1,553) defined as hypotension (systolic blood pressure ≤100 mm Hg) and ≥1 organ failures were included. Discharge diagnoses defined the etiology and were grouped as follows: distributive septic shock (SS), distributive non-septic shock (NS), cardiogenic shock (CS), hypovolemic shock (HS), obstructive shock (OS), and other conditions (OC). Outcomes were etiology-based characteristics, annual IR per 100,000 person-years at risk (95% confidence intervals [CIs]), mortality at 0 to 7-, and 0 to 90 days (95% CIs) and hazard rates (HR) at 0 to 7, 8 to 90 days (95% CIs). Poisson and Cox regression models were used for analyses. Results: Among 1,553 shock patients: 423 (27.2%) had SS, 363 (23.4%) NS, 217 (14.0%) CS, 479 (30.8%) HS, 14 (0.9%) OS, and 57 (3.7%) OC. The corresponding IRs were 16.2/100,000 (95% CI: 14.8–17.9), 13.9/100,000 (95% CI: 12.6–15.4), 8.3/100,000 (95% CI: 7.3–9.5), 18.4/100,000 (95% CI: 16.8–20.1), 0.5/100,000 (95% CI: 0.3–0.9), and 2.2/100,000 (95% CI: 1.7–2.8). SS IR increased from 8.4 to 28.5/100,000 during the period 2000 to 2011. Accordingly, the 7-, and 90-day mortalities of SS, NS, CS, and HS were 30.3% (95% CI: 25.9–34.7) and 56.2% (95% CI: 50.7–61.5), 12.7% (95% CI: 9.2–16.1) and 22.6% (95% CI: 18.1–27.7), 34.6% (95% CI: 28.2–40.9) and 52.3% (95% CI: 44.6–59.8), 19.2% (95% CI: 15.7–22.7), and 36.8% (95% CI: 33.3–43.3). SS (HR = 1.46 [95% CI: 1.03–2.07]), and CS (HR = 2.15 [95% CI: 1.47–3.13]) were independent predictors of death within 0 to 7 days, whereas SS was a predictor within 8 to 90 days (HR = 1.66 [95% CI: 1.14–2.42]). Conclusion: HS and SS are frequent etiological characteristics followed by NS and CS, whereas OS is a rare condition. We confirm the increasing trend of SS, as previously reported. Seven-day mortality ranged from 12.7% to 34.6%, while 90-day mortality ranged from 22.6% to 56.2%. The underlying etiology was an independent predictor of mortality.
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Duclos G, Baumstarck K, Dünser M, Zieleskiewicz L, Leone M. Effects of the discontinuation sequence of norepinephrine and vasopressin on hypotension incidence in patients with septic shock: A meta-analysis. Heart Lung 2019; 48:560-565. [DOI: 10.1016/j.hrtlng.2019.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 01/26/2023]
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Postoperative ward monitoring - Why and what now? Best Pract Res Clin Anaesthesiol 2019; 33:229-245. [PMID: 31582102 DOI: 10.1016/j.bpa.2019.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 06/11/2019] [Accepted: 06/17/2019] [Indexed: 12/20/2022]
Abstract
The postoperative ward is considered an ideal nursing environment for stable patients transitioning out of the hospital. However, approximately half of all in-hospital cardiorespiratory arrests occur here and are associated with poor outcomes. Current monitoring practices on the hospital ward mandate intermittent vital sign checks. Subtle changes in vital signs often occur at least 8-12 h before an acute event, and continuous monitoring of vital signs would allow for effective therapeutic interventions and potentially avoid an imminent cardiorespiratory arrest event. It seems tempting to apply continuous monitoring to every patient on the ward, but inherent challenges such as artifacts and alarm fatigue need to be considered. This review looks to the future where a continuous, smarter, and portable platform for monitoring of vital signs on the hospital ward will be accompanied with a central monitoring platform and machine learning-based pattern detection solutions to improve safety for hospitalized patients.
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Coeckelenbergh S, Van Nuffelen M, Mélot C. Sepsis is frequent in initially non-critical hypotensive emergency department patients and is associated with increased mortality. Am J Emerg Med 2019; 37:2242-2245. [PMID: 31466913 DOI: 10.1016/j.ajem.2019.158360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 07/08/2019] [Accepted: 07/21/2019] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Hypotension, defined as a mean arterial pressure of maximum 70 mmHg, is associated with significant morbidity and mortality. The objective of this study was to determine in initially non-critical hypotensive adult patients the proportion of sepsis and if septic patients had different outcome and clinical factors than non-septic patients. METHODS This retrospective observational study was conducted over a year on adult hypotensive emergency department patients initially considered by triage as non-critical. Patients were separated into three groups: hypotensive septic patients (HSP), hypotensive non-septic infected patients (HNSIP), and other hypotensive patients (OHP). Clinical scores, signs, length of stay (LOS), and mortality were compared using analysis of variance for continuous variables and chi-square analysis for categorical variables. RESULTS There were 136 (35.5%) septic patients, 37 (9.7%) with non-septic infection, and 210 (54.8%) with another cause of hypotension. Overall in-hospital mortality was 12.0% and total mortality was greater in HSP than in HNSIP (20.6% vs. 5.4%, p = 0.031) or OHP (20.6 vs. 7.6%, p < 0.001). LOS was greater for HSP when compared to HNSIP (median(IQR): 9(6-17) vs. 6(1-13), p = 0.004) and OHP (median(IQR): 9(6-17) vs. 3(1-8) days, p < 0.0001). CONCLUSION Sepsis in a priori non-critical hypotensive adult patients, when compared with other causes of hypotension, is associated with significantly higher mortality and increased LOS. Patients that present to the emergency department and have a MAP of 70mmHg or less must be rigorously evaluated and have consistent follow-up.
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Affiliation(s)
- Sean Coeckelenbergh
- Anesthesia Department, Erasme University Hospital, Lennik street 808, B-1070 Brussels, Belgium
| | - Marc Van Nuffelen
- Emergency Department, Erasme University Hospital, Lennik street 808, B-1070 Brussels, Belgium
| | - Christian Mélot
- Emergency Department, Erasme University Hospital, Lennik street 808, B-1070 Brussels, Belgium.
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Cole JB, Knack SK, Karl ER, Horton GB, Satpathy R, Driver BE. Human Errors and Adverse Hemodynamic Events Related to "Push Dose Pressors" in the Emergency Department. J Med Toxicol 2019; 15:276-286. [PMID: 31270748 DOI: 10.1007/s13181-019-00716-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/03/2019] [Accepted: 06/10/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Though the use of small bolus doses of vasopressors, termed "push dose pressors," has become common in emergency medicine, data examining this practice are scant. Push dose pressors frequently involve bedside dilution, which may result in errors and adverse events. The objective of this study was to assess for instances of human error and adverse hemodynamic events during push dose pressor use in the emergency department. METHODS This was a structured chart and video review of all patients age ≥ 16 years undergoing resuscitation and receiving push dose pressors from a single center from January 2010 to November 2017. Push dose pressors were defined as intended intravenous boluses of phenylephrine (any dose) or epinephrine (≤ 100 mcg). RESULTS A total of 249 patients were analyzed. Median age was 60 years (range, 16-97), 58% were male, 49% survived to discharge. Median initial epinephrine dose was 20 mcg (n = 139, IQR 10-100, range 1-100); median phenylephrine dose was 100 mcg (n = 110, IQR 100-100, range 25-10,000). Adverse hemodynamic events occurred in 98 patients (39%); 30 in the phenylephrine group (27%; 95% CI, 19-36%), and 68 in the epinephrine group (50%; 95% CI, 41-58%). Human errors were observed in 47 patients (19%), including 7 patients (3%) experiencing dosing errors (all overdoses; range, 2.5- to 100-fold) and 43 patients (17%) with a documentation error. Only one dosing error occurred when a pharmacist was present. CONCLUSIONS Human errors and adverse hemodynamic events were common with the use of push dose pressors in the emergency department. Adverse hemodynamic events were more common than in previous studies. Future research should determine if push dose pressors improve outcomes and if so, how to safely implement them into practice.
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Affiliation(s)
- Jon B Cole
- Department of Emergency Medicine, Hennepin Healthcare, 701 Park Ave, Mail Code RL.240, Minneapolis, MN, 55415, USA.
| | - Sarah K Knack
- Department of Emergency Medicine, Hennepin Healthcare, 701 Park Ave, Mail Code RL.240, Minneapolis, MN, 55415, USA.,Duke University School of Medicine, Durham, NC, USA
| | - Erin R Karl
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Gabriella B Horton
- Department of Emergency Medicine, Hennepin Healthcare, 701 Park Ave, Mail Code RL.240, Minneapolis, MN, 55415, USA
| | - Rajesh Satpathy
- Department of Emergency Medicine, Hennepin Healthcare, 701 Park Ave, Mail Code RL.240, Minneapolis, MN, 55415, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin Healthcare, 701 Park Ave, Mail Code RL.240, Minneapolis, MN, 55415, USA
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Pulse Pressure as an Early Warning of Hemorrhage in Trauma Patients. J Am Coll Surg 2019; 229:184-191. [PMID: 31103597 DOI: 10.1016/j.jamcollsurg.2019.03.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hypotension based on low systolic blood pressure (SBP) is a well-documented indicator of ongoing blood loss. However, the utility of pulse pressure (PP) for detection of hemorrhage has not been well studied. The purpose of this study was to determine whether a narrowed PP in nonhypotensive patients is an independent predictor of critical administration threshold (CAT+) hemorrhage requiring surgical or endovascular control. STUDY DESIGN We performed a retrospective single-center study (January 2010 to October 2014), including trauma patients ≥16 years old with SBP ≥ 90 mmHg upon emergency department (ED) admission. We identified patients who were both CAT+ and required either surgical or interventional radiology for definitive hemorrhage control as the active hemorrhage (AH) group. Analyses were then performed to elucidate the association between PP and hemorrhage. RESULTS Of the total 18,015 patients identified, 283 (1.6%) met the criteria for clinically significant hemorrhage. Mean PP was significantly lower in the AH group compared with the non-AH group (39 ± 18 mmHg vs 53 ± 19 mmHg, p < 0.0001). Multivariate analysis revealed that narrowed initial ED PP is an independent predictor of AH (adjusted odds ratio [AOR] 0.975) along with age (AOR 1.01), penetrating mechanism (AOR 9.476), field SBP (AOR 0.985), ED heart rate (AOR 1.024), and Injury Severity Score (AOR 1.126). Cutoff analysis of PP values identified a significantly higher risk of AH at a PP cutoff of 55 mmHg (AOR 3.44, p = 0.005, AUC 0.955) in patients 61 years or older vs 40 mmHg (AOR 2.73, p < 0.0001, AUC 0.940) for patients 16 to 60 years old. The predicted probability of AH increases as PP narrows. CONCLUSIONS In patients who are nonhypotensive, a narrowed PP is an independent early predictor of active hemorrhage requiring blood product transfusion and intervention for hemorrhage control.
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Cross R, Considine J, Currey J. Nursing handover of vital signs at the transition of care from the emergency department to the inpatient ward: An integrative review. J Clin Nurs 2018; 28:1010-1021. [DOI: 10.1111/jocn.14679] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 09/03/2018] [Accepted: 09/13/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Rachel Cross
- School of Nursing and Midwifery Deakin University Burwood Victoria Australia
- School of Nursing and Midwifery La Trobe University Melbourne Victoria Australia
| | - Julie Considine
- Centre for Quality and Patient Safety Research School of Nursing and Midwifery Deakin University Geelong Victoria Australia
- Centre for Quality and Patient Safety Research Eastern Health Partnership Box Hill Victoria Australia
| | - Judy Currey
- Centre for Quality and Patient Safety Research School of Nursing and Midwifery Deakin University Geelong Victoria Australia
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30
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Swenson K, Rankin S, Daconti L, Villarreal T, Langsjoen J, Braude D. Safety of bolus-dose phenylephrine for hypotensive emergency department patients. Am J Emerg Med 2018; 36:1802-1806. [DOI: 10.1016/j.ajem.2018.01.095] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/30/2018] [Indexed: 11/29/2022] Open
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31
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Maheshwari K, Turan A, Mao G, Yang D, Niazi AK, Agarwal D, Sessler DI, Kurz A. The association of hypotension during non-cardiac surgery, before and after skin incision, with postoperative acute kidney injury: a retrospective cohort analysis. Anaesthesia 2018; 73:1223-1228. [PMID: 30144029 DOI: 10.1111/anae.14416] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2018] [Indexed: 12/15/2022]
Abstract
Intra-operative hypotension is associated with acute postoperative kidney injury. It is unclear how much hypotension occurs before skin incision compared with after, or whether hypotension in these two periods is similarly associated with postoperative kidney injury. We analysed the association of mean arterial pressure < 65 mmHg with postoperative kidney injury in 42,825 patients who were anaesthetised for elective non-cardiac surgery. Intra-operative hypotension occurred in 30,423 (71%) patients: 22,569 (53%) patients before skin incision; and 24,102 (56%) patients after incision. Anaesthetised patients who were hypotensive had mean arterial pressures < 65 mmHg for a median (IQR [range]) of 5.5 (0.0-14.7 [0.0-60.0]) min.h-1 before skin incision, compared with 1.7 [0.3-5.1 [0.0-57.5]) min.h-1 after incision: a median (IQR [range]) of 36% (0%-84% [0%-100%]) of hypotensive readings were before incision. We diagnosed postoperative kidney injury in 2328 (5%) patients. The odds ratio (95%CI) for acute kidney injury was 1.05 (1.02-1.07) for each doubling of the duration of hypotension, p < 0.001. Postoperative kidney injury was associated with the product of hypotension duration and severity, that is, area under the curve, before skin incision and after, odds ratio (95%CI): 1.02 (1.01-1.04), p = 0.004; and 1.02 (1.00-1.04), p = 0.016, respectively. A substantial fraction of all hypotension happened before surgical incision and was thus completely due to anaesthetic management. We recommend that anaesthetists should avoid mean arterial pressure < 65 mmHg during surgery, especially after induction, assuming that its association with postoperative kidney injury is, at least in part, causal.
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Affiliation(s)
- K Maheshwari
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, OH, USA
| | - A Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, OH, USA
| | - G Mao
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, OH, USA
| | - D Yang
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, OH, USA
| | - A K Niazi
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, OH, USA
| | - D Agarwal
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, OH, USA
| | - D I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, OH, USA
| | - A Kurz
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, OH, USA
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32
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Early Liberal Fluid Therapy for Sepsis Patients Is Not Harmful: Hydrophobia Is Unwarranted but Drink Responsibly. Crit Care Med 2018; 44:2263-2269. [PMID: 27749314 PMCID: PMC5113226 DOI: 10.1097/ccm.0000000000002145] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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33
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Lee M, Taylor DM, Ugoni A. The association between abnormal vital sign groups and undesirable patient outcomes. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907917752959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: To determine the association between both abnormal individual vital signs and abnormal vital sign groups in the emergency department, and undesirable patient outcomes: hospital admission, medical emergency team calls and death. Method: We undertook a prospective cohort study in a tertiary referral emergency department (February–May 2015). Vital signs were collected prospectively in the emergency department and undesirable outcomes from the medical records. The primary outcomes were undesirable outcomes for individual vital signs (multivariate logistic regression) and vital sign groups (univariate analyses). Results: Data from 1438 patients were analysed. Admission was associated with tachycardia, tachypnoea, fever, ≥1 abnormal vital sign on admission to the emergency department, ≥1 abnormal vital sign at any time in the emergency department, a persistently abnormal vital sign, and vital signs consistent with both sepsis (tachycardia/hypotension/abnormal temperature) and pneumonia (tachypnoea/fever) (p < 0.05). Medical emergency team calls were associated with tachycardia, tachypnoea, ≥1 abnormal vital sign on admission (odds ratio: 2.3, 95% confidence interval: 1.4–3.8), ≥2 abnormal vital signs at any time (odds ratio: 2.4, 95% confidence interval: 1.2–4.7), and a persistently abnormal vital sign (odds ratio: 2.7, 95% confidence interval: 1.6–4.6). Death was associated with Glasgow Coma Score ≤13 (odds ratio: 6.3, 95% confidence interval: 2.5–16.0), ≥1 abnormal vital sign on admission (odds ratio: 2.6, 95% confidence interval: 1.2–5.6), ≥2 abnormal vital signs at any time (odds ratio: 6.4, 95% confidence interval: 1.4–29.5), a persistently abnormal vital sign (odds ratio: 4.3, 95% confidence interval: 2.0–9.0), and vital signs consistent with pneumonia (odds ratio: 5.3, 95% confidence interval: 1.9–14.8). Conclusion: Abnormal vital sign groups are generally superior to individual vital signs in predicting undesirable outcomes. They could inform best practice management, emergency department disposition, and communication with the patient and family.
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Affiliation(s)
- Marina Lee
- Emergency Department, Austin Hospital, Heidelberg, VIC, Australia
| | - David McD Taylor
- Emergency Department, Austin Hospital, Heidelberg, VIC, Australia
- Department of Medicine and Radiology, The University of Melbourne, Parkville, VIC, Australia
| | - Antony Ugoni
- Department of Physiotherapy, The University of Melbourne, Parkville, VIC, Australia
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34
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Oliveira-Paula GH, Pinheiro LC, Ferreira GC, Garcia WNP, Lacchini R, Garcia LV, Tanus-Santos JE. Angiotensin converting enzyme inhibitors enhance the hypotensive effects of propofol by increasing nitric oxide production. Free Radic Biol Med 2018; 115:10-17. [PMID: 29138017 DOI: 10.1016/j.freeradbiomed.2017.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 11/04/2017] [Accepted: 11/09/2017] [Indexed: 10/18/2022]
Abstract
Propofol anesthesia is usually accompanied by hypotension. Studies have shown that the hypotensive effects of propofol increase in patients treated with angiotensin-converting enzyme inhibitors (ACEi). Given that both propofol and ACEi affect nitric oxide (NO) signaling, the present study tested the hypothesis that ACEi treatment induces pronounced hypotensive responses to propofol by increasing NO bioavailability. In this study we evaluated 65 patients, divided into three groups: hypertensive patients chronically treated with ACEi (HT-ACEi; n = 21), hypertensive patients treated with other antihypertensive drugs instead of ACEi, such as angiotensin II receptor blockers, β-blockers or diuretics (HT; n = 21) and healthy normotensive subjects (NT; n = 23). Venous blood samples were collected at baseline and after 10min of anesthesia with propofol 2mg/kg administrated intravenously by bolus injection. Hemodynamic parameters were recorded at each blood sample collection. Nitrite levels were determined by using an ozone-based chemiluminescence assay, while NOx (nitrites+nitrates) levels were measured by using the Griess reaction. Additionally, experimental approaches were used to validate our clinical findings. Higher decreases in blood pressure after propofol anesthesia were observed in HT-ACEi group as compared with those found in NT and HT groups. Consistently, rats treated with the ACEi enalapril showed more intense hypotensive responses to propofol. The hypotensive effects of propofol were associated with increased NO production in both clinical and experimental approaches. Enhanced increases in nitrite levels after propofol anesthesia were observed in HT-ACEi patients compared with NT and HT groups. Accordingly, rats treated with enalapril showed increased vascular NO formation after propofol anesthesia compared with rats receiving vehicle. Our data show that ACEi enhance the hypotensive responses to propofol anesthesia and increase nitrite concentrations. These findings suggest that increased NO bioavailability may account for the enhanced hypotensive effects of propofol in ACEi-treated patients.
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Affiliation(s)
- Gustavo H Oliveira-Paula
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Lucas C Pinheiro
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Graziele C Ferreira
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Waynice N P Garcia
- Department of Biomechanics, Medicine and Rehabilitation of the Locomotor System, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Riccardo Lacchini
- Department of Psychiatric Nursing and Human Sciences, Ribeirao Preto College of Nursing, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Luis V Garcia
- Department of Biomechanics, Medicine and Rehabilitation of the Locomotor System, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Jose E Tanus-Santos
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil.
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35
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Dine SE, Soyuncu S, Dinc B, Oskay A, Bektas F. The Effect of the Emergency Physicians' Clinical Decision of Targeted Ultrasonography Application in Non-Traumatic Shock Patients. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791502200605] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Clinical evaluation of non-traumatic shock patients with high risk of mortality and morbidity is problematic for emergency physicians. In this study, changes in the investigations, diagnosis and treatment decision of the physicians using the Abdominal and Cardiac Evaluation with Sonography in Shock (ACES) protocol were examined. Methods In this clinical prospective study, the patients were ultrasonographically examined within the scope of the ACES protocol at 6 quadrants including cardiac, pleural, peritoneal, inferior vena cava and aorta. Pre- and post-US investigations, diagnoses and treatments were compared. Results A total of 141 patients were included in this study. Of these, 92 (65.2%) of the patients were males and 49 (34.8%) were females. The average age of the patients was 62.9±16.8 years (18-97). After the ultrasonographic evaluation, request for new investigations was needed in 25 (17%), and modification of the treatment was needed in 57 (40.4%) of the patients. It was seen that with a targeted ultrasonography (US), the number of the considered pre-diagnoses decreased in 51 (36.2%) of the patients, and the physicians made a new pre-diagnosis in 6 (4.3%) of the patients. When the pre-diagnoses made by the physicians after the US and the final diagnoses clinically made at the end of the follow-up process were compared, there were no changes in the diagnoses in 124 (87.9%) patients. Conclusion Ultrasonographic examination is considered useful for rapid evaluation, early diagnosis and treatment planning in non-traumatic shock patients in emergency department. (Hong Kong j.emerg.med. 2015;22:364-370)
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Affiliation(s)
- SE Dine
- Isparta State Hospital, Department of Emergency Medicine, Isparta, Turkey
| | - S Soyuncu
- Akdeniz University Faculty of Medicine, Department of Emergency Medicine, Antalya, Turkey
| | | | - A Oskay
- Denizli State Hospital, Department of Emergency Medicine, Denizli, Turkey
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Todd A, Blackley S, Burton JK, Stott DJ, Ely EW, Tieges Z, MacLullich AMJ, Shenkin SD. Reduced level of arousal and increased mortality in adult acute medical admissions: a systematic review and meta-analysis. BMC Geriatr 2017; 17:283. [PMID: 29216846 PMCID: PMC5721682 DOI: 10.1186/s12877-017-0661-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/09/2017] [Indexed: 12/20/2022] Open
Abstract
Background Reduced level of arousal is commonly observed in medical admissions and may predict in-hospital mortality. Delirium and reduced level of arousal are closely related. We systematically reviewed and conducted a meta-analysis of studies in adult acute medical patients of the relationship between reduced level of arousal on admission and in-hospital mortality. Methods We conducted a systematic review (PROSPERO: CRD42016022048), searching MEDLINE and EMBASE. We included studies of adult patients admitted with acute medical illness with level of arousal assessed on admission and mortality rates reported. We performed meta-analysis using a random effects model. Results From 23,941 studies we included 21 with 14 included in the meta-analysis. Mean age range was 33.4 - 83.8 years. Studies considered unselected general medical admissions (8 studies, n=13,039) or specific medical conditions (13 studies, n=38,882). Methods of evaluating level of arousal varied. The prevalence of reduced level of arousal was 3.1%-76.9% (median 13.5%). Mortality rates were 1.7%-58% (median 15.9%). Reduced level of arousal was associated with higher in-hospital mortality (pooled OR 5.71; 95% CI 4.21-7.74; low quality evidence: high risk of bias, clinical heterogeneity and possible publication bias). Conclusions Reduced level of arousal on hospital admission may be a strong predictor of in-hospital mortality. Most evidence was of low quality. Reduced level of arousal is highly specific to delirium, better formal detection of hypoactive delirium and implementation of care pathways may improve outcomes. Future studies to assess the impact of interventions on in-hospital mortality should use validated assessments of both level of arousal and delirium. Electronic supplementary material The online version of this article (10.1186/s12877-017-0661-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amy Todd
- Medicine of the Elderly, NHS Lothian, Royal Infirmary, Edinburgh, Scotland
| | - Samantha Blackley
- Medicine of the Elderly, NHS Lothian, Royal Infirmary, Edinburgh, Scotland
| | - Jennifer K Burton
- Alzheimer Scotland Dementia Research Centre, Edinburgh, Scotland.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland.,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences University of Glasgow, Glasgow, Scotland
| | - E Wesley Ely
- Tennessee Valley Veteran's Affairs Geriatric Research Education and Clinical Centre (GRECC), Nashville, TN, USA.,Vanderbilt University Medical Centre, Nashville, TN, USA
| | - Zoë Tieges
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland.,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland
| | - Alasdair M J MacLullich
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland.,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland
| | - Susan D Shenkin
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland. .,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland.
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Becker TK, Tafoya CA, Osei-Ampofo M, Tafoya MJ, Kessler RA, Theyyunni N, Yakubu HA, Opuni D, Clauw DJ, Cranford JA, Oppong CK, Oteng RA. Cardiopulmonary ultrasound for critically ill adults improves diagnostic accuracy in a resource-limited setting: the AFRICA trial. Trop Med Int Health 2017; 22:1599-1608. [PMID: 29072885 DOI: 10.1111/tmi.12992] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the effects of a cardiopulmonary ultrasound (CPUS) examination on diagnostic accuracy for critically ill patients in a resource-limited setting. METHODS Approximately half of the emergency medicine resident physicians at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, were trained in a CPUS protocol. Adult patients triaged to the resuscitation area of the emergency department (ED) were enrolled if they exhibited signs or symptoms of shock or respiratory distress. Patients were assigned to the intervention group if their treating physician had completed the CPUS training. The physician's initial diagnostic impression was recorded immediately after the history and physical examination in the control group, and after an added CPUS examination in the intervention group. This was compared to a standardised final diagnosis derived from post hoc chart review of the patient's care at 24 h by two blinded, independent reviewers using a clearly defined and systematic process. Secondary outcomes were 24-h mortality and use of IV fluids, diuretics, vasopressors and bronchodilators. RESULTS Of 890 patients presenting during the study period, 502 were assessed for eligibility, and 180 patients were enrolled. Diagnostic accuracy was higher for patients who received the CPUS examination (71.9% vs. 57.1%, Δ 14.8% [CI 0.5%, 28.4%]). This effect was particularly pronounced for patients with a 'cardiac' diagnosis, such as cardiogenic shock, congestive heart failure or acute valvular disease (94.7% vs. 40.0%, Δ 54.7% [CI 8.9%, 86.4%]). Secondary outcomes were not different between groups. CONCLUSIONS In an urban ED in Ghana, a CPUS examination improved the accuracy of the treating physician's initial diagnostic impression. There were no differences in 24-h mortality and a number of patient care interventions.
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Affiliation(s)
- Torben K Becker
- Department of Emergency Medicine, University of Florida, Gainesville, FL, USA
| | - Chelsea A Tafoya
- Department of Emergency Medicine, Highland Hospital, Oakland, CA, USA
| | - Maxwell Osei-Ampofo
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Matthew J Tafoya
- Department of Emergency Medicine, Highland Hospital, Oakland, CA, USA
| | - Ross A Kessler
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Nikhil Theyyunni
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Hussein A Yakubu
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Daniel Opuni
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Daniel J Clauw
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - James A Cranford
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Chris K Oppong
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Rockefeller A Oteng
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
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Abstract
Vital signs are the simplest, cheapest and probably the most important information gathered on patients in hospital. In this narrative review we present a large amount of evidence that vital signs are currently little valued, not regularly or accurately recorded, and frequently not acted on appropriately. It is probable that few hospitals would keep their accreditation with regulatory bodies if they collected and acted on their laboratory results in the same way that they collect and act on vital signs. Professional societies and regulatory bodies need to address this issue: if vital signs were more accurately and frequently measured, and acted on promptly and appropriately hospital care would be safer, better and cheaper.
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Affiliation(s)
- John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark.
| | - Frank Sebat
- Faculty Internal Medicine, Mercy Medical Center, Redding, CA, USA
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39
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Increased mortality in trauma patients who develop postintubation hypotension. J Trauma Acute Care Surg 2017; 83:569-574. [PMID: 28930950 DOI: 10.1097/ta.0000000000001561] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Postintubation hypotension (PIH) is common and associated with poor outcomes in critically ill patient populations requiring emergency endotracheal intubation (ETI). The importance of PIH in the trauma population remains unclear. The objective of this study was to determine the prevalence of PIH in trauma patients and assess the association of PIH with patient outcomes. METHODS Retrospective case series of adult (≥16 years) patients who were intubated on arrival at a tertiary trauma center in Halifax, Nova Scotia, Canada, between 2000 and 2015. Data were collected from the Nova Scotia Trauma Registry and patient chart, and included demographics, comorbidities, trauma characteristics, intubation time, as well as all fluids, medications, adverse events, interventions, and vital signs during the 15 minutes before/after ETI. We evaluated the prevalence of PIH and created a logistic regression model to determine likelihood of mortality in the PIH and non-PIH groups after controlling for patient and provider characteristics. RESULTS Overall, 477 patients required ETI on assessment by the trauma service, of which 444 patients met eligibility criteria and were included in the analysis. The prevalence of PIH was 36.3% (161 of 444) in our study population. In-hospital mortality occurred in 29.8% (48 of 161) of patients in the PIH group, compared with 15.9% (45 of 283) of patients in the non-PIH group (p = 0.001). Development of PIH was associated with increased mortality in the emergency department (adjusted odds ratio, 3.45; 95% confidence interval, 1.42-8.36) and in-hospital (adjusted odds ratio, 1.83; 95% confidence interval, 1.01-3.31). CONCLUSION In our study of trauma patients requiring ETI, development of PIH was common (36.3%) and associated with increased mortality. Intubation practices in critically ill trauma patients is an important patient safety issue that requires further investigation. LEVEL OF EVIDENCE Prognostic and epidemiological, level III; Level IV, Therapeutic.
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Patient physiological status during emergency care and rapid response team or cardiac arrest team activation during early hospital admission. Eur J Emerg Med 2017; 24:359-365. [DOI: 10.1097/mej.0000000000000375] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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New Advances in Emergency Ultrasound Protocols for Shock. J Med Ultrasound 2017; 25:191-194. [PMID: 30065491 PMCID: PMC6029327 DOI: 10.1016/j.jmu.2017.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 09/20/2017] [Indexed: 12/02/2022] Open
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Lambe K, Currey J, Considine J. Emergency nurses’ decisions regarding frequency and nature of vital sign assessment. J Clin Nurs 2017; 26:1949-1959. [DOI: 10.1111/jocn.13597] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2016] [Indexed: 01/17/2023]
Affiliation(s)
- Katherine Lambe
- Nursing and Midwifery Education and Strategy, Monash Health; School of Nursing and Midwifery; Deakin University; Geelong Vic. Australia
| | - Judy Currey
- Centre for Quality and Patient Safety Research; School of Nursing and Midwifery; Deakin University; Geelong Vic. Australia
| | - Julie Considine
- Centre for Quality and Patient Safety Research; School of Nursing and Midwifery; Deakin University; Geelong Vic. Australia
- Centre for Quality and Patient Safety - Eastern Health Partnership; Australia
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Sustainable Resuscitation Ultrasound Education in a Low-Resource Environment: The Kumasi Experience. J Emerg Med 2017; 52:723-730. [PMID: 28284769 DOI: 10.1016/j.jemermed.2017.01.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/28/2017] [Accepted: 01/31/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Point-of-care-ultrasound (POCUS) is an increasingly important tool for emergency physicians and has become a standard component of emergency medicine residency training in high-income countries. Cardiopulmonary ultrasound (CPUS) is emerging as an effective way to quickly and accurately assess patients who present to the emergency department with shock and dyspnea. Use of POCUS, including CPUS, is also becoming more prevalent in low- and middle-income countries (LMICs); however, formal ultrasound training for emergency medicine resident physicians in these settings is not widely available. OBJECTIVES To evaluate the feasibility of integrating a high-intensity ultrasound training program into the formal curriculum for emergency medicine resident physicians in an LMIC. METHODS We conducted a pilot ultrasound training program focusing on CPUS for 20 emergency medicine resident physicians in Kumasi, Ghana, which consisted of didactic sessions and hands-on practice. Competency was assessed by comparing pretest and posttest scores and with an Objective Structured Clinical Examination (OSCE) performed after the final training session. RESULTS The mean score on the pretest was 61%, and after training, the posttest score was 96%. All residents obtained passing scores above 70% on the OSCE. CONCLUSION A high-intensity ultrasound training program can be successfully integrated into an emergency medicine training curriculum in an LMIC.
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Henning DJ, Puskarich MA, Self WH, Howell MD, Donnino MW, Yealy DM, Jones AE, Shapiro NI. An Emergency Department Validation of the SEP-3 Sepsis and Septic Shock Definitions and Comparison With 1992 Consensus Definitions. Ann Emerg Med 2017; 70:544-552.e5. [PMID: 28262318 DOI: 10.1016/j.annemergmed.2017.01.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/09/2016] [Accepted: 01/06/2017] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE The Third International Consensus Definitions Task Force (SEP-3) proposed revised criteria defining sepsis and septic shock. We seek to evaluate the performance of the SEP-3 definitions for prediction of inhospital mortality in an emergency department (ED) population and compare the performance of the SEP-3 definitions to that of the previous definitions. METHODS This was a secondary analysis of 3 prospectively collected, observational cohorts of infected ED subjects aged 18 years or older. The primary outcome was all-cause inhospital mortality. In accordance with the SEP-3 definitions, we calculated test characteristics of sepsis (quick Sequential Organ Failure Assessment [qSOFA] score ≥2) and septic shock (vasopressor dependence plus lactate level >2.0 mmol/L) for mortality and compared them to the original 1992 consensus definitions. RESULTS We identified 7,754 ED patients with suspected infection overall; 117 had no documented mental status evaluation, leaving 7,637 patients included in the analysis. The mortality rate for the overall population was 4.4% (95% confidence interval [CI] 3.9% to 4.9%). The mortality rate for patients with qSOFA score greater than or equal to 2 was 14.2% (95% CI 12.2% to 16.2%), with a sensitivity of 52% (95% CI 46% to 57%) and specificity of 86% (95% CI 85% to 87%) to predict mortality. The original systemic inflammatory response syndrome-based 1992 consensus sepsis definition had a 6.8% (95% CI 6.0% to 7.7%) mortality rate, sensitivity of 83% (95% CI 79% to 87%), and specificity of 50% (95% CI 49% to 51%). The SEP-3 septic shock mortality was 23% (95% CI 16% to 30%), with a sensitivity of 12% (95% CI 11% to 13%) and specificity of 98.4% (95% CI 98.1% to 98.7%). The original 1992 septic shock definition had a 22% (95% CI 17% to 27%) mortality rate, sensitivity of 23% (95% CI 18% to 28%), and specificity of 96.6% (95% CI 96.2% to 97.0%). CONCLUSION Both the new SEP-3 and original sepsis definitions stratify ED patients at risk for mortality, albeit with differing performances. In terms of mortality prediction, the SEP-3 definitions had improved specificity, but at the cost of sensitivity. Use of either approach requires a clearly intended target: more sensitivity versus specificity.
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Affiliation(s)
- Daniel J Henning
- Division of Emergency Medicine, University of Washington, Seattle, WA
| | | | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt, Nashville, TN
| | - Michael D Howell
- Center for Healthcare Delivery Science and Innovation, University of Chicago Medicine, Chicago, IL
| | - Michael W Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine, Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh and UPMC, Pittsburgh, PA
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi, Jackson, MS
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
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Schwartz MB, Ferreira JA, Aaronson PM. The impact of push-dose phenylephrine use on subsequent preload expansion in the ED setting. Am J Emerg Med 2016; 34:2419-2422. [DOI: 10.1016/j.ajem.2016.09.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 08/29/2016] [Accepted: 09/18/2016] [Indexed: 10/21/2022] Open
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Frequency of vital sign assessment and clinical deterioration in an Australian emergency department. ACTA ACUST UNITED AC 2016; 19:217-222. [DOI: 10.1016/j.aenj.2016.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/07/2016] [Accepted: 09/13/2016] [Indexed: 11/18/2022]
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Sawe HR, Haeffele C, Mfinanga JA, Mwafongo VG, Reynolds TA. Predicting Fluid Responsiveness Using Bedside Ultrasound Measurements of the Inferior Vena Cava and Physician Gestalt in the Emergency Department of an Urban Public Hospital in Sub-Saharan Africa. PLoS One 2016; 11:e0162772. [PMID: 27677085 PMCID: PMC5038941 DOI: 10.1371/journal.pone.0162772] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 08/22/2016] [Indexed: 01/20/2023] Open
Abstract
Background Bedside inferior vena cava (IVC) ultrasound has been proposed as a non-invasive measure of volume status. We compared ultrasound measurements of the caval index (CI) and physician gestalt to predict blood pressure response in patients requiring intravenous fluid resuscitation. Methods This was a prospective study of adult emergency department patients requiring fluid resuscitation. A structured data sheet was used to record serial vital signs and the treating clinician’s impression of patient volume status and cause of hypotension. Bedside ultrasound CI measurements were performed at baseline and after each 500mL of fluid. Receiver operating characteristic (ROC) curve analysis was performed to characterize the relationship between CI and Physician gestalt, and the change in mean arterial pressure (MAP). Results We enrolled 364 patients, 52% male, mean age 36 years. Indications for fluid resuscitation were haemorrhage (54%), dehydration (30%), and sepsis (17%). Receiver operating characteristic curve analysis found optimal CI cut-off values of 45%, 52% and 53% to predict a MAP rise of 5, 8 and 10 mmHg per litre of fluid, respectively. The sensitivity and specificity of CI of 50% for predicting a 10mmHg increase in MAP per litre were 88% (95%CI 81–93%) and 73% (95%CI 67–79%), respectively, area under the curve (AUC) = 0.85 (0.81–0.89). The sensitivity and specificity of physician gestalt estimate of volume depletion severity were 68% (95%CI 60–75%) and 86% (95%CI 80–90%), respectively, AUC = 0.83 (95% CI: 0.79–0.87). Those with a baseline CI ≥ 50% (51% of patients) had a 2.8-fold greater fluid responsiveness than those with a baseline CI<50% (p<0.0001). Conclusion Ultrasound measurement of the CI can predict blood pressure response among patients requiring intravenous fluid resuscitation and may be useful in early identification of patients who will benefit most from volume resuscitation, and those who will likely require other interventions.
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Affiliation(s)
- Hendry Robert Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
- * E-mail:
| | - Cathryn Haeffele
- School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
| | - Juma A. Mfinanga
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Victor G. Mwafongo
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Teri A. Reynolds
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, United States of America
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L'incidence de l'hypotension post-intubation endotrachéale chez des patients en salle de réanimation: impact des définitions. CAN J EMERG MED 2016; 18:370-8. [PMID: 27465996 DOI: 10.1017/cem.2016.354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
UNLABELLED Objectif Notre objectif primaire est de mesurer l'incidence d'HPI selon quatre définitions différentes retrouvées dans la littérature. Notre principal objectif secondaire est d'évaluer l'impact de la présence d'instabilité hémodynamique avant l'intubation sur l'incidence d'HPI. Le deuxième objectif secondaire consiste à déterminer l'incidence de l'HPI en fonction de l'intervalle de temps durant lequel la première hypotension survient. Méthode Une cohorte prospective a été constituée par les patients intubés en salle de réanimation à l'hôpital de l'Enfant-Jésus entre le 28/06/2011 et le 12/07/2012. L'HPI était globalement définie comme ≥1 mesure de tension artérielle systolique <90 mmHg suivant l'intubation. Les différentes définitions étudiées faisaient varier le temps de mesure de la tension artérielle (TA) après l'intubation, soit 1) jusqu'à 5 minutes, 2) jusqu'à 15 minutes, 3) jusqu'à 30 minutes et 4) en tout temps lors du séjour en salle de réanimation. Résultat Au cours de la période à l'étude, 155 patients ont été intubés sur place dont 81 patients qui répondaient aux critères d'inclusion. L'incidence de l'HPI pour chaque définition est respectivement de 9.9%, 18.5%, 24.7% et 28.4%. La comparaison entre chacune de ces incidences révèle une différence statistiquement significative (p<0.05), à l'exception des deux dernières. L'incidence cumulative d'HPI à tout moment suivant l'intubation chez les patients présentant une hypotension pré-intubation est de 62.5% (IC 95% 28.5-87.5) en opposition aux patients hémodynamiquement stables en pré-intubation qui présentaient une incidence d'HPI de 24.7% (IC 95% 16.1-35.8). CONCLUSION L'hypotension post-intubation est un effet indésirable fréquent chez les patients au département d'urgence et son incidence varie de façon significative en fonction de la définition temporelle utilisée au sein d'une même cohorte de patients.
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Allen C, Washington S. The role of etomidate as an anaesthetic induction agent for critically ill patients. Br J Hosp Med (Lond) 2016; 77:282-6. [PMID: 27166106 DOI: 10.12968/hmed.2016.77.5.282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Etomidate is an anaesthetic induction agent which may be favoured in critically ill patients because of its cardiovascular stability. However, etomidate causes adrenocortical suppression which may be particularly harmful in these patients. This article reviews current evidence and debates the use of etomidate in critical illness.
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Affiliation(s)
- Claire Allen
- ST6 in Anaesthesia in the Department of Anaesthesia, University Hospital of South Manchester NHS Foundation Trust, Manchester M23 9LT
| | - Stephen Washington
- Consultant Anaesthetist in the Department of Anaesthesia, University Hospital of South Manchester NHS Foundation Trust, Manchester
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Oxygen extraction and perfusion markers in severe sepsis and septic shock: diagnostic, therapeutic and outcome implications. Curr Opin Crit Care 2016; 21:381-7. [PMID: 26348417 DOI: 10.1097/mcc.0000000000000241] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The purpose of this study is to review the recent literature examining the clinical utility of markers of systemic oxygen extraction and perfusion in the diagnosis, treatment and prognosis of severe sepsis and septic shock. RECENT FINDINGS When sepsis is accompanied by conditions in which systemic oxygen delivery does not meet tissue oxygen demands, tissue hypoperfusion begins. Tissue hypoperfusion leads to oxygen debt, cellular injury, organ dysfunction and death. Tissue hypoperfusion can be characterized using markers of tissue perfusion (central venous oxygen saturation and lactate), which reflect the interaction between systemic oxygen delivery and demands. For the last two decades, studies and quality initiatives incorporating the early detection and interruption of tissue hypoperfusion have been shown to improve mortality and altered sepsis care. Three recent trials, while confirming an all-time improvement in sepsis mortality, challenged the concept that rapid normalization of markers of perfusion confers outcome benefit. By defining and comparing haemodynamic phenotypes using markers of tissue perfusion, we may better understand which patients are more likely to benefit from early goal-directed haemodynamic optimization. SUMMARY The phenotypic haemodynamic characterization of patients using perfusion markers has diagnostic, therapeutic and outcome implications in severe sepsis and septic shock. However, irrespective of haemodynamic phenotype, the outcome reflects the quality of care provided at the point of presentation. Utilizing these principles may allow more objective interpretation of resuscitation trials and translate these findings into current practice.
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