Bench-to-bedside review: Resuscitation in the emergency department

Erratum: Concordance and limits between transcutaneous and arterial carbon dioxide pressure in emergency department patients with acute respiratory failure: a single-center, prospective, and observational study

Abstract

After publication of this article (Scand J Trauma Resusc Emerg Med 23:40, 2015), it came to light that an earlier version had been published in error. This erratum contains the correct version of the article, which incorporates revisions made in response to reviewer comments. Additionally, one of the authors was inadvertently omitted from the author list. This author, Justin Yan, has been included in the corrected author list above.

Background

Transcutaneous CO₂ (PtCO₂) is a continuous and non-invasive measure recommended by scientific societies in the management of respiratory distress. The objective of this study was to evaluate the correlation between PtCO₂ and arterial partial pressure of CO₂ (PaCO₂) by arterial blood gas analysis in emergency patients with dyspnoea, and to determine the factors that interfere with this correlation.

Methods

From January to June 2014, all adult patients admitted to the RR with dyspnoea during business hours were included in the study if arterial blood gas measurements were indicated. A sensor measuring the PtCO₂ was attached to the ear lobe of the patient before the gas analysis. Anamnesis, clinical and laboratory parameters were identified.

Results

Ninety patients with dyspnoea were included (104 pairs of measurements). The median (IQR) age was 79 years (69 – 85). The correlation between PtCO₂ and PaCO₂ was R² =.83 (p<.001) but became lower for values of PaCO₂ above 60 mm Hg. The mean bias (± SD) between the two methods of measurement (Bland-Altman analysis) was −1.4 mm Hg (± 7.7) with limits of agreement from −16.4 to 13.7 mm Hg. In univariate analysis, PaO₂ interfered with this correlation. After multivariate analysis, temperature (OR = 3.01; 95 % CIs [1.16, 7.80]) and PaO₂ (OR = 1.22; 95 % CIs [1.02, 1.47]) significantly interfered with this correlation.

Conclusions

There is a significant correlation between PaCO₂ and PtCO₂ values for patients admitted to the emergency department for acute respiratory failure. One limiting factor to routine use of PtCO₂ measurements in the emergency department is the presence of hyperthermia.

Concordance and limits between transcutaneous and arterial carbon dioxide pressure in emergency department patients with acute respiratory failure: a single-center prospective observational study

Introduction

Transcutaneous CO ₂ (PtCO ₂) is a continuous and non-invasive measure recommended by scientific societies in the management of respiratory distress. The objective of this study is to evaluate the correlation between PtCO ₂ and blood pressure of CO ₂ (PaCO ₂) by blood gas analysis in emergency patients with dyspnoea and to determine the factors that interfere in this correlation.

Methods

From January to June 2014, all patients admitted to resuscitation room of the emergency department targeted for arterial blood gases were included prospectively. A sensor measuring the PtCO ₂ was attached to the ear lobe of the patient before the gas analysis. Anamnesis, clinical and laboratory parameters were identified.

Results

90 patients with dyspnoea were included (with 104 pairs of measurements), the median age was 79 years [69-85]. The correlation between PtCO ₂ and PaCO ₂ was R ²= 0.83 (p <0.001) but became lower for values of PaCO ₂>60 mm Hg. The mean bias (±SD) between the two methods of measurement (Bland-Altman analysis) was -1.4 mm Hg (±7.7) with limits of agreement of -16.4 to 13.7 mm Hg. In univariate analysis, PaO ₂ interfered in this correlation. After multivariate analysis, the temperature (OR = 3.01, 95% CI = 1.16-7.09) and the PaO ₂ (OR = 1.22, 95% CI = 1.02-1.47) were found to be significant.

Conclusions

In patients admitted in emergency unit for acute respiratory failure, there is a significant correlation between PaCO ₂ and PtCO ₂, mainly for values below 60 mm Hg. The two limiting factors of use are hyperthermia and users training.

Maintaining tissue perfusion in high-risk surgical patients: a systematic review of randomized clinical trials

BACKGROUND

Surgical patients with limited organic reserve are considered high-risk patients and have an increased perioperative mortality. For this reason, they need a more rigorous perioperative protocol of hemodynamic control to prevent tissue hypoperfusion. In this study, we systematically reviewed the randomized controlled clinical trials that used a hemodynamic protocol to maintain adequate tissue perfusion in the high-risk surgical patient.

METHODS

We searched MEDLINE, Embase, LILACS, and Cochrane databases to identify randomized controlled clinical studies of surgical patients studied using a perioperative hemodynamic protocol of tissue perfusion aiming to reduce mortality and morbidity; the latter characterized at least one dysfunctional organ in the postoperative period. Pooled odds ratio (POR) and 95% confidence interval (CI) were calculated for categorical outcomes.

RESULTS

Thirty-two clinical trials were selected, comprising 5056 high-risk surgical patients. Global meta-analysis showed a significant reduction in mortality rate (POR: 0.67; 95% CI: 0.55-0.82; P < 0.001) and in postoperative organ dysfunction incidence (POR: 0.62; 95% CI: 0.55-0.70; P < 0.00,001) when a hemodynamic protocol was used to maintain tissue perfusion. When the mortality rate was >20% in the control group, the use of a hemodynamic protocol to maintain tissue optimization resulted in a further reduction in mortality (POR: 0.32; 95% CI: 0.21-0.47; P < 0.00,001). Monitoring cardiac output with a pulmonary artery catheter and increasing oxygen transport and/or decreasing consumption also significantly reduced mortality (POR: 0.67; 95% CI: 0.54-0.84; P < 0.001 and POR: 0.71; 95% CI: 0.57-0.88; P < 0.05, respectively). Therapy directed at increasing mixed or central venous oxygen saturation did not significantly reduce mortality (POR: 0.68; 95% CI: 0.22-2.10; P > 0.05). The only study using lactate as a marker of tissue perfusion failed to demonstrate a statistically significant reduction in mortality (OR: 0.33; 95% CI: 0.07-1.65; P > 0.05).

CONCLUSIONS

In high-risk surgical patients, the use of a hemodynamic protocol to maintain tissue perfusion decreased mortality and postoperative organ failure. Monitoring cardiac output calculating oxygen transport and consumption helped to guide therapy. Additional randomized controlled clinical studies are necessary to analyze the value of monitoring mixed or central venous oxygen saturation and lactate in high-risk surgical patients.

Liver metabolomic changes identify biochemical pathways in hemorrhagic shock

BACKGROUND

Despite ongoing advances in treatment, thousands of patients still die annually from complications due to hemorrhagic shock, a condition causing dramatic physiologic and metabolic changes as cells switch to anaerobic metabolism in response to oxygen deprivation. As the shift from aerobic to anaerobic metabolism occurs in the peripheral tissues during shock, the liver must increase production of endogenous glucose as well as process excess lactate produced in the periphery. This places the liver at the center of metabolic regulation in the body during hemorrhagic shock. Therefore, we hypothesized that liver tissue from pigs during an in vivo model of hemorrhagic shock (n = 6) would reflect resultant metabolic changes.

MATERIALS AND METHODS

The in vivo model of shock consisted of 45 min of shock followed by 8 h of hypotensive resuscitation (80 mmHg) and subsequent normotensive resuscitation (90 mmHg) ending 48 h after the shock period. Control groups of pigs (n = 3) (1) shock with no resuscitation, and (2) only anesthesia and instrumentation, also were included. Metabolic changes within the liver after shock and during resuscitation were investigated using both proton ((1)H) and phosphorous ((31)P) nuclear magnetic resonance (NMR) spectroscopy.

RESULTS

Concentrations of glycerylphosphorylcholine (GPC) and glycerylphosphorylethanolamine (GPE) were significantly lower at 8 h after shock, with recovery to baseline by 23 and 48 h after shock. Uridine diphosphate-glucose (UDP-glucose), and phosphoenolpyruvate (PEP) were elevated 23 h after shock.

CONCLUSIONS

These results indicate that (1)H and (31)P NMR spectroscopy can be used to identify differences in liver metabolites in an in vivo model of hemorrhagic shock, indicating that metabolomic analysis can be used to elucidate biochemical events occurring during this complex disease process.

Improving outcomes for severe sepsis and septic shock: tools for early identification of at-risk patients and treatment protocol implementation

Sepsis is a significant problem, and septicemia is the 10th leading cause of death in the United States. Sepsis incidence is increasing, and the mortality rate is 20% to 50% for patients with severe sepsis. This article identifies methods for improving outcomes of severe sepsis and septic shock. Included are recommendations for diagnosis and treatment. Case studies are included.