A Clinical Score for Predicting Successful Weaning from Noninvasive Positive Pressure Ventilation in Emergency Department; a Retrospective Cohort Study

Introduction

Noninvasive positive pressure ventilation (NIPPV) is recognized as an efficient treatment for patients with acute respiratory failure (ARF) in emergency department (ED). This study aimed to develop a scoring system for predicting successful weaning from NIPPV in patients with ARF.

Methods

In this retrospective cohort study patients with ARF who received NIPPV in the ED of Ramathibodi Hospital, Thailand, between January 2020 and March 2022 were evaluated. Factors associated with weaning from NIPPV were recorded and compared between cases with and without successful weaning from NIPPV. Multivariable logistic regression analysis was used to develop a predictive model for weaning from NIPPV in ED.

Results

A total of 494 eligible patients were treated with NIPPV of whom 203(41.1%) were successfully weaned during the study period. Based on the multivariate analysis the successful NIPPV weaning (SNOW) score was designed with six factors before discontinuation: respiratory rate, heart rate ≤ 100 bpm, systolic blood pressure ≥ 100 mmHg, arterial pH≥ 7.35, arterial PaCO2, and arterial lactate. The scores were classified into three groups: low, moderate, and high. A score of >14.5 points suggested a high probability of successful weaning from NIPPV with a positive likelihood ratio of 3.58 (95%CI: 2.56-4.99; p < 0.001). The area under the receiver operating characteristic (ROC) curve of the model in predicting successful weaning was 0.79 (95% confidence interval (CI): 0.75-0.83).

Conclusion

It seems that the SNOW score could be considered as a helpful tool for predicting successful weaning from NIPPV in ED patients with ARF. A high predictive score, particularly one that exceeds 14.5, strongly suggests a high likelihood of successful weaning from NIPPV.

Comparing the Efficacy of Long Spinal Board, Sked Stretcher, and Vacuum Mattress in Cervical Spine Immobilization; a Method-Oriented Experimental Study

Introduction

Inadequate spinal motion restriction in patients suffering from spinal injuries could lead to further neurological damage, ultimately worsening their prognosis. This study aimed to investigate the efficacy of long spinal boards (LSB), ske stretcher, and vacuum mattress for cervical spine immobilization during transportation of patients by measuring the angular motion of the cervical spine following lifting, transferring, and tilting.

Methods

We conducted an experimental study using a box of three randomizations and crossover designs without a washout period effect for the long spinal board, sked stretcher, and vacuum mattress. We concealed the randomization with sequentially numbered, opaque, sealed envelopes (SNOSE). Kinematic data were collected using eight optoelectronic cameras at 200 Hz (BTS Bioengineering, Milan, Italy) in triangular planes (lateral bending, flexion-extension, and axial rotation) while performing all three motions (static lift-hold, transfer, and 90° tilt).

Results

12 cases (7 males and 5 females) with the mean age of 20 ± 3.03 (range: 18-28) years were studied. The three highest angular motions were observed in the axial rotation plane during patient's tilting under immobilization on all devices (Vacuum mattress having the highest value of 99.01±8.93, followed by the LSB at 89.89±34.35 and the sked stretcher at 86.30±7.73 degrees). During patient lifting, a higher angular motion was observed with vacuum mattress immobilization in flexion extension (Coefficient = 4.45; 95%CI: 0.46 - 8.45; p =0.029) and axial rotation (Coefficient = 3.70; 95%CI: 0.58 - 6.81; p =0.020) planes. During patient transfer, a higher angular motion was observed with sked stretcher in the flexion-extension plane (Coefficient = 2.98; 95%CI: 0.11 - 5.84; p = 0.042). During patient tilting to 90 degrees, a higher angular motion was observed with vacuum mattress immobilization in lateral bending (Coefficient = -4.08; 95%CI: -7.68 - -0.48; p = 0.026) for the vacuum mattress.

Conclusion

Based on the finding of the present study, patients on the vacuum mattress experience significantly higher angular motion in flexion extension and axial rotation during lifting, as well as lateral bending during 90-degree tilting. In addition, patients on the sked stretcher showed significantly higher angular motion in flexion-extension during the transferring. However, the predictive margins for immobilization across all devices did not demonstrate clinically significant differences among the three immobilization devices.

Clinical Prediction Score for Early Diagnosis of Acute Pancreatitis in Emergency Departments

Background

In Thailand, most primary care hospitals cannot measure serum lipase and amylase; no 24 hours computed tomography and magnetic resonance imaging available, and no on-call gastroenterologists. Thus, acute pancreatitis cannot be diagnosed based on the established diagnostic criteria that require this information. The resultant delayed management increases morbidity and mortality. This study was performed to create a clinical prediction score for early diagnosis of acute pancreatitis in emergency departments without requiring a computed tomography scan or laboratory measurement to assist in the initial diagnosis, treatment, or referral.

Methods

Patients with suspected acute pancreatitis who had available data regarding lipase and amylase measurements and visited the emergency department from June 2019 to August 2020 were retrospectively analyzed. The baseline predictive factors were compared between patients with and without acute pancreatitis according to the 2012 revised Atlanta classification. Multivariable logistic regression was used to explore potential predictive factors and develop a clinical prediction score for the diagnosis of acute pancreatitis.

Results

A total of 506 eligible patients, 84 (16%) had acute pancreatitis. The PRE-PAN score [area under the receiver operating characteristics curve, 0.88; 95% confidence interval (CI), 0.84–0.93] included six factors: alcohol drinking, epigastric pain, pain radiating to the back, persistent pain, nausea or vomiting, and the pain score. A score of >7.5 points suggested a high probability of acute pancreatitis [positive likelihood ratio, 6.80 (95% CI, 4.75–9.34; p < 0.001); sensitivity, 66.7% (95% CI, 54.6–77.3); specificity, 90.2% (95% CI, 86.6–93.1); positive predictive value, 58.5% (95% CI, 47.1–69.3);, 92.9% (95% CI, 89.6–95.4)].

Conclusion

A PRE-PAN risk score is a screening tool for predicting acute pancreatitis without using the lipase concentration or radiological findings. A high predictive score, especially >7.5, suggests a high probability of acute pancreatitis.

Early detection of non-invasive ventilation failure among acute respiratory failure patients in the emergency department

Background

Non-invasive mechanical ventilation (NIV) has become an alternative to an invasive artificial airway for the management of acute respiratory failure (ARF). NIV failure causes delayed intubation, which eventually has been associated with increased morbidity and mortality. This study aimed to develop the clinical scoring system of NIV failure in ARF patients.

Methods

This study was a diagnostic, retrospectively cross-sectional, and exploratory model at the Emergency Medicine Department in Ramathibodi Hospital between February 2017 and December 2017. We included all of the acute respiratory failure patients aged > 18 years and received non-invasive ventilation (NIV). Clinical factors associated with NIV failure were recorded. The predictive model and prediction score for NIV failure were developed by multivariable logistic regression analysis.

Result

A total of 329 acute respiratory failure patients have received NIV success (N = 237) and failure (N = 92). This study showed that NIV failure was associated with heart rate >  110 bpm, systolic BP <  110 mmHg, SpO2 < 90%, arterial pH < 7.30 and serum lactate. The clinical scores were classified into three groups: low, moderate, and high.

Conclusion

We suggested that the novel clinical scoring of the NIV failure in this study may use as a good predictor for NIV failure in the emergency room.