Prognostic Role of Initial Thromboelastography in Emergency Department Patients with Primary Postpartum Hemorrhage: Association with Massive Transfusion

BACKGROUND

The early prediction of the need for massive transfusions (MTs) and the preparation of blood products are essential for managing patients with primary postpartum hemorrhage (PPH). Thromboelastography (TEG) enables a thorough evaluation of coagulation status and is useful for guiding the treatment of hemorrhagic events in various diseases. We investigated the role of TEG in predicting the need for MT in patients with primary PPH.

METHODS

A retrospective observational study was conducted in the emergency department (ED) of a university-affiliated, tertiary referral center between November 2015 and August 2023. TEG was performed upon admission. We defined MT as the requirement for transfusion of more than 10 units of packed red blood cells within the first 24 h. The primary outcome was the need for MT.

RESULTS

Among the 184 patients with initial TEG, 34 (18.5%) required MT. Except for lysis after 30 min, the MT and non-MT groups had significantly different TEG values. Based on multivariate analysis, an angle < 60 was an independent predictor of MT (odds ratio (OR) 7.769; 95% confidence interval (CI), 2.736-22.062), along with lactate (OR, 1.674; 95% CI, 1.218-2.300) and shock index > 0.9 (OR, 4.638; 95% CI, 1.784-12.056). Alpha angle < 60 degrees indicated the need for MT with 73.5% sensitivity, 72.0% specificity, and 92.3% negative predictive value.

CONCLUSIONS

Point-of-care testing of TEG has the potential to be a useful tool in accurately predicting the necessity for MT in ED patients with primary PPH at an early stage.

The usefulness of lactate/albumin ratio, C-reactive protein/albumin ratio, procalcitonin/albumin ratio, SOFA, and qSOFA in predicting the prognosis of patients with sepsis who presented to EDs

PURPOSE

Early identification of sepsis with a poor prognosis in the emergency department (ED) is crucial for prompt management and improved outcomes. This study aimed to examine the predictive value of sequential organ failure assessment (SOFA), quick SOFA (qSOFA), lactate to albumin ratio (LAR), C-reactive protein to albumin ratio (CAR), and procalcitonin to albumin ratio (PAR), obtained in the ED, as predictors for 28-day mortality in patients with sepsis and septic shock.

MATERIALS AND METHODS

We included 3499 patients (aged ≥19 years) from multicenter registry of the Korean Shock Society between October 2015 and December 2019. The SOFA score, qSOFA score, and lactate level at the time of registry enrollment were used. Albumin, C-reactive protein, and procalcitonin levels were obtained from the initial laboratory results measured upon ED arrival. We evaluated the predictive accuracy for 28-day mortality using the area under the receiver operating characteristic (AUROC) curve. A multivariable logistic regression analysis of the independent predictors of 28-day mortality was performed. The SOFA score, LAR, CAR, and PAR were converted to categorical variables using Youden's index and analyzed. Adjusting for confounding factors such as age, sex, comorbidities, and infection focus, adjusted odds ratios (aOR) were calculated.

RESULTS

Of the 3499 patients, 2707 (77.4%) were survivors, whereas 792 (22.6%) were non-survivors. The median age of the patients was 70 (25th-75th percentiles, 61-78), and 2042 (58.4%) were male. LAR for predicting 28-day mortality had the highest AUROC, followed by the SOFA score (0.715; 95% confidence interval (CI): 0.69-0.74 and 0.669; 95% CI: 0.65-0.69, respectively). The multivariable logistic regression analysis revealed that the aOR of LAR >1.52 was 3.75 (95% CI: 3.16-4.45), and the aOR, of SOFA score at enrollment >7.5 was 2.67 (95% CI: 2.25-3.17).

CONCLUSION

The results of this study showed that LAR is a relatively strong predictor of sepsis prognosis in the ED setting, indicating its potential as a straightforward and practical prognostic factor. This finding may assist healthcare providers in the ED by providing them with tools to risk-stratify patients and predict their mortality.

Correlation of handgrip strength with quality of life-adjusted pulmonary function in adults

BACKGROUND

Handgrip strength (HGS) is acknowledged as a key indicator of overall physical fitness and is associated with various health outcomes.

OBJECTIVES

This research investigates the correlation between HGS and quality of life (QoL), focusing on its relation to pulmonary function in the general adult population.

METHOD

The study involved 19,402 participants aged 40 and above, spanning from 2014 to 2019, who underwent pulmonary function and HGS tests. Participants were categorized based on lung function, and regression analyses were employed to examine the relationship between HGS and QoL, with adjustments made for lung function.

RESULTS

The average age of the cohort was 58.2 years, comprising 44.6% males and 41.2% smokers. Out of the 18,708 participants who completed the European Quality of Life Scale-Five Dimensions (EQ-5D-3L) assessment, higher severity levels in mobility, self-care, usual activities, pain or discomfort, and anxiety or depression were linked to lower HGS in both sexes. Additionally, among the 3,723 participants who completed the Health-related Quality of Life Instrument with 8 Items (HINT-8) assessment, higher severity levels in pain, work, and depression were associated with lower HGS in men. In women, higher severity levels in climbing stairs, pain, vitality, and work correlated with lower HGS.

CONCLUSIONS

As problems indicated by EQ-5D worsened, there was a consistent decrease in handgrip strength (HGS) across both genders. The HINT-8 assessment further revealed that increased severity in pain and work-related issues led to reduced HGS in both men and women. This study highlights the relationship between HGS and Quality of Life (QoL), taking lung function into consideration, and underscores the importance of HGS as a potential marker of physical health and fitness.

Comparison of Modified Shock Index and Shock Index for Predicting Massive Transfusion in Women with Primary Postpartum Hemorrhage: A Retrospective Study

BACKGROUND The modified shock index (MSI) is calculated as the ratio of heart rate (HR) to mean arterial pressure (MAP) and has been used to predict the need for massive transfusion (MT) in trauma patients. This retrospective study from a single center aimed to compare the MSI with the traditional shock index (SI) to predict the need for MT in 612 women diagnosed with primary postpartum hemorrhage (PPH) at the Emergency Department (ED) between January 2004 and August 2023. MATERIAL AND METHODS The patients were divided into the MT group and the non-MT group. The predictive power of MSI and SI was compared using the areas under the receiver operating characteristic curve (AUC). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value were calculated. RESULTS Out of 612 patients, 105 (17.2%) required MT. The MT group had higher median values than the non-MT group for MSI (1.58 vs 1.07, P<0.001) and SI (1.22 vs 0.80, P<0.001). The AUC for MSI, with a value of 0.811 (95% confidence interval [CI], 0.778-0.841), did not demonstrate a significant difference compared to the AUC for SI, which was 0.829 (95% CI, 0.797-0.858) (P=0.066). The optimal cutoff values for MSI and SI were 1.34 and 1.07, respectively. The specificity and PPV for MT were 77.1% and 40.2% for MSI, and 83.2% and 45.9% for SI. CONCLUSIONS Both MSI and SI were effective in predicting MT in patients with primary PPH. However, MSI did not demonstrate superior performance to SI.

Sex differences in in-hospital management in patients with sepsis and septic shock: a prospective multicenter observational study

Sex differences in the in-hospital management of sepsis exist. Previous studies either included patients with sepsis that was defined using previous definitions of sepsis or evaluated the 3-h bundle therapy. Therefore, this study sought to assess sex differences in 1-h bundle therapy and in-hospital management among patients with sepsis and septic shock, defined according to the Sepsis-3 definitions. This observational study used data from Korean Shock Society (KoSS) registry, a prospective multicenter sepsis registry. Adult patients with sepsis between June 2018 and December 2021 were included in this study. The primary outcome was adherence to 1-h bundle therapy. Propensity score matching (PSM) and multivariable logistic regression analyses were performed. Among 3264 patients with sepsis, 3129 were analyzed. PSM yielded 2380 matched patients (1190 men and 1190 women). After PSM, 1-h bundle therapy was performed less frequently in women than in men (13.0% vs. 19.2%; p < 0.001). Among the bundle therapy components, broad-spectrum antibiotics were administered less frequently in women than in men (25.4% vs. 31.6%, p < 0.001), whereas adequate fluid resuscitation was performed more frequently in women than in men (96.8% vs. 95.0%, p = 0.029). In multivariable logistic regression analysis, 1-h bundle therapy was performed less frequently in women than in men [adjusted odds ratio (aOR) 1.559; 95% confidence interval (CI) 1.245-1.951; p < 0.001] after adjustment. Among the bundle therapy components, broad-spectrum antibiotics were administered less frequently to women than men (aOR 1.339, 95% CI 1.118-1.605; p = 0.002), whereas adequate fluid resuscitation was performed more frequently for women than for men (aOR 0.629, 95% CI 0.413-0.959; p = 0.031). Invasive arterial blood pressure monitoring was performed less frequently in women than in men. Resuscitation fluid, vasopressor, steroid, central-line insertion, ICU admission, length of stay in the emergency department, mechanical ventilator use, and renal replacement therapy use were comparable for both the sexes. Among patients with sepsis and septic shock, 1-h bundle therapy was performed less frequently in women than in men. Continuous efforts are required to increase adherence to the 1-h bundle therapy and to decrease sex differences in the in-hospital management of patients with sepsis and septic shock.

Sex differences in chronic obstructive pulmonary disease characteristics: the Korea National Health and Nutrition Examination Survey 2007-2018

BACKGROUND/AIMS

Chronic obstructive pulmonary disease (COPD) is less prevalent in females than males, but it affects mortality in females. There may be sex differences in the clinical characteristics of COPD.

METHODS

We analyzed the Korea National Health and Nutrition Examination Survey dataset from 2007 to 2018. We compared the clinical characteristics and comorbidities in subjects with COPD according to sex. We adjusted the multivariate logistic regression of lung cancer prevalence according to COPD and sex by age and smoking amount.

RESULTS

Females with COPD tended to be older than males with COPD (64.1 ± 0.4 yr vs. 62.3 ± 0.2 yr, respectively, p < 0.001). Approximately 89% of males with COPD had a smoking history, while 86% of females with COPD were non-smokers (p < 0.001). Household income was lower (p < 0.001) and asthma and overall malignancy were more prevalent in females with COPD than males with COPD (25.5 vs. 11.6%, respectively, p < 0.001; (6.3 vs. 5.4%, respectively, p < 0.001). However, lung cancer was more common in males with COPD than females with COPD (0.9 vs. 0.1%, respectively, p < 0.001). Lung cancer prevalence increased in males with moderate COPD compared to subjects without COPD (OR, 4.409; 95% CI, 1.741-9.419).

CONCLUSION

Females with COPD had a lower smoking rate, household income, and lung cancer prevalence than males with COPD. More active COPD screening is needed for women of low socioeconomic status, even if they do not smoke.

Respiratory rate‑oxygenation (ROX) index for predicting high-flow nasal cannula failure in patients with and without COVID-19

BACKGROUND

The predictive value of the respiratory rate‑oxygenation (ROX) index for a high-flow nasal cannula (HFNC) in patients with COVID-19 with acute hypoxemic respiratory failure (AHRF) may differ from patients without COVID-19 with AHRF, but these patients have not yet been compared. We compared the diagnostic accuracy of the ROX index for HFNC failure in patients with AHRF with and without COVID-19 during acute emergency department (ED) visits.

METHODS

We performed a retrospective analysis of patients with AHRF treated with an HFNC in an ED between October 2020 and April 2022. The ROX index was calculated at 1, 2, 4, 6, 12, and 24 h after HFNC placement. The primary outcome was the failure of the HFNC, which was defined as the need for subsequent intubation or death within 72 h. A receiver operating characteristic (ROC) curve was used to evaluate discriminative power of the ROX index for HFNC failure.

RESULTS

Among 448 patients with AHRF treated with an HFNC in an ED, 78 (17.4%) patients were confirmed to have COVID-19. There was no significant difference in the HFNC failure rates between the non-COVID-19 and COVID-19 groups (29.5% vs. 33.3%, p = 0.498). The median ROX index was higher in the non-COVID-19 group than in the COVID-19 group at all time points. The prognostic power of the ROX index for HFNC failure as evaluated by the area under the ROC curve was generally higher in the COVID-19 group (0.73-0.83) than the non-COVID-19 group (0.62-0.75). The timing of the highest prognostic value of the ROX index for HFNC failure was at 4 h for the non-COVID-19 group, whereas in the COVID-19 group, its performance remained consistent from 1 h to 6 h. The optimal cutoff values were 6.48 and 5.79 for the non-COVID-19 and COVID-19 groups, respectively.

CONCLUSIONS

The ROX index had an acceptable discriminative power for predicting HFNC failure in patients with AHRF with and without COVID-19 in the ED. However, the higher ROX index thresholds than those in previous publications involving intensive care unit (ICU) patients suggest the need for careful monitoring and establishment of a new threshold for patients admitted outside the ICU.

Modified Cardiovascular Sequential Organ Failure Assessment Score in Sepsis: External Validation in Intensive Care Unit Patients

BACKGROUND

There is a need to update the cardiovascular (CV) Sequential Organ Failure Assessment (SOFA) score to reflect the current practice in sepsis. We previously proposed the modified CV SOFA score from data on blood pressure, norepinephrine equivalent dose, and lactate as gathered from emergency departments. In this study, we externally validated the modified CV SOFA score in multicenter intensive care unit (ICU) patients.

METHODS

A multicenter retrospective observational study was conducted on ICU patients at six hospitals in Korea. We included adult patients with sepsis who were admitted to ICUs. We compared the prognostic performance of the modified CV/total SOFA score and the original CV/total SOFA score in predicting 28-day mortality. Discrimination and calibration were evaluated using the area under the receiver operating characteristic curve (AUROC) and the calibration curve, respectively.

RESULTS

We analyzed 1,015 ICU patients with sepsis. In overall patients, the 28-day mortality rate was 31.2%. The predictive validity of the modified CV SOFA (AUROC, 0.712; 95% confidence interval [CI], 0.677-0.746; P < 0.001) was significantly higher than that of the original CV SOFA (AUROC, 0.644; 95% CI, 0.611-0.677). The predictive validity of modified total SOFA score for 28-day mortality was significantly higher than that of the original total SOFA (AUROC, 0.747 vs. 0.730; 95% CI, 0.715-0.779; P = 0.002). The calibration curve of the original CV SOFA for 28-day mortality showed poor calibration. In contrast, the calibration curve of the modified CV SOFA for 28-day mortality showed good calibration.

CONCLUSION

In patients with sepsis in the ICU, the modified SOFA score performed better than the original SOFA score in predicting 28-day mortality.

Predicting acute brain lesions on magnetic resonance imaging in acute carbon monoxide poisoning: a multicenter prospective observational study

An acute brain lesion (ABL) identified by brain magnetic resonance imaging (MRI) after acute carbon monoxide (CO) poisoning is a strong prognostic factor for the development of delayed neuropsychiatric syndrome (DNS). This study aimed to identify predictors of ABLs on MRI in patients with acute CO poisoning. This was a multicenter prospective registry-based observational study conducted at two tertiary hospitals. A total of 1,034 patients were included. Multivariable logistic regression analysis showed that loss of consciousness (LOC) (adjusted odds ratio [aOR] 2.68, 95% Confidence Interval [CI]: 1.49-5.06), Glasgow Coma Scale (GCS) score < 9 (aOR 2.41, 95% CI: 1.49-3.91), troponin-I (TnI) (aOR 1.22, 95% CI: 1.08-1.41), CO exposure duration (aOR 1.09, 95% CI: 1.05-1.13), and white blood cell (WBC) (aOR 1.05, 95% CI: 1.01-1.09) were independent predictors of ABLs on MRI. LOC, GCS score, TnI, CO exposure duration, and WBC count can be useful predictors of ABLs on MRI in patients with acute CO poisoning, helping clinicians decide the need for an MRI scan or transfer the patient to an appropriate institution for MRI or hyperbaric oxygen therapy.

Effect of adjuvant thiamine and ascorbic acid administration on the neurologic outcomes of out-of-hospital cardiac arrest patients: A before-and-after study

AIM

This study aimed to evaluate the impact of early thiamine and ascorbic acid administration on the neurologic outcome in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM).

METHODS

This before-and-after cohort study used data extracted from two hospitals of the Korean Hypothermia Network prospective registry. The treatment group incorporated patients enrolled from December 2019 to May 2021, that received intravenous thiamine (200 mg) and ascorbic acid (3 g) at 12-hour intervals for a total of six doses. The control group incorporated those enrolled from May 2018 to November 2019. The one-month good neurologic outcome, defined as a Cerebral Performance Category score ≤ 2, between the groups was evaluated using inverse probability of treatment weighting (IPTW).

RESULTS

Among the 234 OHCA survivors with TTM, 102 were included in the treatment group and 132 were included in the control group. The one-month (31.4 % vs. 29.5 %, respectively; P = 0.76) good neurologic outcome rates did not differ between the treatment and control groups. After adjusting using the IPTW, vitamin supplementation was not associated with good neurologic outcome (odds ratio [OR], 1.134; 95 % confidence interval [CI], 0.644-1.999; P = 0.66). In subgroup analysis, vitamin administration was significantly associated with a good neurologic outcome in older (≥65 years) patients (adjusted OR, 5.53; 95 % CI, 1.21-25.23; P = 0.03).

CONCLUSION

Adjuvant thiamine and ascorbic acid administration in OHCA survivors with TTM did not improve their neurologic outcome after one month. Further clinical trials are warranted.

Association Between Body Weight Changes and Subsequent Development of Out-of-Hospital Cardiac Arrest: A Population-Based Nested Case-Control Study

BACKGROUND

Body weight is a modifiable demographic factor. Although the association of body mass index (BMI) categories with sudden cardiac death was reported, dynamic changes of BMI and the risk of cardiac arrest remain unknown. This study aimed to evaluate the association between the out-of-hospital cardiac arrest (OHCA) occurrence within a year and the percent changes of BMI preceding the OHCA.

METHODS

This population-based nested case-control study used the National Health Insurance Service Data of Korea. In all, 24,465 patients with non-traumatic OHCA between 2010 and 2018, who underwent national health check-up twice (one within a year and the other within 2-4 years before OHCA) and 32,434 controls without OHCA, were matched for age and sex. The association between the risk of OHCA and BMI percent change stratified by sex was investigated.

RESULTS

All the BMI percent changes of ≥ 5% significantly increased the OHCA occurrence with a reverse J-shaped association. Compared to individuals with a stable weight, those with severe (> 15%) BMI decrease had the highest odds ratio (OR) of 4.29 (95% confidence intervals [CIs], 3.72-4.95) for OHCA occurrence followed by those with moderate (10-15%) weight loss (OR, 2.80; 95% CI, 2.55-3.08) and those with severe (> 15%) weigh gain (OR, 2.24; 95% CI, 1.96-2.57), respectively. The impact of weight loss on the cardiac arrest occurrence was more prominent in men, while the impact of weight gain was more prominent in women.

CONCLUSION

Significant weight changes increase the risk of OHCA within a year with a reverse J-shaped association. Significant weight loss might be a warning sign for OHCA especially for men.

Telephone-based evaluation of cognitive impairment and mood disorders in cardiac arrest survivors with good neurologic outcomes: a retrospective cohort study

This study determined the occurrence of cognitive impairment and mood disorders in out-of-hospital cardiac arrest (OHCA) survivors with good neurologic outcomes. We performed a retrospective, cross-sectional, single-center study with a total of 97 patients. We evaluated cognitive dysfunction via the Montreal Cognitive Assessment and Alzheimer's disease-8 mood disorders via the Patient Health Questionnaire-9 and the Hospital Anxiety and Depression Scale. We measured quality of life with the European Quality of Life 5-Dimension 5-Levels questionnaire. Cognitive impairment and mood disorders were common among patients with good neurologic recovery. There were 23 patients who experienced cognitive impairments (23.7%) and 28 who suffered from mood disorders (28.9%). Age (adjusted OR 1.07, 95% CI 1.02-1.12), mood disorders (adjusted OR 22.80, 95% CI 4.84-107.49) and hospital length of stay (adjusted OR 1.05, 95% CI 1.02-1.09) were independent risk factors for cognitive impairment. The occurrence of cognitive impairments (adjusted OR 9.94, 95% CI 2.83-35.97) and non-cardiac causes of cardiac arrest (adjusted OR 11.51, 95% CI 3.15-42.15) were risk factors for mood disorders. Quality of life was significantly lower in the OHCA survivors with each disorder than the healthy individuals. Routine screening and intervention are needed for OHCA survivors.

Hemodynamic management of septic shock: beyond the Surviving Sepsis Campaign guidelines

Although the Surviving Sepsis Campaign guidelines provide standardized and generalized guidance, they are less individualized. This review focuses on recent updates in the hemodynamic management of septic shock. Monitoring and intervention for septic shock should be personalized according to the phase of shock. In the salvage phase, fluid resuscitation and vasopressors should be given to provide life-saving tissue perfusion. During the optimization phase, tissue perfusion should be optimized. In the stabilization and de-escalation phases, minimal fluid infusion and safe fluid removal should be performed, respectively, while preserving organ perfusion. There is controversy surrounding the use of restrictive versus liberal fluid strategies after initial resuscitation. Fluid administration after initial resuscitation should depend upon the patient's fluid responsiveness and requires individualized management. A number of dynamic tests have been proposed to monitor fluid responsiveness, which can help clinicians decide whether to give fluid or not. The optimal timing for the initiation of vasopressor agents is unknown. Recent data suggest that early vasopressor initiation should be considered. Inotropes can be considered in patients with decreased cardiac contractility associated with impaired tissue perfusion despite adequate volume status and arterial blood pressure. Venoarterial extracorporeal membrane oxygenation should be considered for refractory septic shock with severe cardiac systolic dysfunction.

Prognostic accuracy of initial and 24-h maximum SOFA scores of septic shock patients in the emergency department

Background

We compared the prognostic accuracy of in-hospital mortality of the initial Sequential Organ Failure Assessment (SOFAini) score at the time of sepsis recognition and resuscitation and the maximum SOFA score (SOFAmax) using the worst variables in the 24 h after the initial score measurement in emergency department (ED) patients with septic shock.

Methods

This was a retrospective observational study using a multicenter prospective registry of septic shock patients in the ED between October 2015 and December 2019. The primary outcome was in-hospital mortality. The prognostic accuracies of SOFAini and SOFAmax were evaluated using the area under the receiver operating characteristic (AUC) curve.

Results

A total of 4860 patients was included, and the in-hospital mortality was 22.1%. In 59.7% of patients, SOFAmax increased compared with SOFAini, and the mean change of total SOFA score was 2.0 (standard deviation, 2.3). There was a significant difference in in-hospital mortality according to total SOFA score and the SOFA component scores, except cardiovascular SOFA score. The AUC of SOFAmax (0.71; 95% confidence interval [CI], 0.69-0.72) was significantly higher than that of SOFAini (AUC, 0.67; 95% CI, 0.66-0.69) in predicting in-hospital mortality. The AUCs of all scores of the six components were higher for the maximum values.

Conclusion

The prognostic accuracy of the initial SOFA score at the time of sepsis recognition was lower than the 24-h maximal SOFA score in ED patients with septic shock. Follow-up assessments of organ failure may improve discrimination of the SOFA score for predicting mortality.

Modification of HEART Pathway for Patients With Chest Pain: A Korean Perspective

BACKGROUND AND OBJECTIVES

The History, Electrocardiography, Age, Risk factors, and Troponin (HEART) pathway was developed to identify patients at low risk of a major adverse cardiac event (MACE) among patients presenting with chest pain to the emergency department.

METHODS

We modified the HEART pathway by replacing the Korean cut-off of 25 kg/m² with the conventional threshold of 30 kg/m² in the definition of obesity among risk factors. The primary outcome was a MACE within 30 days, which included acute myocardial infarction, primary coronary intervention, coronary artery bypass grafting, and all-cause death.

RESULTS

Of the 1,304 patients prospectively enrolled, MACE occurred in 320 (24.5%). The modified HEART pathway identified 37.3% of patients as low-risk compared with 38.3% using the HEART pathway. Of the 500 patients classified as low-risk with HEART pathway, 8 (1.6%) experienced MACE, and of the 486 low-risk patients with modified HEART pathway, 4 (0.8%) experienced MACE. The modified HEART pathway had a sensitivity of 98.8%, a negative predictive value (NPV) of 99.2%, a specificity of 49.0%, and a positive predictive value (PPV) of 38.6%, compared with the original HEART pathway, with a sensitivity of 97.5%, a NPV of 98.4%, a specificity of 50.0%, and a PPV of 38.8%.

CONCLUSIONS

When applied to Korean population, modified HEART pathway could identify patients safe for early discharge more accurately by using body mass index cut-off levels suggested for Koreans.

Predicting the probability of good neurological outcome after in-hospital cardiac arrest based on prearrest factors: validation of the good outcome following attempted resuscitation 2 (GO-FAR 2) score

The Good Outcome Following Attempted Resuscitation (GO-FAR) 2 score is a prognostic tool developed to support decision-making for do-not-attempt-resuscitation (DNAR) orders by predicting neurological outcomes after in-hospital cardiac arrest (IHCA) based on prearrest variables. However, this scoring system requires further validation. We aimed to validate the GO-FAR 2 score for predicting good neurological outcome in Korean patients with IHCA. A single-centre registry of adult patients with IHCA from 2013 to 2017 was analysed. The primary outcome was discharge with good neurological outcome (Cerebral Performance Category score of 1 or 2). The patients were divided into four categories according to the GO-FAR 2 score: very poor (≥ 5), poor (2-4), average (- 3 to 1), and above-average (< - 3) likelihood of good neurological outcome. Of 1,011 patients (median age, 65 years), 63.1% were men. The rate of good neurological outcome was 16.0%. The proportions of patients categorised as having very poor, poor, average, and above-average probability of good neurological outcome were 3.9%, 18.3%, 70.2%, and 7.6%, respectively. In each category, good neurological outcome was observed in 0%, 1.1%, 16.8%, and 53.2%, respectively. Among patients in below-average categories (very poor + poor, GO-FAR 2 score ≥ 2), only 0.9% had good outcome. GO-FAR 2 score ≥ 2 showed a sensitivity of 98.8% and a negative predictive value of 99.1% in predicting good neurological outcome. The GO-FAR 2 score can predict neurological outcome after IHCA. In particular, GO-FAR 2 score ≥ 2 may support decision-making for DNAR orders.

Different neuroprognostication thresholds of neuron-specific enolase in shockable and non-shockable out-of-hospital cardiac arrest: a prospective multicenter observational study in Korea (the KORHN-PRO registry)

BACKGROUND

Serum neuron-specific enolase (NSE) is the only recommended biomarker for multimodal prognostication in postcardiac arrest patients, but low sensitivity of absolute NSE threshold limits its utility. This study aimed to evaluate the prognostic performance of serum NSE for poor neurologic outcome in out-of-hospital cardiac arrest (OHCA) survivors based on their initial rhythm and to determine the NSE cutoff values with false positive rate (FPR) < 1% for each group.

METHODS

This study included OHCA survivors who received targeted temperature management (TTM) and had serum NSE levels measured at 48 h after return of spontaneous circulation in the Korean Hypothermia Network, a prospective multicenter registry from 22 university-affiliated teaching hospitals in South Korea between October 2015 and December 2018. The primary outcome was poor outcome at 6 month, defined as a cerebral performance category of 3-5.

RESULTS

Of 623 patients who underwent TTM with NSE measured 48 h after the return of spontaneous circulation, 245 had an initial shockable rhythm. Median NSE level was significantly higher in the non-shockable group than in the shockable group (104.6 [40.6-228.4] vs. 25.9 [16.7-53.4] ng/mL, P < 0.001). Prognostic performance of NSE assessed by area under the receiver operating characteristic curve to predict poor outcome was significantly higher in the non-shockable group than in the shockable group (0.92 vs 0.86). NSE cutoff values with an FPR < 1% in the non-shockable and shockable groups were 69.3 (sensitivity of 42.1%) and 102.7 ng/mL (sensitivity of 76%), respectively.

CONCLUSION

NSE prognostic performance and its cutoff values with FPR < 1% for predicting poor outcome in OHCA survivors who underwent TTM differed between shockable and non-shockable rhythms, suggesting postcardiac arrest survivor heterogeneity. Trial registration KORHN-PRO, NCT02827422. Registered 11 September 2016-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02827422.

Impact of Developing Dialysis-Requiring Acute Kidney Injury on Long-Term Mortality in Cancer Patients with Septic Shock

(1) Background: Considering recent advances in both cancer and sepsis management, we chose to evaluate the associated factors for occurrence of septic acute kidney injury in cancer patients using a nationwide population-based cohort data. (2) Methods: Using data from the National Health Insurance Service of Korea, adult cancer patients who presented to emergency departments with septic shock from 2009 to 2017 were analyzed. A Cox-proportional hazard model was conducted to evaluate the clinical effect of sepsis-related acute kidney injury requiring dialysis. (3) Results: Among 42,477 adult cancer patients with septic shock, dialysis-requiring acute kidney injury occurred in 5449 (12.8%). Recovery from dialysis within 30 days was 77.9% and, overall, 30-day and 2-year mortality rates were 52.1% and 85.1%, respectively. Oncologic patients with dialysis-requiring acute kidney injury frequently occurred in males and patients with hematologic cancer. A multivariate Cox-proportional hazard model showed that dialysis-requiring acute kidney injury had the highest adjusted hazard ratio of 1.353 (95% confidence interval 1.313-1.395) for 2-year mortality. (4) Conclusions: Dialysis-requiring septic acute kidney injury did not occur commonly. However, it had a significant association with increased long-term mortality, which suggests emphasis should be placed on the prevention of acute kidney injury, particularly in male hematologic cancer patients.

Machine Learning-Based Models for Prediction of Critical Illness at Community, Paramedic, and Hospital Stages

Overcrowding of emergency department (ED) has put a strain on national healthcare systems and adversely affected the clinical outcomes of critically ill patients. Early identification of critically ill patients prior to ED visits can help induce optimal patient flow and allocate medical resources effectively. This study aims to develop ML-based models for predicting critical illness in the community, paramedic, and hospital stages using Korean National Emergency Department Information System (NEDIS) data. Random forest and light gradient boosting machine (LightGBM) were applied to develop predictive models. The predictive model performance based on AUROC in community stage, paramedic stage, and hospital stage was estimated to be 0.870 (95% CI: 0.869-0.871), 0.897 (95% CI: 0.896-0.898), and 0.950 (95% CI: 0.949-0.950) in random forest and 0.877 (95% CI: 0.876-0.878), 0.899 (95% CI: 0.898-0.900), and 0.950 (95% CI: 0.950-0.951) in LightGBM, respectively. The ML models showed high performance in predicting critical illness using variables available at each stage, which can be helpful in guiding patients to appropriate hospitals according to their severity of illness. Furthermore, a simulation model can be developed for proper allocation of limited medical resources.

Effectiveness of Initial Troponin I and Brain Natriuretic Peptide Levels as Biomarkers for Predicting Delayed Neuropsychiatric Sequelae in Patients with CO Poisoning: A Retrospective Multicenter Observational Study

BACKGROUND

Delayed neuropsychiatric sequelae (DNS) are a severe complication of carbon monoxide (CO) poisoning, and predicting DNS is difficult. This study aimed to investigate whether cardiac markers can be used as biomarkers to predict DNS occurrence following acute CO poisoning.

METHODS

This was a retrospective observational study that included patients with acute CO poisoning who visited two emergency medical centers in Korea from January 2008 to December 2020. The primary outcome was whether the occurrence of DNS was associated with laboratory results.

RESULTS

Of the 1327 patients with CO poisoning, 967 patients were included. Troponin I and BNP were significantly higher in the DNS group. As a result of multivariate logistic regression analysis, it was found that troponin I, mentality, creatine kinase, brain natriuretic peptide, and lactate levels independently influenced DNS occurrence in CO poisoning patients. The adjusted odds ratios for DNS occurrence were 2.12 (95% CI 1.31-3.47, p = 0.002) for troponin I and 2.80 (95% CI 1.81-3.47, p < 0.001) for BNP.

CONCLUSION

Troponin I and BNP might be useful biomarkers for predicting the occurrence of DNS in patients with acute CO poisoning. This finding can help to identify high-risk patients who require close monitoring and early intervention to prevent DNS.

Association between the number of prehospital defibrillation attempts and a sustained return of spontaneous circulation: a retrospective, multicentre, registry-based study

BACKGROUND

Currently, there is no consensus on the number of defibrillation attempts that should be made before transfer to a hospital in patients with out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the association between the number of defibrillations and a sustained prehospital return of spontaneous circulation (ROSC).

METHODS

A retrospective analysis of a multicentre, prospectively collected, registry-based study in Republic of Korea was conducted for OHCA patients with prehospital defibrillation. The primary outcome was sustained prehospital ROSC, and the secondary outcome was a good neurological outcome at hospital discharge, defined as Cerebral Performance Category score 1 or 2. Cumulative incidence of sustained prehospital ROSC and good neurological outcome according to number of defibrillations were examined. Multivariable logistic regression analysis was used to examine whether the number of defibrillations was independently associated with the outcomes.

RESULTS

Excluding 172 patients with missing data, a total of 1983 OHCA patients who received prehospital defibrillation were included. The median time from arrest to first defibrillation was 10 (IQR 7-15) min. The numbers of patients with sustained prehospital ROSC and good neurological outcome were 738 (37%) and 549 (28%), respectively. Sustained ROSC rates decreased as the number of defibrillation attempts increased from the first to the sixth (16%, 9%, 5%, 3%, 2% and 1%, respectively). The cumulative sustained ROSC rate, and good neurological outcome rate from initial defibrillation to sixth defibrillation were 16%, 25%, 30%, 34%, 36%, 36% and 11%, 18%, 22%, 25%, 26%, 27%, respectively. With adjustment for clinical characteristics and time to defibrillation, a higher number of defibrillations was independently associated with a lower chance of a sustained ROSC (OR 0.81, 95% CI 0.76 to 0.86) and a lower chance of good neurological outcome (OR 0.86, 95% CI 0.80 to 0.92).

CONCLUSIONS

We observed no significant increase in ROSC after five defibrillations, and no absolute increase in ROSC after seven defibrillations. These data provide a starting point for determination of the optimal defibrillation strategy prior to consideration for prehospital extracorporeal cardiopulmonary resuscitation (ECPR) or conveyance to a hospital with an ECPR capability.

TRIAL REGISTRATION NUMBER

NCT03222999.

Vitamin D deficiency on admission to the emergency department is a mortality predictor for patients with septic shock treated with early protocol-driven resuscitation bundle therapy

BACKGROUND

Vitamin D is an important immune modulator and is associated with susceptibility to infection. However, past studies have reported inconsistent results regarding the association between vitamin D deficiency and mortality in patients with sepsis, and early-stage data regarding septic shock are limited. This study aimed to determine the relationship between vitamin D deficiency on admission to the emergency department (ED) and mortality in patients with septic shock.

METHODS

We analyzed prospectively collected data on adult patients with septic shock who were treated with protocol-driven resuscitation bundle therapy in the ED between September 2019 and February 2021. Septic shock was defined by the sepsis-3 definition and vitamin D deficiency was defined as a 25-hydroxyvitamin D <20 ng/ml. The primary outcome was 30-day mortality.

RESULTS

A total of 302 patients were included, 236 (78.1%) patients had vitamin D deficiency; it was significantly higher in non-survivors than in survivors (89.3% vs. 73.9%, P = 0.004). Mortality was higher in vitamin D deficient patients than in non-deficient patients (31.8% vs. 13.6%, P = 0.004). In multivariate analysis, vitamin D deficiency (odds ratio [OR], 2.43; 95 % confidence interval [CI], 1.03-5.74), hyperlactatemia (OR, 3.65; 95 % CI, 1.95-6.83), Sequential Organ Failure Assessment scores (OR, 1.22; 95% CI, 1.09-1.36), and albumin levels (OR, 0.39; 95% CI, 0.21-0.73) were significantly associated with 30-day mortality.

CONCLUSIONS

Vitamin D deficiency was prevalent in patients with septic shock visiting the ED and was associated with mortality.

Pre-arrest comorbidity burden and the future risk of out-of-hospital cardiac arrest in Korean adults

OBJECTIVE

To investigate the impact of pre-arrest comorbidities on future out-of-hospital cardiac arrest (OHCA) development using a nationwide dataset.

METHODS

This population-based, matched case-control study used the national health insurance claims data relevant to OHCA in South Korea from January 2009 to December 2018. Case patients were randomly matched to controls by age, sex and date of cardiac arrest. Controls were defined as patients who did not experience OHCA based on claim codes in national health screening data. The comorbidity burden was assessed using the Charlson Comorbidity Index (CCI).

RESULTS

A total of 191 370 OHCA patients were matched to 347 568 controls. The mean CCI in the case group was 3.76, which was significantly higher than that in the control group (1.75, p<0.001). Overall, OHCA was 1.35 (95% CI 1.34 to 1.35) times more likely to occur with every 1 point increase in the CCI. All other comorbidities constituting the CCI were associated with the OHCA risk (p<0.001). Patients with CCI ≥3 presented an OR of 3.71 (95% CI 3.67 to 3.76) for the risk of OHCA occurrence. This association was more pronounced in patients aged <70 years than in those aged ≥70 years (OR (95% CI) 16.07 (15.48 to 16.68) vs 6.50 (6.33 to 6.68)).

CONCLUSION

A high burden of pre-arrest comorbidity was associated with a higher risk of OHCA development, which was more pronounced in patients with less advanced age.

Coagulation measures after cardiac arrest (CMACA)

BACKGROUND

During cardiac arrest (CA) and after cardiopulmonary resuscitation, activation of blood coagulation and inadequate endogenous fibrinolysis occur. The aim of this study was to describe the time course of coagulation abnormalities after out-of-hospital CA (OHCA) and to examine the association with clinical outcomes in patients undergoing targeted temperature management (TTM) after OHCA.

METHODS

This prospective, multicenter, observational cohort study was performed in eight emergency departments in Korea between September 2018 and September 2019. Laboratory findings from hospital admission and 24 hours after return of spontaneous circulation (ROSC) were analyzed. The primary outcome was cerebral performance category (CPC) at discharge, and the secondary outcome was in-hospital mortality.

RESULTS

A total of 170 patients were included in this study. The lactic acid, prothrombin time (PT), activated partial thrombin time (aPTT), international normalized ratio (INR), and D-dimer levels were higher in patients with poor neurological outcomes at admission and 24 h after ROSC. The lactic acid and D-dimer levels decreased over time, while fibrinogen increased over time. PT, aPTT, and INR did not change over time. The PT at admission and D-dimer levels 24 h after ROSC were associated with neurological outcomes at hospital discharge. Coagulation-related factors were moderately correlated with the duration of time from collapse to ROSC.

CONCLUSION

The time-dependent changes in coagulation-related factors are diverse. Among coagulation-related factors, PT at admission and D-dimer levels 24 h after ROSC were associated with poor neurological outcomes at hospital discharge in patients treated with TTM.

Computed tomography coronary angiography after excluding myocardial infarction: high-sensitivity troponin versus risk score-guided approach

BACKGROUND

Patients with suspected acute coronary syndrome (ACS) in whom myocardial infarction has been ruled out are still at risk of having obstructive coronary artery disease (CAD). This rate is higher among patients with intermediate high-sensitivity troponin I (hsTnI) concentrations (5 ng/L to 99th percentile) than low concentrations (<5 ng/L). Therefore, an intermediate concentration has been suggested as a candidate for downstream investigation with computed tomography coronary angiography (CTCA). We tried to compare the HEART score-guided vs. hsTnI-guided approach for identifying obstructive CAD.

METHODS

From a prospective cohort study of patients presenting to the emergency department with suspected ACS, 433 patients without elevated hsTnI who also underwent CTCA were selected and analyzed. The performances of hsTnI concentration and HEART score were compared using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

Overall, 120 (27.7%) patients had obstructive CAD. Patients with intermediate hsTnI concentrations were more likely to have obstructive CAD than those with low hsTnI concentrations (40.0% vs. 18.1%); patients with non-low-risk HEART scores (≥4 points) were also more likely to have obstructive CAD than those with low-risk scores (0 to 3 points) (41.0% vs. 7.6%). The HEART score had higher sensitivity and NPV for detecting obstructive CAD in each classification than hsTnI concentration (sensitivity: 89.2% vs. 63.3% NPV: 92.4% vs. 81.9%, respectively).

CONCLUSION

After excluding myocardial infarction in patients with suspected ACS, adding the HEART score for selecting candidates for CTCA could improve patient risk stratification more accurately than relying on hsTnI concentration.

Augmented-Medication CardioPulmonary Resuscitation Trials in out-of-hospital cardiac arrest: a pilot randomized controlled trial

BACKGROUND

Previously conducted physician-centered trials on the usefulness of vasopressin have yielded negative results; thus, patient-oriented trials have been warranted. We hypothesize that Augmented-Medication CardioPulmonary Resuscitation could be helpful for selected patients with out-of-hospital cardiac arrest (OHCA).

METHODS

This is a double-blind, single-center, randomized, placebo-controlled trial conducted in the emergency department in a tertiary, university-affiliated hospital in Seoul, Korea. A total of 148 adults with non-traumatic OHCA who had initial diastolic blood pressure (DBP) < 20 mm Hg via invasive arterial monitoring during the early cardiac compression period were randomly assigned to two groups. Patients received a dose of 40 IU of vasopressin or placebo with initial epinephrine. The primary endpoint was a sustained return of spontaneous circulation. Secondary endpoints were survival discharge, and neurologic outcomes at discharge.

RESULTS

Of the 180 included patients, 32 were excluded, and 148 were enrolled in the trial. A sustained return of spontaneous circulation was achieved by 27 patients (36.5%) in the vasopressin group and 24 patients (32.4%) in the control group (risk difference, 4.1%; P = .60). Survival discharge and good neurologic outcomes did not differ between groups. The trial group had significantly higher median DBPs during resuscitation than the control group (16.0 vs. 14.5 mm Hg, P < 0.01). There was no difference in end-tidal carbon dioxide, acidosis, and lactate levels at baseline, 10 min, and end-time.

CONCLUSION

Among patients with refractory vasodilatory shock in OHCA, administration of vasopressin, compared with placebo, did not significantly increase the likelihood of return of spontaneous circulation.

Augmented-Medication CardioPulmonary Resuscitation (AMCPR) trial: a study protocol for a randomized controlled trial

Objective Clinical trials on demodynamic-directed cardiopulmonary resuscitation have been limited. The aim of this study is to investigate whether Augmented-Medication CardioPulmonary Resuscitation (AMCPR) would improve the odds of return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest. Methods This is a double-blind, single-center, randomized placebo-controlled trial that will be conducted in the emergency department of a tertiary, university-affiliated hospital in Seoul, Korea. A total of 148 adult patients with nontraumatic, nonshockable, out-of-hospital cardiac arrest who have an initial diastolic blood pressure above 20 mmHg will be randomly assigned to two groups of 74 patients (a 1:1 ratio). Patients will receive an intravenous dose of 40 IU of vasopressin with epinephrine, or a placebo with epinephrine. The primary endpoint is a sustained ROSC (over 20 minutes). Secondary endpoints are enhanced diastolic blood pressure, end-tidal carbon dioxide levels, acidosis, and lactate levels during resuscitation. Discussion AMCPR is a trial about tailored medication for select patients during resuscitation. This is the first randomized control trial to identify patients who would benefit from vasopressin for achieving ROSC. This study will provide evidence about the effect of administration of vasopressin with epinephrine to increase ROSC rate. Trial registration ClinicalTrials.gov identifier: NCT03191240. Registered on June 19, 2017.

Ion Shift Index at the Immediate Post-Cardiac Arrest Period as an Early Prognostic Marker in Out-of-Hospital Cardiac Arrest Survivors

The ion shift index (ISI) is a suggested marker to reflect the magnitude of ischemic damage. This study aimed to investigate the prognostic value of the ISI for predicting poor neurological outcomes at 6 months in comatose out-of-hospital cardiac arrest (OHCA) survivors by comparing it with the OHCA and Cardiac Arrest Hospital Prognosis (CAHP) scores. This observational registry-based cohort study included adult comatose OHCA survivors admitted to a tertiary care hospital in Korea between 2015 and 2021. The ISI was calculated using the serum electrolyte levels obtained within one hour of resuscitation. The primary outcome was poor neurological function (Cerebral Performance Category score of 3−5) at 6 months. Of the 250 OHCA survivors, 164 (65.6%) had poor neurological outcomes. These patients had a higher median ISI than those with good neurological outcomes (4.95 vs. 3.26, p < 0.001). ISI (adjusted odds ratio, 2.107; 95% confidence interval, 1.350−3.288, p = 0.001) was associated with poor neurological outcomes. The prognostic performance of ISI (area under the curve [AUC], 0.859) was similar to that of the OHCA score (AUC, 0.858; p = 0.968) and the CAHP score (AUC, 0.894; p = 0.183). ISI would be a prognostic biomarker for comatose OHCA survivors that is available during the immediate post-cardiac arrest period.

Clinical efficacy and nephrotoxicity of intravenous colistin sulfate in the treatment of carbapenem-resistant gram-negative bacterial infections: a retrospective cohort study

Background

Carbapenem-resistant gram-negative bacteria (CR-GNB) are becoming increasingly important bacterial pathogens in critically ill patients. Several clinicians use Intravenous colistin sulfate to treat infections due to CR-GNB, although the clinical data is limited. The aim of our retrospective observational study was to evaluate the effectiveness and nephrotoxicity of intravenous colistin sulfate in the treatment of CR-GNB infections.

Methods

Fifty critically ill intensive care patients with infections due to CR-GNB were retrospectively enrolled between January 2020 and December 2021 in the Zhejiang Provincial People’s Hospital. Favorable clinical response rate, bacterial clearance rate, nephrotoxicity, and 28-day mortality were evaluated.

Results

The overall favorable clinical response rate was 58%, the bacterial clearance rate was 40%, and the 28-day all-cause mortality was 44%. Temperature, neutrophil count, C-reaction protein (CRP), procalcitonin (PCT), creatinine (Cr), and lactate levels were also significantly decreased (P<0.05). The major adverse reaction is nephrotoxicity, and renal function was evaluated on the day before and after treatment with colistin sulfate. Possible nephrotoxicity was observed in three patients (6%). Backward logistic regression was conducted to determine risk factors for the nephrotoxicity of colistin sulfate, the result showed there were no significant differences in the duration and dose of colistin sulfate.

Conclusions

Our results provide evidence for the positive clinical efficacy and safety of colistin sulfate. Appropriate use of colistin sulfate may be viable and safe in the treatment of severe infections caused by CR-GNB.

Modified cardiovascular SOFA score in sepsis: development and internal and external validation

BACKGROUND

The Sepsis-3 criteria introduced the system that uses the Sequential Organ-Failure Assessment (SOFA) score to define sepsis. The cardiovascular SOFA (CV SOFA) scoring system needs modification due to the change in guideline-recommended vasopressors. In this study, we aimed to develop and to validate the modified CV SOFA score.

METHODS

We developed, internally validated, and externally validated the modified CV SOFA score using the suspected infection cohort, sepsis cohort, and septic shock cohort. The primary outcome was 28-day mortality. The modified CV SOFA score system was constructed with consideration of the recently recommended use of the vasopressor norepinephrine with or without lactate level. The predictive validity of the modified SOFA score was evaluated by the discrimination for the primary outcome. Discrimination was assessed using the area under the receiver operating characteristics curve (AUC). Calibration was assessed using the calibration curve. We compared the prognostic performance of the original CV/total SOFA score and the modified CV/total SOFA score to detect mortality in patients with suspected infection, sepsis, or septic shock.

RESULTS

We identified 7,393 patients in the suspected cohort, 4038 patients in the sepsis cohort, and 3,107 patients in the septic shock cohort in seven Korean emergency departments (EDs). The 28-day mortality rates were 7.9%, 21.4%, and 20.5%, respectively, in the suspected infection, sepsis, and septic shock cohorts. The model performance is higher when vasopressor and lactate were used in combination than the vasopressor only used model. The modified CV/total SOFA score was well-developed and internally and externally validated in terms of discrimination and calibration. Predictive validity of the modified CV SOFA was significantly higher than that of the original CV SOFA in the development set (0.682 vs 0.624, p < 0.001), test set (0.716 vs 0.638), and all other cohorts (0.648 vs 0.557, 0.674 vs 0.589). Calibration was modest. In the suspected infection cohort, the modified model classified more patients to sepsis (66.0 vs 62.5%) and identified more patients at risk of septic mortality than the SOFA score (92.6 vs 89.5%).

CONCLUSIONS

Among ED patients with suspected infection, sepsis, and septic shock, the newly-developed modified CV/total SOFA score had higher predictive validity and identified more patients at risk of septic mortality.

Cardiac arrest caused by anaphylaxis refractory to prompt management: A case series and review of the literature

BACKGROUND

Anaphylaxis is a potentially life-threatening condition that occurs in the emergency department (ED). Although anaphylaxis is rapidly recognized and treated in the hospital compared with that in the community, in some cases, it does not respond to proper management.

OBJECTIVE

The aim of this study is to describe our experience of cases of refractory anaphylaxis leading to cardiac arrest in hospital, to review their characteristics compared with those seen in the community, and to discuss the best management practices for anaphylaxis-induced cardiac arrest with a literature review.

METHODS

We reviewed the medical records of patients referred to the ED with possible in-hospital anaphylaxis between January 2017 and May 2021. According to the anaphylaxis protocol, epinephrine, corticosteroid, and antihistamine were administered immediately on-site at our institution before the study period. Refractory anaphylaxis was defined as the development of anaphylaxis-induced cardiac arrest even after following the anaphylaxis protocol.

RESULTS

A total of 246 cases were evaluated for possible anaphylaxis, with 236 cases meeting the criteria for a diagnosis of anaphylaxis. Among them, 178 patients showed the signs and symptoms of shock, and cardiac arrest occurred in 6 patients (2.5%). Of the six patients, three had a return of spontaneous circulation before admission to the ED, while two died due to refractory cardiac arrest despite resuscitation in the ED. Following post-cardiac arrest care, including temperature management, one patient who received extracorporeal cardiopulmonary resuscitation survived neurologically intact.

CONCLUSION

We present our case series to highlight the risk of developing refractory anaphylaxis with subsequent in-hospital cardiac arrest. Patients may progress to cardiac arrest within minutes despite prompt recognition and management. If patients present with potentially fatal symptoms, a more aggressive approach, including intravenous adrenaline infusion, should be taken.

The association of different target temperatures in targeted temperature management with neurological outcome after out-of-hospital cardiac arrest based on a prospective multicenter observational study in Korea (the KORHN-PRO registry): IPTW analysis

Background

Among comatose survivors of out-of-hospital cardiac arrest (OHCA), targeted temperature management (TTM) has improved neurological outcomes. However, although the target temperature shifted from 33°C to 33°C~36°C, the optimal target temperature is still unclear. The goal of this study was to evaluate neurological outcomes at 6 months at target temperatures of 33°C and 36°C.

Materials and methods

We analyzed OHCA survivors who underwent TTM and were recorded in the Korean Hypothermia Network, a prospective multicenter registry, from October 2015 to December 2018. The primary outcome was good neurological outcome at six months, defined as a cerebral performance category of 1–2, and the secondary outcome was survival at 6 months.

Results

A total of 1339 patients were treated with TTM in twenty-two emergency departments. Of those, 1054 were treated at 33°C, and 285 were treated at 36°C. There was no significant difference in good neurological outcomes at 6 months (30.6% vs. 31.2%, p = 0.850, adjusted OR 0.97, 95% CI = 0.73–1.29]) and survival at six months (41.4% vs. 38.7%, p = 0.401, adjusted HR 1.08, 95% CI = 0.91–1.28]) between TTM 33°C and TTM 36°C. After propensity score matching, good neurological outcomes at 6 months (OR 0.93, 95% CI = 0.74–1.18) and survival at 6 months (HR 1.05, 95% CI = 0.92–1.21) were still not associated with TTM 33°C and TTM 36°C.

Conclusion

In this study, patients treated with a target temperature of 33°C had similar good neurological outcomes and survival at six months compared with those treated with a target temperature of 36°C.

Current updates in acute traumatic aortic injury: radiologic diagnosis and management

Acute traumatic aortic injuries, which have substantial lethal outcomes at the time of admission, are fatal in 80% to 90% of cases. These injuries are relatively rare and have nonspecific clinical presentations. Radiologists and emergency physicians need to identify the radiological signs of acute traumatic aortic injury and differentiate them from common imaging errors to ensure accurate diagnosis and determine appropriate management protocols. In combination with image-guided interventions, advances in cross-sectional imaging have enabled nonsurgical management of acute traumatic aortic injuries. Timely and precise diagnoses of these injuries following prompt treatment are essential as up to 90% of patients presenting at the hospital can undergo early repair.

Alpha-power in electroencephalography as good outcome predictor for out-of-hospital cardiac arrest survivors

This study aimed to investigate the utility of quantitative EEG biomarkers for predicting good neurologic outcomes in OHCA survivors treated with targeted temperature management (TTM) using power spectral density (PSD), event-related spectral perturbation (ERSP), and spectral entropy (SE). This observational registry-based study was conducted at a tertiary care hospital in Korea using data of adult nontraumatic comatose OHCA survivors who underwent standard EEG and treated with TTM between 2010 and 2018. Good neurological outcome at 1 month (Cerebral Performance Category scores 1 and 2) was the primary outcome. The linear mixed model analysis was performed for PSD, ESRP, and SE values of all and each frequency band. Thirteen of the 54 comatose OHCA survivors with TTM and EEG were excluded due to poor EEG quality or periodic/rhythmic pattern, and EEG data of 41 patients were used for analysis. The median time to EEG was 21 h, and the rate of the good neurologic outcome at 1 month was 52.5%. The good neurologic outcome group was significantly younger and showed higher PSD and ERSP and lower SE features for each frequency than the poor outcome group. After age adjustment, only the alpha-PSD was significantly higher in the good neurologic outcome group (1.13 ± 1.11 vs. 0.09 ± 0.09, p = 0.031) and had best performance with 0.903 of the area under the curve for predicting good neurologic outcome. Alpha-PSD best predicts good neurologic outcome in OHCA survivors and is an early biomarker for prognostication. Larger studies are needed to conclusively confirm these findings.

A quick Sequential Organ Failure Assessment-negative result at triage is associated with low compliance with sepsis bundles: a retrospective analysis of a multicenter prospective registry

OBJECTIVE

We investigated the effects of a quick Sequential Organ Failure Assessment (qSOFA)-negative result (qSOFA score <2 points) at triage on the compliance with sepsis bundles among patients with sepsis who presented to the emergency department (ED).

METHODS

Prospective sepsis registry data from 11 urban tertiary hospital EDs between October 2015 and April 2018 were retrospectively reviewed. Patients who met the Third International Consensus Definitions for Sepsis and Septic Shock criteria were included. Primary exposure was defined as a qSOFA score ≥2 points at ED triage. The primary outcome was defined as 3-hour bundle compliance, including lactate measurement, blood culture, broad-spectrum antibiotics administration, and 30 mL/kg crystalloid administration. Multivariate logistic regression analysis to predict 3-hour bundle compliance was performed.

RESULTS

Among the 2,250 patients enrolled in the registry, 2,087 fulfilled the sepsis criteria. Only 31.4% (656/2,087) of the sepsis patients had qSOFA scores ≥2 points at triage. Patients with qSOFA scores <2 points had lower lactate levels, lower SOFA scores, and a lower 28-day mortality rate. Rates of compliance with lactate measurement (adjusted odds ratio [aOR], 0.47; 95% confidence interval [CI], 0.29-0.75), antibiotics administration (aOR, 0.64; 95% CI, 0.52-0.78), and 30 mL/kg crystalloid administration (aOR, 0.62; 95% CI, 0.49-0.77) within 3 hours from triage were significantly lower in patients with qSOFA scores <2 points. However, the rate of compliance with blood culture within 3 hours from triage (aOR, 1.66; 95% CI, 1.33-2.08) was higher in patients with qSOFA scores <2 points.

CONCLUSION

A qSOFA-negative result at ED triage is associated with low compliance with lactate measurement, broad-spectrum antibiotics administration, and 30 mL/kg crystalloid administration within 3 hours in sepsis patients.

Acute exacerbation of COPD increases the risk of hip fractures: a nested case-control study from the Korea National Health Insurance Service

BACKGROUND/AIMS

Hip fracture and acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) could increase mortality in patients with COPD. There are no data on the relationship between AE-COPD and hip fracture, which may significantly affect the prognosis of patients with COPD. Therefore, we conducted this study to determine the effects of AE-COPD on hip fractures in patients with COPD.

METHODS

This retrospective, nested, case-control study included 253,471 patients with COPD (≥ 40 years of age) identified from the Korea National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) from 2002 to 2015. Among 176,598 patients with COPD, 1,415 patients with hip fractures were identified. Each case was matched to one control for age (within 10 years), sex, and year of COPD diagnosis. We estimated the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for hip fractures associated with AE-COPD using conditional logistic regression analysis, adjusting for underlying diseases and smoking history.

RESULTS

In patients with AE-COPD, the risk of hip fracture was 2.50 times higher, regardless of systemic corticosteroid use and underlying disease (aOR, 2.50; 95% CI, 1.67 to 3.75). The risk of hip fracture increased if there was one episode of AE in the year before hip fractures (aOR, 2.25; 95% CI, 1.66 to 3.05). Moreover, the risk of hip fracture also increased in patients with more than two episodes of AE the year before hip fractures (aOR, 2.57; 95% CI, 1.61 to 4.10).

CONCLUSION

AE-COPD increases the risk of hip fracture regardless of underlying diseases, including osteoporosis, and treatment with systemic corticosteroids.

Prognostic factors for late death in septic shock survivors: a multi-center, prospective, registry-based observational study

Septic shock patients who survive past the acute period are associated with an increased risk of long-term mortality. However, factors for predicting late death remain unclear. We aimed to investigate the prognostic factors associated with late mortality in septic shock patients with 28-day survival after admission. This retrospective observational study used a prospective, multi-center registry of septic shock patients between October 2015 and December 2019 involving 12 emergency departments (EDs) from the Korean Shock Society. Adult septic shock patients visiting the ED with 28-day survival after admission were included. Among 4624 septic shock patients, 3588 (77.6%) who survived past day 28 were analyzed. The 90-day mortality rate was 14.2%. Non-survivors were older (66.8 vs. 68.9 years; p = 0.032) and had higher lactate levels (3.7 vs. 4.0 mmol/L; p = 0.028) than survivors. Pulmonary and hepatobiliary infections and a history of malignancy (27.7 vs. 57.5%; p < 0.001) were more frequent in the non-survivor group than in the survivor group. Independent risk factors for late death on multivariate regression analysis were age; malignancy; and hemoglobin, blood urea nitrogen, and albumin levels. The length of intensive care unit stay and Sequential Organ Failure Assessment score were independently associated with late death. Approximately, one-seventh of septic shock patients who survived past day 28 of admission died by day 90. Physicians must pay attention to survivors with these risk factors during the post-acute period as they have an increased mortality risk.

Relationship between time of emergency department admission and adherence to the Surviving Sepsis Campaign bundle in patients with septic shock

BACKGROUND

Nighttime hospital admission is often associated with increased mortality risk in various diseases. This study investigated compliance rates with the Surviving Sepsis Campaign (SSC) 3-h bundle for daytime and nighttime emergency department (ED) admissions and the clinical impact of compliance on mortality in patients with septic shock.

METHODS

We conducted an observational study using data from a prospective, multicenter registry for septic shock provided by the Korean Shock Society from 11 institutions from November 2015 to December 2017. The outcome was the compliance rate with the SSC 3-h bundle according to the time of arrival in the ED.

RESULTS

A total of 2049 patients were enrolled. Compared with daytime admission, nighttime admission was associated with higher compliance with the administration of antibiotics within 3 h (adjusted odds ratio (adjOR), 1.326; 95% confidence interval (95% CI), 1.088-1.617, p = 0.005) and with the complete SSC bundle (adjOR, 1.368; 95% CI, 1.115-1.678; p = 0.003), likely to result from the increased volume of all patients and sepsis patients admitted during daytime hours. The hazard ratios of the completion of SSC bundle for 28-day mortality and in-hospital mortality were 0.750 (95% CI 0.590-0.952, p = 0.018) and 0.714 (95% CI 0.564-0.904, p = 0.005), respectively.

CONCLUSION

Septic shock patients admitted to the ED during the daytime exhibited lower sepsis bundle compliance than those admitted at night. Both the higher number of admitted patients and the higher patients to medical staff ratio during daytime may be factors that are responsible for lowering the compliance.

Impact of central venous pressure on the mortality of patients with sepsis-related acute kidney injury: a propensity score-matched analysis based on the MIMIC IV database

Background

Sepsis has long been a life-threatening organ dysfunction. Sepsis associated acute kidney injury (SA-AKI) is an important complication of sepsis, as an important hemodynamic index, the impact of central venous pressure (CVP) on sepsis patients needs to be explored. Thus this study aimed to investigate the relationship between CVP and the mortality of SA-AKI.

Methods

Clinical data of adult patients with sepsis-related acute kidney injury, defined as met both the Sepsis 3.0 criteria and the Kidney Disease Improving Global Outcomes Clinical Practice Guideline (KDIGO) criteria, were obtained from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database. The included cohort was divided into a high CVP and a low CVP group were determined based on the cuf-off value from receiver operating characteristic curve, with propensity score-matched analysis of the 28-day mortality for both groups and sensitivity analysis using inverse the probability-weighting model, multifactorial regression, and doubly robust estimation, patients acquired chronic coronary syndrome (CCS) and diabetes were also taken into consideration.

Results

Of 1,377 patients with sepsis-related acute kidney injury, low CVP group (<13 mmHg) was 67.4% (n=928) and high CVP group (≥13 mmHg) was 32.6% (n=449). The two groups were matched 1:1 by propensity score to obtain a matched cohort (n=288). The mortality rates in the low versus high CVP group (19.4% vs. 34.7%) were statistically difference (odds ratio OR: 0.454; 95% confidence interval 0.263, 0.771). Moreover, the bistable analysis of logistic regression of the matched cohort (OR: 0.434; 95% CI: 0.244, 0.757), propensity score inverse probability weighting (IPW) (OR: 0.547; 95% CI: 0.454, 0.658), and multifactorial logistic regression (OR: 0.352; 95% CI: 0.127, 0.932) all yielded the same results.

Conclusions

In patients with sepsis-related acute kidney injury, a lower CVP level (<13 mmHg) is an independent variable associated with decreased mortality. The threshold of CVP needs to be controlled in clinical work to improve the prognosis of patients with SA-AKI.

The feasibility of extracorporeal cardiopulmonary resuscitation for patients with active cancer who undergo in-hospital cardiac arrest

Indications of extracorporeal cardiopulmonary resuscitation (ECPR) are still debatable, particularly in patients with cancer. Prediction of the prognosis of in-hospital cardiac arrest (IHCA) in patients with cancer receiving ECPR is important given the increasing prevalence and survival rate of cancer. We compared the neurologic outcomes and survival rates of IHCA patients with and without cancer receiving ECPR. Data from the extracorporeal membrane oxygenation registry between 2015 and 2019 were used in a retrospective manner. The primary outcome was 6-month good neurologic outcome, defined as a Cerebral performance category score of 1 or 2. The secondary outcomes were 1- and 3-month good neurologic outcome, and 6-month survival. Among 247 IHCA patients with ECPR, 43 had active cancer. The 6-month good neurologic outcome rate was 27.9% and 32.4% in patients with and without active cancer, respectively (P > 0.05). Good neurologic outcomes at 1-month (30.2% vs. 20.6%) and 3-month (30.2% vs. 28.4%), and the survival rate at 6-month (39.5% vs. 36.5%) were not significantly different (all P > 0.05) Active cancer was not associated with 6-month good neurologic outcome by logistic regression analyses. Therefore, patients with IHCA should not be excluded from ECPR solely for the presence of cancer itself.

Biomarker Analysis for Combination Therapy of Vitamin C and Thiamine in Septic Shock: A Post-Hoc Study of the ATESS Trial

INTRODUCTION

We evaluated the effects of vitamin C and thiamine administration on biomarkers in patients with septic shock.

METHODS

This was a post-hoc analysis of the Ascorbic Acid and Thiamine Effect in Septic Shock (ATESS) trial, a multicenter, double-blind, randomized controlled trial. Patients were randomized to either a treatment group (intravenous vitamin C and thiamine for 48 h) or a control group. Interleukin (IL)-6, IL-10, angiopoietin-II (AP2), and S100β were assessed at baseline and at 72 h. The primary outcomes were the biomarker levels at 72 h, and the secondary outcome was reduction rate.

RESULTS

Forty-five patients were assigned to the treatment group and 52 were assigned to the control group. Baseline biomarker levels and at 72 h were not significantly different between the treatment and the placebo groups. The reduction rates were not significantly different between the two groups. These outcome variables showed fair diagnostic accuracy for predicting 28-day mortality according to the area under the receiver operating characteristic curve.

CONCLUSION

Vitamin C and thiamine administration during the early phase of septic shock did not significantly change prognostic biomarker levels of IL-6, IL-10, AP2, and S100β.

TRIAL REGISTRATION

NCT, ClinicalTrials.gov NCT03756220, ATESS. Registered 28 November 2018, https://clinicaltrials.gov/ct2/show/NCT03756220.

Subcutaneous fat area at the upper thigh level is a useful prognostic marker in the elderly with femur fracture

BACKGROUND

The aim of this study was to evaluate prognostic value of body tissue composition at the upper thigh level for 1 year mortality in elderly patients with proximal femur fracture.

METHODS

This retrospective cohort study included consecutive elderly (aged ≥65) patients diagnosed with proximal femur fracture based on the findings of pelvic bone computed tomography (CT) performed at the emergency department of a tertiary care hospital and treated with surgery between 2010 and 2017. The cross-sectional area of subcutaneous fat and skeletal muscle at the upper thigh level was measured using CT. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for 1 year mortality were estimated using a Cox proportional hazards model. Survival based on the SFA quartiles was assessed using nonparametric Kaplan-Meier survival analysis and compared used log-rank tests.

RESULTS

Among 876 elderly patients included in this study, the median age was 79.0 years, and 646 (73.7%) patients were female. A total of 93 (10.6%) died within 1 year after admission to the emergency department. Survivors had a significantly higher median subcutaneous fat area (SFA) than non-survivors (170.2 vs. 133.0 cm² , P < 0.001), but no significant difference was observed between the skeletal muscle area (median, 156.7 vs. 160.3 cm² , P = 0.504) and muscle density (median, 19.0 vs. 19.1 HU, P = 0.861) of both groups. After adjustment of other clinical characteristics and body compositions, the multivariate Cox proportional hazard analysis showed that SFA (adjusted HR, 0.987; 95% CI, 0.982-0.992; P < 0.001) was independently associated with 1 year mortality. With 384 deaths during 51 322 person-months of follow-up, the median estimated survival duration of all the patients was 92.8 months (95% CI, 80.8-104.7 months). The patients with SFA in the third (165.6-195.0 cm² ) and fourth (>195.0 cm² ) quartiles showed significantly longer survival duration than those with SFA in the first (<131.4 cm² ; median survival time, 51.3 months) and second (131.4-165.5 cm² ; median survival time, 88.7 months) quartiles (P < 0.001 by log-rank test).

CONCLUSIONS

The SFAs measured at the upper thigh level and 1 year mortality are positively associated in elderly patients with proximal femur fracture. SFA may be an independent prognostic biomarker for 1 year mortality of femur fracture.

Dynamic changes in arterial blood gas during cardiopulmonary resuscitation in out-of-hospital cardiac arrest

We aimed to investigate the prognostic value of dynamic changes in arterial blood gas analysis (ABGA) measured after the start of cardiopulmonary resuscitation (CPR) for return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA). This prospective observational study was conducted at the emergency department of a university hospital from February 2018 to February 2020. All blood samples for gas analysis were collected from a radial or femoral arterial line, which was inserted during CPR. Changes in ABGA parameters were expressed as delta (Δ), defined as the values of the second ABGA minus the values of the initial ABGA. The primary outcome was sustained ROSC. Out of the 80 patients included in the analysis, 13 achieved sustained ROSC after in-hospital resuscitation. Multivariable logistic analysis revealed that ΔpaO₂ (odds ratio [OR] = 1.023; 95% confidence interval [CI] = 1.004–1.043, p = 0.020) along with prehospital shockable rhythm (OR = 84.680; 95% CI = 2.561–2799.939, p = 0.013) and total resuscitation duration (OR = 0.881; 95% CI = 0.805–0.964, p = 0.006) were significant predictors for sustained ROSC. Our study suggests a possible association between ΔpaO₂ in ABGA during CPR and an increased rate of sustained ROSC in the late phase of OHCA.

Background frequency can enhance the prognostication power of EEG patterns categories in comatose cardiac arrest survivors: a prospective, multicenter, observational cohort study

Background

We assessed the prognostic accuracy of the standardized electroencephalography (EEG) patterns (“highly malignant,” “malignant,” and “benign”) according to the EEG timing (early vs. late) and investigated the EEG features to enhance the predictive power for poor neurologic outcome at 1 month after cardiac arrest.

Methods

This prospective, multicenter, observational, cohort study using data from Korean Hypothermia Network prospective registry included adult patients with out-of-hospital cardiac arrest (OHCA) treated with targeted temperature management (TTM) and underwent standard EEG within 7 days after cardiac arrest from 14 university-affiliated teaching hospitals in South Korea between October 2015 and December 2018. Early EEG was defined as EEG performed within 72 h after cardiac arrest. The primary outcome was poor neurological outcome (Cerebral Performance Category score 3–5) at 1 month.

Results

Among 489 comatose OHCA survivors with a median EEG time of 46.6 h, the “highly malignant” pattern (40.7%) was most prevalent, followed by the “benign” (33.9%) and “malignant” (25.4%) patterns. All patients with the highly malignant EEG pattern had poor neurologic outcomes, with 100% specificity in both groups but 59.3% and 56.1% sensitivity in the early and late EEG groups, respectively. However, for patients with “malignant” patterns, 84.8% sensitivity, 77.0% specificity, and 89.5% positive predictive value for poor neurologic outcome were observed. Only 3.5% (9/256) of patients with background EEG frequency of predominant delta waves or undetermined had good neurologic survival. The combination of “highly malignant” or “malignant” EEG pattern with background frequency of delta waves or undetermined increased specificity and positive predictive value, respectively, to up to 98.0% and 98.7%.

Conclusions

The “highly malignant” patterns predicted poor neurologic outcome with a high specificity regardless of EEG measurement time. The assessment of predominant background frequency in addition to EEG patterns can increase the prognostic value of OHCA survivors.

Trial registration KORHN-PRO, NCT02827422. Registered 11 September 2016—Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03823-y.