Undercorrection of hypernatremia is frequent and associated with mortality

Background

About 1% of patients admitted to the Emergency Department (ED) have hypernatremia, a condition associated with a mortality rate of 20 to 60%. Management recommendations originate from intensive care unit studies, in which patients and medical diseases differ from those in ED.

Methods

We retrospectively studied clinical characteristics, treatments, and outcomes of severely hypernatremic patients in the ED and risk factors associated with death occurrence during hospitalization.

Results

During 2010, 85 cases of severe hypernatremia ≥150 mmol/l were admitted to ED. Hypernatremia occurred in frail patients: mean age 79.7 years, 55% institutionalized, 28% with dementia.

Twenty four percent of patients died during hospitalization. Male gender and low mean blood pressure (MBP) were independently associated with death, as well as slow natremia correction speed, but not the severity of hyperosmolarity at admission. Infusion solute was inappropriate for 45% of patients with MBP <70 mmHg who received hypotonic solutes and 22% of patients with MBP ≥70 mmHg who received isotonic solutes or were not perfused.

Conclusions

This is the first study assessing outcome of hypernatremic patients in the ED according to the treatment provided. It appears that not only a too quick, but also a too slow correction speed is associated with an increased risk of death regardless of initial natremia. Medical management of hypernatremic patients must be improved regarding evaluation and treatment.

Use of heliox in patients with severe exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

To assess whether patients with chronic obstructive pulmonary disease treated with heliox have a better prognosis than those treated with standard therapy.

DESIGN

Retrospective analysis over 18 months.

SETTING

Academic emergency department.

PATIENTS

Eighty-one patients admitted with exacerbation of chronic obstructive pulmonary disease and respiratory acidosis.

INTERVENTIONS

Use of helium-oxygen mixture as an adjunctive therapy.

MEASUREMENTS AND MAIN RESULTS

The following data were collected: age, gender, medical history, vital signs, arterial blood gas at admission, emergency room treatment, requirement for intubation, admission in intensive care unit, length of stay, and evolution. Patients were classified into two groups according to whether heliox was used as a therapeutic agent (heliox group) or not (standard group). Chi-square test and Student's t-test were used for statistical analysis (significant at p <.05). In both groups, the following data were similar: age, gender, medical history, vital signs, initial arterial blood gas, and emergency room treatment. Significant decreases in intubation, and mortality rate were identified in the heliox group. Significant decreases in intensive care unit stay and in-hospital stay were observed for survivors in the heliox group.

CONCLUSION

Use of heliox seems to improve prognosis in patients with severe acute exacerbation of chronic obstructive pulmonary disease. Prospective randomized studies are needed to confirm these results.

Medical student effect on emergency department length of stay

STUDY OBJECTIVE

Taking advantage of a medical student strike, the authors evaluated the effect of medical students on emergency department length of stay (LOS).

METHODS

ED LOS and patient characteristics were compared for the 4-day strike period and the same days the week before. Proportions were compared by using the Mann-Whitney U test and the chi(2) test (P <.05).

RESULTS

Eight hundred thirty-one patients were studied. There was no significant difference between the study and control periods for the general patient characteristics or laboratory or radiologic investigations. Median LOS decreased by 24% (31 minutes, 95% confidence interval [CI] 24 to 38) during the strike (110 minutes [95% CI 65 to 178] to 79 minutes [95% CI 40 to 135], P <10(-4)).

CONCLUSION

Medical students lengthen ED LOS. This should be explained to patients and should be considered as one justification for increasing medical staff in the teaching ED.

[The effect of "seniorization" on the prescription of biological tests in an admissions and emergency service]

This prospective study compared the prescriptions of biological tests (PBT) for patients admitted to an Emergency medical service (EMS) of a University hospital, according as to whether the staff consisted either of medical residents only (study period P1) or of residents trained in emergency medicine and continuously supervised by a senior specialist (study period P2). During the one-month study periods, a total of 5,948 patients were admitted (2,781 during P1 and 3,167 during P2 respectively). Between P1 and P2 the rate of PBT decreased by 38.8% (P < 0.0001), the mean expenses for PBT per patient by 13.8% (P < 0.0001) and the total expenses by 53.4%. Teaching and training of residents in emergency medicine and supervision by a senior specialist improve the quality of care and decrease health care cost.