The effects of a limited infusion rate of fluid in the early resuscitation of sepsis on glycocalyx shedding measured by plasma syndecan-1: a randomized controlled trial

Background

Aggressive fluid administration is recommended in the resuscitation of septic patients. However, the delivery of a rapid fluid bolus might cause harm by inducing degradation of the endothelial glycocalyx. This research aimed to examine the effects of the limited infusion rate of fluid on glycocalyx shedding as measured by syndecan-1 in patients with sepsis-induced hypoperfusion.

Methods

A prospective, randomized, controlled, open-label trial was conducted between November 2018 and February 2020 in an urban academic emergency department. Patients with sepsis-induced hypoperfusion, defined as hypotension or hyperlactatemia, were randomized to receive either the standard rate (30 ml/kg/h) or limited rate (10 ml/kg/h) of fluid for the first 30 ml/kg fluid resuscitation. Subsequently, the fluid rate was adjusted according to the physician’s discretion but not more than that of the designated fluid rate for the total of 6 h. The primary outcome was differences in change of syndecan-1 levels at 6 h compared to baseline between standard and limited rate groups. Secondary outcomes included adverse events, organ failure, and 90-day mortality.

Results

We included 96 patients in the intention-to-treat analysis, with 48 assigned to the standard-rate strategy and 48 to the limited-rate strategy. The median fluid volume in 6 h in the limited-rate group was 39 ml/kg (interquartile range [IQR] 35–52 ml/kg) vs. 53 ml/kg (IQR 46–64 ml/kg) in the standard-rate group (p < 0.001). Patients in the limited-rate group were less likely to received vasopressors (17% vs 42%; p = 0.007) and mechanical ventilation (20% vs 41%; p = 0.049) during the first 6 h. There were no significantly different changes in syndecan-1 levels at 6 h between the two groups (geometric mean ratio [GMR] in the limited-rate group, 0.82; 95% confidence interval [CI], 0.66–1.02; p = 0.07). There were no significant differences in adverse events, organ failure outcomes, or mortality between the two groups.

Conclusions

In sepsis resuscitation, the limited rate of fluid resuscitation compared to the standard rate did not significantly reduce changes in syndecan-1 at 6 h.

Trial registration

Thai Clinical Trials Registry number: TCTR20181010001. Registered 8 October 2018, http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=4064

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-020-00515-7.

High sensitivity Troponin-I levels in asymptomatic hemodialysis patients

Reduction in renal clearance and removal by hemodialysis adversely affect the level and utility of high-sensitivity troponin I (hsTnI) for diagnosis of acute myocardial infarction (AMI) in hemodialysis (HD) patients. Furthermore, HD process itself might cause undesirable myocardial injury and enhance post HD hsTnI levels. This comparative cross-sectional study was conducted to compare the hsTnI levels between 100 asymptomatic HD patients and their 107 matched non-chronic kidney disease (CKD) population. The hsTnI levels in HD group were higher than non-CKD group [median (IQR): 54.3 (20.6-152.7) vs. 18 (6.2-66.1) ng/L, p < .001)]. The hsTnI levels reduced after HD process from 54.3 (20.6-152.7) ng/L in pre-HD to 27.1 (12.3-91.4) ng/L in post-HD (p = .015). Of interest, 25% of HD patients had increment of hsTnI after HD and might represent HD-induced myocardial injury. The significant risk factors were high hemoglobin level and high blood flow rate. In conclusion, the baseline hsTnI levels in asymptomatic HD patients were higher than non-CKD population. The dynamic change of hsTnI over time would be essential for the diagnosis of AMI. Certain numbers of asymptomatic HD patients had HD-induced silent myocardial injury and should be aggressively investigated to prevent further cardiovascular mortality.

Randomized Controlled Trial of Ultrasound-guided Fluid Resuscitation of Sepsis-Induced Hypoperfusion and Septic Shock

Introduction

The ultrasound measurement of inferior vena cava (IVC) diameter change during respiratory phase to guide fluid resuscitation in shock patients is widely performed, but the benefit on reducing the mortality of sepsis patients is questionable. The study objective was to evaluate the 30-day mortality rate of patients with sepsis-induced tissue hypoperfusion (SITH) and septic shock (SS) treated with ultrasound-guided fluid management (UGFM) using ultrasonographic change of the IVC diameter during respiration compared with those treated with the usual-care strategy.

Methods

This was a randomized controlled trial conducted in an urban, university-affiliated tertiary-care hospital. Adult patients with SITH/SS were randomized to receive treatment with UGFM using respiratory change of the IVC (UGFM strategy) or with the usual-care strategy during the first six hours after emergency department (ED) arrival. We compared the 30-day mortality rate and other clinical outcomes between the two groups.

Results

A total of 202 patients were enrolled, 101 in each group (UGFM vs usual-care strategy) for intention-to-treat analysis. There was no significant difference in 30-day overall mortality between the two groups (18.8% and 19.8% in the usual-care and UGFM strategy, respectively; p > 0.05 by log rank test). Neither was there a difference in six-hour lactate clearance, a change in the sequential organ failure assessment score, or length of hospital stay. However, the cumulative fluid amount given in 24 hours was significantly lower in the UGFM arm.

Conclusion

In our ED setting, the use of respiratory change of IVC diameter determined by point-of-care ultrasound to guide initial fluid resuscitation in SITH/SS ED patients did not improve the 30-day survival probability or other clinical parameters compared to the usual-care strategy. However, the IVC ultrasound-guided resuscitation was associated with less amount of fluid used.

Risk factors of extended-spectrum beta-lactamaseproducing Enterobacteriaceae bacteremia in Thai emergency department: a retrospective case-control study

Background: Infections caused by resistant extended-spectrum beta-lactamase (ESBL)-producing enteric bacteria and their risk factors are globally recognized. However, such risk factors have not been explored in emergency department (ED) where the first choice of empirical antimicrobials is crucial.

Objective: Determine risk factors of ESBL bacteremia in ED, especially in our geographic area.

Methods: A retrospective case-double-control study was conducted at King Chulalongkorn Memorial Hospital. All adult ED patients with ESBL-producing E. coli and K. pneumoniae in blood cultures between October 2007 and October 2008 were recruited for this study. The potential risk factors were analyzed and compared with non- ESBL-producing bacteremic patients (control group 1) and matched general ED patients (control group 2). Nonbeta- lactam susceptibility testing among the cohort was also evaluated.

Results: Thirty ESBL (cases), 103 group 1 controls, and 100 group 2 controls were assessed. Based on the univariate analysis, age, chronic kidney diseases, malignancy, poor functional status, previous hospitalization within 90 days, and previous antimicrobial exposure especially to cephalosporins, quinolones, and carbapenems within 30 days were the risk factors for ESBL bacteremia compared with both types of control patients. Age > 60 and previous cephalosporin use were consistently identified as the risk factors by multivariate models using both control groups. The susceptibility to non-beta-lactam agents in the ESBL group was significantly lower than the non-ESBL. No carbapenem resistance was found.

Conclusion: Elderly ED patients, especially those who had previous cephalosporin exposure within 30 days, were at higher risk of ESBL-producing bacteremic infections. ESBLs tended to have less susceptibility to the non-β-lactam agents.

A randomized controlled trial of adding intravenous corticosteroids to H1 antihistamines in patients with acute urticaria

BACKGROUND

Acute urticaria is a common dermatological condition in emergency departments (EDs). The main therapy involves controlling pruritus with antihistamines. Although guidelines have promoted the use of corticosteroids in addition to H1 antihistamines, well-designed clinical trials evaluating this approach are scarce.

METHODS

Adult ED patients with acute urticaria and a pruritus score > 5 on a visual analog scale (VAS) were randomized into three groups: (i) IV chlorpheniramine (CPM) treatment, (ii) IV CPM and IV dexamethasone (CPM/Dex) and (iii) IV CPM and IV dexamethasone with oral prednisolone as discharge medication for 5 days (CPM/Dex/Pred). The primary outcomes were self-reported pruritus VAS scores at 60 min after treatment. We also evaluated 1-week and 1-month urticaria activity scores for 7 days and adverse events.

RESULTS

Seventy-five patients (25 per group) were enrolled. The VAS scores of all groups decreased, but no significant difference was found in the VAS scores at 60 min after treatment between patients in the CPM group (n = 25) and those who received both CPM and dexamethasone (n = 50). At the 1-week and 1-month follow-ups, active urticaria (indicated by the urticaria activity score at 7 days) was more prevalent in the CPM/Dex/Pred group (n = 25) than in the control group.

CONCLUSIONS

The present study did not find evidence that adding IV dexamethasone improves the treatment of severe pruritus from uncomplicated acute urticaria. Oral corticosteroid therapy may be associated with persistent urticaria activity. Due to the lack of clinical benefits and the potential for side effects, using corticosteroids as an adjunctive treatment is discouraged.

Difficult airway predictors were associated with decreased use of neuromuscular blocking agents in emergency airway management: a retrospective cohort study in Thailand

Background

It is recommended that difficult airway predictors be evaluated before emergency airway management. However, little is known about how patients with difficult airway predictors are managed in emergency departments. We aimed to explore the incidence, management and outcomes of patients with difficult airway predictors in an emergency department.

Methods

We conducted a retrospective study using intubation data collected by a prospective registry in an academic emergency department from November 2017 to October 2018. Records with complete assessment of difficult airway predictors were included. Two categories of predictors were analyzed: predicted difficult intubation by direct laryngoscopy and predicted difficult bag-mask ventilation. The former was evaluated based on difficult external appearance, mouth opening and thyromental distance, Mallampati score, obstruction, and limited neck mobility as in the mnemonic “LEMON”. The latter was evaluated based on difficult mask sealing, obstruction or obesity, absence of teeth, advanced age and reduced pulmonary compliance as in the mnemonic “MOANS”. The incidence, management and outcomes of patients with these difficult airway predictors were explored.

Results

During the study period, 220 records met the inclusion criteria. At least 1 difficult airway predictor was present in 183 (83.2%) patients; 57 (25.9%) patients had at least one LEMON feature, and 178 (80.9%) had at least one MOANS feature. Among patients with at least one difficult airway predictor, both sedation and neuromuscular blocking agents were used in 105 (57.4%) encounters, only sedation was used in 65 (35.5%) encounters, and no medication was administered in 13 (7.1%) encounters. First-pass success was accomplished in 136 (74.3%) of the patients. Compared with patients without predictors, patients with positive LEMON criteria were less likely to receive neuromuscular blocking agents (OR 0.46 (95% CI 0.24–0.87), p = 0.02) after adjusting for operator experience and device used. There were no significant differences between the two groups regarding glottic view, first-pass success, or complications. The LEMON criteria poorly predicted unsuccessful first pass and glottic view.

Conclusions

In emergency airway management, difficult airway predictors were associated with decreased use of neuromuscular blocking agents but were not associated with glottic view, first-pass success, or complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00434-2.

Intensive fever control using a therapeutic normothermia protocol in patients with febrile early septic shock: A randomized feasibility trial and exploration of the immunomodulatory effects

Objectives:

Fever control has been shown to reduce short-term mortality in patients with septic shock. This study aimed to explore the feasibility of early intensive fever control in patients with septic shock and to assess the immunomodulatory effects of this intervention.

Methods:

In this single-center, randomized, open-label trial, febrile patients with septic shock presenting to the emergency department were assigned to either a standard fever control or therapeutic normothermia group. Therapeutic normothermia involved intensive fever control in maintaining normothermia below 37°C. The primary outcome was the feasibility of fever control for 24 h. Secondary outcomes included changes in immunomodulatory biomarkers and adverse events.

Results:

Fifteen patients were enrolled and analyzed. Fever control was comparable in both groups, but significantly more patients in the therapeutic normothermia group experienced shivering (p = 0.007). Both groups demonstrated increased C-reactive protein and unchanged neutrophil chemotaxis and CD11b expression. The therapeutic normothermia group revealed significant decreased IL-6 and IL-10. The standard fever control group significantly expressed increased monocytic human leukocyte antigen. There were no significant differences between the groups in terms of immunomodulation.

Conclusions:

Therapeutic normothermia was feasible in patients with febrile septic shock but was not superior to standard fever control in terms of average body temperature and host defense function. Shivering was more frequent in the therapeutic normothermia group.

Trial registration:

Thai Clinical Trials Registry number: TCTR20160321001

Prevalence and factors associated with preventable drug-related emergency department visits (DREDp) in elderly patients

BACKGROUND

The prevalence of emergency department (ED) visits among the elderly is high and increasing. While emergency services for the elderly involve many factors, drug-related problems (DRPs) that can worsen patient conditions are less frequently discussed. This study investigates the prevalence of preventable drug-related ED visits (DREDp) and the characteristics of DRPs in elderly ED patients through a comprehensive medication review.

METHODS

A cross-sectional study was conducted at a non-trauma ED of a university-affiliated tertiary-care hospital. All adult patients aged 60 years and older who were on medications and visited the ED were included. A clinical pharmacist conducted comprehensive medication reviews for each patient. Patients were classified as experiencing drug-related ED visits (DRED) if their primary reason for the visit was associated with a DRP, as determined by both the physician and pharmacist. DRPs attributed to medication errors were categorized as preventable, while other DRPs were assessed for preventability using modified Schumock and Thornton criteria.

RESULTS

The study involved 351 patients with a mean age of 75.5 years (SD 9.3) and an equal male-to-female ratio of ED visits. The median number of comorbidities was five (IQR 3-6), with about half of the patients taking ten or more medications. The interdisciplinary team classified 43 patients (12.3%) as DREDp, accounting for 58.1% of the 74 (21.1%) drug-related ED visits. All medication errors categorized as causing harm (level E and higher) occurred within the DREDp group, constituting approximately half of all DREDp (22 cases, 51.2%). Approximately two-thirds of drug-related ED visits were associated with adverse drug events (ADEs), predominantly involving antithrombotics, oral hypoglycemic agents, and antineoplastics. Multivariable analysis identified that ED visits involving potentially inappropriate medications (PIMs) according to the STOPP criteria and the presence of multiple comorbidities (six or more concurrent diseases) were significantly associated with DREDp.

CONCLUSIONS

About one in ten elderly patients visited the ED due to preventable DRPs. The majority of DRPs leading to ED visits were ADEs. Both the prescription of PIMs and the presence of multiple comorbidities were significantly associated with DREDp.

Reducing 48-h emergency department revisits and subsequent admissions: a retrospective study of increased emergency medicine resident floor coverage

BACKGROUND

Early unexpected hospital admission after emergency department (ED) discharge is an important topic regarding effective preventive measures. Reducing avoidable return visits can improve ED effectiveness and emergency care. This study evaluated the effects of an increase in the number of physicians and the 24-h coverage of emergency physicians on 48-h ED revisits with subsequent hospital admission. The characteristics and risk factors of the patients were also investigated.

RESULTS

This was a retrospective analysis performed 2 years before and 2 years after the implementation of an intervention in a tertiary care hospital in Thailand. The medical records of adult patients who revisited the ED within 48 h for related complaints were reviewed. The effect of the intervention was analyzed, and a prediction model was developed based on logistic regression. After implementing the intervention, the hospital admission rate at the second ED visit decreased from 44.5 to 41.1%; no significant difference was found (95% confidence interval (CI) - 5.05 to 11.78). Patients who required hospital admission had a significantly higher comorbidity score, more ED visits, and more hospitalizations within the past 12 months. A significantly higher hospital admission rate was also observed among patients older than 60 years, those who had an initial infectious diagnosis, and those who had a higher triage severity level (ESI II) at their first visit. The odds ratio (OR) showed lower odds of hospital admission at the second visit in the postintervention period; this difference was not significant (OR 0.87; 95% CI 0.61 to 1.23).

CONCLUSION

Our intervention did not significantly decrease the incidence of admission at an ED revisit. However, some factors identified in this study seem to have some benefits and might be helpful for preventing errors and constructing a standard discharge care plan for patients with these risk factors.

Real-time machine learning-assisted sepsis alert enhances the timeliness of antibiotic administration and diagnostic accuracy in emergency department patients with sepsis: a cluster-randomized trial

Machine learning (ML) has been applied in sepsis recognition across different healthcare settings with outstanding diagnostic accuracy. However, the advantage of ML-assisted sepsis alert in expediting clinical decisions leading to enhanced quality for emergency department (ED) patients remains unclear. A cluster-randomized trial was conducted in a tertiary-care hospital. Adult patient data were subjected to an ML model for sepsis alert. Patient visits were assigned into one of two groups. In the intervention cluster, staff received alerts on a display screen if patients met the ML threshold for sepsis diagnosis, while patients in the control cluster followed the regular alert process. The study compared triage-to-antibiotic (TTA) time, length of stay, and mortality rate between the two groups. Additionally, the diagnostic performance of the ML model was assessed. A total of 256 (intervention) and 318 (control) sepsis patients were analyzed. The proportions of patients who received antibiotics within 1 and 3 h were higher in the intervention group than in the control group (in 1 h; 68.4 vs. 60.1%, respectively; P = 0.04, in 3 h; 94.5 vs. 89.0%, respectively; P = 0.02). The median TTA times were marginally shorter in the intervention group (46 vs. 50 min). The area under the receiver operating characteristic curve (AUROC) of ML in early sepsis identification was significantly higher than qSOFA, SIRS, and MEWS. The ML-assisted sepsis alert system may help sepsis ED patients receive antibiotics more rapidly than with the conventional, human-dedicated alert process. The diagnostic performance of ML in prompt sepsis detection was superior to that of the rule-based system.Trial registration Thai Clinical Trials Registry TCTR20230120001. Registered 16 January 2023-Retrospectively registered, https://www.thaiclinicaltrials.org/show/TCTR20230120001 .

Characteristics and Outcomes of Implementing Emergency Department-based Intensive Care Units: A Scoping Review

Introduction

The prolonged stay of critically ill patients in the emergency department (ED) may lead to worse clinical outcomes. An emergency department (ED)-based intensive care unit (ICU) is one of the proposed solutions to deliver critical care in the ED. We thus aimed to characterize existent ED-ICU models and their reported association with clinical outcomes in critically ill adult patients.

Methods

We searched the Ovid MEDLINE database from inception to October 2, 2023. We included studies that report an ED-ICU structure, defined as a space capable of providing ICU-level care within or adjacent to the ED, and its characteristics. We excluded personnel-focused intervention (without the presence of a separated space) or a space without ICU-level care capability. We collected information on process measures, patient-related outcomes, and cost-related outcomes.

Results

We screened 2,824 studies, of which 125 full-text articles were assessed for eligibility and 31 studies were included in this scoping review. Studies reported on 14 ED-ICUs across seven countries, with capacities ranging from 3-17 beds. All ED-ICUs served early and ongoing critical care needs in the ED, including three distinct themes: short-stay; palliative care; and disaster-response ICUs. Implementing the ED-ICU was associated with decreased time to ICU-level care and reduced number of inpatient ICU admissions, but it was not consistently associated with improved survival.

Conclusion

Several ED-ICUs have been established around the world with different characteristics depending on local needs. Implementation of the ED-ICU may be associated with improved clinical outcomes and patient flow.