Ischemia-Modified Albumin, Lactate, and Combination for Predicting Mortality in Patients with Septic Shock in the Emergency Department.

Ischemia-modified albumin (IMA) is produced during ischemia and reactive oxygen species production. This study aimed to evaluate the association between IMA and mortality in a larger population and the prognostic value of the combination of IMA and lactate for predicting mortality in septic shock patients in the emergency department. This retrospective observational study included adult septic shock patients between October 2019 and December 2021. A multivariable Cox proportional hazards model was performed. IMA was significantly higher in the non-surviving group than in the surviving group (89.1 ± 7.2 vs. 83.8 ± 6.2 U/mL, p < 0.001). IMA was independently associated with 28-day mortality after adjustments (adjusted hazard ratio [aHR]: 1.075, 95% confidence interval [CI]: 1.016-1.138, p = 0.012). The area under the ROC curve (AUROC) of IMA was 0.712 (95% CI: 0.648-0.775, p < 0.001) and was comparable to that of lactate. The AUROC of the combination of IMA and lactate was 0.838 (95% CI: 0.786-0.889, p < 0.001). The group with both high lactate and high IMA levels showed an extremely high risk of mortality than other groups (86.1%; aHR 8.956, 95% CI 4.071-19.70, p < 0.001). The elevation of IMA was associated with mortality in septic shock patients. The combination of IMA and lactate can be a helpful tool for early risk stratification of septic shock patients.

Artificial intelligence for predicting shockable rhythm during cardiopulmonary resuscitation: In-hospital setting.

AIM OF THE STUDY: This study aimed to develop an artificial intelligence (AI) model capable of predicting shockable rhythms from electrocardiograms (ECGs) with compression artifacts using real-world data from emergency department (ED) settings. Additionally, we aimed to explore the black box nature of AI models, providing explainability. METHODS: This study is retrospective, observational study using a prospectively collected database. Adult patients who presented to the ED with cardiac arrest or experienced cardiac arrest in the ED between September 2021 and February 2024 were included. ECGs with a compression artifact of 5 s before every rhythm check were used for analysis. The AI model was designed based on convolutional neural networks. The ECG data were assigned into training, validation, and testing sets on a per-patient basis to ensure that ECGs from the same patient did not appear in multiple sets. Gradient-weighted class activation mapping was employed to demonstrate AI explainability. RESULTS: A total of 1,889 ECGs with compression artifacts from 172 patients were used. The area under the receiver operating characteristic curve (AUROC) for shockable rhythm prediction was 0.8672 (95% confidence interval [CI]: 0.8161-0.9122). The AUROCs for manual and mechanical compression were 0.8771 (95% CI: 0.8054-0.9408) and 0.8466 (95% CI: 0.7630-0.9138), respectively. CONCLUSION: This study was the first to accurately predict shockable rhythms during compression using an AI model trained with actual patient ECGs recorded during resuscitation. Furthermore, we demonstrated the explainability of the AI. This model can minimize interruption of cardiopulmonary resuscitation and potentially lead to improved outcomes.

Mortality case due to minimal bentazone intoxication.

Bentazone is a widely used herbicide and is considered a moderate hazard. Fatalities are rarely reported, with reports of deaths occurring in doses of 200 ml or more. In some literature, it is accompanied by generalized rigidity. Malignant hyperthermia (MH) is a pharmacogenetic diseases that presents a hypermetabolic response to anesthetic gases or depolarizing muscle relaxant due to calcium channel dysfunction. The classic symptom of MH include hyperthermia and muscle rigidity. In this article, we report a case of a 65-year-old man who died 4 hours after presenting to the emergency department after taking approximately 75 ml of Basagran M60 (bentazone 33.6%, 25.2 g). This is the smallest dose (364 mg/kg) reported in a fatal case to date. Electrocardiogram changes, including QRS widening and QT prolongation, were present, and hypocalcemia was confirmed. We propose the possibility that bentazone intoxication causes patient deterioration by a mechanism similar to malignant hyperthermia.

Thigh muscle mass evaluated by point-of-care ultrasound is associated with short-term mortality in patients with sepsis in the emergency department.

Muscle mass depletion is associated with mortality and morbidity in various conditions including sepsis. However, few studies have evaluated muscle mass using point-of-care ultrasound in patients with sepsis. This study aimed to evaluate the association between thigh muscle mass, evaluated using point-of-care ultrasound with panoramic view in patients with sepsis in the emergency department, and mortality. From March 2021 to October 2022, this prospective observational study used sepsis registry. Adult patients who were diagnosed with sepsis at the emergency department and who underwent point-of-care ultrasounds for lower extremities were included. The thigh muscle mass was evaluated by the cross-sectional area of the quadriceps femoris (CSA-QF) on point-of-care ultrasound using panoramic view. The primary outcome was 28 day mortality. Multivariable Cox proportional hazard model was performed. Of 112 included patients with sepsis, mean CSA-QF was significantly lower in the non-surviving group than surviving group (49.6 [34.3-56.5] vs. 63.2 [46.9-79.6] cm2, p = 0.002). Each cm2 increase of mean CSA-QF was independently associated with decreased 28 day mortality (adjusted hazard ratio 0.961, 95% CI 0.928-0.995, p = 0.026) after adjustment for potential confounders. The result of other measurements of CSA-QF were similar. The muscle mass of the quadriceps femoris evaluated using point-of-care ultrasound with panoramic view was associated with mortality in patients with sepsis. It might be a promising tool for determining risk factors for mortality in sepsis patients in the early stages of emergency department.

Age and sex-related differences in outcomes of OHCA patients after adjustment for sex-based in-hospital management disparities.

OBJECTIVES: Out-of-hospital cardiac arrest (OHCA) survival differences due to sex remain controversial. Previous studies adjusted for prehospital variables, but not sex-based in-hospital management disparities. We aimed to investigate age and sex-related differences in survival outcomes in OHCA patients after adjustment for sex-based in-hospital management disparities. METHODS: This retrospective observational study used a prospective multicenter OHCA registry to review data of patients from October 2015 to December 2020. The primary outcome was good neurological outcome defined as cerebral performance category score 1 or 2. We performed multivariable logistic regression and restricted cubic spline analysis according to age. RESULTS: Totally, 8988 patients were analyzed. Women showed poorer prehospital characteristics and received fewer coronary angiography, percutaneous coronary interventions, targeted temperature management, and extracorporeal membrane oxygenation than men. Good neurological outcomes were lower in women than in men (5.8% vs. 12.2%, p < 0.001). After adjustment for age, prehospital variables, and in-hospital management, women were more likely to have good neurological outcomes than men (adjusted odds ratio [aOR] 1.37, 95% confidence interval [CI] 1.07-1.74, p = 0.012). The restricted cubic spline curve showed a reverse sigmoid pattern of adjusted predicted probability of outcomes and dynamic associations of sex and age-based outcomes. CONCLUSIONS: Women with OHCA were more likely to have good neurological outcome after adjusting for age, prehospital variables, and sex-based in-hospital management disparities. There were non-linear associations between sex and survival outcomes according to age and age-related sex-based differences.

Predicting septic shock in patients with sepsis at emergency department triage using systolic and diastolic shock index.

INTRODUCTION: Identifying patients with at a high risk of progressing to septic shock is essential. Due to systemic vasodilation in the pathophysiology of septic shock, the use of diastolic blood pressure (DBP) has emerged. We hypothesized that the initial shock index (SI) and diastolic SI (DSI) at the emergency department (ED) triage can predict septic shock. METHOD: This observational study used the prospectively collected sepsis registry. The primary outcome was progression to septic shock. Secondary outcomes were the time to vasopressor requirement, vasopressor dose, and severity according to SI and DSI. Patients were classified by tertiles according to the first principal component of shock index and diastolic shock index. RESULTS: A total of 1267 patients were included in the analysis. The area under the receiver operating characteristic curve (AUC) for predicting progression to septic shock for DSI was 0.717, while that for SI was 0.707. The AUC for predicting progression to septic shock for DSI and SI were significantly higher than those for conventional early warning scores. Middle tertile showed adjusted Odd ratio (aOR) of 1.448 (95% CI 1.074-1.953), and that of upper tertile showed 3.704 (95% CI 2.299-4.111). CONCLUSION: The SI and DSI were significant predictors of progression to septic shock. Our findings suggest an association between DSI and vasopressor requirement. We propose stratifying lower tertile as being at low risk, middle tertile as being at intermediate risk, and upper tertile as being at high risk of progression to septic shock. This system can be applied simply at the ED triage.

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.

The mortality of patients with sepsis increases in the first month of a new academic year.

OBJECTIVE: Many studies have examined the July effect. However, little is known about the July effect in sepsis. We hypothesized that the July effect would result in worse outcomes for patients with sepsis. METHODS: Data from patients with sepsis, collected prospectively between January 2018 and December 2021, were analyzed. In Korea, the new academic year starts on March 1, so the "July effect" appears in March. The primary outcome was 30-day mortality. Secondary outcomes included adherence to the Surviving Sepsis Campaign bundle. Outcomes in March were compared to other months. A multivariate Cox proportional hazard regression was performed to adjust for confounders. RESULTS: We included 843 patients. There were no significant differences in sepsis severity. The 30-day mortality in March was higher (49.0% vs. 28.5%, P<0.001). However, there was no difference in bundle adherence in March (42.2% vs. 48.0%, P=0.264). The multivariate Cox proportional hazard regression showed that the July effect was associated with 30-day mortality in patients with sepsis (adjusted hazard ratio, 1.925; 95% confidence interval, 1.405-2.638; P<0.001). CONCLUSION: The July effect was associated with 30-day mortality in patients with sepsis. However, bundle adherence did not differ. These. RESULTS: suggest that the increase in mortality during the turnover period might be related to unmeasured in-hospital management. Intensive supervision and education of residents caring for patients with sepsis is needed in the beginning of training.

Risk factors for delayed hemothorax in patients with rib fracture in the emergency department.

OBJECTIVES: Although rib fractures are a risk factor, not all rib fracture patients will develop delayed hemothorax. This study aimed to evaluate risk factors which can identify rib fracture patients in the emergency department who may develop delayed hemothorax. METHODS: Adult patients seen in the emergency room between January 2016 and February 2021 with rib fractures caused by blunt chest trauma were included in this retrospective observational study. Patients who underwent chest tube insertion within 2 days and those without follow-up chest radiographs within 2-30 days were excluded. We used a stepwise backward-elimination multivariable logistic regression model for analysis. RESULTS: A total of 202 patients were included in this study. The number of total (P < 0.001), lateral (P = 0.019), and displaced (P < 0.001) rib fractures were significantly associated with delayed hemothorax. Lung contusions (P = 0.002), and initial minimal hemothorax (P < 0.001) and pneumothorax (P < 0.001) were more frequently associated with delayed hemothorax. Age (adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.00-1.06, P = 0.022), mechanical ventilator use (aOR 9.67, 95% CI 1.01-92.75, P = 0.049), initial hemothorax (aOR 2.21, 95% CI 1.05-4.65, P = 0.037) and pneumothorax (aOR 2.99, 95% CI 1.36-6.54, P = 0.006), and displaced rib fractures (aOR 3.51, 95% CI 1.64-7.53, P = 0.001) were independently associated with delayed hemothorax. CONCLUSIONS: Age, mechanical ventilation, initial hemo- or pneumothorax, and displaced rib fractures were risk factors for delayed hemothorax. Patients with these risk factors, and especially those with ≥2 displaced rib fractures, require close chest radiography follow-up of 2-30 days after the initial trauma.

Association of prehospital advanced airway and epinephrine with survival in patients with out-of-hospital cardiac arrest.

Survival benefits of prehospital advanced airway and epinephrine in out-of-hospital cardiac arrest (OHCA) patients are controversial, but few studies evaluated this together. This study evaluated association of prehospital advanced airway and epinephrine with survival outcomes in OHCA patients. This was observational study using a prospective multicentre KoCARC registry. Adult OHCA patients between October 2015 and December 2021 were included. The variables of interest were prehospital managements, which was classified into basic life support (BLS)-only, BLS + advanced airway, and BLS + advanced airway + epinephrine. In total, 8217 patients were included in analysis. Survival to discharge and good neurological outcomes were lowest in the BLS + advanced airway + epinephrine group (22.1% in BLS-only vs 13.2% in BLS + advanced airway vs 7.5% in BLS + advanced airway + epinephrine, P < 0.001 and 17.1% in BLS-only vs 9.2% in BLS + advanced airway vs 4.3% in BLS + advanced airway + epinephrine, P < 0.001, respectively). BLS + advanced airway + epinephrine group was less likely to survive to discharge and have good neurological outcomes (aOR 0.39, 95% CI 0.28-0.55, P < 0.001 and aOR 0.33, 95% CI 0.21-0.51, P < 0.001, respectively) than BLS-only group after adjusting for potential confounders. In prehospital settings with intermediate EMS providers and prehospital advanced airway insertion is performed followed by epinephrine administration, prehospital management with BLS + advanced airway + epinephrine in OHCA patients was associated with lower survival to discharge rate compared to BLS-only.

Characteristics of rib fracture patients who require chest computed tomography in the emergency department.

BACKGROUND: The disadvantages and complications of computed tomography (CT) can be minimized if CT is performed in rib fracture patients with high probability of intra-thoracic and intra-abdominal injuries and CT is omitted in rib fracture patients with low probability of intra-thoracic and intra-abdominal injuries. This study aimed to evaluate the factors that can identify patients with rib fractures with intra-thoracic and intra-abdominal injuries in the emergency department among patients with rib fracture. METHODS: This retrospective observational study included adult patients (age ≥ 18 years) diagnosed with rib fracture on chest radiography prior to chest CT due to blunt chest trauma in the emergency department who underwent chest CT from January 2016 to February 2021. The primary outcomes were intra-thoracic and intra-abdominal injuries that could be identified on a chest CT. Multivariate logistic regression analysis was performed. RESULTS: Among the characteristics of rib fractures, the number of rib fractures was greater (5.0 [3.0-7.0] vs. 2.0 [1.0-3.0], p < 0.001), bilateral rib fractures were frequent (56 [20.1%] vs. 12 [9.8%], p = 0.018), and lateral and posterior rib fracture was more frequent (lateral rib fracture: 160 [57.3%] vs. 25 [20.5%], p < 0.001; posterior rib fracture: 129 [46.2%] vs. 21 [17.2%], p < 0.001), and displacement was more frequent (99 [35.5%] vs. 6 [6.6%], p < 0.001) in the group with intra-thoracic and intra-abdominal injuries than in the group with no injury. The number of rib fractures (adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.16-1.78; p = 0.001), lateral rib fracture (aOR, 2.80; 95% CI, 1.32-5.95; p = 0.008), and posterior rib fracture (aOR, 3.18; 95% CI, 1.45-6.94; p = 0.004) were independently associated with intra-thoracic and intra-abdominal injuries. The optimal cut-off for the number of rib fractures on the outcome was three. The number of rib fractures ≥ 3 (aOR, 3.01; 95% CI, 1.35-6.71; p = 0.007) was independently associated with intra-thoracic and intra-abdominal injuries. CONCLUSION: In patients with rib fractures due to blunt trauma, those with lateral or posterior rib fractures, those with ≥ 3 rib fractures, and those requiring O2 supplementation require chest CT to identify significant intra-thoracic and intra-abdominal injuries in the emergency department.

Prediction of Mortality Among Patients With Isolated Traumatic Brain Injury Using Machine Learning Models in Asian Countries: An International Multi-Center Cohort Study.

Abstract Traumatic brain injury (TBI) is a significant healthcare concern in several countries, accounting for a major burden of morbidity, mortality, disability, and socioeconomic losses. Although conventional prognostic models for patients with TBI have been validated, their performance has been limited. Therefore, we aimed to construct machine learning (ML) models to predict the clinical outcomes in adult patients with isolated TBI in Asian countries. The Pan-Asian Trauma Outcome Study registry was used in this study, and the data were prospectively collected from January 1, 2015, to December 31, 2020. Among a total of 6540 patients (≥ 15 years) with isolated moderate and severe TBI, 3276 (50.1%) patients were randomly included with stratification by outcomes and subgrouping variables for model evaluation, and 3264 (49.9%) patients were included for model training and validation. Logistic regression was considered as a baseline, and ML models were constructed and evaluated using the area under the precision-recall curve (AUPRC) as the primary outcome metric, area under the receiver operating characteristic curve (AUROC), and precision at fixed levels of recall. The contribution of the variables to the model prediction was measured using the SHapley Additive exPlanations (SHAP) method. The ML models outperformed logistic regression in predicting the in-hospital mortality. Among the tested models, the gradient-boosted decision tree showed the best performance (AUPRC, 0.746 [0.700-0.789]; AUROC, 0.940 [0.929-0.952]). The most powerful contributors to model prediction were the Glasgow Coma Scale, O2 saturation, transfusion, systolic and diastolic blood pressure, body temperature, and age. Our study suggests that ML techniques might perform better than conventional multi-variate models in predicting the outcomes among adult patients with isolated moderate and severe TBI.

Association between metformin and survival outcomes in in-hospital cardiac arrest patients with diabetes.

INTRODUCTION: Metformin has shown cardioprotective and neuroprotective effects in cardiac arrest and ischemia-reperfusion injury animal models. Therefore, this study aimed to determine the association between diabetes medication and survival outcomes in in-hospital cardiac arrest (IHCA) patients with type 2 DM (T2DM). METHODS: This retrospective observational study included adult IHCA patients with T2DM between April 2017 and March 2022. The variable of interest was administration of diabetes medications within 24 h before cardiac arrest. Multivariable logistic regression analysis was performed. RESULTS: In the 377 included patients, administration of metformin within 24 h before IHCA was associated with a higher rate of survival to discharge and good neurologic outcome (41.5% vs 11.7%, P < 0.001 and 18.9% vs 6.2%, P = 0.004, respectively). Administration of metformin within 24 h before IHCA was independently associated with survival to discharge and good neurologic outcome (aOR: 5.37, 95% CI: 2.13-13.53, P < 0.001 and aOR: 3.57, 95% CI: 1.14-11.17, P = 0.029). The rate of survival to discharge was the highest in patients who were administered 500-1000 mg/day metformin (P < 0.001). CONCLUSIONS: In IHCA patients with T2DM, administration of metformin within 24 h before IHCA was independently associated with survival to discharge.

Risk of hypertension and treatment on out-of-hospital cardiac arrest incidence: A case-control study.

ABSTRACT: Hypertension (HTN) is a high risk factor for major cardiovascular adverse events. This study aimed to investigate the effect of HTN risk on out-of-hospital cardiac arrest (OHCA) incidence and determine whether the effect of HTN on OHCA incidence differs according to antihypertensive medication.This case-control study used the Korean Cardiac Arrest Resuscitation Consortium and Korean Community Health Survey (CHS). Cases were defined as emergency medical service-treated adult OHCA patients presumed to have a cardiac etiology from 2015 to 2017. Patients without information on HTN diagnosis were excluded from the study. The Korean CHS database's controls were matched at a 1:2 ratio with strata, including age, gender, and county of residence. Multivariable conditional logistic regression analysis was conducted to estimate HTN risk and antihypertensive treatment on OHCA incidence,A total of 2633 OHCA patients and 5266 community-based controls were enrolled in this study. Among them, 1176 (44.7%) patients and 2049 (38.9%) controls were diagnosed with HTN. HTN was associated with an increased risk of OHCA (adjusted odds ratio [AOR]: 1.19 [1.07-1.32]). On comparing HTN with or without the antihypertensive treatment group with the non-HTN-diagnosed group (as a reference), the HTN without treatment group had the highest AOR (95% confidence interval) (3.41 [2.74-4.24]). The AOR in the HTN treatment group was reduced to that in the non-HTN-diagnosed group (0.96 [0.86-1.08]).HTN increased OHCA risk, and the HTN without treatment group had the highest OHCA risk. Conversely, OHCA risk decreased to the non-HTN-diagnosed group level with HTN treatment.

Sex-related disparities in the in-hospital management of patients with out-of-hospital cardiac arrest.

AIM: We investigated sex-related differences in the in-hospital management of patients with out-of-hospital cardiac arrest (OHCA). METHODS: We retrospectively analyzed prospectively collected data from the Korean Cardiac Arrest Resuscitation Consortium (KoCARC) registry, a prospective, multicenter OHCA registry. We enrolled adult patients with OHCA between October 2015 and June 2020. The primary outcomes were coronary angiography (CAG), percutaneous coronary intervention (PCI), targeted temperature management (TTM), and extracorporeal membrane oxygenation (ECMO) performed in the hospital. Propensity score matching (PSM) was performed to minimize differences in baseline demographics and characteristics. RESULTS: Among 12,321 patients in the KoCARC registry, we analyzed 8,177 with OHCA. PSM yielded 5,564 matched patients (2,782 women and men, respectively). In the unmatched cohort, women were less likely to undergo CAG, PCI, TTM, and ECMO. In the PSM cohort, women were less likely to undergo CAG and PCI (6.4% vs. 9.1%, p < 0.001 and 1.9% vs. 3.7%, p < 0.001). The duration of cardiopulmonary resuscitation was shorter in women (19 vs. 20 min, p < 0.001). TTM, ECMO use, and survival outcomes did not differ significantly between sexes. The subgroup analysis according to age showed that among patients aged < 65 years, women were less likely than men to undergo CAG and PCI (12.7% vs. 19.2%, p < 0.001 and 2.3% vs. 8.1%, p < 0.001). CONCLUSIONS: In the PSM cohort, women with OHCA underwent CAG and PCI less frequently than men, regardless of the initial rhythm. However, these sex-related differences narrowed with increasing age. Further studies are needed to confirm the sex-related disparities in the in-hospital management of patients with OHCA.

Association of ROX Index with Mechanical Ventilator Use in Sepsis Patients in the Emergency Department.

Detecting sepsis patients who are at a high-risk of mechanical ventilation is important in emergency departments (ED). The respiratory rate oxygenation (ROX) index is the ratio of tissue oxygen saturation/fraction of inspired oxygen to the respiratory rate. This study aimed to investigate whether the ROX index could predict mechanical ventilator use in sepsis patients in an ED. This retrospective observational study included quick sequential organ failure assessment (qSOFA) ≥ 2 sepsis patients that presented to the ED between September 2019 and April 2020. The ROX and ROX-heart rate (HR) indices were significantly lower in patients with mechanical ventilator use within 24 h than in those without the use of a mechanical ventilator (4.0 [3.2-5.4] vs. 10.0 [5.9-15.2], p < 0.001 and 3.9 [2.7-5.8] vs. 10.1 [5.4-16.3], p < 0.001, respectively). The area under the receiver operating characteristic (ROC) curve of the ROX and ROX-HR indices were 0.854 and 0.816 (both p < 0.001). The ROX and ROX-HR indices were independently associated with mechanical ventilator use within 24 h (adjusted hazard ratio = 0.78, 95% CI: 0.68-0.90, p < 0.001 and adjusted hazard ratio = 0.87, 95% CI 0.79-0.96, p = 0.004, respectively). The 28-day mortality was higher in the low ROX and low ROX-HR groups. The ROX and ROX-HR indices were associated with mechanical ventilator use within 24 h in qSOFA ≥ 2 patients in the ED.

Diagnostic and prognostic value of presepsin and procalcitonin in non-infectious organ failure, sepsis, and septic shock: a prospective observational study according to the Sepsis-3 definitions.

BACKGROUND: We investigated the diagnostic and prognostic value of presepsin among patients with organ failure, including sepsis, in accordance with the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). METHODS: This prospective observational study included 420 patients divided into three groups: non-infectious organ failure (n = 142), sepsis (n = 141), and septic shock (n = 137). Optimal cut-off values of presepsin to discriminate between the three groups were evaluated using receiver operating characteristic curve analysis. We determined the optimal cut-off value of presepsin levels to predict mortality associated with sepsis and performed Kaplan-Meier survival curve analysis according to the cut-off value. Cox proportional hazards model was performed to determine the risk factors for 30-day mortality. RESULTS: Presepsin levels were significantly higher in sepsis than in non-infectious organ failure cases (p < 0.001) and significantly higher in patients with septic shock than in those with sepsis (p = 0.002). The optimal cut-off value of the presepsin level to discriminate between sepsis and non-infectious organ failure was 582 pg/mL (p < 0.001) and between sepsis and septic shock was 1285 pg/mL (p < 0.001). The optimal cut-off value of the presepsin level for predicting the 30-day mortality was 821 pg/mL (p = 0.005) for patients with sepsis. Patients with higher presepsin levels (≥ 821 pg/mL) had significantly higher mortality rates than those with lower presepsin levels (< 821 pg/mL) (log-rank test; p = 0.004). In the multivariate Cox proportional hazards model, presepsin could predict the 30-day mortality in sepsis cases (hazard ratio, 1.003; 95% confidence interval 1.001-1.005; p = 0.042). CONCLUSIONS: Presepsin levels could effectively differentiate sepsis from non-infectious organ failure and could help clinicians identify patients with sepsis with poor prognosis. Presepsin was an independent risk factor for 30-day mortality among patients with sepsis and septic shock.

Prognostic utility of lactate concentrations and kinetics to predict adverse events associated with acute drug overdose.

OBJECTIVE: Clinical research on drug intoxication is necessary for appropriate action in emergency departments (EDs). However, currently, there are no evident biomarkers for predicting adverse events (AEs) in patients with drug intoxication. We aimed to evaluate the prognostic value of serum lactate concentrations and lactate kinetics for AEs such as cardiogenic or respiratory failure in patients admitted to the ED with acute drug overdose. METHODS: We conducted a single-center retrospective study by reviewing the prospective suicide registry of patients visiting the ED. The primary outcome was composite AEs at any point during the ED visit or hospital stay. RESULTS: A total of 566 patients with acute drug overdose were enrolled in this study. Of these, 62 patients had AEs, whereas 363 patients did not, yielding an AE rate of 14.6%. The median 0 h lactate concentrations in the AE and non-AE groups were 2.7 [2.1-5.1] mmol/L and 2.1 [1.4-2.9] mmol/L, respectively (p < 0.001). The median 6 h lactate concentrations in the AE and non-AE groups were 2.0 [1.5-3.9] mmol/L and 1.3 [0.9-2.2] mmol/L, respectively (p < 0.001). The area under the curve of lactate at 0 h for predicting AEs was 0.705 (95% CI: 0.659-0.748). The optimal lactate cutoff point was 4.2 mmol/L (37.1% sensitivity, 92.8% specificity). Multivariable analysis using a stepwise backward method showed that the 0 h lactate concentration was associated with AEs in acute drug intoxication after adjusting for confounders (adjusted OR of 0 h lactate, 1.47; 95% CI, 1.23-1.77). However, the 6 h lactate concentrations, lactate clearance, and delta lactate levels did not predict the outcomes. CONCLUSION: Lactate concentrations and kinetics in patients admitted to the ED with an acute drug overdose exhibited limited prognostic utility in predicting AEs and should be interpreted with caution when considered for clinical decision-making.

Vasoactive-Inotropic Score as an Early Predictor of Mortality in Adult Patients with Sepsis.

Vasoactive and inotropic medications are essential for sepsis management; however, the association between the maximum Vasoactive-Inotropic score (VISmax) and clinical outcomes is unknown in adult patients with sepsis. We investigated the VISmax as a predictor for mortality among such patients in the emergency department (ED) and compared its prognostic value with that of the sequential organ failure assessment (SOFA) score. This single-center retrospective study included 910 patients diagnosed with sepsis between January 2016 and March 2020. We calculated the VISmax using the highest doses of vasopressors and inotropes administered during the first 6 h on ED admission and categorized it as 0-5, 6-15, 16-30, 31-45, and >45 points. The primary outcome was 30-day mortality. VISmax for 30-day mortality was significantly higher in non-survivors than in survivors. The mortality rates in the five VISmax groups were 17.2%, 20.8%, 33.3%, 54.6%, and 70.0%, respectively. The optimal cut-off value of VISmax to predict 30-day mortality was 31. VISmax had better prognostic value than the cardiovascular component of the SOFA score and initial lactate levels. VISmax was comparable to the APACHE II score in predicting 30-day mortality. Multivariable analysis showed that VISmax 16-30, 31-45, and >45 were independent risk factors for 30-day mortality. VISmax in ED could help clinicians to identify sepsis patients with poor prognosis.

Association of ischemia modified albumin with mortality in qSOFA positive sepsis patients by sepsis-3 in the emergency department.

BACKGROUND: The early detection and treatment of sepsis and septic shock patients in emergency departments are critical. Ischemia modified albumin (IMA) is a biomarker produced by ischemia and oxygen free radicals which are related to the pathogenesis of sepsis-induced organ dysfunction. This study aimed to investigate whether IMA was associated with short-term mortality in quick sequential organ failure assessment (qSOFA)-positive sepsis or septic shock patients screened by the sepsis management program. METHOD: From September 2019 to April 2020, patients who arrived at the emergency departments with qSOFA-positive sepsis or septic shock were included in this retrospective observational study. RESULTS: Among 124 patients analyzed, IMA was higher in the non-surviving group than in the surviving group (92.6 ± 8.1 vs. 86.8 ± 6.2 U/mL, p < 0.001). The area under the receiver operating characteristics curve was 0.703 (95% CI: 0.572-0.833, p < 0.001). The optimal IMA cutoff was 90.45 (sensitivity 60.9%, specificity 79.2%). IMA values were independently associated with 28-day mortality in the multivariate Cox proportional hazard model (adjusted hazard ratio (aHR) = 1.16, 95% CI: 1.06-1.27, p < 0.01). CONCLUSIONS: In this study, we showed that IMA in the emergency departments was associated with 28-day mortality in qSOFA-positive sepsis and septic shock patients. Further studies are needed to evaluate the clinical value of IMA as a useful biomarker in large populations and multicenter institutions.