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OBJECTIVES: Hypothermia is associated with poor outcomes in sepsis patients, and hypothermic sepsis patients exhibit temperature alterations during initial treatment. The objective of this study was to classify hypothermic sepsis patients based on body temperature trajectories and investigate the associations of these patients with 28-day mortality. METHODS: This was a retrospective analysis of prospectively collected data from adult sepsis or septic shock patients who visited three emergency departments between August 2014 and December 2019. Hypothermic sepsis was defined as an initial body temperature <36 °C. delta temperature was calculated by subtracting the 0 h body temperature from the 6 h body temperature. We divided the patients into three groups according to delta temperature: Group A (delta temperature ≤ 0), Group B (0 < delta temperature ≤ 1) and Group C (delta temperature > 1). The primary outcome was 28-day mortality, and a multivariable Cox proportional hazards regression model was generated. RESULTS: Among 7344 patients with sepsis or septic shock, 325 hypothermic patients were included in the analysis, and the overall mortality rate was 36%. While initial body temperature was not different between survivors and nonsurvivors, survivors exhibited a higher body temperature at 6 h. The 28-day mortality rates for Groups A, B and C were 53.1%, 36.0%, and 30.0%, respectively, and Group A had significantly higher mortality than Group C did (p < 0.05). Group C demonstrated a 44.2% decrease in 28-day mortality compared to Group A (adjusted hazard ratio of 0.558; 95% confidence interval of 0.330-0.941). CONCLUSIONS: In hypothermic sepsis patients, an increase of 1 °C or more in body temperature after the initial 6 h is associated with a reduced risk of 28-day mortality.
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OBJECTIVES: To determine whether there is a difference in antibiotic administration time and prognosis in afebrile sepsis patients compared to febrile sepsis patients. METHODS: This was retrospective multicenter observational study. Data collected from three referral hospitals. Data were collected from May 2014 through February 2016 under the SEPSIS-2 criteria and from March 2016 to April 2020 under the newly released SEPSIS-3 criteria. Patients were divided into two groups based on body temperature: afebrile (<37.3 °C) and febrile (≥37.3 °C). The relationship between initial body temperature and 28-day mortality were analyzed using multivariable logistic regression. The subgroup analysis was conducted on patients with complete Hour-1 bundle performance records. RESULTS: We included 4293 patients in this study. Initial body temperatures in 28-day survivors were significantly higher than in 28-day non-survivors (37.5 °C ± 1.2 °C versus 37.1 °C ± 1.2 °C, p < 0.01). Multivariable logistic regression analysis was performed in afebrile and febrile sepsis patients. Adjusted odds ratio of afebrile sepsis patients for 28-day mortality was 1.76 (95% Confidence interval 1.46-2.12). As a result of performing the Hour-1 bundle, the number of patients who received antibiotics within 1 h was smaller in the afebrile sepsis patients (323/2076, 15.6%) than in the febrile sepsis patients (395/2156, 18.3%) (p = 0.02). In the subgroup analysis of patients with complete Hour-1 bundle performance records adjusted odds ratio of afebrile sepsis patients for 28-day mortality was 1.68 (95% Confidence interval 1.34-2.11). The febrile sepsis patients received antibiotics faster than the afebrile sepsis patients (175.5 ± 207.9 versus 209.3 ± 277.9, p < 0.01). CONCLUSIONS: Afebrile sepsis patients were associated with higher 28-day mortality compared to their febrile counterparts and were delayed in receiving antibiotics. This underscores the need for improved early detection and treatment strategies for the afebrile sepsis patients.
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Antibacterianos , Visitas a la Sala de Emergencias , Servicio de Urgencia en Hospital , Fiebre , Sepsis , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Antibacterianos/uso terapéutico , Temperatura Corporal , Visitas a la Sala de Emergencias/estadística & datos numéricos , Fiebre/tratamiento farmacológico , Mortalidad Hospitalaria , Modelos Logísticos , Pronóstico , Estudios Retrospectivos , Sepsis/tratamiento farmacológico , Sepsis/mortalidad , Tiempo de Tratamiento/estadística & datos numéricosRESUMEN
BACKGROUND: There is insufficient evidence supporting the theory that mechanical ventilation can replace the manual ventilation method during CPR. RESEARCH QUESTION: Is using automatic mechanical ventilation (MV) feasible and comparable to the manual ventilation method during CPR? STUDY DESIGN AND METHODS: This pilot randomized controlled trial compared MV and manual bag ventilation (BV) during CPR after out-of-hospital cardiac arrest (OHCA). Patients with medical OHCA arriving at the ED were randomly assigned to two groups: an MV group using a mechanical ventilator and a BV group using a bag valve mask. Primary outcome was any return of spontaneous circulation (ROSC). Secondary outcomes were changes of arterial blood gas analysis results during CPR. Tidal volume, minute volume, and peak airway pressure were also analyzed. RESULTS: A total of 60 patients were enrolled, and 30 patients were randomly assigned to each group. There were no statistically significant differences in basic characteristics of OHCA patients between the two groups. The rate of any return of spontaneous circulation was 56.7% in the MV group and 43.3% in the BV group, indicating no significant (P = .439) difference between the two groups. There were also no statistically significant differences in changes of PH, Pco2, Po2, bicarbonate, or lactate levels during CPR between the two groups (P values = .798, 0.249, .515, .876, and .878, respectively). Significantly lower tidal volume (P < .001) and minute volume (P = .009) were observed in the MV group. INTERPRETATION: In this pilot trial, the use of MV instead of BV during CPR was feasible and could serve as a viable alternative. A multicenter randomized controlled trial is needed to create sufficient evidence for ventilation guidelines during CPR. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT05550454; URL: www. CLINICALTRIALS: gov.
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Reanimación Cardiopulmonar , Paro Cardíaco Extrahospitalario , Respiración Artificial , Humanos , Masculino , Paro Cardíaco Extrahospitalario/terapia , Femenino , Proyectos Piloto , Respiración Artificial/métodos , Respiración Artificial/instrumentación , Reanimación Cardiopulmonar/métodos , Anciano , Persona de Mediana Edad , Análisis de los Gases de la Sangre , Volumen de Ventilación Pulmonar/fisiología , Resultado del TratamientoRESUMEN
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.
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Puntuaciones en la Disfunción de Órganos , Sepsis , Adulto , Humanos , Sepsis/diagnóstico , Cuidados Críticos , Unidades de Cuidados Intensivos , Estudios Retrospectivos , Pronóstico , Ácido Láctico , Curva ROCRESUMEN
OBJECTIVE: The clinical benefit of automatic temperature control devices remains unclear. We investigated the outcomes of out-of-hospital cardiac arrest (OHCA) survivors who had undergone either target temperature management (TTM) with a temperature feedback system (TFS) or maintenance of normothermia without a TFS during post-resuscitation care. METHODS: This study was a retrospective analysis of a multicenter prospective cohort of OHCA survivors who had received postcardiac arrest care from August 2014 to December 2018. The overlap propensity score weighting method was applied for adjustment between groups. RESULTS: A total of 405 OHCA survivors were included. TTM with a TFS and normothermia without a TFS were applied to 318 and 87 patients, respectively. Fever events were more common in patients with normothermia without a TFS. After propensity score matching, no statistically significant differences were observed in the 1-month good neurologic outcome (odds ratio 0.99, 95% confidence interval [CI] 0.56-1.25) or survival rate (odds ratio 1.25, 95% CI 0.88-1.78). CONCLUSION: No significant differences in the 1-month neurologic outcome were observed between patients receiving TTM with a TFS and those undergoing normothermia without a TFS.
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Reanimación Cardiopulmonar , Hipotermia Inducida , Paro Cardíaco Extrahospitalario , Reanimación Cardiopulmonar/métodos , Retroalimentación , Humanos , Hipotermia Inducida/efectos adversos , Paro Cardíaco Extrahospitalario/terapia , Estudios Prospectivos , Estudios Retrospectivos , Sobrevivientes , TemperaturaRESUMEN
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.
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Sepsis , Choque Séptico , Humanos , Ácido Láctico , Puntuaciones en la Disfunción de Órganos , Pronóstico , Curva ROC , Estudios Retrospectivos , Sepsis/diagnóstico , Choque Séptico/diagnósticoRESUMEN
BACKGROUND: Rearrest occurs commonly after initial resuscitation following out-of-hospital cardiac arrest (OHCA). We determined (1) the predictors of rearrest during hospitalisation that can be identified in the hours immediately after OHCA, (2) the association between rearrest and favourable long-term outcomes, and (3) the predictors of favourable long-term outcomes in rearrest patients. METHODS: Conditional multivariable logistic regression analyses were performed using the Korean Hypothermia Network prospective registry data, which included details of adult OHCA patients treated with targeted temperature management at 22 teaching hospitals in South Korea. RESULTS: Among the 1,233 patients, 260 (21.1%) experienced rearrest. Of the 192 patients resuscitated from first rearrest, 33 (17.2%) achieved 6-month favourable outcomes. Arrhythmia, heart failure, ST-segment elevation, lower initial Glasgow coma scale (GCS) motor score, higher initial lactate level, and antiarrhythmic drug use within 1 h were independently associated with rearrest. Higher lactate level and antiarrhythmic drug use were associated with shockable first rearrest, while arrhythmia, heart failure, ST-segment elevation, and lower GCS motor score were associated with non-shockable first rearrest. Rearrest was independently associated with a lower likelihood of 6-month favourable outcomes (P = 0.003). Initial shockable rhythm after OHCA, absence of diabetes, shorter cumulative time to restoration of spontaneous circulation, coronary angiography, and hypophosphataemia within 7 d were independently associated with 6-month favourable outcomes in the patients resuscitated from first rearrest. CONCLUSIONS: Rearrest during hospitalisation after OHCA was inversely associated with 6-month favourable outcomes. We identified several risk factors for rearrest and prognostic factors for patients resuscitated from first rearrest.
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Reanimación Cardiopulmonar , Paro Cardíaco Extrahospitalario , Adulto , Coma/etiología , Coma/terapia , Hospitalización , Humanos , Paro Cardíaco Extrahospitalario/terapia , Pronóstico , Factores de RiesgoRESUMEN
AIM OF STUDY: To investigate whether regional cerebral oxygen saturation (rSO2) differs in out-of-hospital cardiac arrest (OHCA) survivors undergoing targeted temperature management (TTM) 36 °C versus 33 °C. METHODS: A randomized clinical trial was conducted at intensive care units in two referral hospitals. Fifty-seven comatose OHCA survivors were randomized into either a 36 °C or 33 °C group. Patients were cooled and maintained at an oesophageal temperature of either 36 °C or 33 °C for 24 hours, rewarmed at a rate of 0.25 °C/hour, and maintained at <37.5 °C until 72 hours. During 72 hours of TTM, rSO2 was continuously monitored on the left forehead using near-infrared spectroscopy (INVOSTM 5100C). The rSO2 level at 72 hours was compared between the two groups. Next, serial rSO2 levels for 72 hours were compared using mixed effects regression. The association between rSO2 levels and 6-month neurological outcomes was also evaluated. RESULTS: There were no significant differences in the rSO2 level at 72 hours between the 36 °C and 33 °C groups (p = 0.372). Furthermore, serial rSO2 levels for 72 hours of TTM were not different between the two groups (p = 0.733). However, low rSO2 levels, particularly at 24 hours of TTM, were significantly associated with poor 6-month neurological outcomes (odds ratio = 0.899, 95% confidence interval: 0.831-0.974). The area under the receiver operating characteristic curve of the rSO2 level at 24 hours for poor neurological outcomes was 0.800. CONCLUSIONS: Regardless of target temperatures, low rSO2 levels during TTM were significantly associated with poor 6-month neurological outcomes in OHCA survivors.
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Hipotermia Inducida , Paro Cardíaco Extrahospitalario , Humanos , Paro Cardíaco Extrahospitalario/terapia , Oxígeno , Espectroscopía Infrarroja Corta , SobrevivientesRESUMEN
OBJECTIVE: Acute diverticulitis (AD) is a common disease with various outcomes. When AD is diagnosed in the emergency department (ED), the ED clinician must determine the patient's treatment strategy whether the patient can be discharged, needs to be admitted to the general ward, ICU, or needs surgical consultation. This study aimed to identify potential risk factors for clinically important outcomes (CIOs) and to develop a prediction model for CIOs in AD to aid clinical decision making in the ED. METHODS: Retrospective data from between 2013 and 2017 in an ED in an urban setting were reviewed for adult AD. Potential risk factors were age, sex, past medical history, symptoms, physical exams, laboratory results, and imaging results. A CIO was defined as a case with one of the following outcomes: hospital death, ICU admission, surgery or invasive intervention, and admission for 7 or more days. The prediction model for CIOs was developed using potential risk factors. Model discrimination and calibration were assessed using the area under the curve (AUC) and 95% confidence intervals (CIs) and the Hosmer-Lemeshow (HL) test, respectively. Model validation was conducted using 500 random bootstrap samples. RESULTS: Of the final 337 AD patients, 63 patients had CIOs. Six potential factors (age, abdominal pain (≥ 3 days), anorexia, rebound tenderness, white blood cell count (> 15,000/µl), C-reactive protein (> 10 mg/dL), and CT findings of a complication) were used for the final model. The AUC (95% CI) for CIOs was 0.875 (0.826-0.923), and χ2 was 2.969 (p-value = 0.936) with the HL test. Validation using bootstrap samples resulted in an optimism-corrected AUC of 0.858 (0.856-0.861). CONCLUSION: A prediction model for clinically important outcomes of AD visiting a single ED showed good discrimination and calibration power with an acceptable range.
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Técnicas de Apoyo para la Decisión , Diverticulitis/terapia , Servicio de Urgencia en Hospital , Enfermedad Aguda , Adulto , Anciano , Biomarcadores/análisis , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Factores de RiesgoRESUMEN
(1) Background: Sepsis is a life-threatening disease, and various demographic and socioeconomic factors affect outcomes in sepsis. However, little is known regarding the potential association between health insurance status and outcomes of sepsis in Korea. We evaluated the association of health insurance and clinical outcomes in patients with sepsis. (2) Methods: Prospective cohort data of adult patients with sepsis and septic shock from March 2016 to December 2018 in three hospitals were retrospectively analyzed. We categorized patients into two groups according to their health insurance status: National Health Insurance (NHI) and Medical Aid (MA). The primary end point was in-hospital mortality. The multivariate logistic regression model and propensity score matching were used. (3) Results: Of a total of 2526 eligible patients, 2329 (92.2%) were covered by NHI, and 197 (7.8%) were covered by MA. The MA group had fewer males, more chronic kidney disease, more multiple sources of infection, and more patients with initial lactate > 2 mmol/L. In-hospital, 28-day, and 90-day mortality were not significantly different between the two groups and in-hospital mortality was not different in the subgroup analysis. Furthermore, health insurance status was not independently associated with in-hospital mortality in multivariate analysis and was not associated with survival outcomes in the propensity score-matched cohort. (4) Conclusions: Our propensity score-matched cohort analysis demonstrated that there was no significant difference in in-hospital mortality by health insurance status in patients with sepsis.
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Sepsis , Adulto , Estudios de Cohortes , Mortalidad Hospitalaria , Humanos , Seguro de Salud , Masculino , Estudios Prospectivos , República de Corea/epidemiología , Estudios RetrospectivosRESUMEN
Changes in microcirculation are believed to perform an important role after cardiac arrest. In particular, rheological changes in red blood cells (RBCs) have been observed during and after ischemic-reperfusion injury. Employing three-dimensional laser interferometric microscopy, we investigated three-dimensional shapes and deformability of RBCs during and after asphyxial cardiac arrest in rats at the individual cell level. Rat cardiac arrest was induced by asphyxia. Five rats were maintained for 7 min of no-flow time, and then, cardiopulmonary resuscitation (CPR) was started. Blood samples were obtained before cardiac arrest, during CPR, and 60 min after return of spontaneous circulation (ROSC). Quantitative phase imaging (QPI) techniques based on laser interferometry were used to measure the three-dimensional refractive index (RI) tomograms of the RBC, from which structural and biochemical properties were retrieved. Dynamic membrane fluctuations in the cell membrane were also quantitatively and sensitively measured in order to investigate cell deformability. Mean corpuscular hemoglobin, mean cell volume, mean corpuscular hemoglobin concentration, and red blood cell distribution width remained unchanged during CPR and after ROSC compared with those before cardiac arrest. QPI results revealed that RBC membrane fluctuations, sphericity, and surface area did not change significantly during CPR or after ROSC compared with initial values. In conclusion, no three-dimensional shapes and cell deformability changes in RBCs were detected.
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BACKGROUND: Septic shock is a life-threatening condition with underlying circulatory and cellular/metabolic abnormalities. Vitamin C and thiamine are potential candidates for adjunctive therapy; they are expected to improve outcomes based on recent experimental and clinical research. The aim of the Ascorbic Acid and Thiamine Effect in Septic Shock (ATESS) trial is to evaluate the effects of early combination therapy with intravenous vitamin C and thiamine on recovery from organ failure in patients with septic shock. METHODS: This study is a randomized, double-blind, placebo-controlled, multicentre trial in adult patients with septic shock recruited from six emergency departments in South Korea. Patients will be randomly allocated into the treatment or control group (1:1 ratio), and we will recruit 116 septic shock patients (58 per group). For the treatment group, vitamin C (50 mg/kg) and thiamine (200 mg) will be mixed in 50 ml of 0.9% saline and administered intravenously every 12 h for a total of 48 h. For the placebo group, an identical volume of 0.9% saline will be administered in the same manner. The primary outcome is the delta Sequential Organ Failure Assessment (SOFA) score (ΔSOFA = initial SOFA at enrolment - follow-up SOFA after 72 h). DISCUSSION: This trial will provide valuable evidence about the effectiveness of vitamin C and thiamine therapy for septic shock. If effective, this therapy might improve survival and become one of the main therapeutic adjuncts for patients with septic shock. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03756220 . Registered on 5 December 2018.
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Ácido Ascórbico/administración & dosificación , Choque Séptico/tratamiento farmacológico , Tiamina/administración & dosificación , Complejo Vitamínico B/administración & dosificación , Adulto , Anciano , Anciano de 80 o más Años , Ácido Ascórbico/efectos adversos , Método Doble Ciego , Combinación de Medicamentos , Femenino , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , República de Corea , Choque Séptico/diagnóstico , Choque Séptico/mortalidad , Choque Séptico/fisiopatología , Tiamina/efectos adversos , Factores de Tiempo , Resultado del Tratamiento , Complejo Vitamínico B/efectos adversos , Adulto JovenRESUMEN
This study evaluated the prognostic ability of lactate normalization achieved within 6 and 24 h from septic shock recognition. Data from a septic shock registry from October 2015 to February 2017 were reviewed. The study included 2,102 eligible septic shock patients to analyze the prognostic ability of lactate normalization, defined as a follow-up lactate level <2 mmol/L within six hours of bundle therapy and within 24 hours of delayed normalization. The primary outcome was 28-day mortality. The overall 28-day mortality rate was 21.4%. The rates of lactate normalization within 6 and 24 h were significantly higher in the survivor groups than in the non-survivor group (42.4% vs. 23.4% and 60.2% vs. 31.2%; P<0.001, respectively). Multivariate logistic regression analysis showed that both 6- and 24-h lactate normalization were independent predictors (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.45-0.75, p<0.001 and OR 0.42, 95% CI 0.33-0.54, p<0.001, respectively). When we could not achieve the lactate normalization, the sensitivity, specificity, positive, and negative predictive value to predict mortality were 76.6%, 42.4%, 26.5% and 87.0% respectively for 6-h normalization, and 68.8%, 60.2%, 32.0% and 87.7% respectively for 24-h normalization. Besides 6-h lactate normalization, 24-h delayed lactate normalization was associated with decreasing mortality in septic shock patients. Lactate normalization may have a role in early risk stratification and as a therapeutic target.
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Ácido Láctico/metabolismo , Choque Séptico/mortalidad , Choque Séptico/terapia , Adulto , Anciano , Femenino , Humanos , Masculino , Análisis Multivariante , Factores de TiempoRESUMEN
BACKGROUND: Although coronary artery disease (CAD) is a major cause of out-of-hospital cardiac arrest (OHCA), there has been no convinced data on the necessity of routine invasive coronary angiography (ICA) in OHCA. We investigated clinical factors associated with obstructive CAD in OHCA. METHODS: Data from 516 OHCA patients (mean age 58 years, 83% men) who underwent ICA after resuscitation was obtained from a nation-wide OHCA registry. Obstructive CAD was defined as the lesions with diameter stenosis ≥ 50% on ICA. Independent clinical predictors for obstructive CAD were evaluated using multiple logistic regression analysis, and their prediction performance was compared using area under the receiver operating characteristic curve with 10,000 repeated random permutations. RESULTS: Among study patients, 254 (49%) had obstructive CAD. Those with obstructive CAD were older (61 vs. 55 years, P < 0.001) and had higher prevalence of hypertension (54% vs. 36%, P < 0.001), diabetes mellitus (29% vs. 21%, P = 0.032), positive cardiac enzyme (84% vs. 74%, P = 0.010) and initial shockable rhythm (70% vs. 61%, P = 0.033). In multiple logistic regression analysis, old age (≥ 60 years) (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.36-3.00; P = 0.001), hypertension (OR, 1.74; 95% CI, 1.18-2.57; P = 0.005), positive cardiac enzyme (OR, 1.72; 95% CI, 1.09-2.70; P = 0.019), and initial shockable rhythm (OR, 1.71; 95% CI, 1.16-2.54; P = 0.007) were associated with obstructive CAD. Prediction ability for obstructive CAD increased proportionally when these 4 factors were sequentially combined (P < 0.001). CONCLUSION: In patients with OHCA, those with old age, hypertension, positive cardiac enzyme and initial shockable rhythm were associated with obstructive CAD. Early ICA should be considered in these patients.
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Enfermedad de la Arteria Coronaria/patología , Paro Cardíaco Extrahospitalario/patología , Factores de Edad , Anciano , Anciano de 80 o más Años , Área Bajo la Curva , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/etiología , Femenino , Humanos , Hipertensión/complicaciones , Hipertensión/patología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Paro Cardíaco Extrahospitalario/complicaciones , Curva ROC , Sistema de Registros , República de Corea , Factores de RiesgoRESUMEN
Although nutritional problems are a major concern for the homeless, their vitamin D status has not yet been widely evaluated. This study was a retrospective chart review conducted at a single academic, urban public hospital's emergency department (ED). Patients whose serum 25-hydroxyvitamin D [25(OH)D] levels had been checked in the ED from July 2014 to June 2015 were reviewed and enrolled. For a healthy settled civilian control, 2011 and 2012 data from the Fifth Korean National Health and Nutrition Examination Survey (KNHANES) were used. A total of 179 patients were enrolled. Vitamin D deficiency was observed in 133 patients (73.7%). The vitamin D deficiency group showed a lower hemoglobin level than that of non-vitamin D deficiency group (p = 0.02). Winter visits were more common among the deficiency group (p = 0.048). Rhabdomyolysis was observed only in the deficiency homeless group (p = 0.03). When using age and sex as covariates of propensity score matching 25(OH)D levels were lower in the homeless than in the healthy control (15.7 ± 7.4 ng/mL vs. 18.2 ± 5.5 ng/mL, p < 0.001). Moreover, when the controls were limited to residents of the same city, the serum 25(OH)D level also was lower in the homeless than in the control (15.7 ± 7.4 ng/mL vs. 17.1 ± 5.4 ng/mL, p = 0.03). In summary, vitamin D deficiency was common and more frequent among homeless patients.
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Servicio de Urgencia en Hospital , Personas con Mala Vivienda , Deficiencia de Vitamina D/epidemiología , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , República de Corea/epidemiología , Estudios RetrospectivosRESUMEN
PURPOSE: We investigated the change in pupil size and pupil light reflex (PLR) using a pupillography capable of continuous measurement both during CPR and immediately following the return-of-spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) comatose patients in an emergency department. METHODS: Pupil size and PLR were continuously measured both during CPR and immediately following ROSC until intensive care unit (ICU) admission. The changes in pupil sizes during CPR were categorized into three groups (no change - N, decreased - D, and increased - I groups). RESULTS: Pupillography was applied for 118 and 60 patients during CPR and immediately following ROSC, respectively. Only two patients had a PLR during CPR. The number of patients included each group were 58 (N-group), 21 (D-group) and 39 (I-group). In the D-group, the proportion of witnessed arrest was higher than in the N-group and I-group (81% vs. 55% and 49%, respectively; pâ¯=â¯0.049). There were statistically significant shorter prehospital time in the D-group than the N-group and I-group (13 vs. 23 and 24â¯min, respectively; pâ¯=â¯0.012). PLR was observed immediately following ROSC in 14 patients. PLR was maintained in seven of these patients until admission to intensive care unit. Six of the seven patients who remained with PLR until ICU admission had survival to hospital discharge, and three of them had good neurological recovery. CONCLUSION: Our study demonstrated that measurement of the continuous pupillary response can be feasible. Patients with the presence of PLR following ROSC had better outcomes.
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Reanimación Cardiopulmonar , Coma , Servicios Médicos de Urgencia/métodos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Monitoreo Fisiológico/métodos , Paro Cardíaco Extrahospitalario , Trastornos de la Pupila , Reflejo Pupilar , Anciano , Reanimación Cardiopulmonar/efectos adversos , Reanimación Cardiopulmonar/métodos , Coma/diagnóstico , Coma/etiología , Estudios de Factibilidad , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Paro Cardíaco Extrahospitalario/diagnóstico , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Evaluación de Resultado en la Atención de Salud/métodos , Pronóstico , Trastornos de la Pupila/diagnóstico , Trastornos de la Pupila/etiologíaRESUMEN
BACKGROUND: Activated charcoal is the most frequently and widely used oral decontaminating agent in emergency departments (EDs). However, there is some debate about its clinical benefits and risks. In Korea, activated charcoal with sorbitol was unavailable as of the mid-2015, and our hospital had been unable to use it from September 2015. This study examined the differences of clinical features and outcomes of patients during the periods charcoal was and was not available. METHODS: We retrospectively reviewed the electronic medical records of patients who had visited an urban tertiary academic ED for oral drug poisoning between January 2013 and January 2017. RESULTS: For the charcoal-available period, 413 patients were identified and for the charcoal-unavailable period, 221. Activated charcoal was used in the treatment of 141 patients (34%) during the available period. The mortality rates during the available and unavailable periods were 1.9 and 0.9%, respectively (p = 0.507). There was also no interperiod difference in the development of aspiration pneumonia (9.9 versus 9.5%, p = 0.864), the endotracheal intubation rate (8.4 versus 7.2%, p = 0.586), and vasopressor use (5.3 versus 5.0%, p = 0.85). Intensive care unit (ICU) admission was higher in the unavailable period (5.8 versus 13.6%, p = 0.001). ICU days were lower in the unavailable period (10 [4.5-19] versus 4 [3-9], p = 0.01). Hospital admission (43.3 versus 29.9%, p = 0.001) was lower in the unavailable period. CONCLUSIONS: In this single center study, there appeared to be no difference in mortality, intubation rates, or vasopressor use between the charcoal-available and charcoal-unavailable periods.
RESUMEN
OBJECTIVE: Brain computed tomography (CT) is commonly performed to diagnose acute altered mental status (AMS), a critically important symptom in many serious diseases. However, negative CT results are common, which result in unnecessary CT use. Therefore, this study aimed to determine the clinical factors associated with positive CT findings. METHODS: Patients with acute AMS selected from an emergency department-based registry were retrospectively evaluated. Patients with non-traumatic and noncommunicable diseases on initial presentation and with Glasgow Comal Scale scores of <15 were included in the study. RESULTS: Among the 367 brain CT results of patients with AMS during the study period, 146 (39.8%) were positive. In a multivariate analysis, the presence of focal neurologic deficit (odds ratio [OR], 132.6; 95% confidence interval [CI], 37.8 to 464.6), C-reactive protein level <2 mg/dL (OR, 3.9; 95% CI, 1.4 to 10.6), and Glasgow Comal Scale score <9 (OR, 2.4; 95% CI, 1.2 to 4.8) were significantly associated with positive brain CT results. CONCLUSION: The presence of focal neurologic deficit, initial Glasgow Comal Scale score of <9, and initial C-reactive protein levels of <2 mg/dL can facilitate the selection of brain CT to diagnose patients with acute AMS in the emergency department.
RESUMEN
BACKGROUND: When an out-of-hospital cardiac arrest (OHCA) patient receives cardiopulmonary resuscitation (CPR) in the emergency department (ED), blood laboratory test results can be obtained by using point-of-care testing during CPR. In the present study, the relationship between blood laboratory test results during CPR and outcomes of OHCA patients was investigated. METHODS: This study was a multicenter retrospective analysis of prospective registered data that included 2716 OHCA patients. Data from the EDs of three university hospitals in different areas were collected from January 2009 to December 2014. Univariate and multivariable analyses were conducted to elucidate the factors associated with survival to discharge and neurological outcomes. A final analysis was conducted by including patients who had no prehospital return of spontaneous circulation and those who underwent rapid blood laboratory examination during CPR. RESULTS: Overall, 2229 OHCA patients were included in the final analysis. Among them, the rate of survival to discharge and a good Cerebral Performance Categories Scale score were 14% and 4.4%, respectively. The pH level was independently related to survival to hospital discharge (adjusted OR 6.287, 95% CI 2.601-15.197; p < 0.001) and good neurological recovery (adjusted OR 15.395, 95% CI 3.439-68.911; p < 0.001). None of the neurologically intact patients had low pH levels (< 6.8) or excessive potassium levels (> 8.5 mEq/L) during CPR. CONCLUSIONS: Among the blood laboratory test results during CPR of OHCA patients, pH and potassium levels were observed as independent factors associated with survival to hospital discharge, and pH level was considered as an independent factor related to neurological recovery.