A practical scoring model to predict the occurrence of critical illness in hospitalized patients with SARS-CoV-2 omicron infection.

Background: The variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have emerged repeatedly, especially the Omicron strain which is extremely infectious, so early identification of patients who may develop critical illness will aid in delivering proper treatment and optimizing use of resources. We aimed to develop and validate a practical scoring model at hospital admission for predicting which patients with Omicron infection will develop critical illness. Methods: A total of 2,459 patients with Omicron infection were enrolled in this retrospective study. Univariate and multivariate logistic regression analysis were performed to evaluate predictors associated with critical illness. Moreover, the area under the receiver operating characteristic curve (AUROC), continuous net reclassification improvement, and integrated discrimination index were assessed. Results: The derivation cohort included 1721 patients and the validation cohort included 738 patients. A total of 98 patients developed critical illness. Thirteen variables were independent predictive factors and were included in the risk score: age > 65, C-reactive protein > 10 mg/L, lactate dehydrogenase > 250 U/L, lymphocyte < 0.8*10^9/L, white blood cell > 10*10^9/L, Oxygen saturation < 90%, malignancy, chronic kidney disease, chronic cardiac disease, chronic obstructive pulmonary disease, diabetes, cerebrovascular disease, and non-vaccination. AUROC in the derivation cohort and validation cohort were 0.926 (95% CI, 0.903-0.948) and 0.907 (95% CI, 0.860-0.955), respectively. Moreover, the critical illness risk scoring model had the highest AUROC compared with CURB-65, sequential organ failure assessment (SOFA) and 4C mortality scores, and always obtained more net benefit. Conclusion: The risk scoring model based on the characteristics of patients at the time of admission to the hospital may help medical practitioners to identify critically ill patients and take prompt measures.

[Effect of early intervention bundle on clinical prognosis of patients with latent/overt septic shock in emergency department].

OBJECTIVE: To observe the effect of early intervention bundle on clinical prognosis of patients with latent/overt septic shock in emergency department and analyze the risk factors for mortality. METHODS: Patients with latent and overt septic shock admitted to the North Hospital of Huashan Hospital Affiliated to Fudan University from January 2018 to December 2019 were retrospectively analyzed and divided into latent shock group and overt shock group. The gender, age, main infection site, the time of shock diagnosis, the indicators of early (3-hour) intervention bundle, 6-hour compliance rate of intervention bundle, the remission time and 28-day prognosis were observed. Logistic regression analysis was used to identify risk factors for 28-day mortality. Receiver operating characteristic (ROC) curve was used to analyze its prognostic value. RESULTS: Totally 181 patients were included in the analysis. There were 102 cases in the latent shock group, and 28-day mortality was 15.69% (16 cases); 79 cases in the overt shock group, and 28-day mortality was 31.65% (25 cases). Compared with the latent shock group, patients in overt shock group had higher compliance rate of early intervention bundle (93.67% vs. 58.82%), higher blood lactate acid at admission [Lac (mmol/L): 7.09±2.08 vs. 5.69±1.27], higher compliance rate of blood culture before antibiotics (93.67% vs. 63.73%), higher proportion of antibiotics use at the first and second hours (45.57% vs. 31.37%, 54.43% vs. 33.33%), higher proportion of rapid fluid resuscitation at the first hour (crystal liquid: 59.49% vs. 11.76%, crystal fluid combined with human serum albumin: 40.51% vs. 0%), and higher proportion of vasoactive use at the first hour (100% vs. 9.80%). The stable time was significantly prolonged (days: 4.40±1.35 vs. 1.49±0.55), while the onset time (days: 1.47±0.97 vs. 2.95±1.61), the time of diagnosis (minutes: 31.30±12.54 vs. 79.15±13.81), 6-hour lactate clearance [(50.27±21.53)% vs. (61.82±13.12)%], the proportion of antibiotics use at the third hour (0% vs. 35.29%), the proportion of rapid fluid resuscitation at the second and third hour (second hour crystal liquid: 0% vs. 60.78%, second hour crystal fluid combined with human serum albumin: 0% vs. 14.71%, third hour crystal liquid: 0% vs. 12.75%), 6-hour compliance rate of the standard of central venous blood saturation (ScvO2, 60.76% vs. 78.43%) and the success rate of treatment (28-day mortality: 31.65% vs. 15.69%) were lower than those of the latent shock group (all P < 0.05). Ten patients with latent shock developed into overt shock within 24 hours after admission. All patients with overt shock needed vasoactive drugs to maintain mean arterial pressure (MAP) ≥ 65 mmHg (1 mmHg = 0.133 kPa). Compared with the survival patients, the Lac (mmol/L: 7.59±2.27 vs. 5.92±1.24) and the proportion of vasoactive drugs use (65.85% vs. 44.29%) were significantly increased in the death patients, while the 6-hour lactate clearance [(46.58±15.83)% vs. (59.60±17.92)%], the proportion of antibiotics use in the third hour (4.88% vs. 24.29%), and 6-hour compliance rate of urine volume and ScvO2 (56.10% vs. 82.86%, 43.90% vs. 78.57%) were significantly decreased (all P < 0.05). Binary Logistic regression analysis showed that Lac at admission, 6-hour lactate clearance, the use of antibiotics at the third hour, rapid fluid resuscitation at the first hour, and 6-hour compliance rate of ScvO2 were independent risk factors for 28-day mortality [odds ratio (OR) was 1.618, 0.021, 0.100, 0.307 and 3.018, all P < 0.05]. ROC curve analysis showed that the Lac at admission had the highest predictive value for 28-day mortality, the area under the ROC curve (AUC) was 0.706; followed by 6-hour compliance rate of ScvO2 (AUC was 0.673). CONCLUSIONS: Patients with latent/overt septic shock need early diagnosis and intervention bundle to improve the 6-hour blood lactate clearance and 6-hour compliance rate of ScvO2 and reduce the mortality.

[Significance of the ratio of C-reactive protein to prealbumin in patients with traumatic brain injury].

OBJECTIVE: To investigate the value of serum C-reactive protein/prealbumin ratio (CRP/PA) in predicting the disease progression of adult patients with traumatic brain injury. METHODS: A prospective study was conducted. Patients with traumatic brain injury who were over 18 years old and were followed up for more than 72 hours admitted to the department of emergency of Huashan North Hospital Affiliated to Fudan University from May 2018 to December 2019 were enrolled. The levels of serum CRP, PA were measured immediately after injury and at 6, 24, 48 and 72 hours after injury, and the CRP/PA ratio was calculated. Glasgow coma score (GCS) was dynamically measured and head CT was reviewed regularly. If the GCS decreased by more than 3 and/or the intracranial injury was aggravated by CT scan within 72 hours after injury, the patients were included in the aggravating group. If there were no above changes, they were included in the stable group. The differences of each index between the two groups were compared, and the receiver operating characteristic (ROC) curve was drawn to evaluate the predictive value of each index at different time points on the patient's disease progress. RESULTS: A total of 106 patients were selected, including 89 patients in the stable group and 17 patients in the aggravating group, and the baseline data of the two groups were balanced. CRP, CRP/PA increased and PA decreased in brain trauma patients 6 hours after injury, and reached the peak value or valley value at 48 hours. Compared with the stable group, CRP/PA significantly increased at 24, 48 and 72 hours in the aggravating group [24 hours: 34.18 (20.19, 67.10) vs. 13.98 (4.36, 38.30), 48 hours: 71.10 (45.55, 96.97) vs. 16.02 (5.05, 41.76), 72 hours: 23.25 (4.46, 38.61) vs. 4.72 (2.38, 12.95), all P < 0.05]. ROC curve analysis showed that CRP/PA ratio at 24 hours and 48 hours after injury could be used as a predictor of disease progression. The area under the ROC curve (AUC) of 24 hours CRP/PA was 0.71, 95% confidence interval (95%CI) was 0.58-0.84, the cut-off value was 28.29, the sensitivity was 76.5%, and the specificity was 73.0%. The AUC of 48 hours CRP/PA was 0.76, 95%CI was 0.62-0.90, and the cut-off value was 37.18, the sensitivity was 88.2%, and the specificity was 70.8%. CONCLUSIONS: The dynamic monitoring of CRP/PA ratio in adult after traumatic brain injury can evaluate the disease condition, and the CRP/PA ratio of 24 hours and 48 hours can predict the progress of the disease.

[Design and implementation of an integrated information platform for emergency interconnection].

OBJECTIVE: To establish a "patient-centered" integrated information platform for emergency interconnection. METHODS: Based on the existing software, hardware and network systems of the hospital, design ideas of the modularization, process and standardized were used to reshape the process of emergency diagnosis and treatment in department of emergency-critical care medicine of Huashan North Hospital, Fudan University, and develop integrated information platform for emergency interconnection, including triage, emergency physician workstation, electronic medical records, clinical pathways of key diseases, medical integration, electronic handover classes, imaging, testing, ultrasound, drug counseling and medication safety, performance appraisal and management systems of scientific research, etc. RESULTS: The information platform for emergency interconnection was successfully developed. The functional logic of each system was clear and concise. It had strong compatibility, stable performance and powerful processing capability. It could quickly query the target content and support free and fast switching of each window. At present, daily diagnosis and treatment of emergency patients were realized by informationization, which completely liberated the manual labor of medical staff, shortened the processing time of unit patient, and significantly improved efficiency of the work. At the peak of the patients' visit, the overall operation of the emergency department was stable, and all the work was carried out in an orderly manner. There was no delay of the diagnosis and treatment for critically ill patients in the emergency department. Emergency access to patients with key diseases was smooth, and waiting time was significantly shortened. Clinical decision-making of medical staff had been effectively regulated. The success rates of the patients with acute trauma or acute respiratory failure were significantly improved, the time of the critical treatment were significantly shortened in patients with emergency respiratory cardiac arrest or acute ST-segment elevation myocardial, and compliance rate of the door-to-balloon time met the requirements of the Emergency Room to Balloon Expansion Time (DTB) Alliance. CONCLUSIONS: The integrated information platform for emergency interconnection ran through the whole process of emergency diagnosis and treatment, based on emergency clinical practice, which could meet the needs of daily work in emergency department and help improve the quality of emergency medical and department management.

[Clinical practice and evaluation of management of patients based on clinical pathway of emergency respiratory and cardiac arrest].

OBJECTIVE: To explore the effect of clinical pathway of emergency respiratory and cardiac arrest on management of patients with sudden respiratory and cardiac arrest. METHODS: The clinical data of patients with sudden respiratory and cardiac arrest admitted to Huashan North Hospital Affiliated to Fudan University from 1 year before to 1 year (started in July 2017) after the implementation of clinical pathway of emergency respiratory and cardiac arrest were retrospectively analyzed. The patients who managed by clinical pathway of emergency respiratory and cardiac arrest (from July 2017 to June 2018) were served as observational group, and those manually managed by 2015 American Heart Association cardiopulmonary resuscitation and cardiovascular emergency guide update and the procession in the management of emergency key diseases (from July 2016 to June 2017) were set as control group. The gender, age, underlying disease, the initiation time of cardiopulmonary resuscitation (CPR), the first time of defibrillation, the completion time of endotracheal intubation, the time of venous access, the usage time of the first dose of adrenaline, the usage time of vasoactive drugs, the completion rate of high quality CPR, the success rate of return of spontaneous circulation (ROSC) and the table procedure of clinical pathway were compared between the two groups. RESULTS: There was no statistically significant difference in gender, age or underlying disease between the two groups. Compared with the control group, the clinical pathway could effectively guide the decision-making of the emergency medical staffs, significantly reduce the variation in the procession of the resuscitation, the first time of defibrillation, the completion time of the deep vein catheterization, the usage time of norepinephrine and the completion time of the blood specimen delivery were significantly shortened [the first time of defibrillation (minutes): 1.28±0.86 vs. 2.93±1.61, the completion time of deep vein catheter (minutes): 15.13±2.73 vs. 17.25±3.02, the usage time of norepinephrine (minutes): 15.43±2.80 vs. 17.88±1.67, the completion time of blood specimen delivery (minutes): 7.81±1.42 vs. 9.00±1.03, all P < 0.05]. There was no statistically significant difference in the initiation time of CPR, the completion time of tracheal intubation, the time of peripheral venous access, the usage time of the first dose of adrenaline or sodium bicarbonate, or the success rate of ROSC between the two groups. However, the usage time of the first dose of adrenaline and sodium bicarbonate was shortened in the observation group [the usage time of the first dose of adrenaline (minutes): 3.81±1.22 vs. 4.00±1.32, the usage time of the first does of sodium bicarbonate (minutes): 8.94±3.49 vs. 11.19±3.54, both P > 0.05], and the success rate of ROSC was relatively increased as compared with those in the control group [15.04% (17/113) vs. 12.50% (12/96), P > 0.05]. CONCLUSIONS: The clinical pathway of emergency respiratory and cardiac arrest could effectively guide the clinical decision-making of the emergency medical staffs, significantly reduce the variation in the procession of the resuscitation, improve the quality of the resuscitation, and ensure medical safety of emergency department.

[Analysis on distribution and drug resistance of pathogen caused community-onset bloodstream infection].

OBJECTIVE: To investigate the distribution and drug resistance of pathogen caused community-onset bloodstream infection (COBSI) in patients of affiliated hospital of university, and to provide evidence for the clinical therapy. METHODS: The clinical data of patients with COBSI in emergency department admitted to Huashan North Hospital Affiliated to Fudan University from January 2014 to December 2017 were collected, and the distribution and drug resistance of pathogen were retrospectively analyzed. The patients were divided into community-acquired bloodstream infection (CABSI) group and health care-associated bloodstream infection (HCABSI) group according to clinical diagnosis. The source of patients, past health status, blood culture isolation of pathogens, drug sensitivity test results were recorded, and the trend of drug resistance of main pathogens to common antibiotics from 2014 to 2017 were analyzed. RESULTS: A total of 258 pathogens were isolated from patients, including 186 Gram-negative pathogens (G- pathogens, 72.09%) and 72 Gram-positive pathogens (G+ pathogens, 27.91%), while the fungal strain was not isolated. The two most frequently isolated G- pathogens causing CABSI were Escherichia coli (80 isolates, 65.57%) and Klebsiella pneumonia (24 isolates, 19.67%), including extended-spectrum beta-lactamases (ESBLs)-producing Escherichia coli (37 isolates) and Klebsiella pneumonia (3 isolates), the average detection rates were 46.25% and 12.50% respectively. The two most frequently isolated G+ pathogens were Streptococcus (32 isolates, 57.14%) and Staphylococcus (15 isolates, 26.79%), but methicillin-resistant Staphylococcus aureus (MRSA) had not been isolated. The two most frequently isolated G- pathogens causing HCABSI were Escherichia coli (45 isolates, 70.32%) and Klebsiella pneumonia (7 isolates, 10.94%), including ESBLs-producing Escherichia coli (20 isolates) and Klebsiella pneumonia (1 isolate), the average detection rate was 44.44% and 14.29%, respectively. The most frequently isolated G+ pathogens were Staphylococcus (10 isolates, 62.50%), Streptococcus (3 isolates, 18.75%) and Enterococcus faecium (3 isolates, 18.75%), including MRSA (3 isolates). ESBLs-positive Escherichia coli and Klebsiella pneumoniae were almost completely resistant to cefazolin and highly resistant to ampicillin, ampicillin sodium and sulbactam sodium, ceftriaxone and furadantin, with the drug resistance rates of higher than 50%, and the drug resistance rate was significantly higher than that of corresponding ESBLs-producing negative pathogens. Escherichia coli were completely sensitive to piperacillin tazobactam, imipenem, and ertapenem, but Klebsiella pneumoniae had some resistance to piperacillin tazobactam and imipenem. Methicillin-resistant coagulase-negative Staphylococci (MRCNS) were highly resistant to common antibiotics, while Streptococcus strains and MRSA had low resistance rates, and all pathogens were completely sensitive to linezolid and vancomycin. The average annual resistance rate of Escherichia coli to common antibiotics in CABSI group was increased, but the difference was significant only for ciprofloxacin (from 2014 to 2017, they were 37.5%, 28.6%, 52.6%, 65.2%, respectively, Z = 5.076, P = 0.024). The average annual resistance rate of Klebsiella pneumonia to cefazolin and ciprofloxacin in CABSI group and that of Escherichia coli to ceftriaxone in HCABSI group showed an increasing trend without significant differences. CONCLUSIONS: Escherichia coli and Klebsiella pneumoniae were the main pathogens of emergency COBSI, ESBLs-producing Escherichia coli were more common, and the average annual drug resistance rate to common clinical antibiotics was increasing. The drug resistance of ESBLs-producing Escherichia coli and Klebsiella pneumoniae was more serious than that of ESBLs-producing negative pathogens, so antibiotics should be used rationally.