Shortened time to neuromuscular recovery with lower doses of rocuronium in elderly patients.

INTRODUCTION: The effect of neuromuscular blocking agents may be reversed by administration of neostigmine, when two twitches are present using train-of-four (TOF) stimulation. However, in elderly patients, limited data are available about when to administer neostigmine. We hypothesised that time to two twitches after TOF (TOF-2) was shorter after rocuronium 0.6 mg/kg than after rocuronium 0.9 mg/kg. Also, we hypothesised that time to TOF-2 would be shorter after rocuronium 0.3 mg/kg than after rocuronium 0.6 mg/kg. METHODS: This was a secondary analysis of 50 elderly patients > 80 years; 16 patients received rocuronium 0.6 mg/kg, another 16 patients received rocuronium 0.9 mg/kg; and, finally, 18 patients received rocuronium 0.3 mg/kg. Patients received total intravenous anaesthesia, and neuromuscular block was monitored with acceleromyography. RESULTS: Time to TOF-2 was shorter after rocuronium 0.6 mg/kg than after rocuronium 0.9 mg/kg: 37 min. versus 59 min. (difference: 22 min. (95% confidence intervals (CI): 10 to 33 min.), p = 0.0007). Time to TOF-2 after rocuronium 0.3 mg/kg was shorter than after rocuronium 0.6 mg/kg: 19 min. versus 37 min. (difference: 18 min. (95% CI: 11 to 25 min.), p = 0.00006). However, only 33% of the patients receiving 0.3 mg/kg obtained full effect i.e. TOF-0. CONCLUSION: Time to TOF-2 was shorter after rocuronium 0.6 mg/kg than after 0.9 mg/kg and shorter after rocuronium 0.3 mg/kg than after 0.6 mg/kg. FUNDING: This work was supported by departmental sources. TRIAL REGISTRATION: This study was a secondary analysis of two clinical trials. CLINICALTRIALS: gov (NCT04512313), (NCT03857750).

Intravenous MELAtonin for prevention of Postoperative Agitation and Emergence Delirium in children (MELA-PAED): A protocol and statistical analysis plan for a randomized clinical trial.

BACKGROUND: Emergence agitation and delirium in children remain a common clinical challenge in the post-anesthetic care unit. Preoperative oral melatonin has been suggested as an effective preventive drug with a favorable safety profile. The oral bioavailability of melatonin, however, is low. Therefore, the MELA-PAED trial aims to investigate the efficacy and safety of intraoperative intravenous melatonin for the prevention of emergence agitation in pediatric surgical patients. METHODS: MELA-PAED is a randomized, double-blind, parallel two-arm, multi-center, superiority trial comparing intravenous melatonin with placebo. Four hundred participants aged 1-6 years will be randomized 1:1 to either the intervention or placebo. The intervention consists of intravenous melatonin 0.15 mg/kg administered approximately 30 min before the end of surgery. Participants will be monitored in the post-anesthetic care unit (PACU), and the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS) will be performed on days 1, 7, and 14 after the intervention. Serious Adverse Events (SAE) will be assessed up to 30 days after the intervention. RESULTS: The primary outcome is the incidence of emergence agitation, assessed dichotomously as any Watcha score >2 during the participant's stay in the post-anesthetic care unit. Secondary outcomes are opioid consumption in the post-anesthetic care unit and adverse events. Exploratory outcomes include SAEs, postoperative pain, postoperative nausea and vomiting, and time to awakening, to first oral intake, and to discharge readiness. CONCLUSION: The MELA-PAED trial investigates the efficacy of intravenous intraoperative melatonin for the prevention of emergence agitation in pediatric surgical patients. Results may provide further knowledge concerning the use of melatonin in pediatric perioperative care.

Comparing restrictive versus liberal oxygen strategies for trauma patients: The TRAUMOX2 trial-Statistical analysis plan.

BACKGROUND: The international advanced trauma life support guidelines recommend that all severely injured trauma patients receive supplemental oxygen based on very limited evidence. The TRAUMOX2 trial randomises adult trauma patients to a restrictive or liberal oxygen strategy for 8 h. The primary composite outcome consists of 30-day mortality and/or development of major respiratory complications (pneumonia and/or acute respiratory distress syndrome). This manuscript presents the statistical analysis plan for TRAUMOX2. METHODS: Patients are randomised 1:1 in variable block sizes of four, six and eight, stratified by including centre (pre-hospital base or trauma centre) and tracheal intubation at inclusion. The trial will include 1420 patients to be able to detect a 33% relative risk reduction with the restrictive oxygen strategy of the composite primary outcome with 80% power at the 5% significance level. We will conduct modified intention-to-treat analyses on all randomised patients and per-protocol analyses for the primary composite outcome and key secondary outcomes. The primary composite outcome and two key secondary outcomes will be compared between the two allocated groups using logistic regression reported as odds ratios with 95% confidence intervals adjusted for the stratification variables as in the primary analysis. A p-value below 5% will be considered statistically significant. A Data Monitoring and Safety Committee has been established to conduct interim analyses after inclusion of 25% and 50% of the patients. CONCLUSION: This statistical analysis plan of the TRAUMOX2 trial will minimise bias and add transparency to the statistics applied in the analysis of the trial. The results will add evidence on restrictive and liberal supplemental oxygen strategies for trauma patients. TRIAL REGISTRATION: EudraCT number: 2021-000556-19; ClinicalTrials.gov identifier: NCT05146700 (date of registration: 7 December 2021).

Comparison of onset time, duration of action, and intubating conditions after cisatracurium 0.15 mg/kg in young and elderly patients.

INTRODUCTION: Tracheal intubation during anesthesia can be facilitated by the neuromuscular blocking agent cisatracurium. However, limited data exists about onset time, duration of action and effect on intubating conditions in elderly patients above 80 years of age. We hypothesized that elderly patients would present a longer onset time and duration of action compared to younger adults. METHODS: This prospective observational study included 31 young (18-40 years) and 29 elderly (≥ 80 years) patients. Patients were given fentanyl 2 µg/kg and propofol 1.5-2.5 mg/kg for induction of anesthesia and maintained with remifentanil and propofol. Monitoring of neuromuscular function was performed with acceleromyography. Primary outcome was onset time defined as time from injection of cisatracurium 0.15 mg/kg (based on ideal body weight) to a train-of-four (TOF) count of 0. Other outcomes included duration of action (time to TOF ratio ≥ 0.9), intubation conditions using the Fuchs-Buder scale and the Intubating Difficulty Scale (IDS), and occurrence of hoarseness and sore throat postoperatively. RESULTS: Elderly patients had significantly longer onset time compared with younger patients; 297 seconds (SD 120) vs. 199 seconds (SD 59) (difference: 98 seconds (95% CI: 49-147), P < 0.001)). Duration of action was also significantly longer in elderly patients compared with younger patients; 89 minutes (SD 17) vs. 77 minutes (SD 14) (difference: 12 minutes (95% CI: 2.5-20.5) P = 0.01)). No difference was found in the proportion of excellent intubating conditions (Fuchs-Buder); 19/29 (66%) vs 21/31 (68%) (P = 0.86) or IDS score (P = 0.74). A larger proportion of elderly patients reported hoarseness 24 hours postoperatively; 62% vs 34% P = 0.04. CONCLUSION: In elderly patients cisatracurium 0.15 mg/kg had significantly longer onset time and duration of action compared with younger patients. No difference was found in intubating conditions at a TOF count of 0. TRIAL REGISTRATION: Clinicaltrials.gov (NCT04921735, date of registration 10 June 2021).

Time to CT scan for patients with acute severe neurological symptoms: a quality assurance study.

Emergent brain computed tomography (CT) scan allows for identification of patients presenting with acute severe neurological symptoms in whom medical and surgical interventions may be lifesaving. The aim of this study was to evaluate if time to CT from arrival at the emergency department exceeded 30 min in patients admitted with acute severe neurological symptoms. This was a retrospective register-based quality assurance study. We identified patients admitted to the emergency department with acute severe neurological symptoms between April 1st, 2016 and September 30th, 2020. Data were retrieved from the registry of acute medical team activations. We considered that time to CT from arrival at the emergency department should not exceed 30 min in more than 10% of patients. A total of 559 patients were included. Median time from arrival at the emergency department until CT scan was 24 min (IQR 16-35) in children (< 18 years), 10 min (IQR 7-17) for adults (18-59 years), and 11 min (IQR 7-16) for elders (> 60 years). This time interval exceeded 30 min for 8.2% (95% CI 6.1-10.9) of all included patients, 35.3% of children, 5.9% of adults, and 8.6% of elders. No children died within 30 days. The 30-day mortality was 21.3% (95% CI 16.4-27) in adults, and 43.9% (95% CI 38.2-49.8) in elders. Time from arrival at our emergency department until brain CT scan exceeded 30 min in 8.2% of all included patients but exceeded the defined quality aim in children and could be improved.

Clinical assessment as a part of an early warning score-a Danish cluster-randomised, multicentre study of an individual early warning score.

BACKGROUND: The clinical benefit of Early Warning Scores (EWSs) is undocumented. Nursing staff's clinical assessment might improve the prediction of outcome and allow more efficient use of resources. We aimed to investigate whether the combination of clinical assessment and EWS would reduce the number of routine measurements without increasing mortality. METHODS: We did a cluster-randomised, crossover, non-inferiority study at eight hospitals in Denmark. Patients aged 18 years or older, admitted for more than 24 h were included. Admissions to paediatric or obstetric wards were excluded. The participating hospitals were randomly assigned 1:1 to start as either intervention or control with subsequent crossover. Primary outcomes were 30-day all-cause mortality (non-inferiority margin=0·5%) and average number of EWS per day per patient. The intervention was implementation of the Individual EWS (I-EWS), in which nursing staff can adjust the calculated score on the basis of their clinical assessment of the patient. I-EWS was compared with the National Early Warning Score (NEWS). The study is registered at ClinicalTrials.gov, NCT03690128 and is complete. FINDINGS: Unique admissions longer than 24 h were included from Oct 15, 2018 to Sept 30, 2019. Of 90 964 patients assessed, n=46 470 were assigned to the I-EWS group and n=44 494 to the NEWS group. Mortality within 30 days was 4·6% for the I-EWS group, and 4·3% for the NEWS group (adjusted odds ratio 1·05 [95% CI 0·99-1·12], p=0·12). In subgroup analyses I-EWS showed increased 30-day mortality for hospitals that did I-EWS in fall-winter, which was probably due to seasonality, and within patients admitted in a surgical specialty. Overall risk difference was 0·22% (95% CI -0·04 to 0·48) meaning that the non-inferiority criteria were met. The average number of scorings per patient per day was reduced from 3·14 to 3·10 (ie, a relative reduction of 0·64% [95% CI -0·16 to -1·11], p=0·0084) in the I-EWS group. INTERPRETATION: Including clinical assessment in I-EWS was feasible and overall non-inferior to the widely implemented NEWS in terms of all-cause mortality at 30 days, and the number of routine measurements was minimally reduced. However I-EWS should be used with caution in surgical patients. FUNDING: Capital Region Research Foundation, Gangsted Foundation, Candys Foundation, Herlev-Gentofte Hospital Research Foundation, Laerdal Foundation, and The Foundation of Director Boennelycke and wife.

Prehospital triage of trauma patients before and after implementation of a regional triage guideline.

INTRODUCTION: Severely injured trauma patients have a considerable mortality rate. One way to reduce the mortality is to ensure optimal triage. The American College of Surgeons Committee on Trauma has since 1986 made guidelines for the triage of trauma patients. These guidelines formed the basis, when the capital region of Denmark implemented a regional trauma triage guideline on February 15th 2016. It is uncertain how the implementation of the regional trauma triage guideline has influenced the triage of trauma patients. The aim of this study was to investigate the changes in admission pattern of trauma patients in the entire region after the implementation of the regional trauma triage guideline. We hypothesized that there would be a reduction in the proportion of trauma patients admitted to the trauma center after the implementation of the regional trauma triage guideline. PATIENTS AND METHODS: In this observational cohort study with one-year follow-up, we used a national patient registry in Denmark. We identified trauma patients three years before and three years after the implementation of a new regional trauma triage guideline. The primary outcome was the proportion of trauma patients triaged to the regional trauma center. Secondary outcomes were: 30-day and one-year mortality, overtriage, and undertriage. RESULTS: We found a significant reduction in the proportion of trauma patients triaged to the trauma center from 2115/5951 (35.5%) to 1970/5857 (33.6%), after the implementation of the regional trauma triage guideline, the difference being 1.9% (95% CI: 0.19 to 3.6%); P = 0.03. Further, a significant reduction of overtriage from 15.4% to 9.5% (difference 5.9% with 95% CI of 3.8 to 7.9%) was found. No significant changes in undertriage, 30-day or one-year mortality were found (1.07% vs 0.97%, 4.3% vs 4.5%, and 15.7% vs 16.6% respectively). CONCLUSION: A significant decrease in the proportion of trauma patients admitted to the trauma center was found after implementation of a new regional trauma triage guideline. A reduction was seen in overtriage, but no changes were found in undertriage and both short-term and long-term mortality remained unchanged.

Criteria-based dispatch of emergency medical services in non-traumatic subarachnoid haemorrhage.

INTRODUCTION: Timely admission to a facility capable of providing highly specialised treatment is key in patients with spontaneous subarachnoid haemorrhage. We aimed to determine the time elapsed from the initial emergency telephone call to arrival at a neurosurgical department. Also, we aimed to determine the ambulance dispatch criteria used and the activated prehospital responses. METHODS: This was a retrospective study. Patients admitted in the Capital Region of Denmark within a 3.5-year period were identified in the Danish National Patient Register. Data were extracted from medical records and from automated telephone logs at the Emergency Medical Dispatch Centre. RESULTS: Time intervals were available in 124 out of 262 patients and ambulance dispatch criteria in 98 patients. The median time from call to neurosurgical admission was 207.5 minutes. The dispatch criterion sudden severe headache had a sensitivity of 17.4%. An ambulance with lights and sirens was dispatched to 77% of patients and 28% were brought directly to a hospital with neurosurgical facilities. CONCLUSIONS: The median time from emergency call to neurosurgical admission was 3.5 hours. No single dispatch criterion detected the condition with an acceptable sensitivity. A high proportion of patients received an ambulance with lights and sirens, but more than two out of three were not initially brought to a hospital with neurosurgical facilities. FUNDING: the non-profit organisation Trygfonden Trial registration: NCT03786068 - www.clinicaltrials.gov.

Symptoms presented during emergency telephone calls for patients with spontaneous subarachnoid haemorrhage.

BACKGROUND: A spontaneous subarachnoid haemorrhage (SAH) is one of the most critical neurological emergencies a dispatcher can face in an emergency telephone call. No study has yet investigated which symptoms are presented in emergency telephone calls for these patients. We aimed to identify symptoms indicative of SAH and to determine the sensitivity of these and their association (odds ratio, OR) with SAH. METHODS: This was a nested case-control study based on all telephone calls to the medical dispatch center of Copenhagen Emergency Medical Services in a 4-year time period. Patients with SAH were identified in the Danish National Patient Register; diagnoses were verified by medical record review and their emergency telephone call audio files were extracted. Audio files were replayed, and symptoms extracted in a standardized manner. Audio files of a control group were replayed and assessed as well. RESULTS: We included 224 SAH patients and 609 controls. Cardiac arrest and persisting unconsciousness were reported in 5.8% and 14.7% of SAH patients, respectively. The highest sensitivity was found for headache (58.9%), nausea/vomiting (46.9%) and neck pain (32.6%). Among conscious SAH patients these symptoms were found to have the strongest association with SAH (OR 27.0, 8.41 and 34.0, respectively). Inability to stand up, speech difficulty, or sweating were reported in 24.6%, 24.2%, and 22.8%. The most frequent combination of symptoms was headache and nausea/vomiting, which was reported in 41.6% of SAH patients. More than 90% of headaches were severe, but headache was not reported in 29.7% of conscious SAH patients. In these, syncope was described by 49.1% and nausea/vomiting by 37.7%. CONCLUSION: Headache, nausea/vomiting, and neck pain had the highest sensitivity and strongest association with SAH in emergency telephone calls. Unspecific symptoms such as inability to stand up, speech difficulty or sweating were reported in 1 out of 5 calls. Interestingly, 1 in 3 conscious SAH patients did not report headache. Trial registration NCT03980613 ( www.clinicaltrials.gov ).

Measurements of Cardiac Output and Management of Blood Transfusions During Burn Surgery-An Observational Prospective Study.

Burn surgery can cause extensive bleeding, which lead to perioperative blood transfusions. The purpose of this study was to investigate whether blood transfusions during burn surgery, guided by standard monitoring with inspection of the operative field, measurements of blood pressure, heart rate, hourly diuresis, and concentrations of hemoglobin and lactate could sustain the preoperative cardiac output (CO) till end of surgery. We investigated 15 patients ≥18 years of age scheduled for burn surgery, where the perioperative monitoring included an arterial line. After induction of anesthesia and before start of surgery, we measured baseline values of CO with the minimally invasive LiDCOrapid, mean arterial pressure, and concentrations of hemoglobin and lactate in arterial blood. We measured these values every 30 minutes through surgery. The primary outcome was change in CO from baseline till end of surgery. Secondary outcomes included the change in concentrations of hemoglobin and lactate from baseline till end of surgery. We found no statistically significant change in CO from baseline till end of surgery (6.6 [±2.4] liters/min; 7.2 [±3.2] liters/min; P = .26). We found a statistically significant decrease in concentration of hemoglobin (7.2 [±0.8] mmol/liter; 6.2 [±0.9] mmol/liter; P = .0002), and a statistically significant increase in concentration of lactate (1.3 [±0.5] mmol/liter; 1.7 [±1] mmol/liter; P = .02). The perioperative blood transfusion guided by standard monitoring seemed to sustain CO from baseline till end of surgery; however, further research is needed to confirm this.

Management of Ambulatory Anesthesia in Older Adults.

The number of older patients is increasing globally. Combined with the growing number of ambulatory surgeries, many older patients will undergo ambulatory surgery in the future. The ambulatory setting offers many advantages: early mobilization, higher patient satisfaction, lower costs, and a low incidence of several complications such as infections and thromboembolic events. Moreover, cognitive recovery seems to be enhanced compared with in-hospital surgery, and both frail patients and patients with dementia can benefit from ambulatory surgery. This review provides suggestions for managing perioperative anesthesia for older patients in the ambulatory setting. Not all older patients are eligible for ambulatory surgery, and clinicians must be aware of risk factors for complications, especially frailty. Most anesthesia techniques and agents can be used in the ambulatory setting, but short-acting agents are preferred to ensure fast recovery. Both regional and general anesthesia are useful, but clinicians must be familiar with the physiological changes and specific implications in the older population. The older patients are more sensitive to anesthetic agents, meaning that a lower dose is needed to obtain the desired effect. However, they exhibit huge variation in pharmacodynamics and pharmacokinetics. Prolonged onset time may lead to overdosing and extended recovery. After surgery, effective pain management with opioid minimization is essential to ensure rapid recovery.

Spontaneous Subarachnoid Haemorrhage as a Cause of Out-of-Hospital Death.

BACKGROUND: There are no recent studies on the incidence rate of out-of-hospital death due to spontaneous subarachnoid haemorrhage (SAH). The primary aim of this study was to determine how often SAH was the cause of out-of-hospital death. The secondary aim was to determine if decedents had contacted any health care services within the last 72 h prior to the time of death. METHODS: This was a retrospective cohort study. The reports of all autopsies carried out at the Department of Forensic Medicine in the Capital Region of Denmark in a ten-year period were read. Police records and Emergency Medical Services (EMS) telephone records were searched for health care contacts within the last 72 h prior to the time of death. Descriptive statistics were used, and to analyse the incidence rates for trend Poisson regression was used. RESULTS: In total, 6,903 decedents underwent autopsy. Out-of-hospital SAH was the cause of death in 58 decedents, resulting in an average incidence rate of 0.34 per 100.000 persons per year. No significant change in the incidence rate over time was found (p = 0.52). No EMS data were available for eleven decedents in the first part of the study period. Of the remaining 47 decedents, 2 (3.5%, 95% CI: 0.4-11.9) had called the EMS, and in regards to 27 of the 58 decedents, the police records contained information on health care system contacts. Five (8.6%, 95% CI: 2.9-18.9) patients had contacted a general practitioner and three (5.2%, 95% CI: 1.1-14.4) patients had been admitted to hospital but were discharged again within 72 h prior to their death. CONCLUSION: The incidence rate of out-of-hospital death from SAH was 0.34 per 100.000 persons per year and remained stable across the years 2009-2018. Several patients had sought medical attention shortly before their death, emphasizing the vital importance of recognizing the early symptoms of SAH.

Time from injury to arrival at the trauma centre in patients undergoing interhospital transfer.

INTRODUCTION: Trauma patients may require interhospital transfer to definitive care following initial assessment at a primary facility. A prolonged time to transfer may be associated with a poor outcome. The aim of this study was to determine the time from injury to arrival in patients undergoing interhospital transfer to the Trauma Centre at Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. METHODS: Data were obtained from our local trauma registry for the period from 1 November 2016 to 31 October 2019. We included patients who underwent interhospital transfer to our trauma centre. Patients were compared according to a 360-minute time interval between injury and arrival. RESULTS: In the study period, 250 patients underwent interhospital transfer to our trauma centre. The median age was 47 years (interquartile range (IQR) 26-65), the majority were male (68.4%) and a total of 113 patients (46.9%) had an Injury Severity Score (ISS) > 15. The 30-day mortality was 6% (95% confidence interval (CI) 3.6-9.7). The median time from injury to arrival at our trauma centre was 255 minutes (IQR 192-371). We found that 67 patients (27%; 95% CI 21.7-32.6) arrived at our trauma centre more than 360 minutes after time of injury. The patients arriving later than 360 minutes were significantly older (p = 0.004) than the remaining patients. There was no significant difference in the unadjusted 30-day mortality (odds ratio (OR) 1.01, 95% CI 0.3-3.3). CONCLUSIONS: Time from injury to arrival at our trauma centre exceeded 360 minutes for 67 patients (27%) who were significantly older than the remaining patients transferred. FUNDING: departmental funding. TRIAL REGISTRATION: not relevant.

Adjusting Early Warning Score by clinical assessment: a study protocol for a Danish cluster-randomised, multicentre study of an Individual Early Warning Score (I-EWS).

INTRODUCTION: Track and trigger systems (TTSs) based on vital signs are implemented in hospitals worldwide to identify patients with clinical deterioration. TTSs may provide prognostic information but do not actively include clinical assessment, and their impact on severe adverse events remain uncertain. The demand for prospective, multicentre studies to demonstrate the effectiveness of TTSs has grown the last decade. Individual Early Warning Score (I-EWS) is a newly developed TTS with an aggregated score based on vital signs that can be adjusted according to the clinical assessment of the patient. The objective is to compare I-EWS with the existing National Early Warning Score (NEWS) algorithm regarding clinical outcomes and use of resources. METHOD AND ANALYSIS: In a prospective, multicentre, cluster-randomised, crossover, non-inferiority study. Eight hospitals are randomised to use either NEWS in combination with the Capital Region of Denmark NEWS Override System (CROS) or implement I-EWS for 6.5 months, followed by a crossover. Based on their clinical assessment, the nursing staff can adjust the aggregated score with a maximum of -4 or +6 points. We expect to include 150 000 unique patients. The primary endpoint is all-cause mortality at 30 days. Coprimary endpoint is the average number of times per day a patient is NEWS/I-EWS-scored, and secondary outcomes are all-cause mortality at 48 hours and at 7 days as well as length of stay. ETHICS AND DISSEMINATION: The study was presented for the Regional Ethics committee who decided that no formal approval was needed according to Danish law (J.no. 1701733). The I-EWS study is a large prospective, randomised multicentre study that investigates the effect of integrating a clinical assessment performed by the nursing staff in a TTS, in a head-to-head comparison with the internationally used NEWS with the opportunity to use CROS. TRIAL REGISTRATION NUMBER: NCT03690128.

Risk assessment models for potential use in the emergency department have lower predictive ability in older patients compared to the middle-aged for short-term mortality - a retrospective cohort study.

BACKGROUND: Older patients is a complex group at increased risk of adverse outcomes compared to younger patients, which should be considered in the risk assessment performed in emergency departments. We evaluated whether the predictive ability of different risk assessment models for acutely admitted patients is affected by age. METHODS: Cohort study of middle-aged and older patients. We investigated the accuracy in discriminating between survivors and non-survivors within 7 days of different risk assessment models; a traditional triage algorithm, a triage algorithm with clinical assessment, vital signs, routine biomarkers, and the prognostic biomarker soluble urokinase plasminogen activator receptor (suPAR). RESULTS: The cohort included 22,653 (53.2%) middle-aged patients (age 40-69 years), and 19,889 (46.8%) older patients (aged 70+ years). Death within 7 days occurred in 139 patients (0.6%) in middle-aged patients and 596 (3.0%) of the older patients. The models based on vital signs and routine biomarkers had the highest area under the curve (AUC), and both were significantly better at discriminating 7-day mortality in middle-aged patients compared to older patients; AUC (95% CI): 0.88 (0.84-0.91), 0.75 (0.72-0.78), P < 0.01, and 0.86 (0.82-0.90), 0.76 (0.73-0.78), P < 0.001. In a subgroup of the total cohort (6.400 patients, 15.0%), the suPAR level was available. suPAR had the highest AUC of all individual predictors with no significant difference between the age groups, but further research in this biomarker is required before it can be used. CONCLUSION: The predictive value was lower in older patients compared to middle-aged patients for all investigated models. Vital signs or routine biomarkers constituted the best models for predicting 7-day mortality and were better than the traditional triage model. Hence, the current risk assessment for short-term mortality can be strengthened, but modifications for age should be considered when constructing new risk assessment models in the emergency department.

Soluble Urokinase Plasminogen Activator Receptor (suPAR) as an Added Predictor to Existing Preoperative Risk Assessments.

BACKGROUND: Risk assessment strategies, such as using the American Society of Anesthesiologists (ASA) physical status classification, attempt to identify surgical high-risk patients. Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker reflecting overall systemic inflammation and immune activation, and it could potentially improve the identification of high-risk surgical patients. METHODS: We included patients acutely admitted to the emergency department who subsequently underwent surgery within 90 days of admission. Patients were stratified into low-risk or high-risk groups, according to ASA classification (ASAlow: ASA I-II; ASAhigh: ASA III-VI) and suPAR level, measured at admission (suPARhigh above and suPARlow below 5.5 ng/ml), respectively. Pre-specified complications were identified in national registries and electronic medical records. The association between ASA classification, suPAR level, CRP and the rate of postoperative complications was analyzed with logistic regression and Cox regression analyses, estimating odds ratios and hazard ratios (HRs). RESULTS: During 90-day follow-up from surgery, 31 (7.0%) patients died and 158 (35.6%) patients had postoperative complications. After adjusting for age, sex, and ASA classification, the HR for 90-day postoperative mortality was 2.5 (95% CI 1.6-4.0) for every doubling of suPAR level. suPAR was significantly better than CRP at predicting mortality and all complications (P = 0.0036 and P = 0.0041, respectively). Combining ASA classification and suPAR level significantly improved prediction of mortality and the occurrence of a postoperative complication within 90 days after surgery (P < 0.0001). CONCLUSION: Measuring suPAR levels in acutely admitted patients may aid in identifying high-risk patients and improve prediction of postoperative complications.

A simple clinical assessment is superior to systematic triage in prediction of mortality in the emergency department.

OBJECTIVE: To compare the Danish Emergency Process Triage (DEPT) with a quick clinical assessment (Eyeball triage) as predictors of short-term mortality in patients in the emergency department (ED). METHODS: The investigation was designed as a prospective cohort study conducted at North Zealand University Hospital. All patient visits to the ED from September 2013 to December 2013 except minor injuries were included. DEPT was performed by nurses. Eyeball triage was a quick non-systematic clinical assessment based on patient appearance performed by phlebotomists. Both triage methods categorised patients as green (not urgent), yellow, orange or red (most urgent). Primary analysis assessed the association between triage level and 30-day mortality for each triage method. Secondary analyses investigated the relation between triage level and 48-hour mortality as well as the agreement between DEPT and Eyeball triage. RESULTS: A total of 6383 patient visits were included. DEPT was performed for 6290 (98.5%) and Eyeball triage for 6382 (~100%) of the patient visits. Only patients with both triage assessments were included. The hazard ratio (HR) for 48-hour mortality for patients categorised as yellow was 0.9 (95% CI 0.4 to 1.9) for DEPT compared with 4.2 (95% CI 1.2 to 14.6) for Eyeball triage (green is reference). For orange the HR for DEPT was 2.2 (95% CI 1.1 to 4.4) and 17.1 (95% CI 5.1 to 57.1) for Eyeball triage. For red the HR was 30.9 (95% CI 12.3 to 77.4) for DEPT and 128.7 (95% CI 37.9 to 436.8) for Eyeball triage. For 30-day mortality the HR for patients categorised as yellow was 1.7 (95% CI 1.2 to 2.4) for DEPT and 2.4 (95% CI 1.6 to 3.5) for Eyeball triage. For orange the HR was 2.6 (95% CI 1.8 to 3.6) for DEPT and 7.6 (95% CI 5.1 to 11.2) for Eyeball triage, and for red the HR was 19.1 (95% CI 10.4 to 35.2) for DEPT and 27.1 (95% CI 16.9 to 43.5) for Eyeball triage. Agreement between the two systems was poor (kappa 0.05). CONCLUSION: Agreement between formalised triage and clinical assessment is poor. A simple clinical assessment by phlebotomists is superior to a formalised triage system to predict short-term mortality in ED patients.

[Review of Early Warning Score in preventing sudden critical illness and death].

Early Warning Score (EWS) are used extensively to identify patients at risk of deterioration during hospital admission. The validation of EWS has primarily focused on investigating predictive validity, i.e. the association between EWS and severe adverse events. Few studies have tested, whether EWS work in the clinical setting, and if it prevents severe adverse events from occurring. Many of these studies have methodological limitations, and their clinical relevance could be questioned. Currently, there is limited evidence to support, that the implementation of EWS reduces the occurrence of severe adverse events.