Utility of point-of-care synovial lactate to identify septic arthritis in the emergency department.

BACKGROUND: Synovial lactate is a promising biomarker to distinguish septic from aseptic arthritis. If available as a point-of care test, synovial lactate would be rapidly available to aid the emergency provider in clinical decision making. This study assesses the test characteristics of synovial lactate obtained using an EPOC© point-of-care (POC) analyzer to rapidly distinguish septic from aseptic arthritis in the emergency department. METHODS: We enrolled a convenience sample of patients with possible septic arthritis presenting to the emergency department at a large urban academic center between October 2016 and April 2018. Enrolled patients underwent arthrocentesis based on the clinical judgment of the treating provider. We obtained synovial lactate levels (SLL) from the POC device. Standard laboratory analysis, synovial fluid culture, emergency and hospital course, operative procedures, antibiotics, and discharge diagnosis were abstracted from the electronic medical record. RESULTS: Thirty-nine patients undergoing forty separate arthrocentesis procedures were enrolled in this study over the two-year period. The sensitivity and specificity of SLL ≥ 5 mmol/L was 0.55 and 0.76 respectively, with +LR 2.3 and -LR 0.6. The sensitivity and specificity of SLL ≥ 10 mmol/L was 0.27 and 0.97 respectively, with +LR 7.9 and -LR 0.8; SLL ≥ 10 mmol/L performed similarly to overall synovial WBC ≥ 50,000/µL by conventional laboratory testing. CONCLUSION: It is feasible to obtain a synovial lactate level using the EPOC© POC device. In our study, POC SLL performs similarly to other markers used to diagnose septic arthritis. Further study with larger sample sizes is warranted.

Pre-hospital qSOFA as a predictor of sepsis and mortality.

BACKGROUND: The quick sequential organ failure assessment score (qSOFA) has been proposed as a simple tool to identify patients with sepsis who are at risk for poor outcomes. Its utility in the pre-hospital setting has not been fully elucidated. METHODS: This is a retrospective observational study of adult patients arriving by ambulance in September 2016 to an academic emergency department in Fresno, California. The qSOFA score was calculated from pre-hospital vital signs. We investigated its association with sepsis, ED diagnosis of infection, and mortality. RESULTS: Of 2292 adult medical patients transported by ambulance during the study period, the sensitivity of qSOFA for sepsis and in-hospital mortality were 42.9% and 40.6%, respectively. Specificity of qSOFA for sepsis and mortality were 93.8% and 91.9%, respectively. Of those with an ED diagnosis of infection compared to all patients, qSOFA was more specific but less sensitive for sepsis. Increasing qSOFA score was associated with a discharge diagnosis of sepsis (OR 4.21, 95% CI 3.41-5.21, p < 0.001), in-hospital mortality (OR 3.30, 95% CI 2.28-4.78, p < 0.001), and ED diagnosis of infection (OR 1.37, 95% CI 1.18-1.58, p < 0.001). Higher qSOFA score was associated with triage to a higher acuity zone and longer hospital and ICU length of stay, but not up-triage during ED stay. CONCLUSIONS: Pre-hospital qSOFA is specific, but poorly sensitive, for sepsis and sepsis outcomes, especially among patients with an ED diagnosis of infection. Higher qSOFA score was associated with worse outcomes.

Hot and Cold Drugs: National Park Service Medication Stability at the Extremes of Temperature.

STUDY OBJECTIVE: National Park Service (NPS) Parkmedics provide medical care in austere environments. The objective of this study was to evaluate the stability of specific medications used by Parkmedics at extremes of temperatures likely to be faced in the field. METHODS: This is a bench research study conducted in the laboratory setting over a 4-week period. Parenteral medications were separated into 4 temperature exposure groups: A) 45°C (hot); B) -20°C (cold); C) hot then cold temperatures alternating weekly; and D) cold then hot temperatures alternating weekly. At study start and the end of each week, three aliquots from each group were sampled to determine the remaining drug concentration through liquid chromatography-quadrupole time-of-flight mass spectrometry (Agilent LC 1260- QTOF/MS 6550). Quantitative analysis was done using Agilent MassHunter Quantitative Analysis software. The mean drug concentration from triplicate aliquots was expressed as percentage of its baseline concentration to monitor the drug's stability during storage. RESULTS: Eight medications were analyzed (atropine, diphenhydramine, fentanyl, hydromorphone, midazolam, morphine, naloxone, ondansetron). Hydromorphone, morphine, and ondansetron showed the greatest stability, at above 90% of original concentration in all study arms. Diphenhydramine, fentanyl and midazolam showed heat independent degradation, degrading the same way regardless of heat exposure. By the end of the study period, 51-56% midazolam remained in all groups. Atropine and naloxone showed heat dependent degradation, degrading more when exposed to heat. Atropine had the most degradation, being undetectable after 4 weeks of heat exposure. CONCLUSIONS: We recommend that EMS providers replace atropine, naloxone, diphenhydramine, fentanyl, and midazolam frequently if they are practicing in low call volume or high-temperature environments. Further studies will be needed to determine if re-dosing midazolam, naloxone, and atropine is the appropriate clinical strategy in this setting if adequate clinical effect is not reached with a single dose.

Refractory vasodilatory shock secondary to metformin overdose supported with VA ECMO.

Metformin overdose may result in vasodilatory shock, lactic acidosis and death. Hemodialysis is an effective means of extracorporeal elimination, but may be insufficient in the shock setting. We present a case of a 39 yo male who presented with hypotension, coma, hypoglycemia, and lactate of 6.5 mmol/L after ingesting an unknown medication. Metformin overdose was suspected, and he was started on hemodialysis. He developed profound vasoplegia refractory to high doses of norepinephrine, vasopressin, epinephrine and phenylephrine. Venoarterial extracorporeal membrane oxygenation (VA ECMO) was initiated and he had full recovery. Serum analysis with high resolution liquid chromatography mass spectrometry revealed a metformin level of 678 µg/mL and trazodone level of 2.1 µg/mL. This case is one of only a handful of reported cases of metformin overdose requiring ECMO support, and we report the highest serum metformin levels in the literature to date. We recommend early aggressive hemodialysis and vasopressor support in all suspected cases of metformin toxicity as well as VA ECMO if refractory to these therapies. OBJECTIVE: We present a case of vasodilatory shock secondary to metformin overdose requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) support. This case is one of only a handful of reported cases of metformin overdose requiring ECMO support, and we report the highest serum metformin levels in the literature to date. DATA SOURCES: University of San Francisco, Fresno. STUDY DESIGN: Case report. DATA EXTRACTION: Clinical records and high resolution liquid chromatography mass spectroscopy analysis. DATA SYNTHESIS: None. CONCLUSIONS: Venoarterial ECMO provided an effective means of hemodynamic support for a patient with severe metformin toxicity.

Impact of Providing a Tape Measure on the Provision of Lung-protective Ventilation.

INTRODUCTION: Emergency department (ED) patients are frequently ventilated with excessively large tidal volumes for predicted body weight based on height, which has been linked to poorer patient outcomes. We hypothesized that supplying tape measures to respiratory therapists (RT) would improve measurement of actual patient height and adherence to a lung-protective ventilation strategy in an ED-intensive care unit (ICU) environment. METHODS: On January 14, 2019, as part of a ventilator-associated pneumonia prevention bundle in our ED-based ICU, we began providing RTs with tape measures and created a best practice advisory reminding them to record patient height. We then retrospectively collected data on patient height and tidal volumes before and after the intervention. RESULTS: We evaluated 51,404 tidal volume measurements in 1,826 patients over the 4 year study period; of these patients, 1,579 (86.5%) were pre-intervention and 247 (13.5%) were post-intervention. The intervention was associated with a odds of the patient's height being measured were 10 times higher post-intervention (25.1% vs 3.2%, P <0.05). After the bundle was initiated, we observed a significantly higher percentage of patients ventilated with mean tidal volumes less than 8 cubic centimeters per kilogram (93.9% vs 84.5% P < 0.05). CONCLUSION: Patients in an ED-ICU environment were ventilated with a lung-protective strategy more frequently after an intervention reminding RTs to measure actual patient height and providing a tape measure to do so. A significantly higher percentage of patients had height measured rather than estimated after the intervention, allowing for more accurate determination of ideal body weight and calculation of lung-protective ventilation volumes. Measuring all mechanically ventilated patients' height with a tape measure is an example of a simple, low-cost, scalable intervention in line with guidelines developed to improve the quality of care delivered to critically ill ED patients.

Delivery of end-of-life care in an emergency department-based intensive care unit.

OBJECTIVE: Intensive care unit (ICU) admissions near the end of life have been associated with worse quality of life and burdensome costs. Patients may not benefit from ICU admission if appropriate end-of-life care can be delivered elsewhere. The objective of this study was to descriptively analyze patients receiving end-of-life care in an emergency department (ED)-based ICU (ED-ICU). METHODS: This is a retrospective analysis of patient outcomes and resource use in adult patients receiving end-of-life care in an ED-ICU. In 2015, an "End of Life" order set was created to standardize delivery of palliative therapies and comfort measures. We identified adult patients (>18 years) receiving end-of-life care in the ED-ICU from December 2015 to March 2020 whose clinicians used the end-of-life order set. RESULTS: A total of 218 patients were included for analysis; 50.5% were female, and the median age was 73.6 years. The median ED-ICU length of stay was 13.3 hours (interquartile range, 7.4-20.6). Two patients (0.9%) were admitted to an inpatient ICU, 117 (53.7%) died in the ED-ICU, 77 (35.3%) were admitted to a non-intensive care inpatient service, and 22 (10.1%) were discharged from the ED-ICU. CONCLUSIONS: An ED-ICU can be used for ED patients near the end of life. Only 0.9% were subsequently admitted to an ICU, and 10.1% were discharged from the ED-ICU. This practice may benefit patients and families by avoiding costly ICU admissions and benefit health systems by reducing ICU capacity strain.