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ABSTRACT: There are reports of AA amyloidosis associated with intravenous and/or subcutaneous injection of street drugs, such as heroin and cocaine. Most reports describe patients with substance use disorder, renal amyloidosis and concurrent viral infections, such as hepatitis and/or human immunodeficiency virus. Herein, we present a case of systemic AA amyloidosis and sepsis in a 34-year-old woman with a history of intravenous injection of oral prescription medications (as evidenced by excipient lung disease) who had no known history of human immunodeficiency virus nor of hepatitis B or C. Our case shows the broader spectrum of pathology that can occur with the misuse of prescription medications.
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Amiloidosis , Abuso de Sustancias por Vía Intravenosa , Adulto , Amiloidosis/complicaciones , Analgésicos Opioides/efectos adversos , Autopsia , Femenino , Humanos , Inyecciones Intravenosas , Prescripciones , Proteína Amiloide A Sérica , Abuso de Sustancias por Vía Intravenosa/complicacionesRESUMEN
BACKGROUND: More than 640,000 combined in-hospital and out-of-hospital cardiac arrests occur annually in the United States. However, survival rates and meaningful neurologic recovery remain poor. Although "shockable" rhythms (i.e., ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) have the best outcomes, many of these ventricular dysrhythmias fail to return to a perfusing rhythm (resistant VF/VT), or recur shortly after they are resolved (recurrent VF/VT). OBJECTIVE: This review discusses 4 emerging therapies in the emergency department for treating these resistant or recurrent ventricular dysrhythmias: beta-blocker therapy, dual simultaneous external defibrillation, stellate ganglion blockade, and extracorporeal cardiopulmonary resuscitation. We discuss the underlying physiology of each therapy, review relevant literature, describe when these approaches should be considered, and provide evidence-based recommendations for these techniques. DISCUSSION: Esmolol may mitigate some of epinephrine's negative effects when used during resuscitation, improving both postresuscitation cardiac function and long-term survival. Dual simultaneous external defibrillation targets the region of the heart where ventricular fibrillation typically resumes and may apply a more efficient defibrillation across the heart, leading to higher rates of successful defibrillation. Stellate ganglion blocks, recently described in the emergency medicine literature, have been used to treat patients with recurrent VF/VT, resulting in significant dysrhythmia suppression. Finally, extracorporeal cardiopulmonary resuscitation is used to provide cardiopulmonary support while clinicians correct reversible causes of arrest, potentially resulting in improved survival and good neurologic functional outcomes. CONCLUSION: These emerging therapies do not represent standard practice; however, they may be considered in the appropriate clinical scenario when standard therapies are exhausted without success.
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Reanimación Cardiopulmonar , Paro Cardíaco Extrahospitalario , Taquicardia Ventricular , Cardioversión Eléctrica , Humanos , Taquicardia Ventricular/terapia , Fibrilación Ventricular/complicaciones , Fibrilación Ventricular/terapiaRESUMEN
PURPOSE: International clinical practice guidelines call for initial volume resuscitation of at least 30 mL/kg body weight for patients with sepsis-induced hypotension or shock. Although not considered in the guidelines, preexisting cardiac dysfunction may be an important factor clinicians weigh in deciding the quantity of volume resuscitation for patients with septic shock. METHODS: We conducted a multicenter survey of clinicians who routinely treat patients with sepsis to evaluate their beliefs, behaviors, knowledge, and perceived structural barriers regarding initial volume resuscitation for patients with sepsis and concomitant heart failure with reduced ejection fraction (HFrEF) <40%. Initial volume resuscitation preferences were captured as ordinal values, and additional testing for volume resuscitation preferences was performed using McNemar and Wilcoxon signed rank tests as indicated. Univariable logistic regression models were used to identify significant predictors of ≥30 mL/kg fluid administration. RESULTS: A total of 317 clinicians at 9 US hospitals completed the survey (response rate 47.3%). Most respondents were specialists in either internal medicine or emergency medicine. Substantial heterogeneity was found regarding sepsis resuscitation preferences for patients with concomitant HFrEF. The belief that patients with septic shock and HFrEF should be exempt from current sepsis bundle initiatives was shared by 39.4% of respondents. A minimum fluid challenge of â¼30 mL/kg or more was deemed appropriate in septic shock by only 56.4% of respondents for patients with concomitant HFrEF, compared to 89.1% of respondents for patients without HFrEF (P < .01). Emergency medicine physicians were most likely to feel that <30 mL/kg was most appropriate in patients with septic shock and HFrEF. CONCLUSIONS: Clinical equipoise exists regarding initial volume resuscitation for patients with sepsis-induced hypotension or shock and concomitant HFrEF. Future studies and clinical practice guidelines should explicitly address resuscitation in this subpopulation.
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Insuficiencia Cardíaca , Sepsis , Choque Séptico , Fluidoterapia , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/terapia , Humanos , Resucitación , Sepsis/complicaciones , Sepsis/terapia , Choque Séptico/tratamiento farmacológico , Choque Séptico/terapia , Volumen Sistólico , Encuestas y Cuestionarios , Equipoise TerapéuticoRESUMEN
OBJECTIVES: A recently published simulation study suggested that women are inferior leaders of cardiopulmonary resuscitation efforts. The aim of this study was to compare female and male code leaders in regard to cardiopulmonary resuscitation outcomes in a real-world clinical setting. DESIGN: Retrospective cohort review. SETTING: Two academic, urban hospitals in San Diego, California. SUBJECTS: One-thousand eighty-two adult inpatients who suffered cardiac arrest and underwent cardiopulmonary resuscitation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed whether physician code leader gender was independently associated with sustained return of spontaneous circulation and survival to discharge and with markers of quality cardiopulmonary resuscitation. Of all arrests, 327 (30.1%) were run by female physician code leaders with 251 (76.8%) obtaining return of spontaneous circulation, and 122 (37.3%) surviving to discharge. Male physicians ran 757 codes obtaining return of spontaneous circulation in 543 (71.7%) with 226 (29.9%) surviving to discharge. When adjusting for variables, female physician code leader gender was independently associated with a higher likelihood of return of spontaneous circulation (odds ratio, 1.36; 95% CI, 1.01-1.85; p = 0.049) and survival to discharge (odds ratio, 1.53; 95% CI, 1.15-2.02; p < 0.01). Additionally, the odds ratio for survival to discharge was 1.62 (95% CI, 1.13-2.34; p < 0.01) for female physicians with a female code nurse when compared with male physician code leaders paired with a female code nurse. Gender of code leader was not associated with cardiopulmonary resuscitation quality. CONCLUSIONS: In contrast to data derived from a simulated setting with medical students, real life female physician leadership of cardiopulmonary resuscitation is not associated with inferior outcomes. Appropriately, trained physicians can lead high-quality cardiopulmonary resuscitation irrespective of gender.
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Reanimación Cardiopulmonar , Paro Cardíaco/terapia , Liderazgo , Médicos Mujeres , California , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
BACKGROUND: Post-resuscitation hemodynamic instability following out-of-hospital cardiac arrest (OHCA) may occur from myocardial dysfunction underlying cardiogenic shock and/or inflammation-mediated distributive shock. Distinguishing the predominant shock subtype with widely available clinical metrics may have prognostic and therapeutic value. METHODS: A two-hospital cohort was assembled of patients in shock following OHCA. Left ventricular ejection fraction (LVEF) was assessed via echocardiography or cardiac ventriculography within 1 day post arrest and used to delineate shock physiology. The study evaluated whether higher LVEF, indicating distributive-predominant shock physiology, was associated with neurocognitive outcome (primary endpoint), survival, and duration of multiple organ failures. The study also investigated whether volume resuscitation exhibited a subtype-specific association with outcome. RESULTS: Of 162 patients with post-resuscitation shock, 48% had normal LVEF (> 40%), consistent with distributive shock physiology. Higher LVEF was associated with less favorable neurocognitive outcome (OR 0.74, 95% CI 0.58-0.94 per 10% increase in LVEF; p = 0.01). Higher LVEF also was associated with worse survival (OR 0.81, 95% CI 0.67-0.97; p = 0.02) and fewer organ failure-free days (ß = - 0.67, 95% CI - 1.28 to - 0.06; p = 0.03). Only 51% of patients received a volume challenge of at least 30 ml/kg body weight in the first 6 h post arrest, and the volume received did not differ by LVEF. Greater volume resuscitation in the first 6 h post arrest was associated with favorable neurocognitive outcome (OR 1.59, 95% CI 0.99-2.55 per liter; p = 0.03) and survival (OR 1.44, 95% CI 1.02-2.04; p = 0.02) among patients with normal LVEF but not low LVEF. CONCLUSIONS: In post-resuscitation shock, higher LVEF-indicating distributive shock physiology-was associated with less favorable neurocognitive outcome, fewer days without organ failure, and higher mortality. Greater early volume resuscitation was associated with more favorable neurocognitive outcome and survival in patients with this shock subtype. Additional studies with repeated measures of complementary hemodynamic parameters are warranted to validate the clinical utility for subtyping post-resuscitation shock.
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Paro Cardíaco Extrahospitalario/complicaciones , Choque/clasificación , Volumen Sistólico/fisiología , APACHE , Anciano , Electrocardiografía/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Resucitación/métodos , Choque/diagnóstico , Resultado del Tratamiento , Función Ventricular Izquierda/fisiologíaRESUMEN
RATIONALE: Neurocognitive outcome after out-of-hospital cardiac arrest (OHCA) is often poor, even when initial resuscitation succeeds. Lower tidal volumes (Vts) attenuate extrapulmonary organ injury in other disease states and are neuroprotective in preclinical models of critical illness. OBJECTIVE: To evaluate the association between Vt and neurocognitive outcome after OHCA. METHODS: We performed a propensity-adjusted analysis of a two-center retrospective cohort of patients experiencing OHCA who received mechanical ventilation for at least the first 48 hours of hospitalization. Vt was calculated as the time-weighted average over the first 48 hours, in milliliters per kilogram of predicted body weight (PBW). The primary endpoint was favorable neurocognitive outcome (cerebral performance category of 1 or 2) at discharge. MEASUREMENTS AND MAIN RESULTS: Of 256 included patients, 38% received time-weighted average Vt greater than 8 ml/kg PBW during the first 48 hours. Lower Vt was independently associated with favorable neurocognitive outcome in propensity-adjusted analysis (odds ratio, 1.61; 95% confidence interval [CI], 1.13-2.28 per 1-ml/kg PBW decrease in Vt; P = 0.008). This finding was robust to several sensitivity analyses. Lower Vt also was associated with more ventilator-free days (ß = 1.78; 95% CI, 0.39-3.16 per 1-ml/kg PBW decrease; P = 0.012) and shock-free days (ß = 1.31; 95% CI, 0.10-2.51; P = 0.034). Vt was not associated with hypercapnia (P = 1.00). Although the propensity score incorporated several biologically relevant covariates, only height, weight, and admitting hospital were independent predictors of Vt less than or equal to 8 ml/kg PBW. CONCLUSIONS: Lower Vt after OHCA is independently associated with favorable neurocognitive outcome, more ventilator-free days, and more shock-free days. These findings suggest a role for low-Vt ventilation after cardiac arrest.
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Lesiones Encefálicas/etiología , Lesión Pulmonar/etiología , Paro Cardíaco Extrahospitalario/terapia , Respiración Artificial/métodos , Volumen de Ventilación Pulmonar , Anciano , Femenino , Humanos , Lesión Pulmonar/fisiopatología , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/complicaciones , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Efforts to reduce preventable deaths in the in-hospital setting should target both cardiopulmonary arrest (CPA) prevention and optimal resuscitation. This requires consideration of a broad range of clinical issues and processes. A comprehensive, integrated system of care (SOC) that links data collection with a modular education program to reduce preventable deaths has not been defined. METHODS: This study was conducted in two urban university hospitals from 2005 to 2009. The Advanced Resuscitation Training (ART) program was implemented in 2007, incorporating hands-on resuscitative skills and in-hospital-specific training with an institutional resuscitation database. Linkage between the database and training modules occurs via the ART Matrix, which classifies all CPA events into the following etiologies: sepsis, hemorrhage, pulmonary embolus, heart failure, tachyarrhythmias, bradyarrhythmias, acute respiratory distress syndrome, non-intubated pulmonary disease, obstructive apnea, traumatic brain injury, ischemic brain injury, and intracranial mass lesions. This taxonomy was validated using descriptive statistics, before-and-after analysis evaluating CPA incidence, and multivariate logistic regression to predict CPA survival. RESULTS: A total of 336 inpatients suffered a cardiopulmonary arrest during the study period-187 in the pre-ART period and 149 in the post-ART period. The vast majority of CPA events were categorized using the ART Matrix with high inter-observer reliability. As anticipated, changes in CPA incidence and survival were observed for some Matrix categories but not others following ART implementation. In addition, multivariate logistic regression revealed strong independent associations between taxonomy classifications and outcome. CONCLUSION: A novel SOC using a unique taxonomy for arrest classification appears to be effective at reducing inpatient CPA incidence and outcome.
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Reanimación Cardiopulmonar/métodos , Paro Cardíaco/terapia , Mortalidad Hospitalaria/tendencias , Hospitales Universitarios/organización & administración , Mejoramiento de la Calidad/organización & administración , Anciano , Protocolos Clínicos/normas , Femenino , Paro Cardíaco/clasificación , Paro Cardíaco/etiología , Equipo Hospitalario de Respuesta Rápida/organización & administración , Hospitales Universitarios/normas , Humanos , Capacitación en Servicio/organización & administración , Modelos Logísticos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Estudios Prospectivos , Mejoramiento de la Calidad/normas , Reproducibilidad de los Resultados , Gestión de la Calidad Total/organización & administraciónAsunto(s)
Síndrome de Dificultad Respiratoria , Enfermedad Crítica , Disnea , Humanos , Presión , Respiración ArtificialRESUMEN
OBJECTIVES: Healthcare ransomware cyberattacks have been associated with major regional hospital disruptions, but data reporting patient-oriented outcomes in critical conditions such as cardiac arrest (CA) are limited. This study examined the CA incidence and outcomes of untargeted hospitals adjacent to a ransomware-infected healthcare delivery organization (HDO). DESIGN SETTING AND PATIENTS: This cohort study compared the CA incidence and outcomes of two untargeted academic hospitals adjacent to an HDO under a ransomware cyberattack during the pre-attack (April 3-30, 2021), attack (May 1-28, 2021), and post-attack (May 29, 2021-June 25, 2021) phases. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Emergency department and hospital mean daily census, number of CAs, mean daily CA incidence per 1,000 admissions, return of spontaneous circulation, survival to discharge, and survival with favorable neurologic outcome were measured. The study evaluated 78 total CAs: 44 out-of-hospital CAs (OHCAs) and 34 in-hospital CAs. The number of total CAs increased from the pre-attack to attack phase (21 vs. 38; p = 0.03), followed by a decrease in the post-attack phase (38 vs. 19; p = 0.01). The number of total CAs exceeded the cyberattack month forecast (May 2021: 41 observed vs. 27 forecasted cases; 95% CI, 17.0-37.4). OHCA cases also exceeded the forecast (May 2021: 24 observed vs. 12 forecasted cases; 95% CI, 6.0-18.8). Survival with favorable neurologic outcome rates for all CAs decreased, driven by increases in OHCA mortality: survival with favorable neurologic rates for OHCAs decreased from the pre-attack phase to attack phase (40.0% vs. 4.5%; p = 0.02) followed by an increase in the post-attack phase (4.5% vs. 41.2%; p = 0.01). CONCLUSIONS: Untargeted hospitals adjacent to ransomware-infected HDOs may see worse outcomes for patients suffering from OHCA. These findings highlight the critical need for cybersecurity disaster planning and resiliency.
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Aim of the study: Overactivation of the parasympathetic nervous system can lead to reflex syncope (RS) and, in extreme cases, trigger an unusual and underrecognized form of cardiac arrest. We characterized the epidemiology and prognosis of reflex-mediated cardiac arrest (RMCA) and hypothesized it is associated with intervenable patient factors. Methods: This retrospective case-control study examined RMCAs at two academic hospitals from 1/2016 to 6/2022 using a resuscitation quality improvement database. RMCA cases were identified as cardiac arrests preceded by vagal trigger(s). Cases of RS, defined as syncope with bradycardia and hypotension preceded by vagal trigger(s), between 1/2021 and 12/2021 were used as controls. For the secondary analysis, RMCA outcomes were compared to in-hospital cardiac arrest (IHCA) of other causes. Results: We identified 46 RMCA and 67 RS cases. Compared to RS patients, RMCA patients were more likely to have spinal cord injury (13.0% vs 1.5%, p = 0.02). Airway clearance i.e., coughing and suctioning triggered a higher proportion of RMCA events than RS events (23.9% vs 3.0%, p < 0.01). Compared to 1,021 IHCAs of other causes, RMCAs had 100% return of spontaneous circulation, were more likely to survive to discharge (84.8% vs 36.2%, p < 0.001) and have favorable neurological outcomes (cerebral performance category 1 or 2, 58.7% vs 26.9%, p < 0.001). Conclusions: RMCA has a favorable prognosis compared to other IHCAs and is potentially preventable. Spinal cord injury and airway clearance were patient factors significantly associated with RMCA.
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Over the past 20 years, despite significant advancements in pulmonary arterial hypertension (PAH) medical therapy, many patients require admission to the hospital and are at risk for in-hospital cardiac arrest (IHCA). Prior data found poor survival in PAH patients after cardiac arrest. The purpose of this study was to explore post-IHCA outcomes in PAH patients receiving advanced medical therapies. This is a single-center retrospective study of PAH patients who underwent cardiopulmonary resuscitation for IHCA between July 2005 and May 2021. Patients were identified through an internal cardiac arrest database. Twenty six patients were included. Half of the cohort had idiopathic PAH, with 54% of patients on combination therapy, 27% on monotherapy, and 19% of patients on no therapy. Mean right atrial pressure, mean pulmonary artery pressure, cardiac index, and pulmonary vascular resistance were 13 ± 6 mmHg, 57 ± 13 mmHg, 2.0 ± 0.7 L/min/m2, and 14.5 ± 7.6 Wood units, respectively. Most common etiology of cardiac arrest was circulatory collapse. Initial arrest rhythm in all but one patient was pulseless electrical activity. Six patients (23%) achieved return of spontaneous circulation (ROSC) and one patient (4%) survived to hospital discharge. Rates of ROSC and survival to discharge after IHCA are poor in patients with PAH. Even patients with mild hemodynamics had low likelihood of survival. In patients who are lung transplant candidates, there should be early consideration of extracorporeal support before cardiac arrest.
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INTRODUCTION: A nurse-triggered sepsis alert called "Code Sepsis" was implemented for early recognition and management of sepsis. The researchers analyzed its impact on antimicrobial use and identified factors associated with infection as source of Code Sepsis. METHODS: The medical records of hospitalized patients with Code Sepsis between January 1 and June 30, 2018, were reviewed. Patients were classified as "Infection" when probable or definitive infection was identified or "No Infection" when a probable or definitive noninfectious source was identified. Patients were categorized as "Escalation" with addition or change to broader-spectrum antimicrobials or "No Escalation" with no change or change to narrower-spectrum antimicrobials. Escalation was classified as "Indicated" with appropriate escalation or "Not Indicated" with inappropriate escalation. Logistic regression model was used to identify factors associated with Infection as Code Sepsis trigger. RESULTS: Code Sepsis was activated in 529 patients, with Escalation in 246 (46.5%) and No Escalation in 283 (53.5%) patients. Escalation was Indicated in 157 (63.8%) and Not Indicated in 89 (36.2%) patients. Infection was identified in 356 (67.3%) and No Infection in 173 (32.7%) patients. History of HIV (odds ratio [OR]â¯=â¯2.75, pâ¯=â¯0.03), temperature > 38.3°C or < 36°C (ORâ¯=â¯2.63, p < 0.01), and respiratory rate > 20/minute (ORâ¯=â¯1.56, pâ¯=â¯0.02) were associated with Infection, while surgery within 3 days (ORâ¯=â¯0.30, p < 0.01) was associated with No Infection. CONCLUSION: One hospital system's Code Sepsis inadvertently identified patients without infections and led to antimicrobial overuse. By refocusing Code Sepsis on early recognition of severe sepsis and septic shock only, the organization hopes to optimize resource utilization and improve patient outcomes.
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Sepsis , Choque Séptico , Antibacterianos/uso terapéutico , Humanos , Pacientes Internos , Modelos Logísticos , Sepsis/diagnóstico , Sepsis/tratamiento farmacológicoRESUMEN
BACKGROUND: Neurological status at hospital discharge is routinely used to assess patient outcome after cardiac arrest. However, attribution of impairment to the arrest is valid only if baseline neurological status is known. This study evaluated whether incorporating baseline neurological status improves performance of a widely employed neurological outcome scale for quantifying arrest-attributable morbidity. METHODS: Retrospective cohort study of two U.S. hospitals. Neurological function was assessed via Cerebral performance category (CPC), an ordinal five-point scale with 1 indicating sufficient cognition to lead an independent life and 5 representing brain death. Hospitalized adult patients who suffered in-hospital cardiac arrest for which cardiopulmonary resuscitation was attempted between 2011-2015 were included. Patients were identified through a quality improvement registry that captures all inpatient arrests in the two hospitals. RESULTS: Of 486 patients who suffered in-hospital cardiac arrest, 124 (25.5%) had baseline abnormal neurological function (pre-hospitalization CPC>1). Although 54 patients had a normal discharge CPC of 1, 80 patients had no change in CPC from their prior baseline (11.1% vs. 16.5% met criterion for "normal" outcome defined as CPC of 1 vs. change-in-CPC of 0; McNemar pâ¯<â¯.01; kappa for agreement: .78, 95% CI .69-.86). Across several formulations of criteria for "good" neurological outcome, similar discordance existed between conventional definitions considering only discharge CPC and modified definitions that included change-in-CPC from baseline. CONCLUSIONS: Incorporating change-in-CPC into criteria for "good" neurological outcome post-arrest yields discordant results from traditional approaches that consider discharge CPC only and increases face validity of reporting arrest-related morbidity.
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Reanimación Cardiopulmonar , Pruebas Diagnósticas de Rutina , Paro Cardíaco/terapia , Vida Independiente , Enfermedades del Sistema Nervioso , Examen Neurológico , Pruebas Neuropsicológicas , Anciano , Reanimación Cardiopulmonar/efectos adversos , Reanimación Cardiopulmonar/métodos , Ensayos Clínicos como Asunto , Pruebas Diagnósticas de Rutina/métodos , Pruebas Diagnósticas de Rutina/normas , Pruebas Diagnósticas de Rutina/estadística & datos numéricos , Femenino , Humanos , Masculino , Enfermedades del Sistema Nervioso/diagnóstico , Enfermedades del Sistema Nervioso/etiología , Evaluación de Procesos y Resultados en Atención de Salud/métodos , Evaluación de Procesos y Resultados en Atención de Salud/normas , Alta del Paciente/estadística & datos numéricos , Mejoramiento de la Calidad , Estados UnidosRESUMEN
BACKGROUND: Patients with severe sepsis generally respond well to initial therapy administered in the emergency department (ED), but a subset later decompensate and require unexpected transfer to the intensive care unit (ICU). This study aimed to identify clinical factors that can predict patients at increased risk for delayed transfer to the ICU and the association of delayed ICU transfer with mortality. METHODS: This is a nested case-control study in a prospectively collected registry of patients with severe sepsis and septic shock at two EDs. Cases had severe sepsis and unexpected ICU transfer within 48 h of admission from the ED; controls had severe sepsis but remained in a non-ICU level of care. Univariate and multivariate regression analyses were used to identify predictors of unexpected transfer to the ICU, which was the primary outcome. Differences in mortality between these two groups as well as a cohort of patients directly admitted to the ICU were also calculated. RESULTS: Of the 914 patients in our registry, 358 patients with severe sepsis were admitted from the ED to non-ICU level of care; 84 (23.5%) had unexpected ICU transfer within 48 h. Demographics and baseline co-morbidity burden were similar for patients requiring versus not requiring delayed ICU transfer. In unadjusted analysis, lactate ≥4 mmol/L and infection site were significantly associated with unexpected ICU upgrade. In forward selection multivariate logistic regression analysis, lactate ≥4 mmol/L (OR 2.0, 95% CI 1.03, 3.73; p = 0.041) and night (5 PM to 7 AM) admission (OR 1.9, 95% CI 1.07, 3.33; p = 0.029) were independent predictors of unexpected ICU transfer. Mortality of patients who were not upgraded to the ICU was 8.0%. Patients with unexpected ICU upgrade had similar mortality (25.0%) to those patients with severe sepsis/septic shock (24.6%) who were initially admitted to the ICU, despite less severe indices of illness at presentation. CONCLUSIONS: Serum lactate ≥4 mmol/L and nighttime admissions are associated with unexpected ICU transfer in patients with severe sepsis. Mortality among patients with delayed ICU upgrade was similar to that for patients initially admitted directly to the ICU.
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BACKGROUND: Inpatient peri-intubation cardiac arrest (PICA) following emergent endotracheal intubation (ETI) is an uncommon but potentially preventable type of cardiac arrest (CA). Limited published data exist describing factors associated with inpatient PICA and patient outcomes. This study identifies risk factors associated with PICA among hospitalized patients emergently intubated out of the operating room and compares PICA to other types of inpatient CA. METHODS: Retrospective case-control study of patients at our institution over a five-year period. Cases were defined as inpatients emergently intubated outside of the operating room that experienced cardiac arrest within 20min after ETI. The control group consisted of inpatients emergently intubated out of the operating room without CA. Predictors of PICA were identified through univariate and multivariate analysis. Clinical outcomes were compared between PICA and other inpatient CAs, identified through a prospectively enrolled CA registry at our institution. RESULTS: 29 episodes of PICA occurred over 5 years, accounting for 5% of all inpatient arrests. Shock index ≥1.0, intubation within one hour of nursing shift change, and use of succinylcholine were independently associated with PICA. Sustained ROSC, survival to discharge, and neurocognitive outcome did not differ significantly between groups. CONCLUSION: Patients outcomes following PICA were comparable to other causes of inpatient CA. Potentially modifiable factors were associated with PICA. Hemodynamic resuscitation, optimized staffing strategies, and possible avoidance of succinylcholine were associated with decreased risk of PICA. Clinical trials testing targeted strategies to optimize peri-intubation care are needed to identify effective interventions to prevent this potentially avoidable type of CA.