Predicting sepsis at emergency department triage: Implementing clinical and laboratory markers within the first nursing assessment to enhance diagnostic accuracy.

BACKGROUND: Early identification of sepsis in the emergency department (ED) triage is both valuable and challenging. Numerous studies have endeavored to pinpoint clinical and biochemical criteria to assist clinicians in the prompt diagnosis of sepsis, but few studies have assessed the efficacy of these criteria in the ED triage setting. The aim of the study was to explore the accuracy of clinical and laboratory markers evaluated at the triage level in identifying patients with sepsis. METHODS: A prospective study was conducted in a large academic urban hospital, implementing a triage protocol aimed at early identification of septic patients based on clinical and laboratory markers. A multidisciplinary panel of experts reviewed cases to ensure accurate identification of septic patients. Variables analyzed included: Charlson comorbidity index, mean arterial pressure (MAP), partial pressure of carbon dioxide (PetCO2), white cell count, eosinophil count, C-reactive protein to albumin ratio, procalcitonin, and lactate. RESULTS: A total of 235 patients were included. Multivariable analysis identified procalcitonin ≥1 ng/mL (OR 5.2; p < 0.001); CRP-to-albumin ratio ≥32 (OR 6.6; p < 0.001); PetCO2 ≤ 28 mmHg (OR 2.7; p = 0.031), and MAP <85 mmHg (OR 7.5; p < 0.001) as independent predictors for sepsis. MAP ≥85 mmHg, CRP/albumin ratio <32, and procalcitonin <1 ng/mL demonstrated negative predictive values for sepsis of 90%, 89%, and 88%, respectively. CONCLUSIONS: Our study underscores the significance of procalcitonin and mean arterial pressure, while introducing CRP/albumin ratio and PetCO2 as important variables to consider in the very initial assessment of patients with suspected sepsis in the ED. CLINICAL RELEVANCE: Early identification of sepsis since the emergency department (ED) triage is challenging Implementing the ED triage protocol with simple clinical and laboratory markers allows to recognize patients with sepsis with a very good discriminatory power (AUC 0.88).

Tetraparesis and failure of pacemaker capture induced by severe hyperkalemia: case report and systematic review of available literature.

BACKGROUND: In severe hyperkalemia, neurologic symptoms are described more rarely than cardiac manifestations. We report a clinical case; present a systematic review of available literature on secondary hyperkalemic paralysis (SHP); and also discuss pathogenesis, clinical effects, and therapeutic options. CASE REPORT: A 75-year-old woman presented to the emergency department complaining of tetraparesis. Her serum potassium level was 11.4 mEq/L. Electrocardiogram (ECG) showed a pacemaker (PMK)-induced rhythm, with loss of atrial capture and wide QRS complexes. After emergency treatment to restore cell membrane potential threshold and lower serum potassium, neurologic and ECG signs completely disappeared. An acute myocardial infarction subsequently occurred, possibly linked to tachycardia induced by salbutamol therapy. We reviewed 99 articles (119 patients). Mean serum potassium was 8.8 mEq/L. In most cases, ECG showed the presence of tall T waves; loss of PMK atrial capture was documented in 5 patients. In 94 patients, flaccid paralysis was described and in 25, severe muscular weakness; in 65 patients, these findings were associated with other symptoms. Concurrent renal failure was often documented. The most frequent treatments were dialysis and infusion of insulin and glucose. Eighty-seven percent of patients had complete resolution of symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Severe hyperkalemia is always a life-threatening medical emergency, as it can precipitate fatal dysrhythmias and paralysis. SHP should be considered in the differential diagnosis of neurologic signs and symptoms of uncertain etiology, especially in a subject with kidney failure or who is taking medications that may worsen renal function. The presence of a PMK does not necessarily impede hyperkalemic cardiac toxicity.

Early-onset thrombosis of internal jugular vein associated with introducer catheter for heart catheterization in cardiac surgery.

PURPOSE: In cardiac surgery, Swan-Ganz catheter (SGC) is often necessary and is inserted before the intervention through an introducer catheter. Catheter-related thrombosis (CRT) is a frequent complication of this procedure and often remains subclinical. The aims of this prospective cohort study were to determinate the incidence of CRT after positioning an SGC through an introducer and to identify factors relating to their occurrence. METHODS: One-hundred and sixteen cardiac surgery patients underwent ultrasound examination of the thoracic-cervical vessels, before and after introducer catheter removal. Data about drugs infused through the introducer catheter were also collected. RESULTS: The incidence of internal jugular vein CRT was 26.7%, corresponding to 70.5 cases per 1,000 catheter days. The incidence of "fibrin sleeve" was 28.4%. All introducer catheter tips lay in the brachiocephalic vein or in the upper third of the superior vena cava. The incidence of CRT was not associated with duration of the placement of the introducer catheter (average 3.9±2 days) or the SGC (average of 2.4±1.7 days). Infusion of total parenteral nutrition and dextran showed a significantly increased risk of thrombosis in both univariate and multivariate analyses. An overly proximal position of the introducer catheter tip was strongly associated with CRT incidence. CONCLUSIONS: The presence of an introducer catheter for SGC, even for a short time, is associated with a high incidence of early-onset CRT. This incidence is significantly related to the catheter tip being positioned in the brachiocephalic vein and to its use as a central venous access.