Cardiac index measurements by transcutaneous Doppler ultrasound and transthoracic echocardiography in adult and pediatric emergency patients.

INTRODUCTION: Non-invasive hemodynamic monitoring may facilitate resuscitation in critically ill patients. Validation studies examining a transcutaneous Doppler ultrasound technology, USCOM-1A, using pulmonary artery catheter as the reference standard showed varying results. In this study, we compared non-invasive cardiac index (CI) measurements by USCOM-1A with transthoracic echocardiography (TTE). METHODS: This study was a prospective, observational cohort study at a university tertiary-care emergency department, enrolling a convenience sample of adult and pediatric patients. Paired measures of CI, stroke volume index (SVI), aortic outflow tract diameter (OTD), velocity time integral (VTI) were obtained using USCOM-1A and TTE. Pearson's correlation and Bland-Altman analyses were performed. RESULTS: One-hundred and sixteen subjects were enrolled, with obtainable USCOM-1A CI measurements for 99 subjects (55 adults age 50 +/- 20 years and 44 children age 11 +/- 4 years) in the final analysis. Cardiac, gastrointestinal and infectious illnesses were the most common presenting diagnostic categories. The reference standard TTE measurements of CI, SVI, OTD, and VTI in all subjects were 3.08 +/- 1.18 L/min/m(2), 37.10 +/- 10.91 mL/m(2), 1.92 +/- 0.36 cm, and 20.36 +/- 4.53 cm, respectively. Intra-operator reliability of USCOM-1A CI measurements showed a correlation coefficient of r = 0.79, with 11 +/- 22% difference between repeated measures. The bias and limits of agreement of USCOM-1A compared to TTE CI were 0.58 (-1.48 to 2.63) L/min/m(2). The percent difference in CI measurements with USCOM-1A was 31 +/- 28% relative to TTE measurements. CONCLUSIONS: The USCOM-1A hemodynamic monitoring technology showed poor correlation and agreement to standard transthoracic echocardiography measures of cardiac function. The utility of USCOM-1A in the management of critically ill patients remains to be determined.

Standardization of severe sepsis management: a survey of methodologies in academic and community settings.

BACKGROUND: Evidence-based therapies for severe sepsis include early antibiotics, early goal-directed therapy, corticosteroids, recombinant human activated protein C, glucose control, and lung protective strategies. OBJECTIVE: The objective of this study was to analyze methods, challenges, and outcomes observed by hospitals that implemented a hospital-wide sepsis management protocol incorporating evidence-based therapies. METHODS: In a cross-sectional multi-center telephone survey over a 4-month period, clinicians (participants) responsible for developing a hospital sepsis protocol were questioned regarding its development and outcomes. RESULTS: Participants completing surveys represented 40 hospitals (20 academic and 20 community). Twenty-seven percent of protocol champions were Emergency physicians or nurses. Sixty-three percent reported protocol development time of 6-12 months. Eighty-eight percent of participants reported protocol initiation in the Emergency Department. Three participants reported hiring a nurse educator to implement the protocol. Ninety-five percent of participants measure lactate as part of patient screening. Protocol therapies reported included early antibiotics (98%), early goal directed-therapy (EGDT) (98%), corticosteroids (80%), and activated protein C (73%). Contributions to success included having a protocol champion (85%) and sepsis education program (65%). Twenty-one participants had recorded patient-level data, totaling 2319 protocol patients, compared to 1719 non-protocol patients, with in-hospital mortality of 23% and 44%, respectively. CONCLUSIONS: Implementation of a sepsis management protocol incorporating evidence-based therapies can be accomplished in both academic and community hospitals, with minimal additional staffing. The presence of a protocol champion and education program is crucial to success, and may result in improved patient outcome.

Mortality predictions using current physiologic scoring systems in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle.

Physiologic scoring systems are often used to prognosticate mortality in critically ill patients. This study examined the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II, Mortality in Emergency Department Sepsis (MEDS), and Mortality Probability Models (MPM) II0 in predicting in-hospital mortality of patients in the emergency department meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. The discrimination and calibration characteristics of APACHE II, SAPS II, MEDS, and MPM II0 were evaluated. Data are presented as median and quartiles (25th, 75th). Two-hundred forty-six patients aged 68 (52, 81) years were analyzed from a prospectively maintained sepsis registry, with 76.0% of patients in septic shock, 45.5% blood culture positive, and 35.0% in-hospital mortality. Acute Physiology and Chronic Health Evaluation II, SAPS II, and MEDS scores were 29 (21, 37), 54 (40, 70), and 13 (11, 16), with predicted mortalities of 64% (40%, 85%), 58% (25%, 84%), and 16% (9%, 39%), respectively. Mortality Probability Models II0 showed a predicted mortality of 60% (27%, 80%). The area under the receiver operating characteristic curves was 0.73 for APACHE II, 0.71 for SAPS II, 0.60 for MEDS, and 0.72 for MPM II0. The standardized mortality ratios were 0.59, 0.63, 1.68, and 0.64, respectively. Thus, APACHE II, SAPS II, MEDS, and MPM II0 have variable abilities to discriminate early and estimate in-hospital mortality of patients presenting to the emergency department requiring the severe sepsis resuscitation bundle. Adoption of these prognostication tools in this setting may influence therapy and resource use for these patients.

The utility of a quality improvement bundle in bridging the gap between research and standard care in the management of severe sepsis and septic shock in the emergency department.

The research in the management of severe sepsis and septic shock has resulted in a number of therapeutic strategies with significant survival benefits. These results also emphasize the primary importance of early hemodynamic resuscitation, or early goal-directed therapy (EGDT), and place the emergency physician in the center of the multidisciplinary team caring for patients with this disease. However, in a busy emergency department, the translation of research into clinical practice is far from ideal. While the benefits are significant, the successful implementation of EGDT is filled with challenges and obstacles. In this article, we will discuss the steps taken at our institution to create, implement, measure, and improve on a six-hour severe sepsis and septic shock treatment bundle incorporating EGDT in the emergency department setting, resulting in significant mortality benefit.

Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality.

OBJECTIVE: The purpose of this study was to examine the outcome implications of implementing a severe sepsis bundle in an emergency department as a quality indicator set with feedback to modify physician behavior related to the early management of severe sepsis and septic shock. DESIGN: Two-year prospective observational cohort. SETTING: Academic tertiary care facility. PATIENTS: Patients were 330 patients presenting to the emergency department who met criteria for severe sepsis or septic shock. INTERVENTIONS: Five quality indicators comprised the bundle for severe sepsis management in the emergency department: a) initiate central venous pressure (CVP)/central venous oxygen saturation (Scvo2) monitoring within 2 hrs; b) give broad-spectrum antibiotics within 4 hrs; c) complete early goal-directed therapy at 6 hrs; d) give corticosteroid if the patient is on vasopressor or if adrenal insufficiency is suspected; and e) monitor for lactate clearance. MEASUREMENTS AND MAIN RESULTS: Patients had a mean age of 63.8 +/- 18.5 yrs, Acute Physiology and Chronic Health Evaluation II score 29.6 +/- 10.6, emergency department length of stay 8.5 +/- 4.4 hrs, hospital length of stay 11.3 +/- 12.9 days, and in-hospital mortality 35.2%. Bundle compliance increased from zero to 51.2% at the end of the study period. During the emergency department stay, patients with the bundle completed received more CVP/Scvo2 monitoring (100.0 vs. 64.8%, p < .01), more antibiotics (100.0 vs. 89.7%, p = .04), and more corticosteroid (29.9 vs. 16.2%, p = .01) compared with patients with the bundle not completed. In a multivariate regression analysis including the five quality indicators, completion of early goal-directed therapy was significantly associated with decreased mortality (odds ratio, 0.36; 95% confidence interval, 0.17-0.79; p = .01). In-hospital mortality was less in patients with the bundle completed compared with patients with the bundle not completed (20.8 vs. 39.5%, p < .01). CONCLUSIONS: Implementation of a severe sepsis bundle using a quality improvement feedback to modify physician behavior in the emergency department setting was feasible and was associated with decreased in-hospital mortality.

Interrater reliability of cardiac output measurements by transcutaneous Doppler ultrasound: implications for noninvasive hemodynamic monitoring in the ED.

INTRODUCTION: Hemodynamic monitoring is an important aspect of caring for the critically ill patients boarding in the emergency department (ED). The purpose of this study is to investigate the interrater agreement of noninvasive cardiac output measurements using transcutaneous Doppler ultrasound technique. METHODS: This is a prospective observational cohort study performed in a 32-bed adult ED of an academic tertiary center with approximately 65000 annual patient visits. Patients were enrolled after verbal consent over a 7-month period. The raters were ED personnel involved in patient care. Paired measurements of cardiac index (CI) and stroke volume index (SVI) were obtained from a transcutaneous Doppler ultrasound cardiac output monitor. RESULTS: A convenience sample of 107 (50 women and 57 men) patients with a median age of 49 (32, 62) years was enrolled. One hundred two paired measurements were performed in 91 patients in whom adequate Doppler ultrasound signals were obtainable. The raters included 35 emergency medicine attending physicians, 31 emergency medicine residents, 80 medical students, 47 nurses, and 11 emergency medical technicians. Cardiac index range was 0.6 to 5.3 L/min per square meter, and SVI range was 7.7 to 63.0 mL/m(2). The correlation of CI measurements between 2 raters was good (r(2) = 0.87; 95% confidence interval, 0.86-1.00; P < .001). Likewise, SVI measurements between 2 raters also showed acceptable correlation (r(2) = 0.84; 95% confidence interval, 0.81-0.96; P < .001). Interrater reliability was strong for CI (kappa = 0.83 with 92.2% agreement) and SVI measurements (kappa = 0.72 with 88.2% agreement). Most patients had an interrater difference below 10% in CI and SVI measurements. CONCLUSIONS: Emergency department personnel, regardless of their role in patient care, are able to obtain reliable cardiac output measurements in ED patients over a wide range of CI and SVI. Transcutaneous Doppler ultrasound technique may be an alternative to traditional invasive hemodynamic monitoring of critically ill patients presenting to the ED.

Early goal-directed therapy, corticosteroid, and recombinant human activated protein C for the treatment of severe sepsis and septic shock in the emergency department.

OBJECTIVES: To describe our experience with early goal-directed therapy (EGDT), corticosteroid administration, and recombinant human activated protein C (rhAPC) administration in patients with severe sepsis or septic shock and an Acute Physiology and Chronic Health Evaluation (APACHE) II score > or =25 in the emergency department (ED). METHODS: This was a retrospective case series of a prospectively maintained ED sepsis registry. Data are presented as median (25th, 75th percentile). The setting was an academic tertiary ED with approximately 60,000 annual patient visits. Patients with severe sepsis or septic shock and an APACHE II score > or =25 entered in an ED sepsis registry over a four-month period were included. Patients who received rhAPC in the intensive care unit were excluded. Central venous catheterization for central venous pressure and central venous oxygen saturation monitoring, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, inotropes, corticosteroids, and rhAPC were initiated by the emergency physicians and continued in the intensive care unit by intensivists. RESULTS: Twenty-four patients were enrolled. Patient characteristics were as follows: age, 79.5 (68.0, 83.5) years; APACHE II score, 31.5 (29.8, 36.0); ED length of stay, 6.5 (4.0, 10.5) hours; predicted mortality, 76.7% (71.9, 86.4); and in-hospital mortality, 45.8%. All patients received broad-spectrum antibiotics, 54.2% completed EGDT, 33.3% received corticosteroids, and 33.3% received rhAPC. Time of antibiotic administration was 1.5 (1.0, 2.0) hours, time of central venous pressure/central venous oxygen saturation monitoring was 1.0 (0.5, 2.5) hour, and time of rhAPC administration was 9.5 (6.8, 10.5) hours after patients met criteria for severe sepsis or septic shock. In-hospital mortality of patients who received rhAPC in addition to other therapies was 25.0%. CONCLUSIONS: EGDT, corticosteroid administration, and rhAPC administration are feasible in the ED setting. While these evidence-based therapies individually have been shown to improve outcomes for patients with severe sepsis or septic shock, further studies are needed to examine their combined effectiveness during the early stages of this disease.

Procedural sedation use in the ED: management of pediatric ear and nose foreign bodies.

This is the first report of which we are aware that describes the use of procedural sedation for the emergency department management of ear and nose foreign bodies in children < 18 years of age. During a 5.5-year period, we identified 312 cases of children with a foreign body in a single orifice (174 ear, 138 nose). Procedural sedation was performed in 23% of cases (43 ear, 28 nose) and ketamine was used most commonly (92%). Emergency physicians had a high rate of success in removing foreign bodies (84% ear, 95% nose) and a low complication rate. Procedural sedation had a positive effect on the success rate as more than half of the sedation cases had undergone failed attempts without sedation by the same physician. Emergency physicians should have familiarity with this indication for procedural sedation.

Investigation of afebrile neonates with a history of fever.

OBJECTIVE: Our objective was to describe clinically significant infections in a cohort of afebrile neonates who underwent an emergency department (ED) septic workup because of the history of a measured fever at home. METHODS: Retrospective medical record review of all infants (3/4)28 days of age who presented to our tertiary care pediatric ED between Jan. 1, 1999, and Aug. 22, 2002, underwent lumbar puncture in the ED, had a reported temperature at home of >or=38 degrees C, and an ED triage temperature of <38 degrees C. Laboratory and radiographic results were tabulated. RESULTS: During the study period, 206 neonates underwent lumbar puncture in our ED. Of these, 108 were excluded because their home temperature was not documented, and 71 were excluded because they were still febrile on presentation to the ED. The study group consisted of the remaining 27 subjects, 4 of whom had received acetaminophen prior to ED arrival. Infections were confirmed in 10 (37%) subjects (3 urinary tract infections, 2 aseptic meningitis, 1 enterovirus meningitis, 1 respiratory syncytial virus bronchiolitis, 1 rotavirus enteritis and 2 pneumonias). CONCLUSIONS: Clinically important infections are not uncommon among afebrile neonates undergoing ED septic workup because of a measured fever at home. Some diagnostic testing is warranted in this group, although the clinical utility and indications for specific test modalities remain unclear.