The prevalence of bacteremia in out of hospital cardiac arrest patients presenting to the emergency department of a tertiary care hospital.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains one of the most common causes of death. There is a scarcity of evidence concerning the prevalence of bacteraemia in cardiac arrest patients presenting to the Emergency Department (ED). We aimed to determine the prevalence of bacteraemia in OHCA patients presenting to the ED, as well as study the association between bacteraemia and in-hospital mortality in OHCA patients. In addition, the association between antibiotic use during resuscitation and in-hospital mortality was examined. METHODS AND RESULTS: This was a study of 200 adult OHCA patients who presented to the ED between 2015 and 2019. Bacteraemia was confirmed if at least one of the blood culture bottles grew a non-skin flora pathogen or if two blood culture bottles grew a skin flora pathogen from two different sites. The prevalence of bacteraemia was 46.5%. Gram positive bacteria, specifically Staphylococcus species, were the most common pathogens isolated from the bacteremic group. 42 patients survived to hospital admission. The multivariate analysis revealed that there was no association between bacteraemia and hospital mortality in OHCA patients (OR = 1.3, 95% CI= 0.2-9.2) with a p-value of .8. There was no association between antibiotic administration during resuscitation and hospital mortality (OR = 0.6, 95% CI= 0.1 - 3.8) with a p-value of .6. CONCLUSION: In our study, the prevalence of bacteraemia among OHCA patients presenting to the ED was found to be 46.5%. Bacteremic and non-bacteremic OHCA patients had similar initial baseline characteristics and laboratory parameters except for higher serum creatinine and BUN in the bacteremic group. In OHCA patients who survived their ED stay there was no association between hospital mortality and bacteraemia or antibiotic administration during resuscitation. There is a need for randomised controlled trials with a strong patient oriented primary outcome to better understand the association between in-hospital mortality and bacteraemia or antibiotic administration in OHCA patients.KEY MESSAGESWe aimed to determine the prevalence of bacteraemia in OHCA patients presenting to the Emergency Department. In our study, we found that 46.5% of patients presenting to our ED with OHCA were bacteremic.Bacteremic and non-bacteremic OHCA patients had similar initial baseline characteristics and laboratory parameters except for higher serum creatinine and BUN in the bacteremic group.We found no association between bacteraemia and hospital mortality. There was no association between antibiotic administration during resuscitation and hospital mortality.There is a need for randomised controlled trials with a strong patient oriented primary outcome to better understand the association between in-hospital mortality and bacteraemia or antibiotic administration in OHCA patients.

Sepsis in patients with haematological versus solid cancer: a retrospective cohort study.

OBJECTIVES: This study aims to examine the outcome of haematological and patients with solid cancer presenting with sepsis to the emergency department (ED). DESIGN: Single-centred, retrospective cohort study. Setting conducted at an academic emergency department of a tertiary hospital. PARTICIPANTS: All patients >18 years of age admitted with sepsis were included. INTERVENTIONS: Patients were stratified into two groups: haematological and solid malignancy. PRIMARY AND SECONDARY OUTCOME: The primary outcome of the study was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) mortality, ICU and hospital lengths of stay and mechanical ventilation duration. RESULTS: 442 sepsis cancer patients were included in the study, of which 305 patients (69%) had solid tumours and 137 patients (31%) had a haematological malignancy. The mean age at presentation was 67.92 (±13.32) and 55.37 (±20.85) (p<0.001) for solid and liquid tumours, respectively. Among patients with solid malignancies, lung cancer was the most common source (15.6%). As for the laboratory workup, septic solid cancer patients were found to have a higher white blood count (12 576.90 vs 9137.23; p=0.026). During their hospital stay, a total of 158 (51.8%) patients with a solid malignancy died compared with 57 (41.6%) patients with a haematological malignancy (p=0.047). There was no statistically significant association between cancer type and hospital mortality (OR 1.15 for liquid cancer p 0.58). There was also no statistically significant difference regarding intravenous fluid administration, vasopressor use, steroid use or intubation. CONCLUSION: Solid tumour patients with sepsis or septic shock are at the same risk of mortality as patients with haematological tumours. However, haematological malignancy patients admitted with sepsis or septic shock have higher rates of bacteraemia.

Clinical Outcome of Septic Patients With Heart Failure With Preserved Ejection Fraction Presenting to the Emergency Department of a Tertiary Hospital: A Retrospective Cohort Study.

Background: Patients with heart failure with preserved ejection fraction (HFpEF) may be at a higher risk of mortality from sepsis than patients without heart failure. Objective: The aim of this study is to compare sepsis-related morbidity and mortality between patients with HFpEF and patients without heart failure presenting to the emergency department (ED) of a tertiary medical center. Design: Single-center retrospective cohort study conducted at an academic ED between January 1, 2015 and December 31, 2018. Patients: Patients with a diagnosis of sepsis were included. Main Measures: Bivariate and multivariate analyses were performed to look at differences in demographics, infection, and treatment parameters as well as outcomes of patients with sepsis. The primary outcome of the study was in-hospital mortality. Secondary outcomes included ED mortality, lengths of stay, and treatment differences between both groups. Key Results: A total of 1,092 patients presented with sepsis to the ED, of which 305 (27.93%) had HFpEF. There was no significant difference in in-hospital mortality between the two groups (40.7% vs. 37.4%; p = 0.314). However, there was a significant increase in ED mortality for septic HFpEF patients compared to non-heart failure patients (2.4 vs. 0.4%; p = 0.003). Septic HFpEF patients presenting to the ED were older than non-heart failure patients (76.84 vs. 68.44 years old; p < 0.0001). On the other hand, there was no significant increase in the use of vasopressors in the first 24 h between both groups. There was a significantly higher rate of intubation in the first 48 h for septic HFpEF patients (17.5 vs. 8.9%; p < 0.0001). Finally, there was significantly less intravenous fluid requirement at 6 h (1.94 L vs. 2.41L; p < 0.0001) and 24 h (3.11 L vs. 3.54L; p = 0.004) for septic patients with HFpEF compared to non-heart failure patients. Conclusion: Septic HFpEF patients experienced an increase in ED mortality, intubation, and steroid use compared to septic non-heart failure patients.

Lactate/Albumin Ratio as a Predictor of In-Hospital Mortality in Septic Patients Presenting to the Emergency Department.

Background: The aim of this study is to evaluate the prognostic value of the Lactate to Albumin (L/A) ratio compared to that of lactate only in predicting morbidity and mortality in sepsis patients. Methods: This was a single-center retrospective cohort study. All adult patients above the age of 18 with a diagnosis of sepsis who presented between January 1, 2014 and June 30, 2019 were included. The primary outcome was in-hospital mortality. Results: A total of 1,381 patients were included, 44% were female. Overall in-hospital mortality was 58.4% with the mortalities of sepsis and septic shock being 45.8 and 67%, respectively. 55.5% of patients were admitted to the intensive care unit. The area under the curve value for lactate was 0.61 (95% CI 0.57-0.65, p < 0.001) and for the L/A ratio was 0.67 (95% CI 0.63-0.70, p < 0.001). The cutoff generated was 1.22 (sensitivity 59%, specificity 62%) for the L/A ratio in all septic patients and 1.47 (sensitivity 60%, specificity 67%) in patients with septic shock. The L/A ratio was a predictor of in-hospital mortality (OR 1.53, CI 1.32-1.78, p < 0.001). Conclusion: The L/A ratio has better prognostic performance than initial serum lactate for in-hospital mortality in adult septic patients.

Does implementation of the PECARN rules for minor head trauma improve patient-centered outcomes in a lower resource emergency department: a retrospective cohort study.

BACKGROUND: Managing children with minor head trauma remains challenging for physicians who evaluate for the need for computed tomography (CT) imaging for clinically important traumatic brain injury (ciTBI) identification. The Pediatric Emergency Care Applied Research Network (PECARN) prediction rules were adopted in our pediatric emergency department (PED) in December 2013 to identify children at low risk for ciTBI. This study aimed to evaluate this implementation's impact on CT rates and clinical outcomes. METHODS: Retrospective cohort study on pediatric patients with head trauma presenting to the PED of the American University of Beirut Medical Center in Lebanon. Participants were divided into pre- (December 2012 to December 2013) and post-PECARN (January 2014 to December 2016) groups. Patients were further divided into < 2 and ≥ 2 years and stratified into groups of low, intermediate and high risk for ciTBI. Bivariate analysis was conducted to determine differences between both groups. RESULTS: We included 1362 children of which 425 (31.2%) presented pre- and 937 (68.8%) presented post-PECARN rules implementation with 1090 (80.0%) of low, 214 (15.7%) of intermediate and 58 (4.3%) of high risk for ciTBI. CTs were ordered on 92 (21.6%) pre- versus 174 (18.6%) patients post-PECARN (p = 0.18). Among patients < 2 years, CT rates significantly decreased from 25.2% (34/135) to 16.5% (51/309) post-PECARN (p = 0.03), and dropped in all risk groups but only significantly for low risk patients from 20.7% (24/116) to 11.4% (30/264) (p = 0.02). There was no significant decrease in CT rates in patients ≥2 years (20% pre (58/290) vs 19.6% post (123/628), p = 0.88). There was no increase in bounce back numbers, nor in admission rates or positive CT findings among bounce backs. CONCLUSIONS: PECARN rules implementation did not significantly change the overall CT scan rate but reduced the CT scan rate in patients aged < 2 years at low risk of ciTBI. The implementation did not increase the number of missed ciTBI.

Characteristics and Outcomes of Pediatric Septic Patients With Cancer: A Retrospective Cohort Study.

BACKGROUND: Pediatric oncology patients may be at a higher risk of complications and mortality from sepsis compared with their nononcology counterpart. OBJECTIVES: The aim of this study is to compare characteristics, treatment, and sepsis-related mortality between oncology and nononcology patients presenting to the emergency department (ED). METHODS: This is a retrospective single-center cohort study including patients <18 years old with a diagnosis of sepsis, severe sepsis, septic shock, or bacteremia presenting to an academic ED between January 2009 and January 2015. A total of 158 patients were included with 53.8% having an underlying malignancy. The primary outcome of the study was in-hospital mortality. Secondary outcomes included ED vital signs, resuscitation parameters, laboratory work, infection site, general practitioner unit, intensive care unit length of stay, and hospital length of stay. RESULTS: Oncology patients had a higher in-hospital mortality (5.9% vs. 2.7%), however, it did not meet statistical significance (p = 0.45). On presentation, oncology patients had a lower respiratory rate (24.33 ± 9.48 vs. 27.45 ± 7.88; p = 0.04). There was a significant increase in the white blood count in oncology patients (4.011 ± 4.965 vs. 17.092 ± 12.806; p < 0.001) with this cohort receiving more intravenous fluids. In the first 6 hours (33.0 ± 27.7 mL/kg vs. 24.9 ± 16.1 mL/kg; p = 0.029) as well as having a higher percentage of vasopressor administration (15.3% vs. 1.4%; p = 0.002). Antibiotics were initiated at an earlier stage in the oncology cohort (1.25 ± 1.95 vs. 3.33 ± 1.97 hours; p < 0.0001). Cancer-free patients had a significantly higher rate of lung infections compared with cancer patients (68.5% vs. 32.9%; p < 0.0001). In terms of infection characteristics, cancer patients had a higher percentage of bacteremia (27.1% vs. 4.1%; p < 0.001). CONCLUSION: There was no statistical significance regarding mortality between the 2 cohorts. Pediatric cancer patients were found to have a higher incidence of bacteremia and received more aggressive treatment.

Mesenteric venous thrombosis presenting as gastrointestinal bleeding, a challenging diagnosis.

Acute mesenteric venous thrombosis (MVT) is an uncommon cause of intestinal ischemia and is associated with high morbidity and mortality. Patients with acute MVT often present with gastrointestinal (GI) bleeding and other unspecific findings making the diagnosis challenging. This condition requires emergent treatment. The high rates of misdiagnosis of these patients and subsequently the delay in proper and quick management put patients at increased risk of having a negative outcome. Physicians should suspect acute MVT in patients with GI bleed while also considering other factors such as, a past medical history of pro-thrombotic conditions, past surgical history of splenectomy, symptoms of nausea, vomiting, abdominal pain, physical exam findings of abdominal tenderness and abdominal distention and a laboratory workup indicating leukocytosis and an increased plasma lactic acid level. An increase in the yield of accurate diagnosis of acute MVT is possible if physicians in the ED accurately interpret all these findings. The authors herein present a case of acute MVT in a patient whose initial complaint was GI bleeding and provide a thorough review of the literature of cases of acute MVT presenting with GI bleed.

Atypical presentation of gangrenous cholecystitis: A case series.

Gangrenous cholecystitis (GC) is a serious complication of acute cholecystitis that has been associated with increased morbidity. Patient with GC can present with a wide variety of non-specific clinical, laboratory, and imaging characteristics, making the diagnosis challenging. This disease requires emergent treatment, which is why a quick and reliable diagnosis is essential for the wellbeing of the patient. The authors herein present a case of GC in a patient whose initial complaint was intractable hiccups, and provide a thorough review of the literature of cases of GC with atypical presentations.

Dual defibrillation in patients with refractory ventricular fibrillation.

In the setting of cardiac arrest, refractory ventricular fibrillation (VF) is difficult to manage, and mortality rates are high. Double sequential defibrillation (DSD) has been described in the literature as a successful means to terminate this malignant rhythm, after failure of traditional Advanced Cardiac Life Support (ACLS) measures. The authors herein present a case of refractory VF in a patient with cardiac arrest, on whom DSD was successful in reversion to sinus rhythm, and provide a thorough review of similar cases in the literature.