Effect of the 1-h bundle on mortality in patients with suspected sepsis in the emergency department: a stepped wedge cluster randomized clinical trial.

PURPOSE: The efficacy of the 1-h bundle for emergency department (ED) patients with suspected sepsis, which includes lactate measurement, blood culture, broad-spectrum antibiotics administration, administration of 30 mL/kg crystalloid fluid for hypotension or lactate ≥ 4 mmol/L, remains controversial. METHODS: We carried out a pragmatic stepped-wedge cluster-randomized trial in 23 EDs in France and Spain. Adult patients with Sepsis-3 criteria or a quick sequential organ failure assessment (SOFA) score ≥ 2 or a lactate > 2 mmol/L were eligible. The intervention was the implementation of the 1-h sepsis bundle. The primary outcome was in-hospital mortality truncated at 28 days. Secondary outcomes included volume of fluid resuscitation at 24 h, acute heart failure at 24 h, SOFA score at 72 h, intensive care unit (ICU) length of stay, number of days on mechanical ventilation or renal replacement therapy, vasopressor free days, unnecessary antibiotic administration, and mortality at 28 days. 1148 patients were planned to be analysed; the study period ended after 873 patients were included. RESULTS: 872 patients (mean age 66, 42% female) were analyzed: 387 (44.4%) in the intervention group and 485 (55.6%) in the control group. Median SOFA score was 3 [1-5]. Median time to antibiotic administration was 40 min in the intervention group vs 113 min in the control group (difference - 73 [95% confidence interval (CI) - 93 to - 53]). There was a significantly higher rate, volume, and shorter time to fluid resuscitation within 3 h in the intervention group. There were 47 (12.1%) in-hospital deaths in the intervention group compared to 61 (12.6%) in the control group (difference in percentage - 0.4 [95% CI - 5.1 to 4.2], adjusted relative risk (aRR) 0.81 [95% CI 0.48 to 1.39]). There were no differences between groups for other secondary endpoints. CONCLUSIONS: Among patients with suspected sepsis in the ED, the implementation of the 1-h sepsis bundle was not associated with significant difference in in-hospital mortality. However, this study may be underpowered to report a statistically significant difference between groups.

Is the shock index correlated with blood loss? An experimental study on a controlled hemorrhagic shock model in piglets.

INTRODUCTION: The quantification of blood loss in a severe trauma patient allows prognostic quantification and the engagement of adapted therapeutic means. The Advanced Trauma Life Support classification of hemorrhagic shock, based in part on hemodynamic parameters, could be improved. The search for reproducible and non-invasive parameters closely correlated with blood depletion is a necessity. An experimental model of controlled hemorrhagic shock allowed us to obtain hemodynamic and echocardiographic measurements during controlled blood spoliation. The primary aim was to demonstrate the correlation between the Shock Index (SI) and blood depletion volume (BDV) during the hemorrhagic phase of an experimental model of controlled hemorrhagic shock in piglets. The secondary aim was to study the correlations between blood pressure (BP) values and BDV, SI and cardiac output (CO), and pulse pressure (PP) and stroke volume during the same phase. METHODS: We analyzed data from 66 anesthetized and ventilated piglets that underwent blood spoliation at 2 mL.kg-1.min-1 until a mean arterial pressure (MAP) of 40 mmHg was achieved. During this bleeding phase, hemodynamic and echocardiographic measurements were performed regularly. RESULTS: The correlation coefficient between the SI and BDV was 0.70 (CI 95%, [0.64; 0.75]; p < 0.01), whereas between MAP and BDV, the correlation coefficient was -0.47 (CI 95%, [-0.55; -0.38]; p < 0.01). Correlation coefficient between SI and CO and between PP and stroke volume were - 0.45 (CI 95%, [-0.53; -0.37], p < 0.01) and 0.62 (CI 95%, [0.56; 0.67]; p < 0.01), respectively. CONCLUSIONS: In a controlled hemorrhagic shock model in piglets, the correlation between SI and BDV seemed strong.

Untargeted plasma metabolomic fingerprinting highlights several biomarkers for the diagnosis and prognosis of coronavirus disease 19.

Objectives: The COVID-19 pandemic has been a serious worldwide public health crisis since 2020 and is still challenging healthcare systems. New tools for the prognosis and diagnosis of COVID-19 patients remain important issues. Design: Here, we studied the metabolome of plasma samples of COVID-19 patients for the identification of prognosis biomarkers. Patients: Plasma samples of eighty-six SARS-CoV-2-infected subjects and 24 healthy controls were collected during the first peak of the COVID-19 pandemic in France in 2020. Main results: Plasma metabolome fingerprinting allowed the successful discrimination of healthy controls, mild SARS-CoV-2 subjects, and moderate and severe COVID-19 patients at hospital admission. We found a strong effect of SARS-CoV-2 infection on the plasma metabolome in mild cases. Our results revealed that plasma lipids and alterations in their saturation level are important biomarkers for the detection of the infection. We also identified deoxy-fructosyl-amino acids as new putative plasma biomarkers for SARS-CoV-2 infection and COVID-19 severity. Finally, our results highlight a key role for plasma levels of tryptophan and kynurenine in the symptoms of COVID-19 patients. Conclusion: Our results showed that plasma metabolome profiling is an efficient tool for the diagnosis and prognosis of SARS-CoV-2 infection.

Evaluation of a New Echocardiographic Tool for Cardiac Output Monitoring: An Experimental Study on A Controlled Hemorrhagic Shock Model in Anesthetized Piglets.

BACKGROUND: Cardiac output (CO) monitoring is recommended in patients with shock. The search for a reliable, rapid, and noninvasive tool is necessary for clinical practice. A new echocardiographic CO flow index (COF) is the automatic calculation of the sub-aortic VTI multiplied by the automatic calculation of the heart rate (HR). The primary objective of this study was to show the correlation between COF and CO measured by thermodilution (COth) in a controlled hemorrhagic shock model in anesthetized piglets. Secondary objectives were to show the correlation between COth and CO calculated from left outflow tract (LVOT) measurement and manual VTI (COman), and CO measured by LVOT measurement and VTIauto (COauto). METHODS: Prospective interventional experimental study. In seventeen ventilated and anesthetized piglets, a state of hemorrhagic shock was induced, maintained, then resuscitated and stabilized. The gold standard for CO and stroke volume measurement was thermodilution (COth). RESULTS: 191 measurements were performed. The correlation coefficients (r) between COth and COF, COman, and COauto were 0.73 [0.62; 0.81], 0.66 [0.56; 0.74], and 0.73 [0.63; 0.81], respectively. CONCLUSIONS: In this study, the COF appears to have a strong correlation to the COth. This automatic index, which takes into account the HR and does not require the measurement of LVOT, could be a rapidly obtained index in clinical practice.

A cross-sectional study to assess job strain of emergency healthcare workers by Karasek questionnaire: The SEEK study.

Background: Emergency healthcare workers (eHCWs) are particularly at risk of stress, but data using the gold standard questionnaire of Karasek are scarce. We assessed the level of stress of eHCWs and aimed to compare it with the general population. Methods: This is a cross-sectional nationwide study in French Emergency Departments (EDs), using the job-content questionnaire of Karasek, compared with the 25,000 answers in the French general population (controls from the SUMER study). The descriptions of job demand, job control, and social support were described as well as the prevalence of job strain and isostrain. Putative factors were searched using mixed-method analysis. Results: A total of 166 eHCWs (37.9 ± 10.5 years old, 42% men) from five French EDs were included: 53 emergency physicians and 104 emergency paramedics, compared to 25,000 workers with other occupations. Job demand was highest for physicians (28.3 ± 3.3) and paramedics (25.9 ± 3.8), compared to controls (36.0 ± 7.2; p < 0.001). Job control was the lowest for physicians (61.2 ± 5.8) and paramedics (59.1 ± 6.8), compared to controls (70.4 ± 11.7; p < 0.001). Mean social support did not differ between groups (23.6 ± 3.4 for physicians, 22.6 ± 2.9 for paramedics, and 23.7 ± 3.6 for controls). The prevalence of job strain was massively higher for physicians (95.8%) and paramedics (84.8%), compared to controls (23.9%; p < 0.001), as well as for isostrain (45.1% for physicians, 56.8% for paramedics, and 14.3% for controls, p < 0.001). We did not find any significant impact of sociodemographic characteristics on job control, job demand, or social support. Conclusion: Emergency healthcare workers have a dramatic rate of job strain, necessitating urgent promotion of policy to take care of them.

Stress among Emergency Health Care Workers on Nuclear or Radiation Disaster: A Preliminary State Survey.

BACKGROUND: The nuclear or radiation disaster risk within the French Auvergne-Rhone-Alpes state is low (but not absent) due to its proximity to four Nuclear Power Generation Centers and two regional cancer control centers. This study aims to compare subjective stress ratings for emergency health care workers regarding nuclear and radiation disasters between two locations: at work versus at home. MATERIALS AND METHODS: We distributed an anonymous online questionnaire via RedCap® to all emergency health care workers who could be involved in patient care after a nuclear or radiation disaster. It comprised 18 questions divided into three parts-theoretical knowledge and practical assessment, stress assessment, and sociodemographic criteria. RESULTS: We analyzed 107 responses. There was a significant 11-point increase in stress levels between work and home regarding nuclear or radiation disaster risks (p = 0.01). Less than 25% of emergency health care workers surveyed benefited from annual training. CONCLUSION: The stress levels of emergency health care workers regarding nuclear or radiation disaster were higher at work than at home and increased without annual training. It is important to increase knowledge about these protocols and to mandate yearly training for all workers potentially involved in these disasters.

Focal cardiac ultrasound learning with pocked ultrasound device: A bicentric prospective blinded randomized study.

PURPOSE: Point-of-care ultrasound using a pocket-ultrasound-device (PUD) is increasing in clinical medicine but the optimal way to teach focused cardiac ultrasound is not clear. We evaluated whether teaching using a PUD or a conventional-ultrasound-device (CUD) is different when the final exam was conducted on a PUD. The primary aim was to compare the weighted total quality scale (WTQS, out of 100) obtained by participants in the two groups (CUD and PUD) on a live volunteer 2-4 weeks after their initial training. The secondary aims were to compare examination time and students' confidence levels (out of 50). METHODS: This bicentric, prospective single-blind randomized trial included undergraduate medical students. After watching a 15 min video about echocardiography views, students had a 45 min hands-on training session with a live volunteer using a PUD or a CUD. The final examination was conducted with a PUD on a live volunteer. RESULTS: Eighty-six comparable students were included, with 4 ± 1 years of medical training. In the PUD group, the mean WTQS was 65 ± 16 versus 60 ± 15 in the CUD group [p = 0.22; in multivariate analysis, OR 0.8 95% CI (0.1;1.6), p = 0.34]. The examination time was 10.0 [6.2-12.4] min in the PUD group versus 11.4 [7.3-13.2] in the CUD group (p = 0.39), while the confidence level was 27.9 ± 7.7 in the PUD group versus 27.4 ± 7.2 in the CUD group (p = 0.76). CONCLUSION: There was no difference between teaching echocardiographic views using a PUD as compared to a CUD on the PUD image quality, exam time, or confidence level of students.

Protocol of the Study on Emergency Health Care Workers' Responses Evaluated by Karasek Questionnaire: The SEEK-Study Protocol.

BACKGROUND: Stress is a significant public health concern that can be self-evaluated using the job control demands model from Karasek. Emergency health care workers are particularly exposed to stress because of the intrinsic characteristics associated with the job (i.e., life-threatening emergencies, overcrowding, lack of bed spaces). However, these attributes have never been studied using the Karasek model. METHODS: An observational, prospective, multicentric study in French Emergency Departments will be conducted using a cohort of emergency health care workers. Four questionnaires before a control day and after a nightshift will be assessed every 5 years in the same emergency departments. Also, the Karasek questionnaire, a sociodemographic questionnaire, the Maslach Burnout Inventory scale, the Hospital Anxiety, Depression Scale, and a food intake questionnaire will be evaluated. Salivary biomarkers (cortisol, immunoglobulin A, lysozyme) will be collected from every emergency health care worker who consents to participating in the study. CONCLUSION: This study will provide a point of care for the emergency health care workers' stress situation every 5 years. Ethics: This protocol was registered in Clinical Trials under the identification NCT02401607 after the French Ethics Committee's approval.

Effect of an Emergency Department Care Bundle on 30-Day Hospital Discharge and Survival Among Elderly Patients With Acute Heart Failure: The ELISABETH Randomized Clinical Trial.

Importance: Clinical guidelines for the early management of acute heart failure in the emergency department (ED) setting are based on only moderate levels of evidence, with subsequent low adherence to these guidelines. Objective: To test the effect of an early guideline-recommended care bundle on short-term prognosis in older patients with acute heart failure in the ED. Design, Setting, and Participants: Stepped-wedge cluster randomized trial in 15 EDs in France of 503 patients 75 years and older with a diagnosis of acute heart failure in the ED from December 2018 to September 2019 and followed up for 30 days until October 2019. Interventions: A care bundle that included early intravenous nitrate boluses; management of precipitating factors, such as acute coronary syndrome, infection, or atrial fibrillation; and moderate dose of intravenous diuretics (n = 200). In the control group, patient care was left to the discretion of the treating emergency physician (n = 303). Each center was randomized to the order in which they switched to the "intervention period." After the initial 4-week control period for all centers, 1 center entered in the intervention period every 2 weeks. Main Outcomes and Measures: The primary end point was the number of days alive and out of hospital at 30 days. Secondary outcomes included 30-day all-cause mortality, 30-day cardiovascular mortality, unscheduled readmission, length of hospital stay, and kidney impairment. Results: Among 503 patients who were randomized (median age, 87 years; 298 [59%] women), 502 were analyzed. In the intervention group, patients received a median (interquartile range) of 27.0 (9-54) mg of intravenous nitrates in the first 4 hours vs 4.0 (2.0-6.0) mg in the control group (adjusted difference, 23.8 [95% CI, 13.5-34.1]). There was a significantly higher percentage of patients in the intervention group treated for their precipitating factors than in the control group (58.8% vs 31.9%; adjusted difference, 31.1% [95% CI, 14.3%-47.9%]). There was no statistically significant difference in the primary end point of the number of days alive and out of hospital at 30 days (median [interquartile range], 19 [0- 24] d in both groups; adjusted difference, -1.9 [95% CI, -6.6 to 2.8]; adjusted ratio, 0.88 [95% CI, 0.64-1.21]). At 30 days, there was no significant difference between the intervention and control groups in mortality (8.0% vs 9.7%; adjusted difference, 4.1% [95% CI, -17.2% to 25.3%]), cardiovascular mortality (5.0% vs 7.4%; adjusted difference, 2.1% [95% CI, -15.5% to 19.8%]), unscheduled readmission (14.3% vs 15.7%; adjusted difference, -1.3% [95% CI, -26.3% to 23.7%]), median length of hospital stay (8 d in both groups; adjusted difference, 2.5 [95% CI, -0.9 to 5.8]), and kidney impairment (1% in both groups). Conclusions and Relevance: Among older patients with acute heart failure, use of a guideline-based comprehensive care bundle in the ED compared with usual care did not result in a statistically significant difference in the number of days alive and out of the hospital at 30 days. Further research is needed to identify effective treatments for acute heart failure in older patients. Trial Registration: ClinicalTrials.gov Identifier: NCT03683212.

High Prevalence of Acquired Thrombophilia Without Prognosis Value in Patients With Coronavirus Disease 2019.

Background Recent literature reports a strong thrombotic tendency in patients hospitalized for a coronavirus disease 2019 (COVID-19) infection. This characteristic is unusual and seems specific to COVID-19 infections, especially in their severe form. Viral infections can trigger acquired thrombophilia, which can then lead to thrombotic complications. We investigate for the presence of acquired thrombophilia, which could participate in this phenomenon, and report its prevalence. We also wonder if these thrombophilias participate in the bad prognosis of severe COVID-19 infections. Methods and Results In 89 consecutive patients hospitalized for COVID-19 infection, we found a 20% prevalence of PS (protein S) deficiency and a high (ie, 72%) prevalence of antiphospholipid antibodies: mainly lupus anticoagulant. The presence of PS deficiency or antiphospholipid antibodies was not linked with a prolonged activated partial thromboplastin time nor with D-dimer, fibrinogen, or CRP (C-reactive protein) concentrations. These coagulation abnormalities are also not linked with thrombotic clinical events occurring during hospitalization nor with mortality. Conclusions We assess a high prevalence of positive tests detecting thrombophilia in COVID-19 infections. However, in our series, these acquired thrombophilias are not correlated with the severity of the disease nor with the occurrence of thrombotic events. Albeit the strong thrombotic tendency in COVID-19 infections, the presence of frequent acquired thrombophilia may be part of the inflammation storm of COVID-19 and should not systematically modify our strategy on prophylactic anticoagulant treatment, which is already revised upwards in this pathological condition. Registration URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT04335162.

Association Between Pulmonary Embolism and COVID-19 in Emergency Department Patients Undergoing Computed Tomography Pulmonary Angiogram: The PEPCOV International Retrospective Study.

BACKGROUND: There have been reports of procoagulant activity in patients with COVID-19. Whether there is an association between pulmonary embolism (PE) and COVID-19 in the emergency department (ED) is unknown. The aim of this study was to assess whether COVID-19 is associated with PE in ED patients who underwent a computed tomographic pulmonary angiogram (CTPA). METHODS: A retrospective study in 26 EDs from six countries. ED patients in whom a CTPA was performed for suspected PE during a 2-month period covering the pandemic peak. The primary endpoint was the occurrence of a PE on CTPA. COVID-19 was diagnosed in the ED either on CT or reverse transcriptase-polymerase chain reaction. A multivariable binary logistic regression was built to adjust with other variables known to be associated with PE. A sensitivity analysis was performed in patients included during the pandemic period. RESULTS: A total of 3,358 patients were included, of whom 105 were excluded because COVID-19 status was unknown, leaving 3,253 for analysis. Among them, 974 (30%) were diagnosed with COVID-19. Mean (±SD) age was 61 (±19) years and 52% were women. A PE was diagnosed on CTPA in 500 patients (15%). The risk of PE was similar between COVID-19 patients and others (15% in both groups). In the multivariable binary logistic regression model, COVID-19 was not associated with higher risk of PE (adjusted odds ratio = 0.98, 95% confidence interval = 0.76 to 1.26). There was no association when limited to patients in the pandemic period. CONCLUSION: In ED patients who underwent CTPA for suspected PE, COVID-19 was not associated with an increased probability of PE diagnosis. These results were also valid when limited to the pandemic period. However, these results may not apply to patients with suspected COVID-19 in general.

Presepsin versus other biomarkers to predict sepsis and septic shock in patients with infection defined by Sepsis-3 criteria: the PREDI study of diagnostic accuracy. / Capacidad diagnóstica de presepsina comparada con otros biomarcadores para predecir sepsis y shock séptico en pacientes con infección siguiendo la definición Sepsis-3 (estudio PREDI).

OBJECTIVES: An accurate diagnosis of sepsis in the emergency department must be made before appropriate treatment can be started. Many biomarkers that are potentially useful have been studied. The main aim of this study was to compare the diagnostic accuracy of blood levels of presepsin, lactate, C-reactive protein (CRP), and procalcitonin (PCT) for predicting sepsis as defined by the Sepsis-3 criteria. The secondary aim was to evaluate the diagnostic accuracy of these biomarkers for predicting bacteremia whether or not sepsis or septic shock was present. MATERIAL AND METHODS: Single-center, prospective, observational cohort study in the emergency department of a university hospital. Consecutive patients suspected of having infection were enrolled prospectively if they had at least 2 criteria for systemic inflammatory response syndrome. We measured presepsin, PCT, CRP, and lactate in blood extracted on admission. RESULTS: Blood samples from 359 patients were analyzed; 228 (63.5%) met the criteria for sepsis and 20 (5.6%) met the criteria for septic shock. PCT and presepsin levels were the best predictors of sepsis and septic shock with areas under the receiver operating characteristic curve (AUC) of 0.711 (95% CI, 0.660-0.758) and 0.709 (95% CI, 0.658- 0.756), respectively (P <.001, both comparisons). The AUCs for CRP and lactate concentrations were, respectively, 0.63 (95% CI, 0.58-0.69) and 0.61 (95% CI, 0.56-0.66) (P <.05, both comparisons). On applying the diagnostic cut points of 0.25 ng/mL for PCT and 500 pg/mL for presepsin, the odds ratios were 2.51 (95% CI, 1.53-4.12) for PCT and 3.19 (95% CI, 1.91-5.31) for presepsin. The diagnostic accuracy of the combination of presepsin and PCT results (AUC, 0.71; 95% CI 0.66-0.76; P <.001) was no better than the accuracy of PCT alone. The most accurate predictor of bacteremia was PCT (AUC, 0.835; 95% CI, 0.79-0.87; P <.001). CONCLUSION: Presepsin and PCT seem to be the best predictors of a diagnosis of sepsis or septic shock in emergency department patients.

OBJETIVO: El diagnóstico correcto de la sepsis en urgencias es clave para iniciar el tratamiento de forma adecuada. Para ello, se han estudiado múltiples biomarcadores que podrían ser de utilidad. El objetivo principal de este estudio fue evaluar la capacidad diagnóstica de presepsina en sangre, en comparación con procalcitonina (PCT), proteína C reactiva (PCR) y lactato, para predecir sepsis o shock séptico según la definición de Sepsis-3. El objetivo secundario fue valorar la capacidad de estos biomarcadores para predecir bacteriemia, independientemente del diagnóstico final de sepsis o shock séptico. METODO: Estudio prospectivo de cohorte observacional, realizado en un único servicio de urgencias (SU) de un hospital universitario. Se incluyeron pacientes con sospecha clínica de infección y al menos dos criterios de síndrome de respuesta inflamatoria sistémica. En todos los pacientes se determinó en sangre presepsina, PCT, PCR y lactato en el momento de la visita en el SU. RESULTADOS: Se analizaron 359 pacientes, de los que 228 (63,5%) presentaban criterios de sepsis y 20 (5,6%) de shock séptico. PCT y presepsina fueron los mejores biomarcadores para predecir la sepsis/shock séptico con un área bajo la curva (ABC) de la capacidad operativa del receptor (ROC) de 0,711 (IC 95% 0,660-0,758; p < 0,001) y 0,709 (IC 95% 0,658-0,756; p < 0,001). La PCR obtuvo una ABC de 0,635 (IC 95% 0,582-0,686; p < 0,05), y el lactato una ABC de 0,61 (IC 95% 0,556-0,661; p < 0,05). Se utilizó un punto de decisión de 0,25 ng/ml para PCT y de 500 pg/ ml para presepsina. La odds ratio de presepsina para predecir sepsis fue de 3,19 (IC 95% 1,91-5,31) y para PCT de 2,51 (IC 95% 1,53-4,12). El diagnóstico de sepsis/shock séptico no mejoró al combinar presepsina y PCT (el ABC-ROC fue de 0,714, IC 95% 0,66-0,76; p < 0,001) en comparación con PCT aislada. La PCT fue el predictor más preciso de bacteriemia en pacientes con infección con un ABC-ROC de 0,835 (IC 95% 0,79-0,87; p < 0,001). CONCLUSIONES: La presepsina y la PCT son los biomarcadores con mejor rendimiento para el diagnóstico de sepsis y shock séptico en el SU.

Capacidad diagnóstica de presepsina comparada con otros biomarcadores para predecir sepsis y shock séptico en pacientes con infección siguiendo la definición Sepsis-3 (estudio PREDI) / Presepsin versus other biomarkers to predict sepsis and septic shock in patients with infection defined by Sepsis-3 criteria: the PREDI study of diagnostic accuracy

Objetivos. El diagnóstico correcto de la sepsis en urgencias es clave para iniciar el tratamiento de forma adecuada. Para ello, se han estudiado múltiples biomarcadores que podrían ser de utilidad. El objetivo principal de este estudio fue evaluar la capacidad diagnóstica de presepsina en sangre, en comparación con procalcitonina (PCT), proteína C reactiva (PCR) y lactato, para predecir sepsis o shock séptico según la definición de Sepsis-3. El objetivo secundario fue valorar la capacidad de estos biomarcadores para predecir bacteriemia, independientemente del diagnóstico final de sepsis o shock séptico. Método. Estudio prospectivo de cohorte observacional, realizado en un único servicio de urgencias (SU) de un hospital universitario. Se incluyeron pacientes con sospecha clínica de infección y al menos dos criterios de síndrome de respuesta inflamatoria sistémica. En todos los pacientes se determinó en sangre presepsina, PCT, PCR y lactato en el momento de la visita en el SU. Resultados. Se analizaron 359 pacientes, de los que 228 (63,5%) presentaban criterios de sepsis y 20 (5,6%) de shock séptico. PCT y presepsina fueron los mejores biomarcadores para predecir la sepsis/shock séptico con un área bajo la curva (ABC) de la capacidad operativa del receptor (ROC) de 0,711 (IC 95% 0,660-0,758; p < 0,001) y 0,709 (IC 95% 0,658-0,756; p < 0,001). La PCR obtuvo una ABC de 0,635 (IC 95% 0,582-0,686; p < 0,05), y el lactato una ABC de 0,61 (IC 95% 0,556-0,661; p < 0,05). Se utilizó un punto de decisión de 0,25 ng/ml para PCT y de 500 pg/ml para presepsina. La odds ratio de presepsina para predecir sepsis fue de 3,19 (IC 95% 1,91-5,31) y para PCT de 2,51 (IC 95% 1,53-4,12). El diagnóstico de sepsis/shock séptico no mejoró al combinar presepsina y PCT (el ABC-ROC fue de 0,714, IC 95% 0,66-0,76; p < 0,001) en comparación con PCT aislada. La PCT fue el predictor más preciso de bacteriemia en pacientes con infección con un ABC-ROC de 0,835 (IC 95% 0,79-0,87; p < 0,001). Conclusión. La presepsina y la PCT son los biomarcadores con mejor rendimiento para el diagnóstico de sepsis y shock séptico en el SU

Objectives. An accurate diagnosis of sepsis in the emergency department must be made before appropriate treatment can be started. Many biomarkers that are potentially useful have been studied. The main aim of this study was to compare the diagnostic accuracy of blood levels of presepsin, lactate, C-reactive protein (CRP), and procalcitonin (PCT) for predicting sepsis as defined by the Sepsis-3 criteria. The secondary aim was to evaluate the diagnostic accuracy of these biomarkers for predicting bacteremia whether or not sepsis or septic shock was present. Methods. Single-center, prospective, observational cohort study in the emergency department of a university hospital. Consecutive patients suspected of having infection were enrolled prospectively if they had at least 2 criteria for systemic inflammatory response syndrome. We measured presepsin, PCT, CRP, and lactate in blood extracted on admission. Results. Blood samples from 359 patients were analyzed; 228 (63.5%) met the criteria for sepsis and 20 (5.6%) met the criteria for septic shock. PCT and presepsin levels were the best predictors of sepsis and septic shock with areas under the receiver operating characteristic curve (AUC) of 0.711 (95% CI, 0.660-0.758) and 0.709 (95% CI, 0.658-0.756), respectively (P<.001, both comparisons). The AUCs for CRP and lactate concentrations were, respectively, 0.63 (95% CI, 0.58-0.69) and 0.61 (95% CI, 0.56-0.66) (P<.05, both comparisons). On applying the diagnostic cut points of 0.25 ng/mL for PCT and 500 pg/mL for presepsin, the odds ratios were 2.51 (95% CI, 1.53-4.12) for PCT and 3.19 (95% CI, 1.91-5.31) for presepsin. The diagnostic accuracy of the combination of presepsin and PCT results (AUC, 0.71; 95% CI 0.66-0.76; P<.001) was no better than the accuracy of PCT alone. The most accurate predictor of bacteremia was PCT (AUC, 0.835; 95% CI, 0.79-0.87; P<.001). Conclusion. Presepsin and PCT seem to be the best predictors of a diagnosis of sepsis or septic shock in emergency department patients

Intranasal sufentanil given in the emergency department triage zone for severe acute traumatic pain: a randomized double-blind controlled trial.

The goal of our study was to determine if an intranasal (IN) dose of sufentanil delivered in the ED triage zone would improve the management of severely painful patients. We performed a randomized, double blind and placebo-controlled trial on adult patients suffering from an acute severe pain (≥ 6/10) consecutive to an isolated limb injury. We compared 2 analgesic strategies: the usual pain treatment with IV-only multimodal analgesics (IVMA) including IV opioids if needed (control group) and another strategy (active group) based on a single dose of IN sufentanil (0.4 µg/kg) given at triage and followed by IV multimodal analgesia. Our primary outcome was the proportion of patients reaching pain-relief (≤ 3/10) 30 min after IN injection at triage. Secondary outcomes were rates of adverse events, frequency of clinical interventions required by these events, and satisfaction of patients. A total of 144 adult participants completed the study, 72 in each group. Compared with usual IV-only pain management, the analgesic strategy initiated in triage zone with a dose of IN sufentanil increased the proportion of patients reaching pain relief in 30 min: 72.2% versus 51.4%, in our trial (p = 0.01 and number needed to treat of 5). There was no serious adverse event (AE) in both groups. Patients who received IN sufentanil experienced more frequently minor opiate side effects. Proportion of respiratory AEs was higher in the active group (12.5% of bradypnea < 10 cycles per minute versus 1.4%) but these events were of mild severity, as only 2 participants (one in each group) received temporary low dose oxygen therapy, and none required naloxone. Lengths of stay in the ED were similar in both groups, as well as satisfaction of patients (above 9/10) and pain scores at discharge (< 2/10). We found that a single dose of IN sufentanil delivered in the ED triage zone significantly increases the proportion of severely painful patients reaching painrelief in 30 min, compared to usual analgesia with IV-only multimodal analgesia.

Early variation of quick sequential organ failure assessment score to predict in-hospital mortality in emergency department patients with suspected infection.

BACKGROUND: The quick sequential organ failure assessment (qSOFA) score showed good prognostic performance in patients with suspicion of infection in the emergency department (ED). However, previous studies only assessed the performance of individual values of qSOFA during the ED stay. As this score may vary over short timeframes, the optimal time of measurement, and the prognostic value of its variation are unclear. The objective of the present study was to prospectively assess the prognostic value of the change in qSOFA over the first 3 h (ΔqSOFA = qSOFA at 3 h-qSOFA at inclusion). PATIENTS AND METHODS: This is an international prospective cohort study conducted in 17 EDs in France, Belgium, and Spain. From November 2016 to March 2017, patients with a suspected infection and a qSOFA score of 2 or higher were included and followed up until death or hospital discharge. qSOFA was measured at inclusion, 1 h and 3 h. Primary end point was in-hospital mortality, truncated at 28 days. RESULTS: Of 534 recruited patients, 512 were included in the analysis. The qSOFA was improved at 3 h (ΔqSOFA < 0) in 287 (55%) patients. Overall in-hospital mortality was 27%: 44% when ΔqSOFA greater than 0, 36% when ΔqSOFA = 0, and 18% when ΔqSOFA less than 0. A positive ΔqSOFA was independently associated with reduced in-hospital mortality (adjusted hazard ratio of 0.48, 95% confidence interval: 0.34-0.68). After modeling qSOFA kinetics in the first 3 h, there was a significant difference in adjusted slopes between patients who died and those who survived (0.15, 95% confidence interval: 0.09-0.22, P < 0.001). CONCLUSION: In patients with suspected infection presenting to the ED with a qSOFA of 2 or higher, the early change in qSOFA is a strong independent predictor of mortality.

Blood lactate measurement within the emergency department: A two-year retrospective analysis.

We evaluate in this retrospective cohort, the clinical situations leading emergency physicians to take a blood lactate sample, the prevalence of hyperlactatemia and its impact on short-term adverse outcome. ED patients requiring a blood lactate measurement (BLM) during a two-year period were included. Early patients' outcomes were extracted and discharge diagnoses were classified into 12 diagnostic categories. A total of 118,737 patients were analyzed. A BLM was carried out in 13,089 of them. Surprisingly, the proportion of patients having a BLM was higher in those admitted for seizure (31.4%) than in those admitted for infection (27.9%). Ten percent of patients who had a blood lactate test had a lactate level >4 mmol/l (1,315). Among them, 23.2% were admitted for infections, 20% for seizures, and 11% for cardiovascular diseases. After excluding the patients older than 75 years from the analysis in order to prevent a selection bias, the patient's severity was independently associated to an age over 65 years (OR: 1.26), an arterial blood sampling (OR: 2.77) and the blood lactate level (OR: 1.31). The blood lactate level was very informative to detect the sicker patients in the infection group whereas its interest was poor in the group of patients admitted for seizures. In conclusion, blood lactate testing has become routine in emergency departments and a large proportion of patients have abnormal blood lactate levels. The most frequent causes of high blood lactate in the ED are infection and seizures but the prognostic value of blood lactate seems to be different from one diagnostic category to the other.