Quick Sequential Organ Failure Assessment, Sequential Organ Failure Assessment, and Procalcitonin for Early Diagnosis and Prediction of Death in Elderly Patients with Suspicion of Sepsis in the Emergency Department, Based on Sepsis-3 Definition.

BACKGROUND: Sepsis is a disease with a high mortality rate without prompt treatment. However, this entity is difficult to diagnose in the elderly population in the emergency room; for this reason, it is necessary to have diagnostic tools for early detection. OBJECTIVE: The aim of the study was to determine the highest diagnostic yield of procalcitonin (PCT), Quick Sequential Organ Failure Assessment (qSOFA), and Sequential Organ Failure Assessment (SOFA) for sepsis (based on the sepsis-3 consensus), on admission at the emergency department, in those older than 65 years. METHODS: This is a diagnostic test study of a historical cohort of 65-year-old patients with suspected sepsis. RESULTS: In the sample of 179 patients, 53.6% had confirmed sepsis. Significant differences were found (p < 0.0001), with a greater diagnostic and predictive capacity of PCT for the diagnosis of sepsis (receiver operating characteristics curve area [area under the curve (AUC) = 0.883, 95% CI: 0.835-0.931] than qSOFA (AUC = 0.559, 95% CI: 0.485-0.663) and SOFA (AUC = 0.662, 95% CI: 0.584-0.739); these results were similar in the cohort of patients ≥75 years. In positive PCT(≥0.5 ng/mL), the sensitivity was 71.8% (95% CI: 62.36-81.39), specificity of 89.1% (95% CI: 81.87-96.45%), V+ 88.4% (95% CI: 80.73-96.19%), V- of 73.2% (95% CI: 64.14-82.39%), positive likelihood ratio of 6.63 (95% CI: 3.53-12.44), and negative likelihood ratio of 0.32 (95% CI: 0.23-0.44); these results were similar in the cohort of patients ≥75 years. Lactate ≥2 mmol/L (RR = 1.659 [95% CI: 1.002-2.747]) and PCT ≥0.5 ng/mL (RR = 1.942 [95% CI: 1.157-3.261]) showed a significant association with in-hospital mortality. CONCLUSION: In the elderly population with suspicion of infection on admission to the emergency department, qSOFA presents a low diagnostic performance of confirmed sepsis and in-hospital mortality, for which other tools with higher diagnostic and prognostic performance should be added, such as PCT and lactate.

USER Protocol as a Guide to Resuscitation of the Patient with Septic Shock in the Emergency Department.

INTRODUCTION: Sepsis is a disease that is still associated with high mortality, in which timely interventions are related to better results. OBJECTIVE: To determine if there is a difference in in-hospital mortality, fluid balances, norepinephrine initiation and recovery time of blood pressure, when comparing the resuscitation of the patient who is admitted to the emergency room in septic shock by applying the ultrasound protocol (USER) versus the standard of care. PATIENTS AND METHODS: This is a prospective, cohort study conducted in the emergency room of a highly complex hospital of patients with septic shock. RESULTS: 83 patients recruited in total. The groups were comparable in demographics, mean baseline blood pressure, disease severity given by the SOFA value, and arterial lactate. A statistically significant difference was documented in the fluid balances at 4 hours, median 1325mL (IQR:451-2455mL) in Group C versus 900mL (IQR:440-1292) in Group U (p=0.048) and at 6 hours, median 1658mL (IQR:610-2925mL) versus 1107mL (IQR:600-1500mL), p=0.026, as well as in the total fluid balance of hospital stay, median 14,564mL (IQR:8660-18,705mL) versus 8660mL (IQR:5309-16,974mL), p=0.049. On the other hand, in the USER Group, the mean blood pressure ≥ 65mmHg was achieved in 97.4% of the patients 4 hours after the start of the protocol versus 50% in Group C (p=<0.001). Mortality with the use of the protocol compared with conventional therapy was (56.4% vs 61.36%, p=0.647). CONCLUSION: The use of the USER protocol in patients with septic shock in the emergency room showed lower fluid balances at 4 and 6 hours, and of the total hospital stay, as well as earlier initiation of norepinephrine and statistically significant faster improvement in blood pressure. Although a statistically significant difference was not found in the days of ICU stay, hospitalization and in-hospital mortality, a trend was observed in the reduction of these parameters.

Rhythms and prognosis of patients with cardiac arrest, emphasis on pseudo-pulseless electrical activity: another reason to use ultrasound in emergency rooms in Colombia.

BACKGROUND: The cardiac arrest is still an emergency with a bad prognosis. The growing adoption of bedside ultrasound allowed to classify PEA in two groups: the true PEA and the pseudo-PEA. pPEA is used to describe a patient who has a supposed PEA in the absence of pulse, with evidence of some cardiac activity on the bedside ultrasound. OBJECTIVE: This work aims to assess the bedside ultrasound use as a predictor for ROSC and survival at discharge in cardiac arrest patients and compare the pseudo-pulseless electrical activity to other cardiac arrest rhythms, including shockable rhythms. MATERIALS AND METHODS: This is an observational, historic cohort study carried out in the emergency room of the University Hospital Mayor Méderi. Data were collected from all the adult patients treated for cardiac arrest from June 2018 to 2019. An ultrasound was performed to every cardiac arrest patient. RESULTS: Of a total of 108 patients, the median of the age was 71 years, 65.8% were male subjects, and the most frequent cause for cardiac arrest was the cardiogenic shock (32.4%). ROSC was observed in 41 cases (37.9%) and survival at discharge was 18 cases (16.7%). VF/VT and pPEA were the two rhythms that showed the highest ROSC and survival at discharge. For the pPEA group, we were able to conclude that the cardiac activity type is related to ROSC. CONCLUSION: There is a significant difference for ROSC and survival at discharge prognosis among the cardiac arrest rhythms, with better outcomes for VF/VT and pPEA. Among patients with PEA, a routine ultrasound assessment is recommended. The type of cardiac activity recorded during the ultrasound of the cardiac arrest patient might be related to the ROSC and survival at discharge prognosis.

Approach of minimal invasive monitoring and initial treatment of the septic patient in emergency medicine.

Sepsis and septic shock constitute a complex disease condition that requires the engagement of several medical specialties. A great number of patients with this disease are constantly admitted to the emergency department, which warrants the need for emergency physicians to lead in the recognition and early management of septic patients. Timely and appropriate interventions may help reduce mortality in a disease with an unacceptably high mortality rate. Poor control of cellular hypoperfusion is one of the most influential mechanisms contributing to the high mortality rate in these patients. This article aims to make an evidence-based approach and an algorithm for the active identification of hypoperfusion in patients with suspicion of severe infection, based on both clinical variables (capillary refill, mottling index, left ventricular function by ultrasound, temperature gradient, etc.) and laboratory-measured variables (lactate, central venous oxygen saturation [ScvO2], and venous-to-arterial carbon dioxide tension difference [P (v-a) CO2]). Such variables are feasible to use in the emergency department and would help to explain the cause behind the inadequate oxygen use by cells, thereby guiding treatment at the macrovascular, microvascular, or cellular level.

Ultrasound-guided central venous catheter placement in the emergency department: experience in a hospital in Bogotá, Colombia.

INTRODUCTION: The use of central venous catheters (CVCs) in the emergency room (ER) is a valuable tool for the comprehensive management of critically ill patients; however, the positioning of these devices is not free of complications. Currently, the use of ultrasound is considered a useful and safe tool to carry out these procedures, but in Colombia, the number of emergency departments providing this tool is scarce and there is no literature describing the experience in our country. OBJECTIVE: The objective of this study was to describe the experience regarding placement of ultrasound-guided CVCs by emergency physicians in an institution in Bogotá, as well as the associated complications. MATERIALS AND METHODS: This is a descriptive cross-sectional retrospective study. Medical records of 471 patients requiring insertion of CVCs in the resuscitation area from January 2014 to December 2014 were reviewed. Insertion site and complications are described. RESULTS: For 471 total cases, the average age of patients was 68.6 years, the most frequent diagnosis was sepsis (30.7%), the preferred route of insertion was the right internal jugular vein, and insertion was successful at the first attempt in 85.9% of patients. Pneumothorax was the most common complication (1.2%), followed by extensive hematoma and infection. CONCLUSION: Insertion of ultrasound-guided CVCs by emergency physicians is a safe procedure that involves complications similar to those reported in the literature; it is necessary to expand the use of ultrasound-guided CVCs in ERs.