Myocardial injury and mortality in patients with excessive oxygen administration before cardiac arrest.

INTRODUCTION: Hyperoxia after cardiac arrest may be associated with higher mortality, and trials have found that excess oxygen administration in patients with myocardial infarction is associated with increased infarct size. The effect of hyperoxia before cardiac arrest is sparsely investigated. Our aim was to assess the association between excessive oxygen administration before cardiac arrest and the extent of subsequent myocardial injury. METHODS: We performed a retrospective study including patients who had in-hospital cardiac arrest during 2014 in the Capital Region of Denmark. We excluded patients without peripheral oxygen saturation measurements within 48 hours before cardiac arrest. Patients were divided in three groups of pre-arrest oxygen exposure, based on average peripheral oxygen saturation and supplemental oxygen. Primary outcome was peak troponin concentration within 30 days. Secondary outcomes included 30-day mortality. Data were analyzed using multiple logistic regression and Wilcoxon rank sum test. RESULTS: Of 163 patients with cardiac arrest, 28 had excessive oxygen administration (17%), 105 had normal oxygen administration (64%) and 30 had insufficient oxygen administration (18%) before cardiac arrest. Peak troponin was median 224 ng/L in the excessive oxygen administration group vs 365 ng/L in the normal oxygen administration group (P = .54); 20 of 28 (71%) in the excessive oxygen administration group died within 30 days compared to 54 of 105 (51%) in the normal oxygen administration group. (OR 1.87, 95% CI 0.56-6.19) CONCLUSIONS: Excessive oxygen administration within 48 hours before in-hospital cardiac arrest was not statistically associated with significantly higher peak troponin or mortality.

The association between pre-operative sepsis and 30-day mortality in hip fracture patients-A cohort study.

BACKGROUND: Post-operative sepsis considerably increases mortality, but the extent of pre-operative sepsis in hip fracture patients and its consequences are sparsely elucidated. The aim of this study was to assess the association between pre-operative sepsis and 30-day mortality after hip fracture surgery. METHODS: We conducted a retrospective analysis of data collected among 1894 patients who underwent hip fracture surgery in the Capital Region of Denmark in 2014 (NCT03201679). Data on vital signs, cultures and laboratory data were obtained. Sepsis was defined as a positive culture of any kind and presence of systemic inflammatory response syndrome within 24 hours and was assessed within 72 hours before surgery and 30 days post-operatively. Primary outcome was 30-day mortality. Secondary outcomes included length of hospital stay and admission to intensive care unit. RESULTS: A total of 144 (7.6%) of the hip fracture patients met the criteria for pre-operative sepsis. The 30-day mortality was 13.9% in patients with pre-operative sepsis as compared to 9.0% in those without (OR 1.69, 95% CI [1.00; 2.85], P = .08). Patients with pre-operative sepsis had longer hospital stays (median 10 days vs 9 days, mean difference 2.1 [SD 9.4] days, P = .03), and higher frequency of ICU admission (11.1% vs 2.7%, OR 4.15, 95% CI [2.19; 7.87], P < .0001). CONCLUSION: Pre-operative sepsis in hip fracture patients was associated with an increased length of hospital stay and tended to increase mortality. Pre-operative sepsis in hip fracture patients merits more intensive surveillance and increased attention to timely treatment.

Modifications of the National Early Warning Score for patients with chronic respiratory disease.

BACKGROUND: The National Early Warning Score (NEWS) uses physiological variables to detect deterioration in hospitalized patients. However, patients with chronic respiratory disease may have abnormal variables not requiring interventions. We studied how the Capital Region of Denmark NEWS Override System (CROS), the Chronic Respiratory Early Warning Score (CREWS) and the Salford NEWS (S-NEWS) affected NEWS total scores and NEWS performance. METHODS: In an observational study, we included patients with chronic respiratory disease. The frequency of use of CROS and the NEWS total score changes caused by CROS, CREWS and S-NEWS were described. NEWS, CROS, CREWS and S-NEWS were compared using 48-h mortality and intensive care unit (ICU) admission within 48 h as outcomes. RESULTS: We studied 11,266 patients during 25,978 admissions; the use of CROS lowered NEWS total scores in 40% of included patients. CROS, CREWS and S-NEWS had lower sensitivities than NEWS for 48-h mortality and ICU admission. Specificities and PPV were higher. CROS, CREWS and S-NEWS downgraded, respectively, 51.5%, 44.9% and 32.8% of the NEWS total scores from the 'mandatory doctor presence' and 'immediate doctor presence and specialist consultation' total score intervals to lower intervals. CONCLUSION: Capital Region of Denmark NEWS Override System was frequently used in patients with chronic respiratory disease. CROS, CREWS and S-NEWS reduced sensitivity for 48-h mortality and ICU admission. Using the methodology prevalent in the NEWS literature, we cannot conclude on the safety of these systems. Future prospective studies should investigate the balance between detection rate and alarm fatigue of different systems, or use controlled designs and patient-centred outcomes.

Respiratory rates measured by a standardised clinical approach, ward staff, and a wireless device.

BACKGROUND: Respiratory rate is among the first vital signs to change in deteriorating patients. The aim was to investigate the agreement between respiratory rate measurements by three different methods. METHODS: This prospective observational study included acutely admitted adult patients in a medical ward. Respiratory rate was measured by three methods: a standardised approach over 60 s while patients lay still and refrained from talking, by ward staff and by a wireless electronic patch (SensiumVitals). The Bland-Altman method was used to compare measurements and three breaths per minute (BPM) was considered a clinically relevant difference. RESULTS: We included 50 patients. The mean difference between the standardised approach and the electronic measurement was 0.3 (95% CI: -1.4 to 2.0) BPM; 95% limits of agreement were -11.5 (95% CI: -14.5 to -8.6) and 12.1 (95% CI: 9.2 to 15.1) BPM. Removal of three outliers with huge differences lead to a mean difference of -0.1 (95% CI: -0.7 to 0.5) BPM and 95% limits of agreement of -4.2 (95% CI: -5.3 to -3.2) BPM and 4.0 (95% CI: 2.9 to 5.0) BPM. The mean difference between staff and electronic measurements was 1.7 (95% CI: -0.5 to 3.9) BPM; 95% limits of agreement were -13.3 (95% CI: -17.2 to -9.5) BPM and 16.8 (95% CI: 13.0 to 20.6) BPM. CONCLUSION: A concerning lack of agreement was found between a wireless monitoring system and a standardised clinical approach. Ward staff's measurements also seemed to be inaccurate.

End points for validating early warning scores in the context of rapid response systems: a Delphi consensus study.

INTRODUCTION: When investigating early warning scores and similar physiology-based risk stratification tools, death, cardiac arrest and intensive care unit admission are traditionally used as end points. A large proportion of the patients identified by these end points cannot be saved, even with optimal treatment. This could pose a limitation to studies using these end points. We studied current expert opinion on end points for validating tools for the identification of patients in hospital wards at risk of imminent critical illness. METHODS: The Delphi consensus methodology was used. We identified 22 experts based on objective criteria; 17 participated in the study. Each expert panel member's suggestions for end points were collected and distributed to the entire expert panel in anonymised form. The experts reviewed, rated and commented the suggested end points through the rounds in the Delphi process, and the experts' combined rating of the usefulness of each suggestion was established. RESULTS: A gross list of 86 suggestions for end points, relating to 13 themes, was produced. No items were uniformly recognised as ideal. The themes cardiac arrest, death, and level of care contained the items receiving highest ratings. CONCLUSIONS: End points relating to death, cardiac arrest and intensive care unit admission currently comprise the most obvious compromises for investigating early warning scores and similar risk stratification tools. Additional end points from the gross list of suggested end points could become feasible with the increased availability of large data sets with a multitude of recorded parameters.

Cimetidine improves GERD symptoms in patients selected by a validated GERD questionnaire.

A questionnaire was constructed and validated to improve the accuracy of symptom assessment in diagnosing gastro-oesophageal reflux disease (GERD). The GERD questionnaire consisted of four questions describing an upward moving, uncomfortable feeling in the chest frequently accompanied by retrosternal burning that is improved with antacids. It was found that if a patient answered yes to all four questions the likelihood was 85% that erosive oesophagitis would be detected on endoscopy or that pathological gastro-oesophageal reflux on 24-hour pH-monitoring would be documented, or both. The GERD questionnaire was used to identify 269 patients with probable GERD who after one week on placebo entered a 2-week double-blind placebo-controlled study which was completed by 251 patients. Cimetidine (400 mg) b.d. was given to 124 patients and placebo to 127 patients. On diary cards the patients noted the number, the mean duration and the mean severity of GERD symptoms episodes. Cimetidine was significantly superior to placebo in increasing the percentage of symptom-free days, and in reducing the median number of daily symptom episodes. This trial demonstrates that 400 mg cimetidine b.d. is effective in improving GERD symptoms in patients identified by a descriptive, validated GERD questionnaire.

Vasopressin in anergic schizophrenia. A cross-over study with lysine-8-vasopressin and placebo.

Sixteen out of 19 patients suffering from chronic anergic schizophrenia completed a placebo-controlled cross-over study with lysine-8-vasopressin (LVP), following a schedule of 1 week of placebo, 3 weeks of LVP, starting with 22.5 IU/day, gradually increased to 67.5 IU/day, and finally 4 weeks of placebo. The psychic state was evaluated with the Brief Psychiatric Rate Scale (BPRS), during weekly live interviews, and following videotaped BPRS interviews at the beginning and end of the LVP period, and at the end of the final placebo period. Symptoms of parkinsonism and tardive dyskinesia were also videotaped during a standardized examination at the same intervals. The videotapes were subsequently randomized and evaluated blindly. The results of liver interviews showed a significant (P less than 0.05) decrease in the BPRS anergic factor after 2 and 3 weeks of LVP treatment, but there were no changes in any single item, other BPRS factors, or the BPRS total score. The results of the videotape evaluations showed that the BPRS thinking disorder factor was significantly (P less than 0.05) decreased after 3 weeks of LVP, whereas the BPRS score was unchanged. No consistent changes in parkinsonism or tardive dyskinesia were found. Although side effects were few, six patients became agitated or aggressive during the LVP treatment. The beneficial effect on thought disorder and anergia, but the absence of global effects on the schizophrenic syndrome, illustrates the need for further research with other vasopressin analogues. The advantages and disadvantages of live and videotaped psychiatric interviews are also discussed.