The Impact of Do-Not-Resuscitate Order in the Emergency Department on Respiratory Failure after ICU Admission.

(1) Background: It has been hypothesized that a discrepancy exists in the understanding of a do-not-resuscitate (DNR) order among physicians. We hypothesized that a DNR order signed in the emergency department (ED) could influence the patients' prognosis after intensive care unit (ICU) admission. (2) Methods: We included patients older than 17 years, who visited the emergency department for non-traumatic disease, who had respiratory failure, required ventilator support, and were admitted to the ICU between January 2010 and December 2016. The associations between DNR and mortality, hospital length of stay (LOS), and medical fees were analyzed. Prolonged hospital LOS was defined as hospital stay ≥75th percentile (≥26 days for the study). Patients were classified as those who did and did not sign a DNR order. A 1:4 propensity score matching was conducted for demographics, comorbidities, and etiology. (3) Results: The study enrolled a total of 1510 patients who signed a DNR and 6040 patients who did not sign a DNR. The 30-day mortality rates were 47.4% and 28.0% among patients who did and did not sign a DNR, respectively. A DNR order was associated with mortality after adjusting for confounding factors (hazard ratio, 1.9; confidence interval, 1.70−2.03). It was also a risk factor for prolonged hospital LOS in survivors (odds ratio, 1.2; confidence interval, 1.02−1.44). Survivors who signed a DNR order were charged higher medical fees than those who did not sign a DNR (217,159 vs. 245,795 New Taiwan Dollars, p < 0.001). (4) Conclusions: Signing a DNR order in the ED increased the ICU mortality rate among patients who had respiratory failure and needed ventilator support. It increased the risk of prolonged hospital LOS among survivors. Finally, signing a DNR order was associated with high medical fees among survivors.

Significant predictive factors of the severity and outcomes of the first attack of acute angioedema in children.

BACKGROUND: The initial episode of angioedema in children can be potential life-threatening due to the lack of prompt identification and treatment. We aimed to analyze the factors predicting the severity and outcomes of the first attack of acute angioedema in children. METHODS: This was a retrospective study with 406 children (< 18 years) who presented in the emergency department (ED) with an initial episode of acute angioedema and who had subsequent follow-up visits in the out-patient department from January 2008 to December 2014. The severity of the acute angioedema was categorized as severe (requiring hospital admission), moderate (requiring a stay in the short-term pediatric observation unit [POU]), or mild (discharged directly from the ED). The associations among the disease severity, patient demographics and clinical presentation were analyzed. RESULT: In total, 109 (26.8%) children had severe angioedema, and the majority of those children were male (65.1%). Most of the children were of preschool age (56.4%), and only 6.4% were adolescents. The co-occurrence of pyrexia or urticaria, etiologies of the angioedema related to medications or infections, the presence of respiratory symptoms, and a history of allergies (asthma, allergic rhinitis) were predictors of severe angioedema (all p < 0.05). Finally, the duration of angioedema was significantly shorter in children who had received short-term POU treatment (2.1 ± 1.1 days) than in those who discharged from ED directly (2.3 ± 1.4 days) and admitted to the hospital (3.5 ± 2.0 days) (p < 0.001). CONCLUSION: The co-occurrence of pyrexia or urticaria, etiologies related to medications or infections, the presence of respiratory symptoms, and a history of allergies were predictors of severe angioedema. More importantly, short-term POU observation and prompt treatment might be benefit for patients who did not require hospital admission.

Use High-Flow Nasal Cannula for Acute Respiratory Failure Patients in the Emergency Department: A Meta-Analysis Study.

OBJECTIVE: To evaluate the efficacy of high-flow nasal cannula (HFNC) therapy compared with conventional oxygen therapy (COT) or noninvasive ventilation (NIV) for the treatment of acute respiratory failure (ARF) in emergency departments (EDs). METHOD: We comprehensively searched 3 databases (PubMed, EMBASE, and the Cochrane Library) for articles published from database inception to 12 July 2019. This study included only randomized controlled trials (RCTs) that were conducted in EDs and compared HFNC therapy with COT or NIV. The primary outcome was the intubation rate. The secondary outcomes were the mortality rate, intensive care unit (ICU) admission rate, ED discharge rate, need for escalation, length of ED stay, length of hospital stay, and patient dyspnea and comfort scores. RESULT: Five RCTs (n = 775) were included. There was a decreasing trend regarding the application of HFNC therapy and the intubation rate, but the difference was not statistically significant (RR, 0.53; 95% CI, 0.26-1.09; p=0.08; I 2 = 0%). We found that compared with patients who underwent COT, those who underwent HFNC therapy had a reduced need for escalation (RR, 0.41; 95% CI, 0.22-0.78; p=0.006; I 2 = 0%), reduced dyspnea scores (MD -0.82, 95% CI -1.45 to -0.18), and improved comfort (SMD -0.76 SD, 95% CI -1.01 to -0.51). Compared with the COT group, the HFNC therapy group had a similar mortality rate (RR, 1.25; 95% CI, 0.79-1.99; p=0.34; I 2 = 0%), ICU admission rate (RR, 1.11; 95% CI, 0.58-2.12; p=0.76; I 2 = 0%), ED discharge rate (RR, 1.04; 95% CI, 0.63-1.72; p=0.87; I 2 = 0%), length of ED stay (MD 1.66, 95% CI -0.95 to 4.27), and hospital stay (MD 0.9, 95% CI -2.06 to 3.87). CONCLUSION: Administering HFNC therapy in ARF patients in EDs might decrease the intubation rate compared with COT. In addition, it can decrease the need for escalation, decrease the patient's dyspnea level, and increase the patient's comfort level compared with COT.

Time to epinephrine treatment is associated with the risk of mortality in children who achieve sustained ROSC after traumatic out-of-hospital cardiac arrest.

BACKGROUND: The benefits of early epinephrine administration in pediatric with nontraumatic out-of-hospital cardiac arrest (OHCA) have been reported; however, the effects in pediatric cases of traumatic OHCA are unclear. Since the volume-related pharmacokinetics of early epinephrine may differ obviously with and without hemorrhagic shock (HS), beneficial or harmful effects of nonselective epinephrine stimulation (alpha and beta agonists) may also be enhanced with early administration. In this study, we aimed to analyze the therapeutic effect of early epinephrine administration in pediatric cases of HS and non-HS traumatic OHCA. METHODS: This was a multicenter retrospective study (2003-2014). Children (aged ≤ 19 years) who experienced traumatic OHCA and were administered epinephrine for resuscitation were included. Children were classified into the HS (blood loss > 30% of total body fluid) and non-HS groups. The demographics, outcomes, postresuscitation hemodynamics (the first hour) after the sustained return of spontaneous circulation (ROSC), and survival durations were analyzed and correlated with the time to epinephrine administration (early < 15, middle 15-30, late > 30 min) in the HS and non-HS groups. Cox regression analysis was used to adjust for risk factors of mortality. RESULTS: A total of 509 children were included. Most of them (n = 348, 68.4%) had HS OHCA. Early epinephrine administration was implemented in 131 (25.7%) children. In both the HS and non-HS groups, early epinephrine administration was associated with achieving sustained ROSC (both p < 0.05) but was not related to survival or good neurological outcomes (without adjusting for confounding factors). However, early epinephrine administration in the HS group increased cardiac output but induced metabolic acidosis and decreased urine output during the initial postresuscitation period (all p < 0.05). After adjusting for confounding factors, early epinephrine administration was a risk factor of mortality in the HS group (HR 4.52, 95% CI 2.73-15.91). CONCLUSION: Early epinephrine was significantly associated with achieving sustained ROSC in pediatric cases of HS and non-HS traumatic OHCA. For children with HS, early epinephrine administration was associated with both beneficial (increased cardiac output) and harmful effects (decreased urine output and metabolic acidosis) during the postresuscitation period. More importantly, early epinephrine was a risk factor associated with mortality in the HS group.

Impact of Different Serum Potassium Levels on Postresuscitation Heart Function and Hemodynamics in Patients with Nontraumatic Out-of-Hospital Cardiac Arrest.

BACKGROUND: Sustained return of spontaneous circulation (ROSC) can be initially established in patients with out-of-hospital cardiac arrest (OHCA); however, the early postresuscitation hemodynamics can still be impaired by high levels of serum potassium (hyperkalemia). The impact of different potassium levels on early postresuscitation heart function has remained unclear. We aim to analyze the relationship between different levels of serum potassium and postresuscitation heart function during the early postresuscitation period (the first hour after achieving sustained ROSC). METHODS: Information on 479 nontraumatic OHCA patients with sustained ROSC was retrospectively obtained. Measures of early postresuscitation heart function (rate, blood pressure, and rhythm), hemodynamics (urine output and blood pH), and the duration of survival were analyzed in the case of different serum potassium levels (low: <3.5; normal: 3.5-5; high: >5 mmol/L). RESULTS: Most patients (59.9%, n = 287) had previously presented with high levels of potassium. Bradycardia, nonsinus rhythm, urine output <1 ml/kg/hr, and acidosis (pH < 7.35) were more common in patients with high levels of potassium (all p < 0.05). Compared with hyperkalemia, a normal potassium level was more likely to be associated with a normal heart rate (OR: 2.97, 95% CI: 1.74-5.08) and sinus rhythm (OR: 2.28, 95% CI: 1.45-3.58). A low level of potassium was more likely to be associated with tachycardia (OR: 3.54, 95% CI: 1.32-9.51), urine output >1 ml/kg/hr (OR: 5.35, 95% CI: 2.58-11.10), and nonacidosis (blood pH >7.35, OR: 7.74, 95% CI: 3.78-15.58). The duration of survival was shorter in patients with hyperkalemia than that in patients whose potassium levels were low or normal (p < 0.05). CONCLUSION: Early postresuscitation heart function and hemodynamics were associated with the serum potassium level. A high potassium level was more likely to be associated with bradycardia, nonsinus rhythm, urine output <1 ml/kg/hr, and acidosis. More importantly, a high potassium level decreased the duration of survival.

Comparison of Clinical Practice in the Emergency Department: Female Versus Male Emergency Physicians.

BACKGROUND: There are fewer female emergency physicians (EPs) than male ones. This study attempted to analyze the differences in clinical practice between female and male EPs in the emergency department (ED). MATERIALS AND METHODS: A retrospective, 1-year cohort study was conducted across 4 EDs in the largest healthcare system in Taiwan. A total of 199,757 adult patients without trauma treated by 76 EPs (9 females and 67 males) were included in the study. The clinical practice of female and male EPs was compared. The door-to-order and door-to-disposition times were used to evaluate EP efficiency. Indicators of diagnostic tool use included laboratory examinations and computed tomography scans. Patient dispositions included discharge, ED observation, general ward and intensive care unit admissions and ED mortality rate. Disposition accuracy was evaluated by determining the 72-hour ED revisit rate. RESULTS: The clinical practice of female and male EPs was similar. After adjusting for the potential confounding factors through a regression model, female EPs showed slight increase in laboratory examination use (adjusted odds ratio = 1.05; 95% CI: 1.01-1.09) compared with male EPs, but no difference in computed tomography use was observed between sexes. Additionally, no differences among patient dispositions and 72-hour ED revisit rates (adjusted odds ratio = 1.0; 95% CI: 0.93-1.06) were observed between female and male EPs. CONCLUSIONS: Female and male EPs had similar clinical efficiency on patient evaluation, and they had no difference in diagnostic tool use. Furthermore, they showed similar patient disposition with the same accuracy.

The influence of crowding on clinical practice in the emergency department.

BACKGROUND: This study aimed to clarify the association between the crowding and clinical practice in the emergency department (ED). METHODS: This 1-year retrospective cohort study conducted in two EDs in Taiwan included 70,222 adult non-trauma visits during the day shift between July 1, 2011, and June 30, 2012. The ED occupancy status, determined by the number of patients staying during their time of visit, was used to measure crowding, grouped into four quartiles, and analyzed in reference to the clinical practice. The clinical practices included decision-making time, patient length of stay, patient disposition, and use of laboratory examinations and computed tomography (CT). RESULT: The four quartiles of occupancy statuses determined by the number of patients staying during their time of visit were <24, 24-39, 39-62, and >62. Comparing >62 and <24 ED occupancy statuses, the physicians' decision-making time and patients' length of stay increased by 0.3h and 1.1h, respectively. The percentage of patients discharged from the ED decreased by 15.5% as the ED observation, general ward, and intensive care unit admissions increased by 10.9%, 4%, and 0.7%, respectively. CT and laboratory examination slightly increased in the fourth quartile of ED occupancy. CONCLUSION: Overcrowding in the ED might increase physicians' decision-making time and patients' length of stay, and more patients could be admitted to observation units or an inpatient department. The use of CT and laboratory examinations would also increase. All of these could lead more patients to stay in the ED.

Can different physicians providing urgent and non-urgent treatment improve patient flow in emergency department?

BACKGROUND: Emergency Department (ED) overcrowding is a worldwide problem, and it might be caused by prolonged patient stay in the ED. This study tried to analyze if different practice models influence patient flow in the ED. MATERIALS AND METHODS: A retrospective, 1-year cohort study was conducted across two EDs in the largest healthcare system in Taiwan. A total of 37,580 adult non-trauma patients were involved in the study. The clinical practice between two ED practice models was compared. In one model, urgent and non-urgent patients were treated by different emergency physicians (EPs) separately (separated model). In the other, EPs treated all patients assigned randomly (merged model). The ED length of stay (LOS), diagnostic tool use (including laboratory examinations and computed tomography scans), and patient dispositions (including discharge, general ward admission, intensive care unit (ICU) admissions, and ED mortality) were selected as outcome indicators. RESULT: Patients discharged from ED had 0.4h shorter ED LOS in the separated model than in merged model. After adjusting for the potential confounding factors through regression model, there was no difference of patient disposition of the two practice models. However, the separated model showed a slight decrease in laboratory examination use (adjusted odds ratio, 0.9; 95% confidence interval, 0.83-0.96) compared with the merged model. CONCLUSION: The separated model had better patient flow than the merged model did. It decreased the ED LOS in ED discharge patients and laboratory examination use.

The influence of resident seniority on supervised practice in the emergency department.

To investigate the influence of resident seniority on supervised clinical practice in the emergency department (ED).This was a retrospective, 1-year cohort study conducted in 5 EDs within Taiwan largest healthcare system. All adult nontrauma visits presenting to the EDs during the day shift between July 1, 2011 and June 30, 2012 were included in the analysis. Visits were divided into supervised (ie, treated by resident under attending physician's supervision) and attending-alone. Supervised visits were further categorized by resident seniority (junior, intermediate, and senior). The decision-making time (door-to-order and door-to-disposition time), patient dispositions (eg, ED observation and hospital admission), and diagnostic tool use (laboratory examination or computed tomography [CT]) were selected as clinical performance indicators. The differences in clinical performance were determined between supervised visits (ie, resident-seniority groups) and attending-alone visits.Junior residents were found to have longer median door-to-order and door-to-disposition time than were the other residents for urgent and nonurgent patients. Furthermore, compared with attending-alone visits, supervised visits with junior residents had a greater odds of ED observation (adjusted odds ratio [aOR], 1.1; 95% CI, 1.07-1.20), while supervised visits with all 3 resident-seniority groups had significantly greater odds of laboratory examinations (junior: aOR, 1.1; 95% CI, 1.03-1.16; intermediate: aOR, 1.1; 95% CI, 1.04-1.15; and senior: aOR, 1.1; 95% CI, 1.05-1.15).As resident seniority increases, less time is needed for decision making in supervised visits. However, compared to attending-alone visits, supervised visits still resulted in greater use of laboratory examinations and delayed patient disposition.

The Prognosis of Cardiac Origin and Noncardiac Origin in-Hospital Cardiac Arrest Occurring during Night Shifts.

Background. The survival rates of in-hospital cardiac arrests (IHCAs) are reportedly low at night, but the difference between the survival rates of cardiac origin and noncardiac origin IHCAs occurring at night remains unclear. Methods. Outcomes of IHCAs during different shifts (night, day, and evening) were compared and stratified according to the etiology (cardiac and noncardiac origin). Result. The rate of return of spontaneous circulation (ROSC) was 24.7% lower for cardiac origin IHCA and 19.4% lower for noncardiac origin IHCA in the night shift than in the other shifts. The survival rate was 8.4% lower for cardiac origin IHCA occurring during the night shift, but there was no difference for noncardiac origin IHCA. After adjusting the potential confounders, chances of ROSC (aOR: 0.3, CI: 0.15-0.63) and survival to discharge (aOR: 0.1; CI: 0.01-0.90) related to cardiac origin IHCA were lower during night shifts. Regarding noncardiac origin IHCA, chances of ROSC (aOR: 0.5, CI: 0.30-0.78) were lower in the night shift, but chances of survival to discharge (aOR: 1.3, CI: 0.43-3.69) were similar in these two groups. Conclusion. IHCA occurring at night increases mortality, and this is more apparent for cardiac origin IHCAs than for noncardiac origin IHCA.

Physician Risk Tolerance and Head Computed Tomography Use for Patients with Isolated Headaches.

BACKGROUND: Headaches are one of the most common afflictions in adults and reasons for emergency department (ED) visits. OBJECTIVE: We sought to determine the association between physician risk tolerance and head computed tomography (CT) use in patients with headaches in the ED. METHODS: We performed a retrospective study of patients with nontraumatic isolated headaches in the ED and then administered two instruments (Risk-Taking subscale [RTS] of the Jackson Personality Index and a Malpractice Fear Scale [MFS]) to attending physicians who had evaluated these patients and made decisions regarding head CT scans. Outcomes were head CT use during ED evaluation and hospital admission. A hierarchical logistic regression was used to determine the effect of risk scales on head CT use. RESULTS: Of the 1328 patients with headaches, 521 (39.2%) received brain CTs and 83 (6.9%) were admitted; 33 (2.5%) patients received a final diagnosis that the central nervous system was the origin of the disease. Among the 17 emergency physicians (EPs), the median of the MFS and RTS was 23 (interquartile range [IQR] 19-25) and 21 (IQR 20-23), respectively. EPs who were relatively risk-averse and those who possessed a higher level of malpractice fear were not more likely to order brain CTs for patients with isolated headaches. CONCLUSIONS: Individual EP risk tolerance, as measured by RTS, and malpractice concerns, measured by MFS, were not predictive of CT use in patients with isolated headaches.

Seniority of Emergency Physician, Patient Disposition and Outcome Following Disposition.

OBJECTIVES: The relationship between the seniority of emergency physicians (EPs) and disposition decision-making is not well defined. As most responsibility by EPs involves developing an appropriate disposition plan, this study aimed to examine the influence of EP seniority on decisions regarding patient dispositions in the emergency department (ED). MATERIALS AND METHODS: This retrospective, 1-year, cohort study was conducted in 3 EDs including all day-shift nontraumatic adult patients. The outcome involves patient dispositions at the end of the shift, patient final dispositions and patient 72-hour ED return. The EPs were categorized into the following 3 groups according to seniority: junior group (≤5 years of work experience), intermediate group (6-10 years) and senior group (>10 years). RESULTS: The dispositions of 68,333 ED patients as determined by the 59 full-time EPs were studied. Compared to junior and intermediate EPs, senior EPs kept more patients in the ED (2.7% more than junior EP, 2.3% more than intermediate EP); they had the lowest patient mortality rate especially in first triage patients (3.4% fewer than junior EP, 1.3% fewer than intermediate EP); they took more time for patient discharge (0.2 more hours than junior EP, 0.1 more hours than intermediate EP); they had fewer patients return to the ED within 72 hours after discharge (0.5% fewer than junior EP, 0.3% fewer than intermediate EP). CONCLUSIONS: Senior EPs had the best quality of care (lowest mortality, fewest 72-hour returns). This best quality of care is accompanied with a slightly longer length of stay.

Influence of CT utilisation on patient flow in the emergency department: a retrospective 1-year cohort study.

OBJECTIVE: CT, an important diagnostic tool in the emergency department (ED), might increase the ED length of stay (LOS). Considering the issue of ED overcrowding, it is important to evaluate whether CT use delays or facilitates patient disposition in the ED. DESIGN: A retrospective 1-year cohort study. SETTING: 5 EDs within the same healthcare system dispersed nationwide in Taiwan. PARTICIPANTS: All adult non-trauma patients who visited the 5 EDs from 1 July 2011 to 30 June 2012. INTERVENTIONS: Patients were grouped by whether or not they underwent a CT scan (CT and non-CT groups, respectively). PRIMARY AND SECONDARY OUTCOME MEASURES: The ED LOS and hospital LOS between patients who had and had not undergone CT scans were compared by stratifying different dispositions and diagnoses. RESULTS: CT use prolonged patient ED LOS among those who were directly discharged from the ED. Among patients admitted to the observation unit and then discharged, patients diagnosed with nervous system disease had shorter ED LOS if they underwent a CT scan. CT use facilitated patient admission to the general ward. CT use also accelerated patients' admission to the intensive care unit (ICU) for patients with nervous system disease, neoplasm and digestive disease. Finally, patients admitted to the general wards had shorter hospital LOS if they underwent CT scans in the ED. CONCLUSIONS: CT use did not seem to have delayed patient disposition in ED. While CT use facilitated patient disposition if they were finally hospitalised, it mildly prolonged ED LOS in cases of patients discharged from the ED.

Impact of Different Initial Epinephrine Treatment Time Points on the Early Postresuscitative Hemodynamic Status of Children With Traumatic Out-of-hospital Cardiac Arrest.

The postresuscitative hemodynamic status of children with traumatic out-of-hospital cardiac arrest (OHCA) might be impacted by the early administration of epinephrine, but this topic has not been well addressed. The aim of this study was to analyze the early postresuscitative hemodynamics, survival, and neurologic outcome according to different time points of first epinephrine treatment among children with traumatic OHCA.Information on 388 children who presented to the emergency departments of 3 medical centers and who were treated with epinephrine for traumatic OHCA during the study period (2003-2012) was retrospectively collected. The early postresuscitative hemodynamic features (cardiac functions, end-organ perfusion, and consciousness), survival, and neurologic outcome according to different time points of first epinephrine treatment (early: <15, intermediate: 15-30, and late: >30 minutes after collapse) were analyzed.Among 165 children who achieved sustained return of spontaneous circulation, 38 children (9.8%) survived to discharge and 12 children (3.1%) had good neurologic outcomes. Early epinephrine increased the postresuscitative heart rate and blood pressure in the first 30 minutes, but ultimately impaired end-organ perfusion (decreased urine output and initial creatinine clearance) (all P < 0.05). Early epinephrine treatment increased the chance of achieving sustained return of spontaneous circulation, but did not increase the rates of survival and good neurologic outcome.Early epinephrine temporarily increased heart rate and blood pressure in the first 30 minutes of the postresuscitative period, but impaired end-organ perfusion. Most importantly, the rates of survival and good neurologic outcome were not significantly increased by early epinephrine administration.

The Impact of Emergency Physician Seniority on Clinical Efficiency, Emergency Department Resource Use, Patient Outcomes, and Disposition Accuracy.

The ability of emergency physicians (EPs) to continue within the specialty has been called into question due to high stress in emergency departments (EDs).The purpose of this study was to investigate the impact of EP seniority on clinical performance.A retrospective, 1-year cohort study was conducted across 3 EDs in the largest health-care system in Taiwan. Participants included 44,383 adult nontrauma patients who presented to the EDs. Physicians were categorized as junior, intermediate, and senior EPs according to ≤5, 6 to 10, and >10 years of ED work experience. The door-to-order and door-to-disposition time were used to evaluate EP efficiency. Emergency department resource use indicators included diagnostic investigations of electrocardiography, plain film radiography, laboratory tests, and computed tomography scans. Discharge and mortality rates were used as patient outcomes. Disposition accuracy was evaluated by ED revisit rate.Senior EPs were found to have longer door-to-order (11.3, 12.4 minutes) and door-to-disposition (2, 1.7 hours) time than nonsenior EPs in urgent and nonurgent patients (junior: 9.4, 10.2 minutes and 1.7, 1.5 hours; intermediate: 9.5, 10.7 minutes and 1.7, 1.5 hours). Senior EPs tended to order fewer electrocardiograms, radiographs, and computed tomography scans in nonurgent patients. Adjusting for age, sex, disease acuity, and medical setting, patients treated by junior and intermediate EPs had higher mortality in the ED (adjusted odd ratios, 1.5 and 1.6, respectively).Compared with EPs with ≤10 years of work experience, senior EPs take more time for order prescription and patient disposition, use fewer diagnostic investigations, particularly for nonurgent patients, and are associated with a lower ED mortality rate.

Characteristics and Risk Factors of Out-of-Hospital Cardiac Arrest Within 72 Hours After Discharge.

OBJECTIVE: To determine the characteristics and risk factors for patients who developed out-of-hospital cardiac arrest (OHCA) within 72 hours after emergency department (ED) discharge. METHODS: A nested case-control study (1:4 ratio) was conducted in 5 EDs from January 2002 to December 2011. The study group consisted of adults experiencing nontraumatic OHCA who revisited ED within 72 hours after discharge. Patients matched in sex, age group and chief complaints were selected for the control group. Demographic data, discharge diagnosis, discharge vital signs and laboratory result were collected. Etiologies of cardiac arrest and whether the events were expected or related to the 1st ED visit were reviewed. RESULTS: In all, 1,657,870 patients were discharged during the study period; 109 developed OHCA within 72 hours of ED discharge (6.6/100,000 per year). The mean age was 64.7 years and 67.9% were men. After comparison with the control group, a higher heart rate (88.5 ± 18.23 versus 81.7 ± 15.93 beat per minutes, P = 0.003) and higher serum creatinine level (2.2 ± 2.30 versus 1.4 ± 1.38 mg/dL, P = 0.002) remain the statistical significant characteristics of study group by conditional logistic regression. Approximately 60% events were expected or unrelated to the 1st ED visit. Among patients whose OHCA were unexpected and related to the 1st ED visit, 71.4% had a cardiac cause. Of these, 20% had chest pain, but 40% had angina-equivalent symptoms during 1st presentation. CONCLUSIONS: A higher discharge heart rate and higher creatinine level are risk factors in these patients.

The role of meperidine in reduction of postanesthetic shivering and its possible impact on flap outcomes.

Postoperative vascular compromise is a common but critical complication requiring emergent re-exploration, and remains a chief cause of free flap failure. This study investigated the relationship between postanesthetic shivering (PAS) and the development of postoperative complications associated with free flap reconstruction. One hundred thirty-six patients who underwent head and neck cancer resection and free flap reconstruction were retrospectively enrolled. Fifteen patients were assigned to the PAS group, while the others were assigned to the non-PAS (NPAS) group. The odds ratios of acute re-exploration or total failure of the free flap in the PAS group was 3.5 and 14.9, respectively. The dose of meperidine was positively correlated with PAS prevention in our statistical ROC curve analysis. The minimum effective dose of meperidine for PAS prevention was 0.35 mg/kg with 75% sensitivity and 60% specificity. These findings indicate that an optimal dose of meperidine could prevent PAS, which is shown to be associated with a decrease in the incidence of the early post-surgical re-exploration rate of these free flaps related to circulatory compromise.