Relation between pulse oximetry plethysmographic waveform amplitude induced by passive leg raising and cardiac index in spontaneously breathing subjects.

INTRODUCTION: Previous studies suggested that variation of pulse oximetric plethysmographic (POP) waveform amplitude (Delta POP) could predict fluid responsiveness in mechanically ventilated patients. Our objective was to correlate the variations of Delta POP and the variations of cardiac index (CI) induced by passive leg raising (PLR) in spontaneously breathing volunteers. METHODS: We studied 26 spontaneously breathing volunteers using a pulse oximeter attached to the middle finger. We assessed hemodynamic variables, including Delta POP (%) (POP(max) - POP(min))/[(POP(max) + POP(min))/2] and CI determined by transthoracic echocardiography at baseline (eg, semirecumbent position), during PLR at 60 degrees, and back to baseline. RESULTS: Cardiac index significantly increased from 2.2 to 2.5 L/min x m(2) (P < .01) at 60 degrees PLR. Conversely, Delta POP significantly decreased from 22% to 15% (P < .01) at 60 degrees PLR. There was a weak correlation between CI and Delta POP variations at 60 degrees PLR (r = 0.40; P < .01). The area under curve of the receiver operating characteristic curve for Delta POP as a predictor of an increase of CI of 15% was not significant (0.67 +/- 0.10; P = .16). CONCLUSION: The variation of Delta POP induced by PLR is not an accurate predictor of increase in CI.

Stroke in elderly patients: management and prognosis in the ED.

PURPOSE: The aim of the study was to analyze the effect of age on management and prognosis of stroke. METHODS: A retrospective study was performed in consecutive patients admitted to an emergency department (ED) with a diagnosis of stroke. Comparison according to age (< 75 vs > or = 75 years old) was done, with a 1-year follow-up including autonomy and outcome. RESULTS: In older patients, brain magnetic resonance imaging (6% vs 27%, P < .001) and immediate referral to the stroke unit were less frequent (6% vs 28%, P < .001); median length of stay was longer (11 vs 8 days, P = .007); and in-hospital mortality tended to be higher (12% vs 6%, not significant). After discharge, 1-year mortality was higher (27% vs 14%, P = .004). In a multivariate analysis, severity of stroke, hemorrhagic stroke, and dementia were independent positive predictors of 1-year mortality, whereas age was not. CONCLUSION: Despite the fact that age was not an independent predictor when stroke severity was considered, our data suggest differences in the management of elderly compared with younger stroke patients admitted to the ED.

Serum procalcitonin measurement as diagnostic and prognostic marker in febrile adult patients presenting to the emergency department.

INTRODUCTION: Identification of bacterial infections is crucial if treatment is to be initiated early and antibiotics used rationally. The primary objective of this study was to test the efficiency of procalcitonin (PCT) in identifying bacterial/parasitic episodes among febrile adult patients presenting to an emergency department. Secondary objectives were to identify clinical or biological variables associated with either bacterial/parasitic infection or critical illness. METHODS: This was a prospective, single centre, non-interventional study, conducted in the adult emergency department of an academic tertiary care hospital. We included patients with body temperature of 38.5 degrees C or greater. A serum sample for measurement of PCT was collected in the emergency room. Patients were followed up until day 30. After reviewing the medical files, two independent experts, who were blind to the PCT results, classified each of the patients as having a bacterial/parasitic infection, viral infection, or another diagnosis. RESULTS: Among 243 patients included in the study, 167 had bacterial/parasitic infections, 35 had viral infections and 41 had other diagnoses. The PCT assay, with a 0.2 microg/l cutoff value, had a sensitivity of 0.77 and a specificity of 0.59 in diagnosing bacterial/parasitic infection. Of the patients with PCT 5 microg/l or greater, 51% had critical illness (death or intensive care unit admission) as compared with 13% of patients with lower PCT values. CONCLUSION: Bearing in mind the limitations of an observational study design, the judgements of the emergency department physicians were reasonably accurate in determining the pretest probability of bacterial/parasitic infection. PCT may provide additional, valuable information on the aetiology and prognosis of infection in the emergency department.

Assessment of early administration of abciximab in acute ST-segment elevation myocardial infarction in the emergency room.

OBJECTIVE: Abciximab, a platelet glycoprotein IIb/IIIa inhibitor, administered in conjunction with primary coronary stenting, improves the outcome of acute myocardial infarction, and the earlier it is administered, the greater the improvement. We sought to assess the feasibility of early administration of abciximab in the emergency room (ER) before primary coronary stenting and compare our results with those of a group of patients treated in the prehospital (ambulance) phase. METHODS: Data and outcome of patients with acute ST-segment elevation myocardial infarction who received abciximab (0.25 mg x kg(-1) then 0.125 mg x kg(-1) x h(-1)) in the ER before primary coronary stenting were compared with those of patients who received abciximab in the prehospital phase. RESULTS: Characteristics of the group treated in the ER did not differ significantly from those of patients treated before arrival at the hospital, except for prevalence of diabetes (22 versus 5%, p<0.05) and administration of analgesic to control chest pain (22 versus 65%, p<0.05). Nor did the median time between onset of pain and abciximab administration differ significantly different (120 versus 160 min, NS). In contrast, the median delay between the beginning of abciximab administration and insertion of the cardiac catheter was significantly shorter in the ER group (35 versus 55 min, p<0.05). There were no significant differences between groups in TIMI flow grade before or after revascularization, specific revascularization performed, or outcome. CONCLUSION: Our study provides some evidence that early administration of abciximab in the ER is safe, feasible, and justified by the delay required for coronary revascularization.