RESUMEN
Background and objectives: To compare the first pass success (FPS) rate of the C-MAC video laryngoscope (C-MAC) and conventional Macintosh-type direct laryngoscopy (DL) during cardiopulmonary resuscitation (CPR) in the emergency department (ED). Materials and Methods: This study was a single-center, retrospective study conducted from April 2014 to July 2018. Patients were categorized into either the C-MAC or DL group, according to the device used on the first endotracheal intubation (ETI) attempt. The primary outcome was the FPS rate. A multiple logistic regression model was developed to identify factors related to the FPS. Results: A total of 573 ETIs were performed. Of the eligible cases, 263 and 310 patients were assigned to the C-MAC and DL group, respectively. The overall FPS rate was 75% (n = 431/573). The FPS rate was higher in the C-MAC group than in the DL group, but there was no statistically significant difference (total n = 431, 79% compared to 72%, p = 0.075). In the multiple logistic regression analysis, the C-MAC use had higher FPS rate (adjusted odds ratio: 1.80; 95% CI, 1.17-2.77; p = 0.007) than that of the DL use. Conclusions: The C-MAC use on the first ETI attempt during cardiopulmonary resuscitation in the emergency department had a higher FPS rate than that of the DL use.
Asunto(s)
Intubación Intratraqueal/instrumentación , Laringoscopios/normas , Resucitación/instrumentación , Anciano , Manejo de la Vía Aérea , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Intubación Intratraqueal/métodos , Laringoscopios/efectos adversos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud/normas , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Resucitación/métodos , Estudios RetrospectivosRESUMEN
PURPOSE: Postintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department (ED) endotracheal intubation. This study aimed to evaluate the association between sedative dose adjustment and PIH during emergency airway management. We also investigated the impact of patient and procedural factors on the incidence of PIH. MATERIALS AND METHODS: This was a single-center, retrospective study that used a prospectively collected registry of airway management performed at the ED from April 2014 to February 2017. Adult patients who received emergency endotracheal intubation were included. Multivariable logistic regression models were used to evaluate the association of PIH with sedative dose, patient variables, and procedural variables. RESULTS: Overall, 689 patients were included, and 233 (33.8%) patients developed PIH. In the patients overall, multivariable logistic regression demonstrated that ageâ¯>â¯70â¯years, shock index >0.8, arterial acidosis (pHâ¯<â¯7.2), intubation indication, and use of non-depolarizing neuromuscular blocking agent were significantly related to PIH. In patients overall, the sedative dose was not related to PIH (overdose; OR: 1.09, 95%CI: 0.57-2.06), (reduction; OR: 0.93, 95%CI: 0.61-1.42), (none used; OR: 1.28, 95%CI: 0.64-2.53). In subgroup analysis, ketamine dose was not related to PIH (overdose; OR: 0.81, 95%CI: 0.27-2.38, reduction; OR: 1.41, 95%CI: 0.78-2.54). Reduction of etomidate dose was significantly associated with decreased PIH (reduction; OR: 0.46, 95%CI: 0.22-0.98, overdose; OR: 1.77, 95%CI: 0.79-3.93). CONCLUSIONS: PIH was mainly related to predisposing patient-related factors. Only adjustment of etomidate dose was associated with the incidence of PIH.
Asunto(s)
Servicio de Urgencia en Hospital , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/efectos adversos , Hipotensión/etiología , Intubación Intratraqueal/efectos adversos , Anciano , Manejo de la Vía Aérea/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
OBJECTIVES: We determined the usefulness of C-MAC video laryngoscope (C-MAC) as a safe training tool for the direct laryngoscopy technique in the emergency department. METHODS: We retrospectively analyzed an institutional airway registry of adult (≥18 years old) patients from April 2014 through October 2016. In this study, the operator used C-MAC as a direct laryngoscope (DL) with limited access to the screen, and the supervisor instructed the operator via verbal feedback while watching the screen. Patients were categorized into the DL group if a conventional DL was used and the C-DL group if a C-MAC used as a DL. RESULTS: Of 744 endotracheal intubations, 163 propensity score-matched pairs were generated (1-to-n matching: C-DL group, 163 vs. DL group, 428). For the propensity-matched groups, the overall first pass success rate was 69%, while those in the C-DL and DL groups were 79% and 65%, respectively. Overall, multiple attempts were required in 8% of patients, with 4% in the C-DL group and 9% in the DL group. The overall complication rate was 11%, with 4% in the C-DL group and 14% in the DL group. In multivariable analysis, the adjusted odds ratios of C-DL use for first pass success, multiple attempts, and complications were 2.05 (95% confidence interval [CI] 1.18-2.87, p < 0.01), 0.38 (95% CI 0.15-0.94; p < 0.01), and 0.28 (95% CI 0.12-0.63; p < 0.01), respectively. CONCLUSIONS: Our study suggests that the C-MAC could be useful for training residents in the direct laryngoscopy while ensuring patient safety in the emergency department.
Asunto(s)
Internado y Residencia , Intubación Intratraqueal/instrumentación , Laringoscopios/efectos adversos , Laringoscopía/educación , Seguridad del Paciente/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Intubación Intratraqueal/efectos adversos , Laringoscopía/efectos adversos , Laringoscopía/instrumentación , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Puntaje de Propensión , Estudios RetrospectivosRESUMEN
OBJECTIVES: We describe our 3-year experience with endotracheal intubation (ETI) outcomes during a multidisciplinary emergency department (ED)-based quality improvement (QI) program. METHODS: This was a single-center, observational study taking place during a QI program. We used a registry for airway management performed in the ED from April 2014 to February 2017. The QI program focused on procedural standardization, airway management education, and comprehensive preparation of airway equipment. The primary outcome was first-pass success (FPS) rate. The secondary outcomes were multiple-attempts rate and overall rate of complications. RESULTS: A total of 1087 emergent ETIs were included. The FPS rate significantly increased from 68% in the first year to 74% in the second year and 79% in the third year (P for trend <0.01). The multiple-attempts rate in the first year was 12%, followed by 7% and 6% in the second and third years, respectively (P for trend <0.01). The overall complication rate was 16% in the first year, 8% in the second year, and 8% in the third year (P for trend <0.01). CONCLUSIONS: We observed improved ETI outcomes in the ED, including increased FPS rate and decrease in multiple-attempt rate and overall complication rate during the multidisciplinary QI program to enhance patient safety.
Asunto(s)
Competencia Clínica/normas , Servicio de Urgencia en Hospital/normas , Intubación Intratraqueal/métodos , Mejoramiento de la Calidad/normas , Femenino , Humanos , MasculinoRESUMEN
OBJECTIVE: Coronary angiography (CAG) for survivors of out-of-hospital cardiac arrest (OHCA) enables early identification of coronary artery disease and revascularization, which might improve clinical outcome. However, little is known for the role of CAG in patients with initial non-shockable cardiac rhythm. METHODS: We investigated clinical outcomes of successfully resuscitated 670 adult OHCA patients who were transferred to 27 hospitals in Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES), a Korean nationwide multicenter registry. The primary outcome was 30-day survival with good neurological outcome. Propensity score matching and inverse probability of treatment weighting analyses were performed to account for indication bias. RESULTS: A total of 401 (60%) patients showed initial non-shockable rhythm. CAG was performed only in 13% of patients with non-shockable rhythm (53 out of 401 patients), whereas more than half of patients with shockable rhythm (149 out of 269 patients, 55%). Clinical outcome of patients who underwent CAG was superior to patients without CAG in both non-shockable (hazard ratio (HR) = 3.6, 95% confidence interval (CI) = 2.5-5.2) and shockable rhythm (HR = 3.7, 95% CI = 2.5-5.4, p < 0.001, all). Further analysis after propensity score matching or inverse probability of treatment weighting showed consistent findings (HR ranged from 2.0 to 3.2, p < 0.001, all). CONCLUSIONS: Performing CAG was related to better survival with good neurological outcome of OHCA patients with initial non-shockable rhythms as well as shockable rhythms.
Asunto(s)
Angiografía Coronaria , Paro Cardíaco Extrahospitalario/fisiopatología , Anciano , Reanimación Cardiopulmonar , Electrocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , República de Corea , Resultado del TratamientoRESUMEN
OBJECTIVE: Acute myocardial infarction is a major cause of out-of-hospital cardiac arrest (OHCA). Coronary angiography (CAG) enables diagnostic confirmation of coronary artery disease and subsequent revascularization, which might improve the prognosis of OHCA survivors. Non-randomized data has shown a favorable impact of CAG on prognosis for this population. However, the optimal timing of CAG has been debated. METHODS: The clinical outcomes of 607 OHCA patients registered in CAPTURES (Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance), a nationwide multicenter registry performed in 27 hospitals, were analyzed. Early CAG was defined as CAG performed within 24 hours of emergency department admission. The primary outcome was survival to discharge, with neurologically favorable status defined by cerebral performance category scores ≤2. RESULTS: Compared to patients without CAG (n=469), patients who underwent early CAG (n=138) were younger, more likely to be male, and more likely to have received bystander cardiopulmonary resuscitation, pre-hospital defibrillation, and revascularization (P<0.01 for all). Analysis of 115 propensity score-matched pairs showed that early CAG is associated with a 2.3-fold increase in survival to discharge with neurologically favorable status (P<0.001, all). Survival to discharge increased consistently according to the time interval between emergency department visit and CAG (P<0.05). CONCLUSION: Early CAG of OHCA patients was associated with better survival and favorable neurologic outcomes at discharge. However, there was no clear time threshold for CAG that predicted survival to discharge.
RESUMEN
Survivors of out-of-hospital cardiac arrest (OHCA) have high mortality and morbidity. An acute coronary event is the most common cause of sudden cardiac death. For this reason, coronary angiography is an important diagnostic and treatment strategy for patients with postcardiac arrest. This study aimed to identify the correlation between postreturn of spontaneous circulation (ROSC) on an electrocardiogram (ECG) and results of coronary angiography of OHCA survivors.We collected data from our OHCA registry from January 2010 to November 2014. We categorized OHCA survivors into 2 groups according to post-ROSC ECG results. Emergent coronary artery angiography (CAG) (CAG performed within 12âhours after cardiac arrest) was performed in patients who showed ST segment elevation or new onset of left bundle branch block (LBBB) in post-ROSC ECG. For other patients, the decision for performing CAG was made according to agreement between the emergency physician and the cardiologist.During the study period, 472 OHCA victims visited our emergency department and underwent cardiopulmonary resuscitation. Among 198 OHCA survivors, 82 patients underwent coronary artery intervention. Thirty-one (70.4%) patients in the ST segment elevation or LBBB group and 10 (24.4%) patients in the nonspecific ECG group had coronary artery lesions (Pâ<â.01). Seven (18.4%) patients in the nonspecific ECG group showed coronary spasm.OHCA survivors without ST segment elevation or new onset LBBB still have significant coronary lesions in CAG. If there is no other obvious arrest cause in patients without significant changes in post ROSC ECG, CAG should be considered to rule out the possibility of coronary artery problems, including coronary spasm.
Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Paro Cardíaco Extrahospitalario/fisiopatología , Paro Cardíaco Extrahospitalario/cirugía , Intervención Coronaria Percutánea/métodos , Adulto , Anciano , Anciano de 80 o más Años , Reanimación Cardiopulmonar , Angiografía Coronaria , Electrocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/diagnóstico por imagen , Paro Cardíaco Extrahospitalario/mortalidad , Estudios RetrospectivosRESUMEN
A 59-year-old man presented to the emergency department with a chief complaint of sore throat after swallowing sodium picosulfate/magnesium citrate powder for bowel preparation, without first dissolving it in water. The initial evaluation showed significant mucosal injury involving the oral cavity, pharynx, and epiglottis. Endotracheal intubation was performed for airway protection in the emergency department, because the mucosal swelling resulted in upper airway compromise. After conservative treatment in the intensive care unit, he underwent tracheostomy because stenosis of the supraglottic and subglottic areas was not relieved. The tracheostomy tube was successfully removed after confirming recovery, and he was discharged 3 weeks after admission.
RESUMEN
Background. Basic life support (BLS) training with hands-on practice can improve performance during simulated cardiac arrest, although the optimal duration for BLS training is unknown. This study aimed to assess the effectiveness of various BLS training durations for acquiring cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) skills. Methods. We randomised 485 South Korean nonmedical college students into four levels of BLS training: level 1 (40 min), level 2 (80 min), level 3 (120 min), and level 4 (180 min). Before and after each level, the participants completed questionnaires regarding their willingness to perform CPR and use AEDs, and their psychomotor skills for CPR and AED use were assessed using a manikin with Skill-Reporter™ software. Results. There were no significant differences between levels 1 and 2, although levels 3 and 4 exhibited significant differences in the proportion of overall adequate chest compressions (p < 0.001) and average chest compression depth (p = 0.003). All levels exhibited a greater posttest willingness to perform CPR and use AEDs (all, p < 0.001). Conclusions. Brief BLS training provided a moderate level of skill for performing CPR and using AEDs. However, high-quality skills for CPR required longer and hands-on training, particularly hands-on training with AEDs.
Asunto(s)
Reanimación Cardiopulmonar/educación , Reanimación Cardiopulmonar/instrumentación , Reanimación Cardiopulmonar/métodos , Desfibriladores , Educación Médica , Encuestas y Cuestionarios , Adulto , Femenino , Humanos , MasculinoRESUMEN
AIMS: Clinical evidence supporting triple rule-out computed tomography (TRO-CT) for rapid screening of cardiovascular disease is limited. We investigated the clinical value of TRO-CT in patients with acute chest pain. METHODS: We retrospectively enrolled 1024 patients who visited the emergency department (ED) with acute chest pain and underwent TRO-CT using a 128-slice CT system. TRO-CT was classified as "positive" if it revealed clinically significant cardiovascular disease including obstructive coronary artery disease, pulmonary thromboembolism, or acute aortic syndrome. The clinical endpoint was occurrence of a major adverse cardiovascular event (MACE) within 30 days, defined by a composite of all cause death, myocardial infarction, revascularization, major cardiovascular surgery, or thrombolytic therapy. Clinical risk scores for acute chest pain including TIMI, GRACE, Diamond-Forrester, and HEART were determined and compared to the TRO-CT findings. RESULTS: TRO-CT revealed clinically significant cardiovascular disease in 239 patients (23.3%). MACE occurred in 119 patients (49.8%) with positive TRO-CT and in 7 patients (0.9%) with negative TRO-CT (p < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value of TRO-CT was 95%, 88%, 54%, and 99%, respectively. TRO-CT was a better discriminator between patients with vs. without events as compared to clinical risk scores (c-statistics = 0.91 versus 0.64 to 0.71; integrated discrimination improvement = 0.31 to 0.37; p < 0.001 for all comparisons). Patients with a negative TRO-CT showed shorter ED stay times and admission rates compared to patients with positive TRO-CT, irrespective of clinical risk scores (p < 0.001 for all comparisons). CONCLUSION: Triple rule-out CT has high predictive performance for 30-day MACE and permits rapid triage and low admission rates irrespective of clinical risk scores.
Asunto(s)
Angina de Pecho/diagnóstico por imagen , Enfermedades Cardiovasculares/diagnóstico por imagen , Tomografía Computarizada Multidetector , Triaje/métodos , Anciano , Angina de Pecho/etiología , Angina de Pecho/mortalidad , Angina de Pecho/terapia , Servicio de Cardiología en Hospital , Enfermedades Cardiovasculares/complicaciones , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/terapia , Servicio de Urgencia en Hospital , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Admisión del Paciente , Valor Predictivo de las Pruebas , Pronóstico , Sistema de Registros , Reproducibilidad de los Resultados , República de Corea , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de TiempoRESUMEN
AIM: We aimed to evaluate the prognostic value of optic nerve sheath diameter (ONSD) and grey-to-white matter (GWR) either alone or in combination in patients treated with targeted temperature management (TTM) after cardiac arrest (CA). METHODS: We conducted a retrospective single centre study of post cardiac arrest patients treated with TTM. ONSD and GWR on brain computed tomography (CT) was measured by two emergency physicians. We analysed the prognostic performance and cut offs of GWR and ONSD, singly and in combination in predicting poor neurologic outcome (CPC 3-5). RESULTS: Of the 119 patients studied, 74 patients showed poor outcome. The combination of ONSD and GWR significantly (p=0.002) improved prognostic performance (AUROC 0.67, 95% CI: 0.58-0.76, p<0.001) in predicting poor neurologic outcomes rather than each ONSD (AUROC 0.59, 95% CI: 0.50-0.68, p=0.08) or GWR (AUROC 0.65, 95% CI: 0.56-0.74, p=0.002) alone. A combined cut off of 'GWR and ONSD (1.16 and 4.9)' and 'GWR or ONSD (1.13 or 6.5)' improved the sensitivity for predicting poor outcome while maintaining high specificity compared to GWR alone. CONCLUSION: The combination of ONSD and GWR yielded improved prognostic value for predicting poor neurologic outcomes in post cardiac arrest patients treated with TTM.
Asunto(s)
Sustancia Gris/diagnóstico por imagen , Paro Cardíaco/mortalidad , Nervio Óptico/diagnóstico por imagen , Daño por Reperfusión/mortalidad , Sustancia Blanca/diagnóstico por imagen , Adulto , Anciano , Cuidados Críticos , Femenino , Sustancia Gris/patología , Paro Cardíaco/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Nervio Óptico/patología , Curva ROC , Daño por Reperfusión/etiología , Estudios Retrospectivos , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X/métodos , Sustancia Blanca/patologíaRESUMEN
PURPOSE: Central diabetes insipidus (CDI) after cardiac arrest is not well described. Thus, we aim to study the occurrences, outcomes, and risk factors of CDI of survivors after out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS: We retrospectively analyzed post-OHCA patients treated at a single center. Central diabetes insipidus was retrospectively defined by diagnostic criteria. One-month cerebral performance category (CPC) scores were collected for outcomes. RESULTS: Of the 169 patients evaluated, 36 patients (21.3%) were diagnosed with CDI. All CDI patients had a poor neurologic outcome of either CPC 4 (13.9%) or CPC 5 (86.1%), and CDI was strongly associated with mortality. Age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.93-0.99), respiratory arrest (OR, 6.62; 95% CI, 1.23-35.44), asphyxia (OR, 9.26; 95% CI, 2.17-34.61), and gray to white matter ratio on brain computed tomogram (OR, 0.88; 95% CI, 0.81-0.95) were associated with the development of CDI. The onset of CDI was earlier (P < .001) and the maximum 24-hour urine output was larger (P = .03) in patients with worst outcomes. CONCLUSIONS: All patients diagnosed with CDI had poor neurologic outcomes, and occurrence of CDI was associated with mortality. Central diabetes insipidus patients with death or brain death had earlier occurrence of CDI and more maximum urine output.
Asunto(s)
Diabetes Insípida Neurogénica/complicaciones , Cardiomiopatías Diabéticas/complicaciones , Nefropatías Diabéticas/complicaciones , Paro Cardíaco Extrahospitalario/complicaciones , Adulto , Diabetes Insípida Neurogénica/mortalidad , Diabetes Insípida Neurogénica/terapia , Cardiomiopatías Diabéticas/mortalidad , Cardiomiopatías Diabéticas/terapia , Nefropatías Diabéticas/mortalidad , Nefropatías Diabéticas/terapia , Femenino , Humanos , Hipotermia Inducida/métodos , Hipotermia Inducida/mortalidad , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
Massive pulmonary embolism (MPE) with hemodynamic instability is a clinical condition with a poor prognosis and high mortality rates. There are no definitive treatment options for cardiac arrest due to MPE. A 52-year-old female presented at our emergency department with cardiac arrest, and a 62-year-old female presented after achieving return of spontaneous circulation of cardiac arrest from a local hospital, respectively. In each case, computed tomographic pulmonary angiography after return of spontaneous circulation demonstrated heavy burdens of pulmonary embolism in the pulmonary arteries. We immediately started therapeutic hypothermia and fibrinolytic therapy. They were transferred to the thoracic surgery and cardiology departments respectively, and then discharged with a cerebral performance categories scale score of 1. In summary, we report two cases of out-of-hospital cardiac arrest due to MPE in which fibrinolytic therapy was successfully combined with therapeutic hypothermia.
RESUMEN
OBJECTIVE: We aimed to estimate the accuracy of visual estimation of chest compression depth and identify potential factors affecting accuracy. METHODS: This simulation study used a basic life support mannequin, the Ambu man. We recorded chest compression with 7 different depths from 1 to 7 cm. Each video clip was recorded for a cycle of compression. Three different viewpoints were used to record the video. After filming, 25 clips were randomly selected. Health care providers in an emergency department were asked to estimate the depth of compressions while watching the selected video clips. Examiner determinants such as experience and cardiopulmonary resuscitation training and environment determinants such as the location of the camera (examiner) were collected and analyzed. An estimated depth was considered correct if it was consistent with the one recorded. A multivariate analysis predicting the accuracy of compression depth estimation was performed. RESULTS: Overall, 103 subjects were enrolled in the study; 42 (40.8%) were physicians, 56 (54.4%) nurses, and 5 (4.8%) emergency medical technicians. The mean accuracy was 0.89 (standard deviation, 0.76). Among examiner determinants, only subjects' occupation and clinical experience showed significant association with outcome (P=0.03 and P=0.08, respectively). All environmental determinants showed significant association with the outcome (all P<0.001). Multivariate analysis showed that accuracy rate was significantly associated with occupation, camera position, and compression depth. CONCLUSIONS: The accuracy rate of chest compression depth estimation was 0.89 and was significantly related with examiner's occupation, camera view position, and compression depth.
RESUMEN
Radial artery puncture, an invasive procedure, is frequently used for critical patients. Although considered safe, severe complications such as finger necrosis can occur. Herein, we review the clinical course of finger necrosis after accidental radial artery puncture. A 63-year-old woman visited the emergency department (ED) with left second and third finger pain after undergoing intravenous (IV) access in her wrist for procedural sedation. During the IV access, she experienced wrist pain, which increased during the 12 hours prior to her ED presentation. Emergency angiography revealed a pseudoaneurysm in her left radial artery and absence of blood flow to the proper palmar digital artery. Subsequent angiointervention and urokinase thrombolysis failed. The second finger was eventually amputated owing to gangrene. Radial artery puncture can occur accidentally during IV wrist access, resulting in severe morbidity. Providers should carefully examine the puncture site and collateral flow, followed by multiple examinations to ensure distal circulation.
RESUMEN
OBJECTIVE: We aimed to investigate the effect of timely antibiotic administration on outcomes in patients with severe sepsis and septic shock. METHODS: We analyzed data from a sepsis registry that included adult patients who initially presented to the emergency department (ED) and met criteria for severe sepsis or septic shock. Timely antibiotic use was defined as administration of a broad-spectrum antibiotic within three hours from the time of ED arrival. Multivariable logistic and linear regression analyses were performed to assess associations between timely administration of antibiotics and outcomes, including hospital mortality, 48-hour change in Sequential Organ Failure Assessment (SOFA) score (delta SOFA), and hospital length of stay (LOS). RESULTS: A total of 591 patients were included in the study. In-hospital mortality was 16.9% for patients receiving timely antibiotics (n=377) and 22.9% for patients receiving delayed antibiotics (n=214; P=0.04). The adjusted odds ratio for in-hospital survival was 0.54 (95% confidence interval [CI], 0.34 to 0.87; P=0.01) in patients who received timely antibiotics. Timely antibiotic administration was also significantly associated with higher delta SOFA (2 vs. 1) and shorter hospital LOS among survivors (11 days vs. 15 days). Multivariable linear regression analyses showed that timely antibiotic administration was significantly associated with increased delta SOFA and decreased hospital LOS. CONCLUSION: Antibiotic administration within three hours from the time of ED arrival was significantly associated with improved outcomes, including in-hospital survival, reversal of organ failure, and shorter hospital LOS, in patients with severe sepsis and septic shock.
RESUMEN
It has been proven that safety and efficiency of out-of-hospital cardiac arrest (OHCA) patients is transported to specialized hospitals that have the capability of performing therapeutic hypothermia (TH). However, the outcome of the patients who have been transferred after return of spontaneous circulation (ROSC) has not been well evaluated. We conducted a retrospective observational study between January 2010 to March 2012. There were primary outcomes as good neurofunctional status at 1 month and the secondary outcomes as the survivals at 1 month between Samsung Medical Center (SMC) group and transferred group. A total of 91 patients were enrolled this study. There was no statistical difference between good neurologic outcomes between both groups (38% transferred group vs. 40.6% SMC group, P=0.908). There was no statistical difference in 1 month survival between the 2 groups (66% transferred group vs. 75.6% SMC group, P=0.318). In the univariate and multivariate models, the ROSC to induction time and the induction time had no association with good neurologic outcomes. The good neurologic outcome and survival at 1 month had no significant differences between the 2 groups. This finding suggests the possibility of integrated post-cardiac arrest care for OHCA patients who are transferred from other hospitals after ROSC in the cardiac arrest center.
Asunto(s)
Paro Cardíaco/mortalidad , Adulto , Anciano , Reanimación Cardiopulmonar , Electrocardiografía , Femenino , Humanos , Hipotermia Inducida , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Paro Cardíaco Extrahospitalario , Estudios Retrospectivos , Tomografía Computarizada por Rayos XRESUMEN
We aimed to compare outcomes of sepsis patients according to their hemodynamic presentation: cryptic shock (CS), cryptic to overt shock (COS), and overt shock (OS). We analyzed the sepsis registry for adult patients who presented to the emergency department (ED) of a tertiary hospital and met the criteria for severe sepsis or septic shock between August 2008 and March 2012. We classified the patients as having CS, COS, or OS. "Cryptic shock" was defined as severe sepsis with a lactate level of 4 mmol/L or greater and normotension, "COS" was defined as initial CS that progressed to septic shock within 72 h, and "OS" was defined as septic shock on ED arrival. The primary outcome was in-hospital mortality. We performed a multivariable logistic regression analysis to assess variables related to in-hospital mortality and a multivariable Cox regression analysis to assess predictive factors for progression to OS in patients who initially showed CS. A total of 591 patients were included. We assigned 187 (31.6%) patients to the CS group, 157 (26.6%) patients to the COS group, and 247 (41.8%) patients to the OS group. There was a significant difference in unadjusted in-hospital mortality among groups (7.0% in the CS group, 27.4% in the COS group, and 21.9% in the OS group; P < 0.01). Multivariable analysis showed an odds ratio (OR) for in-hospital mortality of 0.17 (95% confidence interval, 0.07 - 0.40; P < 0.01) for the CS group and 0.83 (95% confidence interval, 0.46 - 1.49; P = 0.54) for the COS group compared with the OS group. A higher blood lactate concentration and respiratory failure were significant risk factors for progression to OS. In conclusion, CS without deterioration to hypotension during initial treatment showed significantly lower mortality than OS. The mortality from CS that progressed to apparent hypotension, however, was comparable to the mortality associated with OS.