Ah Jin Kim

Application of high-flow nasal cannula in the ED for patients with solid malignancy.

Age, y 71.6 ± 10.6 Male sex 4 (36.3%) Body mass index, kg/m 20.3 ± 5.4 Mode of arrival, ambulance 8 (72.7%) Triage, red 10 (90.9%) Location of primary cancer Lung 4 (36.3%) Gastrointestinal tract 4 (36.3%) Hepatobiliary tract 2 (18.1%) Disease status Active 8 (72.7%) No evidence of disease 3 (27.2%) Metastasis to lungs 5 (45.4%) Chemotherapy in the last 30 d 3 (27.2%) Comorbid conditions Diabetes mellitus 3 (27.2%) Heart diseases 2 (18.1%) Neurodegenerative diseases 2 (18.1%) Chronic lung diseases 1 (9.0%) APACHE II 23.3 ± 4.0 Reasons for acute respiratory failure Pneumonia 8 (72.7%) Cardiogenic 1 (9.0%) Nephrogenic 1 (9.0%) Other 1 (9.0%) Do-not-intubate order 4 (36.3%) Vital signs on presentation Systolic blood pressure, mm Hg 136.8 ± 39.9 Diastolic blood pressure, mm Hg 76.4 ± 20.1 Heart rate, beats/min 112.9 ± 27.7 Respiratory rate, breaths/min 32.1 ± 6.2 Body temperature, °C 36.7 ± 0.8 Saturation, % 79.1 ± 8.9 Bilateral pulmonary infiltrates on chest radiograph 9 (81.8%) Arterial blood gas on presentation pH 7.3 ± 0.1 PCO2, mm Hg 37.4 ± 13.0 PO2, mm Hg 48.1 ± 12.2 HCO3, mmol/L 19.4 ± 5.0 SpO2 76.3 ± 16.9 Neutropenia 1 (9.0%) CRP, mg/dL 12.3 ± 11.2 Use of vasopressor 2 (18.1%) Hopeless discharge 2 (18.1%) Death 4 (36.3%)

Proposal of improvement in patients with urinary tract infection in emergency department: Adding HCO3− to quick sepsis-related organ failure assessment (qSOFA) with a cut-off value of 1:

Background: In 2016, the Sepsis-3 Task Force introduced a simpler algorithm, named quick sepsis-related organ failure assessment, for patients in a non-intensive care unit setting. Objectives: The study was designed to investigate the predictive performance of quick sepsis-related organ failure assessment for intensive care unit admission using the area under the curve of receiver operating characteristic specifically in patients of clinically diagnosed urinary tract infection in the emergency department and to compare its performance with that of systemic inflammatory response syndrome and sequential (sepsis-related) organ failure assessment. Methods: Retrospective analyses on adult urinary tract infection patients presenting to the emergency department between June 2015 and May 2016 were undertaken. We compared patients who were admitted to the intensive care unit to those who were not. Results: Of the total 220 urinary tract infection patients, 20 (9.1%) were hospitalized to the intensive care unit and there was no in-hospital mortality. Independent predictors for intensive care unit admission using multiple logistic regression were HCO3− and creatinine. The area under the curve of receiver operating characteristic values of systemic inflammatory response syndrome, quick sepsis-related organ failure assessment, and sequential (sepsis-related) organ failure assessment were 0.759, 0.752, and 0.824 on intensive care unit admission, respectively, and there was no significant difference between any of them. Interestingly, adding HCO3− to quick sepsis-related organ failure assessment improved the predictive performance compared to quick sepsis-related organ failure assessment alone (AUC: 0.844 vs 0.752, respectively; p < 0.05), and a cut-off value of 20 mmol/L for HCO3− yielded the largest area under the curve of receiver operating characteristic value. Moreover, when lowering the cut-off value of quick sepsis-related organ failure assessment to 1 and combining to HCO3−, its sensitivity was increased from 22% to 90%. Conclusion: Among patients presenting to the emergency department with clinically diagnosed urinary tract infection, the use of a new model, which is adding HCO3− to quick sepsis-related organ failure assessment with a lowered cut-off value of 1, resulted in greater predictive performance regarding intensive care unit admission than original quick sepsis-related organ failure assessment.

Hemodynamic changes in patients with influenza A after propacetamol infusion in the emergency department

Objectives: Recently, there has been an emerging clinical data suggesting that intravenous propacetamol may cause iatrogenic hypotension. The primary objective of this study was to evaluate hemodynamic changes after propacetamol infusion in the emergency department (ED) with the patients of influenza A. Secondary objective was to assess the incidence of propacetamol‐induced significant hypotension and to evaluate factors associated with this adverse effect by comparing two groups of patients with or without a significant reduction in blood pressure (BP). Methods: We retrospectively reviewed the medical records of the patients with laboratory‐confirmed influenza A who received intravenous propacetamol for the control of fever in the ED during the 2015–16 influenza season. Results: 101 patients of influenza A were included in this study. Overall, all the vital signs including BP, pulse rate and body temperature recorded after propacetamol administration were lower than the pre‐infusion values. A significant reduction in BP was observed in 30 (29.7%) patients and 6 (20%) of them required crystalloid infusion. Interestingly, pre‐infusion BPs were higher in the group of propacetamol‐induced significant hypotension, yet there was no difference in post‐infusion BPs between the groups. Discussion: To our knowledge this is the first study on the effect of intravenous propacetamol in the ED patients with influenza A infection. We hypothesized that the group with a significant reduction in BP could have higher sympathetic tone, consequently showing higher pre‐infusion BPs and pulse rate. And there was no difference in post‐infusion BPs because baroreflex homeostasis could compensate further decrease in BPs.

Spontaneous intercostal artery bleeding in a hemodialysis patient

Spontaneous rupture of an intercostal artery (ICA) is a rare but could be a life‐threatening emergency requiring prompt diagnosis and intervention for optimal outcome. We report a patient presented with swelling in his right‐side back which started immediately after scheduled hemodialysis and continued to increase in size. Contrast computed tomography scan revealed soft tissue attenuated lesion with internal enhancing dots which suggested expanding hematoma with active bleeding. Arteriography detected focal contrast extravasation from seventh ICA, and transcatheter arterial embolization was successfully done. To the best of our knowledge, this is the first report describing spontaneous bleeding of ICA in a hemodialysis patient.

Hemodynamic changes after propacetamol administration in patients with febrile UTI in the emergency department

Objectives Clinical studies have indicated that transient hypotension can occur after propacetamol administration. This study aimed to analyze the hemodynamic changes after propacetamol administration in patients visiting the ED due to febrile UTI. We also examined the incidence of propacetamol‐induced hypotension and compared the clinical characteristics of patients with persistent hypotension, defined as requiring additional fluids or vasopressors, to those with transient hypotension. Methods A retrospective analysis of the electronic medical records of patients who visited the ED between June 2015 and May 2016, were diagnosed with febrile UTI, and treated with propacetamol, was conducted. Results We included 195 patients in this study; of these, 87 (44.6%) showed hypotension. In all patients, significant decreases in systolic blood pressure (SBP; 135.06 ± 20.45 mm Hg vs 117.70 ± 16.41 mm Hg), diastolic blood pressure (DBP; 79.74 ± 12.17 mm Hg vs 69.69 ± 10.96 mm Hg), and heart rate (97.46 ± 17.14 mm Hg vs 90.72 ± 14.90 mm Hg) were observed after propacetamol administration. The basal SBP and DBP were higher in the hypotension than in the non‐hypotension group (basal SBP: 144.4 ± 22.3 mm Hg vs 127.6 ± 15.3 mm Hg; basal DBP: 83.3 ± 12.6 mm Hg vs 76.9 ± 11.0 mm Hg). Patients with persistent hypotension had a lower baseline BP, which was not elevated despite fever, and a higher rate of bacteremia than those with transient hypotension. Conclusions Although febrile UTI patients treated with propacetamol in the ED showed hemodynamic changes, these changes did not have a large effect on their prognosis. However, in patients who showed bacteremia or a normal initial BP despite fever, the possibility of developing persistent hypotension should be considered.