Min Seob Sim

Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation*

Objective:We investigated whether the survival of patients with inhospital cardiac arrest could be extended by extracorporeal cardiopulmonary resuscitation supported with extracorporeal membrane oxygenation compared with those of conventional cardiopulmonary resuscitation. Design:A retrospective, single-center, observational study. Setting:A tertiary care university hospital. Patients:We retrospectively analyzed a total of 406 adult patients with witnessed inhospital cardiac arrest receiving cardiopulmonary resuscitation for >10 mins from January 2003 to June 2009 (85 in the extracorporeal cardiopulmonary resuscitation group and 321 in the conventional cardiopulmonary resuscitation group). Interventions:None. Measurements and Main Results:The primary end point was a survival discharge with minimal neurologic impairment. Propensity score matching was used to balance the baseline characteristics and cardiopulmonary resuscitation variables that could potentially affect prognosis. In the matched population (n = 120), the survival discharge rate with minimal neurologic impairment in the extracorporeal cardiopulmonary resuscitation group was significantly higher than that in the conventional cardiopulmonary resuscitation group (odds ratio of mortality or significant neurologic deficit, 0.17; 95% confidence interval, 0.04–0.68; p = .012). In addition, there was a significant difference in the 6-month survival rates with minimal neurologic impairment (hazard ratio, 0.48; 95% confidence interval, 0.29–0.77; p = .003; p <.001 by stratified log-rank test). In the subgroup based on cardiac origin, extracorporeal cardiopulmonary resuscitation also showed benefits for survival discharge (odds ratio, 0.19; 95% confidence interval, 0.04–0.82; p = .026) and 6-month survival with minimal neurologic impairment (hazard ratio, 0.56; 95% confidence interval, 0.33–0.97; p = .038; p = .013 by stratified log-rank test). Conclusions:Extracorporeal cardiopulmonary resuscitation showed a survival benefit over conventional cardiopulmonary resuscitation in patients who received cardiopulmonary resuscitation for >10 mins after witnessed inhospital arrest, especially in cases with cardiac origins.

Two-year survival and neurological outcome of in-hospital cardiac arrest patients rescued by extracorporeal cardiopulmonary resuscitation☆

BACKGROUND The clinical benefit of extracorporeal cardiopulmonary resuscitation (E-CPR) has been proved in short-term follow-up studies. However, the benefit of E-CPR beyond 1 year has been not known. We investigated 2-year outcome of patients who received E-CPR or conventional CPR (C-CPR). METHODS We analyzed a total of 406 adult in-hospital cardiac arrest victims who underwent CPR for more than 10 min from 2003 to 2009. The two-year survival and neurological outcome of E-CPR (n=85) and C-CPR (n=321) were compared using propensity score-matched analysis. RESULTS The 2-year survival with minimal neurological impairment was 4-fold higher in the E-CPR group than the C-CPR group (23.5% versus 5.9%, hazard ratio (HR)=0.57, 95% confidence interval (CI)=0.43-0.75, p<0.001) by unadjusted analysis. After propensity-score matching, it was still 4-fold higher in the E-CPR group than the C-CPR group (20.0% versus 5.0%, HR=0.53, 95% CI=0.36-0.80, p=0.002). In the E-CPR group, the independent predictors associated with minimal neurological impairment were age ≤65 years (HR=0.46; 95% CI=0.26-0.81; p=0.008), CPR duration ≤35 min (HR=0.37; 95% CI=0.18-0.76; p=0.007), and subsequent cardiovascular intervention including coronary intervention or cardiac surgery (HR=0.36; 95% CI=0.18-0.68; p=0.002). CONCLUSIONS The initial survival benefit of E-CPR for cardiac arrest patients persisted at 2 years.

Acute health problems related to the operation mounted to clean the Hebei Spirit oil spill in Taean, Korea

The authors investigated acute health problems in people engaged in the operation mounted to clear the Hebei Spirit oil spill which occurred in December 2007 in Taean County, South Korea, and identified the risk factors associated with the development of symptoms. Eight hundred forty-six people engaged in the clean up operation for periods between 7 and 14 days were examined. Demographic information and risk factors were obtained using a questionnaire. Symptoms were classified into six categories: back pain, skin lesions, headache, and eye, neurovestibular, and respiratory symptoms. Residents and volunteers engaged in the Hebei Spirit oil spill clean up operation experienced acute health problems. Risk analyses revealed that more frequent and greater exposure was strongly associated with a higher occurrence of symptoms.

Improvements in Compliance With Resuscitation Bundles and Achievement of End Points After an Educational Program on the Management of Severe Sepsis and Septic Shock

ABSTRACT The objectives of this study were to determine whether an educational program could improve compliance with resuscitation bundles and the outcomes of patients with severe sepsis or septic shock and to evaluate which resuscitation bundle end points were associated with in-hospital mortality. This was a retrospective observational study of 366 patients (163 of historical controls and 203 of treatment patients) with severe sepsis or septic shock who presented to the emergency department between May 2007 and July 2009. Compliance with resuscitation bundles and achievement of the corresponding end points were compared before and after the 3-month educational program. Compliance with central line insertion and monitoring of central venous pressure (29% vs. 67%, P < 0.001) and central venous oxygen saturation (ScvO2) (25% vs. 68%, P < 0.001) was significantly improved after the educational program. The achievement of target ScvO2 within the first 6 h was significantly improved (62% vs. 88%, P < 0.001). In-hospital mortality was independently associated with adequate fluid challenge (odds ratio [OR], 0.161; 95% confidence interval [CI], 0.046–0.559) and the achievement of target mean arterial pressure (OR, 0.056; 95% CI, 0.008–0.384) and ScvO2 (OR, 0.251; 95% CI, 0.072–0.875) among the five sepsis resuscitation bundles. In conclusion, an educational program can improve compliance with resuscitation bundles and achievement of their corresponding end points.

Predicting factors associated with clinical deterioration of sepsis patients with intermediate levels of serum lactate.

ABSTRACT Clinical deterioration among hemodynamically stable sepsis patients occurs frequently, and patients with intermediate lactate levels (between 2.0 and 4.0 mmol/L) are particularly at risk for mortality. The aim of this study was to identify factors for predicting early deterioration in sepsis patients with intermediate levels of serum lactate. A retrospective cohort study of adult sepsis patients with lactate levels between 2.0 and 4.0 mmol/L was conducted in the emergency department of a tertiary care hospital between August 2008 and July 2010. The primary outcome was progression to sepsis-induced shock defined as persistent hypotension despite initial fluid challenge or a blood lactate concentration 4 mmol/L or greater within 72 hours of emergency department arrival. Among the 474 patients enrolled in the study, there were 108 cases of sepsis-induced tissue hypoperfusion (22.7%) and 48 deaths (10.1%). In a multivariate regression analysis, independent predictors for progression were hyperthermia, neutropenia, band neutrophils appearance, hyponatremia, blood urea nitrogen level, serum lactate level, and organ failure including respiratory, cardiovascular, and central nervous system. Initial Sequential Organ Failure Assessment score was also associated with progression. In patients with a Sequential Organ Failure Assessment score of 5 or greater, the predicted rate of progression to tissue hypoperfusion was 38.9%. Our study demonstrates potential risk factors, including organ failure, for progression to sepsis-induced tissue hypoperfusion in patients with intermediate levels of serum lactate. We suggest that an early aggressive treatment strategy is needed in patients with these risk factors.

The adverse effect of emergency department crowding on compliance with the resuscitation bundle in the management of severe sepsis and septic shock

IntroductionThe aim of this study is to evaluate the effects of emergency department (ED) crowding on the implementation of tasks in the early resuscitation bundle during acute care of patients with severe sepsis and septic shock, as recommended by the Surviving Sepsis Campaign guidelines.MethodsWe analyzed the sepsis registry from August 2008 to March 2012 for patients presenting to an ED of a tertiary urban hospital and meeting the criteria for severe sepsis or septic shock. The ED occupancy rate, which was defined as the total number of patients in the ED divided by the total number of ED beds, was used for measuring the degree of ED crowding. It was categorized into three groups (low; intermediate; high crowding). The primary endpoint was the overall compliance with the entire resuscitation bundle.ResultsA total of 770 patients were enrolled. Of the eligible patients, 276 patients were assigned to the low crowding group, 250 patients to the intermediate crowding group, and 244 patients to the high crowding group (ED occupancy rate: ≤ 115; 116–149; ≥ 150%). There was significant difference in compliance rates among the three groups (31.9% in the low crowding group, 24.4% in the intermediate crowding group, and 16.4% in the high crowding group, P < 0.001). In a multivariate model, the high crowding group had a significant association with lower compliance (adjusted odds ratio (OR), 0.44; 95% confidence interval (CI), 0.26 to 0.76; P = 0.003). When the ED occupancy rate was included as a continuous variable in the model, it had also a negative correlation with the overall compliance (OR of 10% increase of the ED occupancy rate, 0.90; 95% CI, 0.84 to 0.96, P = 0.002).ConclusionsED crowding was significantly associated with lower compliance with the entire resuscitation bundle and decreased likelihood of the timely implementation of the bundle elements.

Factors influencing compliance with early resuscitation bundle in the management of severe sepsis and septic shock.

ABSTRACT The Surviving Sepsis Campaign guidelines recommend implementing a 6-h resuscitation bundle, which has been associated with reduced mortality of patients presenting with severe sepsis or septic shock. However, this resuscitation bundle has not yet become a widely implemented treatment protocol. It is still unclear what factors are associated with the rate of compliance with the resuscitation bundle. In this study, we evaluated the potential factors associated with implementation and compliance of a 6-h resuscitation bundle in patients presenting with severe sepsis or septic shock in the emergency department. We conducted a retrospective observational study involving adult patients presenting with severe sepsis or septic shock in the emergency department of a tertiary care hospital during the period between August 2008 and July 2010. The resuscitation bundle consisted of seven interventions according to the Surviving Sepsis Campaign guidelines. The primary outcome measure was the rate of high compliance with the 6-h resuscitation bundle, defined as implementation of more than five of seven interventions. Multivariable logistic regression analysis was used to adjust for the confounding factors. A total of 317 patients were enrolled into the study. One hundred seventy-two patients (54.3%) were assigned to the high compliance group, and 145 patients (45.7%) to the low compliance group. Significant factors associated with high compliance of the 6-h resuscitation bundle were hyperthermia (adjusted odds ratio [OR], 1.37; 95% confidence interval [95% CI], 1.10–1.70), care from experienced nurses who had 3 or more years of clinical experience (adjusted OR, 1.69; 95% CI, 1.10–2.58), and care from senior residents or board-certified emergency physicians (adjusted OR, 3.68; 95% CI, 1.68–6.89). Factors related with lower compliance were cryptic shock (adjusted OR, 0.26; 95% CI, 0.13–0.52) and higher serum lactate levels (adjusted OR, 0.90; 95% CI, 0.82–0.98). Furthermore, we found several potential factors that influence compliance with the sepsis resuscitation bundle. To improve the compliance with the resuscitation bundle, interventions focusing on those factors will be needed.

Neutrophil-to-lymphocyte ratio as a prognostic marker in critically-ill septic patients

Background: We evaluated the associations between the neutrophil‐to‐lymphocyte ratio (NLR) or changes in NLR and outcomes in septic patients. Methods: Patients who met the criteria for severe sepsis or septic shock were categorized into five groups according to the quintile of initial NLR value. We defined two risk groups according to NLR value and changes in NLR during the first two days (defined as the persistently low NLR group and the persistently high NLR group). The primary outcome was 28‐day mortality. Results: A total of 1395 patients were included. The median initial NLR values from Quintile 1 to Quintile 5 were as follows: 0.2 (IQR [interquartile range], 0.1–0.7), 3.4 (IQR, 2.6–4.7), 8.6 (IQR, 7.1–9.9), 15.4 (IQR, 13.3–17.8), and 31.0 (IQR, 24.6–46.8), respectively. The 28‐day mortality values for the same groups were as follows: 24.4%, 12.2%, 11.1%, 11.8%, and 16.1% (P < .01). Cox regression analysis showed that inclusion in Quintile 1 or Quintile 5 was a significant risk factor predicting 28‐day mortality compared to Quintile 3 (adjusted hazard ratio [HR]: 1.79 (95% confidence interval [CI], 1.15–2.78) in Quintile 1; 1.67 (95% CI, 1.04–2.66) in Quintile 5). The analysis indicated that persistently low NLR (adjusted HR: 2.25, 95% CI, 1.63–3.11) and persistently high NLR (adjusted HR: 2.65, 95% CI, 1.64–4.29) were significant risk factors. Conclusions: In summary, the initial NLR measured at ED admission was independently associated with 28‐day mortality in patients with severe sepsis and septic shock. In addition, change in NLR may prove to be a valuable prognostic marker.

Low Accuracy of Positive qSOFA Criteria for Predicting 28-Day Mortality in Critically Ill Septic Patients During the Early Period After Emergency Department Presentation

Study objective We determine the diagnostic performance of positive Quick Sequential Organ Failure Assessment (qSOFA) scores for predicting 28‐day mortality among critically ill septic patients during the early period after emergency department (ED) presentation. Methods This was a retrospective cohort study at a tertiary care academic center. We reviewed a registry of adult (≥18 years) patients who received a diagnosis of severe sepsis or septic shock during an ED stay from August 2008 through September 2014. We identified the point at which patients met 2 or more of the 3 qSOFA criteria (indicating a positive qSOFA score) simultaneously during the initial 24 hours. The diagnostic performance of positive qSOFA score for predicting 28‐day mortality was assessed (on ED arrival and within 3, 6, and 24 hours after ED presentation). Results A total of 1,395 patients were included, and the overall 28‐day mortality was 15%. For patients with positive qSOFA score, 28‐day mortality was 23% (95% confidence interval [CI] 19% to 28%) on ED arrival, 20% (95% CI 17% to 23%) at 3 hours, 20% (95% CI 17% to 22%) at 6 hours, and 17% (95% CI 15% to 20%) at 24 hours. Positive qSOFA score for predicting 28‐day mortality had a sensitivity, specificity, and area under the receiver operating curve, respectively, of 39% (95% CI 32% to 46%), 77% (95% CI 75% to 80%), and 0.58 (95% CI 0.55 to 0.62) on ED arrival; 68% (95% CI 62% to 75%), 52% (95% CI 49% to 55%), and 0.60 (95% CI 0.57 to 0.63) within 3 hours; 82% (95% CI 76% to 87%), 41% (95% CI 38% to 44%), and 0.61 (95% CI 0.58 to 0.64) within 6 hours; and 91% (95% CI 86% to 94%), 23% (95% CI 21% to 25%), and 0.57 (95% CI 0.54 to 0.59) within 24 hours. Conclusion The diagnostic performance of positive qSOFA score for predicting 28‐day mortality was low in critically ill septic patients, particularly during the early period after ED presentation. The study requires further prospective validation because of limitations with its retrospective design and use of single‐center data.

Association between hemodynamic presentation and outcome in sepsis patients.

ABSTRACT 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.