Mun Ju Kang

Better lactate clearance associated with good neurologic outcome in survivors who treated with therapeutic hypothermia after out-of-hospital cardiac arrest

IntroductionSeveral methods have been proposed to evaluate neurological outcome in out-of-hospital cardiac arrest (OHCA) patients. Blood lactate has been recognized as a reliable prognostic marker for trauma, sepsis, or cardiac arrest. The objective of this study was to examine the association between initial lactate level or lactate clearance and neurologic outcome in OHCA survivors who were treated with therapeutic hypothermia.MethodsThis retrospective cohort study included patients who underwent protocol-based 24-hour therapeutic hypothermia after OHCA between January 2010 and March 2012. Serum lactate levels were measured at the start of therapy (0xa0hours), and after 6xa0hours, 12xa0hours, 24xa0hours, 48xa0hours and 72xa0hours. The 6xa0hour and 12xa0hour lactate clearance were calculated afterwards. Patients’ neurologic outcome was assessed at one month after cardiac arrest; good neurological outcome was defined as Cerebral Performance Category one or two. The primary outcome was an association between initial lactate level and good neurologic outcome. The secondary outcome was an association between lactate clearance and good neurologic outcome in patients with initial lactate level >2.5xa0mmol/l.ResultsOut of the 76 patients enrolled, 34 (44.7%) had a good neurologic outcome. The initial lactate level showed no significant difference between good and poor neurologic outcome groups (6.07 ±4 .09xa0mmol/L vs 7.13u2009±u20093.99xa0mmol/L, Pu2009=u20090.42), However, lactate levels at 6xa0hours, 12xa0hours, 24xa0hours, and 48xa0hours in the good neurologic outcome group were lower than in the poor neurologic outcome group (3.81u2009±u20092.81 vs 6.00u2009±u20093.22 P <0.01, 2.95u2009±u20092.07 vs 5.00u2009±u20093.49 P <0.01, 2.17u2009±u20091.24 vs 3.86u2009±u20093.92 P <0.01, 1.57u2009±u20091.02 vs 2.21u2009±u20091.35 Pu2009=u20090.03, respectively). The secondary analysis showed that the 6-hour and 12-hour lactate clearance was higher for good neurologic outcome patients (35.3u2009±u200934.6% vs 6.89u2009±u200947.4% Pu2009=u20090.01, 54.5u2009±u200923.7% vs 25.6u2009±u200943.7% P <0.01, respectively). After adjusting for potential confounding variables, the 12-hour lactate clearance still showed a statistically significant difference (Pu2009=u20090.02).ConclusionThe lactate clearance rate, and not the initial lactate level, was associated with neurological outcome in OHCA patients after therapeutic hypothermia.

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, Pu2009<u20090.001). 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; Pu2009=u20090.003). 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, Pu2009=u20090.002).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.

Evaluating the Accuracy of Emergency Medicine Resident Interpretations of Abdominal CTs in Patients with Non-Traumatic Abdominal Pain

Abdominal computed tomography (CT) is widely used as a diagnostic tool in emergency medicine (EM) to accurately diagnose abdominal pain. EM residents must be able to offer preliminary interpretations of CT imaging. In this study, we evaluated the preliminary interpretation ability of a sample of emergency residents presented with adult abdominal CT images, and compared their results with those of radiology residents. We conducted a prospective observational study from November 16, 2008 to June 30, 2009. During this time, we gathered preliminary interpretations of consecutive abdominal CT made by emergency and radiology residents. We assessed the discrepancy rates of both samples by comparing their findings to the final reports from attending radiologists. A total of 884 cases were enrolled in the present study. The discrepancy rates of emergency and radiology residents were 16.7% and 12.2%, respectively. When female genital organs, peritoneum, adrenal glands, or the musculoskeletal system were abnormal, we found that emergency residents preliminary interpretations of CT images were insufficient compared to those of radiology residents. Therefore more formal education is needed to emergency residents. If possible, the preliminary interpretations of radiology attending physicians are ideal until improving the ability of interpretations of emergency residents in abdomen CT.