Peter Hallas

Hypoalbuminemia Is a Strong Predictor of 30-Day All-Cause Mortality in Acutely Admitted Medical Patients: A Prospective, Observational, Cohort Study

Objective Emergency patients with hypoalbuminemia are known to have increased mortality. No previous studies have, however, assessed the predictive value of low albumin on mortality in unselected acutely admitted medical patients. We aimed at assessing the predictive power of hypoalbuminemia on 30-day all-cause mortality in a cohort of acutely admitted medical patients. Methods We included all acutely admitted adult medical patients from the medical admission unit at a regional teaching hospital in Denmark. Data on mortality was extracted from the Danish Civil Register to ensure complete follow-up. Patients were divided into three groups according to their plasma albumin levels (0–34, 35–44 and ≥45 g/L) and mortality was identified for each group using Kaplan-Meier survival plot. Discriminatory power (ability to discriminate patients at increased risk of mortality) and calibration (precision of predictions) for hypoalbuminemia was determined. Results We included 5,894 patients and albumin was available in 5,451 (92.5%). A total of 332 (5.6%) patients died within 30 days of admission. Median plasma albumin was 40 g/L (IQR 37–43). Crude 30-day mortality in patients with low albumin was 16.3% compared to 4.3% among patients with normal albumin (p<0.0001). Patients with low albumin were older and admitted for a longer period of time than patients with a normal albumin, while patients with high albumin had a lower 30-day mortality, were younger and were admitted for a shorter period. Multivariable logistic regression analyses confirmed the association of hypoalbuminemia with mortality (OR: 1.95 (95% CI: 1.31–2.90)). Discriminatory power was good (AUROC 0.73 (95% CI, 0.70–0.77)) and calibration acceptable. Conclusion We found hypoalbuminemia to be associated with 30-day all-cause mortality in acutely admitted medical patients. Used as predictive tool for mortality, plasma albumin had acceptable discriminatory power and good calibration.

Complication with intraosseous access: scandinavian users' experience.

Introduction: Intraosseous access (IO) is indicated if vascular access cannot be quickly established during resuscitation. Complication rates are estimated to be low, based on small patient series, model or cadaver studies, and case reports. However, user experience with IO use in real-life emergency situations might differ from the results in the controlled environment of model studies and small patient series. We performed a survey of IO use in real-life emergency situations to assess users’ experiences of complications. Methods: An online questionnaire was sent to Scandinavian emergency physicians, anesthesiologists and pediatricians. Results: 1,802 clinical cases of IO use was reported by n=386 responders. Commonly reported complications with establishing IO access were patient discomfort/pain (7.1%), difficulties with penetration of periosteum with IO needle (10.3%), difficulties with aspiration of bone marrow (12.3%), and bended/broken needle (4.0%). When using an established IO access the reported complications were difficulties with injection fluid and drugs after IO insertion (7.4%), slow infusion (despite use of pressure bag) (8.8%), displacement after insertion (8.5%), and extravasation (3.7%). Compartment syndrome and osteomyelitis occurred in 0.6% and 0.4% of cases respectively. Conclusion: In users’ recollection of real-life IO use, perceived complications were more frequent than usually reported from model studies. The perceived difficulties with using IO could affect the willingness of medical staff to use IO. Therefore, user experience should be addressed both in education of how to use, and research and development of IOs.

Current use of intraosseous infusion in Danish emergency departments: a cross-sectional study

BackgroundIntraosseous infusion (IOI) is recommended when intravenous access cannot be readily established in both pediatric and adult resuscitation. We evaluated the current use of IOI in Danish emergency departments (EDs).MethodsAn online questionnaire was e-mailed to the Heads of Department of the twenty EDs currently established in Denmark. The questionnaire focused on the use of IOI in the EDs and included questions on frequency of use, training, equipment and attitudes towards IOI.ResultsWe received a total of 19 responses (response rate of 95%). Of the responding 19 Danish EDs 74% (n = 14) reported having intraosseous devices available. The median number of IOI procedures performed in these departments over the preceding 12 months was 5.0 (range: 0-45). In 47% (n = 9) of the departments, prior training sessions in the use of intraosseous devices had not been provided, and 42% (n = 8) did not have local guidelines on IOI. The indication for IOI use was often not clearly defined and only 11% (n = 2) consistently used IOI on relevant indication. This is surprising as 95% (n = 18) of responders were aware that IOI can be utilized in both pediatric and adult resuscitation.ConclusionsThe study shows considerable variations in IOI usage in Danish EDs despite the fact that IOI devices were available in the majority of EDs. In addition, in many EDs there were no local guidelines on IOI and no training in the procedure. We recommend more extensive training of medical staff in IOI techniques in Danish EDs.

Reasons for not using intraosseous access in critical illness

Aim To identify reasons for not using intraosseous access (IO) when intravenous access is difficult during resuscitation. Methods Questionnaire made available to members of selected Scandinavian medical societies. Results Of 759 responders to the questionnaire, 23.5% (n=178) had experienced one or more situations where there was a need for IO but none was placed. The most common stated reasons for not performing IO were a lack of equipment (48.3%), a lack of knowledge about the procedure (32.6%), and intravenous access preferred over IO (23.0%). Conclusions The main reasons for not using IO were lack of equipment and lack of training. The authors recommend increased training in IO use and greater availability of IO equipment for front-line staff in Scandinavian countries. The use of non-purpose-designed needles for IO should be evaluated.

Hoping for a domino effect: a new specialty in Sweden is a breath of fresh air for the development of Scandinavian emergency medicine

Editorial Friday the 6th of July, 2012, was a great day for emergency medicine (EM) in Scandinavia: As the first in Scandinavia, the Swedish National Board of Health and Welfare (Socialstyrelsen) announced that emergency medicine (Akutsjukvard) will become a primary medical specialty in Sweden. This is a great leap forward for emergency care in Scandinavia and should be celebrated. It should also prompt medical authorities the in rest of Scandinavia to acknowledge that a specialty in EM is an important element in modern, high-quality emergency care. EM is now a specialty (or supraspecialty) in more than 60 countries including USA, UK, Australia, The Netherlands, Ireland, Iceland and Finland [1]. The number of new countries that recognize EM as a specialty is rapidly increasing. The Swedes success with securing specialty status for EM is a case study in how a specialty in EM can be established as part of a concept of high quality emergency care. Learning from the experiences from Sweden could help improve emergency care in other countries, in particular Denmark and Norway.

How many training modalities are needed to obtain procedural confidence in intraosseous access? A questionnaire study.

Participants in advanced resuscitation courses are often expected to learn to perform intraosseous access (IO). But how many learning modalities are needed to achieve procedural confidence in IO? We distributed an online questionnaire to members of emergency medicine, paediatric and anaesthesiology societies in Scandinavia. The responders without real-life experience with IO (n=322) were classified as ‘not confident’ or ‘confident’ in IO. Of total responders 22.8% without training felt confident. Confidence increased to 74.8% after one training modality, 87.9% after two modalities, 98.7% after three modalities and 100% after four modalities (P<0.0001). Of total responders 89.5% who had ‘workshop or similar training with hands-on experience’ as sole teaching method was confident. Confidence in IO increases with the number of learning modalities. ‘Workshop or similar training with hands-on experience’ as single training modality seemed as effective as the combination of two modalities.

Level of training and experience in physicians performing interhospital transfers of adult patients in the internal medicine department

Aim: To establish the level of training doctors who participate in interhospital transfers in Denmark. Methods: A questionnaire was sent to every hospital department in Denmark with acute internal medicine admissions. Results: Eighty-nine internal medicine departments were contacted and 84 responded (response rate 94.4%). Of the 84 hospitals, 75 (89.3%) indicated that they perform interhospital transfers. Most transfers were performed by interns (61.3%) or senior house officers (10.7%) with only a few months’ experience in their current speciality. Training in interhospital transfer was offered by 24.0% of departments. When presented with cases of interhospital transfers of critically ill patients, 77.3% of the responders stated that their department would not follow guidelines when performing the transfer. Conclusions: The gap between recommended professional standards and current practice shows a need to establish educational programmes in interhospital transfer.

The use of 'brutacaine' in Danish emergency departments.

We aimed to investigate whether there was an unmet need for paediatric procedural pain management and/or sedation in Danish emergency departments (EDs). Cross-sectional survey of the 21 emergency hospitals in Denmark. Physical restraint during painful procedures was used by 80% (n=12) of the departments and procedural sedation in children was used in 33% (n=5) of the EDs. A total of 73% (n=11) of the participants reported that they believed that there was a need for better pain management and/or sedation of children in their ED. There is an unmet need for paediatric procedural pain management in Scandinavian EDs. Scandinavian guidelines on paediatric pain management and sedation in the ED are needed.

Current use of ultrasound for central vascular access in children and infants in the Nordic countries – a cross-sectional study

Purpose The use of ultrasound (US) guidance for central vascular access in children has been advocated as a safer approach compared to traditional landmark techniques. We therefore collected data on the current use of US for central vascular access in children and infants in the Nordic countries. Methods A cross-sectional survey using an online questionnaire was distributed to one anaesthesiologist at every hospital in the Nordic countries; a total of 177 anaesthesiologists were contacted from July till August 2012. Results The use of US for placing central venous catheters (CVCs) seems widespread across the Nordic countries. Close to 80% of respondents were using it “almost always” or “frequently” across all paediatric age groups for internal jugular vein cannulation. US was least frequently used when catheterizing the subclavian vein. The two most common reasons given when not using US were lack of training followed by lack of equipment. We found no difference in the use of US between high-volume centres and low-volume centres. (High-volume centres placed paediatric CVCs at least weekly.) Conclusions US was commonly used for cannulation of the internal jugular vein but infrequently for the subclavian vein. A lack of training seems to be a barrier for further increasing the use of US. Establishing standardized training programmes based on current evidence should alleviate this.

Preferred anatomic site for intraosseous infusion in Danish emergency departments

Background Intraosseous infusion (IOI) is recommended when intravenous access cannot be readily established in resuscitation. There has been debate as to whether which anatomic site should be preferred for IOI. Although success and flow rates in e.g. proximal tibia compared with proximal humerus are not significant different some stress that the tibia should be first choice for IOI because of easily identifiable landmarks. We have as part of a project on IOI use in Danish emergency departments (EDs) assessed the preferred anatomic site for IOI. We hope to promote a debate concerning first choice insertion site for IOI.