Taegyun Kim

Red cell distribution width is a prognostic factor in severe sepsis and septic shock.

OBJECTIVEnThis study was performed to investigate the association of red cell distribution width (RDW) with 28-day mortality in patients with severe sepsis and septic shock.nnnMETHODSnWe performed a retrospective analysis of patients with severe sepsis and septic shock. Patients demographic data, comorbidities, the blood test results including RDW at admission to the emergency department, and Acute Physiologic and Chronic Health Evaluation II score were compared between 28-day survivors and nonsurvivors. Red cell distribution width was categorized into tertiles as 14% or less, 14.1% to 15.7%, and 15.8% or greater. Multivariate Cox proportional hazards regression analysis was performed to determine the risk factors for mortality.nnnRESULTSnA total of 566 patients were included, and overall mortality was 29%. Red cell distribution width was significantly higher in nonsurvivors than in survivors, and the corresponding mortality of patients with an RDW of 14% or less, 14.1% to 15.7%, and 15.8% or greater was 13.1%, 30.1%, and 44.9%, respectively (P < .001). In Cox proportional hazards analysis, groups with higher RDW are independently associated with 28-day mortality compared with groups with an RDW of 14.0% or less: RDW 14.1% to 15.7% (hazard ratio, 1.66; 95% confidence interval [CI], 1.00-2.76) and RDW of 15.8% or greater (hazard ratio, 2.57; 95% CI, 1.53-4.34). The area under the receiver operating curve of RDW was 0.68 (95% CI, 0.63-0.72).nnnCONCLUSIONnRed cell distribution width is associated with 28-day mortality in patients with severe sepsis and septic shock.

Long-term survival of out-of-hospital cardiac arrest patients with malignancy

Background: The aim of this study was to investigate whether the 1‐year survival rate of out‐of‐hospital cardiac arrest (OHCA) patients with malignancy was different from that of those without malignancy. Methods: All adult OHCA patients were retrospectively analyzed in a single institution for 6 years. The primary outcome was 1‐year survival, and secondary outcomes were sustained return of spontaneous circulation (ROSC), survival to hospital admission, survival to discharge and discharge with a good neurological outcome (CPC 1 or 2). Kaplan‐Meier survival analysis and Cox proportional hazard regression analysis were performed to test the effect of malignancy. Results: Among 341 OHCA patients, 59 patients had malignancy (17.3%). Sustained ROSC, survival to admission, survival to discharge and discharge with a good CPC were not different between the two groups. The 1‐year survival rate was lower in patients with malignancy (1.7% vs 11.4%; P = 0.026). Kaplan‐Meier survival analysis revealed that patients with malignancy had a significantly lower 1‐year survival rate when including all patients (n = 341; P = 0.028), patients with survival to admission (n = 172, P = 0.002), patients with discharge CPC 1 or 2 (n = 18, P = 0.010) and patients with discharge CPC 3 or 4 (n = 57, P = 0.008). Malignancy was an independent risk factor for 1‐year mortality in the Cox proportional hazard regression analysis performed in patients with survival to admission and survival to discharge. Conclusions: Although survival to admission, survival to discharge and discharge with a good CPC rate were not different, the 1‐year survival rate was significantly lower in OHCA patients with malignancy than in those without malignancy.

Prognostic performance of Emergency Severity Index (ESI) combined with qSOFA score

Objective We conducted this study to investigate whether ESI combined with qSOFA score (ESI + qSOFA) predicts hospital outcome better than ESI alone in the emergency department (ED). Methods This was a retrospective study for patients aged over 15 years who visited an ED of a tertiary referral hospital from January 1st, 2015 to December 31st, 2015. We calculated and compared predictive performances of ESI alone and ESI + qSOFA for prespecified outcomes. The primary outcome was hospital mortality, and the secondary outcome was composite outcome of in‐hospital mortality and ICU admission. We calculated in‐hospital mortality rates by positive qSOFA in each subgroup divided according to ESI levels (1, 2, 3, 4 + 5). Results 43,748 patients were enrolled. The area under receiver‐operating characteristics curves were higher in ESI + qSOFA than in ESI alone for both mortality and composite outcome (0.786 vs. 0.777, P < .001 for mortality; 0.778 vs. 0.774, P < .001 for composite outcome). In each subgroup divided by ESI levels, patients with positive qSOFA had significantly higher in‐hospital mortality rate compared to those with negative qSOFA (20.4% vs. 14.7%, P = .117 in ESI level 1 subgroup; 11.3% vs. 2.7%, P = .001 in ESI level 2 subgroup; 2.3% vs. 0.4%, P < .001 in ESI level 3 subgroup; 0.0% vs. 0.0% in ESI level 4 or 5 subgroup). Conclusion The prognostic performance of ESI + qSOFA for in‐hospital mortality was significantly higher than that of ESI alone. Within each subgroup, patients with positive qSOFA had higher in‐hospital mortality compared to those with negative qSOFA.

Epileptiform discharge detection with the 4-channel frontal electroencephalography during post-resuscitation care

INTRODUCTIONnWe performed this study to investigate whether the SEDline system, a 4-channel-processed electroencephalography (EEG) monitoring device in the frontal area, can detect epileptiform discharges accurately during post-resuscitation care in comatose cardiac arrest survivors.nnnMETHODSnAdult comatose cardiac arrest survivors, who were admitted to the intensive care unit (ICU) for post-resuscitation care including TTM, were enrolled. Within 72h post-return of spontaneous circulation (ROSC), conventional EEG was conducted for 30min. The SEDline system data were recorded with a video camera simultaneously with conventional EEG. Data retrieved from conventional EEG were interpreted by a neurologist and data from the SEDline system were interpreted by three emergency physicians blinded to the conventional EEG data. Then, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the SEDline system to detect epileptiform discharges were calculated.nnnRESULTSnThirty-nine patients were enrolled in this study. Epileptiform discharges were confirmed in 6 patients (15.4%) who had the same patterns of generalized periodic epileptiform discharges in both conventional EEG and the concurrent SEDline system. The SEDline system showed 100.0% (95% confidence interval (CI), 54.1-100.0%) of sensitivity, 100.0% (95% CI, 89.4-100.0%) of specificity, 100.0% (95% CI, 54.1-100.0%) of PPV, and 100.0% (95% CI, 89.4-100.0%) of NPV. The overall classification accuracy of the SEDline system to detect epileptiform discharges was 100.0%.nnnCONCLUSIONnThe SEDline system detected epileptiform discharges accurately in comatose cardiac arrest survivors during post-resuscitation care.

Apocynin suppressed the nuclear factor-κB pathway and attenuated lung injury in a rat hemorrhagic shock model

BACKGROUND The aim of this study was to investigate whether a nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (Nox) inhibitor, apocynin, reduces reactive oxygen species (ROS) production, suppresses the nuclear factor &kgr;B (NF-&kgr;B) pathway, attenuates lung injury, and improves survival in rat hemorrhagic shock (HS) model. METHODS Blood was drawn from male Sprague–Dawley rats (290–340 g) to maintain a mean arterial pressure of 20–25 mm Hg for 40 minutes. The rats were resuscitated with the drawn blood, and a vehicle (HS), a low dose of apocynin (20 mg/kg, LD-Apo), or a high dose of apocynin (40 mg/kg, HD-Apo) was administered intraperitoneally. The survival of the rats was observed for 72 hours. Then, a separated set of rats was euthanized at 6 hours post-HS induction. We measured gp91-phox (Nox2) expression, Nox activity, cytoplasmic phosphorylated inhibitor &kgr;B-&agr; (p-I&kgr;B-&agr;) expression, NF-&kgr;B p65 DNA-binding activity, tumor necrosis factor-&agr; (TNF-&agr;) and interleukin-6 (IL-6) gene expressions, malondialdehyde (MDA) level, myeloperoxidase (MPO) activity, and histological damage in the lung tissues. RESULTS The survival rates of the sham, HS, HS + LD-Apo, and HS + HD-Apo groups were 100% (5/5), 30% (3/10), 40% (4/10), and 70% (7/10), respectively. A high dose of apocynin decreased gp91-phox expression, Nox activity, and MDA level in the lung tissues during HS and resuscitation. It also decreased p-I&kgr;B-&agr; expression, NF-&kgr;B p65 DNA-binding activity, TNF-&agr; and IL-6 gene expressions, and MPO activity in the lung tissues and attenuated histological lung injuries. However, a low dose of apocynin failed to show these benefits. CONCLUSIONS The administration of a high dose of apocynin inhibited Nox2 expression and Nox activity, reduced lipid peroxidation, suppressed the NF-&kgr;B pathway and subsequent pro-inflammatory cytokines transcription in the lung tissues, and attenuated lung injury during HS and resuscitation in rats.

End-tidal CO 2 -guided automated robot CPR system in the pig. Preliminary communication

BACKGROUNDnOur aim was to compare the efficacy of the end-tidal CO2-guided automated robot CPR (robot CPR) system with manual CPR and mechanical device CPR.nnnMETHODSnWe developed the algorithm of the robot CPR system which automatically finds the optimal compression position under the guidance of end-tidal CO2 feedback in swine models of cardiac arrest. Then, 18 pigs after 11u202fmin of cardiac arrest were randomly assigned to one of three groups, robot CPR, LUCAS CPR, and manual CPR groups (nu202f=u202f6 each group). Return of spontaneous circulation (ROSC) and Neurological Deficit Score 48u202fh after ROSC were compared.nnnRESULTSnA ROSC was achieved in 5 pigs, 4 pigs, and 3 pigs in the robot CPR, LUCAS CPR, and manual CPR groups, respectively (pu202f=u202f0.47). Robot CPR showed a significant difference in Neurological Deficit Score 48u202fh after ROSC compared to manual CPR, whereas LUCAS CPR showed no significant difference over manual CPR. (pu202f=u202f0.01; Robot versus Manual adjusted pu202f=u202f0.04, Robot versus LUCAS adjusted pu202f=u202f0.07, Manual versus LUCAS adjusted pu202f=u202f1.00).nnnCONCLUSIONSnThe end-tidal CO2-guided automated robot CPR system did not significantly improve ROSC rate in a swine model of cardiac arrest. However, robot CPR showed significant improvement of Neurological Deficit Score 48u202fh after ROSC compared to Manual CPR while LUCAS CPR showed no significant improvement compared to Manual CPR.

Prediction of neurological outcomes following the return of spontaneous circulation in patients with out-of-hospital cardiac arrest: Retrospective fast-and-frugal tree analysis

AIMnAlthough various quantitative methods have been developed for predicting neurological prognosis in patients with out-of-hospital cardiac arrest (OHCA), they are too complex for use in clinical practice. We aimed to develop a simple decision rule for predicting neurological outcomes following the return of spontaneous circulation (ROSC) in patients with OHCA using fast-and-frugal tree (FFT) analysis.nnnMETHODSnWe performed a retrospective analysis of prospectively collected data archived in a multi-centre registry. Good neurological outcomes were defined as cerebral performance category (CPC) values of 1 or 2 at 28-day. Variables used for FFT analysis included age, sex, witnessed cardiac arrest, bystander cardiopulmonary resuscitation, initial shockable rhythm, prehospital defibrillation, prehospital ROSC, no flow time, low flow time, cause of arrest (cardiac or non-cardiac), pupillary light reflex, and Glasgow Coma Scale score after ROSC.nnnRESULTSnAmong the 456 patients enrolled, 86 (18.9%) experienced good neurological outcomes. Prehospital ROSC (trueu2009=u2009good), prompt or sluggish light reflex response after ROSC (trueu2009=u2009good), and presumed cardiac cause (trueu2009=u2009good, falseu2009=u2009poor) were selected as nodes for the decision tree. Sensitivity, specificity, positive predictive value, and negative predictive value of the decision tree for predicting good neurological outcomes were 100% (42/42), 64.0% (119/186), 38.5% (42/109), and 100% (119/119) in the training set and 95.5% (42/44), 57.6% (106/184), 35.0% (42/120), and 98.1% (106/108) in the test set, respectively.nnnCONCLUSIONnA simple decision rule developed via FFT analysis can aid clinicians in predicting neurological outcomes following ROSC in patients with OHCA.

Lower serum kallistatin level is associated with 28-day mortality in patients with septic shock

Purpose: Investigation for whether serum levels of kallistatin, vascular cell adhesion molecule‐1 (VCAM‐1), and E‐selectin are associated with outcomes in patients with septic shock Material and methods: Biomarker levels were measured using blood samples from patients with septic shock at admission, 24 h, and 72 h and from healthy volunteers. The primary outcome was 28‐day mortality. Results: Fifty‐eight survivors, fourteen non‐survivors, and six healthy volunteers were enrolled. Serum kallistatin level was lower and serum VCAM‐1 and E‐selectin levels were higher in patients at admission compared with healthy volunteers. Serum kallistatin levels were higher in survivors compared with non‐survivors at all time points (4.4 &mgr;g/mL [2.9–6.1] vs. 2.5 &mgr;g/mL [2.1–5.0], P = 0.019 at admission; 4.3 &mgr;g/mL [3.3–5.2] vs. 3.2 &mgr;g/mL [2.2–3.8], P = 0.004 at 24 h; 3.1 &mgr;g/mL [2.5–4.2] vs. 2.3 &mgr;g/mL [1.7–3.1], P = 0.012 at 72 h), while VCAM‐1 and E‐selectin levels showed no difference. In the multivariable analysis, serum kallistatin level at 24 h was independently associated with 28‐day mortality (OR, 0.29; 95% CI, 0.08–0.69, P = 0.024). Conclusions: Lower serum kallistatin level at 24 h was independently associated with 28‐day mortality in patients with septic shock

Delayed endoscopy is associated with increased mortality in upper gastrointestinal hemorrhage

Objectives: To determine the association between delayed (>24h) endoscopy and hospital mortality in patients with upper gastrointestinal hemorrhage (UGIH). Methods: We retrospectively analyzed all adult patients with UGIH who underwent endoscopy in a single emergency room for 2years. The primary exposure was defined as >24h from the ED visit to the first endoscopy. The primary outcome was defined as all cause hospital mortality. Secondary outcomes were intensive care unit admission rate, ED length of stay, and hospital length of stay. Results: Among 1101 patients enrolled, 898 received endoscopy within 24h (early group) and 203 received endoscopy after 24h (delayed group). The hospital mortality of early and delayed group was 2.8% and 6.4%, respectively (unadjusted relative risk [RR] 2.30: 95% CI, 1.20–4.42, p=0.012). This was significant after adjusting covariates including AIMS65 and Glasgow‐Blatchford score (adjusted RR 2.23: 95% CI, 1.18–4.20, p=0.013). Intensive care unit admission rate was not different between two groups. ED and hospital length of stay were significantly longer in delayed group. Conclusions: Endoscopy performed after 24h was associated with increased hospital mortality in UGIH. Patients in the delayed group stayed longer in the ED and in the hospital.

Relative tachycardia is associated with poor outcomes in post-cardiac arrest patients regardless of therapeutic hypothermia

Background: To investigate whether the relationship between heart rate and neurological outcome is independent of therapeutic hypothermia (TH) and whether heart rate is related to hemodynamic instability post‐cardiac arrest. Methods: Retrospective review of an out‐of‐hospital cardiac arrest registry was performed. The primary exposure was heart rate quartiles at 24 h post‐cardiac arrest. The primary outcome was a poor neurological outcome, which was defined as having a cerebral performance category (CPC) of 3–5 at 28 days. Secondary outcomes were mean blood pressure and serum lactate at 24 h and Sequential Organ Failure Assessment (SOFA) scores at admission. Results: In total, 155 patients were enrolled. The proportion of patients with a poor CPC was significantly greater in higher heart rate quartiles; similar results were observed in patients who did and did not undergo TH. Serum lactate levels at 24 h were significantly higher in the 3rd and 4th quartile groups than in the 1st quartile group. Additionally, SOFA scores were significantly higher in the 4th quartile group than in the 1st and 3rd quartile groups. Conclusions: Relative tachycardia is associated with poor neurological outcomes in post‐cardiac arrest patients, independent of TH, and with higher serum lactate levels and admission SOFA scores.