Young Ho Jin

Modified early warning score with rapid lactate level in critically ill medical patients: the ViEWS-L score

Objectives To examine whether the predictive value of the early warning score (EWS) could be improved by including rapid lactate levels, and to compare the modified EWS with the pre-existing risk scoring systems. Design Retrospective observational study in South Korea. Setting An urban, academic, tertiary hospital. Participants Consecutive adult patients who were admitted to the medical intensive care unit via the emergency department (ED). Outcome measures A newly developed EWS—the VitalPAC EWS (ViEWS), was used in the present study. Lactate level, ViEWS and HOTEL score were obtained from patients at presentation to the ED, and APACHE II, SAPS II and SAPS III scores were obtained after admission. The area under curve of each risk scoring system for in-hospital, 1-week, 2-week and 4-week mortality was compared. Results 151 patients were enrolled and the mortality was 42.4%. The ViEWS-L score was calculated as follows: ViEWS-L score=ViEWS+lactate (mmol/l) according to the regression coefficient. The mean ViEWS-L score was 11.6±7.3. The ViEWS-L score had a better predictive value than the ViEWS score for hospital mortality (0.802 vs 0.742, p=0.009), 1-week mortality (0.842 vs 0.707, p<0.001), 2-week mortality (0.827 vs 0.729, p<0.001) and 4-week mortality (0.803 vs 0.732, p=0.003). The ViEWS-L score also had a better predictive value than the HOTEL and APACHE II scores. The predictive value of ViEWS-L was comparable with SAPS II and SAPS III. Conclusions The ViEWS-L score performed as well as or better than the pre-existing risk scoring systems in predicting mortality in critically ill medical patients who were admitted to the medical intensive care unit via the ED.

Emergency Department Occupancy Ratio is Associated With Increased Early Mortality

BACKGROUND To measure emergency department (ED) crowding, the emergency department occupancy ratio (EDOR) was introduced. OBJECTIVE Our aim was to determine whether the EDOR is associated with mortality in adult patients who visited the study hospital ED. METHODS We reviewed data on all patients who visited the ED of an urban tertiary academic hospital in Korea for 2 consecutive years. The EDOR is defined by the total number of patients in the ED divided by the number of licensed ED beds. We tested the association between the EDOR (quartile) and each outcome using a multivariable logistic regression analysis adjusted for potential confounders: age, sex, emergency medical services transport, transferred case, weekend visit, shift, triage acuity, visit cause of injury, operation, vital signs, intensive care unit or ward admission, and ED length of stay (quartile). The main outcome measures were survival status at discharge and at 1-7 days. RESULTS A total of 54,410 adult patients were enrolled. The EDOR ranged from 0.41 to 2.31 and the median was 1.24. On multivariable analyses, in comparison with the lowest (first) quartile, the highest (fourth) quartile of the EDOR was associated with 1-day mortality (adjusted odds ratio [OR] = 1.42; 95% confidence interval [CI] 1.08-1.88), 2-day mortality (adjusted OR = 1.31; 95% CI 1.04-1.67), and 3-day mortality (adjusted OR = 1.27; 95% CI 1.02-1.58). The EDOR was not significantly associated with 4- to 7-day mortalities and overall mortality at discharge. CONCLUSIONS The EDOR is associated with increased 1- to 3-day mortality even after controlling for potential confounders.

Comparison of the trauma and injury severity score and modified early warning score with rapid lactate level (the ViEWS-L score) in blunt trauma patients

Objective The aim of this study was to compare the predictive value of the VitalPAC Early Warning Score-lactate (ViEWS-L) score with that of the trauma and injury severity score (TRISS), which is a pre-existing risk scoring system used in trauma patients. Methods The patients were blunt trauma victims admitted consecutively to the study hospital between 1 April 2010 and 31 March 2011, who were 15 years or older and had an injury severity score of 9 or higher. The lactate level, the ViEWS and revised trauma score upon arrival at the emergency department, and the injury severity score and TRISS were evaluated. The ViEWS-L score was calculated according to the formula: ViEWS-L=ViEWS+lactate (mmol/l). The ability to predict mortality was assessed by area under the receiver operating characteristic curve (AUC) analysis and calibration analysis. Results A total of 299 patients were available for analysis, of whom 33 died (11.0%). The median ViEWS-L score was 3.7 (interquartile range:1.8–6.4) and the median TRISS was 96.8 (interquartile range: 93.4–98.6). The ViEWS-L score was better than TRISS at predicting hospital mortality (AUC, 0.838; 95% confidence interval, 0.771–0.906 vs. AUC, 0.734; 95% confidence interval, 0.635–0.833, P=0.031). Calibration of the ViEWS-L score (&khgr;2=11.13, P=0.194) was good but that of TRISS was not (&khgr;2=16.97, P=0.018). Conclusion The prognostic value of the ViEWS-L score in terms of discrimination was better than that of TRISS in the blunt trauma patients admitted to the emergency department with an injury severity score of 9 or higher, and the ViEWS-L score showed good calibration.

Initial hyperlactatemia in the ED is associated with poor outcome in patients with ischemic stroke

BACKGROUND Hyperlactatemia may be associated with poor outcome in patients with ischemic stroke because it reflects a state of tissue perfusion. This study aims to know whether initial hyperlactatemia in the emergency department (ED) is associated with poor outcome in patients with ischemic stroke. METHODS A retrospective observational study was performed in an urban tertiary hospital ED. Patients with an admission diagnosis of ischemic stroke were consecutively enrolled between April 1, 2010, and March 31, 2011. Lactate and glucose levels were obtained at the time of presentation to the ED, whereas the National Institutes of Health Stroke Scale score was assessed at the time of admission. Poor outcome was defined as a modified Rankin scale score greater than or equal to 2 at 3 months. The survival status at 3 months was also obtained. Hyperlactatemia was defined by lactate levels greater than 2 mmol/L. RESULTS A total of 292 patients were enrolled. At 3 months after stroke, 183 (62.7%) were considered to have poor outcomes, whereas 16 (5.5%) had died. Seventy (24.0%) had initial hyperlactatemia. Multivariable logistic regression analysis showed that hyperlactatemia was independently associated with a higher risk of poor outcome at 3 months (adjusted odd ratio, 2.15; 95% confidence interval, 1.06-4.37; P=.035) and a trend to death at 3 months (adjusted odd ratio, 4.31; 95% confidence interval, 0.91-20.56; P=.066). CONCLUSIONS Among patients with ischemic stroke, initial hyperlactatemia represents an independent risk factor for poor outcome after controlling for stroke severity, risk factors, initial glucose level, and interval from onset of stroke symptoms to ED arrival.

Initial serum lactate level is associated with inpatient mortality in patients with community-acquired pneumonia ☆ ☆☆ ★

STUDY OBJECTIVE The aim of the present study was to investigate the prognostic value of the initial serum lactate level in patients with community-acquired pneumonia (CAP). METHODS We collected data on hospitalized adult patients with CAP via the study hospital emergency department between October 2012 and September 2013. Demographics, comorbidities, and physiologic and laboratory variables including initial C-reactive protein (CRP) and serum lactate level were extracted from the electronic medical record. The primary outcome was inpatient mortality. Comparisons between survivors and nonsurvivors were performed, and multivariable logistic regression analyses were constructed as dependent variables of both continuous and categorical varieties. RESULTS A total of 397 patients were enrolled, and the mortality cases were 46 (11.6%). The mean lactate level was 1.7 ± 1.4 mmol/L and was significantly higher in the nonsurvivor group than in the survivor group (2.4 ± 2.2 mmol/L vs 1.6 ± 1.2 mmol/L). In the multivariable logistic regression model for inpatient mortality constructed using lactate, CRP, and laboratory variables of pneumonia severity index (PSI), lactate and CRP remained as significant factors, but laboratory variables of PSI were not. In other multivariable logistic regression models for the outcome constructed using collected laboratory variables and PSI, lactate remained as a significant factor (adjusted odds ratio, 1.24; 95% confidence interval, 1.01-1.53; P = .042 by continuous variable; adjusted odds ratio of third tertile, 2.60; 95% confidence interval, 1.02-6.66; P = .046 by category variable). C-reactive protein and albumin were also left as significant factors. CONCLUSIONS The initial serum lactate level is independently associated with mortality in hospitalized patients with CAP. However, laboratory variables of PSI or others were not, except CRP and albumin.

ED crowding is associated with inpatient mortality among critically ill patients admitted via the ED: post hoc analysis from a retrospective study ☆,☆☆,★

BACKGROUND Adverse effects of emergency department (ED) crowding among critically ill patients are not well known. OBJECTIVES We evaluated the association between ED crowding and inpatient mortality among critically ill patients admitted via the ED, and analyzed subsets of patients according to admission diagnosis. METHODS We performed a post hoc analysis using data from a previous retrospective study. We enrolled admitted patients via the ED with an initial systolic blood pressure of 90 mm Hg or lower when presenting to the ED. The ED occupancy ratio was used as a measure of crowding. The primary outcome was inpatient mortality. Multivariable logistic regression models adjusted for potential confounding variables were constructed for the entire cohort and for subsets according to admission diagnosis (infection, cardiac and vascular disease, trauma, gastrointestinal bleeding, and other factors). RESULTS A total of 1801 patients were enrolled, with a mortality rate of 14.6% (262 patients). The mortality rate by ED occupancy ratio quartile was 9.7% for the first quartile, 15.9% for the second quartile, 18.2% for the third quartile, and 14.4% for the fourth quartile. This resulted in adjusted odds ratios of 1.95, 2.51, and 1.93 and corresponding 95% confidence intervals of 1.23-3.12, 1.58-3.99, and 1.21-3.09 for the second, third, and fourth quartiles, respectively, compared with the first quartile. The effect of ED crowding was highest in the trauma subset, followed by the infection subset, whereas ED crowding did not appear to have any effect on the cardiac and vascular disease subsets. CONCLUSION Emergency department crowding was associated with increased inpatient mortality among critically ill patients admitted via the ED.

Reversible Splenial Lesion Syndrome (RESLES) Following Glufosinate Ammonium Poisoning

Isolated and reversible lesion restricted to the splenium of the corpus callosum, known as reversible splenial lesion syndrome, have been reported in patients with infection, high‐altitude cerebral edema, seizures, antiepileptic drug withdrawal, or metabolic disturbances. Here, we report a 39‐year‐old female patient with glufosinate ammonium (GLA) poisoning who presented with confusion and amnesia. Diffusion‐weighted magnetic resonance imaging of the brain revealed cytotoxic edema of the splenium of the corpus callosum. The lesion was not present on follow‐up MR imaging performed 9 months later. We postulate that a GLA‐induced excitotoxic mechanism was the cause of this reversible splenial lesion.

Fitz-Hugh-Curtis syndrome in a male patient due to urinary tract infection

Fitz-Hugh-Curtis syndrome (FHCS) is inflammation of the liver capsule usually associated with pelvic inflammatory disease. FHCS has been rarely reported in male patients, and hematogenous and lymphatic spread to the liver is thought to be the underlying mechanism. Although a confirmatory diagnosis was made by laparoscopy, contrast-enhanced computed tomography scan is considered the first-line imaging tool in clinical diagnosis of FHCS. We report a case of FHCS that developed in a young male patient with a urinary tract infection.

Diagnostic performance of initial serum lactate for predicting bacteremia in female patients with acute pyelonephritis

OBJECTIVES The purpose of the present study was to investigate the diagnostic value of lactate for predicting bacteremia in female patients with acute pyelonephritis (APN). METHODS We conducted a retrospective study of female patients with APN who visited the study hospital emergency department. The demographics, comorbidities, physiologies, and laboratory variables including white blood cell count and segmented neutrophil count, C-reactive protein, and initial serum lactate levels were collected and analyzed to identify associations with the presence of bacteremia. RESULTS During the study period, a total of 314 patients were enrolled. One hundred twenty-three patients (39.2%) had bacteremia. Escherichia coli was the most frequent pathogen. Logistic regression analysis demonstrated that the lactate level was independently associated with the presence of bacteremia (odds ratio, 1.39 [95% confidence interval, 1.08-1.78]). The C-statistic of the lactate level was 0.67 (95% CI, 0.60-0.73). At a cutoff value of 1.4mmol/L, the lactate level predicted bacteremia with a sensitivity (53.7%), specificity (72.3%), positive predictive value (55.5%), negative predictive value (70.8%), positive likelihood ratio (1.93), and negative likelihood ratio (0.64). CONCLUSION The initial serum lactate level showed poor discriminative performance for predicting bacteremia in female patients with APN.

Hyperchloremia Versus Nonhyperchloremia or Hyperchloremia Versus Normochloremia

Critical Care Medicine www.ccmjournal.org e53 The authors reply: We reviewed Jo et al (1) correspondence in which they have raised an important question regarding the contribution of hypochloremia to our analysis (2). In our original study (n = 1,940) (2), we stratified our primary cohort by the presence (n = 615) or absence (n = 1,325) of hyperchloremia (serum chloride ≥ 110 mEq/L) on ICU admission. Jo et al (1) suggested that the strength of the association between higher serum chloride levels and hospital mortality in the hyperchloremic group may perhaps be stronger if patients with hypochloremia were excluded from the nonhyperchloremic group for comparison. Consequently, we identified 361 patients with hypochloremia (serum chloride ≤ 100 mEq/L) on ICU admission in if authors had divided enrolled cohort into two groups; patients with hyperchloremia and normochloremia, excluding patients with hypochloremia. Serum chloride levels would exert bimodal effect, such as pH, WBC, and so on. Because hypochloremic patients were included in the nonhyperchloremic group in this study, statistical results would be more impactive if authors excluded hypochloremic patients. Also, the odds for outcomes comparing the hyperchloremic group with the normochloremic group may be more acceptable to the physicians. Second, the study by Tani et al (4) would be better not to be mentioned in the discussion. Because Tani et al (4) tried to determine the prognostic value of hypochloremia in critically ill patients, it was out of focus to deal with hyperchloremia. Then, studies that evaluated the association of hyperchloremia with hospital mortality in critically ill patients showed consistent results as authors described (3, 5). The authors have disclosed that they do not have any potential conflicts of interest.