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Sheng B, Li S, Wang H, Guo Z, Zhang Z. Association between serum lactate, lactate clearance rate, and 30-day mortality among patients undergoing mechanical ventilation: A retrospective cohort study of MIMIC-III database. Medicine (Baltimore) 2024; 103:e35818. [PMID: 38277542 PMCID: PMC10817166 DOI: 10.1097/md.0000000000035818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/05/2023] [Indexed: 01/28/2024] Open
Abstract
Serum lactate has been used as a prognostic indicator in intensive care unit patients, and however, the single lactate value may not be enough to reflect changes during illness conditions. Herein, this study aims to explore the association between serum lactate and lactate clearance rate and 30-day mortality in patients undergoing mechanical ventilation (MV). Demographic and clinical data of 2628 adults were extracted from the medical information mart for intensive care-III clinical database in this retrospective cohort study. The lactate clearance rate was calculated using the serum lactate at the beginning of MV (T0), and serum lactate at the12 hours after MV beginning (T1). Univariate and multivariate Cox regression analyses were used to screen covariates, and explore the association between serum lactate and lactate clearance rate and 30-day mortality. We also explored these associations in different T0 serum lactate level subgroups. The evaluation indexes were hazard ratios (HRs) and 95% CIs. In addition, receiver operator characteristic (ROC) curve with area under the curve (AUC) was used to reflect the predictive performance of serum lactate and lactate clearance rate on 30-day mortality. A total of 827 (31.47%) mechanically ventilated patients died within 30 days. After adjusting for covariates, elevated T0 (HR = 1.04, 95%CI: [1.02-1.07]) and T1 (HR = 1.07, 95%CI: [1.04-1.10]) serum lactate was both associated with an increased risk of 30-day mortality, while higher lactate clearance rate was negatively associated with the risk of 30-day mortality (HR = 0.64, 95%CI: [0.50-0.81]). Among patients with T0 lactate ≥2 mmol/L, T1 serum lactate ≥4 mmol/L was associated with an increased risk of 30-day mortality, while lactate clearance rate ≥50 was associated with a decreased risk (all P < .05). Moreover, T1 serum lactate had a potential predictive value on 30-day mortality with an AUC of 0.605. Serum lactate and lactate clearance rate were both associated with 30-day mortality in patients undergoing MV. Our results may provide some references for further studies to explore the roles of serum lactate and lactate clearance rate in prognoses of critical patients.
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Affiliation(s)
- Bo Sheng
- Department of Liver ICU, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, P.R. China
| | - Shan Li
- Department of Liver ICU, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, P.R. China
| | - He Wang
- Department of Liver ICU, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, P.R. China
| | - Zhe Guo
- Department of Liver ICU, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, P.R. China
| | - Zhenyu Zhang
- Department of Liver ICU, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, P.R. China
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Ward CL, Olafson SN, Cohen RB, Kaplan MJ, Bloom A, Parsikia A, Moran BJ, Leung PS. Combination of Lactate and Base Deficit Levels at Admission to Predict Mortality in Blunt Trauma Patients. Cureus 2023; 15:e40097. [PMID: 37425498 PMCID: PMC10328425 DOI: 10.7759/cureus.40097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 07/11/2023] Open
Abstract
INTRODUCTION Elevated lactate levels are associated with increased mortality in both trauma and non-trauma patients. The relation between base deficit (BD) and mortality is less clear. Traumatologists debate the utility of elevated lactate (EL) versus BD in predicting mortality. We hypothesized that EL (2mmol/L to 5mmol/L) and BD (≤-2mmol/L) in combination could predict mortality in blunt trauma patients. Methods: This is a retrospective analysis of the trauma registry from 2012 to 2021 at a level 1 trauma center. Blunt trauma patients with admission lactate and BD values were included in the analysis. Exclusion criteria were age <18, penetrating trauma, unknown mortality, and unknown lactate or BD. Logistics regression of the total 5153 charts showed 93% of the patients presented with lactate levels <5mmol/L, therefore patients with lactate >5mmol/L were excluded as outliers. The primary outcome was mortality. RESULTS A total of 4794 patients (151 non-survivors) were included in the analysis. Non-survivors had higher rates of EL + BD (35.8% vs. 14.4%, p <0.001). When comparing survivors and non-survivors, EL + BD (OR 5.69), age >65 (5.17), injury severity score (ISS) >25 (8.87), Glasgow coma scale <8 (8.51), systolic blood pressure (SBP) <90 (4.2), and ICU admission (2.61) were significant predictors of mortality. Other than GCS <8 and ISS >25, EL + BD had the highest odds of predicting mortality. CONCLUSION Elevated lactate + BD on admission in combination represents a 5.6-fold increase in mortality in blunt trauma patients and can be used to predict a patient's outcome on admission. This combination variable provides an additional early data point to identify patients at elevated risk of mortality at the moment of admission.
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Affiliation(s)
- Candace L Ward
- Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Samantha N Olafson
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Ryan B Cohen
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Mark J Kaplan
- Trauma and Acute Care Surgery, Einstein Healthcare Network, Philadelphia, USA
| | - Alexi Bloom
- Trauma and Acute Care Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Afshin Parsikia
- General Surgery, Einstein Healthcare Network, Philadelphia, USA
| | - Benjamin J Moran
- Trauma and Acute Care Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Pak S Leung
- Trauma and Acute Care Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
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Gicheru B, Shah J, Wachira B, Omuse G, Maina D. The diagnostic accuracy of an initial point-of-care lactate at the emergency department as a predictor of in-hospital mortality among adult patients with sepsis and septic shock. Front Med (Lausanne) 2023; 10:1173286. [PMID: 37293300 PMCID: PMC10244658 DOI: 10.3389/fmed.2023.1173286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/24/2023] [Indexed: 06/10/2023] Open
Abstract
Background In patients with sepsis, elevated lactate has been shown to be a strong predictor of in-hospital mortality. However, the optimal cutoff for rapidly stratifying patients presenting to the emergency department at risk for increased in-hospital mortality has not been well defined. This study aimed to establish the optimal point-of-care (POC) lactate cutoff that best predicted in-hospital mortality in adult patients presenting to the emergency department. Methods This was a retrospective study. All adult patients who presented to the emergency department at the Aga Khan University Hospital, Nairobi, between 1 January 2018 and 31 August 2020 with suspected sepsis or septic shock and were admitted to the hospital were included in the study. Initial POC lactate results (GEM 3500® blood gas analyzer) and demographic and outcome data were collected. A receiver operating characteristic (ROC) curve for initial POC lactate values was plotted to determine the area under the curve (AUC). An optimal initial lactate cutoff was then determined using the Youden Index. Kaplan-Meier curves were used to determine the hazard ratio (HR) for the identified lactate cutoff. Results A total of 123 patients were included in the study. They had a median age of 61 years [interquartile range (IQR) 41.0-77.0]. Initial lactate independently predicted in-hospital mortality [adjusted odds ratio (OR) 1.41 95% confidence interval (CI 1.06, 1.87) p = 0.018]. Initial lactate was found to have an area under the curve (AUC) of 0.752 (95% CI, 0.643 to 0.86). Additionally, a cutoff of 3.5 mmol/L was found to best predict in-hospital mortality (sensitivity 66.7%, specificity 71.4%, PPV 70%, NPV 68.2%). Mortality was 42.1% (16/38) in patients with an initial lactate of ≥ 3.5 mmol/L and 12.7% (8/63) in patients with an initial lactate of <3.5 mmol/L (HR, 3.388; 95% CI, 1.432-8.018; p < 0.005). Discussion An initial POC lactate of ≥ 3.5 mmol/L best predicted in-hospital mortality in patients presenting with suspected sepsis and septic shock to the emergency department. A review of the sepsis and septic shock protocols will help in the early identification and management of these patients to reduce their in-hospital mortality.
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Affiliation(s)
- Brenda Gicheru
- Department of Pathology and Laboratory Medicine, Aga Khan University, Nairobi, Kenya
| | - Jasmit Shah
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
- Department of Medicine, Aga Khan University, Nairobi, Kenya
| | - Benjamin Wachira
- Accident and Emergency Department, Aga Khan University, Nairobi, Kenya
| | - Geoffrey Omuse
- Department of Pathology and Laboratory Medicine, Aga Khan University, Nairobi, Kenya
| | - Daniel Maina
- Department of Pathology and Laboratory Medicine, Aga Khan University, Nairobi, Kenya
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Tamakawa T, Endoh H, Kamimura N, Deuchi K, Nishiyama K. Impact on outcomes of measuring lactates prior to ICU in unselected heterogeneous critically ill patients: A propensity score analysis. PLoS One 2022; 17:e0277948. [PMID: 36441770 PMCID: PMC9704607 DOI: 10.1371/journal.pone.0277948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/07/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Elevated blood lactate levels were reported as effective predictors of clinical outcome and mortality in ICU. However, there have been no studies simply comparing the timing of measuring lactates before vs. after ICU admission. METHODS A total of 19,226 patients with transfer time ≤ 24 hr were extracted from the Medical Information Mart for Intensive Care IV database (MIMIC-IV). After 1:1 propensity score matching, the patients were divided into two groups: measuring lactates within 3 hr before (BICU group, n = 4,755) and measuring lactate within 3 hr after ICU admission(AICU group, n = 4,755). The primary and secondary outcomes were hospital mortality, hospital 28-day mortality, ICU mortality, ICU length of stay (LOS), hospital LOS, and restricted mean survival time (RMST). RESULTS Hospital, hospital 28-day, and ICU mortality were significantly higher in AICU group (7.0% vs.9.8%, 6.7% vs. 9.4%, and 4.6% vs.6.7%, respectively, p<0.001 for all) Hospital LOS and ICU LOS were significantly longer in AICU group (8.4 days vs. 9.0 days and 3.0 days vs. 3.5 days, respectively, p<0.001 for both). After adjustment for predefined covariates, a significant association between the timing of measuring lactate and hospital mortality was observed in inverse probability treatment weight (IPTW) multivariate regression, doubly robust multivariate regression, and multivariate regression models (OR, 0.96 [95%CI, 0.95-0.97], OR 0.52 [95%CI, 0.46-0.60], OR 0.66 [95%CI, 0.56-0.78], respectively, p<0.001 for all), indicating the timing as a significant risk-adjusted factor for lower hospital mortality. The difference (BICU-AICU) of RMST at 28- days after ICU admission was 0.531 days (95%CI, 0.002-1.059, p<0.05). Placement of A-line and PA-catheter, administration of intravenous antibiotics, and bolus fluid infusion during the first 24-hr in ICU were significantly more frequent and faster in the BICU vs AICU group (67.6% vs. 51.3% and 126min vs.197min for A-line, 19.6% vs.13.2% and 182min vs. 274min for PA-catheter, 77.5% vs.67.6% and 109min vs.168min for antibiotics, and 57.6% vs.51.6% and 224min vs.278min for bolus fluid infusion, respectively, p<0.001 for all). Additionally, a significant indirect effect was observed in frequency (0.19879 [95% CI, 0.14061-0.25697] p<0.001) and time (0.07714 [95% CI, 0.22600-0.13168], p<0.01) of A-line replacement, frequency of placement of PA-catheter (0.05614 [95% CI, 0.04088-0.07140], p<0.001) and frequency of bolus fluid infusion (0.02193 [95%CI, 0.00303-0.04083], p<0.05). CONCLUSIONS Measuring lactates within 3 hr prior to ICU might be associated with lower hospital mortality in unselected heterogeneous critically ill patients with transfer time to ICU ≤ 24hr, presumably due to more frequent and faster therapeutic interventions.
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Affiliation(s)
- Taro Tamakawa
- Niigata University Faculty of Medicine, Department of Emergency & Critical Care Medicine, Niigata City, Niigata, Japan
- Advanced Emergency and Critical Care Center, Niigata University Medical & Dental Hospital, Niigata City, Niigata, Japan
| | - Hiroshi Endoh
- Niigata University Faculty of Medicine, Department of Emergency & Critical Care Medicine, Niigata City, Niigata, Japan
- * E-mail:
| | - Natuo Kamimura
- Niigata University Faculty of Medicine, Department of Emergency & Critical Care Medicine, Niigata City, Niigata, Japan
- Advanced Emergency and Critical Care Center, Niigata University Medical & Dental Hospital, Niigata City, Niigata, Japan
| | - Kazuki Deuchi
- Niigata University Faculty of Medicine, Department of Emergency & Critical Care Medicine, Niigata City, Niigata, Japan
- Advanced Emergency and Critical Care Center, Niigata University Medical & Dental Hospital, Niigata City, Niigata, Japan
| | - Kei Nishiyama
- Niigata University Faculty of Medicine, Department of Emergency & Critical Care Medicine, Niigata City, Niigata, Japan
- Advanced Emergency and Critical Care Center, Niigata University Medical & Dental Hospital, Niigata City, Niigata, Japan
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Spörl P, Beckers SK, Rossaint R, Felzen M, Schröder H. Shedding light into the black box of out-of-hospital respiratory distress—A retrospective cohort analysis of discharge diagnoses, prehospital diagnostic accuracy, and predictors of mortality. PLoS One 2022; 17:e0271982. [PMID: 35921383 PMCID: PMC9348717 DOI: 10.1371/journal.pone.0271982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 07/11/2022] [Indexed: 11/19/2022] Open
Abstract
Background Although respiratory distress is one of the most common complaints of patients requiring emergency medical services (EMS), there is a lack of evidence on important aspects. Objectives Our study aims to determine the accuracy of EMS physician diagnostics in the out-of-hospital setting, identify examination findings that correlate with diagnoses, investigate hospital mortality, and identify mortality-associated predictors. Methods This retrospective observational study examined EMS encounters between December 2015 and May 2016 in the city of Aachen, Germany, in which an EMS physician was present at the scene. Adult patients were included if the EMS physician initially detected dyspnea, low oxygen saturation, or pathological auscultation findings at the scene (n = 719). The analyses were performed by linking out-of-hospital data to hospital records and using binary logistic regressions. Results The overall diagnostic accuracy was 69.9% (485/694). The highest diagnostic accuracies were observed in asthma (15/15; 100%), hypertensive crisis (28/33; 84.4%), and COPD exacerbation (114/138; 82.6%), lowest accuracies were observed in pneumonia (70/142; 49.3%), pulmonary embolism (8/18; 44.4%), and urinary tract infection (14/35; 40%). The overall hospital mortality rate was 13.8% (99/719). The highest hospital mortality rates were seen in pneumonia (44/142; 31%) and urinary tract infection (7/35; 20%). Identified risk factors for hospital mortality were metabolic acidosis in the initial blood gas analysis (odds ratio (OR) 11.84), the diagnosis of pneumonia (OR 3.22) reduced vigilance (OR 2.58), low oxygen saturation (OR 2.23), and increasing age (OR 1.03 by 1 year increase). Conclusions Our data highlight the diagnostic uncertainties and high mortality in out-of-hospital emergency patients presenting with respiratory distress. Pneumonia was the most common and most frequently misdiagnosed cause and showed highest hospital mortality. The identified predictors could contribute to an early detection of patients at risk.
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Affiliation(s)
- Patrick Spörl
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management and Public Safety, University Hospital RWTH Aachen, Aachen, Germany
- * E-mail:
| | - Stefan K. Beckers
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management and Public Safety, University Hospital RWTH Aachen, Aachen, Germany
- Medical Direction, Emergency Medical Service, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Marc Felzen
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management and Public Safety, University Hospital RWTH Aachen, Aachen, Germany
- Medical Direction, Emergency Medical Service, Aachen, Germany
| | - Hanna Schröder
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management and Public Safety, University Hospital RWTH Aachen, Aachen, Germany
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Voigt I, Mighali M, Manda D, Aurich P, Bruder O. Radiographic assessment of lung edema (RALE) score is associated with clinical outcomes in patients with refractory cardiogenic shock and refractory cardiac arrest after percutaneous implantation of extracorporeal life support. Intern Emerg Med 2022; 17:1463-1470. [PMID: 35169942 DOI: 10.1007/s11739-022-02937-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/19/2022] [Indexed: 01/27/2023]
Abstract
VA-ECMO is a promising therapeutic option in refractory cardiogenic shock (RCS) and refractory cardiac arrest (RCA). However, increase in left ventricular afterload enhances further reduction of LV contractility and pulmonary edema. The aim of this study was to evaluate pulmonary edema based on the RALE score and the prognostic value of the score on ECLS weaning and mortality. In this retrospective study, data from 40 patients (16 RCAs and 24 RCSs) were analyzed. Demographic, clinical data and the RALE score for evaluating pulmonary edema were assessed. Descriptive statistics, intraclass correlation, and receiver operating characteristic (ROC) curves were computed. Weaning from ECLS was successful in 30 (75%) patients, 16 patients (40%) were discharged alive. Overall, the survivors were younger, presenting with a higher left ventricular ejection fraction (30 ± 2% vs.23 ± 9%;p < 0.01) and a lower initial serum lactate concentration 7.7 ± 4.5 mmol/l vs. 11.5 ± 4.9 mmol/l; p = 0.017). Survivors had lower RALE scores than non-survivors (16.3 ± 9.4 vs. 26.4 ± 10.4; p = 0.0034). The interobserver variability of the RALE score was good (0.832). The AUC predicting mortality and weaning from ECLS presented comparable results to the established parameters (SAVE, serum lactate). Implementation of the RALE score could support prediction of outcome parameters during VA-ECMO therapy.
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Affiliation(s)
- Ingo Voigt
- Department of Acute and Emergency Medicine, Elisabeth-Hospital Essen, Essen, Germany.
- Ruhr-University, Bochum, Germany.
| | - Marco Mighali
- Department of Acute and Emergency Medicine, Elisabeth-Hospital Essen, Essen, Germany
| | - Daniela Manda
- Department of Acute and Emergency Medicine, Elisabeth-Hospital Essen, Essen, Germany
| | - Phillip Aurich
- Department of Acute and Emergency Medicine, Elisabeth-Hospital Essen, Essen, Germany
- Department of Cardiology and Angiology, Elisabeth-Hospital Essen, Essen, Germany
| | - Oliver Bruder
- Department of Cardiology and Angiology, Elisabeth-Hospital Essen, Essen, Germany
- Ruhr-University, Bochum, Germany
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Michael M, Kumle B, Kümpers P, Bernhard M. [Management of Critically Ill Non-traumatic Patients in the Emergency Department]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:466-477. [PMID: 35896385 DOI: 10.1055/a-1545-2422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
AbstractResuscitation room management of non-traumatic critically ill patients in the emergency department comprises approximately 1.5% of all emergency department visits. Critically ill patients
are usually brought to the hospital by emergency medical services, where they are first examined, given initial treatment, stabilized and then transported for further in-hospital treatment.
Resuscitation room management plays a key role at the interface of the out-of-hospital and in-hospital treatment chains. While the structured care of traumatological patients has been
established at a very high level for decades, the care of non-traumatic critically ill patients within the framework of resuscitation room care has only come into focus in recent years and
is only now being implemented in some places with professional concepts. Emergency departments at all levels of care are equipped to provide structured care for non-traumatologic shock room
patients. To professionalize non-traumatic resuscitation room management, the creation of uniform standards from alerting criteria, to equipment and staffing, as well as the establishment of
a uniform resuscitation room management algorithm is required. The (PRE_E-)AUD2IT-algorithm provides a structure for the non-traumatic care of critically ill patients in the
resuscitation room and includes preparation, resource retrieval, handover, initial care, diagnostics, differential diagnoses and the interpretation of examination findings. This overview
focuses on the management of critically ill non-traumatic patients in respect to the resuscitation room care concept.
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Kumle B, Michael M, Wermke A, Schmitz C, Hammer N, Kümpers P, Pin M, Bernhard M. ["B problems" in non-traumatic resuscitation room management]. Notf Rett Med 2022; 26:4-14. [PMID: 35287271 PMCID: PMC8908747 DOI: 10.1007/s10049-022-00990-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 02/02/2023]
Abstract
In the primary survey of resuscitation room management in critically ill nontrauma patients, the ABCDE (airway, breathing, circulation, disability, exposure) approach is used for immediate recognition and treatment of life-threatening conditions. "B problems" are associated with respiratory failure and require immediate treatment. The pathogenesis is diverse, especially in the nontrauma resuscitation room. Clinical examination, emergency sonography and knowledge of oxygenation techniques and ventilation are important components of diagnosis and therapy. Standardized procedures and regular training in the emergency room are of fundamental importance.
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Affiliation(s)
- Bernhard Kumle
- Klinik für Akut- und Notfallmedizin, Schwarzwald-Baar Klinikum, Klinikstr. 11, 78052 Villingen-Schwenningen, Deutschland
- Medical Life Science, Campus Schwenningen, Furtwangen University, Schwenningen, Deutschland
| | - Mark Michael
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - Andreas Wermke
- Klinik für Akut- und Notfallmedizin, Schwarzwald-Baar Klinikum, Klinikstr. 11, 78052 Villingen-Schwenningen, Deutschland
| | - Christoph Schmitz
- Interdisziplinäres Notfallzentrum, Kantonsspital Schaffhausen, Schaffhausen, Schweiz
| | - Niels Hammer
- Institut für Klinische und Makroskopische Anatomie, Medizinische Universität Graz, Graz, Österreich
- Klinik für Orthopädie und Unfallchirurgie, Universität Leipzig, Leipzig, Deutschland
- Abteilung Medizintechnik, Fraunhofer-Institut für Werkstoff- und Umformtechnik, Dresden, Deutschland
| | - Philipp Kümpers
- Medizinische Klinik D, Allgemeine Innere Medizin und Notaufnahme sowie Nieren- und Hochdruckkrankheiten und Rheumatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Martin Pin
- Zentrale Notaufnahme, Florence-Nightingale-Krankenhaus, Düsseldorf, Deutschland
| | - Michael Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
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Michael M, Bax S, Finke M, Hoffmann M, Kornstädt S, Kümpers P, Kumle B, Laaf T, Reindl M, Schunk D, Pin M, Bernhard M. Aktuelle Ist-Analyse zur Situation des nichttraumatologischen Schockraummanagements in Deutschland. Notf Rett Med 2022. [DOI: 10.1007/s10049-020-00827-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Zusammenfassung
Einleitung
In Notaufnahmen kommen bundesweit nichttraumatologische kritisch kranke Patienten zur Aufnahme. Zur Struktur, Organisation und Ausstattung des nichttraumatologischen Schockraummanagements ist bisher wenig bekannt. Mittels einer Umfrage sollte daher der Ist-Zustand analysiert werden.
Methodik
Durch die Arbeitsgruppe „Schockraum“ der Deutschen Gesellschaft Interdisziplinäre Notfall- und Akutmedizin (DGINA) wurde mittels E‑Mail den 420 ärztlichen Leiter*Innen des DGINA-Mitgliederregisters eine Onlineumfrage zugesendet. Zwei Wochen nach initialem Anschreiben erfolgte eine Erinnerung. Die Ergebnisse wurden in einer anonymisierten Datenbank extrahiert und ausgewertet.
Ergebnisse
Insgesamt lag die Rücklaufquote mit 131 verwertbaren Antworten bei 31 %. Die Umfrage erfasste Krankenhäuser der Basis- (24 %), erweiterten (39 %) und umfassenden Notfallversorgung (37 %). Korrespondierend zur Versorgungsstufe stiegen die jährlichen Patientenkontakte (21.000 vs. 31.000 vs. 39.000), die Monitorplätze in den Notaufnahmen (9 ± 4 vs. 13 ± 6 vs. 18 ± 10), die Betten der assoziierten Notaufnahmestationen (4 ± 5 vs. 10 ± 17 vs. 13 ± 12), die verfügbaren Schockräume (1 ± 1 vs. 2 ± 1 vs. 3 ± 1) und deren Größe (31 ± 16 vs. 35 ± 9 vs. 38 ± 14 m2) an. Hinsichtlich verschiedener Ausstattungsmerkmale (z. B. Röntgenlafette: 58 vs. 65 vs. 78 %, Computertomographie im Schockraum: 6 vs. 12 vs. 27 %) zeigten sich deutliche Unterschiede in Abhängigkeit von der Versorgungsstufe. Während Kühlungssysteme in 30 % in allen Versorgungsstufen vorgehalten wurden, fanden sich andere Ausstattungsmerkmale (z. B. Videolaryngoskopie: 65 vs. 80 vs. 86 %, Bronchoskopie: 29 vs. 22 vs. 45 %) und spezielle Notfallprozeduren (z. B. REBOA [„resuscitative endovascular balloon occlusion of the aorta“]: 3 vs. 5 vs. 12 %, ACCD [„automated chest compression device“]: 26 vs. 57 vs. 61 %) häufiger in höheren Versorgungsstufen.
Schlussfolgerung
Die vorliegenden Ergebnisse zeigen erstmals den Ist-Zustand der nichttraumatologischen Schockraumversorgung in verschiedenen Versorgungsstufen in Deutschland. Empfehlungen zu Ausstattungsmerkmalen für das nichttraumatologische Schockraummanagement müssen zukünftig formuliert werden.
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Michael M, Kumle B, Pin M, Michels G, Hammer N, Kümpers P, Bernhard M. „C-Probleme“ des nichttraumatologischen Schockraummanagements. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00936-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungIm Rahmen des nichttraumatologischen Schockraummanagements zur Versorgung kritisch kranker Patienten werden akute Störungen der Vitalfunktionen rasch detektiert und behandelt. Beim „primary survey“ (Erstversorgung) dient das etablierte ABCDE-Schema der strukturierten Untersuchung aller relevanten Vitalparameter. Akute Störungen werden hierbei unmittelbar detektiert und therapiert. „C-Probleme“ stellen den größten Anteil der ABCDE-Störungen bei nichttraumatologischen Schockraumpatienten dar und zeichnen sich durch eine hämodynamische Instabilität infolge hypovolämischer, obstruktiver, distributiver oder kardiogener Schockformen aus. Abhängig von den lokalen Versorgungsstrukturen umfasst die nichttraumatologische Schockraumversorgung hierbei auch die Stabilisierung von Patienten mit akutem Koronarsyndrom oder nach prähospitaler Reanimation (Cardiac Arrest Center).
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Lo BD, Merkel KR, Dougherty JL, Kajstura TJ, Cruz NC, Sikorski RA, Frank SM. Assessing predictors of futility in patients receiving massive transfusions. Transfusion 2021; 61:2082-2089. [PMID: 33955577 DOI: 10.1111/trf.16410] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/21/2021] [Accepted: 04/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Massive transfusions are associated with a high mortality rate, but there is little evidence indicating when such efforts are futile. The purpose of this study was to identify clinical variables that could be used as futility indicators in massively transfused patients. METHODS We retrospectively analyzed 138 adult surgical patients at our institution receiving a massive transfusion (2016-2019). Peak lactate and nadir pH within 24 h of massive transfusion initiation, along with other clinical variables, were assessed as predictors of the primary outcome, in-hospital mortality. RESULTS The overall rate of in-hospital mortality among our patient population was 52.9% (n = 73). Increasing lactate and decreasing pH were associated with greater mortality among massively transfused patients. Mortality rates were ~2-fold higher for patients in the highest lactate category (≥10.0 mmol/L: 25 of 37; 67.6%) compared to the lowest category (0.0-4.9 mmol/L: 17 of 48; 35.4%) (p = .005), and ~2.5-fold higher for patients in the lowest pH category (<7.00: 8 of 9; 88.9%) compared to the highest category (≥7.40: 8 of 23; 34.7%) (p = .016). Increasing age was also associated with higher mortality (≥65 years: 24 of 33; 72.7%) when compared to younger patients (18-64 years: 49 of 105; 46.7%) (p = .010). CONCLUSIONS Peak lactate ≥10.0 mmol/L, nadir pH <7.00, and age ≥65 years were significantly associated with higher rates of in-hospital mortality among massively transfused patients. Incorporating these clinical parameters into a futility index for massive transfusions will be useful in situations where blood products are scarce and/or mortality may be unavoidable.
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Affiliation(s)
- Brian D Lo
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Kevin R Merkel
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - James L Dougherty
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Tymoteusz J Kajstura
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Nicolas C Cruz
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Robert A Sikorski
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.,The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Pareek S, Kumar N, Verma D, Gupta K, Kiran M, Mehta M. Venous lactate level as a predictor to determine the outcome in patients with acute upper gastrointestinal hemorrhage in the emergency department. MGM J Med Sci 2021. [DOI: 10.4103/mgmj.mgmj_19_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Brio-Ibañez PD, López-Izquierdo R, Martín-Rodríguez F, Mohedano-Moriano A, Polonio-López B, Maestre-Miquel C, Viñuela A, Durantez-Fernández C, Villamor MÁC, Martín-Conty JL. Clinical Utility of Delta Lactate for Predicting Early In-Hospital Mortality in Adult Patients: A Prospective, Multicentric, Cohort Study. Diagnostics (Basel) 2020; 10:E960. [PMID: 33212827 DOI: 10.3390/diagnostics10110960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 12/23/2022] Open
Abstract
One of the challenges in the emergency department (ED) is the early identification of patients with a higher risk of clinical deterioration. The objective is to evaluate the prognostic capacity of ΔLA (correlation between prehospital lactate (pLA) and hospital lactate (hLA)) with respect to in-hospital two day mortality. We conducted a pragmatic, multicentric, prospective and blinded-endpoint study in adults who consecutively attended and were transported in advanced life support with high priority from the scene to the ED. The corresponding area under the receiver operating characteristics curve (AUROC) was obtained for each of the outcomes. In total, 1341 cases met the inclusion criteria. The median age was 71 years (interquartile range: 54–83 years), with 38.9% (521 cases) females. The total 2 day mortality included 106 patients (7.9%). The prognostic precision for the 2 day mortality of pLA and hLA was good, with an AUROC of 0.800 (95% CI: 0.74–0.85; p < 0.001) and 0.819 (95% CI: 0.76–0.86; p < 0.001), respectively. Of all patients, 31.5% (422 cases) had an ΔLA with a decrease of <10%, of which a total of 66 patients (15.6%) died. A lactate clearance ≥ 10% is associated with a lower risk of death in the ED, and this value could potentially be used as a guide to determine if a severely injured patient is improving in response to the established treatment.
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