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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

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Massive transfusion protocol: the reason it is necessary

Abstract

Objective. The purpose of this study is to identify problems of emergency transfusion at the bedside and to determine need for massive transfusion protocol.

Methods. We included patients who met the criteria for “trauma team activation” and were admitted to division of trauma. The amount of blood product transfused in each unit was investigated for balanced transfusion. We also investigated the compliance with assessment of blood consumption score. The correlation between the time elapsed from patient visit to first transfusion order and time elapsed from first transfusion order to transfusion start was analyzed. Finally, we investigated various factors which serve to influence the decision-making process regarding early transfusion order.

Results. Ratio of packed Red blood cells (pRBC): Fresh frozen plasma (FFP) was well-balanced, but platelet transfusion done was much lower than pRBC and FFP in emergency room. The application of emergency blood release did not match the criteria of assessment of blood consumption (ABC) score. The time from the first transfusion order to the transfusion start was found to be constant irrespective of time from patient visit to first transfusion order. And, the time from the first transfusion order to transfusion start did not differ significantly among patients with early transfusion order and delayed transfusion order. Only systolic blood pressure of < 90 mmHg was identified as a major predictor for early transfusion order.

Conclusion. Balanced transfusion is not easy and emergency transfusion could be delayed at the bedside. Integrated and systematic structures for massive transfusion protocol would be invaluable and indispensable.

Key words: transfusion, emergency, protocol

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Contribution of Presepsin, Procalcitonin and C-reactive protein to the SOFA Score in Early Sepsis Diagnosis in Emergency Abdominal Surgical Patients

Abstract

Purpose: This study examined whether the addition of biomarkers presepsin (PSEP), procalcitonin (PCT) and C-reactive protein (CRP) to the initial SOFA (iSOFA) score can improve diagnostic accuracy of early sepsis diagnosis in emergency abdominal surgery patients.

Materials and Methods: Seventy-two study subjects had diagnosis of acute abdomen due to gastrointestinal disturbances. The study evaluated diagnostic accuracy and predictive value of two models (iSOFA only and iSOFA combined with three biomarkers) for sepsis diagnosis.

Results: The AUC value for the iSOFA was highest, followed by the AUC value obtained for PSEP, PCT and CRP (0.989, 0.738, 0.694 and 0.606, respectively).The logistic regression analysis of the two models showed for the first model that patients with a higher iSOFA score are almost two times more likely to suffer from sepsis. In the second model, patients with a higher iSOFA score and a higher level of biomarkers are three times more likely to have sepsis.

Conclusions: Although the SOFA score is known to be the best diagnostic tool for sepsis diagnosis, it seems that among the three investigated markers PSEP and PCT– although not contributing to the iSOFA score– are good independent markers with significantly higher levels in septic than in non-septic patients. PSEP has the highest diagnostic accuracy for sepsis. Only the conventional marker CRP provides certain added value to the iSOFA score for sepsis prediction.

Further investigations should be performed to study the possible diagnostic value of dynamic changes of the three examined markers in prediction and early diagnosis of sepsis.

Keywords: Sepsis, SOFA, presepsin, procalcitonin, abdominal surgery

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Using age, arterial lactate level and sequential organ failure assessment score in risk stratification of sepsis syndromes

Abstract

Introduction: In low income countries, ICU places are limited and not all sepsis patients will benefit from ICU admission. Stratification is an important step to identify patients who require ICU treatment from patients who can be treated on general ward setting. Improper stratification results in increased length of stay, costs, morbidity and mortality.
Objective: The aim of this study was to stratify the risk of mortality in patients with sepsis syndrome using age, arterial lactate level and SOFA score.
Methods: In this prospective observational study, 250 patients with sepsis were enrolled and followed up until discharge. They were categorized into 2 groups according to 7-days mortality.
Results: SOFA score (≥5) was the only good tool (AUC=0.722) while age (≥65 years) (AUC=0.650) and arterial lactate (≥3.25 mmol/L) (0.690) were fair tools to predict 7-days mortality. A new score “ALSOFA score” (≥10) was an excellent tool for prediction (AUC =0.912, 95%CI: 0.851 to 0.940, p<0.0001). It showed an excellent sensitivity (90.9%) and specificity (85.1%).
Conclusion: In critically ill patients with sepsis syndromes, age, arterial lactate and SOFA score are fair tools of stratification. No single marker/score can be used alone to stratify such patients.

Keywords; Emergency, Critical, Sepsis, SOFA, Arterial Lactate, Stratification

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Effect of transported hospital resources on neurologic outcome after out-of-hospital cardiac arrest

Abstract

Objective. Appropriate regional transport protocol for out-of-hospital cardiac arrest (OHCA) patients is important for achieving favorable outcomes in a certain community. This study aimed to investigate the effect of transported hospital resources on the neurologic outcome after OHCA.

Methods. We categorized cardiac receiving centers (CRC) in our community into two levels (primary [P-CRC] and definite CRC [D-CRC]) according to the hospital resources that were identified by the Hospital Assessment Survey in 2015. OHCA patients with presumed cardiac etiology resuscitated by emergency medical service providers between 2012 and 2014, were enrolled in the study. The main exposure was the level of CRC. The primary endpoint was discharge with good neurologic outcomes. We compared outcomes between CRCs after adjusting for potential confounders.

Results. Among the 9,912 patients, 5,876 were transported to P-CRC and 4,036 to D-CRC from 2012 to 2014. Patients admitted to D-CRC showed better neurologic outcome than those admitted to P-CRC (6.2% vs 1.5%, p<0.001). With regard to patients who survived to admission, the neurologic outcome of patients in D-CRC was better than those in P-CRC (11.3% vs 3.3%, p<0.001). In the multivariable logistic model, the adjusted odds ratio for all OHCA patients was 2.10 (95% confidence interval, 1.51–2.95).

Conclusion. Transportation of OHCA patients to the D-CRC resulted in significantly good neurologic outcome than those transported to P-CRC. Further research is needed to establish a regional OHCA transport protocol.

Key words: cardiac arrest, outcome, regionalization

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Prognostic value of lactate in prehospital care as a predictor of mortality and high-risk patients with trauma

Abstract

Objectives. Major injury is a time-dependent illness in which the quantification of the life prognosis is fundamental for professionals. The objective of this study is to evaluate the capacity of prehospital lactic acid to predict mortality (2, 7 and 30 days) and the admission to the Intensive Care Unit (ICU) from the index event.

Methods. This is a longitudinal, prospective observational study, which included patients who were treated by an Advanced Life Support Unit and transferred to the Emergency Department between April 1 and September 30, 2018. We calculated sensitivity, specificity, and likelihood ratios. The main outcome variable was mortality from any cause (2, 7 and 30 days) and admission to ICU.

Results. 109 patients were included in our study. Eleven patients (10%) experienced early mortality before the first 48 hours after the index event, with an ICU admission rate of 28%. The sensitivity and specificity of the test to determine mortality in less than two days was 63.6% (95% CI, 35.4-84.8%) and 87.8% (95% CI, 79.8-92.9%).

Conclusions. Prehospital lactic acid has an excellent capacity to predict the mortality and the admission of patients with major injury to the ICU, and it is a cheap, easy-to-obtain and reliable diagnostic tool that can help in clinical decision-making.

Key words: Critical care, emergency department, outcome, survival, intensive care

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