Early lactate and glucose kinetics following return to spontaneous circulation after out-of-hospital cardiac arrest

OBJECTIVE: Lactate has been shown to be preferentially metabolized in comparison to glucose after physiological stress, such as strenuous exercise. Derangements of lactate and glucose are common after out-of-hospital cardiac arrest (OHCA). Therefore, we hypothesized that lactate decreases faster than glucose after return-to-spontaneous-circulation (ROSC) after OHCA. RESULTS: We included 155 OHCA patients in our analysis. Within the first 8 h of presentation to the emergency department, 843 lactates and 1019 glucoses were available, respectively. Lactate decreased to 50% of its initial value within 1.5 h (95% CI [0.2-3.6 h]), while glucose halved within 5.6 h (95% CI [5.4-5.7 h]). Also, in the first 8 h after presentation lactate decreases more than glucose in relation to their initial values (lactate 72.6% vs glucose 52.1%). In patients with marked hyperlactatemia after OHCA, lactate decreased expediently while glucose recovered more slowly, whereas arterial pH recovered at a similar rapid rate as lactate. Hospital non-survivors (N = 82) had a slower recovery of lactate (P = 0.002) than survivors (N = 82). The preferential clearance of lactate underscores its role as a prime energy substrate, when available, during recovery from extreme stress

A clinical decision aid for patients with suspected midfacial and mandibular fractures (the REDUCTION-I study):A prospective multicentre cohort study

Purpose To assess physical examination findings related to maxillofacial trauma to identify patients at risk of midfacial and mandibular fractures and then to construct a clinical decision aid to rule out the presence of midfacial and mandibular fractures in emergency department patients. Methods We performed a prospective multicentre cohort study in four hospitals in the Netherlands, including consecutive patients with maxillofacial trauma. Each patient received a standardized physical examination consisting of 15 and 14 findings for midfacial and mandibular traumas, respectively. Consequently, clinical decision aids were constructed with the focus being on ruling out the presence of midfacial and mandibular fractures, and diagnostic accuracy was calculated. Results A total of 993 consecutive patients were identified of whom 766 and 280 patients were suspected of midfacial and mandibular fractures, respectively. Midfacial fractures were diagnosed in 339 patients (44.3%), whereas mandibular fractures were observed in 66 patients (23.6%). The decision aid for midfacial trauma consisting of peri-orbital hematoma, epistaxis, ocular movement limitation, infra-orbital nerve paresthesia, palpable step-off and tooth mobility or avulsion, produced a sensitivity of 89.7 (86.0-92.5), a specificity of 42.6 (38.0-47.4), and a negative predictive value of 83.9% (78.4-88.2). The decision aid for mandibular trauma consisting of the angular compression test, axial chin pressure test, objective malocclusion, tooth mobility or avulsion and the tongue blade bite test resulted in a sensitivity of 98.5 (91.9-99.7), a specificity of 34.6 (28.5-41.2), and a negative predictive value of 98.7% (92.8-99.8). Conclusion The constructed clinical decision aids for maxillofacial trauma may aid in stratifying patients suspected for midfacial and mandibular fractures to reduce unnecessary diagnostic imaging

Potential of Donation After Unexpected Circulatory Death Programs Defined by Their Demographic Characteristics

BACKGROUND. Donation after unexpected circulatory death (uDCD) donors are often suggested to increase the number of donor organs. In 2014, a uDCD protocol was implemented in three transplant centers in the Netherlands which unfortunately did not result in additional transplantations. This study was initiated to identify demographic factors influencing the potential success of uDCD programs. METHODS. Dutch resuscitation databases covering various demographic regions were analyzed for potential donors. The databases were compared with the uDCD implementation project and successful uDCD programs in Spain, France, and Russia. RESULTS. The resuscitation databases showed that 61% of all resuscitated patients were transferred to an emergency department. Age selection reduced this uDCD potential to 46% with only patients aged 18–65 years deemed eligible. Of these patients, 27% died in the emergency department. The urban region of Amsterdam showed the largest potential in absolute numbers (52 patients/y). Comparison with the uDCD implementation project showed large similarities in the percentage of potential donors; however, in absolute numbers, it showed a much smaller potential. Calculation of the potential per million persons and the extrapolation of the potential based on the international experience revealed the largest potential in urban regions. CONCLUSIONS. Implementation of a uDCD program should not only be based on the number of potential donors calculated from resuscitation databases. They show promising potential uDCD percentages for large rural regions and small urban regions; however, actual numbers per hospital are low, leading to insufficient exposure rates. It is, therefore, recommendable to limit uDCD programs to large urban regions

Factors That Complicated the Implementation of a Program of Donation After Unexpected Circulatory Death of Lungs and Kidneys. Lessons Learned From a Regional Trial in the Netherlands

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Koolmonoxidevergiftiging na roken van een waterpijp

Achtergrond Het roken van een waterpijp wordt steeds populairder, maar is niet zo onschuldig als het lijkt. Casus Na het roken van een waterpijp meldden 3 vrouwelijke patiënten zich op de SEH. De 1e patiënte had een syncope doorgemaakt en had daarna nog last van duizeligheid en hoofdpijn. De 2e patiënte had alleen hoofdpijn en de 3e had geen klachten. Lichamelijk onderzoek en standaardcontroles van de vitale functies van alle 3 leverden geen bijzonderheden op. De bloedgasanalyses lieten echter een koolmonoxide(CO)-vergiftiging zien: de patiënten hadden een HbCO-waarde van respectievelijk 22, 19,5 en 5,7% HbCO. We behandelden alle 3 met toediening van hoge concentraties O2, maar de eerste 2 patiënten hielden nog weken lang klachten. De CO-intoxicatie werd waarschijnlijk veroorzaakt doordat de houtskool in de waterpijp onvolledig was verbrand, waardoor CO was vrijgekomen. Conclusie Het regelmatig of zelfs eenmalig roken van een waterpijp met tabak of een gearomatiseerde substantie kan een CO-intoxicatie geven. Na een acute CO-intoxicatie kunnen patiënten nog wekenlang klachten houden

Propofol versus midazolam for procedural sedation in the emergency department:A study on efficacy and safety

Background: Procedural sedation for painful procedures in the emergency department (ED) can be accomplished with various pharmacological agents. The choice of the sedative used is highly dependent on procedure- and patient characteristics and on personal- or local preferences. Methods: We conducted a multicenter retrospective cohort study of procedural sedations performed in the EDs of 5 hospitals in the Netherlands over a 4 year period to evaluate the efficacy- (success rate of the intended procedure) and safety (incidence of sedation (adverse) events) of propofol sedations compared to midazolam sedations. Results: A total of 592 ED sedations were included in our study. Patients sedated with propofol (n = 284, median dose 75 mg) achieved a deeper level of sedation (45% vs. 25% deep sedation, p <0.001), had a higher procedure success rate (92% vs. 81%, p <0.001) and shorter median sedation duration (10 vs. 17 min, p <0.001) compared to patients receiving midazolam (n = 308, median dose 4 mg). A total of 112 sedation events were registered for 99 patients. Transient apnea was the most prevalent event (n = 73), followed by oxygen desaturation (n = 18) airway obstruction responsive to simple maneuvers (n = 13) and hypotension (n = 6). Propofol sedations were more often associated with the occurrence of apnea's (20% vs. 10%, p = 0.004), whereas clinically relevant oxygen desaturations ( Conclusion: Propofol is more effective and at least as safe as midazolam for procedural sedation in the ED. (C) 2017 Elsevier Inc. All rights reserved