Comparison between Capillary and Serum Lactate Levels in Predicting Short-Term Mortality of Septic Patients at the Emergency Department

Sepsis is a time-dependent and life-threating condition related to macro- and micro-circulatory impairment leading to anaerobic metabolism and lactate increase. We assessed the prognostic accuracy of capillary lactates (CLs) vs. serum ones (SLs) on 48-h and 7-day mortality in patients with suspected sepsis. This observational, prospective, single-centre study was conducted between October 2021 and May 2022. Inclusion criteria were: (i) suspect of infection; (ii) qSOFA ≥ 2; (iii) age ≥ 18 years; (iv) signed informed consent. CLs were assessed with LactateProTM2®. 203 patients were included: 19 (9.3%) died within 48 h from admission to the Emergency Department, while 28 (13.8%) within 7 days. Patients deceased within 48 h (vs. survived) had higher CLs (19.3 vs. 5 mmol/L, p < 0.001) and SLs (6.5 vs. 1.1 mmol/L, p = 0.001). The best CLs predictive cut-off for 48-h mortality was 16.8 mmol/L (72.22% sensitivity, 94.02% specificity). Patients within 7 days had higher CLs (11.5 vs. 5 mmol/L, p = 0.020) than SLs (2.75 vs. 1.1 mmol/L, p < 0.001). The multivariate analysis confirmed CLs and SLs as independent predictors of 48-h and 7-day mortality. CLs can be a reliable tool for their inexpensiveness, rapidity and reliability in identifying septic patients at high risk of short-term mortality

Presepsin levels and COVID-19 severity: a systematic review and meta-analysis

Plasmatic presepsin (PSP) is a novel biomarker reported to be useful for sepsis diagnosis and prognosis. During the pandemic, only few studies highlighted a possible correlation between PSP and COVID-19 severity, but results remain inconsistent. The present study aims to establish the correlation between PSP and COVID-19 severity. English-language papers assessing a correlation between COVID-19 and PSP from MEDLINE, PubMed, Google Scholar, Cochrane Library, MeSH, LitCovid NLM, EMBASE, CINAHL Plus and the World Health Organization (WHO) website, published from January 2020 were considered with no publication date limitations. Two independent reviewers performed data abstraction and quality assessment, and one reviewer resolved inconsistencies. The protocol was registered on PROSPERO (CRD42022325971).Fifteen articles met our eligibility criteria. The aggregate study population included 1373 COVID-19 patients who had undergone a PSP assessment. The random-effect meta-analysis was performed in 7 out of 15 selected studies, considering only those reporting the mean PSP levels in low- and high-severity cases (n = 707).The results showed that the pooled mean difference of PSP levels between high- and low-severity COVID-19 patients was 441.70 pg/ml (95%CI: 150.40-732.99 pg/ml).Our data show that presepsin is a promising biomarker that can express COVID-19 severity

A case of hemorrhagic shock due to massive upper gastrointestinal bleeding: from the differential diagnosis to the correct management

Upper Gastro-Intestinal Bleeding (UGIB) spans from minor bleeding to life-threatening events. Identification of early signs of shock, proper management of hemodynamically unstable patients, and correct risk stratification are essential for an appropriate diagnostic workup and therapy. This case reports a young man admitted to the emergency department with haematemesis. His medical history was unremarkable, without any risk factors for gastrointestinal bleeding. A few hours after admission, further episodes of haematemesis occurred, and the patient's condition rapidly deteriorated to irreversible shock. A contrast-enhanced computed tomography (CECT) revealed morphological features of chronic liver disease and oesophagal varices. The patient underwent upper gastrointestinal endoscopy, confirming oesophagal varices with massive bleeding. Although promptly applied, endoscopic hemostasis was ineffective, and the patient died twenty-four hours after admission. Based on this case, we reviewed the diagnostic and therapeutic approaches for patients with massive UGIB and provided a practical approach to this life-threatening emergency

Predicting in-hospital mortality in patients admitted from the emergency department for pulmonary embolism: Incidence and prognostic value of deep vein thrombosis. A retrospective study

Background Pulmonary embolism (PE) is one of the most common causes of death from cardiovascular disease. Although deep vein thrombosis (DVT) is the leading cause of PE, its prognostic role is unclear. This study investigated the incidence and prognostic value of DVT in predicting in-hospital mortality (IHM) in patients admitted from the emergency department (ED) for PE.Methods This retrospective cohort study was conducted in the ED of a third-level university hospital. Patients over 18 years admitted for PE between 1 January 2018 and 31 December 2022 were included.Results Five hundred and thirty patients (mean age 73.13 years, 6% IHM) were included. 69.1% of cases had DVT (36.4% unilateral femoral vein, 3.6% bilateral, 39.1% unilateral popliteal vein, 2.8% bilateral, 45.7% distal vein thrombosis and 7.4% iliocaval involvement). Patients who died in hospital had a higher Pulmonary Embolism Severity Index (PESI) (138.6 vs. 99.65, p < 0.001), European Society of Cardiology risk class (15.6% vs. 1%, intermediate-high in 50% vs. 6.4%, p < 0.001) and more DVT involving the iliac-caval vein axis (18.8% vs. 6.6%, p = 0.011). PESI class >II, right ventricular dysfunction, increased blood markers of myocardial damage and involvement of the iliocaval venous axis were independent predictors of IHM on multivariate analysis.Conclusions Although further studies are needed to confirm the prognostic role of DVT at PE, involvement of the iliocaval venous axis should considered to be a sign of a higher risk of IHM and may be a key factor in prognostic stratification

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide

Pain management at the End of Life in the Emergency Department. A narrative review of the Literature and a practical clinical approach.

This is a narrrative review of the literature on the effective and safe management of pain at the end of life of patients admitted to the emergency departmen

Low-dose systemic thrombolysis in patient with recent major abdominal surgery and high-risk pulmonary embolism: Case report and narrative review

Introduction: Systemic thrombolysis is the treatment of choice for hemodynamically unstable patients with acute pulmonary embolism (PE) while for the intermediate-high risk ones the possibility of severe bleeding seems to outweigh the benefits. Surgical or percutaneous therapy is an option in case of contraindication/failure of fibrinolysis but they are not available in every hospital. Case Report: An 85-year-old woman arrived at the Emergency Department for rapid onset dyspnea, thoracic pain with hypotension, tachycardia, and hypoxia. A computed tomography pulmonary angiography revealed acute PE of the main branches of the pulmonary right and left arteries. Due to hemodynamic instability and a history of recent intestinal resection surgery (25 days before), a continuous infusion of low-dose thrombolysis regimen with 50 mg rt-PA in 2 hours was started. After 30 minutes of rt-PA infusion, all vital signs were improved and at the end of rt-PA infusion. Point of care ultrasound (POCUS) revealed a reduced size of right ventricle with a decrease in right/left ventricle ratio. Hospital stay and a follow-up at two weeks revealed no complication due to the fibrinolytic administration or anticoagulant therapy. Conclusion: Anticoagulation is still the cornerstone therapy for patients with PE, but there’s a lack of trials on reperfusion strategy. Moreover, different guidelines give different short-term risk classifications, indication, and dosage of thrombolytic drugs and absolute and relative contraindications to systemic thrombolysis. This case report shows the potential benefit of low-dose rt-PA in patients with relative contraindications to thrombolysis and presenting with vital signs compatible with hemodynamic instability

Intranasal Fentanyl for Acute Pain Management in Children, Adults and Elderly Patients in the Prehospital Emergency Service and in the Emergency Department: A Systematic Review

This systematic review examined the efficacy and safety of intranasal fentanyl (INF) for acute pain treatment in children, adults, and the elderly in prehospital emergency services (PHES) and emergency departments (ED). ClinicalTrials.gov, LILACS, PubMed, SCOPUS, EMBASE, Google Scholar and Cochrane databases were consulted until 31 December 2022. A total of 23 studies were included: 18 in children (1 PHES, 17 ED), 5 in adults (1 PHES, 4 ED) and 1 in older people (1 PHES subgroup analysis). In children, INF was effective in both settings and as effective as the comparator drugs, with no differences in adverse events (AEs); one randomised controlled trial (RCT) showed that INF was more effective than the comparator drugs. In adults, one study demonstrated the efficacy of INF in the PHES setting, one study demonstrated the efficacy of INF in the ED setting, two RCTs showed INF to be less effective than the comparator drugs and one RCT showed INF to be as effective as the comparator, with no difference in AEs reported. In older people, one study showed effective pain relief and no AEs. In summary, INF appears to be effective and safe in children and adults in PHES and ED. More high-quality studies are needed, especially in PHES and older people

A New Early Predictor of Fatal Outcome for COVID-19 in an Italian Emergency Department: The Modified Quick-SOFA

Background: Since 2019, the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is causing a rapidly spreading pandemic. The present study aims to compare a modified quick SOFA (MqSOFA) score with the NEWS-2 score to predict in-hospital mortality (IHM), 30-days mortality and recovery setting. Methods: All patients admitted from March to October 2020 to the Emergency Department of St. Anna Hospital, Ferrara, Italy with clinically suspected SARS-CoV-2 infection were retrospectively included in this single-centre study and evaluated with the MqSOFA and NEWS-2 scores. Statistical and logistic regression analyses were applied to our database. Results: A total of 3359 individual records were retrieved. Among them, 2716 patients were excluded because of a negative nasopharyngeal swab and 206 for lacking data; thus, 437 patients were eligible. The data showed that the MqSOFA and NEWS-2 scores equally predicted IHM (p p < 0.001). Higher incidences of coronary artery disease, congestive heart failure, cerebrovascular accidents, dementia, chronic kidney disease and cancer were found in the deceased vs. survived group. Conclusions: In this study we confirmed that the MqSOFA score was non-inferior to the NEWS-2 score in predicting IHM and 30-days mortality. Furthermore, the MqSOFA score was easier to use than NEWS-2 and is more suitable for emergency settings. Neither the NEWS-2 nor the MqSOFA scores were able to predict the recovery setting