The usefulness of C-reactive protein and procalcitonin to predict prognosis in septic shock patients: A multicenter prospective registry-based observational study

The objective of this study was to evaluate the prognostic value of C-reactive protein (CRP), procalcitonin (PCT), and their combination for mortality in patients with septic shock. This multicenter, prospective, observational study was conducted between November 2015 and December 2017. A total of 1,772 septic shock patients were included, and the overall 28-day mortality was 20.7%. Although both CRP and PCT were elevated in the non-survivor group, only CRP had statistical significance (11.9 mg/dL vs. 14.7 mg/dL, p = 0.003, 6.4 ng/mL vs. 8.2 ng/mL, p = 0.508). Multivariate analysis showed that CRP and PCT were not independent prognostic markers. In the subgroup analysis of the CRP and PCT combination matrix using their optimal cut-off values (CRP 14.0 mg/dL, PCT 17.0 ng/dL), both CRP and PCT elevated showed significantly higher mortality (Odds ratio 1.552 [95% Confidence intervals 1.184-2.035]) than both CRP and PCT not elevated (p = 0.001) and only PCT elevated (p = 0.007). However, both CRP and PCT elevated was also not an independent predictor in multivariate analysis. Initial levels of CRP and PCT alone and their combinations in septic shock patients had a limitation to predict 28-day mortality. Future research is needed to determine new biomarkers for early prognostication in patients with septic shock.ope

Systematic review of vitamin B12 regimen for patient with subacute combined degeneration of the spinal cord following nitrous oxide abuse

Purpose: The purpose of this study is to evaluate the effectiveness of vitamin B12 treatment in subacute combined degeneration (SCD) caused by nitrous oxide (N2O) abuse. Methods: Relevant literature was accessed through PubMed, EMBASE, Scopus, and KoreaMed. All the literature that was relevant to human use of vitamin B12 treatment for SCD caused by N2O abuse was included. Case reports were excluded if the treatment regimens were not precisely described. The literature search was conducted by two investigators during September 2019 for the final publication period. The languages of the publications were restricted to English and Korean. Results: Twenty-three published articles that contained 24 cases were included. Sixteen cases among them were treated with intramuscular vitamin B12 of 1 mg/day and the rest received different doses or routes. Although most cases described significant clinical improvements, one case showed no beneficial effect due to the patient’s noncooperation. Another case showed adverse events, including spinal myoclonus, following vitamin B12 therapy. Conclusion: Vitamin B12 has been broadly used for the treatment of SCD caused by N2O abuse. However, most of the relevant studies were case reports that reported various regimens of vitamin B12 administration. Further studies are needed to establish a standard regimen of vitamin B12 because the incidence of N2O abuse may increase in South Korea.ope

Delta neutrophil index and shock index can stratify risk for the requirement for massive transfusion in patients with primary postpartum hemorrhage in the emergency department

Background: Postpartum hemorrhage (PPH) constitutes a major risk for maternal mortality and morbidity. Unfortunately, the severity of PPH can be underestimated because it is difficult to accurately measure blood loss by visual estimation. The delta neutrophil index (DNI), which reflects circulating immature granulocytes, is automatically calculated in hematological analyzers. We evaluated the significance of the DNI in predicting hemorrhage severity based on the requirement for massive transfusion (MT) in patients with PPH. Methods: We retrospectively analyzed data from a prospective registry to evaluate the association between the DNI and MT. Moreover, we assessed the predictive ability of the combination of DNI and shock index (SI) for the requirement for MT. MT was defined as a transfusion of ≥10 units of red blood cells within 24 h of PPH. In total, 278 patients were enrolled in this study and 60 required MT. Results: Multivariable logistic regression revealed that the DNI and SI were independent predictors of MT. The optimal cut-off values of ≥3.3% and ≥1.0 for the DNI and SI, respectively, were significantly associated with an increased risk of MT (DNI: positive likelihood ratio [PLR] 3.54, 95% confidence interval [CI] 2.5-5.1 and negative likelihood ratio [NLR] 0.48, 95% CI 0.4-0.7; SI: PLR 3.21, 95% CI 2.4-4.2 and NLR 0.31, 95% CI 0.19-0.49). The optimal cut-off point for predicted probability was calculated for combining the DNI value and SI value with the equation derived from logistic regression analysis. Compared with DNI or SI alone, the combination of DNI and SI significantly improved the specificity, accuracy, and positive likelihood ratio of the MT risk. Conclusion: The DNI and SI can be routinely and easily measured in the ED without additional costs or time and can therefore, be considered suitable parameters for the early risk stratification of patients with primary PPH.ope

2015 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 제 2부: 기본소생술

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Combination therapy of vitamin C and thiamine for septic shock: a multi-centre, double-blinded randomized, controlled study

Purpose To evaluate the effects of early combination therapy with intravenous vitamin C and thiamine on recovery from organ failure in patients with septic shock. Methods The ascorbic acid and thiamine effect in septic shock (ATESS) trial was a multi-centre, double-blind, randomized, controlled trial conducted in four academic emergency departments, enrolling adult patients with septic shock from December 2018 through January 2020. Patients were randomly assigned in a 1:1 ratio to either the treatment group [intravenous vitamin C (50 mg/kg, maximum single dose 3 g) and thiamine (200 mg) administration every 12 h for a total of 48 h] or the placebo group (identical volume of 0.9% saline with the same protocol). The primary outcome was Delta Sequential Organ Failure Assessment (SOFA) score (SOFA score at enrolment-SOFA score after 72 h). Eighteen secondary outcomes were predefined, including shock reversal and 28-day mortality. Results A total of 111 patients were enrolled, of which 53 were assigned to the treatment group and 58 were assigned to the placebo group. There was no significant difference in Delta SOFA scores between the treatment group and the placebo group [3, interquartile range (IQR) - 1 to 5 vs. 3, IQR 0-4, respectively,p = 0.96]. Predefined secondary outcomes were also not significantly different between the groups. Conclusion In this study, vitamin C and thiamine administration in the early phase of septic shock did not improve organ function compared with placebo, despite improvements in vitamin C and thiamine levels.ope

The Poisoning Information Database Covers a Large Proportion of Real Poisoning Cases in Korea.

The poisoning information database (PIDB) provides clinical toxicological information on commonly encountered toxic substances in Korea. The aim of this study was to estimate the coverage rate of the PIDB by comparing the database with the distribution of toxic substances that real poisoning patients presented to 20 emergency departments. Development of the PIDB started in 2007, and the number of toxic substances increased annually from 50 to 470 substances in 2014. We retrospectively reviewed the medical records of patients with toxic exposure who visited 20 emergency departments in Korea from January to December 2013. Identified toxic substances were classified as prescription drug, agricultural chemical, household product, animal or plant, herbal drug, or other. We calculated the coverage rate of the PIDB for both the number of poisoning cases and the kinds of toxic substances. A total of 10,887 cases of intoxication among 8,145 patients was collected. The 470 substances registered in the PIDB covered 89.3% of 8,891 identified cases related to poisoning, while the same substances only covered 45.3% of the 671 kinds of identified toxic substances. According to category, 211 prescription drugs, 58 agricultural chemicals, 28 household products, and 32 animals or plants were not covered by the PIDB. This study suggested that the PIDB covered a large proportion of real poisoning cases in Korea. However, the database should be continuously extended to provide information for even rare toxic substances.ope

Immune Alteration in Rebleeding

PURPOSE: This study evaluates whether the adaptation mechanism could modulate immunosuppression following a hemorrhage. METHODS: Minor hemorrhage (10% of total blood volume) was induced in the rat model, 1, 2, 4, and 7 days before the main hemorrhage. The immune responses were observed by measuring Con A (Concanavalin A) stimulated proliferative capacity of the peripheral lymphocyte subpopulations, and the Interleukin-2 (IL-2) release from splenocytes. RESULTS: The proliferative capacity of the splenocytes (SPC) decreased in two days interval model with hemorrhages more than 20% of the total blood volume. The SPC increased in the group with 10% hemorrhage pretreatment 7 days prior to 20% main hemorrhage than it was for 20% or 30% main hemorrhage only with cardiac puncture groups. The SPC increased on the first day than it was on the fourth day after the 20% main hemorrhage, in the pretreatment group with 7 days interval. The amount of IL-2 release by the splenocytes was higher in the 10~20% group (10% pretreatment hemorrhage and 20% main hemorrhage) than it was in the 0~30% group, when the hemorrhage interval was 7 days, and it was higher on the first day than on the fourth day after the second hemorrhage in the 10~20% group. CONCLUSION: The immune response varied depending on the hemorrhage interval following pretreatment, and it increased after the main hemorrhage that, by itself, would cause immunosuppression. But this effect, however, was only observed during a short period (about 1 day) following the second hemorrhage.ope

2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 2. Environment for cardiac arrest survival and the chain of survival

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Stool White-cell Count as a Predictor of Long-term Admission in Healthy Patients with Acute Diarrhea.

Purpose: This study was designed to investigate the predictors of long-term admission in patients with acute diarrhea at an early stage of their emergency department (ED) visit. Methods: We retrospectively analyzed clinical data of 125 patients who visited our ED with complaints of acute diarrhea and abdominal pain and underwent a stool test during one year (Jan. to Dec. 2001). We excluded patients who were transferred out or were self-discharged and those with another illness. We checked the numbers of cases of diarrhea, the presence of fever and abdominal pain, the stool cell counts, the blood cell counts, platelets, blood urea nitrogen, and creatinine on admission. We also counted the length of stay and defined a stay of over 4 days in the hospital as a long-term admission. We tried to find parameters that could predict long-term admission at an early stage. Results: A total of 125 patients were enrolled (men : 56 ; women : 69), and their mean age was 44±0.25 years. The mean length of stay was 3.0±0.02 days. The length of stay had a statistically significant correlation with the stool WBC (p<0.01, R=0.361). Only the stool WBC a the discriminative variable for long-term admission (p<0.01). Conclusion: The stool WBC was a statistically significant predictive variable to determinate the long-term admission and the severity of acute diarrhea, and we think it could be used to make an early decision for the close medical attention.ope

Up-to-date treatment of acetaminophen poisoning

N-Acetylcysteine (NAC) is the standard antidote treatment for preventing hepatotoxicity caused by acetaminophen (AAP) poisoning. This review summarizes the recent evidence for the treatment of AAP poisoning. Several alternative intravenous regimens of NAC have been suggested to improve patient safety by reducing adverse drug reactions and medication errors. A two-bag NAC infusion regimen (200 mg/kg over 4 h, followed by 100 mg/kg over 16 h) is reported to have similar efficacy with significantly reduced adverse reactions compared to the traditional 3-bag regimen. Massive AAP poisoning due to high concentrations (more than 300-lines in the nomogram) needs to be managed with an increased maintenance dose of NAC. In addition to NAC, the combination therapy of hemodialysis and fomepizole is advocated for severe AAP poisoning cases. In the case of a patient presenting with an altered mental status, metabolic acidosis, elevated lactate, and an AAP concentration greater than 900 mg/L, hemodialysis is recommended even if NAC is used. Fomepizole decreases the generation of toxic metabolites by inhibiting CYP2E1 and may be considered an off-label use by experienced clinicians. Since the nomogram cannot be applied to sustained-release AAP formulations, all potentially toxic sustained-release AAP overdoses should receive a full course of NAC regimen. In case of ingesting less than the toxic dose, the AAP concentration is tested twice at an interval of 4 h or more; NAC should be administered if either value is above the 150-line of the nomogram.ope