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

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

A Case of Cerebral Arterial Gas Embolism after SCUBA Diving

Pulmonary barotrauma during ascent is a common complication in SCUBA diving. One of the most severe forms of pulmonary barotrauma is a cerebral arterial gas embolism(CAGE). It is reported to account for about 30% of diving related deaths. The early recognition of CAGE is very important for the emergency physician because prompt hyperbaric recompression therapy can improve the clinical course. Thus, the emergency physician should know the clinical manifestation of CAGE to apply several treatment modalities early. We report a case of cerebral arterial gas embolism presented with hemiparesis and blurred vision immediately after SCUBA diving at 13 meters.ope

2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 4. Adult advanced life support

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Scombroid Fish Poisoning and Histamine Food Poisoning

Scombroid fish poisoning (SFP) is a form of histamine food poisoning caused by the ingestion of improperly stored fish. The term “scombroid” derives from the family name of the fish family first implicated, such as tuna and mackerel. On the other hand, non-scombroid fish species, such as sardine and herring, can also cause histamine poisoning. The histamine is converted from histidine by a bacterial enzyme in the causative fish. Because the symptoms of SFP can easily be confused with food allergies, it is believed to have been significantly under-reported. In 2016, an outbreak of SFP occurred among primary school students who had eaten yellowtail steak in Korea. The most common findings consisted of a rapid onset of flushing of the face and trunk, erythematous and urticarial rash, diarrhea, and headache occurring soon after consuming the spoiled fish. Usually, the course is self-limiting and antihistamines can be used successfully to relieve symptoms, but several life-threatening SFP cases have been reported. Clinical toxicologists should be familiar with SFP and have competency to make a differential diagnosis between fish allergy and histamine poisoning. SFP is a histamine-induced reaction caused by the ingestion of histamine-contaminated fish, whereas a fish allergy is an IgE-mediated reaction. This review discusses the epidemiology, pathophysiology, diagnosis, treatment, and preventive measures of SFP.ope

Rationale and methods of the Antioxidant and NMDA receptor blocker Weans Anoxic brain damage of KorEa OHCA patients (AWAKE) trial

Background: Ischemic brain injury is a major hurdle that limits the survival of resuscitated out-of-hospital cardiac arrest (OHCA). Methods: The aim of this study is to assess the feasibility and potential for reduction of ischemic brain injury in adult OHCA patients treated with high- or low-dose Neu2000K, a selective blocker of N-methyl-D-aspartate (NMDA) type 2B receptor and also a free radical scavenger, or given placebo. This study is a phase II, multicenter, randomized, double-blinded, prospective, intention-to-treat, placebo-controlled, three-armed, safety and efficacy clinical trial. This trial is a sponsor-initiated trial supported by GNT Pharma. Successfully resuscitated OHCA patients aged 19 to 80 years would be included. The primary outcome is blood neuron-specific enolase (NSE) level on the 3rd day. The secondary outcomes are safety, efficacy defined by study drug administration within 4 h in > 90% of participants, daily NSE up to 5th day, blood S100beta, brain MRI apparent diffusion coefficient imaging, cerebral performance category (CPC), and Modified Rankin Scale (mRS) at 5th, 14th, and 90th days. Assuming NSE of 42 ± 80 and 80 ± 80 μg/L in the treatment (high- and low-dose Neu2000K) and control arms with 80% power, a type 1 error rate of 5%, and a 28% of withdrawal prior to the endpoint, the required sample size is 150 patients. Discussion: The AWAKE trial explores a new multi-target neuroprotectant for the treatment of resuscitated OHCA patients. Trial registration: ClinicalTrials.gov NCT03651557 . Registered on August 29, 2018.ope