qSOFA Has Poor Sensitivity for Prehospital Identification of Severe Sepsis and Septic Shock

Objectives: Sepsis is a common and deadly disease process for which early recognition and intervention can significantly improve clinical outcomes. Despite this, sepsis remains underrecognized and therefore undertreated in the prehospital setting. Recent recommendations by the Society of Critical Care and European Society of Intensive Care Medicine advocate use of the qSOFA (quick Sequential [Sepsis-related] Organ Failure Assessment) score in non-ICU settings to screen for septic patients at greater risk for poor outcomes. Methods: We retrospectively evaluated the sensitivity and specificity of a prehospital qSOFA score ≥ 2 for prehospital identification of patients with severe sepsis or septic shock. Emergency Department (ED) patients with confirmed or suspected infection were classified as having infection without sepsis (n = 71), sepsis (n = 38), or severe sepsis/septic shock (n = 43), where designation of severe sepsis/septic shock required evidence of end-organ dysfunction, hypoperfusion (lactate > 2), or vasopressor requirement. Results: We found that a prehospital qSOFA score ≥ 2 was 16.3% sensitive (95% CI 6.8–30.7%) and 97.3% specific (95% CI 92.1–99.4%) for patients ultimately confirmed to have severe sepsis/septic shock in the ED. Adding an additional point to the prehospital qSOFA score for a pulse > 100, nursing home residence, age > 50, or reported fever increased the sensitivity to 58.1% (95% CI 42.1–73.0%) and decreased the specificity to 78.0% (95% CI 69.0–85.4%). During their ED stay, approximately two-thirds of patients meeting severe sepsis/septic shock criteria eventually met qSOFA criteria with a sensitivity of 67.4% (95% CI 51.5–80.9) and specificity of 86.2% (95% CI 78.3–92). Failure to meet qSOFA criteria prehospital was predominantly due to a systolic blood pressure and respiratory rate that did not yet meet predetermined thresholds. Conclusions: These findings suggest that the dynamic nature of sepsis can make sensitive detection difficult in the prehospital setting, although combining qSOFA with other clinical information (age, nursing home status, fever, and tachycardia) can identify more patients with sepsis who may benefit from time critical interventions.     

Peripheral vascular resistance in septic shock: its relation to outcome

To support the concept that patients who die of septic shock have a persistent defect in peripheral vascular tone irrespective of cardiac index (CI), a retrospective study was undertaken of 42 patients with documented septic shock. From the patient records, the single lowest CI (t=2) measured after initial values (t=1) with concomitantly obtained haemodynamic and metabolic variables was taken. Group 1 consisted of 21 survivors and group 2 of 21 patients, who had died in shock. Initial haemodynamic and metabolic variables were comparable between the groups, reflecting shock with a hyperdynamic circulation and lactic acidemia. At t=2, median CI measured 3.21·min^-1·m^-2 in both groups, but mean arterial pressure (MAP) and systemic vascular resistance index (SVRI) were higher in group 1 than 2 (p<0.0005). Changes in arterial blood lactate levels also differed significantly. The rankcorrelation between CI and SVRI at t=2 was significant in group 1 (r _s=-0.69, p<0.005) but not in group 2 (r _s=-0.34). Our data suggest that when CI decreases in septic shock, patients with a fatal outcome have less capability to augment vascular resistance than survivors. Hence, peripheral vascular failure, even if complicated by inability to maintain an elevated CI, may be a major haemodynamic determinant of mortality in septic shock.     

Prehospital lactate clearance is associated with reduced mortality in patients with septic shock

BackgroundAssessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, blood lactate measurement is broadly used in combination with the clinical evaluation of patients as the clinical picture alone is not sufficient for assessing disease severity and outcomes.MethodsFrom 15th April 2017 to 15th April 2019, patients with SS requiring prehospital mobile Intensive Care Unit intervention (mICU) were prospectively included in this observational study. Prehospital blood lactate clearance was estimated by the difference between prehospital (time of first contact between the patients and the mICU prior to any treatment) and in-hospital (at hospital admission) blood lactate levels divided by prehospital blood lactate.ResultsAmong the 185 patients included in this study, lactate measurement was missing for six (3%) in the prehospital setting and for four (2%) at hospital admission, thus 175 (95%) were analysed for prehospital blood lactate clearance (mean age 70 ± 14 years). Pulmonary, digestive and urinary infections were probably the cause of the SS in respectively 56%, 22% and 10% of the cases. The 30-day overall mortality was 32%.Mean prehospital blood lactate clearance was significantly different between patients who died and those who survived (respectively 0.41 ± 2.50 mmol.l⁻¹ vs 1.65 ± 2.88 mmol.l⁻¹, p = 0.007).Cox regression analysis showed that 30-day mortality was associated with prehospital blood lactate clearance > 10% (HRa [CI95] = 0.49 [0.26–0.92], p = 0.028) and prehospital blood lactate clearance < 10% (HRa [CI95] = 2.04 [1.08–3.84], p = 0.028).ConclusionA prehospital blood lactate clearance < 10% is associated with 30-day mortality increase in patients with SS handled by the prehospital mICU. Further studies will be needed to evaluate if prehospital blood lactate clearance alone or combined with clinical scores could affected the triage decision-making process for those patients.     

Pre-resuscitation Lactate and Hospital Mortality in Prehospital Patients

Abstract

Objective. Serum lactate elevations are associated with morbidity and mortality in trauma patients, but their value in prehospital medical patients prior to resuscitation is unknown. We sought to assess the distribution of blood lactate concentrations prior to intravenous (IV) resuscitation and examine the association of elevation on in-hospital death. Methods. A convenience sample of adult patients over 14 months who received an IV line by eight EMS agencies in Western Pennsylvania had lactate measurement prior to any IV treatment. We assessed the lactate values and any relationship between these and hospital mortality (our primary outcome) and admission to the intensive care unit (ICU). We also compared the ability of lactate to discriminate outcomes with a prehospital critical illness score using age, Glasgow Coma Score, and initial vital signs. Results. We included 673 patients, among whom 71 (11%) were admitted to the ICU and 21 (3.1%) died in-hospital. Elevated lactate (≥2 mmol/L) occurred in 307 (46%) patients and was strongly associated with hospital death after adjustment for known covariates (odds ratio = 3.57, 95% confidence interval [CI]: 1.10, 11.6). Lactate ≥2 mmol/L had a modest sensitivity (76%) and specificity (55%), and discrimination for hospital death (area under the curve [AUC] = 0.66, 95%CI: 0.56, 0.75). Compared to the prehospital critical illness score alone (AUC = 0.69, 95% CI: 0.59, 0.80), adding lactate to the score offered modest improvement (net reclassification improvement = 0.63, 95%CI: 0.23, 1.01, p < 0.05). Conclusions. Initial lactate concentration in our prehospital medical patient population was associated with hospital mortality. However, it is a modest predictor of outcome, offering similar discrimination to a prehospital critical illness score.     

Methylene blue used in the treatment of refractory shock resulting from drug poisoning

Background. Methylene blue inhibits the nitric oxide–cyclic guanosine monophosphate (NO–cGMP) pathway, decreasing vasodilation and increasing responsiveness to vasopressors. It is reported to improve haemodynamics in distributive shock from various causes including septicaemia and post-cardiac surgery. Reports of use in overdose are limited. We describe the use of methylene blue to treat a case of refractory distributive shock following a mixed drug poisoning. Case details. A 41-year-old male presented following reported ingestion of 18 g extended-release quetiapine, 10 g controlled-release carbamazepine, 240 mg fluoxetine, 35 g enteric-coated sodium valproate and 375 mg oxazepam. He was comatose and intubated on presentation. Progressive hypotension developed. Echocardiogram revealed a hyperdynamic left ventricle, suggesting distributive shock. The patient remained hypotensive despite intravenous fluid boluses, escalating vasopressor infusions. Arterial blood gas revealed metabolic acidaemia and high lactate. Methylene blue was administered as loading-dose of 1.5 mg/kg and continuous infusion (1.5 mg/kg/h for 12 h, then 0.75 mg/kg/h for 12 h) resulting in rapid improvement in haemodynamic parameters and weaning of vasopressors. Serum quetiapine concentration was 18600 ng/mL (30–160 ng/mL), collected at the time of peak toxicity. Conclusion. Severe quetiapine poisoning produces hypotension primarily from alpha-adrenoreceptor antagonism. Methylene blue may have utility in the treatment of distributive shock resulting from poisoning refractory to standard vasopressor therapy.     

Controversies in the prehospital management of major trauma

Many traditional therapies in the prehospital management of major trauma may be of little value or may be even harmful. Little scientific evidence exists to support the use of the pneumatic antishock garment, and some studies have shown it to worsen outcome. The traditional role of intravenous fluid resuscitation also has been questioned and, in situations such as penetrating truncal trauma, it may be associated with comparatively worse outcomes. Although some infusion may be appropriate in severe haemorrhage, the clear priority in such patients is evacuation to definitive surgical intervention. Airway control and establishment of intravenous access are recommended en route. Endotracheal intubation may be capable of prolonging the ability to tolerate circulatory arrest, but overzealous ventilation may further compromise cardiac output where there is severe haemodynamic instability. If these procedures delay patient transport, any benefit they may offer could be outweighed by delaying definitive care. Many of the paradigms of prehospital trauma care should be reconsidered and carefully evaluated in future randomized controlled trials.     

Capnometry in the prehospital setting: are we using its potential?

Capnometry is a non-invasive monitoring technique which allows fast and reliable insight into ventilation, circulation, and metabolism. In the prehospital setting it is mainly used to confirm correct tracheal tube placement. In addition it is a useful indicator of efficient ongoing cardiopulmonary resuscitation due to its correlation with cardiac output, and successful resuscitation. It helps to confirm the diagnosis of pulmonary thromboembolism and to sustain adequate ventilation in mechanically ventilated patients. In patients with haemorrhage, capnometry provides improved continuous haemodynamic monitoring, insight into adequacy of tissue perfusion, optimisation within current hypotensive fluid resuscitation strategy, and prevention of shock progression through controlled fluid administration.     

Year in review 2008: Critical Care - cardiology

We review key research papers in cardiology and intensive care published during 2008 in Critical Care. We quote studies on the same subject published in other journals if appropriate. Papers have been grouped into three categories: (a) cardiovascular biomarkers in critical illness, (b) haemodynamic management of septic shock, and (c) haemodynamic monitoring.     

Clinical validation demonstrates concordance of qSOFA and POC lactate Bayesian model: Results from the ACDC Phase-2 program

Sepsis is a common and lethal medical problem. The objective of this study was to validate a Bayesian Model that integrates qSOFA and prehospital Lactate, with a comparison analysis from a real clinical data of patients with sepsis.MethodsWe conducted a two tired validation study with one arm focusing on Bayesian modeling and a second retrospective observational arm addressing real data validation. For Bayesian modeling, sensitivity and specificity of prehospital lactate were attained from pooled meta-analysis data. Later, for clinical validation, we used data from 2016 to 2017 of ED patients diagnosed with sepsis. Pretest probabilities from qSOFA score where combined with prehospital lactate and inserted into a Bayesian model to calculate posttest probabilities. Absolute and relative diagnostic gains were calculated. Statistical significance was assessed via t-test, chi square and odds ratio. P value was set to be 0.05.ResultsFor the Bayesian arm; meta-analysis data for prehospital lactate resulted in a positive likelihood ratio (LR+) of 1.69 and negative likelihood ratio (LR-) of 0.44. Integration of lactate and qSOFA demonstrated significant post-test improvements. On the Clinical Validation arm, 1470 patients were included with 176 patients meeting analysis criteria. When comparing qSOFA + Abnormal Lactate vs qSOFA and normal Lactate, the ICU vs Non-ICU cohorts were statistically different (p < 0.01) Odds Ratio: 2.35 (95% CI [1.22–4.6]).ConclusionBayesian mathematical model demonstrated that a qSOFA-based clinical decision can be complemented by the use of point of-care lactate. These results were confirmed by our clinical validation arm.     

Induction of therapeutic hypothermia after cardiac arrest in prehospital patients using ice-cold Ringer's solution: a pilot study

The cooling and haemodynamic effects of prehospital infusion of ice-cold Ringer's solution were studied in 13 adult patients after successful resuscitation from non-traumatic cardiac arrest. After haemodynamics stabilisation, 30 ml/kg of Ringer's solution was infused at a rate of 100ml/min into the antecubital vein. Arterial blood pressure and blood gases, pulse rate, end-tidal CO(2) and oesophageal temperature were monitored closely. The mean core temperature decreased from 35.8 +/- 0.9 degrees C at the start of infusion to 34.0 +/- 1.2 degrees C on arrival at hospital (P < 0.0001). No serious adverse haemodynamic effects occurred. It is concluded that the induction of therapeutic hypothermia using this technique in the prehospital setting is feasible.     

The effects of a centrifugal pump as a left-ventricular-assist device in myocardial infarction

Cardiogenic shock after acute myocardial infarction and open heart surgery having cardiopulmonary bypass may present a difficult clinical problem with high mortality. The present study was carried out to evaluate a newly developed laminar flow centrifugal pump as a Ieft-ventricular-assist device to support the circulation and prevent myocardial damage in such situations. Experimentally induced acute myocardial infarction in dogs was used as the model.

Cardiogenic shock was effected by ligating enough branches of the left coronary artery. In addition to recording the haemodynamic parameters, samples of myocardium were taken with a biopsy needle from the infarcted area, transitional zone and intact myocardium for determination of adenosine triphosphate, creatine phosphate and lactate. In the first phase of the work the effects of acute myocardial infarction on haemodynamics and high-energy compounds were defined, to form a basis for the evaluation of the pump as left-ventricular-assist device.

Ligation of the branches of the left coronary artery produced a rapid fall in aortic pressure, cardiac output and cardiac performance, elevation of ST-segment in the ECG and fall in high-energy compounds. However, there was a marked spontaneous recovery in the transitional zone within 120 min, despite the haemodynamic deterioration.

The laminar flow pump produced a significant improvement in the haemodynamic and metabolic parameters which exceeded the spontaneous changes noted previously.     

Amrinone for refractory cardiogenic shock following chloroquine poisoning

Cardiac arrhythmias and circulatory collapse account for the high mortality reported after severe chloroquine poisoning. We have recently observed a 17-year-old man who ingested an 8 g chloroquine overdose. Cardiac arrest occurred within 1 h. Cardiogenic shock was refractory to epinephrine, dopamine and molar sodium lactate. Amrinone, a bipyridine analog, was then successfully used to improve haemodynamic conditions.     

High frequency jet ventilation (HFJV) has no better haemodynamic tolerance than controlled mechanical ventilation (CMV) in cardiogenic shock

Six patients with acute myocardial infarction (AMI) complicated by cardiogenic shock were studied in order to compare the haemodynamic tolerance of controlled mechanical ventilation (CMV) and high frequency jet ventilation (HFJV). The comparative analysis of the two techniques was performed with the same levels of PaO₂ (CMV: 101±13 mmHg; HFJV: 104.2±14 p=ns); and PaCO₂ (CMV: 37±1.7; HFJV: 35.7±1.4p=ns). In this situation the values of mean airway pressure (Paw) did not differ significantly (CMV: 13±3 cm H₂O; HFJV: 12.6±3.8 cm H₂O) and no statistically significant difference in haemodynamic values was observed. These results demonstrate that in patients with cardiogenic shock, there is no difference between HFJV and CMV in terms of haemodynamic tolerance. Because of the more difficult clinical management of HFJV, this technique does not seem indicated as ventilatory support in patients with cardiogenic shock states. Presented in part as a communication to the Third Congress of the European Society of Intensive Care Medicine (Hamburg 1986).     

Review article: Prehospital telehealth for emergency care: A scoping review

Telehealth has been successfully implemented in the prehospital setting to expedite emergency care, although applications are still in their infancy. With recent advances in technologies, it is not described how prehospital telehealth has evolved over the past decade. This scoping review aimed to answer the research question ‘what telehealth platforms have been used to facilitate communication between prehospital healthcare providers and emergency clinicians in the past decade?’. The review was guided by Joanna Briggs Institute scoping review methodology and reported in accordance with the PRISMA checklist for scoping reviews. A systematic search of five databases and Google Scholar was undertaken using key terms ‘prehospital’, ‘ambulance’, ‘emergency care’ and ‘telehealth’, and results were limited to research articles published in English language between 2011 and 2021. Articles were included if they related to the research question and reported quantitative, qualitative, mixed-method or feasibility studies. A total of 28 articles were included in the review that reported feasibility (n = 13), intervention (n = 7) or observational studies (n = 8) involving 20 telehealth platforms. Platforms were commonly implemented to provide prehospital staff with medical support for general emergency care and involved a range of devices that were used to transmit video, audio and biomedical data. The benefits of prehospital telehealth to patients, clinicians and organisations were identified. Challenges to telehealth involved technical, clinical and organisational issues. Few facilitators of prehospital telehealth were identified. Telehealth platforms to facilitate prehospital to ED communication continue to develop but require technological advances and improved network connectivity to support implementation in the prehospital environment.     

Predictors of mortality and multiple organ failure in children with sepsis

Objectives: To assess the markers of perfusion which best discriminate survivors from non-survivors of childhood sepsis and to compare the information derived from gastric tonometry with conventionally measured haemodynamic and laboratory parameters. Design: Prospective clinical study of children with sepsis syndrome or septic shock. Setting: Paediatric intensive care unit in a tertiary referral centre. Patients: 31 children with sepsis syndrome or septic shock. Interventions: A tonometer was passed into the stomach via the orogastric route. Measurements and main results: The following data were recorded at admission, 12, 24 and 48 h: heart rate, mean arterial pressure, arterial pH, base deficit, arterial lactate, gastric intramucosal pH (pHi) and DCO₂ (intramucosal carbon dioxide tension minus arterial partial pressure of carbon dioxide). The principal outcome measure was survival. The secondary outcome measure was the number of organ systems failing at 48 h after admission. There were 10 deaths and 21 survivors. No variable discriminated survival from death at presentation. Blood lactate level was the earliest discriminator of survival. Using univariate logistic regression, lactate discriminated survivors from those who died at 12 and 24 h after admission, but not at 48 h (p = 0.049, 0.044 and 0.062, respectively). The area under the receiver operating characteristic (ROC) curve for lactate was 0.81, 0.88 and 0.89 at 12, 24 and 48 h, respectively. At 12 h after admission, a blood lactate level > 3 mmol/l had a positive predictive value for death of 56 % and a lactate level of 3 mmol/l or less had a positive predictive value for survival of 84 %. At 24 h a lactate level > 3 mmol/l had a positive predictive value for death of 71 % and a level of 3 mmol/l or less had a positive predictive value for survival of 86 %. No other variable identified non-survivors from survivors at 12 h. Gastric tonometry could only be done on 19 of the 31 children, of whom 8 died and 11 survived. In these 19 children, DCO₂ measured at 24 h, but not at 12 or 48 h, distinguished those who died from those who survived (p = 0.045 and p = 0.20, respectively). The area under the ROC curve for DCO₂ measured at 24 h as a predictor of survival was 0.71. Neither the absolute value of pHi nor the trend of change in pHi at any time in the first 48 h identified survivors in this series. The mean arterial pressure distinguished survivors from non-survivors at 24 and 48 h (area under ROC curve = 0.80 and 0.78, respectively). The base deficit and heart rate did not identify non-survivors from survivors at any time in the first 48 h. Conclusions: Blood lactate level was the earliest predictor of outcome in children with sepsis. In this group of patients, gastric tonometry added little to the clinical information that could be derived more simply by other means. Received: 19 September 1996 Accepted: 20 February 1997     

Paramedic-Initiated CMS Sepsis Core Measure Bundle Prior to Hospital Arrival: A Stepwise Approach

Background: To improve patient outcomes, the Center for Medicare and Medicaid Services (CMS) implemented core measures that outline the initial treatment of the septic patient. These measures include initial blood culture collection prior to antibiotics, adequate intravenous fluid resuscitation, and early administration of broad spectrum antibiotics. We sought to determine if Paramedics can initiate the CMS sepsis core measure bundle in the prehospital field reliably. Methods: This is a retrospective, case series from a 3rd service EMS system model in Greenville, South Carolina between November 17, 2014 and February 20, 2016. An adult Prehospital Sepsis Assessment Tool was created using the 2012 Surviving Sepsis guidelines: 2 of 3 signs of systemic inflammatory response (heart rate, respiratory rate, oral temperature) and a known or suspected source of infection. A “Sepsis Alert” was called by paramedics and upon IV access a set of blood cultures and blood for lactate analysis was collected prior to field antibiotic administration. The Sepsis Alert was compared to serum lactate levels and ICD 9 or 10 admitting diagnosis of Sepsis, Severe Sepsis, or Septic Shock. Blood culture contamination, serum lactate, and antibiotic match were determined by in-hospital laboratory analysis. Results: A total of 120 trained paramedics called 1,185 “Sepsis Alerts” on 56,643 patients (50.3% Male, mean age 70). Patients with missing discharge diagnosis were eliminated (n = 31). The admitting diagnosis of sepsis overall was 73.5% (848/1154): Sepsis 50% (578/1154), Severe Sepsis 14.6% (169/1154), Septic Shock 8.9% (101/1154). A total of 946 blood cultures were collected in the prehospital setting, with a 95.04% (899/946) no contamination rate. Contamination was found in 4.96% (47/946). A total of 179 (18.9%) of the uncontaminated blood cultures were found to have positive growth with 720 (76.1%) having no growth. EMS administered antibiotics matched blood culture positive growth in 72% of patients. The lactate level was greater than 2.2 in 46.9% of patients. No adverse effects were reported after prehospital administration of antibiotics. Conclusion: This study demonstrates the successful implementation of an EMS-driven CMS Sepsis Core Measure bundle in the prehospital setting. Paramedics can acquire uncontaminated blood cultures, and safely administer antibiotics prior to hospital arrival among patients who were recognized as sepsis alerts.     

Relation between cytokines and routine laboratory data in children with septic shock and purpura

Objective To establish the relation between routine laboratory data (lactate, fibrinogen, CRP) and cytokines (TNF,IL-1 and-6) and to estimate their prognostic value in pediatric patients with severe infectious purpura on admission.Design Prospective study.Setting Pediatric intensive care unit (PICU).Patients 17 children aged 5–172 months (median 46) were hospitalized in our PICU in 1989–90 with severe infectious purpura.Neisseria meningitidis was isolated in 15 children andHaemophilus influenzae in two. The patients were divided into 3 groups: non-shock, shock and severe shock leading to death. Shock was defined by standard criteria.Measurements Arterial blood was sampled for lactate, CRP, fibrinogen, TNF, and IL-1 and-6 on admission. The PRISM (pediatric risk of morality)-score was recorded.Methods Statistical analysis was performed with the Student'st-test using the logarithmic values of the cytokine concentration, and Spearman correlation analysis.Results According to the shock criteria, 9 patients were in shock of whom 4 did not survive. Significant differences existed between the 3 groups concerning lactate, TNF, and IL-6. Fibrinogen, CRP, IL-1, and PRISM-score discriminated only between survivors and non-survivors. A highly significant correlation existed between cytokines, the PRISM-score and lactate (TNF:r=0.69, IL-1:r=0.56, IL-6:r=0.65, PRISM:r=0.65). A significant inverse correlation existed between cytokines and CRP (TNF:r=–0.55, IL-1:r=–0.64, and IL-6:r=–0.56), and IL-6 and fibrinogen (r=–0.65).Conclusion These results show a significant correlation between cytokines and lactate, and lactate, TNF and IL-6 are closely associated with the severity of septic shock with purpura in children.Presented in part at the 5th European Symposium on Pediatric, Surgical and Neonatal Intensive Care, October 8–11, 1991, Madrid, Spain     

Pre-hospital mechanical ventilation in septic shock patients

BackgroundMechanical ventilation can cause deleterious effects on the lung and thus alter patient's prognosis.The aim of this study was to describe the characteristics of prehospital mechanical ventilation in patients with septic shock requiring mechanical ventilation in the prehospital setting.MethodsPatients with septic shock subjected to pre-hospital intubation and mechanical ventilation by a mobile intensive care unit were consecutively included and retrospectively analysed. Septic shock was defined according to the international sepsis-3 consensus conference. Patient's characteristics, interventions, prehospital ventilatory parameters and outcome were retrieved from medical records. The association between the tidal volume indexed on ideal body weight (VTIBW) and mortality at day 28 was evaluated.ResultsFifty-nine patients were included. Septic shock was mainly associated with pulmonary (64%) infection. Mean pre-hospital VTIBW was 7 ± 1 ml.kg^?1 in the overall population. Mortality reached 42%. The AUC of VTIBW was 0.83 [0.72–0.94].Using logistic regression model including: age, prehospital mean blood pressure, volume infused in the prehospital setting, FiO₂ and length of stay in the intensive care unit, the association with mortality remained significant for VTIBW (OR adjusted [CI95] = 4.11 [1.89–10.98]), VTIBW >8 ml·kg^?1 (OR adjusted [CI95] = 8.29 [2.35–34.98]) and VTIBW <8 ml·kg^?1 (OR adjusted [CI95] = 0.12 [0.03–0.43]).ConclusionIn this retrospective study, we observed an association between mortality at day 28 and prehospital VTIBW in pre-hospital mechanically ventilated patients with septic shock. A VTIBW <8 ml·kg^?1 was associated with a decrease and a VTIBW >8 ml·kg^?1 with an increase in mortality.     

Prehospital administration of tranexamic acid in trauma patients: A 1:1 matched comparative study from a level 1 trauma center

PurposeThe purpose of this study was to test the efficacy of prehospital administration of tranexamic acid (TXA) to injured patients on mortality, thromboembolic events and need for blood transfusion in a level 1 trauma center.MethodsWe conducted a retrospective study comparing adult trauma patients receiving or not receiving prehospital TXA between January 2017 and September 2018. Patients not receiving TXA but transfused within 4 h of admission were 1:1 matched to TXA-treated patients for age, sex, injury severity score, head abbreviated injury score, prehospital heart rate and systolic blood pressure.ResultsIn total 204 patients were included (102 TXA and 102 control), with a mean age of 31 years. On admission, shock index (p = 0.03) and serum lactate (p = 0.001) were greater in the control group, whereas the initial base deficit, hemoglobin levels and EMS time were comparable in both groups. The odd ratio (OR) for shock index ≥0.9 after TXA administration was 0.44 (95% CI 0.23–0.84). The median amount of blood transfusion was greater in the control group [eight units (range 1–40) vs three (range 0–40), p = 0.01] as well as the use of massive blood transfusion [OR 0.35 (95% CI 0.19–0.67)]. In the TXA group, VTE was higher [OR 2.0 (95% CI 0.37–11.40)]; whereas the overall mortality was lower [OR 0.78 (95% CI 0.42–1.45)] without reaching statistical significance.ConclusionsPrehospital TXA administration is associated with less in-hospital blood transfusion and massive transfusion protocol (MTP). There is no significant increase in the thromboembolic events and mortality, however, further evaluation in larger clinical trials is needed.     

Effects of bovine polymerized hemoglobin on coagulation in controlled hemorrhagic shock in swine

HBOC-201, a bovine polymerized hemoglobin, has been proposed as a novel oxygen-carrying resuscitative fluid for patients with hemorrhagic shock (HS). Herein, we evaluated the hemostatic effects of HBOC-201 in an animal model of HS. A 40% blood loss-controlled hemorrhage and soft tissue injury were performed in 24 invasively monitored Yucatan mini-pigs. Pigs were resuscitated with HBOC-201 (HBOC) or hydroxyethyl starch (HEX), or were not resuscitated (NON) based on cardiac parameters during a 4-h prehospital phase. Afterward, animals received simulated hospital care for 3 days with blood or saline transfusions. Hemostasis measurements included in vivo bleeding time (BT), thromboelastography (TEG), in vitro bleeding time (platelet function; PFA-CT), prothrombin time (PT), and partial thromboplastin time (PTT). Serum lactate was measured and lung sections were evaluated for microthrombi by electron microscopy. During the prehospital phase, BT remained unchanged in the HBOC group. TEG reaction time increased in HBOC pigs during the late prehospital phase and was greater than in NON or HEX pigs at 24 h (P = 0.03). TEG maximum amplitude was similar for the two fluid-resuscitated groups. PFA-CT increased in both resuscitated groups but less with HBOC (P = 0.02) in the prehospital phase; this effect was reversed by 24 h (P = 0.02). In the hospital phase, PT decreased (P < 0.02), whereas PTT increased above baseline (P < 0.01). Lactic acidosis in HBOC and HEX groups was similar. Aspartate aminotransferase was relatively elevated in the HBOC group at 24 h. Electron microscopy showed no evidence of platelet/fibrin clots or microthrombi in any of the animals. Twenty-four-hour group differences mainly reflected the fact that all HEX animals (8/8) received blood transfusions compared with only one HBOC animal (1/8). In swine with HS, HBOC resuscitation induced less thrombopathy than HEX during the prehospital phase. Mild delayed effects on platelet and clot formation during the hospital phase are transient and likely related to fewer blood transfusions. In swine with HS, HBOC resuscitation induced less thrombopathy than HEX during the prehospital phase but more thrombopathy in the hospital phase. The delayed effects on platelet and clot formation during the hospital phase are transient and may be related to the need for fewer blood transfusions.