Usefulness of Delta Neutrophil Index to Predict 30-day Mortality in Patients with Mechanical Bowel Obstruction

PURPOSE: Mechanical bowel obstruction (MBO) is a common emergency problem resulting in high morbidity and mortality. The delta neutrophil index (DNI), reflecting the fraction of circulating immature granulocytes, is associated with increased mortality in patients with infection and/or systemic inflammation. This study was conducted to investigate the relationship between DNI and 30-day mortality in patients with MBO. METHODS: We retrospectively identified consecutive patients (>18 years old) with MBO admitted to the emergency department from January 1, 2013 to April 30, 2015. The diagnosis of MBO was confirmed using clinical and radiological findings. The DNI was determined on each day of hospitalization. The outcome of interest was the 30-day mortality and the prognostic value of DNI for 30-day mortality was ascertained by Cox proportional hazards model analysis. RESULTS: A total of 518 patients with MBO were included in this study. According to multivariate Cox proportional hazard models, higher DNI at admission (hazard ratio [HR], 1.080; 95% confidence interval [CI], 1.036-1.126; p1.9% on admission (HR, 9.410; 95% CI, 2.671-33.145; p<0.001) was associated with increased 30-day mortality. Furthermore, the accuracy of DNI for predicting 30-day mortality was superior to that of other parameters. CONCLUSION: The DNI can be measured rapidly and simply on emergency department admission without additional cost or time burden. Increased DNI values are associated with 30-day mortality in patients with MBO.

Usefulness of Serial Measurement of the Platelet Volume Indices to Predict 30-day Mortality in Patients with ST Segment Elevation Myocardial Infarction

PURPOSE: Among the survivors of a ST elevation myocardial infarction (STEMI), higher platelet volume indices (mean platelet volume, MPV; platelet distribution width, PDW) are associated with impaired reperfusion and ventricular dysfunction. This study examined the relationship between the platelet volume indices and 30-day mortality with STEMI patients who underwent primary percutaneous coronary intervention (PCI). METHODS: This retrospective cohort study included patients presenting to the emergency department with STEMI between January 2011 and May 2016. The platelet volume indices were measured serially, using an automatic hematology analyzer, from admission to 24 hours after admission. The prognostic value of MPV, PDW for the 30-day mortality was determined by Cox proportional hazards model analysis. RESULTS: A total of 608 STEMI patients, who underwent reperfusion, were enrolled in this study. According to the multivariable Cox proportional hazard model, higher MPV (hazard ratio [HR], 1.414; 95% confidence interval [CI], 1.024-1.953; p=0.035) and PDW (HR, 1.043; 95% CI, 1.006-1.083; p=0.024) values at time-24 (24 hours after admission) were significant risk factors for the 30-day mortality. A MPV value >8.6 fL (HR, 5.953; 95% CI, 2.973-11.918; p56.1% (HR, 5.117; 95% CI, 2.640-9.918; p<0.001) at time-24 were associated with an increased risk of 30-day mortality. CONCLUSION: The platelet volume indices without an additional burden of cost or time, can be measured rapidly and simply. Higher MPV and PDW levels predict independently the 30-day mortality in patients with STEMI after PCI.

The Application of a Dried Balanced Heparin Syringe Can Attenuate the Dilution Effect in Rapid Point-of-care Potassium Testing for the Early Identification of Hyperkalemia in the Emergency Department

PURPOSE: Current methods to evaluate the blood concentration of potassium (K) on point-of-care (POC) are influenced by the relative volumes of heparin and arterial blood. Blood potassium concentration may be underestimated with a high volume of heparin or low volume of blood. This dilution effect can produce false negative results that negatively affect decision-making of clinicians and throw critical patients into crisis. We hypothesized that the application of a dried balanced heparin syringe in rapid POC-K+ could attenuate the dilution effect and would more accurately and consistently measure the concentration of potassium compared with reference testing in emergency situations. METHODS: This retrospective study was conducted between January, 1, 2008 and September, 30, 2013 at an urban hospital affiliated with our institution. To attenuate the dilution effect, dried balanced heparin syringes (HS) were also used between October, 1, 2011 and September, 30, 2013. Concentrations of potassium were compared between the dried balanced HS group and the liquid HS group. The reliability of each of these outcome measures was assessed using intra-class correlation coefficient analysis. RESULTS: Application of dried balanced HS improved the degree of concordance for potassium using two different assays. The false negative rate was significantly improved from 9.1% (95% CI 7.3-11.0) to 5.7% (95% CI 3.5-8.0) in the dried balanced HS group compared with the liquid HS liquid group (p=0.037). CONCLUSION: This study suggests that the usage of dried balanced HS could attenuate the dilution effect in rapid POC-K+ and predict potassium levels more accurately for identification of patients at risk of hyperkalemia in emergency situations.

The Clinical Characteristics for Emergency Endotracheal Intubation in Acute Drug Intoxication

PURPOSE: The aim of this study was to compare the clinical characteristics in emergency endotracheal intubation between patients with acute drug intoxication and medical disease. METHODS: Data for airway registry collected in two emergency departments (ED) between April 2006 and March 2010 were reviewed retrospectively. The airway registry data included patient's demographic information and variables such as Cormack-Lehane grade, 3-3-2 finger analysis, success rate, the number of attempts at intubation, complications of intubation, and clinical outcomes after intubation. RESULTS: A total of 1480 patients were enrolled; 62 patients were classified as belonging to the intubation group after the drug intoxication group. No significant differences in Cormack-Lehane grade, 3-3-2 finger analysis, success rate, the number of attempts at intubation, and complications after intubation were observed between patients with acute drug intoxication and medical disease. However, significant difference was observed for indication of emergency endotracheal intubation. While emergency endotracheal intubations were usually performed in medical patients because of failure of airway patency, they were performed in intoxicated patients with the goal of preventing serious complications. CONCLUSION: Anatomical structures related to endotracheal intubation, the process and clinical outcome of intoxicated patients are not significantly different from those for medical patients.

Evaluating the Utility of Rapid Point-of-Care Potassium Testing for the Early Identification of Hyperkalemia in Patients with Chronic Kidney Disease in the Emergency Department

PURPOSE: Severe hyperkalemia leads to significant morbidity and mortality if it is not immediately recognized and treated. The concentration of potassium (K+) in the serum increases along with deteriorating renal function. The use of point-of-care K+ (POC-K+) in chronic kidney disease (CKD) could reduce the time for an accurate diagnosis and treatment, saving lives. We hypothesized that POC-K+ would accurately report K+ serum level without significant differences compared to reference testing, regardless of the renal function of the patient. MATERIALS AND METHODS: The retrospective study was performed between January 2008 and September 2011 at an urban hospital in Seoul. The screening program using POC was conducted as a critical pathway for rapid evaluation and treatment of hyperkalemia since 2008. When a patient with CKD had at least one warning symptom or sign of hyperkalemia, both POC-K+ and routine laboratory tests were simultaneously ordered. The reliability of the two assays for serum-creatinine was assessed by intra-class correlation coefficient (ICC) analysis using absolute agreement of two-way mixed model. RESULTS: High levels of reliability were found between POC and the laboratory reference tests for K+ (ICC=0.913, 95% CI 0.903-0.922) and between two tests for K+ according to changes in the serum-creatinine levels in CKD patients. CONCLUSION: The results of POC-K+ correlate well with values obtained from reference laboratory tests and coincide with changes in serum-creatinine of patients with CKD.

Usefulness of Delta Neutrophil Index in Prediction of Septic Shock in Patients with Community-acquired Pneumonia

PURPOSE: The delta neutrophil index (DNI) corresponds to the calculated immature granulocyte counts and the severity of sepsis. The aim of this study was to investigate the diagnostic value of DNI as a predictable laboratory marker for septic shock in patients with severe community-acquired pneumonia in emergency department. METHODS: The present study was a retrospective analysis of patients with pathologically confirmed community-acquired pneumonia from December 2011 to February 2012 at a hospital. The DNI was automatically calculated as a subset of routine complete blood count test. The diagnostic performance of DNI for septic shock in patients with community-acquired pneumonia was evaluated. RESULTS: During the study period, 105 patients were enrolled. Among them, 27 patients (25.7%) were confirmed as having septic shock according to predetermined criteria. The initial value of DNI was significantly higher in septic shock group than in non-shock group (8.7% vs 2.3%, p=0.008). The peak value of DNI was also significantly higher in septic shock group (18.6% vs 4%, p<0.001). The sensitivity and specificity of the initial and peak DNI values for predicting septic shock in patients with community-acquired pneumonia were 48.2%, 96.2%, 74.1%, and 87.2%, respectively, at initial and peak cutoff levels of 11.2% and 8.7% with an area under the curve (AUC) of 0.72 and 0.81 on the Receiver Operating Characteristic (ROC) curve. The AUC to predict septic shock was 0.74 for the CURB-65 scale. The AUC was significantly increased when peak DNI was added to CURB-65 scale (p=0.007). CONCLUSION: This study suggested that the DNI is associated with septic shock in patients with community-acquired pneumonia. Clinically, the peak value of DNI added to CURB-65 scale could improve predictable performance of septic shock in patients with community-acquired pneumonia.