Cancer patients with neutropenic septic shock: etiology and antimicrobial resistance

Background/Aims@#Among patients with febrile neutropenia that developed after chemotherapy, high-risk patients, such as those having clinical instability or Multinational Association of Supportive Care in Cancer score of < 21, require hospitalization for intravenous empiric antibiotic therapy. Monotherapy with an anti-pseudomonal ß-lactam agent is recommended. Although many studies reported the microbial etiology of infections and resistant patterns of febrile neutropenia, the patients were not well characterized as having neutropenic septic shock. Therefore, this study aimed to determine the microbial spectrum of infections and resistance patterns of their isolates in patients with chemotherapy-induced neutropenic septic shock. @*Methods@#Data of adult patients diagnosed with neutropenic septic shock in the emergency department between June 2012 and December 2016 were extracted from a prospectively compiled septic shock registry at a single academic medical center. Thereafter, microbiological studies and antimicrobial susceptibility tests were conducted. @*Results@#In total, 109 bacteria were found in patients with neutropenic septic shock. Gram-negative bacteria were the predominant causative organisms (84, 77.1%). Moreover, 33 microorganisms (30.3%) were multidrug-resistant (MDR) bacteria with extended-spectrum ß-lactamase-producing Escherichia coli (17, 50%) being the commonest. The most commonly affected sites in patients with MDR bacterial infections were the gastrointestinal tract (45%) and unknown (43.5%). Approximately 48.5% of MDR bacteria were resistant to cefepime but not to piperacillin- tazobactam or carbapenem. @*Conclusions@#MDR bacteria were prevalent in patients with chemotherapy-induced neutropenic septic shock. Therefore, piperacillin-tazobactam or carbapenem may be considered as empiric antibiotics if MDR bacteria are suspected to be causative agents.

Rapid Collection of Opinions from Healthcare Professionals in Multiple Institutions Using Short Message Service and Google Forms / 대한의료정보학회지

No abstract available.

Characteristics of orbital wall fractures in preschool and school-aged children

OBJECTIVE: This study aimed to evaluate the injury patterns in pediatric patients with an orbital wall fracture (OWF) and to identify the differences in injury patterns between preschool and school-aged patients with OWF who presented to the emergency department. METHODS: We performed a retrospective observational study in the emergency department of a tertiary hospital between January 2004 and March 2014. A total of 177 pediatric patients (7 years) pediatric groups. RESULTS: The inferior wall was the most common fracture site in both the preschool and school-aged pediatric groups (50.0% vs. 64.4%, P=0.15). The male-to-female ratio and the mechanism of injury showed significant differences between the two age groups. Violence was the most common mechanism of injury in the school-aged pediatric group (49.3%), whereas falls from a height caused OWF in approximately half of the patients in the preschool pediatric group (42.9%). Concomitant injuries and facial fractures had a tendency to occur more frequently in the school-aged pediatric group. CONCLUSION: Significant differences according to the sex and mechanisms of injury were identified in preschool and school-aged pediatric patients with OWF.

Post lumbar puncture headache: Case report of a serious adverse event in first-in-human study

A lumbar puncture can be used to measure the concentrations of drugs and/or pharmacodynamic biomarkers during clinical trials of central nervous system drugs. We report a case of a post lumbar puncture headache (PLPH) in a first-in-human study, which was reported as a serious adverse event. A 20-year-old man received 200 mg of the investigational product (IP) for 7 days and underwent a lumbar puncture for cerebrospinal fluid sampling before IP administration (Day 1, pre-dose) and after 7 days and multiple IP administrations (Day 7, 1 hour post-dose). After discharge on Day 8, the subject complained of headache, nausea, vomiting, neck stiffness, and numbness of the extremities. The symptoms occurred when he got up and disappeared after he remained in the supine position for several minutes. Five days later, he visited the neurology clinic of the main hospital. The neurologist recommended hospitalization for further evaluation and symptom management, and the subject was then admitted to the hospital. There were no abnormal findings in vital signs, laboratory results, or brain-computed tomography. His symptoms disappeared during the hospitalization period. It was important to distinguish whether the headache was IP-related or lumbar puncture-related. Therefore, knowledge of clinical characteristics and differential diagnosis of PLPH is paramount. Furthermore, if severe PLPH occurs, a consultation with a neurologist and imaging studies should be considered for a differential diagnosis of PLPH.

Can Glasgow-Blatchford Score and Pre-endoscopic Rockall Score Predict the Occurrence of Hypotension in Initially Normotensive Patients with Non-variceal Upper Gastrointestinal Bleeding? / 대한소화기학회지

BACKGROUND/AIMS: The aim of this study was to identify the ability of Glasgow-Blatchford score (GBS) and pre-endoscopic Rockall score (pre-E RS) to predict the occurrence of hypotension in patients with non-variceal upper gastrointestinal bleeding who are initially normotensive at emergency department. METHODS: Retrospective observational study was conducted at Asan Medical Center emergency department (ED) in patients who presented with non-variceal upper gastrointestinal bleeding from January 1, 2011 to December 31, 2013. Study population was divided according to the development of hypotension, and demographics, comorbidities, and laboratory findings were compared. GBS and pre-E RS were estimated to predict the occurrence of hypotension. RESULTS: A total of 747 patients with non-variceal upper gastrointestinal bleeding were included during the study period, and 120 (16.1%) patients developed hypotesion within 24 hours after ED admission. The median values GBS and pre-E RS were statistically different according to the occurrence of hypotension (8.0 vs. 10.0, 2.0 vs. 3.0, respectively; p<0.001). In the receiver operating characteristic curve analysis of hypotension development, the area under the curve of GBS and pre-E RS were 66% and 64%, respectively. The sensitivity and the specificity of GBS using optimal cut-off value were 81% and 46%, respectively, while those based on the pre-E RS were 74% and 46%, respectively. CONCLUSIONS: GBS and pre-E RS were both not sufficient for predicting the occurrence of hypotension in non-variceal upper gastrointestinal bleeding. Development of other scoring systems are needed.

Early Antibiotic Administration and Mortality in Patients with Septic Shock in Emergency Department

PURPOSE: The Surviving Sepsis Campaign recommend initiating broad spectrum antibiotics within the first hour of recognition of septic shock. An unknown proportion of the effectiveness of earlier antibiotics administration will remain in septic shock patients treated with an early quantitative resuscitation in emergency department (ED). We were to compare the 28-day mortality between earlier antibiotic administration (< or =1 hour) and early antibiotic administration (1 hour to 6 hour) in septic shock patients in ED. METHODS: A total of 536 consecutive septic shock patients were prospectively collected from January 2010 to June 2012. We identified 357 patients who were developed shock at initial assessment, and measured the time of initial antibiotics administration. The primary outcome was 28-day mortality. RESULTS: Mean age was 62.8+/-13.7 years old and 222 patients were male (62.2%). The median time from shock recognition-to-antibiotics administration was 94.0 min (IQR 47.0-150.0) and 28-day mortality rate was 20.2%. When the relationship of 28-day mortality between earlier antibiotic administration (< or =1 hour) and early antibiotic administration (1 hour to 6 hour) was compared, no significant difference was shown (19.5% vs. 20.5%, p=0.82). CONCLUSION: Earlier antibiotics administration may have no additional outcome value in septic shock patients treated with an early quantitative resuscitation in ED.

Methemoglobinemia Caused by an Inert Ingredient after Intentional Ingestion of Pesticide / 대한구급학회지

We report two cases of toxic methemoglobinemia caused by an inert ingredient in pesticide product after intentional ingestion of pesticide. First, 51-year-old male visited to the emergency department (ED) after the ingestion of pesticide in a suicide attempt. Initial methemoglobin (MetHb) level was 25.6%. We did not know the cause of methemoglobinemia at that time. Second, 56-year-old female visited to the ED after the ingestion of the same pesticide in a suicide attempt. MetHb level after 30 minutes was 16.1%. The patients were treated with methylene blue. We contacted to the Korean Rural Development Administration and estimated that magnesium nitrate was more likely to cause methemoglobinemia. This report highlights the importance of considering the possibility of methemoglobinemia caused by inert ingredient in pesticide and early antidotal therapy.

Quantification of Human Plasma-Busulfan Concentration by Liquid Chromatography-Tandem Mass Spectrometry

BACKGROUND: Busulfan, an alkylating agent administered prior to hematopoietic stem cell transplantation, has a narrow therapeutic range and wide variability in metabolism. We developed a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for rapid and accurate quantification of plasma busulfan. METHODS: Busulfan was separated and detected using an LC system containing a C18 column equipped with MS/MS. The sample was eluted with a mobile phase gradient for a total run time of 10 min. Plasma busulfan concentration was quantified against a 6-point standard curve in a multiple reaction monitoring mode at mass-to-charge (m/z) 264.1 > 151.1. Precision, recovery, matrix effect, linearity, detection capability, carryover, and stability were evaluated. The range of plasma busulfan concentration was obtained by analyzing samples from 9 children receiving busulfan. RESULTS: The coefficients of variation of within-run and within-laboratory precision were all below 5%. Recoveries were all within the range of 100-105%. Linearity was verified from 0 to 5,000 ng/mL. Limit of detection and limit of quantification were 1.56 and 25 ng/mL, respectively. Carryover rate was within allowable limits. Plasma busulfan concentration was stable for 2 weeks at -20degrees C and -80degrees C, but decreased by 25% when the plasma was stored for 24 hr at room temperature, and by <5% in 24 hr at 4degrees C. The plasma busulfan concentrations were between 347 ng/mL and 5,076 ng/mL. CONCLUSIONS: Our method using LC-MS/MS enables highly accurate, reproducible, and rapid busulfan monitoring with minimal sample preparation. The method may also enable safe and proper dosage.

Genetic Polymorphisms of the Carboxylesterase 1 (CES1) Gene in a Korean Population

Human carboxylesterase 1 (CES1) is a serine esterase that hydrolyzes various exogenous compounds. Single nucleotide polymorphisms (SNPs) of CES1 may lead to inter-individual metabolic variability of its substrates. The allele and haplotype frequencies of known SNPs have been demonstrated to vary among ethnic groups. We analyzed genetic variations of CES1 in a Korean population. Direct sequencing of all exons and flanking regions of the CES1 gene was performed on samples obtained from 200 Koreans. We identified 41 SNPs. The most frequent SNPs was -914G>C (frequency: 99.5%), followed by 4256G>A (frequency: 65.8%), -75T>G (frequency: 59.3%). Haplotype analysis using the identified SNPs revealed fifteen haplotypes (> or =1% haplotype frequency) in our samples. The most frequent haplotype was Hap1 (frequency: 15.4%). Among the identified 41 SNPs, nine of which are novel variants and 14 SNPs were nonsynonymous variants. Using the functional predictive software PolyPhen-2, the G19V, E221G, and A270S variants were predicted to be most likely damaging to the function and structure of CES1. In-vitro analyses for two of these variants have been previously performed; however, functional evaluation of E221G (11657A>G, rs200707504) still needs to be conducted. Therefore, further studies are warranted to characterize the functional impact of E221G on CES1 activity.

Methemoglobinemia Caused by an Inert Ingredient after Intentional Ingestion of Pesticide / 대한중환자의학회지

We report two cases of toxic methemoglobinemia caused by an inert ingredient in pesticide product after intentional ingestion of pesticide. First, 51-year-old male visited to the emergency department (ED) after the ingestion of pesticide in a suicide attempt. Initial methemoglobin (MetHb) level was 25.6%. We did not know the cause of methemoglobinemia at that time. Second, 56-year-old female visited to the ED after the ingestion of the same pesticide in a suicide attempt. MetHb level after 30 minutes was 16.1%. The patients were treated with methylene blue. We contacted to the Korean Rural Development Administration and estimated that magnesium nitrate was more likely to cause methemoglobinemia. This report highlights the importance of considering the possibility of methemoglobinemia caused by inert ingredient in pesticide and early antidotal therapy.

Hospital disaster plan and disaster medicine

In general, the disaster rescue team should do their work within 1 to 2 hours after disaster, and disaster medical assistance team (DMAT) should care the victims at disaster site within 3 to 6 hours. Since about 10 years ago, world health organization, world meteorological organization, and world congress of disaster emergency medicine emphasized that each countries should complete the disaster plan on 'chemical, biological, radiological, nuclear, explosives' (CBRNE) disaster. After these warnings, the most of countries has strengthened the hospital disaster plan, and also organized disaster services system such as DMAT, hazardous material information system, and others. In Korea, the most of tertiary hospitals can not operate hospital disaster plan effectively, and the government did not support hospitals on disaster plan politically and financially. As a result, only a small number of hospitals is operating DMAT, and a few hospital completed CBRNE disaster preparedness such as disaster drill, personal protective equipments, decontamination set. The poison information center that control information on hazardous material is not established yet, and most physicians can not get information on chemicals, biologics and other hazardous materials when CBRNE disaster occur. To operate effective disaster plan, each hospitals should modernize the disaster plan on internal disaster, external disaster, and CBRNE disaster. The government should support hospitals to keep DMAT and special preparedness on CBRNE disaster. When CBRNE disaster strikes, the poison information center should expand their capability to provide information on the various kinds of hazardous materials.

Clinical Characteristics and Predictive Factors of Septic Shock in Patients with Pyogenic Liver Abscess

PURPOSE: The aim of this study was to describe clinical, biochemical, and radiologic features in patients with pyogenic liver abscess and to investigate predictors of septic shock. METHODS: We consecutively included subjects who were diagnosed as pyogenic liver abscess in the emergency department (ED) from January 1st, 2010 to June 30th, 2013. Through review of medical records, clinical, biochemical, and radiologic data were collected. The primary endpoint was septic shock during hospitalization. RESULTS: A total of 228 patients were included, with a mean age of 60.8+/-12.8 years, and 63.2% were men. Among them, 198 patients presented with fever and GCS or =120/min, respiratory rate > or = 22/min, body temperature (BT) > or =38degrees C, WBC, platelet, BUN, creatinine, albumin, AST, alkaline phosphatase (ALP), Creactive protein (CRP), abscess size > or =5 cm, and bilobal involvement were significantly associated with septic shock (p or =38degrees C (OR 1.95, 1.36-2.78), BUN (OR 1.03, 1.01-1.06), ALP (OR 1.003, 1.000-1.005), and abscess size > or =5 cm (OR 2.31, 1.08-4.94) were independent predictors of septic shock. CONCLUSION: Low Systolic Bp, High Bt, Elevated Bun And Alp, And Abscess Size > or =5 Cm Were Independently Associated With Septic Shock In Patients With Pyogenic Liver Abscess.

Clinical Characteristics of 372 Cases of Transient Global Amnesia in the Emergency Department: A Single Center Study

PURPOSE: Transient global amnesia (TGA) is characterized by abrupt onset of antegrade amnesia usually seeking emergency care. We analyzed the clinical characteristics of TGA patients and the significance of diffusion weighted imaging (DWI) in the diagnosis of TGA. METHODS: Retrospective analysis was performed using electronic medical records of patients diagnosed as TGA in the emergency departments from January 2003 to December 2013. The patient's clinical characteristics and precipitants were analyzed, and detection rate of hippocampal lesion was compared according to the time to DWI after symptom onset (24 h). RESULTS: Of 372 consecutive TGA patients studied, 27 had a positive DWI lesion in hippocampus. Demographics and vascular risk profile were not significantly different between those in DWI (+) and DWI (-), and neither was duration of amnesia (p=0.076). However, the median time interval to DWI was significantly longer in DWI (+) than DWI (-) [7.5 (5.5~15.0) h vs. 6.0 (3.5~9.0) h, p=0.011]. In addition, the detection rate of hippocampal lesion increased with the time interval [0-6 h (4.1%), 6~12 h (10.7%), 12~24 h (11.1%), and >24 h (16.1%), p=0.004]. CONCLUSION: Positive hippocampal lesion on DWI can confirm the diagnosis of TGA; however, difference in lesion detectability in regard to time interval from symptom onset to DWI should be considered in diagnosis of TGA with DWI.

Kind and Estimated Stocking Amount of Antidotes for Initial Treatment for Acute Poisoning at Emergency Medical Centers in Korea

Antidotes for toxicological emergencies can be life-saving. However, there is no nationwide estimation of the antidotes stocking amount in Korea. This study tried to estimate the quantities of stocking antidotes at emergency department (ED). An expert panel of clinical toxicologists made a list of 18 emergency antidotes. The quantity was estimated by comparing the antidote utilization frequency in a multicenter epidemiological study and the nation-wide EDs' data of National Emergency Department Information System (NEDIS). In an epidemiological study of 11 nationwide EDs from January 2009 to December 2010, only 92 (1.9%) patients had been administered emergency antidotes except activated charcoal among 4,870 cases of acute adult poisoning patients. Comparing with NEDIS data, about 1,400,000 patients visited the 124 EDs nationwide due to acute poisoning and about 103,348 adult doses of the 18 emergency antidotes may be required considering poisoning severity score. Of these, 13,224 (1.9%) adult doses of emergency antidotes (575 of atropine, 144 of calcium gluconate or other calcium salts, 2,587 of flumazenil, 3,450 of N-acetylcysteine, 5,893 of pralidoxime, 287 of hydroxocobalamin, 144 of sodium nitrite, and 144 of sodium thiosulfate) would be needed for maintaining the present level of initial treatment with emergency antidotes at EDs in Korea.

A Review on the Clinical Characteristics and Outcomes from Spontaneous Intestinal Intramural Hematoma

PURPOSE: Spontaneous intestinal intramural hematoma (SIMH) is a very rare complication of anticoagulation. Most reports on SIMH have been case reports and case series, not well-established clinical studies. Therefore, the aim of this study was to evaluate the clinical characteristics and outcomes from SIMH. METHODS: A retrospective review of the records of 48 patients with non-traumatic SIMH was performed at an urban academic tertiary hospital between January 2001 and December 2012. These patients were diagnosed with SIMH by computed tomography and confirmed by a radiology specialist. Their clinical characteristics and outcomes from SIMH were determined. RESULTS: Among all SIMH cases, the percentage of warfarin users was 70.8%. The median age at presentation was 66.5 years, whereas warfarin users were older (68.0 years) than non-users (55.0 years) (p<0.01). SIMH patients had abdominal pain (81.3%), nausea and vomiting (50.0%) and 62.5% of them had abdominal tenderness. The most frequently involved site was the small bowel (85.4%) and there was only one patient with bowel obstruction from SIMH. A total of 33(68.6%) patients were admitted for 9.3 days for conservative treatment, including transfusion. On the other hand, two patients had surgical intervention. There were no mortality cases from SIMH during the study period. CONCLUSION: SIMH is rare disease which can treated with supportive care. However, it can cause severe complications, such as bowel obstruction and perforation, requiring surgical intervention. Therefore, emergency physicians have to consider SIMH carefully, especially in patients treated with an anticoagulation agent.

A Randomized, Open Label, 2-Way Crossover Study to Assess the Pharmacokinetic Characteristics and Skin Irritation of Murupe(R) Patch Compared with Trast(R) Patch in Healthy Volunteers

BACKGROUND: A piroxicam patch has been widely used to treat musculoskeletal pain. The aim of this study was to assess the pharmacokinetic (PK) characteristics and skin irritation of Murupe(R) patch (piroxicam 96 mg) compared with Trast(R) patch (piroxicam 96 mg) in healthy volunteers. METHODS: A randomized, open-label, 2-way crossover study was conducted in 12 healthy Korean male subjects. They were allocated to one of the two treatment sequences of RT and TR (R, reference drug, Trast(R) patch; T, test drug, Murupe(R) patch). Each patch was applied to the subject once during 48 hours. Serial blood samples were collected up to 72 hours after removing the patch and plasma concentrations were determined by high performance liquid chromatography. Safety was monitored and the skin irritation potential was assessed. RESULTS: The plasma concentration-time profile during 48 hours showed an exponential increase in both of two patch products. Mean C(max) and AUC(last) values were not statistically different between two patch groups. Mean AUC[0-48h] was lower in Murupe(R) patch group than that in Trast(R) patch group; 806.4 and 1196.5 ng.h/mL. However, the mean AUC[48-120h] value tended to be higher in Murupe(R) patch group, implying more delayed excretion than in Trast(R) patch group; 2724.7 ng.h/mL and 1989.2 ng.h/mL. The overall results of skin irritation potential test showed no clinically significant differences between two patch groups. CONCLUSION: Mean Cmax and AUC(last) values in Murupe(R) patch group were comparable to those in Trast(R) patch group. Murupe(R) patch was safe and well tolerated in healthy male subjects.

A Randomized, Placebo Controlled, Double Blind, Parallel Group, Multiple Dosing, Dose Escalation Clinical Study to Evaluate Pharmacokinetics/Pharmacodynamics and Tolerability of Zofenopril in Healthy Korean Subjects

BACKGROUND: Zofenopril is a new Angiotensin Converting Enzyme (ACE) inhibitor for the treatment of the patients with hypertension and congestive heart failure. This study aimed to evaluate the pharmacokinetics (PKs)/pharmacodynamics (PDs) and tolerability of zofenopril in healthy Korean subjects. METHODS: A randomized, double blind, placebo-controlled, multiple dosing parallel group study with two dosage groups (zofenopril 30 mg or 60 mg) was conducted in healthy Korean male subjects. Each dosage group consisted of 10 subjects and they were randomly assigned to receive zofenopril or placebo with a ratio of 4:1. PK characteristics of zofenopril and its active metabolite, zofenoprilat, were evaluated after single or multiple dosing. Serum ACE activities and blood pressures were measured for PD evaluation. Adverse events, clinical laboratory tests, electrocardiograms, vital signs and physical examinations were performed for tolerability evaluation. RESULTS: The PK characteristics of zofenopril and zofenoprilat after single dose and multiple doses were similar to one another. The metabolic ratio of zofenoprilat to zofenopril after single dose and multiple doses were 12.4 and 14.9, respectively, in the 30 mg dosage group, and were 6.8 and 6.6, respectively, in the 60 mg dosage group. Complete serum ACE activity inhibition was observed within 1 hour in both doses but it was maintained longer in the 60 mg dosage group compared to the 30 mg dosage group. There were no clinically significant abnormalities in tolerability evaluations. CONCLUSION: The PK/PD characteristics of zofenopril and zofenoprilat after single or multiple administrations were explored. Zofenopril was well tolerated after multiple administrations in healthy Korean subjects.

A Placebo-Controlled, Single and Multiple Dose Study to Investigate the Appropriate Parameters for Evaluation of Pharmacodynamic Equivalence of Voglibose in Healthy Korean Volunteers

BACKGROUND: Voglibose is an alpha-glucosidase inhibitor. The purpose of this study was to evaluate the pharmacodynamic characteristics of voglibose for determining the appropriate study design and parameters for a pharmacodynamic equivalence study of voglibose. METHODS: This study consisted of two studies. The single dose study had an open and single sequence design. Nineteen subjects received placebo and then one tablet of voglibose on two consecutive days with sucrose. The multiple dose study was performed with the similar design, except that it was a multiple dose of the single dose study. Nine subjects who showed an effective response in the single dose study received placebo three times and then voglibose 4 times on two consecutive days. Serial blood samples for pharmacodynamic parameters were taken until 180 mins after each administration. The baseline adjusted maximum serum glucose level (G(max)) and area under the serum glucose level-time profiles were determined and compared. RESULTS: In the single dose study, the difference in G(max) was -10.6 +/- 28.7 mg/dL. The area under the serum glucose concentration-time curve (AUGC(0-1h)) of placebo and voglibose were 7825.0 +/- 1145.3 mg.min/dL, 7907.5 +/- 917.2 mg.min/dL, respectively. In the multiple dose study, the difference in G(max) was 46.6 +/- 16.1 mg/dL. The AUGC(0-1h) of placebo and voglibose were 8138.6 +/- 721.9 mg.min/dL and 6499.7 +/- 447.2 mg.min/dL, respectively. The G(max) and AUGC(0-1h) of the multiple dose study was significantly different between placebo and voglibose in paired t-test. CONCLUSION: The differences in G(max) and AUGC(0-1h) are suitable for pharmacodynamic parameters to evaluate bioequivalence of voglibose.

Value of Cardiac Biomarkers for Predicting Hypotension in Non-high-risk Patients with Acute Pulmonary Embolism

PURPOSE: Recent and numerous studies have indicated that cardiac biomarker elevation during acute pulmonary embolism (PE) predicts in-hospital death. However, the role of cardiac biomarkers for predicting the occurrence of hypotension is unknown. The aim of the present study was to evaluate whether increased levels of cardiac biomarkers can predict the occurrence of hypotension (sytolic blood pressure (SBP) 0.05 ng/mL) upon admission were an independent predictor for developing hypotension within 24 hours in patients with stable acute PE at the time of ED admission (odds ratio 11.0, 95% confidence interval (CI) 2.8-43.8, p=0.00). CONCLUSION: In stable patients with acute PE, an elevated TnI can predict the in-hospital development of hypotension within 24 hours. This finding is valuable for selecting patients who might benefit from intensive clinical surveillance and escalated treatment.

The Clinical Value of TnI and BNP for the Evaluation of Sepsis-related Cardiac Dysfunction in the Emergency Department

PURPOSE: Acute cardiac dysfunction is a well recognized manifestation of organ failure in severe sepsis and septic shock. Although echocardiography is the golden standard for the evaluation of cardiac dysfunction, it is difficult to use in the emergency department (ED). The purpose of this study was to determine the availability of cardiac biomarkers for the estimation of cardiac dysfunction in septic shock patients. METHODS: All study subjects included consecutive patients with septic shock diagnosed in the ED and treated with an algorithm of early goal-directed therapy between January 2011 and June 2012. We enrolled patients measured for cardiac biomarkers and performed echocardiography within 24 hours. We divided patients into two groups based on the occurrence of left ventricular dysfunction (defined as an ejection fraction< or =40%) and compared serum levels of troponin-I (TnI) and B-type natriuretic peptide (BNP) between the two groups. The area under the receiver operating characteristic (ROC) curve was used to compare the diagnostic ability of TnI and BNP. RESULTS: A total of 127 patients with septic shock and evaluated for cardiac dysfunction were enrolled in this study. TnI and BNP were significantly higher in the left ventricular dysfunction group group (4.2+/-9.0 vs. 0.6+/-1.8 ng/mL, respectively, p<0.05) compared with the non-dysfunction group (1087.6+/-680.1 vs. 633.2+/-859.1 pg/mL, respectively, p<0.05). However, in the ROC curve for predicting left ventricular dysfunction, the area under the curves of TnI and BNP, respectively, were 0.631(95% CI 0.473-0.788, p=0.103) and 0.704 (95% CI 0.552-0.856, p=0.011). TnI and BNP showed a 84.6% negative predictive value. CONCLUSION: Although TnI and BNP were significantly higher in septic shock patients with cardiac dysfunction but demonstrated limited accuracy compared to echocardiography. However, TnI and BNP have high negative predictive value in septic shock patients for the evaluation of cardiac dysfunction. Therefore they could serve as a valuable supplement for the detection of cardiac dysfunction.