ABSTRACT
Background : Evidence-based guidelines are the best way to ensure the quality of patient care. The 2019 European Society of Cardiology (ESC) guidelines were established for the diagnosis and management of acute pulmonary embolism. Objective : To evaluate the adherence of clinicians to the ESC recommendations in the management of hemodynamically stable patients with pulmonary embolism. To evaluate the identification and orientation of patients at intermediate-high risk of mortality according to the guidelines (sPESI>1 and right ventricle dysfunction and positive troponin test). Material(s) and Method(s): We conducted a retrospective single-centre study on all the patients admitted into the emergency care unit (ECU) and diagnosed for pulmonary embolism from January 2021 to October 2021. Their data were collected from the patient health records of the ECU and the subsequent services where the patients were hospitalized. Hemodynamically unstable patients were excluded (Systolic blood pressure on arrival <90 mmHg, cardiac arrest or use of vasopressors). We evaluated the frequency of use of the recommended tools (PESI or sPESI) as well as the frequency of assessment of right ventricle dysfunction via imaging methods (heart ultrasound or via CT) and of laboratory biomarkers such as Troponin T (cutoff 10 pg/ml) and NT-proBNPs (cutoff 500 ng/L). For all of the selected patients, we retrospectively calculated the sPESI to assign them into three categories of early mortality risk (low, intermediate low and intermediate high) and examined whether the orientations of the patients to the intensive care unit (ICU) or other units were appropriate. Results :A total of 70 patients with a median age of 64 years were included. Sixteen (23%) patients were SARS-CoV2 positive. Out of the 70 patients,15 (21%) had a documented PESI or sPESI score on arrival, 51 (73%) had a troponin measured and 51 (73%) had a cardiac ultrasound performed of whom 9 (13%) had an ultrasound on arrival and 42 (60%) during their hospital stay. After calculating the sPESI on all patients based on the admission data in the ECU,16 (23%) patients were identified as being at intermediate-high risk. Amongst these 16 severely affected patients,10 had indeed benefitted from surveillance in the ICU whereas one did not benefit from surveillance and five were not transferred to the ICU based on the clinician's evaluation or the patient's desire to avoid therapeutic escalation. It appears that sPESI was more frequently calculated (33% vs 4%, p = 0,002) in patients who had certain radiological findings (bilateral embolism or embolism in a main pulmonary artery) compared to patients without radiological signs of severity. Conclusion : Adherence to the scores recommended by evidence-based guidelines was documented in only 23% of cases. This leaves room for improvement in the use of the PESI score and requires more systematic dosage of Troponins T and faster access to cardiac ultrasound. Our observation showed that even if radiological findings (besides signs of RV dysfunction) are not used in the ESC guidelines, some clinicians are prone to using radiological signs of severity to guide their use of the sPESI score. However, this can lead to a lack of identification and appropriate management of patients at intermediate-high risk of early mortality.
ABSTRACT
Background Dry weight is defined as the lowest tolerated post-dialysis weight at which there are minimal signs or symptoms of hypovolemia or hypervolemia. Achieving dry weight is a goal for each dialysis session. That improves blood pressure control and reduces cardiovascular risk in dialysis patients. Haemodialysis patients may experience weight loss likely related to a reduction of dry mass when catabolic reactions and inflammation occur. Our aim was to assess the impact of SARSCov-2 infection on haemodialysis patients and analyse factors associated with dry weight variations observed during the COVID-19 pandemic. Method(s): In this retrospective observational single-centre study, we analysed the clinical characteristics of all patients undergoing haemodialysis at the Pole Hospitalier Jolimont during COVID-19 pandemic from 1 March 2020 to 28 February 2022. We determined dry weight at day 1 after diagnosis of SARSCov-2 infection or at day 1 of a randomly assigned 28-days observation period and at 2, 3 and 4 weeks later. We compared infected and uninfected patients and examined the clinical features associated with SARSCov-2 infection and those associated with changes in dry weight. Result(s): Within the observation period, among the 162 haemodialysis patients, 47 patients were infected with SARSCov-2. Three patients were excluded because they have been infected before the first dialysis session and seventeen others due to missing data. Two patients were infected twice but we considered the second episodes as relevant and had therefore 144 observations. Dry weight variation ratio (dry weight variation divided by dry weight at day 1) was a continuous non normally distributed variable for which we performed Wilcoxon rank sum tests and Student's t-tests. Dry weight variations were bigger in patients infected with SARSCov-2 compared to non-infected patients: the mean dry weight variation ratio was - 2,4 +/- 2,2% (SD) in the infected dialysis patients and - 0,6 +/- 2,0% in the uninfected patients (p < 0.001). A very strong association was found between SARSCov-2 infection and loss of dry weight (0,5 kg and more) with odds ratio = 21,89;95% CI [7,17-66,85]. No difference was found whether infected patients were symptomatic or not (-2,6 +/- 2,2% vs - 2,3 +/- 2,3%;p = 0,662). Infected patients and non-infected patients significantly differ by the sex distribution (76% vs 52% males;p = 0,008). We performed a Cochran-Mantel-Haenszel stratified analysis and confirmed the association between loss of dry weight and SARSCov-2 infection after controlling for effect modification or confounding by sex. Furthermore, dry weight often varies during early haemodialysis sessions and a bias such as a short dialysis duration was also ruled out. Indeed, no correlation was found between the shortest dialysis durations (less than 2 months) and the dry weight variations observed in our population. Discussion(s): SARSCov-2 infection is associated with decreases of dry weight in haemodialysis patients. Systemic effects of SARSCov-2 infection are suspected since dry weight changes are quite similar both in symptomatic and asymptomatic infected dialysis patients. Only 2 patients in our population died from complications related to SARSCov-2 infection. Adapting dry weight may be a major element in lowering mortality in infected dialysis patients.