Correlation between impedance cardiography and B-type natriuretic peptide levels in dyspneic patients.

BACKGROUND: Both serum measurements of B-type natriuretic peptide (BNP) and impedance cardiography (ICG) are used to evaluate patients for congestive heart failure (CHF) in the Emergency Department (ED), but the agreement between the data obtained by these two methods remains uncertain. STUDY OBJECTIVES: We sought to measure the correlation between BNP levels and ICG measurements in patients presenting to the ED with dyspnea, and compare the diagnostic accuracy of each method in diagnosing CHF. METHODS: We performed a prospective observational study of a convenience sample of patients presenting to the ED with dyspnea and being evaluated for CHF as a cause of their symptoms. An ICG measurement was obtained on each patient and the correlation between BNP level and the ICG parameters cardiac index (CI), systemic vascular resistance (SVR), and thoracic fluid content (TFC) was measured. To further quantify the diagnostic accuracy of ICG and BNP, we then constructed receiver operating characteristic curves based on discharge diagnosis of CHF and compared the area under the curve (AUC) of each test. RESULTS: Out of 54 patients enrolled, correlation was poor between BNP and CI (Spearman's ρ = -.07, p = 0.64) and between BNP and SVR (Spearman's ρ = -.10, p = 0.46), but moderate between BNP and TFC (Spearman's ρ = .32, p = 0.02); a wide degree of scatter was seen in all correlations. BNP levels showed the best diagnostic accuracy for a discharge diagnosis of CHF, with an AUC of .77 (95% confidence interval .59-.95), whereas CI had an AUC of .72 (95% confidence interval .55-.88). CONCLUSION: We found limited correlation between BNP levels and ICG parameters, suggesting that, in our population, the two tests may not consistently give similar information. BNP level and CI both provided only fair diagnostic accuracy for discharge diagnosis of CHF.

A comparison of the effects of etomidate and midazolam on hospital length of stay in patients with suspected sepsis: a prospective, randomized study.

STUDY OBJECTIVE: Etomidate, a widely used induction agent for rapid sequence intubation in the emergency department (ED), causes measurable adrenal suppression after a single bolus dose. The clinical significance of this adrenal suppression in patients with sepsis remains controversial. We seek to determine the difference in hospital length of stay between patients with suspected sepsis who receive either etomidate or midazolam during intubation in our ED. METHODS: We performed a prospective, double-blind, randomized study of patients with suspected sepsis who were intubated in our ED during an 18-month period. Eligible patients who were critically ill and were suspected of having sepsis were randomized to receive either etomidate or midazolam before intubation. RESULTS: A total of 122 patients were enrolled; 59 received midazolam and 63 received etomidate. Two patients in the etomidate group were lost to follow-up. Patient baseline characteristics were similar between groups. There were no significant differences in median hospital length of stay (9.5 versus 7.3 days), ICU length of stay (4.2 versus 3.1 days), or ventilator days (2.8 versus 2.1) between patients who received midazolam and those who received etomidate, respectively. Inhospital mortality was 21 of 59 (36%; 95% confidence interval 24% to 49%) for patients who received midazolam and 26 of 61 (43%; 95% confidence interval 30% to 56%) for patients who received etomidate. For patients who survived to hospital discharge, the median length of stay was 11.3 days in the midazolam group versus 11.8 days in the etomidate group; for patients who died, the median length of stay was 2.9 days in the midazolam group versus 3.3 days in the etomidate group. CONCLUSION: Patients with suspected sepsis and who received a single bolus dose of etomidate for rapid sequence intubation showed no significant increase in hospital length of stay compared with patients who received a single bolus dose of midazolam.

ED overcrowding is associated with an increased frequency of medication errors.

OBJECTIVES: Despite the growing problems of emergency department (ED) crowding, the potential impact on the frequency of medication errors occurring in the ED is uncertain. Using a metric to measure ED crowding in real time (the Emergency Department Work Index, or EDWIN, score), we sought to prospectively measure the correlation between the degree of crowding and the frequency of medication errors occurring in our ED as detected by our ED pharmacists. METHODS: We performed a prospective, observational study in a large, community hospital ED of all patients whose medication orders were evaluated by our ED pharmacists for a 3-month period. Our ED pharmacists review the orders of all patients in the ED critical care section and the Chest Pain unit, and all admitted patients boarding in the ED. We measured the Spearman correlation between average daily EDWIN score and number of medication errors detected and determined the score's predictive performance with receiver operating characteristic (ROC) curves. RESULTS: A total of 283 medication errors were identified by the ED pharmacists over the study period. Errors included giving medications at incorrect doses, frequencies, durations, or routes and giving contraindicated medications. Error frequency showed a positive correlation with daily average EDWIN score (Spearman's rho = 0.33; P = .001). The area under the ROC curve was 0.67 (95% confidence interval, 0.56-0.78) with failure defined as greater than 1 medication error per day. CONCLUSIONS: We identified an increased frequency of medication errors in our ED with increased crowding as measured with a real-time modified EDWIN score.

The effect of alpha-blockade in emergency department patients with ureterolithiasis.

BACKGROUND: Recent studies suggest that alpha-blockade with tamsulosin may be useful in the treatment of ureterolithiasis by increasing the success of, and decreasing the time to, stone passage. OBJECTIVES: We sought to determine stone passage success rates in patients diagnosed with ureterolithiasis and discharged from our Emergency Department (ED) with tamsulosin. METHODS: We conducted a non-randomized retrospective cohort study over a 1-year period during which we made monthly follow-up telephone calls to patients discharged from our ED with a diagnosis of ureterolithiasis determined by computed tomography (CT) scan. Stone size and location (proximal, middle, or distal ureter) were determined from radiologist reports and prescriptions were determined from electronic medical records. Patients were asked if they spontaneously passed their stone, how much time was required before stone passage, and if any subsequent hospital visit was required after discharge due to pain or complication resulting from the ureteral stone. RESULTS: During the study, a total of 213 patients were discharged from the ED with ureterolithiasis diagnosed by CT scan; of these, 119 (56%) were successfully contacted and 113 (53%) agreed to participate. Of the 113 patients, 83 (73%) had been prescribed tamsulosin and 30 (27%) had not. Overall age (43 years), gender (67% male), median stone size (3 mm, interquartile range 2-4 mm), and location (71% distal ureter) were similar in the two cohorts. Of tamsulosin recipients, 84% (95% confidence interval [CI] 75-91%) reported passing their stone, whereas 60% (95% CI 42-75%) of non-recipients passed their stone. CONCLUSION: Patients with ureterolithiasis discharged from our ED and given tamsulosin by prescription had moderately high ureteral stone passage success rates in our non-randomized retrospective cohort study. Compared to non-recipients of tamsulosin, patients receiving tamsulosin seemed to have greater success in stone passage.

A prospective observational study of the effect of etomidate on septic patient mortality and length of stay.

OBJECTIVES: Etomidate is known to cause adrenal suppression after single-bolus administration. Some studies suggest that when etomidate is used as an induction agent for intubation of septic patients in the emergency department (ED), this adrenal suppression leads to increased mortality, vasopressor requirements, and length of hospital stay. The authors sought to determine differences in the in-hospital mortality and hospital length of stay (LOS) between septic patients given etomidate and patients given alternative or no induction agents for rapid-sequence intubation in our ED. METHODS: This was a nonrandomized, prospective observational study of all patients meeting sepsis criteria who were intubated in an ED over a 9-month period. Times of patient presentation, intubation, admission, discharge, and/or death were recorded, as well as the intubation agent used, if any, and corticosteroid use. The authors also recorded relevant laboratory and demographic variables to determine severity of illness using the Mortality in Emergency Department Sepsis (MEDS) score. Mortality and survivor LOS between the patients given etomidate and those given alternative or no induction agents were compared. RESULTS: A total of 106 patients with sepsis were intubated over the study period. Of these, 74 patients received etomidate, while 32 patients received ketamine, benzodiazepines, propofol, or no induction agents. Age in years (median = 78; interquartile range [IQR] = 67 to 83), gender (45% male), MEDS score (median = 13; IQR = 10 to 15), and receipt of supplemental corticosteroids (56%) were statistically similar between the two groups. In-hospital mortality of patients given etomidate (38%; 95% confidence interval [CI] = 28% to 49%) was similar to those receiving alternatives (44%; 95% CI = 28% to 61%). Surviving patients had a median hospital LOS after receiving etomidate of 10 days compared to those receiving alternatives (7.5 days; p = 0.08). CONCLUSIONS: No statistically significant increase in hospital LOS or mortality in patients given etomidate for rapid-sequence intubation was found. Suggestions that the use of etomidate for intubation in the ED be abandoned are not supported by these data.

The effect of single-bolus etomidate on septic patient mortality: a retrospective review.

BACKGROUND: Because of its many desirable properties, etomidate is widely used as an induction agent for endotracheal intubation. However, some have recently called into question the safety of etomidate for even single-bolus use due to its known effects on adrenal suppression. OBJECTIVES: We sought to compare the in-hospital mortality between septic patients given etomidate and those given alternative induction agents for intubation. METHODS: We performed a retrospective chart review of intubated septic patients treated in our hospital. We collected data from patients over the age of 18 with sepsis who were intubated in the pre-hospital setting, in our emergency department, or on the wards of our hospital, and calculated the in-hospital mortality of each group. RESULTS: We identified 181 patients with sepsis who were intubated over the study period; 135 received etomidate and 46 received alternative agents or no induction agent. Baseline characteristics, vital signs, and laboratory values were similar between the two groups. Of the 46 patients receiving alternative agents or no agent, 18 died, yielding an unadjusted mortality of 39.1% (95% CI 25.5% to 54.6%), while of the 135 patients receiving etomidate, 63 died, for an unadjusted mortality of 46.7% (95% CI 38.1% to 55.4%), P=0.38. CONCLUSION: We found a non-statistically significant 7.6% absolute increase in mortality in patients given etomidate in our small-sized study population.