Expiratory flow limitation during mechanical ventilation: real-time detection and physiological subtypes.

BACKGROUND: Tidal expiratory flow limitation (EFLT) complicates the delivery of mechanical ventilation but is only diagnosed by performing specific manoeuvres. Instantaneous analysis of expiratory resistance (Rex) can be an alternative way to detect EFLT without changing ventilatory settings. This study aimed to determine the agreement of EFLT detection by Rex analysis and the PEEP reduction manoeuvre using contingency table and agreement coefficient. The patterns of Rex were explored. METHODS: Medical patients ≥ 15-year-old receiving mechanical ventilation underwent a PEEP reduction manoeuvre from 5 cmH2O to zero for EFLT detection. Waveforms were recorded and analyzed off-line. The instantaneous Rex was calculated and was plotted against the volume axis, overlapped by the flow-volume loop for inspection. Lung mechanics, characteristics of the patients, and clinical outcomes were collected. The result of the Rex method was validated using a separate independent dataset. RESULTS: 339 patients initially enrolled and underwent a PEEP reduction. The prevalence of EFLT was 16.5%. EFLT patients had higher adjusted hospital mortality than non-EFLT cases. The Rex method showed 20% prevalence of EFLT and the result was 90.3% in agreement with PEEP reduction manoeuvre. In the validation dataset, the Rex method had resulted in 91.4% agreement. Three patterns of Rex were identified: no EFLT, early EFLT, associated with airway disease, and late EFLT, associated with non-airway diseases, including obesity. In early EFLT, external PEEP was less likely to eliminate EFLT. CONCLUSIONS: The Rex method shows an excellent agreement with the PEEP reduction manoeuvre and allows real-time detection of EFLT. Two subtypes of EFLT are identified by Rex analysis. TRIAL REGISTRATION: Clinical trial registered with www.thaiclinicaltrials.org (TCTR20190318003). The registration date was on 18 March 2019, and the first subject enrollment was performed on 26 March 2019.

Effect of the Ramathibodi Rapid Response System Triggered by the Ramathibodi Early Warning Score and Clinical Warning Signs on in-Hospital Mortality and the Incidence of Cardiopulmonary Resuscitation in Adult Hospitalized Patients.

Purpose: The Ramathibodi Rapid Response System (RRRS), implemented in March 2017, aims to identify and respond to patients with deteriorating conditions outside the ICU. It employs the Ramathibodi early warning score and clinical signs to monitor all admitted patients, providing expert physician monitoring and early treatment for stabilization and appropriate care triage. This study assesses the RRRS's effectiveness in reducing in-hospital mortality and CPR events outside the ICU. Patients and Methods: We conducted a retrospective observational study from March 2014 to February 2020 in a tertiary care hospital's general wards. We included adult patients experiencing unplanned ICU admission, sudden cardiac arrest, or unexpected death. The study compared in-hospital mortality and CPR incidence outside the ICU between pre- and post-RRRS implementation groups. The associations between RRRS implementation and in-hospital mortality and the incidence of CPR outside the ICU were assessed using multiple logistic regression analyses. Results: We evaluated 17,741 admissions, with 9168 before RRRS implementation (1 March 2014 to 28 February 2017) and 8573 after RRRS implementation (1 March 2017 to 29 February 2020). The implementation of RRRS was associated with a significant reduction in in-hospital mortality, which decreased from 30.0% to 20.8% (odds ratio, 0.62; 95% confidence interval [CI], 0.57 to 0.66; P<0.0001). Even after adjusting for age, sex, and comorbidities, the reduction in in-hospital mortality remained significant (adjusted odds ratio, 0.58; 95% CI, 0.54 to 0.63; P<0.0001). The incidence of CPR outside the ICU also decreased from 1.8% to 1.1% (adjusted odds ratio, 0.6; 95% CI, 0.46 to 0.77; P<0.0001). Additionally, the rate of ICU transfer increased from 85.4% to 92.1% (risk difference, 6.7; 95% CI, 7.6 to 5.8; P<0.0001) after implementing the RRRS. Conclusion: Implementing the RRRS is associated with a reduction in in-hospital mortality and the incidence of CPR outside the ICU.

The Association between Emergency Department Length of Stay and In-Hospital Mortality in Older Patients Using Machine Learning: An Observational Cohort Study.

The association between emergency department (ED) length of stay (EDLOS) with in-hospital mortality (IHM) in older patients remains unclear. This retrospective study aims to delineate the relationship between EDLOS and IHM in elderly patients. From the ED patients (n = 383,586) who visited an urban academic tertiary care medical center from January 2010 to December 2016, 78,478 older patients (age ≥60 years) were identified and stratified into three age subgroups: 60-74 (early elderly), 75-89 (late elderly), and ≥90 years (longevous elderly). We applied multiple machine learning approaches to identify the risk correlation trends between EDLOS and IHM, as well as boarding time (BT) and IHM. The incidence of IHM increased with age: 60-74 (2.7%), 75-89 (4.5%), and ≥90 years (6.3%). The best area under the receiver operating characteristic curve was obtained by Light Gradient Boosting Machine model for age groups 60-74, 75-89, and ≥90 years, which were 0.892 (95% CI, 0.870-0.916), 0.886 (95% CI, 0.861-0.911), and 0.838 (95% CI, 0.782-0.887), respectively. Our study showed that EDLOS and BT were statistically correlated with IHM (p < 0.001), and a significantly higher risk of IHM was found in low EDLOS and high BT. The flagged rate of quality assurance issues was higher in lower EDLOS ≤1 h (9.96%) vs. higher EDLOS 7 h

The ratio of respiratory rate to diaphragm thickening fraction for predicting extubation success.

BACKGROUND: Several parameters are used to predict successful extubation but their accuracy varies among studies. We hypothesized that combining conventional and diaphragmatic parameters would be more effective than using just one. Our primary objective was to evaluate the performance of the respiratory rate in relation to the diaphragm thickening fraction (RR/DTF) ratio to predict the success of extubation. METHODS: We enrolled 130 adult patients who required invasive mechanical ventilation, planned to be extubated, and used a spontaneous breathing trial (SBT) in the intensive care unit from July 2020 to April 2022. We measured the conventional parameters and the diaphragmatic parameters 2 h after SBT. The RR/DTF was calculated by dividing the respiratory rate (RR) by the diaphragm thickening fraction (DTF). The definition of weaning success is successful extubation within 48 h. RESULTS: Of 130 patients, 8 patients (6.2%) were reintubated within 48 h. The RR/DTF was significantly lower in the successful extubation group than in the extubation failure group (right hemidiaphragm; 0.47 (0.33-0.64) vs 1.1 (0.6-2.32), p < 0.001 and left hemidiaphragm; 0.45 (0.31-0.65) vs 0.78 (0.48-1.75), p < 0.001). The right RR/DTF using a cut-off point at ≤ 0.81 had a sensitivity of 87.7%, a specificity of 75%, and areas under the receiver operating characteristic curve (AUROC) of 0.762 for predicting successful extubation (p = 0.013). The sensitivity, specificity, and AUROC for predicting extubation success of right DTF at a cut-off point of ≥ 26.2% were 84.3%, 62.5%, and 0.775, respectively (p = 0.009). CONCLUSION: The RR/DTF ratio is a promising tool for predicting extubation outcome. Additionally, using RR/DTF was more reliable than conventional or diaphragmatic parameters alone in predicting extubation success.

The physiological underpinnings of life-saving respiratory support.

Treatment of respiratory failure has improved dramatically since the polio epidemic in the 1950s with the use of invasive techniques for respiratory support: mechanical ventilation and extracorporeal respiratory support. However, respiratory support is only a supportive therapy, designed to "buy time" while the disease causing respiratory failure abates. It ensures viable gas exchange and prevents cardiorespiratory collapse in the context of excessive loads. Because the use of invasive modalities of respiratory support is also associated with substantial harm, it remains the responsibility of the clinician to minimize such hazards. Direct iatrogenic consequences of mechanical ventilation include the risk to the lung (ventilator-induced lung injury) and the diaphragm (ventilator-induced diaphragm dysfunction and other forms of myotrauma). Adverse consequences on hemodynamics can also be significant. Indirect consequences (e.g., immobilization, sleep disruption) can have devastating long-term effects. Increasing awareness and understanding of these mechanisms of injury has led to a change in the philosophy of care with a shift from aiming to normalize gases toward minimizing harm. Lung (and more recently also diaphragm) protective ventilation strategies include the use of extracorporeal respiratory support when the risk of ventilation becomes excessive. This review provides an overview of the historical background of respiratory support, pathophysiology of respiratory failure and rationale for respiratory support, iatrogenic consequences from mechanical ventilation, specifics of the implementation of mechanical ventilation, and role of extracorporeal respiratory support. It highlights the need for appropriate monitoring to estimate risks and to individualize ventilation and sedation to provide safe respiratory support to each patient.

Length-of-Stay in the Emergency Department and In-Hospital Mortality: A Systematic Review and Meta-Analysis.

The effect of emergency department (ED) length of stay (EDLOS) on in-hospital mortality (IHM) remains unclear. The aim of this systematic review and meta-analysis was to determine the association between EDLOS and IHM. We searched the PubMed, Medline, Embase, Web of Science, Cochrane Controlled Register of Trials, CINAHL, PsycInfo, and Scopus databases from their inception until 14−15 January 2022. We included studies reporting the association between EDLOS and IHM. A total of 11,337 references were identified, and 52 studies (total of 1,718,518 ED patients) were included in the systematic review and 33 in the meta-analysis. A statistically significant association between EDLOS and IHM was observed for EDLOS over 24 h in patients admitted to an intensive care unit (ICU) (OR = 1.396, 95% confidence interval [CI]: 1.147 to 1.701; p < 0.001, I2 = 0%) and for low EDLOS in non-ICU-admitted patients (OR = 0.583, 95% CI: 0.453 to 0.745; p < 0.001, I2 = 0%). No associations were detected for the other cut-offs. Our findings suggest that there is an association between IHM low EDLOS and EDLOS exceeding 24 h and IHM. Long stays in the ED should not be allowed and special attention should be given to patients admitted after a short stay in the ED.

Dyspnoea and respiratory muscle ultrasound to predict extubation failure.

BACKGROUND: This study investigated dyspnoea intensity and respiratory muscle ultrasound early after extubation to predict extubation failure. METHODS: The study was conducted prospectively in two intensive care units in France and Canada. Patients intubated for at least 48 h were studied within 2 h after an extubation following a successful spontaneous breathing trial. Dyspnoea was evaluated by a dyspnoea visual analogue scale (Dyspnoea-VAS) ranging from 0 to 10 and the Intensive Care Respiratory Distress Observational Scale (IC-RDOS). The ultrasound thickening fraction of the parasternal intercostal and the diaphragm was measured; limb muscle strength was evaluated using the Medical Research Council (MRC) score (range 0-60). RESULTS: Extubation failure occurred in 21 out of 122 enrolled patients (17%). The median (interquartile range (IQR)) Dyspnoea-VAS and IC-RDOS were higher in patients with extubation failure versus success: 7 (4-9) versus 3 (1-5) (p<0.001) and 3.7 (1.8-5.8) versus 1.7 (1.5-2.1) (p<0.001), respectively. The median (IQR) ratio of parasternal intercostal muscle to diaphragm thickening fraction was significantly higher and MRC was lower in patients with extubation failure compared with extubation success: 0.9 (0.4-2.1) versus 0.3 (0.2-0.5) (p<0.001) and 45 (36-50) versus 52 (44-60) (p=0.012), respectively. The thickening fraction of the parasternal intercostal and its ratio to diaphragm thickening showed the highest area under the receiver operating characteristic curve (AUC) for an early prediction of extubation failure (0.81). AUCs of Dyspnoea-VAS and IC-RDOS reached 0.78 and 0.74, respectively. CONCLUSIONS: Respiratory muscle ultrasound and dyspnoea measured within 2 h after extubation predict subsequent extubation failure.

Malignant pleural mesothelioma in a kidney transplant recipient.

Post-transplantation malignancy is one of the most common complication-related mortality in transplant recipients. Here, we report the case of a kidney transplant patient for 2 years with malignant pleural effusion that was subsequently diagnosed as malignant pleural mesothelioma.

Reverse Triggering Dyssynchrony 24 h after Initiation of Mechanical Ventilation.

BACKGROUND: Reverse triggering is a delayed asynchronous contraction of the diaphragm triggered by passive insufflation by the ventilator in sedated mechanically ventilated patients. The incidence of reverse triggering is unknown. This study aimed at determining the incidence of reverse triggering in critically ill patients under controlled ventilation. METHODS: In this ancillary study, patients were continuously monitored with a catheter measuring the electrical activity of the diaphragm. A method for automatic detection of reverse triggering using electrical activity of the diaphragm was developed in a derivation sample and validated in a subsequent sample. The authors assessed the predictive value of the software. In 39 recently intubated patients under assist-control ventilation, a 1-h recording obtained 24 h after intubation was used to determine the primary outcome of the study. The authors also compared patients' demographics, sedation depth, ventilation settings, and time to transition to assisted ventilation or extubation according to the median rate of reverse triggering. RESULTS: The positive and negative predictive value of the software for detecting reverse triggering were 0.74 (95% CI, 0.67 to 0.81) and 0.97 (95% CI, 0.96 to 0.98). Using a threshold of 1 µV of electrical activity to define diaphragm activation, median reverse triggering rate was 8% (range, 0.1 to 75), with 44% (17 of 39) of patients having greater than or equal to 10% of breaths with reverse triggering. Using a threshold of 3 µV, 26% (10 of 39) of patients had greater than or equal to 10% reverse triggering. Patients with more reverse triggering were more likely to progress to an assisted mode or extubation within the following 24 h (12 of 39 [68%]) vs. 7 of 20 [35%]; P = 0.039). CONCLUSIONS: Reverse triggering detection based on electrical activity of the diaphragm suggests that this asynchrony is highly prevalent at 24 h after intubation under assist-control ventilation. Reverse triggering seems to occur during the transition phase between deep sedation and the onset of patient triggering.

Airway Occlusion Pressure As an Estimate of Respiratory Drive and Inspiratory Effort during Assisted Ventilation.

Rationale: Monitoring and controlling respiratory drive and effort may help to minimize lung and diaphragm injury. Airway occlusion pressure (P0.1) is a noninvasive measure of respiratory drive.Objectives: To determine 1) the validity of "ventilator" P0.1 (P0.1vent) displayed on the screen as a measure of drive, 2) the ability of P0.1 to detect potentially injurious levels of effort, and 3) how P0.1vent displayed by different ventilators compares to a "reference" P0.1 (P0.1ref) measured from airway pressure recording during an occlusion.Methods: Analysis of three studies in patients, one in healthy subjects, under assisted ventilation, and a bench study with six ventilators. P0.1vent was validated against measures of drive (electrical activity of the diaphragm and muscular pressure over time) and P0.1ref. Performance of P0.1ref and P0.1vent to detect predefined potentially injurious effort was tested using derivation and validation datasets using esophageal pressure-time product as the reference standard.Measurements and Main Results: P0.1vent correlated well with measures of drive and with the esophageal pressure-time product (within-subjects R2 = 0.8). P0.1ref >3.5 cm H2O was 80% sensitive and 77% specific for detecting high effort (≥200 cm H2O ⋅ s ⋅ min-1); P0.1ref ≤1.0 cm H2O was 100% sensitive and 92% specific for low effort (≤50 cm H2O ⋅ s ⋅ min-1). The area under the receiver operating characteristics curve for P0.1vent to detect potentially high and low effort were 0.81 and 0.92, respectively. Bench experiments showed a low mean bias for P0.1vent compared with P0.1ref for most ventilators but precision varied; in patients, precision was lower. Ventilators estimating P0.1vent without occlusions could underestimate P0.1ref.Conclusions: P0.1 is a reliable bedside tool to assess respiratory drive and detect potentially injurious inspiratory effort.

Potential for Lung Recruitment Estimated by the Recruitment-to-Inflation Ratio in Acute Respiratory Distress Syndrome. A Clinical Trial.

Rationale: Response to positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome depends on recruitability. We propose a bedside approach to estimate recruitability accounting for the presence of complete airway closure.Objectives: To validate a single-breath method for measuring recruited volume and test whether it differentiates patients with different responses to PEEP.Methods: Patients with acute respiratory distress syndrome were ventilated at 15 and 5 cm H2O of PEEP. Multiple pressure-volume curves were compared with a single-breath technique. Abruptly releasing PEEP (from 15 to 5 cm H2O) increases expired volume: the difference between this volume and the volume predicted by compliance at low PEEP (or above airway opening pressure) estimated the recruited volume by PEEP. This recruited volume divided by the effective pressure change gave the compliance of the recruited lung; the ratio of this compliance to the compliance at low PEEP gave the recruitment-to-inflation ratio. Response to PEEP was compared between high and low recruiters based on this ratio.Measurements and Main Results: Forty-five patients were enrolled. Four patients had airway closure higher than high PEEP, and thus recruitment could not be assessed. In others, recruited volume measured by the experimental and the reference methods were strongly correlated (R2 = 0.798; P < 0.0001) with small bias (-21 ml). The recruitment-to-inflation ratio (median, 0.5; range, 0-2.0) correlated with both oxygenation at low PEEP and the oxygenation response; at PEEP 15, high recruiters had better oxygenation (P = 0.004), whereas low recruiters experienced lower systolic arterial pressure (P = 0.008).Conclusions: A single-breath method quantifies recruited volume. The recruitment-to-inflation ratio might help to characterize lung recruitability at the bedside.Clinical trial registered with www.clinicaltrials.gov (NCT02457741).

Sleep and Pathological Wakefulness at the Time of Liberation from Mechanical Ventilation (SLEEWE). A Prospective Multicenter Physiological Study.

Rationale: Abnormal patterns of sleep and wakefulness exist in mechanically ventilated patients. Objectives: In this study (SLEEWE [Effect of Sleep Disruption on the Outcome of Weaning from Mechanical Ventilation]), we aimed to investigate polysomnographic indexes as well as a continuous index for evaluating sleep depth, the odds ratio product (ORP), to determine whether abnormal sleep or wakefulness is associated with the outcome of spontaneous breathing trials (SBTs). Methods: Mechanically ventilated patients from three sites were enrolled if an SBT was planned the following day. EEG was recorded using a portable sleep diagnostic device 15 hours before the SBT. The ORP was calculated from the power of four EEG frequency bands relative to each other, ranging from full wakefulness (2.5) to deep sleep (0). The correlation between the right and left hemispheres' ORP (R/L ORP) was calculated. Measurements and Main Results: Among 44 patients enrolled, 37 had technically adequate signals: 11 (30%) passed the SBT and were extubated, 8 (21%) passed the SBT but were not deemed to be clinically ready for extubation, and 18 (49%) failed the SBT. Pathological wakefulness or atypical sleep were highly prevalent, but the distribution of classical sleep stages was similar between groups. The mean ORP and the proportion of time in which the ORP was >2.2 were higher in extubated patients compared with the other groups (P < 0.05). R/L ORP was significantly lower in patients who failed the SBT, and the area under the receiver operating characteristic curve of R/L ORP to predict failure was 0.91 (95% confidence interval, 0.75-0.98). Conclusions: Patients who pass an SBT and are extubated reach higher levels of wakefulness as indicated by the ORP, suggesting abnormal wakefulness in others. The hemispheric ORP correlation is much poorer in patients who fail an SBT.

High-flow nasal oxygen versus noninvasive ventilation in adult patients with cystic fibrosis: a randomized crossover physiological study.

BACKGROUND: Noninvasive ventilation (NIV) is the first-line treatment of adult patients with exacerbations of cystic fibrosis (CF). High-flow nasal oxygen therapy (HFNT) might benefit patients with hypoxemia and can reduce physiological dead space. We hypothesized that HFNT and NIV would similarly reduce work of breathing and improving breathing pattern in CF patients. Our objective was to compare the effects of HFNT versus NIV in terms of work of breathing, assessed noninvasively by the thickening fraction of the diaphragm (TFdi, measured with ultrasound), breathing pattern, transcutaneous CO2 (PtcCO2), hemodynamics, dyspnea and comfort. METHODS: Adult CF patients who had been stabilized after requiring ventilatory support for a few days were enrolled and ventilated with HFNT and NIV for 30 min in crossover random order. RESULTS: Fifteen patients were enrolled. Compared to baseline, HFNT, but not NIV, reduced respiratory rate (by 3 breaths/min, p = 0.01) and minute ventilation (by 2 L/min, p = 0.01). Patients also took slightly larger tidal volumes with HFNT compared to NIV (p = 0.02). TFdi per breath was similar under the two techniques and did not change from baseline. MAP increased from baseline with NIV and compared to HFNT (p ≤ 0.01). Comfort was poorer with the application of both HFNT and NIV than baseline. No differences were found for heart rate, SpO2, PtcCO2 or dyspnea. CONCLUSIONS: In adult CF patients stabilized after indication for ventilatory support, HFNT and NIV have similar effects on diaphragmatic work per breath, but high-flow therapy confers additional physiological benefits by decreasing respiratory rate and minute ventilation. CLINICAL TRIAL REGISTRATION: Ethics Committee of St. Michael's Hospital (REB #14-338) and clinicaltrial.gov (NCT02262871).

Expiratory Flow Limitation During Mechanical Ventilation.

Expiratory flow limitation (EFL) is present when the flow cannot rise despite an increase in the expiratory driving pressure. The mechanisms of EFL are debated but are believed to be related to the collapsibility of small airways. In patients who are mechanically ventilated, EFL can exist during tidal ventilation, representing an extreme situation in which lung volume cannot decrease, regardless of the expiratory driving forces. It is a key factor for the generation of auto- or intrinsic positive end-expiratory pressure (PEEP) and requires specific management such as positioning and adjustment of external PEEP. EFL can be responsible for causing dyspnea and patient-ventilator dyssynchrony, and it is influenced by the fluid status of the patient. EFL frequently affects patients with COPD, obesity, and heart failure, as well as patients with ARDS, especially at low PEEP. EFL is, however, most often unrecognized in the clinical setting despite being associated with complications of mechanical ventilation and poor outcomes such as postoperative pulmonary complications, extubation failure, and possibly airway injury in ARDS. Therefore, prompt recognition might help the management of patients being mechanically ventilated who have EFL and could potentially influence outcome. EFL can be suspected by using different means, and this review summarizes the methods to specifically detect EFL during mechanical ventilation.

Cartoon versus traditional self-study handouts for medical students: CARTOON randomized controlled trial.

OBJECTIVE: The objective of this study is to compare the effectiveness of a "cartoon-style" handout with a "traditional-style" handout in a self-study assignment for preclinical medical students. METHODS: Third-year medical students (n = 93) at the Faculty of Medicine Ramathibodi Hospital, Mahidol University, took a pre-learning assessment of their knowledge of intercostal chest drainage. They were then randomly allocated to receive either a "cartoon-style" or a "traditional-style" handout on the same topic. After studying these over a 2-week period, students completed a post-learning assessment and estimated their levels of reading completion. RESULTS: Of the 79 participants completing the post-learning test, those in the cartoon-style group achieved a score 13.8% higher than the traditional-style group (p = 0.018). A higher proportion of students in the cartoon-style group reported reading ≥75% of the handout content (70.7% versus 42.1%). In post-hoc analyses, students whose cumulative grade point averages (GPA) from previous academic assessments were in the middle and lower range achieved higher scores with the cartoon-style handout than with the traditional one. In the lower-GPA group, the use of a cartoon-style handout was independently associated with a higher score. CONCLUSIONS: Students given a cartoon-style handout reported reading more of the material and achieved higher post-learning test scores than students given a traditional handout.

Lactate and combined parameters for triaging sepsis patients into intensive care facilities.

PURPOSE: To find predictors of intensive care unit (ICU) requirement within the first 48 hours in newly diagnosed sepsis patients presenting at the emergency department. MATERIALS AND METHODS: Analysis of a prospective observational cohort was performed. We recruited new sepsis patients at the emergency department, and collected baseline characteristics and parameters. Variables were compared between patients: those that required ICU within 48 hours and those that did not. Multivariate analysis was performed to identify independent predictors. RESULTS: Out of 719 patients enrolled, 275 were confirmed to have sepsis. There were 107 patients (39%) that required ICU admission within 48 hours. Independent predictors for ICU requirement were: lower body temperature (P = .019), initial lactate (P = .02), 2-hour lactate clearance (P = .035), and the Sequential Organ Failure Assessment (SOFA) score without cardiovascular component (SOFA no CVS) (P < .001). The optimal cutoff values for the two strongest predictors were: SOFA no CVS ≥5 (adjusted OR, 5.3; 95% CI, 1.9-14.7) and initial lactate ≥1.9 mmol/L (adjusted OR, 3.3; 95% CI, 1.2-8.9). We also proposed a combined "LACTIC score" with higher predictive ability. CONCLUSIONS: We suggested a way to predict ICU requirement in sepsis patients and proposed a combined score that might be better than individual parameters. Further validation should be performed before using them clinically.

Association between admission delay and adverse outcome of emergency medical patients.

AIM: To determine whether admission delay (lead-time) and other factors are associated with hospital mortality rates of emergency medical patients. METHODS: Patients presenting with emergency conditions during August to November 2009, and admitted to medical wards, including intensive care units, were enrolled. The time each patient spent in the ED, and other parameters were recorded. The primary outcome was the association between lead-time and hospital mortality. The secondary outcome was the association between lead-time and delta Modified Early Warning Score (MEWS) (MEWS at ward - MEWS at ED). RESULTS: 381 cases were analysed. The overall mortality rate was 8.9%. By univariate analysis, the significant factors associated with mortality outcome were lead-time, ECOG (Eastern Cooperative Oncology Group) score, MEWS at ED, delta MEWS and sepsis. By multivariate analysis, the remaining significant factors were MEWS at ED, delta MEWS and sepsis. There was no significant relationship between delta MEWS and lead-time. In a sub-group of patients admitted to intensive care units, however, there was a positive correlation between lead-time and delta MEWS. CONCLUSION: MEWS, delta MEWS and sepsis were predictors of hospital mortality in emergency medical patients. Lead-time was not associated with mortality, which could be due to benefits of various treatments initiated in the ED. In patients requiring intensive care, however, the longer lead-time probably led to higher MEWS and mortality.