Emergencias : revista de la Sociedad Espanola de Medicina de Emergencias最新文献

Objectives: To define quality of care indicators and care process standards for treating patients with COVID-19 in hospital emergency departments (EDs), to determine the level of adherence to standards during the first wave in 2020, and to detect factors associated with different levels of adherence.

Material and methods: We selected care indicators and standards by applying the Delphi method. We then analyzed the level of adherence in the SIESTA cohort (registered by the Spanish Investigators in Emergency Situations Team). This cohort was comprised of patients with COVID-19 treated in 62 Spanish hospitals in March and April 2020. Adherence was compared according to pandemic-related ED caseload pressure, time periods during the wave (earlier and later), and age groups.

Results: Fourteen quality indicators were identified. Three were adhered to in less than 50% of the patients. Polymerase chain reaction testing for SARS-CoV-2 infection was the indicator most often disregarded, in 29% of patients when the caseload was high vs 40% at other times (P .001) and in 30% of patients in the later period vs 37% in the earlier period (P = .04). Adherence to the following indicators was better in the later part of the wave: monitoring of oxygen saturation (100% vs 99%, P = .035), electrocardiogram monitoring in patients treated with hydroxychloroquine (87% vs 65%, P .001), and avoiding of lopinavir/ritonavir treatment in patients with diarrhea (79% vs 53%, P .001). No differences related to age groups were found.

Conclusion: Adherence to certain quality indicators deteriorated during ED treatment of patients with COVID-19 during the first wave of the pandemic. Pressure from high caseloads may have exacerbated this deterioration. A learning effect led to improvement. No differences related to patient age were detected.

Objectives: Ketamine is one of the most widely used drugs for analgesia and sedation when reducing fractures in pediatric emergency departments (EDs). We aimed to analyze the safety of intravenous (IV) ketamine when administered by physicians who are not anesthesiologists.

Material and methods: Prospective observational study of adverse events (AEs) related to pediatric ED specialists' use of analgesia and sedation when reducing fractures in children under the age of 14 years between 2011 and 2019. Multivariate analysis was used to identify independent risk factors for AEs.

Results: We analyzed 1509 cases of IV ketamine administration for analgesia and sedation. The median age of patients was 8 years (interquartile range, 5-11 years). All had American Society of Anesthesiologists risk classifications of 1 or 2 and Mallampati scores of I or II. Prior to the procedure, 937 children (62.1%) had been administered an opioid analgesic. AEs were observed in 201 children (13.3%; 95% CI, 11.7%-15.1%); 71 experienced respiratory complications (4.7%; 95% CI, 3.2%-5.3%). No child required intubation, other advanced resuscitation maneuvers, or hospital admission because of a ketamine-related AE. Age was the only independent risk factor for developing an AE. The odds ratio (OR) for any type of AE in children aged 8 years or older was 1.9 (95% CI, 1.4-2.6). The OR for respiratory AEs in children aged 6 years or older was 2.6 (95% CI, 1.3-5.6). Opioid administration did not increase risk for AEs.

Conclusion: Pediatric emergency physicians who are not anesthesiologists can safely administer IV ketamine for reducing fractures. Prior use of opioids is not associated with greater risk for respiratory AEs after ketamine use.

Objectives: To analyze the association between blood pressure during vasopressor weaning and in-hospital mortality in patients admitted to an intensive care unit (ICU).

Material and methods: Observational retrospective single-center study including patient data registered in the Medical Information Mart for Intensive Care, version 4. The outcome was in-hospital mortality. We used restricted cubic spline (RCS) functions to analyze the associations between mortality and systolic and diastolic blood pressures and mean arterial pressure (SBP, DBP, and MAP, respectively) during weaning from vasopressors. The data was stratified a ccording t o SBP, DBP, and MAP, and sensitivity was assessed with Cox regression analysis.

Results: Data for 8294 patients were analyzed. The RCS functions showed that SBP, DBP, and MAP values had nonlinear U-shaped associations with in-hospital mortality. Patients were classified into the following subgroups according to points of intersection of SBP, DBP, and MAP reference values: SBP 110, 110-150, or >150 mmHg; DBP 60, 60-85, or >85 mmHg; and MAP 75, 75-110, or >110 mmHg. In the lowest blood pressure group the hazard ratio was 0.59 (95% CI, 0.52-0.66) for SBP in the 110-150 mmHg range; 0.62 (95% CI, 0.55-0.70) for DBP in the 60-85 mmHg range; and 0.64 (95% CI, 0.57-0.72) for MAP in the 75-110 mmHg range during weaning. The analysis of subgroups also indicated that blood pressures during weaning interacted with cerebral vascular disease and chronic obstructive pulmonary disease.

Conclusion: Higher blood pressures during vasopressor weaning are associated with longer in-hospital survival in ICU patients. The optimum pressure ranges are SBP, 110-150 mmHg; DBP, 60-85 mmHg; and MAP, 75-110 mmHg. Blood pressures may behave differently according to diagnosis.