Journal of acute medicine最新文献

Background: In order to quantify fluid administration and evaluate the clinical consequences of conservative fluid management without hemodynamic monitoring in undifferentiated shock, we analyzed previously collected data from a study of carotid Doppler monitoring as a predictor of fluid responsiveness (FR).

Methods: This study was a retrospective analysis of data collected from a single tertiary academic center from a previous study. Seventy-four patients were included for post-hoc analysis, and 52 of them were identified as fluid responsive (cardiac output increase > 10% with passive leg raise) according to NICOMTM bioreactance monitoring (Cheetah Medical, Newton Center, MA, USA). Treating teams provided standard of care conservative fluid resuscitation but were blinded to independently performed FR testing results. Outcomes were compared between fluid responsive and fluid non-responsive patients. Primary outcome measures were volume fluids administered and net fluid balance 24- and 72-hour post-FR assessment. Secondary outcome measures included change in vasopressor requirements, mean peak lactate levels, length of hospital/intensive care unit stay, acute respiratory failure, hemodialysis requirement, and durations of vasopressors and mechanical ventilation.

Results: Mean fluids administered within 72 hours were similar between fluid non-responsive and fluid responsive patients (139 mL/kg [95% confidence interval [CI]: 102.00-175.00] vs. 136 mL/kg [95% CI: 113.00-158.00], p = 0.92, respectively). We observed an insignificant trend toward higher 28-day mortality among fluid non-responsive patients (36% vs. 19%, p = 0.14). Volume of fluids administered significantly correlated with adverse outcomes such as increased hemodialysis requirements (32 patients, 43%), (odds ratio [OR] = 1.7200, p = 0.0018). Subgroup analysis suggested administering ≥ 30 mL/kg fluids to fluid responsive patients had a trend toward increased mortality (25% vs. 0%, p = 0.09) and a significant increase in hemodialysis (55% vs. 17%, p = 0.024).

Conclusions: Without formal FR assessment, similar amounts of total fluids were administered in both fluid responsive and non-responsive patients. As greater volumes of intravenous fluids administered were associated with adverse outcomes, we suggest that dedicated FR assessment may be a beneficial utility in early shock resuscitation.

This report is to describe a rare case of urinary tract infection (UTI) with multiple vaginal ulcers. In the report, the 45-year-old female patient was diagnosed with a UTI, but white blood cells and neutrophil are higher than reference value. A vaginal ultrasound was performed with a positive fi nding of uterine myoma and multiple painless vaginal ulcers in the vaginal wall. Also, elevated antinuclear antibodies were found. After treated with antibiotic, self-healed vaginal ulcers were observed even without topical ointment use for vaginal ulcers. In conclusion, UTIs are a common disease in females. This is a rare case of a UTI with multiple vaginal ulcers. Observation of the genital condition is necessary if a woman has a UTI. Treating the source of the UTI is necessary, and the vaginal ulcerations also require appropriate treatment and follow up.

In 2017, the Taiwan Ministry of Health and Welfare established a regional electronic referral system in Central Taiwan to streamline transfers of critically ill patients from the intensive care unit (ICU) of a regional hospital to a medical hospital center. Moreover, in 2018, a one-hour rule for the boarding of referral of critically ill patients from emergency department (ED) to ICU was implemented. This pre- and post-implementation study enrolled consecutive critically ill referral patients from a single academic medical center hospital from January 1, 2017 to December 31, 2018. After implementation of the one-hour rule, two interventions, namely, active bed management before patient arrival and no requirement for laboratory test results to be completed before ICU admissions, were used to improve patient flow in the ED. After implementation of one-hour rule, the proportion of patients transferred to the ICU within 1 hour increased from 3.1% to 65.9% (p < 0.001). Median ED length of stay (LOS) reduced from 129.5 minutes to 52.0 minutes (p < 0.001). The overall mortality rate decreased from 34.4% to 26.8%, without a significant difference. In conclusion, the implementation of the one-hour rule for the boarding of referral of critically ill patients in the ED is safe and possible. Achieving the target significantly reduced ED LOS by 77.5 minutes without an increase in patient mortality rate.

Coronavirus disease 2019 (COVID-19) is still pandemic all over the world. Patients requesting screening in emergency departments (ED) have continually increased. Establishing additional screening stations outside of the ED to increase the number of patients tested and protect the safety of health care workers poses an urgent challenge. We employed a container house near the entrance of an ED to create an outdoor screening station, which separates suspected patients of COVID-19 from regular emergency patients to prevent cross infections. In our experience, a container house station can not only provide additional screen area but also reduce the consumption of personal protective equipment. Container houses are sturdier than tents and can be fully assembled rapidly. Appropriate protective equipment can be installed with them to fulfi ll demands for COVID-19 screening.

Background: Opioids have been shown to increase risk of pneumonia among susceptible population. However, the effect of opioid abuse on the outcome of pneumonia has not been evaluated at the population level. We aimed to compare the outcomes of pneumonia among patients with opioid use disorder and patients without substance use disorder using a large population database.

Methods: We assembled a pneumonia cohort composed of 11,186,564 adult patients from the National Inpatient Sample (NIS; 2005-2014). Patients with opioid disorder were identified using the International Classification of Diseases, 9th Revision, Clinical Modification codes. We compared health-related and economic outcomes between patients with and without opioid disorders using propensity score matching (PSM) analysis to balance baseline differences. The survival differences between two groups of patients were assessed using a Cox proportional hazard model. We further explored the possibility of effect modification by interaction analyses in different populations.

Results: After PSM, patients with opioid use disorder were at increased risk of ventilator use (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.08 to 1.38, p = 0.0014) and associated with increased length of hospital stay by 0.59 days (95% CI: 0.35 to 0.83, p < 0.001), compared with those without substance use disorder. Patients with opioid use also had higher daily (228.00 USD, 95% CI: 180.51 to 275.49, p < 0.001) and total (1,875.72 USD, 95% CI: 1,259.63 to 2,491.80, p < 0.001) medical costs. Subgroup analyses showed similar results.

Conclusions: Compared with patients without any drug dependence, patients with opioid use disorders had increased risk of complications and resource utilization. This study adds evidence for increased risk for pneumonia complications in the growing patients with opioid use disorders.