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BackgroundCurrently, there is no consensus on the number of defibrillation attempts that should be made before transfer to a hospital in patients with out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the association between the number of defibrillations and a sustained prehospital return of spontaneous circulation (ROSC).MethodsA retrospective analysis of a multicentre, prospectively collected, registry-based study in Republic of Korea was conducted for OHCA patients with prehospital defibrillation. The primary outcome was sustained prehospital ROSC, and the secondary outcome was a good neurological outcome at hospital discharge, defined as Cerebral Performance Category score 1 or 2. Cumulative incidence of sustained prehospital ROSC and good neurological outcome according to number of defibrillations were examined. Multivariable logistic regression analysis was used to examine whether the number of defibrillations was independently associated with the outcomes.ResultsExcluding 172 patients with missing data, a total of 1983 OHCA patients who received prehospital defibrillation were included. The median time from arrest to first defibrillation was 10 (IQR 7–15) min. The numbers of patients with sustained prehospital ROSC and good neurological outcome were 738 (37%) and 549 (28%), respectively. Sustained ROSC rates decreased as the number of defibrillation attempts increased from the first to the sixth (16%, 9%, 5%, 3%, 2% and 1%, respectively). The cumulative sustained ROSC rate, and good neurological outcome rate from initial defibrillation to sixth defibrillation were 16%, 25%, 30%, 34%, 36%, 36% and 11%, 18%, 22%, 25%, 26%, 27%, respectively. With adjustment for clinical characteristics and time to defibrillation, a higher number of defibrillations was independently associated with a lower chance of a sustained ROSC (OR 0.81, 95% CI 0.76 to 0.86) and a lower chance of good neurological outcome (OR 0.86, 95% CI 0.80 to 0.92).ConclusionsWe observed no significant increase in ROSC after five defibrillations, and no absolute increase in ROSC after seven defibrillations. These data provide a starting point for determination of the optimal defibrillation strategy prior to consideration for prehospital extracorporeal cardiopulmonary resuscitation (ECPR) or conveyance to a hospital with an ECPR capability.Trial registration numberNCT03222999

Background: There are conflicting results regarding the association between body mass index and the prognosis of cardiac arrest patients. We investigated the association of the composition and distribution of muscle and fat with neurologic outcomes at hospital discharge in successfully resuscitated out-of-hospital cardiac arrest (OHCA) patients.Methods: This prospective, single-centre, observational study involved adult OHCA patients, conducted between April 2019 and June 2021. The ratio of total skeletal muscle, upper limb muscle, lower limb muscle, and total fat to body weight was measured using InBody S10, a bioimpedance analyser, after achieving the return of spontaneous circulation. Restricted cubic spline curves with four knots were used to examine the relationship between total skeletal muscle, upper limb muscle, and lower limb muscle relative to total body weight and neurologic outcome at discharge. Multivariable logistic regression analysis was performed to assess an independent association.Results: A total of 66 patients were enrolled in the study. The proportion of total muscle and lower limb muscle positively correlated with the possibility of having a good neurologic outcome. The proportion of lower limb muscle showed an independent association in the multivariable analysis (adjusted odds ratio, 2.29; 95% confidence interval, 1.06–13.98), and its optimal cut-off value calculated through receiver operating characteristic curve analysis was 23.1%, which can predict a good neurological outcome. Conclusions: A higher proportion of lower limb muscle to body weight was independently associated with the probability of having a good neurologic outcome in OHCA patients.

Excessive accumulation of extravascular lung water impairs respiratory gas exchange and results in respiratory distress. Real-time radiofrequency signals of ultrasound can continuously and quantitatively monitor excessive lung water. This study aims to evaluate the availability of continuous real-time quantitative pulmonary edema monitoring using ultrasound radiofrequency signals and compare it with Pao2/Fio2 (PF) ratio, conventional lung ultrasound, and the Hounsfield unit of chest computed tomography (CT).Male Yorkshire pigs (40.5 ± 0.5 kg) were anesthetized and mechanically ventilated. A balanced crystalloid was administered to induce hydrostatic pulmonary edema. Three different infusion rates of 2, 4, and 6 ml/kg/min were tested to determine the infusion rate for the appropriate swine model. The chest CTs and ultrasonography with radiofrequency signals were taken every 5 minutes during the full inspiration. The ultrasonography with radiofrequency signals were measured at the intercostal space where the line crossing the two armpits and the right anterior axillary line intersected.The infusion rate of fluid for the pulmonary edema model was determined to be 6 ml/kg/min, and a total of 4 pigs were tested at an injection rate of 6 ml/kg. The adjusted R squared of regression analysis between the radiofrequency signal and computer tomography Hounsfield score was 0.990, 0.993, 0.988, and 0.993 (all p values0.05). All radiofrequency signal changes preceded changes in PaO2/FiO2 (PF ratio) or lung ultrasound changes. The area under the receiver operating characteristic curve of the radiofrequency signal for predicting PF ratio300 was 0.88 (95% confidence interval: 0.82-0.93).We evaluated ultrasound radiofrequency signals to assess pulmonary edema in a swine model that can worsen gradually and showed that quantitative ultrasound radiofrequency signal analysis could assess pulmonary edema and its progression prior to PF ratio or lung ultrasound changes.

Objective We investigated the effects of a quick Sequential Organ Failure Assessment (qSOFA)–negative result (qSOFA score

Background: No consensus exists regarding the early use of subcutaneous (SC) basal insulin facilitating the transition from continuous intravenous insulin infusion (CIII) to multiple SC insulin injections in patients with severe hyperglycemia other than diabetic ketoacidosis. This study evaluated the effect of early co-administration of SC basal insulin with CIII on glucose control in patients with severe hyperglycemia.Methods: Patients who received CIII for the management of severe hyperglycemia were divided into two groups: the early basal insulin group (n=86) if they received the first SC basal insulin 0.25 U/kg body weight within 24 hours of CIII initiation and ≥4 hours before discontinuation, and the delayed basal insulin group (n=79) if they were not classified as the early basal insulin group. Rebound hyperglycemia was defined as blood glucose level of >250 mg/dL in 24 hours following CIII discontinuation. Propensity score matching (PSM) methods were additionally employed for adjusting the confounding factors (n=108).Results: The rebound hyperglycemia incidence was significantly lower in the early basal insulin group than in the delayed basal insulin group (54.7% vs. 86.1%), despite using PSM methods (51.9%, 85.2%). The length of hospital stay was shorter in the early basal insulin group than in the delayed basal insulin group (8.5 days vs. 9.6 days, P=0.027). The hypoglycemia incidence did not differ between the groups.Conclusion: Early co-administration of basal insulin with CIII prevents rebound hyperglycemia and shorten hospital stay without increasing the hypoglycemic events in patients with severe hyperglycemia.

Acute traumatic aortic injuries, which have substantial lethal outcomes at the time of admission, are fatal in 80% to 90% of cases. These injuries are relatively rare and have nonspecific clinical presentations. Radiologists and emergency physicians need to identify the radiological signs of acute traumatic aortic injury and differentiate them from common imaging errors to ensure accurate diagnosis and determine appropriate management protocols. In combination with image-guided interventions, advances in cross-sectional imaging have enabled nonsurgical management of acute traumatic aortic injuries. Timely and precise diagnoses of these injuries following prompt treatment are essential as up to 90% of patients presenting at the hospital can undergo early repair.

This study aimed to investigate the effect of the head-up position implemented during cardiopulmonary resuscitation (CPR) on cerebral blood flow (CBF) using near-infrared spectroscopy in out-of-hospital cardiac arrest patients.Baseline characteristics (age, sex, cerebral performance category before cardiac arrest, witnessed cardiac arrest, bystander CPR, first monitored rhythm, no-flow time, prehospital low-flow time, CPR duration in the emergency department (ED), and reason for stopping CPR in the ED) were recorded. The changes of CBF were derived from the optical oscillation waveform measured by near-infrared spectroscopy in adult patients with out-of-hospital cardiac arrest by alternating head-up and supine positions at 4-minute intervals while performing CPR. The CBF velocity according to the head position was also evaluated using the time derivative of the oscillation waveform.During the study period, 28 patients were enrolled. The median increase in CBF in the prefrontal area in the head-up position was 14.6% (Interquartile range, 8.8-65.0), more than that in the supine position. An increase in CBF was observed in the head-up position compared with the supine position in 83.3% of the patients included in the analysis.CBF increased when the head-up position was used during CPR in non-traumatic out-of-hospital cardiac arrest patients.

Background: Hyponatremia overcorrection can result in irreversible neurologic impairment such as osmotic demyelination syndrome. Few prospective studies have identified patients undergoing hypertonic saline treatment with a high risk of hyponatremia overcorrection. Methods: We conducted a post hoc analysis of a multicenter, prospective randomized controlled study, the SALSA trial, in 178 patients aged above 18 years with symptomatic hyponatremia (mean age, 73.1 years; mean serum sodium level, 118.2 mEq/L). Overcorrection was defined as an increase in serum sodium levels by >12 or 18 mEq/L within 24 or 48 hours, respectively. Results: Among the 178 patients, 37 experienced hyponatremia overcorrection (20.8%), which was independently associated with initial serum sodium level (≤110, 110–115, 115–120, and 120–125 mEq/L with 7, 4, 2, and 0 points, respectively), chronic alcoholism (7 points), severe symptoms of hyponatremia (3 points), and initial potassium level (

Fluid resuscitation is crucial in the initial management of sepsis; however, little is known about the serial changes and overall distribution of fluids administered into the body. To identify the feasibility of longitudinal bioelectrical impedance analysis during fluid treatment, a preclinical porcine model of Escherichia coli-induced sepsis was used. After sepsis induction, pigs were treated with fluid and vasopressors and monitored for up to 12 h after bacterial infusion or until death. Bipolar electrodes for bioelectrical impedance analysis were attached to the left extremities and measurements were performed every 10 min. Among the 12 subjects, 7 pigs expired during the experiment, and the median survival was 9.5 h. As sepsis progressed with an increase in cumulative fluid balance, R0 [∝ 1/extracellular water (ECW)] decreased, while Ri [∝ 1/intracellular water (ICW)] and ratio of extracellular water to total body water (ECW/TBW) increased. The phase angle constantly decreased throughout the monitoring period, and all non-survivors died when the phase angle decreased by more than 10%. Among the variables, ΔR0 and Δphase angle showed moderate negative correlations, and ΔECW/TBW showed a moderate positive correlation with the hourly fluid balance. Compared to survivors, a greater increase in ΔECW/TBW and a decrease in phase angle were observed in non-survivors over time, with an increase in cumulative fluid balance. Differences in ΔECW/TBW and phase angle emerged at 240 min when the difference in cumulative fluid balance between the two groups (survivors vs non-survivors) exceeded 1000 mL. In conclusion, continuous measurements of bioelectrical impedance analysis in a porcine sepsis model are feasible and may reflect changes in the body water profile during fluid resuscitation.

Objective Although fluid resuscitation is the cornerstone of treatment for sepsis, the role of body water status in sepsis is poorly understood. This study aimed to understand how body water and its distribution are modified in patients with sepsis and those with non-septic infection compared to healthy individuals.Methods Two groups of adults presumed to have non-septic infection (n=87) and sepsis (n=54) were enrolled in this prospective study in a single emergency department, and they were compared to sex-, age-, and height-matched (1:3 ratio) healthy controls (n=11,190) from retrospective data in a health promotion center. Total body water (TBW), intracellular water (ICW), and extracellular water (ECW), determined using direct segmental multi-frequent bioelectrical impedance analysis (InBody S10) were expressed as indices for normalization by body weight (BW). The ratio of ECW to TBW (ECW/TBW) was evaluated to determine body water distribution.Results TBW/BW, ICW/BW, and ECW/BW were significantly higher in the non-septic infection group than in the healthy group (P

Early and appropriate antibiotic treatment is a keystone in treating patients with sepsis. Despite its importance, blood culture which requires a few days remains as a pillar of diagnostic method for microorganisms and their antibiotic susceptibility.

Resuscitative endovascular balloon occlusion of the aorta (REBOA), originally designed to block blood flow to the distal part of the aorta by placing a balloon in trauma patients, has recently been shown to increase coronary perfusion in cardiac arrest patients. This study evaluated the effect of REBOA on aortic pressure and coronary perfusion pressure (CPP) in non-traumatic out of-hospital cardiac arrest (OHCA) patients.Adult OHCA patients with cerebral performance category 1 or 2 prior to cardiac arrest, and without evidence of aortic disease, were enrolled from January to December 2021. Aortic pressure and right atrial pressure were measured before and after balloon occlusion. The CPP was calculated using the measured aortic and right atrial pressures, and the values before and after the balloon occlusion were compared.Fifteen non-traumatic OHCA patients were enrolled in the study. The median call to balloon time was 46.0 (IQR, 38.0-54.5) min. The median CPP before and after balloon occlusion was 13.5 (IQR, 5.8-25.0) and 25.2 (IQR, 12.0-44.6) mmHg, respectively (P = 0.001). The median increase in the estimated CPP after balloon occlusion was 86.7%.The results of this study suggest that REBOA may increase the CPP during cardiopulmonary resuscitation in patients with non-traumatic OHCA. Additional studies are needed to investigate the effect on clinical outcomes.

Background The impact of HIV infection on survival outcomes after in-hospital cardiopulmonary resuscitation (ICPR) remains controversial. This study aimed to investigate the impacts of HIV infection on both short-term and long-term outcomes after ICPR. Methods This nationwide, population-based cohort study used data taken from the South Korean National Health Insurance Service database. All adult (≥18 years old) patients who experienced ICPR between January 1, 2010, and December 31, 2019, were included. Results A total of 298 676 adult patients who underwent ICPR were initially included in the analysis. Among them, 586 (0.2%) patients were assigned to the patients with symptomatic HIV infection (PWH) group, while 298 090 (99.8%) patients were assigned to the control group. After 1:10 propensity score (PS) matching, 586 patients in the PWH group and 5845 patients in the control group were included in the analysis. Logistic regression analysis after PS matching showed that the PWH group had a 20% lower live discharge rate after ICPR compared with the control group (odds ratio, 0.80; 95% CI, 0.65–0.97; P = .024). However, Cox regression analysis after PS matching showed that the risks of 6-month survival (hazard ratio [HR], 1.01; 95% CI, 0.93–1.11; P = .768) and 1-year survival (HR, 1.02; 95% CI, 0.93–1.11; P = .702) were not significantly different between the PWH and control groups. Conclusions Although the PWH group showed lower live discharge rates compared with the control group after ICPR, long-term survival outcomes from 6 months and 1 year were not significantly different.

The Sepsis-3 criteria introduced the system that uses the Sequential Organ-Failure Assessment (SOFA) score to define sepsis. The cardiovascular SOFA (CV SOFA) scoring system needs modification due to the change in guideline-recommended vasopressors. In this study, we aimed to develop and to validate the modified CV SOFA score.We developed, internally validated, and externally validated the modified CV SOFA score using the suspected infection cohort, sepsis cohort, and septic shock cohort. The primary outcome was 28-day mortality. The modified CV SOFA score system was constructed with consideration of the recently recommended use of the vasopressor norepinephrine with or without lactate level. The predictive validity of the modified SOFA score was evaluated by the discrimination for the primary outcome. Discrimination was assessed using the area under the receiver operating characteristics curve (AUC). Calibration was assessed using the calibration curve. We compared the prognostic performance of the original CV/total SOFA score and the modified CV/total SOFA score to detect mortality in patients with suspected infection, sepsis, or septic shock.We identified 7,393 patients in the suspected cohort, 4038 patients in the sepsis cohort, and 3,107 patients in the septic shock cohort in seven Korean emergency departments (EDs). The 28-day mortality rates were 7.9%, 21.4%, and 20.5%, respectively, in the suspected infection, sepsis, and septic shock cohorts. The model performance is higher when vasopressor and lactate were used in combination than the vasopressor only used model. The modified CV/total SOFA score was well-developed and internally and externally validated in terms of discrimination and calibration. Predictive validity of the modified CV SOFA was significantly higher than that of the original CV SOFA in the development set (0.682 vs 0.624, p 0.001), test set (0.716 vs 0.638), and all other cohorts (0.648 vs 0.557, 0.674 vs 0.589). Calibration was modest. In the suspected infection cohort, the modified model classified more patients to sepsis (66.0 vs 62.5%) and identified more patients at risk of septic mortality than the SOFA score (92.6 vs 89.5%).Among ED patients with suspected infection, sepsis, and septic shock, the newly-developed modified CV/total SOFA score had higher predictive validity and identified more patients at risk of septic mortality.

Objective. Heart rate (HR), an essential vital sign that reflects hemodynamic stability, is influenced by myocardial oxygen demand, coronary blood flow, and myocardial performance. HR at the time of the return of spontaneous circulation (ROSC) could be influenced by the β1-adrenergic effect of the epinephrine administered during cardiopulmonary resuscitation (CPR), and its effect could be decreased in patients who have the failing heart. We aimed to investigate the association between HR at the time of ROSC and the outcomes of adult out-of-hospital cardiac arrest (OHCA) patients. Methods. This study was a secondary analysis of a cardiac arrest registry from a single institution from January 2008 to July 2014. The OHCA patients who achieved ROSC at the emergency department (ED) were included, and HR was retrieved from an electrocardiogram or vital sign at the time of ROSC. The patients were categorized into four groups according to the HR (bradycardia (HR Results. A total of 330 patients were included. In the univariate logistic regression model, the rate of sustained ROSC increased by 17% as HR increased by every 10 beats per minute (bpm) (odds ratio (OR), 1.171; 95% confidence interval (CI), 1.077–1.274, p<0.001). In the multivariate logistic regression model, extreme tachycardia was independently associated with a high probability of sustained ROSC compared to normal heart rate (OR, 15.96; 95% CI, 2.04–124.93, p=0.008). Conclusion. Extreme tachycardia (HR ≥ 150) at the time of ROSC is independently associated with a high probability of sustained ROSC in nontraumatic adult OHCA patients.

BackgroundIschaemic tissue injury caused by tissue hypoperfusion is one of the major consequences of sepsis. Phosphate concentrations are elevated in ischaemic tissue injury. This study was performed to investigate the association of phosphate concentrations with mortality in patients with sepsis.MethodsThis was a retrospective cohort study of patients with sepsis conducted at an urban, tertiary care emergency department (ED) in Korea. Patients with sepsis arriving between March 2010 and April 2017 were stratified into four groups according to the initial phosphate concentration at presentation to the ED: group I (hypophosphataemia, phosphate ResultsOf the 3034 participants in the study, the overall mortality rate was 21.9%. The 28-day mortality rates were group I (hypophosphataemia) 14.6%, group II 17.4% (normophosphataemia), group III (mild hyperphosphataemia) 29.2% and group IV (moderate to severe hyperphosphataemia) 51.4%, respectively (pConclusionsModerate to severe hyperphosphataemia was associated with 28-day mortality in patients with sepsis. Phosphate level could be used as a prognostic indicator in sepsis.

A smaller number of in-hospital medical staff and professionals on the weekend may lead to worsened survival outcomes in patients who have receive in-hospital cardiopulmonary resuscitation (ICPR). However, information regarding the effect of the weekend on survival outcomes after ICPR remains lacking. Therefore, we aimed to evaluate the "weekend effect" on the 6-month and 1-year mortality after ICPR.This population-based cohort study was based on data extracted from the National Health Insurance Service database in South Korea. We enrolled 298,676 adult (≥18 years old) patients who had experienced ICPR due to in-hospital cardiac arrest (IHCA) between January 1, 2010, and December 31, 2019. The primary endpoints were 6-month and 1-year mortality after ICPR. Propensity score matching (PSM) was used to adjust clinical covariates.The survival analysis before and after PSM, 6-month mortality [pre-PSM hazard ratio (HR) =1.04, 95% confidence interval (CI): 1.03-1.04, P0.001; post-PSM HR =1.02, 95% CI: 1.01-1.03, P0.001], and 1 year mortality (pre-PSM HR =1.03, 95% CI: 1.03-1.04, P0.001; post-PSM HR =1.02, 95% CI: 1.01-1.03, P0.001) of the patients who received ICPR on weekends was higher than those on weekdays. The results of the multivariable Cox regression model for 1-year mortality among the entire cohort indicated that there were significant associations between high 1-year mortality after ICPR and the confounders (weekend vs. weekday: HR =1.04, 95% CI: 1.03-1.05, P0.001).The "weekend effect" on ICPR survival outcomes lasted up to 1 year in South Korea. Fast-tracking development of a rapid cardiac intervention delivery system and employing an increased number of professionals on weekends can improve the weekend ICPR mortality rates. Further investigation is required into improvements that can be made to the current ICPR system.

This study investigated the changes in quality of life (QOL) after in-hospital cardiopulmonary arrest (IHCA) among survivors and examined the association between worsening QOL and 3-year all-cause mortality.This population-based cohort study used data from the National Health Insurance Service database in South Korea. Adult survivors who experienced IHCA between January 1, 2010, and December 31, 2018, and were alive for over 1 year after IHCA were included. Worsening QOL among IHCA survivors was determined using three criteria: decreased household income, unemployment, and acquired disability.A total of 22,611 IHCA survivors from 903 hospitals were included in the final analysis, and 7,796 (34.5%) experienced worsening QOL. Specifically, 5,595 (24.7%), 1,694 (7.5%), and 1,617 (7.2%) survivors experienced decreased household income, unemployment, and acquired disability, respectively. The proportion of brain lesion disability increased from 6.3% to 10.8% after IHCA. In multivariable Cox regression, worsening QOL was not associated with 3-year all-cause mortality (adjusted hazard ratio [aHR]: 1.03, 95% confidence interval [CI]: 0.96, 1.11; P = 0.372). However, among the QOL factors, acquired disability was associated with a 1.29-fold higher risk of 3-year all-cause mortality among IHCA survivors (aHR: 1.29, 95% CI: 1.15, 1.46; P 0.001).Approximately one-third of IHCA survivors experienced worsening QOL (decreased household income, unemployment, and acquired disability) at 1-year follow-up after IHCA in South Korea. Although overall worsening of QOL was not associated with 3-year all-cause mortality, acquired disability was associated with increased 3-year all-cause mortality among IHCA survivors.

The quick sequential organ failure assessment (qSOFA) score is suggested to use for screening patients with a high risk of clinical deterioration in the general wards, which could simply be regarded as a general early warning score. However, comparison of unselected admissions to highlight the benefits of introducing qSOFA in hospitals already using Modified Early Warning Score (MEWS) remains unclear. We sought to compare qSOFA with MEWS for predicting clinical deterioration in general ward patients regardless of suspected infection.The predictive performance of qSOFA and MEWS for in-hospital cardiac arrest (IHCA) or unexpected intensive care unit (ICU) transfer was compared with the areas under the receiver operating characteristic curve (AUC) analysis using the databases of vital signs collected from consecutive hospitalized adult patients over 12 months in five participating hospitals in Korea.Of 173,057 hospitalized patients included for analysis, 668 (0.39%) experienced the composite outcome. The discrimination for the composite outcome for MEWS (AUC, 0.777; 95% confidence interval [CI], 0.770-0.781) was higher than that for qSOFA (AUC, 0.684; 95% CI, 0.676-0.686;MEWS is more accurate that qSOFA score for predicting IHCA or unexpected ICU transfer in patients outside the ICU. Our study suggests that qSOFA should not replace MEWS for identifying patients in the general wards at risk of poor outcome.

The impact of HIV infection on survival outcomes after in-hospital cardiopulmonary resuscitation (ICPR) remains controversial. This study aimed to investigate the impacts of HIV infection on both short-term and long-term outcomes after ICPR.This nationwide, population-based cohort study used data taken from the South Korean National Health Insurance Service database. All adult (≥18 years old) patients who experienced ICPR between January 1, 2010, and December 31, 2019, were included.A total of 298 676 adult patients who underwent ICPR were initially included in the analysis. Among them, 586 (0.2%) patients were assigned to the patients with symptomatic HIV infection (PWH) group, while 298 090 (99.8%) patients were assigned to the control group. After 1:10 propensity score (PS) matching, 586 patients in the PWH group and 5845 patients in the control group were included in the analysis. Logistic regression analysis after PS matching showed that the PWH group had a 20% lower live discharge rate after ICPR compared with the control group (odds ratio, 0.80; 95% CI, 0.65-0.97;Although the PWH group showed lower live discharge rates compared with the control group after ICPR, long-term survival outcomes from 6 months and 1 year were not significantly different.

We investigated the association between physician turnover and survival outcomes after in-hospital cardiopulmonary resuscitation (ICPR) in South Korea.This population-based cohort study used the South Korean national registration database as the data source. All adult patients admitted to the hospital and who underwent ICPR between 1 January 2010 and 31 December 2019, were included. Patients who underwent ICPR in March were included in the turnover group, while those who underwent ICPR in the other months were included in the non-turnover group. Propensity score (PS) matching was performed.Overall, 298,676 adult patients who underwent ICPR in 2,553 South Korean hospitals were included in the analysis. Among them, 26,342 (8.8%) and 272,334 (91.2%) were included in the turnover and non-turnover groups, respectively. In total, 7,009 (26.6%) and 6,903 (26.2%) of the 26,342 patients each in the turnover and non-turnover groups, respectively, were discharged alive after ICPR. Using logistic regression analysis in the PS-matched cohort, the two groups did not show any significant association in the live discharge rate after ICPR (odds ratio: 1.02, 95% confidence interval: 0.98, 1.06; P = 0.295). This non-significant association was also observed in patients who underwent ICPR in tertiary general hospitals that had cardiopulmonary resuscitation teams for ICPR (P = 0.136). Moreover, the median survival time in the turnover and non-turnover groups was 4.0 days (95% confidence interval: 3.8 days, 4.2 days; log-rank test, P = 0.796).Significant association between physician turnover and survival outcomes was not observed after ICPR in South Korea.

Background Conventional cardiopulmonary resuscitation (CPR) training for the general public involves the use of a manikin and a training video, which has limitations related to a lack of realism and immersion. To overcome these limitations, virtual reality and extended reality technologies are being used in the field of medical education. The aim of this study is to explore the efficacy and safety of extended reality (XR)-based basic life support (BLS) training. Methods This study is a prospective, multinational, multicentre, randomised controlled study. Four institutions in 4 countries will participate in the study. A total of 154 participants will be randomly assigned to either the XR group or the conventional group stratified by institution and sex (1:1 ratio). Each participant who is allocated to either group will be sent to a separate room to receive training with an XR BLS module or conventional CPR training video. All participants will perform a test on a CPR manikin after the training. The primary outcome will be mean compression depth. The secondary outcome will be overall BLS performance, including compression rate, correct hand position, compression, and full release and hands-off time. Discussion Using virtual reality (VR) to establish a virtual educational environment can give trainees a sense of realism. In the XR environment, which combines the virtual world with the real world, trainees can more effectively learn various skills. This trial will provide evidence of the usefulness of XR in CPR education. Trial registration ClinicalTrials.gov NCT04736888. Registered on 29 January 2021

A reliable prognostic score for minimizing futile treatments in advanced cancer patients with septic shock is rare. A machine learning (ML) model to classify the risk of advanced cancer patients with septic shock is proposed and compared with the existing scoring systems. A multi-center, retrospective, observational study of the septic shock registry in patients with stage 4 cancer was divided into a training set and a test set in a 7:3 ratio. The primary outcome was 28-day mortality. The best ML model was determined using a stratified 10-fold cross-validation in the training set. A total of 897 patients were included, and the 28-day mortality was 26.4%. The best ML model in the training set was balanced random forest (BRF), with an area under the curve (AUC) of 0.821 to predict 28-day mortality. The AUC of the BRF to predict the 28-day mortality in the test set was 0.859. The AUC of the BRF was significantly higher than those of the Sequential Organ Failure Assessment score and the Acute Physiology and Chronic Health Evaluation II score (both p < 0.001). The ML model outperformed the existing scores for predicting 28-day mortality in stage 4 cancer patients with septic shock. However, further studies are needed to improve the prediction algorithm and to validate it in various countries. This model might support clinicians in real-time to adopt appropriate levels of care.

Extended Reality (XR) is a simultaneous combination of the virtual and real world. This paper presents the details of the framework and development methods for an XR basic life support (XR-BLS) simulator, as well as the results of an expert usability survey.The XR-BLS simulator was created by employing a half-torso manikin in a virtual reality environment and using BLS education data that is in line with the 2020 American Heart Association guidelines. A head-mounted display (HMD) and hand-tracking device were used to perform chest compressions and ventilation and to enable the use of an automated external defibrillator in a virtual environment. A usability study of the XR-BLS simulator through an expert survey was also conducted. The survey consisted of a total of 8 items: 3, 2, and 2 questions about the ease of use of XR-BLS, delivery of training, and artificial intelligence (AI) instructor in the simulator, respectively.The XR simulator was developed, and the expert survey showed that it was easy to use, the BLS training was well delivered, and the interaction with the AI instructor was clear and understandable.The XR-BLS simulator is useful as it can conduct BLS education without requiring instructors and trainees to gather.

Background: Hypernatremia is a common electrolyte disorder in children and elderly people and has high short-term mortality. However, no high-quality studies have examined the correction rate of hypernatremia and the amount of fluid required for correction. Therefore, in this study, we will compare the efficacy and safety of rapid intermittent bolus (RIB) and slow continuous infusion (SCI) of electrolyte-free solution in hypernatremia treatment. Methods: This is a prospective, investigator-initiated, multicenter, open-label, randomized controlled study with two experimental groups. A total of 166 participants with severe hypernatremia will be enrolled and divided into two randomized groups; both the RIB and SCI groups will be managed with electrolyte-free water. We plan to infuse the same amount of fluid to both groups, for 1 hour in the RIB group and continuously in the SCI group. The primary outcome is a rapid decrease in serum sodium levels within 24 hours. The secondary outcomes will further compare the efficacy and safety of the two treatment protocols. Conclusion: This is the first randomized controlled trial to evaluate the efficacy and safety of RIB correction compared with SCI in adult patients with severe hypernatremia.

It is not easy to ensure optimal prevention of hospital‐acquired pressure ulcer (HAPU) in crowded emergency departments (EDs). We hypothesised that a prolonged ED length of stay (LOS) is associated with an increased risk of HAPU. This is a single‐centre observational study. Prospectively collected HAPU surveillance data were analysed. Adult (aged ≥20 years) patients admitted through the ED from April 1, 2013 to December 31, 2016 were included. The primary outcome was the development of HAPU within a month. Covariates included demographics, comorbidities, conditions at triage, initial laboratory results, primary ED diagnosis, critical ED interventions, and ED dispositions. The association between ED LOS and HAPU was modelled using logistic and extended Cox regression. A total of 48 641 admissions were analysed. The crude odds ratio (OR) and hazard ratio (HR) for HAPU were increased to 1.44 (95% CI, 1.20‐1.72) and 1.21 (95% CI, 1.02‐1.45), respectively, in ED LOS ≥24 hours relative to ED LOS

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background This study aimed to examine the association between preadmission statin use and 90-day mortality in critically ill patients and to investigate whether this association differed according to statin type and dose. We hypothesized that preadmission statin use was associated with lower 90-day mortality. Methods This retrospective cohort study analyzed the medical records of all adult patients admitted to the intensive care unit in a single tertiary academic hospital between January 2012 and December 2017. Data including preadmission statin use, statin subtype, and daily dosage were collected, and the associations between these variables and 90-day mortality after intensive care unit admission were examined. The primary endpoint was 90-day mortality. Results A total of 24,928 patients (7,396 statin users and 17,532 non–statin users) were included. After propensity score matching, 5,354 statin users and 7,758 non–statin users were finally included. The 90-day mortality rate was significantly higher in non–statin users (918 of 7,758; 11.8%) than in statin users (455 of 5,354; 8.5%; P < 0.001). In Cox regression analysis, the 90-day mortality rate was lower among statin users than among non–statin users (hazard ratio: 0.70, 95% CI: 0.63 to 0.79; P < 0.001). Rosuvastatin use was associated with 42% lower 90-day mortality (hazard ratio: 0.58, 95% CI: 0.47 to 0.72; P < 0.001). There were no specific significant differences in the association between daily statin dose and 90-day mortality. In competing risk analysis, the risk of noncardiovascular 90-day mortality in statin users was 32% lower than that in non–statin users (hazard ratio: 0.68, 95% CI: 0.60 to 0.78; P < 0.001). Meanwhile, cardiovascular 90-day mortality was not significantly associated with statin use. Conclusions Preadmission statin use was associated with a lower 90-day mortality. This association was more evident in the rosuvastatin group and with noncardiovascular 90-day mortality; no differences were seen according to daily dosage intensity.

The prognostic value of low vitamin C levels has not been well investigated in patients with septic shock. We aimed to evaluate the association of vitamin C deficiency with mortality in patients with septic shock. We conducted a retrospective analysis of 165 patients with septic shock from a prospective multicenter trial and institutional sepsis registry between April 2018 and January 2020. The primary outcome was 28-day mortality. The patients were categorized into vitamin C deficiency and normal groups based on a vitamin C cutoff level of 11.4 mmol/L. Multivariable Cox regression analysis was performed to examine the association between vitamin C levels and 28-day mortality. A total of 165 patients was included for analysis and 77 (46.7%) had vitamin C deficiency. There was no significant difference in the 28-day mortality rate between the vitamin C deficiency group and the normal group (23.4% (n = 18/77) vs. 13.6% (n = 12/88), p = 0.083). Multivariable Cox proportional hazard analysis showed vitamin C deficiency to be associated with increased risk of 28-day mortality (adjusted hazard ratio, 2.65, 95% confidence interval (CI), 1.08–6.45; p = 0.032). Initial vitamin C deficiency was associated with a higher risk of 28-day mortality in patients with septic shock after adjusting for intravenous administration of vitamin C and thiamine, baseline characteristics, laboratory findings, and severity of illness.

As advanced life support (ALS) provided by emergency medical services (EMS) on scene becomes more common, the scene time interval (STI) for which EMS providers stay on scene tends to lengthen. We investigated the relationship between the STI and neurological outcome of patients at hospital discharge when ALS was provided by EMS on scene.We conducted a retrospective analysis of prospectively collected out-of-hospital cardiac arrest (OHCA) data between August 2015 and December 2018. A restricted cubic spline curve was used to investigate the relationship between the STI and neurologic outcome, and patients were divided into two groups based on the cut-off value obtained through receiver operating characteristic (ROC) analysis. Comparisons of outcomes between the two groups were performed before and after propensity score matching.4548 patients were included in the analysis. In ROC analysis, the optimal cut-off value for STI was 19 min. For the group with an STI19 min, survival admission, survival discharge, and good neurologic outcome at hospital discharge were all higher than for the group with STI ≥19 min before and after propensity score matching. The multivariable model also showed that the STI ≥19 min was significantly associated with poor neurologic outcome at hospital discharge compared with the STI19 min (adjusted odds ratio, 2.00; 95% CI, 1.40-2.88).A duration of on-scene ALS more than 19 min was associated with a poor neurologic outcome of patients at hospital discharge in OHCA.

Background: Nighttime hospital admission is often associated with increased mortality risk in various diseases. Following sepsis campaign implementation, this study investigated compliance rates with the Surviving Sepsis Campaign 3-h bundle for daytime and nighttime emergency department (ED) admissions and the clinical impact of compliance on mortality. Methods: We conducted an observational study using data from a prospective, multicenter registry for septic shock provided by the Korean Shock Society from 11 institutions from November 2015 to December 2017. The outcome was the compliance rate with the complete 3-hour treatment bundle according to the time of arrival in the ED. Mediation analysis was conducted to evaluate the proportion of the total effect that could be explained by hospital admission times.Results: A total of 2,247 patients were enrolled. Compared with daytime admission, nighttime admission was associated with higher compliance for the administration of antibiotics within 3-h (adjusted odds ratio (AOR), 1.276; 95% confidence interval (95% CI), 1.050–1.550, p=0.014), vasopressor within 3-h (AOR, 1.235; 95% CI, 1.009–1.512; P=0.031) and for the administration of the complete 3-h bundle (AOR, 1.231; 95% CI, 1.004–1.501; P=0.046), likely as a result of the increased volume of patients admitted during daytime hours. Consequently, daytime hospital admission adversely affected in-hospital and 28-day mortality rates, mediated by decreased compliance with the complete 3-h bundle. Conclusions: Septic shock patients admitted to the ED during the daytime exhibited lower sepsis bundle compliance than those admitted at night. Despite sepsis campaign implementation, factors that decrease bundle compliance should be reconsidered in patients with septic shock.

BackgroundConventional cardiopulmonary resuscitation (CPR) training for the general public involves the use of a manikin and a training video, which has limitations of lack of realism and immersion. To overcome these limitations, virtual reality and extended reality technologies are being used in the field of medical education. The aim of this study is to explore the efficacy and safety of the extended reality (XR)-based basic life support (BLS) training.MethodsThis study is a prospective, multinational, multicentre, randomized controlled study. Four institutions in 4 countries will participate in the study. A total of 154 participants will be randomly assigned to either the XR group or the conventional group stratified by institution and sex (1:1 ratio). Each participant who is allocated to either group will be sent to a separate room to receive training with an XR BLS module or conventional CPR training video. All participants will perform a test on a CPR manikin after the training. The primary outcome will be mean compression depth. The secondary outcome will be overall BLS performances, including compression rate, correct hand position, compression and full release and hands-off time. DiscussionUsing VR to establish a virtual educational environment can give trainees a sense of realism. In the XR environment, which combines the virtual world with the real world, trainees can more effectively learn various skills. This trial will provide evidence of the usefulness of XR in CPR education.Trial registrationClinicalTrials.gov NCT04736888. Registered on 29 January 2021

Background Nighttime hospital admission is often associated with increased mortality risk in various diseases. This study investigated compliance rates with the Surviving Sepsis Campaign (SSC) 3-h bundle for daytime and nighttime emergency department (ED) admissions and the clinical impact of compliance on mortality in patients with septic shock. Methods We conducted an observational study using data from a prospective, multicenter registry for septic shock provided by the Korean Shock Society from 11 institutions from November 2015 to December 2017. The outcome was the compliance rate with the SSC 3-h bundle according to the time of arrival in the ED. Results A total of 2049 patients were enrolled. Compared with daytime admission, nighttime admission was associated with higher compliance with the administration of antibiotics within 3 h (adjusted odds ratio (adjOR), 1.326; 95% confidence interval (95% CI), 1.088–1.617, p = 0.005) and with the complete SSC bundle (adjOR, 1.368; 95% CI, 1.115–1.678; p = 0.003), likely to result from the increased volume of all patients and sepsis patients admitted during daytime hours. The hazard ratios of the completion of SSC bundle for 28-day mortality and in-hospital mortality were 0.750 (95% CI 0.590–0.952, p = 0.018) and 0.714 (95% CI 0.564–0.904, p = 0.005), respectively. Conclusion Septic shock patients admitted to the ED during the daytime exhibited lower sepsis bundle compliance than those admitted at night. Both the higher number of admitted patients and the higher patients to medical staff ratio during daytime may be factors that are responsible for lowering the compliance.

Several studies have previously reported that a prolonged emergency department length of stay (EDLOS) is associated with poor outcomes in critically ill patients. This study was performed to investigate the relationship between the EDLOS and the neurologic outcome at 28 days in out-of-hospital cardiac arrest (OHCA) patients.We conducted a retrospective analysis of prospectively collected data from OHCA patients who achieved the return of spontaneous circulation (ROSC) in the EDs of three urban tertiary teaching hospitals from December 2013 to October 2020. Patients were divided into four groups according to the EDLOS, according to the quartile distribution: EDLOS107 min, EDLOS 107-176 min, EDLOS 176-275 min, and EDLOS ≥275 min. Comparisons of outcomes among the groups and multivariable logistic regression analysis were performed.A total of 807 patients were included in the analysis. The proportions of patients with a good neurologic outcome at 28 days in the groups with EDLOS107 min, EDLOS 107-176 min, EDLOS 176-275 min, and EDLOS ≥275 min were 37.0%, 29.8%, 26.9, and 20.4%, respectively (p0.001). In the multivariable analysis, the odds ratios for a poor neurologic outcome at 28 days in the groups with EDLOS 107-176 min, EDLOS 176-275 min, and EDLOS ≥275 min compared with the group with EDLOS107 min were 1.19 (95% CI, 0.67-2.13), 1.73 (95% CI, 0.95-3.21), and 1.91 (95% CI, 1.03-3.57), respectively.An EDLOS longer than 275 min after the ROSC was independently associated with a poor neurologic outcome at 28 days.

We aimed to examine recent trends in in-hospital cardiopulmonary resuscitation in South Korea from 2010 to 2019. A population-based sample of all adult patients who experienced in-hospital cardiopulmonary resuscitation between 1 January 2010 and 31 December 2019, was included. In all, 298,676 patients who received in-hospital cardiopulmonary resuscitation were included in the survival analysis. In 2010, 60.7 per 100,000 adults experienced in-hospital cardiopulmonary resuscitation. A similar rate was observed until 2015. The rate increased to 83.5 per 100,000 adults in 2016 and gradually increased to 92.1 per 100,000 adults in 2019. Among all patients, 78,783 (26.2%) were discharged alive after in-hospital cardiopulmonary resuscitation. The 6-month and 1-year survival rates were 9.8% and 8.7%, respectively. In 2010, the mean total cost of hospitalization was USD 5822.80 (United States Dollar) (standard deviation; SD: USD 7493.4), which increased to USD 7886.20 (SD: USD 13,071.6) in 2019. The rate of in-hospital cardiopulmonary resuscitation and cost of care have significantly increased since 2010, while the 6-month and 1-year rates of survival post in-hospital resuscitation remain low.

Background: Early defibrillation is vital to improve outcomes after out-of-hospital cardiac arrest (OHCA) with shockable rhythm. Currently, there is no agreed consensus on the number of defibrillation attempts before transfer to a hospital. This study aimed to evaluate the correlation between the number of defibrillations on the prehospital return of spontaneous circulation (ROSC).Methods: A multicenter, prospective, observational registry-based study was conducted for OHCA in patients with presumed cardiac etiology that underwent prehospital defibrillation between October 2015 and June 2017. The primary outcome was prehospital ROSC, and the secondary outcome was a good neurologic outcome at hospital discharge, defined as Cerebral Performance Category score 1 or 2. Results: Among 2,155 OHCA patients’ data, 178 patients with missing data were excluded, a total of 1,983 OHCA patients who received prehospital defibrillation were included. The median age was 61 years and prehospital ROSC was observed in 738 patients (37.2%). The median time from arrest to first defibrillation was 10 (interquartile range: 7-15) minutes. The cumulative ROSC rates and good neurologic outcome from the initial defibrillation to the sixth defibrillation were 43%, 68%, 81%, 90%, 95%, 98% and 42%, 66%, 81%, 90%, 95%, 98%, respectively. After clinical characteristics adjustment and time to defibrillation, the number of defibrillations were independently associated with ROSC (odds ratio 0.81 95% CI 0.76-0.86) and good neurologic outcome (odds ratio 0.86 95% CI 0.80-0.91). Moreover, subgroup analysis results with patients that underwent the initial defibrillation within 10 minutes from arrest were consistent (95% up to five times).Conclusion: More than 95% of prehospital ROSC was achieved within five times of defibrillation in OHCA patients. This result provides a basis for the ideal number of defibrillation attempts before transfer to hospital with the possibility of extracorporeal cardiopulmonary resuscitation in these refractory ventricular fibrillation patients.

Background: Evidence supporting the association between 1-hour bundle achievement and patient outcomes is limited and inconsistent. Hence, this study aimed to address the impact of 1-hour bundle achievement on outcomes in septic shock patients.Methods: A prospective multicentre observational study of septic shock patients with a protocolised resuscitation bundle therapy at emergency departments was conducted from October 2015 to December 2018. In-hospital mortality according to 1-hour bundle achievement from shock recognition were compared using multivariable logistic regression analysis. Patients were also divided into six groups according to the time of bundle achievement and outcomes were compared to examine the difference in outcome for each group over time: group 1 (≤1 h; reference), 2 (1–2 h), 3 (2–3 h), 4 (3–4 h), 5 (4–5 h), and 6 (5–6 h). Results: In total, 1,612 patients with septic shock were included and in-hospital mortality was 18.2%. The 1-hour bundle was achieved in 461 (28.6%) patients. In multivariate analysis, the group achieving 1-hour bundle did not show a significant difference in in-hospital mortality compared to those who did not achieve 1-hour bundle (odds ratio = 0.74, confidence interval: 0.522–1.049, p = 0.091). However, groups 2, 3, 4, 5, and 6 showed significantly lower odds ratios of in-hospital mortality compared to those who did not achieve the bundle elements (odds ratio = 0.733, 0.604, 0.541, 0.532, and 0.458, respectively; p = 0.042, 0.001, < 0.001, 0.001, and < 0.001, respectively). There was no significant difference in in-hospital mortality over time for each group compared to that of group 1 used as a reference.Conclusion: One-hour bundle achievement was not associated with improved outcomes in septic shock patients with protocolised resuscitation bundle therapy. However, groups achieving 2-, 3-, 4-, 5-, and 6-hour bundle were associated more with improved outcome than those who did not. Further clinical trials are needed to clarify the clinical implications of 1-hour bundle achievement.

Background: The recently developed deep learning (DL)-based early warning score (DEWS) has shown a potential in predicting deteriorating patients. We aimed to validate DEWS in multiple centers and compare the prediction, alarming and timeliness performance with those of the modified early warning score (MEWS) to identify patients at risk for in-hospital cardiac arrest (IHCA).Methods: This retrospective cohort study included adult patients admitted to the general wards of five hospitals during a 12-month period. We validated DEWS internally at two hospitals and externally at the other three hospitals. The occurrence of IHCA within 24 hours of vital sign observation was the outcome of interest. We used the area under the receiver operating characteristic curve (AUROC) as the main performance metric.Results: The study population consisted of 173,368 patients (224 IHCAs). The predictive performance of DEWS was superior to that of MEWS in both the internal (AUROC: 0.860 vs. 0.754, respectively) and external (AUROC: 0.905 vs. 0.785, respectively) validation cohorts. At the same specificity, DEWS had a higher sensitivity than MEWS, and at the same sensitivity, DEWS had a lower mean alarm count than MEWS, with nearly half of the alarm rate in MEWS. Additionally, DEWS was able to predict more IHCA patients in the 24 to 0.5 hours before the outcome.Conclusion: Our study showed that DEWS was superior to MEWS in the three key aspects (IHCA predictive, alarming, and timeliness performance). This study demonstrates the potential of DEWS as an effective, efficient screening tool in rapid response systems (RRSs) to identify high-risk patients.

Background The recently developed deep learning (DL)-based early warning score (DEWS) has shown potential in predicting deteriorating patients. We aimed to validate DEWS in multiple centres and compare the prediction, alarming and timeliness performance with the modified early warning score (MEWS) to identify patients at risk for in-hospital cardiac arrest (IHCA). Method/research design This retrospective cohort study included adult patients admitted to the general wards of five hospitals during a 12-month period. The occurrence of IHCA within 24 h of vital sign observation was the outcome of interest. We assessed the discrimination using the area under the receiver operating characteristic curve (AUROC). Results The study population consists of 173,368 patients (224 IHCAs). The predictive performance of DEWS was superior to that of MEWS in both the internal (AUROC: 0.860 vs. 0.754, respectively) and external (AUROC: 0.905 vs. 0.785, respectively) validation cohorts. At the same specificity, DEWS had a higher sensitivity than MEWS, and at the same sensitivity, DEWS reduced the mean alarm count by nearly half of MEWS. Additionally, DEWS was able to predict more IHCA patients in the 24–0.5 h before the outcome, and DEWS was reasonably calibrated. Conclusion Our study showed that DEWS was superior to MEWS in three key aspects (IHCA predictive, alarming, and timeliness performance). This study demonstrates the potential of DEWS as an effective, efficient screening tool in rapid response systems (RRSs) to identify high-risk patients.

An index combining respiratory rate and oxygenation (ROX) has been introduced, and the ROX index is defined as the ratio of oxygen saturation by pulse oximetry/fraction of inspired oxygen to respiratory rate. In sepsis, hypoxemia and tachypnea are commonly observed. We performed this study to investigate the association between the ROX index and 28-day mortality in patients with sepsis or septic shock.This retrospective study included 2862 patients. The patients were divided into three groups according to the ROX index: Group I (ROX index20), Group II (ROX index10 and ≤ 20), and Group III (ROX index ≤10).The median ROX index was significantly lower in the nonsurvivors than in the survivors (12.8 and 18.2, respectively) (p 0.001). The 28-day mortality rates in Groups I, II and III were 14.5%, 21.3% and 34.4%, respectively (p 0.001). In the multivariable Cox regression analysis, Group III had an approximately 40% higher risk of death than Group I during the 28-day period (hazard ratio = 1.41, 95% confidence interval 1.13-1.76). The area under the curve of the ROX index was significantly higher than that of the quick Sequential Organ Failure Assessment score (p 0.001).The ROX index was lower in nonsurvivors than in survivors, and a ROX index less than or equal to 10 was an independent prognostic factor for 28-day mortality in patients with sepsis or septic shock. Therefore, the ROX index could be used as a prognostic marker in sepsis.

The aim of the study was to investigate the diagnostic accuracy of initial and post-fluid resuscitation lactate levels in predicting 28 day mortality.We retrospectively analyzed a multi-center registry of suspected septic shock cases that was prospectively collected between October 2015 and December 2018 from 11 Emergency Departments. The primary outcome was 28 day mortality. The diagnostic performance of the initial and post-fluid resuscitation lactate levels as a predictor for 28 day mortality was assessed.A total of 2568 patients were included in the final analysis. The overall 28 day mortality rate was 23%. The area under the receiver operating characteristic curve (AUROC) of initial lactate for predicting 28 day mortality was 0.66 (95% CI, 0.64-0.69) and that of after fluid administration lactate was 0.70 (95% CI, 0.67-0.72), and there was a significant difference (p 0.001). The optimal cutoff point of lactate after fluid administration was 4.4 mmol/L. Compared with this, the Sepsis-3 definition with a lactate level of 2 mmol/L or more was relatively more sensitive and less specific for predicting 28 day mortality.The post-fluid resuscitation lactate level was more accurate than the initial lactate level in predicting 28 day mortality in patients with suspected septic shock.

Objective Metabolic acidosis is commonly associated with the disease severity in patients with sepsis or septic shock. This study was performed to investigate the association between serum total carbon dioxide (TCO2) concentration and 28-day mortality in patients with sepsis. Methods This study was a multicenter retrospective cohort study of patients with sepsis or septic shock. The relationships between serum TCO2 and 28-day mortality, bicarbonate, pH, lactate, and anion gap were determined with cubic spline curves. The patients were divided into four groups according to their serum TCO2 concentration: Group I (TCO2 > 20 mmol/l), Group II (15 Results A total of 3168 patients were included in the analysis, and the overall mortality rate was 24.1%. Serum TCO2 concentrations below 20 mmol/l showed an almost linear correlation with mortality as well as with lactate, bicarbonate, and pH. The 28-day mortality rates of Group I, II, III, and IV were 18.3%, 23.6%, 32.6%, and 50.0%, respectively (p Conclusions Serum TCO2 concentrations of 20 mmol/l or less were associated with 28-day mortality in patients with sepsis.

The study aimed to develop an objectified Korean Triage and Acuity Scale (OTAS) that can objectively and quickly classify severity, as well as a simple age-adjusted OTAS (S-OTAS) that reflects age and evaluate its usefulness.A retrospective analysis was performed of all adult patients who had visited the emergency department at three teaching hospitals. Sex, systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, body temperature, OA total of 44402 patients were analyzed. For 30-day mortality, S-OTAS showed a higher area under the curve (AUC) compared to KTAS (0.751 vs. 0.812 for KTAS and S-OTAS, respectively,S-OTAS showed comparative usefulness for adult patients visiting the emergency department as a triage tool compared to KTAS.

Formyl peptide receptors (FPRs) are G protein-coupled receptors mainly expressed in inflammatory myeloid cells. Previous reports demonstrated that human neutrophils express only FPR1 and FPR2 but not FPR3. Here, we found that FPR3 is expressed in sepsis patient derived neutrophils and Fpr3 is expressed in the mouse neutrophils. To test the role of Fpr3 in neutrophil activity, we synthesized Fpr3 pepducins and successfully developed an agonistic pepducin that stimulates Fpr3, eliciting calcium increase and chemotactic migration of neutrophils. We also found that administration of an Fpr3 pepducin in an experimental mouse sepsis model significantly increased the survival rate. The pepducin markedly inhibited lung injury, splenocyte apoptosis, and inflammatory cytokine production. Bacterial counts were significantly decreased by the pepducin in septic mice. Based on these results, we suggest that FPR3 can be regarded as a new target to control sepsis, and the newly generated Fpr3-based pepducin can be used for the development of anti-septic agents.

Objective The Korean Triage and Acuity Scale (KTAS) was implemented in our emergency department (ED) in May 2016 and is fully integrated into the electronic medical record (EMR) system. Our objective was to determine whether the KTAS is associated with changes in admissions to the hospital, admission disposition, inpatient mortality and length of stay (LOS). Design Quasi-experimental, uncontrolled before-and-after study. Setting The urban tertiary teaching hospital with 1100 beds and receives approximately annual 90 000 ED visits. Participants 122 370 patients who visited the ED during the before-and-the after period. Interventions ED staff were educated on the KTAS for 1 month, after which the KTAS evaluation period began. Admission, disposition, mortality and LOS were compared between the ‘before’ period (1 June 2015 to 30 April 2016) and the ‘after’ period (1 June 2016 to 30 April 2017). Main outcome measures Admissions to the hospital, admission disposition, inpatient mortality and LOS. Results A total of 59 220 and 63 150 patients were included in the before-and-after periods of KTAS implementation, respectively. The pattern of admission and disposition changed significantly after implementation of the KTAS. The mean LOS was 343 min (standard deviation [SD] = 432 min) during the before period, which significantly decreased to 289 min (SD = 333 min) after implementation (P < 0.001). The total mortality rate was significantly reduced after implementation of the KTAS (213 (0.36%) vs. 179 (0.28%), P = 0.020). Conclusion Implementation of the KTAS changed admission and disposition patterns and reduced the LOS and mortality in the ED.

Purpose Previous studies have found an increase in in-hospital mortality when trainee physicians rotate. Our retrospective cohort study investigated whether trainee physicians' turnover influenced 30-day mortality in Korean intensive care units (ICUs), which have high-intensity daytime intensivist coverage only on weekdays. Materials and methods Participants were adults over 19 years old admitted to ICUs in a Korean tertiary care academic hospital between 2012 and 2016. Demographic and clinical data were collected on admission, and dates of death recorded. The primary outcome was the association between ICU admission in the turnover periods (March and May) and 30-day mortality after admission to ICUs with high-intensity daytime intensivist coverage. Results Overall, there was no significant correlation between ICU admission during turnover periods and 30-day mortality [hazard ratio (HR), 1.06; 95% confidence interval (CI), 0.83–1.35, P = 0.647]; the same trend was found for ICU admissions when there was no intensivist coverage (HR: 1.24, 95% CI: 0.91–1.69, P = 0.177). Conclusions We found no overall association between physician turnover and 30-day mortality of patients admitted to ICUs with high-intensity daytime intensivist coverage or with no intensivist coverage.

Ischemia/reperfusion injury is characterized by excess generation of reactive oxygen species (ROS). The purpose of this study is to test the effect of reoxygenation speed on ROS production and the cellular injury responses in hypoxic macrophages RAW 264.7 cells and its potential mechanisms for the generation of ROS.After hypoxic exposure of RAW 264.7 cells for 20 h, reoxygenation was performed for 6 h by stepwise increase in oxygen concentration (0.8% increase of oxygen every 15 min) in the slow reoxygenation (SRox) group or by moving the culture flasks quickly to a normoxic incubator in the rapid reoxygenation (RRox) group. To identify the potential effect of reoxygenation speed on the generation of ROS, the cells were pretreated with apocynin, VAS2870, and MitoTEMPO before the induction of hypoxia.SRox significantly decreased cell death and cytotoxicity compared with RRox (P 0.05). RRox resulted in significantly more generation of ROS, interleukin-1β, interleukin-6, and nitric oxide than SRox (P 0.05). SRox also increased the expression of prosurvival proteins and decreased apoptosis. In cells pretreated with VAS2870 or MitoTEMPO, the reduced ROS generation by SRox was maintained. However, pretreatment with apocynin abolished the effect of reoxygenation speed on ROS generation.SRox compared with RRox decreased cellular injury in hypoxic RAW 264.7 cells by decreasing ROS and inflammatory cytokine production and decreasing apoptosis.

Patients receiving palliative care make avoidable emergency department visits (AvED), which may increase economic and social costs. However, the proportion of AvED among all patients, including cancer patients after curation, and the resulting costs are unknown in Asia. This study aimed to investigate the proportion, characteristics, and costs regarding factors associated with AvED among cancer patients. This retrospective cohort study analyzed the medical records of patients who visited the emergency department (ED) at a tertiary care hospital in Korea in 2016. Data regarding patients’ demographic, cancer-related, and clinical characteristics were collected. ED visits by a total of 4346 patients were included in the analysis, of which 2420 visits (55.7%) were avoidable. In the multivariate logistic model, the following main factors were associated with AvED: stay in ED (odds ratio [OR] 0.998, 95% confidence interval [CI] 0.997–0.999, P