The relationship between qSOFA score and NEWS score
We read with interest the paper by Goulden R and colleagues 1 who compare the efficacy of qSOFA, SIRS and NEWS score in predicting the inhospital mortality of septic patients. Though the research seems to be scientific, we still have some concerns to put forward.
To begin with, there are some minor errs existed in Table 1 of the commented paper 1, as indicated in the first row of Table 1, the total number who was admitted to the intensive care unit (ICU) was 52, however, the second row from the bottom of Table 1 indicates 53 persons had ICU admission, so, how to explain this discordance?
Additionally, according to the data provided by Goulden R et al, the study initially included 1942 patients, nevertheless, to our surprise, 1117 (58%) of them had missing values of qSOFA score, far more than the number of 103 (5%) and 335 (17%) who had missing SIRS scores and missing NEWS scores respectively. There were still 6% missing values in the final analysis of 1818 patients, though most of missing values were supplemented by manual review of paper charts, thus, we are afraid that the major missing values were from qSOFA score, which will result in underestimated sensitivity of qSOFA in predicting the inhospital mortality. As we all know, the qSOFA score contains 3 elements 2 - respiratory rate, mental status, and systolic blood pressure, while NEWS score incorporates 7 elements - respiratory rate, mental stat...
The relationship between qSOFA score and NEWS score
We read with interest the paper by Goulden R and colleagues 1 who compare the efficacy of qSOFA, SIRS and NEWS score in predicting the inhospital mortality of septic patients. Though the research seems to be scientific, we still have some concerns to put forward.
To begin with, there are some minor errs existed in Table 1 of the commented paper 1, as indicated in the first row of Table 1, the total number who was admitted to the intensive care unit (ICU) was 52, however, the second row from the bottom of Table 1 indicates 53 persons had ICU admission, so, how to explain this discordance?
Additionally, according to the data provided by Goulden R et al, the study initially included 1942 patients, nevertheless, to our surprise, 1117 (58%) of them had missing values of qSOFA score, far more than the number of 103 (5%) and 335 (17%) who had missing SIRS scores and missing NEWS scores respectively. There were still 6% missing values in the final analysis of 1818 patients, though most of missing values were supplemented by manual review of paper charts, thus, we are afraid that the major missing values were from qSOFA score, which will result in underestimated sensitivity of qSOFA in predicting the inhospital mortality. As we all know, the qSOFA score contains 3 elements 2 - respiratory rate, mental status, and systolic blood pressure, while NEWS score incorporates 7 elements - respiratory rate, mental status, systolic blood pressure, oxygen saturations, oxygen supplemental, temperature and heart rate, therefore, the NEWS score actually covers all the basic essences of qSOFA score, and we can not understand why the simple qSOFA score unexpectedly had more missing values than the complicated NEWS score which actually contains qSOFA score itself based on the same population.
Furthermore, as a meta analysis 3 demonstrated, the timing of the qSOFA score measurement could siginicantly influence the sensitivity of qSOFA score. In fact, in the study 2 which developed qSOFA, the time window was defined from 48 hours before to 24 hours after the onset of infection which was the time when the first of the two events (antibiotics administration and body fluid cultures collecting) occurred. Nevertheless, Goulden R et al 1 had no limits in the time window of calculating qSOFA, which might cause biased sensitivity of qSOFA.
Notablely, as the first paragraph of ‘limitations’ section of the commented paper 1 indicates, most of dead patients (94%) were not admitted to ICU, then Goulden R et al concluded that invasive organ support was not deemed necessary or appropriate for most of the patients. However, we can not agree with this viewpoint, as a matter of fact, if more invasive organ support had been given outside the ICU, or more patients with serious condition had been admitted to the ICU, more lives could be saved according to the current available evidence 4.
Finally, we are not surprised at the result that NEWS score had higher sensitivity in predicting inhospital mortality of septic patients than qSOFA score as the former actually contains the latter in essential elements. In fact, qSOFA score is neither part of the definition nor clinical criteria of sepsis according to the newest definition for sepsis - Sepsis 3.0 2, it just acts like a ‘simple rule’ 5, which is to be designed as an supplementary tool to raise our attention of suspicious sepsis as soon as possible but not to diagnose sepsis. Thus, it would be more useful and persuasive if we had included and compared SOFA score (one clinical criteria of sepsis) with the other 3 score systems (qSOFA, SIRS and NEWS score) in this study.
Xianshi Zhou, 1 Fanwei Wu 2
1Emergency Department, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China.
2 Famous doctor hall, Bao’ an TCM hospital group, Shenzhen, China
Correspondence to Fanwei Wu, Famous doctor hall, Bao’an TCM hospital group, at Number 25 in the 2nd Yu’an Road, Bao’an District, Shenzhen, 518133, China. Email: wfwiso9000@21cn.com.
Contributors Xianshi Zhou was responsible for the critical questions of the manuscript, Fanwei Wu wrote the draft, both authors revised and approved the last version of this manuscript.
Competing interests None declared.
Ethical Approval and Consent to participate Not applicable
Funding None.
Acknowledgments None.
References:
1 Goulden R, Hoyle MC, Monis J, et al. qSOFA, SIRS and NEWS for predicting inhospital mortality and ICU admission in emergency admissions treated as sepsis. Emerg Med J. 2018; 35: 345-9
(DOI: 10.1136/emermed-2017-207120, PMID:29467173)
2 Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315: 801-10
(DOI: 10.1001/jama.2016.0287, PMID:26903338)
3 Song JU, Sin CK, Park HK, et al. Performance of the quick Sequential (sepsis-related) Organ Failure Assessment score as a prognostic tool in infected patients outside the intensive care unit: a systematic review and meta-analysis. Crit Care. 2018; 22: 28
(DOI: 10.1186/s13054-018-1952-x, PMID:29409518)
4 Rhodes A, Phillips G, Beale R, et al. The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study). Intensive Care Med. 2015; 41: 1620-8
(DOI: 10.1007/s00134-015-3906-y, PMID:26109396)
5 Foex BA. Sepsis-3 and simple rules. Emerg Med J. 2018; 35: 343-4
(DOI: 10.1136/emermed-2018-207668, PMID:29720476)
Dear Sirs
We read with interest your article entitled ‘Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan (1).’
We undertook a study in one of our Accident and Emergency departments which utilised a modified version of the Canadian Triage Acuity Scale (2). Our country is Trinidad and Tobago, in the same geographical region as Haiti. Trinidad, although not classified as a low to middle income country is a developing country. The health expenditure as a percentage of the gross domestic product is 6%.
We appreciated your article and the findings on reliability among nurses about the South African Triage Scale for use in a low to middle income country.
The Accident and Emergency department we studied provides care and treatment to patients with a wide variety of illnesses ranging from motor vehicle accidents and gunshot wounds to presentations such as back pain. Briefly, our study found that those in the immediate category were seen almost immediately. Those in other categories needed to wait and some waited more than 4 hours for a bed once a decision to admit was made. We cited staffing and systematic issues as possible reasons for the delays seen. Our study suffered from not documenting presenting symptoms and signs in order to validate the assigned triage category. The South African Triage Scale is perhaps more realistic in a developing country setting with the green category se...
Dear Sirs
We read with interest your article entitled ‘Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan (1).’
We undertook a study in one of our Accident and Emergency departments which utilised a modified version of the Canadian Triage Acuity Scale (2). Our country is Trinidad and Tobago, in the same geographical region as Haiti. Trinidad, although not classified as a low to middle income country is a developing country. The health expenditure as a percentage of the gross domestic product is 6%.
We appreciated your article and the findings on reliability among nurses about the South African Triage Scale for use in a low to middle income country.
The Accident and Emergency department we studied provides care and treatment to patients with a wide variety of illnesses ranging from motor vehicle accidents and gunshot wounds to presentations such as back pain. Briefly, our study found that those in the immediate category were seen almost immediately. Those in other categories needed to wait and some waited more than 4 hours for a bed once a decision to admit was made. We cited staffing and systematic issues as possible reasons for the delays seen. Our study suffered from not documenting presenting symptoms and signs in order to validate the assigned triage category. The South African Triage Scale is perhaps more realistic in a developing country setting with the green category set at 240 minutes. The South African Triage Scale is therefore another available option as we continuously strive to improve the quality of care and patient experience in our healthcare systems.
References
1. Dalwai M, Tayler-Smith K, Twomey M, et al Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan Emerg Med J Published Online First: 16 March 2018. doi: 10.1136/emermed-2017-207062
2. Shalini Pooransingh, L. K. Teja Boppana, and Isaac Dialsingh, “An Evaluation of a Modified CTAS at an Accident and Emergency Department in a Developing Country,” Emergency Medicine International, vol. 2018, Article ID 6821323, 5 pages, 2018. https://doi.org/10.1155/2018/6821323.
The paper by Sheikh and Horner [1] does not properly describe the context for vitamin C.
Fourteen trials have investigated the effect of vitamin C against post-operative AF (POAF), and significant heterogeneity has appeared between studies carried out in the USA and outside of the USA [2]. In 9 non-US studies vitamin C decreased the incidence of POAF on average by 46% (P<0.00001), but no benefit was seen in 5 US studies.
In 5 non-US studies, intravenous vitamin C shortened the duration of hospital stay on average by 16% and by 1.47 days (P<0.00001). In 7 non-US studies, oral and intravenous vitamin C shortened the duration of ICU stay on average by 7% (P=0.002)[2]. Thus, there is strong evidence from randomized trials indicating that vitamin C may influence the duration of hospital stay and ICU stay in some contexts. It is not reasonable to restrict to mortality as the only outcome of interest [1], when considering potential effects of vitamin C on ICU patients.
Sheikh and Horner do not mention that sometimes vitamin C levels are very low in hospital patients. For example, in one study 18 patients with clinical symptoms of scurvy were identified out of 145 consecutive patients [3]. Scurvy has been reported also in modern ICUs [4].
In their clinical scenario, Sheikh and Horner described a patient with pneumonia, but ignored the association between vitamin C and pneumonia. Vitamin C deficiency increases the risk of pneumonia, and pneumonia d...
The paper by Sheikh and Horner [1] does not properly describe the context for vitamin C.
Fourteen trials have investigated the effect of vitamin C against post-operative AF (POAF), and significant heterogeneity has appeared between studies carried out in the USA and outside of the USA [2]. In 9 non-US studies vitamin C decreased the incidence of POAF on average by 46% (P<0.00001), but no benefit was seen in 5 US studies.
In 5 non-US studies, intravenous vitamin C shortened the duration of hospital stay on average by 16% and by 1.47 days (P<0.00001). In 7 non-US studies, oral and intravenous vitamin C shortened the duration of ICU stay on average by 7% (P=0.002)[2]. Thus, there is strong evidence from randomized trials indicating that vitamin C may influence the duration of hospital stay and ICU stay in some contexts. It is not reasonable to restrict to mortality as the only outcome of interest [1], when considering potential effects of vitamin C on ICU patients.
Sheikh and Horner do not mention that sometimes vitamin C levels are very low in hospital patients. For example, in one study 18 patients with clinical symptoms of scurvy were identified out of 145 consecutive patients [3]. Scurvy has been reported also in modern ICUs [4].
In their clinical scenario, Sheikh and Horner described a patient with pneumonia, but ignored the association between vitamin C and pneumonia. Vitamin C deficiency increases the risk of pneumonia, and pneumonia decreases vitamin C levels in the body [5-7]. Thus, it would be unscientific to argue that the vitamin C level of a pneumonia patient is an uninteresting issue.
I agree with Sheikh and Horner that further trials are required to investigate the role of vitamin C in sepsis [1]. However, while waiting for such trials, it is reasonable to measure vitamin C levels of ICU patients and administer vitamin C to those who have low levels.
Thank you for your detailed response to my recent article outlining the history of the specialty of Emergency Medicine. You are, of course, absolutely right that the Royal Charter was granted at the time of the formation of the College in 2008 and I should have written that in 2015 the Queen granted the College its Royal title. Thank you for pointing out this error.
Dear Editor,
We thank Drs. Vinson et al. for their thoughtful comments as well as their important research that was the basis for our systematic review.1 While we proposed that difference in administration time was one possible explanation for the heterogeneity that we identified, Dr. Vinson’s proposal that the between-drug differences could also explain the heterogeneity is just as plausible. Although we did not include the two trials investigating different administration times of prochlorperazine since we limited our inclusion criteria to trials that used diphenhydramine prophylaxis, we do acknowledge the importance that infusion time of prochlorperazine does not affect the incidence of akathisia given the current evidence.2 3 We completely concur with Dr. Vinson’s conclusion that the differences between prochlorperazine and metoclopramide deserve to be further explored in a randomized trial, but until then, his suggestions of how to proceed appear consistent with our study’s findings.
References
1. D'Souza RS, Mercogliano C, Ojukwu E, et al. Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis. Emerg Med J 2018.
2. Collins RW, Jones JB, Walthall JD, et al. Intravenous administration of prochlorperazine by 15-minute infusion versus 2-minute bolus does not affect the incidence of akathisia: a prospective, randomized, contro...
Dear Editor,
We thank Drs. Vinson et al. for their thoughtful comments as well as their important research that was the basis for our systematic review.1 While we proposed that difference in administration time was one possible explanation for the heterogeneity that we identified, Dr. Vinson’s proposal that the between-drug differences could also explain the heterogeneity is just as plausible. Although we did not include the two trials investigating different administration times of prochlorperazine since we limited our inclusion criteria to trials that used diphenhydramine prophylaxis, we do acknowledge the importance that infusion time of prochlorperazine does not affect the incidence of akathisia given the current evidence.2 3 We completely concur with Dr. Vinson’s conclusion that the differences between prochlorperazine and metoclopramide deserve to be further explored in a randomized trial, but until then, his suggestions of how to proceed appear consistent with our study’s findings.
References
1. D'Souza RS, Mercogliano C, Ojukwu E, et al. Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis. Emerg Med J 2018.
2. Collins RW, Jones JB, Walthall JD, et al. Intravenous administration of prochlorperazine by 15-minute infusion versus 2-minute bolus does not affect the incidence of akathisia: a prospective, randomized, controlled trial. Ann Emerg Med 2001;38(5):491-6.
3. Vinson DR, Migala AF, Quesenberry CP. Slow infusion for the prevention of akathisia induced by prochlorperazine: a randomized controlled trial. J Emerg Med 2001;20(2):113-9.
We commend Dr D’Souza et al for their systematic review of the effects of prophylactic diphenhydramine in the reduction of akathisia induced by intravenous dopamine D2 antagonist antiemetics.1 Akathisia is a dysphoric feeling of restlessness that ranges from mild to severe, the more severe expressions of which can be quite distressing to patients.2 Attention to its prevention is welcome. We took particular interest in the systematic review because we led three of the four studies included in the meta-analysis.2-4
The authors conclude that adjunct diphenhydramine reduces akathisia when dopamine D2 antagonist antiemetics are administered over 2 minutes, but diphenhydramine fails to augment the reduction in akathisia achieved by simply slowing the antiemetic infusion to 15 minutes. They report moderately high heterogeneity among the four included studies (I2 =43%).5 This reveals an inconsistency in results between studies that precludes a one-size-fits-all recommendation on the use of prophylactic diphenhydramine. Such an elevated I2 requires explanation. The authors attribute this heterogeneity to rates of infusion and determine that a 15-minute infusion is less likely to cause akathisia.
But another explanation for the heterogeneity is at hand that the authors did not explore: prochlorperazine and metoclopramide behave differently when it comes to akathisia preventio...
We commend Dr D’Souza et al for their systematic review of the effects of prophylactic diphenhydramine in the reduction of akathisia induced by intravenous dopamine D2 antagonist antiemetics.1 Akathisia is a dysphoric feeling of restlessness that ranges from mild to severe, the more severe expressions of which can be quite distressing to patients.2 Attention to its prevention is welcome. We took particular interest in the systematic review because we led three of the four studies included in the meta-analysis.2-4
The authors conclude that adjunct diphenhydramine reduces akathisia when dopamine D2 antagonist antiemetics are administered over 2 minutes, but diphenhydramine fails to augment the reduction in akathisia achieved by simply slowing the antiemetic infusion to 15 minutes. They report moderately high heterogeneity among the four included studies (I2 =43%).5 This reveals an inconsistency in results between studies that precludes a one-size-fits-all recommendation on the use of prophylactic diphenhydramine. Such an elevated I2 requires explanation. The authors attribute this heterogeneity to rates of infusion and determine that a 15-minute infusion is less likely to cause akathisia.
But another explanation for the heterogeneity is at hand that the authors did not explore: prochlorperazine and metoclopramide behave differently when it comes to akathisia prevention. Their systematic review assumes a drug-class consistency that is absent in the clinical trials. The meta-analysis includes three studies of metoclopramide and one of prochlorperazine.1 This combination at first appears reasonable: both medications are dopamine D2 antagonists and both are effective in the treatment of migraine and vomiting. However, these two drugs may not respond the same way to interventions aimed at akathisia prevention.
Slower infusion rates of metoclopramide are associated with a reduction in akathisia, as multiple studies have shown.2,6,7 The 15-minute infusion of metoclopramide is sufficiently effective to render adjunct diphenhydramine redundant: “Routine prophylaxis with diphenhydramine to prevent akathisia is unwarranted when intravenous metoclopramide is administered over 15 minutes.”2
One might think that slowing the infusion rate of prochlorperazine would have a similar akathisia-reducing effect. The authors mention that “some studies have shown a lower [extra-pyramidal symptom] incidence with [slower] infusion dosing,”1 then reference two studies.6,7 Interestingly, both references are studies of metoclopramide, not prochlorperazine. There are randomized trials of prochlorperazine that compare slow infusion (15 minutes) with more rapid administration (2 minutes), but these were not mentioned in the systematic review.8,9 These studies found that slow infusion of prochlorperazine failed to reduce akathisia. Such results undermine the conclusion of D’Souza et al that slow infusion rates reduce akathisia for all dopamine D2 antagonists across the board. Though a slower infusion rate seems an ineffective method to reduce prochlorperazine-induced akathisia, prophylactic intravenous diphenhydramine is effective.10
Until further studies challenge these unexpected differences between prochlorperazine and metoclopramide, we advocate the following: when administering intravenous prochlorperazine, co-administer diphenhydramine to reduce akathisia; slow infusion is not beneficial. When administering intravenous metoclopramide, infuse it over 15 minutes; adjunct diphenhydramine is not necessary. This approach is in sync with the evidence to date and avoids the drug-class assumption that besets the otherwise helpful review by D’Souza et al.1
References
1. D'Souza RS, Mercogliano C, Ojukwu E, et al. Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis. Emerg Med J 2018 Feb 3 [Epub ahead of print].
2. Friedman BW, Bender B, Davitt M, et al. A randomized trial of diphenhydramine as prophylaxis against metoclopramide-induced akathisia in nauseated emergency department patients. Ann Emerg Med 2009;53:379–85.
3. Friedman BW, Cabral L, Adewunmi V, et al. Diphenhydramine as adjuvant therapy for acute migraine: an emergency department-based randomized clinical trial. Ann Emerg Med 2016;67:32–9.
4. Vinson DR, Drotts DL. Diphenhydramine for the prevention of akathisia induced by prochlorperazine: a randomized, controlled trial. Ann Emerg Med 2001;37:125–31.
5. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ 2003;327:557-60.
6. Cavero-Redondo I, Álvarez-Bueno C, Pozuelo-Carrascosa DP, et al. Risk of extrapyramidal side effects comparing continuous vs. bolus intravenous metoclopramide administration: a systematic review and meta-analysis of randomised controlled trials. J Clin Nurs 2015;24:3638–46.
7. Regan LA, Hoffman RS, Nelson LS. Slower infusion of metoclopramide decreases the rate of akathisia. Am J Emerg Med 2009;27:475–80.
8. Collins RW, Jones JB, Walthall JD, et al. Intravenous administration of prochlorperazine by 15-minute infusion versus 2-minute bolus does not affect the incidence of akathisia: a prospective, randomized, controlled trial. Ann Emerg Med 2001;38:491-6.
9. Vinson DR, Migala AF, Quesenberry CP Jr. Slow infusion for the prevention of akathisia induced by prochlorperazine: a randomized controlled trial. J Emerg Med 2001;20:113-9.
10. Drotts DL, Vinson DR. Prochlorperazine induces akathisia in emergency patients. Ann Emerg Med 1999;34:469-475.
Post traumatic headaches are seriously debilitating. They are often a late symptom in the recovery from brain injury. They tend to be more frequent in female patients with post-concussion syndrome and may be associated with prior migraines. A headache log may help identify environmental underpinnings and shape the treatment plan. I am using a biofeedback protocol here in the Boston area to help down-train the sympathetic-parasympathetic mismatch that is common in TBI. The protocol involves paced breathing and has a growing body of literature in support of treating poor regulation in the autonomic nervous system. Stress of all kinds correlates highly with post-concussion syndrome often prolonging recovery. The protocol I use tends to reduce the impact of the physiological reactivity seen in many TBI and mTBI cases who are still recovering. Sleep hygiene may be a further underlying source of post-concussion syndrome and the heads associated with concussion. I have a few posts on this topic: www.concussionassessment.wordpress.com
The article is incorrect when it states that "... in 2015, the Queen granted the college its royal charter. True independence had at last been gained ..." A glance at the footer of any printed communication sent on the college's official notepaper will reveal that the College of Emergency Medicine (as it was then named) was, in fact, incorporated by royal charter in 2008. The Privy Council granted the college its royal seal on 29 February that year, giving the college its autonomous legal identity. It had previously separated from its six parent colleges in 2006, by means of the Faculty of Accident and Emergency Medicine reconstituting itself as a limited company under the new name.
The title "Royal" is a separate matter; it is not conferred by the Privy Council, and does not necessarily imply that the organisation holds a Royal Charter. It is instead a mark of favour, granted with the permission of the monarch but in practice conferred on the advice of the Ministry of Justice and, latterly, the Royal Names Team at the Cabinet Office. The process is somewhat opaque, and the CEM (as it then was) had begun seeking the royal appellation as early as 2009. Other newer medical colleges in the UK have experienced similar lag periods between their promotion to full college status and the conferral of the royal title.
It is worth noting that royal patronage is yet another concept; the Princess Royal has served as the college's patron sinc...
The article is incorrect when it states that "... in 2015, the Queen granted the college its royal charter. True independence had at last been gained ..." A glance at the footer of any printed communication sent on the college's official notepaper will reveal that the College of Emergency Medicine (as it was then named) was, in fact, incorporated by royal charter in 2008. The Privy Council granted the college its royal seal on 29 February that year, giving the college its autonomous legal identity. It had previously separated from its six parent colleges in 2006, by means of the Faculty of Accident and Emergency Medicine reconstituting itself as a limited company under the new name.
The title "Royal" is a separate matter; it is not conferred by the Privy Council, and does not necessarily imply that the organisation holds a Royal Charter. It is instead a mark of favour, granted with the permission of the monarch but in practice conferred on the advice of the Ministry of Justice and, latterly, the Royal Names Team at the Cabinet Office. The process is somewhat opaque, and the CEM (as it then was) had begun seeking the royal appellation as early as 2009. Other newer medical colleges in the UK have experienced similar lag periods between their promotion to full college status and the conferral of the royal title.
It is worth noting that royal patronage is yet another concept; the Princess Royal has served as the college's patron since 2008, and it was she who ceremonially presented the college with its new royal charter on 1 October 2008.
Do the authors have data on the type of analgesia that was provided, that would enable a secondary analysis with the outcome of "time to APPROPRIATE analgesia"? Whilst there was no statistical difference on the time to first analgesia, it is possible that using an observational score will enable a clinician to provide more appropriate (stronger) analgesia to non-verbal elderly patients with long bone fractures, which would be a valuable intervention.
We would like to comment of the use of waveform capnography (WC) as an adjunct to help determine adequate paralysis during rapid sequence induction (RSI). The article used recognition of apnoea by loss of WC as an early indicator of muscle paralysis and evidence was presented that this method improved first pass success rates and reduced time to intubation for RSI in an emergency setting.
Although apnoea can be a useful indicator for the presence of paralysis we would suggest that use of a peripheral nerve stimulator is a more accurate tool for determining when muscle relaxants have produced an adequate effect. The use of this simple and relatively inexpensive machine is standard practice for anaesthetists in determining the level of paralysis. It is also viewed as a standard for provision of anaesthesia outside of the operating theatre environment (Association of Anaesthetists of Great Britain and Ireland: Recommendations for standards of monitoring during anaesthesia and recovery, 2015, Page 8). We suggest from clinical experience that apnoea alone does not always reflect adequate muscle relaxation to allow for optimal intubating conditions. Reactive vocal cords may be present despite apparent correct dosing and timing of muscle relaxants. In addition, apnoea and loss of WC could possibly be a reflection of respiratory depression due to administration of the anaesthetic induction agent, opiods or a deteriorating clinical condition.
We would like to comment of the use of waveform capnography (WC) as an adjunct to help determine adequate paralysis during rapid sequence induction (RSI). The article used recognition of apnoea by loss of WC as an early indicator of muscle paralysis and evidence was presented that this method improved first pass success rates and reduced time to intubation for RSI in an emergency setting.
Although apnoea can be a useful indicator for the presence of paralysis we would suggest that use of a peripheral nerve stimulator is a more accurate tool for determining when muscle relaxants have produced an adequate effect. The use of this simple and relatively inexpensive machine is standard practice for anaesthetists in determining the level of paralysis. It is also viewed as a standard for provision of anaesthesia outside of the operating theatre environment (Association of Anaesthetists of Great Britain and Ireland: Recommendations for standards of monitoring during anaesthesia and recovery, 2015, Page 8). We suggest from clinical experience that apnoea alone does not always reflect adequate muscle relaxation to allow for optimal intubating conditions. Reactive vocal cords may be present despite apparent correct dosing and timing of muscle relaxants. In addition, apnoea and loss of WC could possibly be a reflection of respiratory depression due to administration of the anaesthetic induction agent, opiods or a deteriorating clinical condition.
We recognise that some Emergency Medicine doctors may not be familiar with the use of nerve stimulators and that they may not be readily available within all Emergency Departments. We suggest that Emergency Departments should consider keeping a peripheral nerve stimulator as standard equipment. We would argue that this would then permit clinicians who are familiar with their use to have a more objective ability to determine depth of muscle relaxation during RSI, leading to improved intubating conditions.
The relationship between qSOFA score and NEWS score
We read with interest the paper by Goulden R and colleagues 1 who compare the efficacy of qSOFA, SIRS and NEWS score in predicting the inhospital mortality of septic patients. Though the research seems to be scientific, we still have some concerns to put forward.
Show MoreTo begin with, there are some minor errs existed in Table 1 of the commented paper 1, as indicated in the first row of Table 1, the total number who was admitted to the intensive care unit (ICU) was 52, however, the second row from the bottom of Table 1 indicates 53 persons had ICU admission, so, how to explain this discordance?
Additionally, according to the data provided by Goulden R et al, the study initially included 1942 patients, nevertheless, to our surprise, 1117 (58%) of them had missing values of qSOFA score, far more than the number of 103 (5%) and 335 (17%) who had missing SIRS scores and missing NEWS scores respectively. There were still 6% missing values in the final analysis of 1818 patients, though most of missing values were supplemented by manual review of paper charts, thus, we are afraid that the major missing values were from qSOFA score, which will result in underestimated sensitivity of qSOFA in predicting the inhospital mortality. As we all know, the qSOFA score contains 3 elements 2 - respiratory rate, mental status, and systolic blood pressure, while NEWS score incorporates 7 elements - respiratory rate, mental stat...
Dear Sirs
Show MoreWe read with interest your article entitled ‘Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan (1).’
We undertook a study in one of our Accident and Emergency departments which utilised a modified version of the Canadian Triage Acuity Scale (2). Our country is Trinidad and Tobago, in the same geographical region as Haiti. Trinidad, although not classified as a low to middle income country is a developing country. The health expenditure as a percentage of the gross domestic product is 6%.
We appreciated your article and the findings on reliability among nurses about the South African Triage Scale for use in a low to middle income country.
The Accident and Emergency department we studied provides care and treatment to patients with a wide variety of illnesses ranging from motor vehicle accidents and gunshot wounds to presentations such as back pain. Briefly, our study found that those in the immediate category were seen almost immediately. Those in other categories needed to wait and some waited more than 4 hours for a bed once a decision to admit was made. We cited staffing and systematic issues as possible reasons for the delays seen. Our study suffered from not documenting presenting symptoms and signs in order to validate the assigned triage category. The South African Triage Scale is perhaps more realistic in a developing country setting with the green category se...
The paper by Sheikh and Horner [1] does not properly describe the context for vitamin C.
Fourteen trials have investigated the effect of vitamin C against post-operative AF (POAF), and significant heterogeneity has appeared between studies carried out in the USA and outside of the USA [2]. In 9 non-US studies vitamin C decreased the incidence of POAF on average by 46% (P<0.00001), but no benefit was seen in 5 US studies.
In 5 non-US studies, intravenous vitamin C shortened the duration of hospital stay on average by 16% and by 1.47 days (P<0.00001). In 7 non-US studies, oral and intravenous vitamin C shortened the duration of ICU stay on average by 7% (P=0.002)[2]. Thus, there is strong evidence from randomized trials indicating that vitamin C may influence the duration of hospital stay and ICU stay in some contexts. It is not reasonable to restrict to mortality as the only outcome of interest [1], when considering potential effects of vitamin C on ICU patients.
Sheikh and Horner do not mention that sometimes vitamin C levels are very low in hospital patients. For example, in one study 18 patients with clinical symptoms of scurvy were identified out of 145 consecutive patients [3]. Scurvy has been reported also in modern ICUs [4].
In their clinical scenario, Sheikh and Horner described a patient with pneumonia, but ignored the association between vitamin C and pneumonia. Vitamin C deficiency increases the risk of pneumonia, and pneumonia d...
Show MoreDear Dr Beecham
Thank you for your detailed response to my recent article outlining the history of the specialty of Emergency Medicine. You are, of course, absolutely right that the Royal Charter was granted at the time of the formation of the College in 2008 and I should have written that in 2015 the Queen granted the College its Royal title. Thank you for pointing out this error.
With best wishes
DavidWilliams.
Dear Editor,
We thank Drs. Vinson et al. for their thoughtful comments as well as their important research that was the basis for our systematic review.1 While we proposed that difference in administration time was one possible explanation for the heterogeneity that we identified, Dr. Vinson’s proposal that the between-drug differences could also explain the heterogeneity is just as plausible. Although we did not include the two trials investigating different administration times of prochlorperazine since we limited our inclusion criteria to trials that used diphenhydramine prophylaxis, we do acknowledge the importance that infusion time of prochlorperazine does not affect the incidence of akathisia given the current evidence.2 3 We completely concur with Dr. Vinson’s conclusion that the differences between prochlorperazine and metoclopramide deserve to be further explored in a randomized trial, but until then, his suggestions of how to proceed appear consistent with our study’s findings.
References
Show More1. D'Souza RS, Mercogliano C, Ojukwu E, et al. Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis. Emerg Med J 2018.
2. Collins RW, Jones JB, Walthall JD, et al. Intravenous administration of prochlorperazine by 15-minute infusion versus 2-minute bolus does not affect the incidence of akathisia: a prospective, randomized, contro...
Dear Editor,
We commend Dr D’Souza et al for their systematic review of the effects of prophylactic diphenhydramine in the reduction of akathisia induced by intravenous dopamine D2 antagonist antiemetics.1 Akathisia is a dysphoric feeling of restlessness that ranges from mild to severe, the more severe expressions of which can be quite distressing to patients.2 Attention to its prevention is welcome. We took particular interest in the systematic review because we led three of the four studies included in the meta-analysis.2-4
The authors conclude that adjunct diphenhydramine reduces akathisia when dopamine D2 antagonist antiemetics are administered over 2 minutes, but diphenhydramine fails to augment the reduction in akathisia achieved by simply slowing the antiemetic infusion to 15 minutes. They report moderately high heterogeneity among the four included studies (I2 =43%).5 This reveals an inconsistency in results between studies that precludes a one-size-fits-all recommendation on the use of prophylactic diphenhydramine. Such an elevated I2 requires explanation. The authors attribute this heterogeneity to rates of infusion and determine that a 15-minute infusion is less likely to cause akathisia.
But another explanation for the heterogeneity is at hand that the authors did not explore: prochlorperazine and metoclopramide behave differently when it comes to akathisia preventio...
Show MorePost traumatic headaches are seriously debilitating. They are often a late symptom in the recovery from brain injury. They tend to be more frequent in female patients with post-concussion syndrome and may be associated with prior migraines. A headache log may help identify environmental underpinnings and shape the treatment plan. I am using a biofeedback protocol here in the Boston area to help down-train the sympathetic-parasympathetic mismatch that is common in TBI. The protocol involves paced breathing and has a growing body of literature in support of treating poor regulation in the autonomic nervous system. Stress of all kinds correlates highly with post-concussion syndrome often prolonging recovery. The protocol I use tends to reduce the impact of the physiological reactivity seen in many TBI and mTBI cases who are still recovering. Sleep hygiene may be a further underlying source of post-concussion syndrome and the heads associated with concussion. I have a few posts on this topic: www.concussionassessment.wordpress.com
The article is incorrect when it states that "... in 2015, the Queen granted the college its royal charter. True independence had at last been gained ..." A glance at the footer of any printed communication sent on the college's official notepaper will reveal that the College of Emergency Medicine (as it was then named) was, in fact, incorporated by royal charter in 2008. The Privy Council granted the college its royal seal on 29 February that year, giving the college its autonomous legal identity. It had previously separated from its six parent colleges in 2006, by means of the Faculty of Accident and Emergency Medicine reconstituting itself as a limited company under the new name.
The title "Royal" is a separate matter; it is not conferred by the Privy Council, and does not necessarily imply that the organisation holds a Royal Charter. It is instead a mark of favour, granted with the permission of the monarch but in practice conferred on the advice of the Ministry of Justice and, latterly, the Royal Names Team at the Cabinet Office. The process is somewhat opaque, and the CEM (as it then was) had begun seeking the royal appellation as early as 2009. Other newer medical colleges in the UK have experienced similar lag periods between their promotion to full college status and the conferral of the royal title.
It is worth noting that royal patronage is yet another concept; the Princess Royal has served as the college's patron sinc...
Show MoreDo the authors have data on the type of analgesia that was provided, that would enable a secondary analysis with the outcome of "time to APPROPRIATE analgesia"? Whilst there was no statistical difference on the time to first analgesia, it is possible that using an observational score will enable a clinician to provide more appropriate (stronger) analgesia to non-verbal elderly patients with long bone fractures, which would be a valuable intervention.
We would like to comment of the use of waveform capnography (WC) as an adjunct to help determine adequate paralysis during rapid sequence induction (RSI). The article used recognition of apnoea by loss of WC as an early indicator of muscle paralysis and evidence was presented that this method improved first pass success rates and reduced time to intubation for RSI in an emergency setting.
Although apnoea can be a useful indicator for the presence of paralysis we would suggest that use of a peripheral nerve stimulator is a more accurate tool for determining when muscle relaxants have produced an adequate effect. The use of this simple and relatively inexpensive machine is standard practice for anaesthetists in determining the level of paralysis. It is also viewed as a standard for provision of anaesthesia outside of the operating theatre environment (Association of Anaesthetists of Great Britain and Ireland: Recommendations for standards of monitoring during anaesthesia and recovery, 2015, Page 8). We suggest from clinical experience that apnoea alone does not always reflect adequate muscle relaxation to allow for optimal intubating conditions. Reactive vocal cords may be present despite apparent correct dosing and timing of muscle relaxants. In addition, apnoea and loss of WC could possibly be a reflection of respiratory depression due to administration of the anaesthetic induction agent, opiods or a deteriorating clinical condition.
We recognise that some Em...
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