Article, Emergency Medicine

Predictive factors of negative appendectomy in children

Correspondence / American Journal of Emergency Medicine 36 (2018) 319338

What’s the evidence for apnoeic oxygenation

335

Thomas Melhuish

during intubation? Who, where and when

Hypoxemia is one of the most significant complications that may arise during intubation. Several strategies have been proposed to curb this risk. A strategy of increasing interest in the literature is the use of apneic oxygen- ation during intubation. Recent reviews have attempted summarise this in- tervention as a whole [1,2]. These reviews have shown promising results with significant reductions in the incidence of desaturation (SpO2 b 93%) and critical desaturation (SpO2 b 80%). However, these results have been linked to high levels of heterogeneity. This is largely related to the highly heterogenous study populations and locations. The American Journal of Emergency Medicine has recently published reviews investigating this in- tervention in specific patient populations and situations [3,4]. Currently there are varying levels of evidence [5] in multiple patient populations, in- tubation locations and elective versus emergency intubation.

Currently there is level 2a evidence to support no significant reduc- tion in desaturation, critical desaturation or mortality in respiratory fail- ure patients [3]. There is level 1b evidence to support a reduction in the incidence of desaturation in obese and Paediatric populations [6,7]. Crit- ical desaturation and mortality did not occur in the study of these pa- tient populations. The use of apneic oxygenation is associated with significantly reduced desaturation and critical desaturation in patients intubated for intracranial haemorrhage (Level 2b evidence) [8].

Multiple studies have been performed in the retrieval setting, emer- gency department, intensive care unit and the operating theatre. In the setting of retrieval and the emergency department there is level 2a evi- dence to support a significant reduction in desaturation and critical desaturation, with no assessment of mortality [3]. In the intensive care unit there is level 1a evidence to support a significant reduction in desaturation and level 2a evidence for a significant reduction in critical desaturation [9]. In the intensive care population there is potentially a trend towards reduced mortality (RR = 0.77; 95%CI = 0.59 to 1.03; p

= 0.08; Level 1a evidence), however further studies are required to estab- lish whether this reduction is significant [9]. In the operating theatre and elective intubation, there is level 1a evidence for a significant reduction in desaturation [10]. Critical desaturation and mortality were not assessed in the operating theatre studies. Finally, there is level 2a evidence to support the use of apneic oxygenation to reduce the incidence of desaturation and critical desaturation during emergency intubation [4]. Similar to the ICU studies, there was a non-significant trend towards reduced mortality (RR = 0.078; 95%CI = 0.59 to 1.02; p N 0.05).

In summary, the use of apneic oxygenation during intubation shows significant benefit in the majority of patient populations, intubation lo- cations and situations. However, it is not a ‘silver bullet’ with no conclu- sive evidence to support a reduction in mortality. The one patient group where no benefit has been shown is patients with respiratory failure. Despite the lack of efficacy in this group, no adverse effects of apneic ox- ygenation have been shown. Therefore, it reasonable to recommend the routine use of apneic oxygenation during intubation.

Conflicts of interest

Nil.

Ruan Vlok

Wagga Wagga Rural referral hospital, Australia University of Notre Dame Australia, School of Medicine Sydney, Australia Corresponding author at:WaggaWagga Rural Referral

Hospital, Australia

E-mail address: [email protected].

Matthew Binks

Wagga Wagga Rural Referral Hospital, Australia

Wagga Wagga Rural Referral Hospital, Australia University of New South Wales, Faculty of Medicine, Australia

Rhys Holyoak

The Wollongong Hospital, Australia

Leigh White Caboolture Hospital, Caboolture, QLD, Australia University of Wollongong, NSW, Australia

18 July 2017

https://doi.org/10.1016/j.ajem.2017.07.074

References

  1. Holyoak RS, Melhuish TM, Vlok R, Binks M, White LD. Intubation using apnoeic ox- ygenation to prevent desaturation: a systematic review and meta-analysis. J Crit Care 2017;41:42-8.
  2. White LD, Melhuish TM, White LK, Wallace LA. Apnoeic oxygenation during in- tubation: a systematic review and meta-analysis. Anaesth Intensive Care 2017; 45(1).
  3. Binks MJ, Holyoak RS, Melhuish TM, Vlok R, Bond E, White LD. Apneic oxygenation during intubation in the emergency department and during retrieval: a systematic review and meta-analysis. Am J Emerg Med 2017;35(10):1542-6.
  4. Pavlov I, Medrano S, Weingart S. Apneic oxygenation reduces the incidence of hyp- oxemia during emergency intubation: A systematic review and meta-analysis. Am J Emerg Med 2017;35(8):1184-9.
  5. Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, et al. The

    2011 Oxford CEBM levels of evidence (introductory document). Available at: http://www.cebm.net/index.aspx?o=5653; 2011.

    Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal Oxygen administration. J Clin Anesth 2010;22(3):164-8.

  6. Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler A. Transnasal hu- midified rapid-insufflation ventilatory exchange (THRIVE) in children: a random- ized controlled trial. Br J Anaesth 2017;118(2):232-8. https://doi.org/10.1093/bja/ aew401.
  7. Sakles JC, Mosier JM, Patanwala AE, Dicken JM. Apneic oxygenation is associated with a reduction in the incidence of hypoxemia during the RSI of patients with intra- cranial hemorrhage in the emergency department. Intern Emerg Med 2016;11(7): 983-92.
  8. Binks M, Holyoak R, Melhuish T, Vlok R, Hodge A, White L. Apnoeic oxygenation dur-

    ing intubation in the intensive care unit: A systematic review and meta-analysis. Heart Lung 2017 [in press].

    Melhuish T, Vlok R, Holyoak R, Binks M, White L. Apnoeic oxygenation during intu- bation in the operating theatre: a systematic review and meta-analysis. Brisbane, Australia: ANZCA ASM; 2017.

    Predictive factors of Negative appendectomy in children

    Dear Editor,

    Acute appendicitis is one of the most common pediatric surgi- cal conditions seen in children. The annual incidence of AA is 37.2 per 10,000 American children between the ages of 0-14 years [1]. The deci- sion to perform operation on a patient with suspected AA is based main- ly on disease history and physical findings and ultrasound findings [2]. However, the diagnosis of acute appendicitis in children is often chal- lenging. This may be related to the variable presentation and greater di- agnostic uncertainty in Younger children presenting with acute abdominal pain. Since Delayed diagnosis and treatment of AA are asso- ciated with increased length of stay, postoperative complications and mortality, Timely intervention is crucial [3-5]. Therefore, it is important to identify clinical predictive factors of appendicitis in order to reduce negative appendectomy rates. The aim of this study is to compare two

    336 Correspondence / American Journal of Emergency Medicine 36 (2018) 319338

    Table 1

    Multivariate analysis of negative appendectomy vs. acute appendicitis.

    Negative Acute appendectomy appendicitis

    p

    Value

    Odds ratio

    References

    Abarbanell AM. Trends in pediatric appendectomy outcomes. J Surg Res 2010;161: 233-4.

  9. Zouari M, Jallouli M, Louati H, et al. Predictive value of C-reactive protein, ultrasound

    and Alvarado score in acute appendicitis: a prospective pediatric cohort. Am J Emerg Med 2016;34(2):189-92.

    Andersson RE. Short and long-term mortality after appendectomy in Sweden 1987 to 2006. Influence of appendectomy diagnosis, sex, age, co-morbidity, surgical method, hospital volume, and time period. A national population-based cohort study. World J Surg 2013;37:974-81.

  10. Andersson MN, Andersson RE. Causes of short-term mortality after appendectomy: a population-based case-controlled study. Ann Surg 2011;254:103-7.
  11. Jeon BG. Predictive factors and outcomes of negative appendectomy. Am J Surg 2017; 213(4):731-8.

    Should patients with traumatic out-of-hospital cardiac arrest be transferred?

    N

    %

    N

    %

    Male gender Yes

    34

    56.7

    309

    64.4

    0.242

    0.723

    No

    26

    43.3

    171

    35.6

    Alvarado score <= 5 Yes

    38

    63.3

    142

    29.6

    b 0.001

    4.111

    No

    22

    36.7

    338

    70.4

    Temperature <= 37.8 ?C Yes

    24

    40

    154

    32.1

    0.219

    1.411

    No

    36

    60

    326

    67.9

    Duration of symptoms >= 72 h Yes

    16

    26.7

    58

    12.1

    0.002

    2.645

    No

    44

    73.3

    422

    87.9

    WBC count <= 10,000/ml Yes

    33

    55

    93

    19.4

    b 0.001

    5.086

    No

    27

    45

    387

    80.6

    CRP <= 6 mg/l Yes

    36

    60

    162

    33.7

    b 0.001

    2.944

    No

    24

    40

    318

    66.3

    MOD of the appendix on Yes

    18

    43.9

    23

    7

    b 0.001

    8.177

    ultrasound <= 5 mm No

    23

    56.1

    303

    93

    To the Editors:

    groups of patients and to assess predictive factors for negative appen- dectomy in children.

    A total of 540 patients who underwent surgical treatment for acute ap- pendicitis from January 2013 to December 2016 were included in this study. There were 343 males and 197 females and their mean age was

    9.23 +- 2.78 years (range, 2-14 years). Of the 540 patients, 316 (58.5%) were diagnosed with simple appendicitis, 164 patients (30.4%) were diag- nosed with complicated appendicitis, and 60 patients (11.1%) were diag- nosed with a normal appendix. The negative appendectomy rate was 11.1%. white blood cell count and C – reactive protein (CRP) were performed in all patients. Ultrasound (US) was performed on 371 (68.7%) patients. The mean WBC count, CRP level, and maximal outer diameter (MOD) of the appendix on US for all cases were 14,583 +- 5248/ml, 51.4

    +- 73.5 mg/l, and 8.9 +- 2.4 mm, respectively.

    In the multivariate analysis, a reverse stepwise logistic regression analysis of the data comparing the negative appendectomy and the acute appendicitis groups demonstrated that children with MOD of the appendix on US <= 5 mm were over eight times more likely to have normal appendix than those with MOD of the appendix N 5 mm. The other predictive factors of negative appendectomy were: Alvarado score <= 5 (P b 0.001, OR = 4.111), duration of symptoms >= 72 h (P = 0.002, OR = 2.645), WBC count <= 10,000/ml (P b 0.001, OR = 5.086),

    CRP level on admission <= 6 mg/l (P b 0.001, OR = 2.944) (Table 1). There was no association between negative appendectomy and age (P = 0.229).

    Our study supports that Prehospital factors can predict negative appendectomy in children with suspected appendicitis. Maximal outer diameter of the appendix on ultrasound <= 5 mm is a strong marker asso- ciated with negative appendectomy. These predictive factors could be incorporated into diagnostic algorithms to increase the accuracy of diagnosis of appendicitis in children and to improve overall quality of patient care.

    M. Zouari, MD*

    Abid, MD

    M. Ben Dhaou, MD

    H. Louati, MD

    M. Jallouli, MD, FACS

    R. Mhiri, MD

    Department of pediatric surgery, Hedi-Chaker Hospital, 3029 Sfax, Tunisia

    *Corresponding author.

    E-mail address: [email protected] (M. Zouari)

    19 July 2017

    https://doi.org/10.1016/j.ajem.2017.07.075

    The debate about when to withhold resuscitation in traumatic out-of- hospital cardiopulmonary arrest (TOHCA) has emerged since the relevant guidelines were published by the National Association of EMS Physicians and the Committee on Trauma of the American College of Surgeons [1].A retrospective study conducted in the USA indicated that only 0.3% of patients with TOHCA survived to hospital discharge, with a Glasgow Coma Scale score of >= 6 [2]. Moreover, a report obtained from a United Kingdom field hospital in Afghanistan showed more favor- able outcomes; it reported the survival of 7.7% of patients with TOHCA and a Neurologically intact state in 25% of these patients [3]. In Taiwan, the withholding of resuscitation does not apply to most patients with TOHCA, except for those presenting with Rigor mortis, de- capitation, or hemicorporectomy. Patients with TOHCA who are resusci- tated to the return of spontaneous circulation (ROSC) in a local hospital are typically transferred to trauma centers because of the lack of expe- rience or equipment to treat patients with polytrauma. However, con- sidering the poor outcomes in patients with TOHCA, the decision to transfer these ROSC patients for further treatment becomes difficult. Therefore, we conducted a retrospective study to determine the clinical features and prognoses of patients with TOHCA who were transferred to

    other hospitals after ROSC.

    This study was approved by the Institutional Review Board of Chi-Mei Medical Center. We searched records of the emergency depart- ments of three hospitals in Southern Taiwan for patients with TOHCA and trauma who were transferred from other facilities. The three hospi- tals were a trauma center (Chi-Mei Medical Center), a teaching hospital (Chi-Mei Hospital, Liouying), and a local hospital (Chi-Mei Hospital, Chiali). We reviewed patients with TOHCA who were resuscitated to ROSC in other facilities and transferred to these hospitals, as well as those who were resuscitated to ROSC in these hospitals and were then transferred to other facilities. The prognoses of patients transferred to other facilities were determined by the sheets returned by other hospi- tals, which indicated the outcomes of the patients.

    From January 1, 2014, to December 31, 2016, the hospitals treated 272 patients with TOHCA, and 91 (33.5%) patients were resuscitated to ROSC. We examined 13 patients with TOHCA who were transferred after ROSC. Most patients were men (8/13) aged 15-85 years (average: 54 years). All the transfers were initiated through telephone contact be- tween the involved hospitals, and patients were transferred by ambu- lances equipped with monitors under the care of nurses.

    Seven (54%) patients died in the emergency departments of the trans- ferred hospital; at transfer, four patients were in the cardiac arrest state and three showed feeble vital signs and eventually died within 1 h of ar- rival. Six patients were admitted to Intensive care units ; only two patients survived to hospital discharge and had Cerebral Performance

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