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Diabetes/metabolism Research and Reviews Jul 2024Fluid resuscitation during diabetic ketoacidosis (DKA) is most frequently performed with 0.9% saline despite its high chloride and sodium concentration. Balanced... (Meta-Analysis)
Meta-Analysis
Fluid resuscitation with balanced electrolyte solutions results in faster resolution of diabetic ketoacidosis than with 0.9% saline in adults - A systematic review and meta-analysis.
Fluid resuscitation during diabetic ketoacidosis (DKA) is most frequently performed with 0.9% saline despite its high chloride and sodium concentration. Balanced Electrolyte Solutions (BES) may prove a more physiological alternative, but convincing evidence is missing. We aimed to compare the efficacy of 0.9% saline to BES in DKA management. MEDLINE, Cochrane Library, and Embase databases were searched for relevant studies using predefined keywords (from inception to 27 November 2021). Relevant studies were those in which 0.9% saline (Saline-group) was compared to BES (BES-group) in adults admitted with DKA. Two reviewers independently extracted data and assessed the risk of bias. The primary outcome was time to DKA resolution (defined by each study individually), while the main secondary outcomes were changes in laboratory values, duration of insulin infusion, and mortality. We included seven randomized controlled trials and three observational studies with 1006 participants. The primary outcome was reported for 316 patients, and we found that BES resolves DKA faster than 0.9% saline with a mean difference (MD) of -5.36 [95% CI: -10.46, -0.26] hours. Post-resuscitation chloride (MD: -4.26 [-6.97, -1.54] mmoL/L) and sodium (MD: -1.38 [-2.14, -0.62] mmoL/L) levels were significantly lower. In contrast, levels of post-resuscitation bicarbonate (MD: 1.82 [0.75, 2.89] mmoL/L) were significantly elevated in the BES-group compared to the Saline-group. There was no statistically significant difference between the groups regarding the duration of parenteral insulin administration (MD: 0.16 [-3.03, 3.35] hours) or mortality (OR: -0.67 [0.12, 3.68]). Studies showed some concern or a high risk of bias, and the level of evidence for most outcomes was low. This meta-analysis indicates that the use of BES resolves DKA faster than 0.9% saline. Therefore, DKA guidelines should consider BES instead of 0.9% saline as the first choice during fluid resuscitation.
Topics: Adult; Humans; Diabetic Ketoacidosis; Electrolytes; Fluid Therapy; Prognosis; Resuscitation; Saline Solution
PubMed: 38925619
DOI: 10.1002/dmrr.3831 -
American Journal of Infection Control Jun 2024Paramedics are exposed to many infectious diseases in their daily professional activities, leading to a high risk of transmitting infectious diseases to patients in...
BACKGROUND
Paramedics are exposed to many infectious diseases in their daily professional activities, leading to a high risk of transmitting infectious diseases to patients in out-of-hospital settings, and possibly leading to healthcare associated infections in hospitals and the community. The coronavirus disease 2019 pandemic has highlighted the importance of infection prevention and control in healthcare more broadly and the role of paramedics in infection control is considered even more critical. Despite this, in many countries such as Australia, research into infection prevention and control research has mainly been focused on in-hospital health care professionals with limited out-of-hospital studies.
METHODS
This scoping review was conducted based upon Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to evaluate the literature relating to knowledge and awareness of infection prevention and control in paramedics in Australia and other countries.
RESULTS/DISCUSSION
Based upon the selection criteria applied, six papers were identified for inclusion in this review. In many studies reviewed, infection prevention and control was identified by paramedics as being important, however compliance with hand hygiene practices was low and most studies highlighting the need for more education and training on infectious disease for paramedics.
CONCLUSION
The current evidence suggests that paramedics have poor compliance with recommended IPC practices. The profession needs to improve IPC education, training, and culture.
PubMed: 38925500
DOI: 10.1016/j.ajic.2024.06.014 -
Injury Jun 2024An emergent front of neck airway (FONA) is needed when a 'can't intubate, can't oxygenate' crisis occurs. A FONA may also in specific cases be the primary choice of...
INTRODUCTION
An emergent front of neck airway (FONA) is needed when a 'can't intubate, can't oxygenate' crisis occurs. A FONA may also in specific cases be the primary choice of airway management. Two techniques exist for FONA, with literature favouring the surgical technique over the percutaneous. The reported need for a prehospital FONA is fortunately rare as the mortality has been shown to be high. Due to the low incidence, literature on FONA is limited with regards to different settings, techniques and operators. As a foundation for future research and improvement of patient care, we aim to describe the frequency, indications, technique, success, and outcomes of FONA in the Finnish helicopter emergency medical services (HEMS).
MATERIALS AND METHODS
This retrospective descriptive study reviews FONA performed at the Finnish HEMS during 1.1.2012 to 8.9.2019. The Finnish HEMS consists of six units, staffed mainly by anaesthesiologists. Clinical data was gathered from a national HEMS database and trough chart reviews. Data on mortality was obtained from a population registry. Only descriptive statistics were performed.
RESULTS
A total of 22 FONA were performed during the study period, 7 were primary and 14 performed after failure to intubate (missing data regarding indication for one attempt). This equals a 0.13 % (14/10,813) need for a rescue FONA and a rate of 0.20 % (22/10,813) FONA out of all advanced airway management. All but one FONA was performed using a surgical approach (20/21, 95 %, missing data = 1) and all were successful (22/22, 100 %). Indications were mainly cardiac arrest (10/22, 45 %) and trauma (6/22, 27 %), and the most common reason for a need for a secondary FONA was obstruction of airway by food or fluids (7/14, 50 %). On-scene mortality was 36 % (8/22) and 30-day mortality 90 % (19/21, missing data = 1).
CONCLUSION
The need for FONA is scarce in a HEMS system with experienced airway providers. Even though the procedure is successfully performed, the mortality is markedly high.
PubMed: 38924838
DOI: 10.1016/j.injury.2024.111689 -
The Journal of Obstetrics and... Jun 2024We present two critical cases of life-threatening postpartum hemorrhage (PPH) due to amniotic fluid embolism (AFE) complicated by disseminated intravascular coagulopathy...
Resuscitative endovascular balloon occlusion of the aorta: A novel approach for treating amniotic fluid embolism with disseminated intravascular coagulopathy-A report of two cases.
We present two critical cases of life-threatening postpartum hemorrhage (PPH) due to amniotic fluid embolism (AFE) complicated by disseminated intravascular coagulopathy (DIC). These cases are the first to show the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for patient survival. In Case 1, the patient, experiencing critical conditions with severe PPH and DIC despite conventional treatments, including rapid blood transfusion and fibrinogen concentrate, was air-transferred to our hospital, where REBOA was promptly employed before hysterectomy was completed. Case 2 involved an ambulance-transferred patient with massive PPH and DIC despite conventional treatments. Prehospital REBOA was performed to prevent cardiac arrest during transfer, and hysterectomy was performed in the hospital. Given the rapid deterioration associated with AFE, REBOA can serve as a bridge until complete hemostasis to maintain vital signs and control bleeding in patients unresponsive to standard therapies before hemostatic interventions or during transfer.
PubMed: 38923672
DOI: 10.1111/jog.16007 -
Diabetic Medicine : a Journal of the... Jun 2024In tackling rising diabetes-related emergencies, the need to understand and address emergency service usage by people with type 1 diabetes is vital. This review aimed to... (Review)
Review
AIMS
In tackling rising diabetes-related emergencies, the need to understand and address emergency service usage by people with type 1 diabetes is vital. This review aimed to quantify current trends in presentations for type 1 diabetes-related emergencies and identify public health strategies that reduce the frequency of diabetes-related emergencies and improve glycaemic management.
METHODS
Medline (OVID), Cochrane and CINAHL were searched for studies published between 2000 and 2023, focusing on people with type 1 diabetes, severe hypoglycaemia and/or diabetic ketoacidosis, and ambulance and/or emergency department usage. There were 1313 papers identified, with 37 publications meeting review criteria.
RESULTS
The incidence of type 1 diabetes-related emergencies varied from 2.4 to 14.6% over one year for hypoglycaemic episodes, and between 0.07 and 11.8 events per 100 person-years for hyperglycaemic episodes. Notably, our findings revealed that ongoing diabetes education and the integration of diabetes technology, such as continuous glucose monitoring and insulin pump therapy, significantly reduced the incidence of these emergencies. However, socio-economic disparities posed barriers to accessing these technologies, subsequently shifting the cost to emergency healthcare and highlighting the need for governments to consider subsidising these technologies as part of preventative measures.
CONCLUSIONS
Improving access to continuous glucose monitoring and insulin pump therapy, in combination with ongoing diabetes education focusing on symptom recognition and early management, will reduce the incidence of diabetes-related emergencies. Concurrent research assessing emergency healthcare usage patterns during the implementation of such measures is essential to ensure these are cost-effective.
PubMed: 38923618
DOI: 10.1111/dme.15384 -
Ergonomics Jun 2024This study examines the barriers to integrating portable Magnetic Resonance Imaging (MRI) systems into ambulance services to enable effective triaging of patients to the...
This study examines the barriers to integrating portable Magnetic Resonance Imaging (MRI) systems into ambulance services to enable effective triaging of patients to the appropriate hospitals for timely stroke care and potentially reduce door-to-needle time for thrombolytic administration. The study employs a qualitative methodology using a digital twin of the patient handling process developed and demonstrated through semi-structured interviews with 18 participants, including 11 paramedics from an Emergency Medical Services system and seven neurologists from a tertiary stroke care centre. The interview transcripts were thematically analysed to determine the barriers based on the Systems Engineering Initiative for Patient Safety framework. Key barriers include the need for MRI operation skills, procedural complexities in patient handling, space constraints, and the need for training and policy development. Potential solutions are suggested to mitigate these barriers. The findings can facilitate implementing MRI systems in ambulances to expedite stroke treatment.
PubMed: 38916114
DOI: 10.1080/00140139.2024.2367157 -
National Health Statistics Reports Jun 2024Objectives-This report describes emergency department (ED) visits by homeless status and sex. Methods-Nationally representative estimates were calculated from data...
Objectives-This report describes emergency department (ED) visits by homeless status and sex. Methods-Nationally representative estimates were calculated from data collected in the 2016-2021 National Hospital Ambulatory Medical Care Survey, an annual national probability sample survey of ED visits in the United States. Visits by people experiencing homelessness were defined using data on patient residence from medical records. Visits by males and females experiencing homelessness are compared with each other and with visits by males and females not experiencing homelessness. Results-During 2016-2021, approximately 981,000 and 460,000 ED visits were made annually by males and females experiencing homelessness, respectively. Significant differences by sex were found for this population for many ED visit characteristics, including arrival by ambulance, diagnoses, and chronic conditions. ED visits by males and females experiencing homelessness also differed significantly from ED visits by males and females not experiencing homelessness based on age, geographic region, expected source of payment, primary diagnosis, chronic conditions, and other characteristics. Conclusion-This report highlights certain differences by sex among the population experiencing homelessness who visited the ED and compares them with people who visited the ED but were not experiencing homelessness.
Topics: Humans; Ill-Housed Persons; Emergency Service, Hospital; United States; Male; Female; Adult; Middle Aged; Adolescent; Young Adult; Aged; Health Care Surveys; Sex Factors; Child; Child, Preschool; Infant; Emergency Room Visits
PubMed: 38912857
DOI: No ID Found -
BMJ Open Jun 2024To explore students' and facilitators' experiences of using a developed digital activity for interprofessional learning (IPL) focusing on critically ill patient...
Facilitating interprofessional learning: experiences of using a digital activity for training handover of critically ill patients between a primary health care centre and ambulance services - a qualitative study.
OBJECTIVE
To explore students' and facilitators' experiences of using a developed digital activity for interprofessional learning (IPL) focusing on critically ill patient handovers from a primary healthcare (PHC) centre to the ambulance service.
DESIGN
A qualitative study design was employed, and the reporting of this study adheres to the Consolidated criteria for Reporting Qualitative research guidelines for qualitative studies.
SETTING
A PHC centre and the ambulance service in Stockholm, Sweden.
PARTICIPANTS
A total of 31 participants were included in the study: 22 students from five different healthcare professions, seven facilitators and two observers.
INTERVENTION
A digital IPL activity was developed to overcome geographical distances, and the scenario included the handover of a critically ill patient from personnel within the PHC centre to the ambulance service personnel for transport to an emergency department. Four digital IPL activities were conducted in 2021.
RESULTS
The digital IPL activity eliminated the issue of geographical distance for students and facilitators, and it enabled the students to find an interprofessional model for collaboration through reasoning, by communicating and sharing knowledge with the support of a common structure. Participants perceived the digital IPL activity and scenario as authentic, feasible and facilitated IPL. Using a case with an acute and life-threatening condition was a success factor for students to experience high realism in their IPL on patient safety, handover, care and treatment.
CONCLUSION
The developed digital IPL activity facilitated the students' IPL and demonstrated potential sustainability as the digital approach supported overcoming geographical distances for both students and facilitators. By using a scenario involving an authentic case focusing on handovers of a critically ill patient, IPL, feasibility and acceptability were supported. However, it is crucial to emphasise that a comprehensive evaluation, both quantitative and qualitative, over an extended period of clinical rotations and involving a larger group of students is still warranted to ensure continuous improvement and development.
Topics: Humans; Qualitative Research; Patient Handoff; Sweden; Primary Health Care; Ambulances; Critical Illness; Male; Female; Interprofessional Relations; Adult; Interprofessional Education
PubMed: 38908853
DOI: 10.1136/bmjopen-2023-083585 -
Current Neurology and Neuroscience... Jun 2024Mobile stroke units (MSU) have established a new, evidence-based treatment in prehospital stroke care, endorsed by current international guidelines and can facilitate... (Review)
Review
PURPOSE OF REVIEW
Mobile stroke units (MSU) have established a new, evidence-based treatment in prehospital stroke care, endorsed by current international guidelines and can facilitate pre-hospital research efforts. In addition, other novel pre-hospital modalities beyond the MSU are emerging. In this review, we will summarize existing evidence and outline future trajectories of prehospital stroke care & research on and off MSUs.
RECENT FINDINGS
The proof of MSUs' positive effect on patient outcomes is leading to their increased adoption in emergency medical services of many countries. Nevertheless, prehospital stroke care worldwide largely consists of regular ambulances. Advancements in portable technology for detecting neurocardiovascular diseases, telemedicine, AI and large-scale ultra-early biobanking have the potential to transform prehospital stroke care also beyond the MSU concept. The increasing implementation of telemedicine in emergency medical services is demonstrating beneficial effects in the pre-hospital setting. In synergy with telemedicine the exponential growth of AI-technology is already changing and will likely further transform pre-hospital stroke care in the future. Other promising areas include the development and validation of miniaturized portable devices for the pre-hospital detection of acute stroke. MSUs are enabling large-scale screening for ultra-early blood-based biomarkers, facilitating the differentiation between ischemia, hemorrhage, and stroke mimics. The development of suitable point-of-care tests for such biomarkers holds the potential to advance pre-hospital stroke care outside the MSU-concept. A multimodal approach of AI-supported telemedicine, portable devices and blood-based biomarkers appears to be an increasingly realistic scenario for improving prehospital stroke care in regular ambulances in the future.
PubMed: 38907812
DOI: 10.1007/s11910-024-01351-0 -
Frontiers in Nutrition 2024With the prevalence of high body mass index (HBMI) increasing over the past 30 years, it is essential to examine the impact of obesity on kidney cancer. This study...
PURPOSE
With the prevalence of high body mass index (HBMI) increasing over the past 30 years, it is essential to examine the impact of obesity on kidney cancer. This study aims to explore the attributable burden of kidney cancer associated with HBMI and its proportion at different levels.
METHODS AND MATERIALS
The data used in this research were obtained from the Global Burden of Diseases Study 2019. We utilized DisMod-MR 2.1, a Bayesian meta-regression tool, to estimate the burden of kidney cancer attributable to HBMI, which was measured by age-standardized mortality rate (ASMR) and age-standardized disability-adjusted life years rate (ASDR). Correlation analysis was conducted by the Spearman rank order correlation method. The temporal trends were analyzed by estimating the estimated annual percentage change (EAPC).
RESULTS
Globally in 2019, there were a total of 31.7 thousand deaths and 751.89 thousand disability-adjusted life years (DALYs) attributable to kidney cancer caused by HBMI, increased by 183.1 and 164%, respectively. Over the period from 1990 to 2019, the burden of kidney cancer attributable to HBMI increased in all regions, with the most significant increases occurring in Low-middle socio-demographic index (SDI) and Low SDI regions. At the national level, countries with lower SDI had lower ASMR and ASDR compared to developed nations. However, the EAPC values, which indicate the rate of increase, were significantly higher in these countries than in developed nations. Furthermore, across all years from 1990 to 2019, males experienced a greater and more rapidly increasing burden of kidney cancer attributable to HBMI than females.
CONCLUSION
As the population grows and dietary patterns shift, the burden of kidney cancer attributable to HBMI is expected to become even more severe. Males and developed regions have borne a heavier burden from 1990 to 2019. However, the EAPC values for both ASMR and ASDR were higher in males but not in regions with higher SDI values.
PubMed: 38903629
DOI: 10.3389/fnut.2024.1358017