Negative anion gap metabolic acidosis and low level of salicylate cannot ignore salicylate toxicity!
Correspondence / American Journal of Emergency Medicine 32 (2014) 277–285
Kablau M, et al. Treatment with tPA predicts better outcome even if MCA occlusion persists. Int J Stroke 2013;8(7):496-502.
Anion gap metabolic acidosis an”>symptoms. Cerebrovasc Dis 2008;27(2):160-6.
279
Hooman Hossein-nejad, MD
Department of Emergency Medicine
Imam Khomeini Hospital
Kvistad CE, et al. Safety of off-label stroke treatment with tissue plasminogen activator. Acta Neurol Scand 2013;128(1):48-53.
recombinant tissue plasminogen activator for minor strokes: the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study experience. Ann Emerg Med 2005;46(3):243-52.
ETCO2 and ultrasound fail to directly confirm the depth of ETT placement
The authors respond:
We are pleased to respond to the reader’s comments. As a matter of fact, Esophageal intubation cannot be detected by Chest x-ray , yet there are other possibilities of endotracheal tube misplace- ment, such as inappropriate depth of the tube or bronchial intubation. End tidal CO2 (ETCO2) or ultrasonography is used to distinguish between esophageal and tracheal intubation. Nevertheless, they have not been useful for the direct confirmation of the appropriate tracheal depth of ETT [1,2]. References, including American Heart Association and American College of Emergency Physician guidelines , do not consider these methods alternatives to CXR to confirm the appropriate depth of the tube. However, obtaining a CXR after endotracheal intubation is advised by the corresponding references.
As stated clearly in the introduction, our article discusses the depth of ETT [3]. In the mentioned study, esophageal intubation has been ruled out (although End tidal CO2 was not used) and the CXR has been applied in order to confirm the appropriate position of the ETT in the trachea. Actually, the study aims to show the limitations of physical examination in determining the appropriate depth of the tube down the respiratory system (as mentioned in the introduction and the study design of the article).
To the best of our knowledge, in a wide majority of emergency departments in Iran, neither ETCO2 detector device nor ultrasound is available. In addition, a number of emergency physicians lack the knowledge about the usage ultrasonography in this field. Therefore, at the moment of placement, the tube is inserted 21 + or – 2 cm deep in the trachea under direct (or indirect) visualization, then it is adjusted with physical examination (auscultation) and is fixed. The depth of the tube cannot be estimated unless physical examination, the number of the tube which is near the corner of mouth and CXR obtaining are applied.
Tehran University of Medical Sciences, Tehran, Iran E-mail address: hoseinnejad@tums.ac.ir
http://dx.doi.org/10.1016/j.ajem.2013.10.052
References
- Geisser W, Maybauer DM, Wolff H, et al. Radiological validation of tracheal tube insertion depth in out-of-hospital and in-hospital emergency patients. Anaesthesia 2009;64(9):973-7.
- Brown lll Calvin A, Walls Ron M. Airway. In: Marx John A, Hockberger Robert S, et al, editors. Rosen’s emergency medicine: concepts and clinical practice. Philadelphia, PA: Elsevier; 2014. p. 3-22.
- Hossein-Nejad Hooman, Payandemehr Pooya, Bashiri Sayed Ali. Chest radiography after endotracheal tube placement: is it necessary or not? Am J Emerg Med 2013;31: 1181-2.
Negative anion gap metabolic acidosis and low level of salicylate cannot ignore Salicylate toxicity!?,??,?,??
To the Editor,
We thank Viren et al [1] for their article entitled “Negative anion gap metabolic acidosis in salicylate overdose–a zebra!” which was published in The American Journal of Emergency Medicine.
The authors wrote very excellent case report and review on a 30- year-old man who presented to the emergency department because of salicylate overdose; and interestingly, laboratory results showed negative anion gap. We also have the same interesting case scenario. We report a 16-year-old adolescent girl who was transferred to our critical care unit after multiple Drug overdoses without knowing the name of the medications. The first drug screening test at around one and a half hours after she took the medications showed a Salicylate level of 14 mg/dL. She was intubated after alteration of consciousness to protect the airway. Subsequently, the salicylate level was up to 34 mg/dL and peaked at 51 mg/dL after 24 hours from first Blood draw. Her metabolic panel during the course of admission showed normal anion gap. The patient was treated with multiple repeated activated charcoals and alkalization of urine, and she was extubated without consequence. This case demonstrates the importance of negative anion gap and that low salicylate level cannot rule out Salicylate poisoning and should follow up the salicylate level base on strong suspicious even though, classically, the diagnosis of salicylate toxicity is based on anion gap acidosis and elevated serum salicylate concentration [2].
Narat Srivali, MD Patompong Ungprasert, MD Lee C. Edmonds, MD Department of Internal Medicine Bassett Medical Center and
Columbia University College of Physicians and Surgeons
Cooperstown, NY 13326, USA E-mail address: Narat.Srivali@bassett.org
http://dx.doi.org/10.1016/j.ajem.2013.11.033
The results of the study show that although physical examination
is already known to be useful/ practicable in detecting esophageal intubation, it is not accurate enough to determine the appropriate depth of the tube.
To sum up, due to the fact that this study mainly focuses on the appropriate depth of the endotracheal tube in the trachea, the procedure we have adopted seems to be vindicable.
? Funding: none.
?? Conflict of interest statement for all authors: We do not have any financial or
nonfinancial potential conflicts of interest.
? Authors’ contributions: All authors had access to the data and a role in writing the
manuscript. All authors approve the manuscript.
?? This manuscript is an original research that has not been published and is not
under consideration elsewhere.
280 Correspondence / American Journal of Emergency Medicine 32 (2014) 277–285
References
Kaul V, Imam SH, Gambhir HS, Sangha A, Nandavaram S. Am J Emerg Med 2013;31(10):1536.e3-4.
Table
Sepsis admission and mortality volume and rates
Epoch 1 Epoch 2 Epoch 3
Brubacher, Jeffrey R. Salicylism from topical salicylates: review of the literature.
Read more: http://informahealthcare.com/doi/abs/10.3109/15563659609013814? journalCode=ctx. Clinical Toxicology. 34.4 (1996):431-436. Print.
Does adoption of a regional sepsis protocol reduce mortality??,??
In November 2008, Northern California Kaiser Permanente (KP), which is the largest health maintenance organization in the United States, adopted a regional sepsis protocol [1] based on a study published by Rivers et al [2] in 2001 in which it was reported that
Sepsis admission volume
sepsis mortality volume
total admission volume
Sepsis admission rate (95% confidence intervals)
SAV-D sepsis mortality (95% confidence intervals)
SAV-I sepsis mortality (95% confidence intervals)
16 049 4584 6791
3883 937 1064
450 182 107 178 103 569
35.7 (35.1-36.2) 42.8 (41.6-44.0) 65.6 (64.1-67.1)
24.2% (23.5-24.9) 20.4% (19.3-21.6) 15.7% (14.8-16.5)
8.6 (8.4-8.9) 8.7 (8.2-9.3) 10.3 (9.7-10.9)
“early goal-directed therapy” (EGDT) led to a 16% absolute reduction in sepsis mortality. Subsequent to adoption of the EGDT protocol, KP representatives have published claims of even greater reductions in sepsis mortality than originally reported in the study of Rivers et al [1,3-6]. The object of this correspondence is to analyze whether the available KP data support these claims.
Kaiser Permanente representatives have based their claims of improved sepsis care on declining rates of sepsis mortality calculated as the percentage of patients admitted with a sepsis-related diagnosis who died [1,3-6]. This rate varies inversely with sepsis admission volume and is referred to, subsequently, in this correspondence as sepsis admission volume-dependent (SAV-D) mortality. The rate of patients dying of sepsis per 1000 admissions for all causes is less dependent on sepsis admission rates because sepsis admissions account for a small fraction of total hospital admissions and is referred to, subsequently, as sepsis admission volume-independent (SAV-I) mortality.
Kaiser Permanente representatives have not directly reported SAV-I mortality, but raw data included with a KP regional newsletter
[3] allow one to calculate this rate. These raw data include the total monthly sepsis admission and sepsis mortality volumes during a 50- month period, from January 2006 through February 2010. The data also include the mean rates of sepsis-related admissions per 1000 admissions for all causes for 3 epochs; epoch 1, from January 2006 to November 2008, the date of adoption of the EGDT protocol; epoch 2, from November 2008 through June 2009 immediately after adoption of the EGDT protocol; and epoch 3, from July 2009 through February 2010, during which adherence to the EGDT protocol was actively promoted throughout the 21 Northern California KP medical centers. Using the available raw KP data, the author calculated the total number of admissions for all causes for each of the 3 epochs by dividing the reported sepsis admission volumes by the reported mean sepsis admission rates. The author calculated SAV-D sepsis mortality by dividing sepsis mortality volume by sepsis admission volume, and SAV-I sepsis mortality by dividing sepsis mortality volume by total admission volume. The author calculated confidence intervals using the Normal Approximation Method with Microsoft Excel 2010software (Redmond, WA).
As shown in Table and Fig., SAV-D sepsis mortality declined from 24.2% in epoch 1 to 15.7% in epoch 3, but over the same period, the sepsis admission rate rose even more sharply, and there was a small but statistically significant increase in SAV-I sepsis mortality, from 8.6 in epoch 1 to 10.3 in epoch 3.
If one accepts KP’s claims that adoption of the regional sepsis protocol led to Improved care, then to reconcile these claims with the KP data and mortality rates shown in Table and Fig., one must postulate that
? Source(s) of funding: None.
?? Name of organization and date of assembly if the article has been presented:
Not applicable.
Epoch 1, January 2006 to November 2008, the 34-month period prior to adoption of EGDT protocol. Epoch 2, November, 2008 through June, 2009, the 8-month period immediately after adoption of the EGDT protocol. Epoch 3, July 2009 through February 2010, the 8-month period during active promotion of adherence to EGDT protocol.
Sepsis admission volume, total number of patients admitted with a sepsis-related diagnosis; sepsis mortality volume, total number of patients dying of sepsis; total admission volume, total number of hospital admissions for all causes; sepsis admission rate, number of patients admitted with sepsis-related diagnosis per 1,000 admissions for all causes; SAV-D, percentage of patients admitted with a sepsis-related diagnosis who died of sepsis; SAV-I, number of patients who died of sepsis per 1000 admissions for all causes.
either a sepsis outbreak coincidentally struck Northern California just at the same time that KP adopted the EGDT protocol, or that prior to adoption of the protocol, not only were KP physicians failing to correctly diagnose a significant number of septic patients when they first saw them, they were also failing to recognize that the patients were septic when they died. A much more likely explanation for KP data is that there was no net improvement in sepsis care after adoption of the EGDT protocol, but that after adoption of the protocol, KP physicians began applying less stringent criteria for making the diagnosis of sepsis. As part of implementation of the protocol, KP physicians were encouraged to define sepsis as “Suspected infection and the presence of two or more signs of the Systemic Inflammatory Response Syndrome ” [1]. It has been noted that SIRS criteria include relatively minor perturbations in vital signs and white blood count and that defining sepsis based on SIRS criteria is a marked departure from “sepsis as we have known it….the
Fig. Sepsis admission and mortality rates. Vertical bars indicate 95% confidence intervals. Epoch 1, January 2006 to November 2008, the 34-month period prior to adoption of EGDT protocol. Epoch 2, November, 2008 through June, 2009, the 8-month period immediately after adoption of the EGDT protocol. Epoch 3, July 2009 through February 2010, the 8-month period during active promotion of adherence to EGDT protocol. Sepsis admission rate, number of patients admitted with sepsis-related diagnosis per 1000 admissions for all causes; SAV-D, percentage of patients admitted with a sepsis-related diagnosis who died of sepsis; SAV-I, number of patients who died of sepsis per 1000 admissions for all causes.
