Article, Emergency Medicine

Risk factors for unplanned transfer to the intensive care unit after emergency department admission: Methodological issues

Correspondence / American Journal of Emergency Medicine 35 (2017) 15611580

Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, et al. Part 5:


Saeid Safiri

adult basic life support and cardiopulmonary Resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emer- gency cardiovascular care. Circulation 2015;132:S414-35.

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  • Risk factors for unplanned transfer to the intensive care unit after emergency department admission: Methodological issues

    To the Editor,

    We read the study conducted by Boerma and colleagues that was published in American Journal of Emergency Medicine, with great interest [1]. The authors tried to determine important determinants of deterio- ration which require ICU transfer within 24 h after ED admission. The

    Managerial Epidemiology Research Center, Department of Public Health, School of Nursing and Midwifery, Maragheh University of Medical Sciences,

    Maragheh, Iran

    Erfan Ayubi

    Department of Epidemiology, School of Public Health, Shahid Beheshti

    University of Medical Sciences, Tehran, Iran Department of Epidemiology & Biostatistics, School of Public Health, Tehran

    University of Medical Sciences, Tehran, Iran Corresponding author at: Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences

    Tehran, Iran.

    E-mail address: [email protected]


    1. Boerma LM, Reijners EPJ, Hessels RAPA, Hooft MAA V. Risk factors for unplanned transfer to the intensive care unit after emergency department admission. Am J Emerg Med 2017;35:1154-8.
    2. Ayubi E, Sani M. procalcitonin levels predict identification of bacterial strains in blood

      cultures of septic patients: effect measures of association. Am J Emerg Med 2016;34: 2453-4.

      Safiri S, Sani M, Ayubi E. Impact of an emergency medicine pharmacist on time to thrombolysis in acute ischemic stroke: strength of association. Am J Emerg Med 2017;35:345.

    3. Ashrafi-Asgarabad A, Ayubi E, Safiri S. Predictors of health-related quality of life in people with amyotrophic lateral sclerosis: methodological issues. J Neurol Sci 2017; 372:228.

      acute pulmonary edema associated with ketamine use in a patient with coronary artery disease

      results suggested that the number (%) of hypercapnia between inten-

      sive care unit (ICU) admission and Non-ICU admission was statistically different. They point out hypercapnia can be important predictor for de- terioration which requires ICU transfer within 24 h after ED admission [1].

      Although the results were interesting, but an important question that may be raised in the mind is that why the authors did not provide measures of association for relationship between the studied explanato- ry variables and the studied outcome. The measures of association refer to a different type of indicators that quantify the statistical strength of the relationship on the variables of interest. Relative risks such as odds ratio, risk ratio and rate ratio are common measures of association in ep- idemiology. Unfortunately, some clinicians are still largely unfamiliar with available methods to estimate relative risks [2,3].

      We estimated the odds ratio of hypercapnia for deterioration which requires ICU transfer within 24 h after ED admission with provided data in the study conducted by Boerma and colleagues [1]. We find that the odds ratio (95% confidence intervals) is 3.24 (1.15, 9.11). It means odds of ICU admission in patients with hypercapnia increased by 3.24 times.

      Moreover, inference on prediction in cross sectional studies should be interpreted with caution because valid and robust prediction will be achieved in longitudinal studies [4].

      Conflict of interest



      The authors would like to thanks statistics consultants of Research Development Center of Sina Hospital for their technical assistance. This work was not supported by any organization.


      Ketamine Pulmonary edema

      Ischemic heart disease

      To the Editor,

      I read with a great interest the case report from Burmon et al. [1] re- lating the occurrence of an acute pulmonary edema in an obese 58-year- old patient with a past history of coronary artery disease (CAD), given 50 mg of intravenous ketamine for procedural sedation.

      Even if the described extreme pain exerted a potential role, it is un- questionable that ketamine was responsible for an acute hypertensive and tachycardic event (with a heart rate as elevated as 180 bpm), which was obviously a precipitating condition in this patient with CAD. Initial atropine dose was possibly an aggravating process in this setting, because it is known that it takes a while before reducing secre- tions and because atropine itself has been reported to be responsible for acute events in CAD [2].

      Burmon et al. are right when they call our attention to the dangers of the increasing use of ketamine in the ED without a strict protocol; but I believe there is no need for a change in the safety profile of ketamine, because caution is clearly warranted when using ketamine in such pa- tients. CAD has always been a relative contra-indication to the use of ke- tamine and it has been recognized since the first reports by Domino et al. (in the sixties) that ketamine induced tachycardia and hypertension through sympathetic activation. The fact that this patient with type 2 di- abetes and hypertension had benefited from a CABG 10 years before was obviously not a guarantee against the deterioration of her ischemic heart disease.

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