The prognostic performance of the L/A ratio was superior to that of a single lactate measurement for predicting 28-day mortality of critically ill sepsis patients. L/A ratio can be a useful prognostic factor regardless of initial lactate level and the presence of hepatic or renal dysfunction.

BackgroundThe purpose of this study was to identify the relationship between the deeper and faster chest compressions suggested by the 2010 cardiopulmonary resuscitation guidelines and complications arising from chest compressions, using multi-detector computed tomography.MethodsWe performed a retrospective analysis of prospective registry data. This study was conducted with in- and out-of-hospital cardiac arrest patients who underwent successful resuscitation in the emergency departments of two academic tertiary care centres from October 2006 to September 2010 (pre-2010 group) and from October 2011 to September 2015 (post-2010 group). We examined chest injuries related to chest compressions, classified as follows: rib fracture, sternal fracture, and other uncommon complications.ResultsWe enrolled 185 patients in this study. The most frequent complication to occur in both groups was rib fracture: 27 (62.8%) and 112 (78.9%) patients in the pre-2010 and post-2010 groups, respectively (p = 0.03). However, we observed no statistical differences in sternum fracture, the second most common complication (p = 0.80). Retrosternal and mediastinal haematoma were not reported in the pre-2010 group but 13 patients (9.1%) in the post-2010 group were reported to have haematoma (p = 0.04). Nine serious, life-threatening complications occurred, all in the post-2010 group. Among the younger group (less than 65 years old), 8 (38.1%) patients in the pre-2010 group and 40 (64.5%) in the post-2010 group sustained rib fractures.DiscussionThe deeper and faster chest compressions for enhancing ROSC are associated with increased occurrence of complications. Additional studies are needed to compensate for the limitations of our study design.ConclusionsThis study found that the 2010 guidelines, recommending deeper and faster chest compressions, led to an increased proportion of rib fractures and retrosternal and mediastinal haematoma.

Background: Septic shock can be defined both by the presence of hyperlactatemia and need of vasopressors. Lactate levels should be measured after volume resuscitation (as per the Sepsis-3 definition). However, currently, no studies have evaluated patients who have been excluded by the new criteria for septic shock. The aim of this study was to determine the clinical characteristics and prognosis of these patients, based on their lactate levels after initial fluid resuscitation. Methods: This observational study was performed using a prospective, multi-center registry of septic shock, with the participation of 10 hospitals in the Korean Shock Society, between October 2015 and February 2017. We compared the 28-day mortality between patients who were excluded from the new definition (defined as lactate level <2 mmol/L after volume resuscitation) and those who were not (≥2 mmol/L after volume resuscitation), from among a cohort of patients with refractory hypotension, and requiring the use of vasopressors. Other outcome variables such as in-hospital mortality, intensive care unit (ICU) stay (days), Sequential Organ Failure Assessment (SOFA) scores and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were also analyzed. Results: Of 567 patients with refractory hypotension, requiring the use of vasopressors, 435 had elevated lactate levels, while 83 did not have elevated lactate levels (either initially or after volume resuscitation), and 49 (8.2%) had elevated lactate levels initially, which normalized after fluid resuscitation. Thus, these 49 patients were excluded by the new definition of septic shock. These patients, in whom perfusion was restored, demonstrated significantly lower age, platelet count, and initial and subsequent lactate levels (all p < 0.01). Similarly, significantly lower 28-day mortality was observed in these patients than in those who had not been excluded (8.2% vs 25.5%, p = 0.02). In-hospital mortality and the maximum SOFA score were also significantly lower in the excluded patients group (p = 0.03, both). Conclusions: It seems reasonable for septic shock to be defined by the lactate levels after volume resuscitation. However, owing to the small number of patients in whom lactate levels were improved, further study is warranted.

BackgroundThe effects of the flipped classroom have been demonstrated in various fields of education in recent years. Training in emergency medicine is also beginning to gradually implement the flipped classroom; however, its practical effect in emergency medicine contexts is not yet clear.ObjectiveThe present study investigates the effects of the flipped classroom on advanced cardiopulmonary life support (ACLS) training implemented among practicum students in emergency medicine.MethodsThe study randomly assigned into control and experimental conditions 108 fourth year students in the College of Medicine at Yonsei University, in Seoul, who were scheduled to take clinical practice in emergency medicine between March and July 2017. Students were taught about ACLS in either a traditional lecture-based classroom (control condition) or a flipped classroom (experimental condition); then, simulation training with ACLS scenarios was carried out. Finally, each student was rated on performance using a rating form developed in advance.ResultsACLS simulation scores of the students in the flipped classroom were 70.9±10.9, which was higher than those of the students in the traditional classroom (67.1±11.3); however, this difference was not statistically significant (p = 0.339). In addition, the difference in student satisfaction as measured on a survey was statistically insignificant (p = 0.655).ConclusionsCompetency assessment after simulation-based training in ACLS undergone by senior medical students randomly assigned to flipped and traditional classrooms showed no statistical difference in competency between the two groups.

Objective: To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". Design:A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. Methods:The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.