Objective Early recognition of symptoms is essential in anaphylaxis management. The Canadian Paediatric Emergency Triage and Acuity Scale prioritizes anaphylaxis to level I or II (resuscitation or emergency). We analyzed the accuracy of pediatric anaphylaxis triage. Methods This was a retrospective review of the triage charts (adaptation of the Canadian Paediatric Emergency Triage and Acuity Scale) of 137 children attended for anaphylaxis at our pediatric emergency department. Per triages' accuracy, charts were divided into TR1 (levels I–II) and TR2 (levels III–V), comparing demographics, initial triage level given by initial assessment (Paediatric Assessment Triangle), vital signs, observations recorded by the staff, and waiting times for physician. Results Forty-six (33.3%) were triaged correctly (TR1 group), and 91 (66.7%) were not. Median ages were similar (TR1: 5 years [interquartile range, 13.1 years] vs TR2: 4.5 years [interquartile range, 14.5 years]; P = 0.837). Initial triage level 5 was given by Paediatric Assessment Triangle to 69.5% of TR1 and 83% of TR2 cases (P = 0.001; likelihood ratio for TR2: 1.985 [95% confidence interval, 1.11–3.49]). Vital signs were normal in 71.7% of TR1 and 94.5% of TR2 patients (P < 0.001; likelihood ratio for TR2: 2.602 [95% confidence interval, 1.22–5.52]). Symptoms suggestive of anaphylaxis (mention of 2 different organs) were recorded in 45.6% of TR1 and 48.3% of TR2 charts (P = 0.08). Median waiting times were 3 minutes (interquartile range, 26 minutes) and 11 minutes (interquartile range, 111 minutes) for TR1 and TR2, respectively (P = 0.001). Conclusions Current triage, based on severity perception, missed most of the cases. Anaphylaxis-defining symptoms were overlooked. Inaccurate triage delayed medical attention. Improving measures, such as emphasizing symptom recognition and defining anaphylaxis risk discriminators, is mandatory to improve their identification.
Our BEI has been effective, improving the identification and priorization of children with anaphylaxis and reducing their WT. We need to pay attention to the functioning of our patients´ reference ED and establish interdisciplinary measures that allow optimizing anaphylaxis´ management.
Background New treatment strategies are needed to improve the prognosis in acute heart failure (AHF), recently PIONEER-HF results have been published showing in a selected group of patients a potential use of sacubitril/valsartan with safety in this scenario Purpose To evaluate the impact of PIONEER-HF potential indication in daily practice after AHF hospitalization at discharge Methods We included a subgroup of 909 patients consecutively admitted with AHF between October 2013 and December 2014 from a national multicentre, prospective registry with the complete data for this analysis. In the trial left ventricular ejection fraction (LVEF) ≤40% and natriuretic peptides at admission with values of NT-ProBNP≥1600 pg/ml were needed to be included. The clinical and analytic stability at discharge to safely start sacubitril/valsartan was considered as MDRD estimated Glomerular Filtration Rate≥30 mL/min/1.73 m2, Systolic Blood Pressure ≥100 mmHg and Potassium ≤5.2 mmol/L. Results The mean age was 72.1±12.01 years. Of these, 373 (38.8%) were female, 734 (76,6%) were hypertensive, 462 (48.2%) had diabetes and 282 (29.9%) coronary artery disease. At admission atrial fibrillation was found in 403 patients (40.1%) and 409 (45%) had reduced LVEF. The mean levels of NT-ProBNP 7259.4±9437.1 pg/ml. In this group of patients, the in-hospital mortality was 28 (2.9%) and the 1 year follow up mortality was 197 (20.5%) and the heart failure rehospitalizations in 1 year were 303 (31,5%). In table 1 the percentage of patients that fulfil the needed criteria for the application of PIONEER HF is shown. In our registry 235 patients (25.9%) could be potential users of sacubitril/valsartan after the acute phase of hospitalization Table 1 Elements to stablish indication Number of patients (%) NT-ProBNP ≥1600 pg/ml at admission 730 (80.3%) MDRD estimated GFR ≥30 mL/min/1.73 m2 at discharge 798 (87.8%) Systolic Blood Pressure ≥100 mmHg at discharge 755 (83.1%) Serum Potassium ≤5.2 mmol/L at discharge 856 (94.2%) Clinical and analytic stability at discharge 636 (70%) Left ventricular ejection fraction ≤40% 409 (45%) PIONEER HF Criteria 235 (25.9%) GFR: Glomerular Filtration Rate. Conclusions In our cohort of AHF patients around 1 out 4 could be treated with sacubitril/valsartan at discharge if we apply the PIONEER HF criteria in a contemporary setting, this finding could have potential implications in the prognosis and current costs of care in a population with high morbidity and mortality. Acknowledgement/Funding Heart Failure Program of the Red de Investigaciόn Cardiovascular del Instituto de Salud Carlos III, Madrid, Spain (RD12/0042) and FEDER
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