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THE R.E.S.H. STUDY: WHAT ABOUT THE PATIENTS ON SHOCK IN SPAIN ?

SPANISH GROUP OF SHOCK. THE R.E.S.H. STUDY: WHAT ABOUT THE PATIENTS ON SHOCK IN SPAIN ?. Professor ANA NAVÍO M.D. Ph.D. NATIONAL DIRECTOR OF THE SPANISH GROUP OF SHOCK EMERGENCY DEPARTMENT, LA PAZ ACADEMICAL HOSPITAL, MADRID, SPAIN. THE R.E.S.H. STUDY. SPANISH GROUP OF SHOCK.

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THE R.E.S.H. STUDY: WHAT ABOUT THE PATIENTS ON SHOCK IN SPAIN ?

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  1. SPANISH GROUP OF SHOCK THE R.E.S.H. STUDY: WHAT ABOUT THE PATIENTS ON SHOCK IN SPAIN ? Professor ANA NAVÍO M.D. Ph.D. NATIONAL DIRECTOR OF THE SPANISH GROUP OF SHOCK EMERGENCY DEPARTMENT, LA PAZ ACADEMICAL HOSPITAL, MADRID, SPAIN

  2. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK • R.E.S.H.= Spanish register of shock • Why??? • We have no information about these kind of patients attended at the Spanish E.D. but, séptic shock. • So that, we put on work……… M.C. Fariñas.  M.A. Ballesteros.  E. Miñambres.  Sepsis y shock séptico.Medicine.2010; 10(49) :3282-92

  3. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK • TheSpanishGroup of Shock has 35 members. • All of them, working at E.D.(phisicians and nurses). www.grupodeshock.org

  4. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK NAME AND WORK CENTER (in alphabeticalorder) 1) FERNANDO ABAD ESTEBAN.SUMMA 112 2) SIRA AGUILÓ. H. Clinic, Barcelona 3) JOSE EMILIO ALONSO LASHERAS.H.U.C, Tenerife 4) DANIEL AFONSO RIVERO.H. La Princesa, Madrid 5) Mª ANGELES ARAGÓN.H. de Jerez, Cádiz 6) MAITE AYUSO ARAGONÉS H. La Paz, Madrid 7) CONSUELO CANENCIA.SAMUR Ayto Madrid 8) JUAN CAÑERO.H.Virgen de Victoria, Málaga 9) JUAN CARLOS COBO BARQUIN.H. Central, Asturias 10) MANUEL CUESTA MARTÍN. H. Cruces, Bilbao

  5. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK NAME AND WORK CENTER (in alphabetical order) 11)SONIA FERNANDEZ-ARRUTY FERRO. H.U. de Santiago, Coruña  12) VANESA GALLEGO VILLALVILLA. H.12 de Octubre, Madrid 13) JOSE CARLOS GARCÍA CARAVACA. H. Morales Meseguer, Murcia  14) ELENA GOMEZ DEL PULGAR. H. La Paz, Madrid  15) ELBA GONZALEZ DE LINARES. H. Marqués de Valdecilla, Santander 16) PABLO GUALLAR SOLA. Fundación H.de Calahorra (La Rioja) 17)AMAIA IBARRA. H. Virgen del Camino, Navarra 18) VICTOR MARQUINA. H.G. Alicante 19) ESTHER MARTÍNEZ LARRUL. H. Gregorio Marañón, Madrid

  6. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK NAME AND WORK CENTER (in alphabetical order) 20) ANA NAVÍO SERRANO. H. La Paz, Madrid 21) OSCAR ORTIGOSA. H Miguel Servet, Zaragoza 22) FELIPE PASCUAL CLEMENTE. H. Ramón y Cajal, Madrid 23) ERNESTO PERALES. H. G Cáceres 24) RAMÓN PERALES PARDO. UCH Albacete 25) FRANCISCO DE BORJA QUERO ESPINOSA. H Reina Sofía, Córdoba 26) MICHEL RIESCO. H.U. de Salamanca 27)ALEJANDRO RODRIGUEZ CAMACHO. H. Puerta del Mar Cádiz

  7. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK NAME AND WORK CENTER (in alphabetical order) 28) ANTONIO ROJAS RAMIREZ. H. Osuna, Sevilla. 29) JAVIER RUBIO ALONSO. H. Son Llatzer, Mallorca 30)SANTIAGO RUBIO H Royo Villanova, Zaragoza 31)FRANCISCO JAVIER RUIZ CASTILLA. H. Puerta Del Mar, Cádiz 32)ANA SAGARRA. H. de Jerez, Cádiz 33)FUENSANTA SORIANO. H. Inf.anta Margarita, Cabra, Córdoba 34)JUAN SINISTERRA S.E.S. Alicante 35)JOSE MANUEL TORRES MURILLO. H. Reina Sofía, Córdoba

  8. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK BACKGROUND E.D. phisicians must be experts in the rapid recognition of shock to allow aggressive targeted intervention and reduce morbidity and mortality. The AIM of this study is trying to know characteristics of these patients in Spain , and so, the importance of an early identification and intervention.

  9. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK METHODS Nacional Multicenter 3) Trial 4) Prospective 5) Observational 6) Approvedbythe local ethicscommitees

  10. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK Enrollmentwaslimitedtopatientswith : 1) Age: from 14 to 100 2) A diagnosis criteria of shock 3) Exclusioncriteriaincluding: pregnantwomen

  11. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK • Data werecollectedduring 3 monthsbytheinvestigators and held and analyzedbyanstatisticalteam in Madrid. • Number of patients: 587 • Number of data fields per patientwere: 88: • Demographics, thepresence of famliy and personal diseases, laboratory and imaginresults,thewaytheycontactedwiththe E.D.

  12. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK R E S U L T S

  13. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK Number of patients : 587 Age, mean (DS) : 69 (18) years 3 Morocco 95,7 % 2 Colombia Guinea Romania Russia 1 Germany Italy México Perú

  14. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK P= 0,508 P= 0,110 NO SIGNIFICANT DIFFERENCE

  15. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK • FAMILY MEDICAL HISTORY of SHOCK • One case : 0,2 % • Never have one : 10,1 % • DO NOT KNOW: 89,8 % • PERSONAL MEDICAL HISTORY of SHOCK: (NS) • The 9,2 % have one kind of shock before : • Septic (64 %) • Hipovolemic (20 %) • Cardiogenic (12 %) • Anafilactic (2 %) • Others (2 %) • Never have one : 66,7 % • DO NOT KNOW : 24,1 %

  16. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK (*):risk of shock (**):mortality

  17. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK P>0,324 NO SIGNIFICANT DIFFERENCE

  18. THE R.E.S.H. STUDY PERSONAL MEDICAL HISTORY (I) SPANISH GROUP OF SHOCK NO SIGNIFICANT DIFFERENCE

  19. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK SIGNIFICANT DIFFERENCE P< 0,002 P>0,226 NO SIGNIFICANT DIFFERENCE

  20. THE R.E.S.H. STUDY PRINCIPAL SYMPTOM

  21. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK Wehavefound : STATISTICAL DIFFERENCE between a DELAY in the FILLED CAPILLARY and the MORTALITY in SHOCK p< 0,000 TI: 2,4-2,6; OR: 4,28 NO SIGNIFICANT DIFFERENCE PALENESS P> 0,110

  22. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK THE LOWER THE SYSTOLIC,DISTOLIC BLOOD PRESSURE, TEMPERATURE ARE, and THE HIGHER RESPIRATORY RATE IS, THE HIGHER MORTALITY IS , with E.S.

  23. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK • Out of the E.D.:33% • Into the E.D.: 67% • When the patient came to the E.D. with the venous access, the mortality was :42,9% and into E.D., 32,6%!!!!!!! CIRCULATORY ACCESS SIGNIFICANT DIFFERENCE P< 0,016

  24. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK

  25. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK

  26. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK NO: 78 % YES: 22 % ¿Didthepatientgoto a G.P.? SIGNIFICANT DIFFERENCE P< 0,003

  27. THE R.E.S.H. STUDY E.K.G. SPANISH GROUP OF SHOCK In 54 cases, therewere NO ekg The 55,2% present a sinusrythm and 44,8%, others. Themostprevalentarrythmia was AF (36,1%) SIGNIFICANT DIFFERENCE P< 0,002

  28. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK In 62 cases, there were no radiography There were normal in a 46,3% and pathological 53,7%, THORAX RADIOGRAPHY There were a statistical relationship between the result of the first radiograph and the mortality PATHOLOGICAL 53,7% NORMAL 46,3% SIGNIFICANT DIFFERENCE P< 0,005

  29. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK Among the pathological findings, we can review: •INFILTRATES (52,8%) : 69,4%,20,4% Right/Left •PLEURAL EFFUSIONS (5.6%):79%,21% Right/Left •OTHERS: (41,6%) THORAX RADIOGRAPHY

  30. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK ECOCARDIOGRAPHY IT WAS USED ONLY IN A 1,7% OF THE PATIENTS. The results were, one case with normal findings and other with a severe pericardic effusion. NO SIGNIFICANT DIFFERENCE: P>1,000

  31. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK ABDOMINAL ULTRASOUND It was only used in 18% of the patients. 45,5%, normal; 54,5%,pathological SIGNIFICANT DIFFERENCE: P<0,004

  32. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK THE ULTRASOUND IN THE PATIENT IN SHOCK, IT IS RARELY USED (19%). FOUR HOURS AFTER ARRIVAL OF THE PATIENT AT E.D.

  33. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK If we do not use the ultrasound, in a patient in shock, the mortality is higher (38,4%),but the others (21,7%). Among the first ones, we have found a dimising of mortality, more than >50% (OR:0,45) confidence interval of 95% (0,24-0,83). SIGNIFICANT DIFFERENCE P<0,004

  34. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK THORAX CT: Itwasonlyused in 5,3% of thepatients,( 94,7%) NO SIGNIFICANT DIFFERENCE: P>1,000

  35. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK ABDOMINAL CT ABDOMINAL CT It was only used in 6,1% of the patients (93,9%) NO SIGNIFICANT DIFFERENCE: P>0,646

  36. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK BRAIN CT • It was only used in 5,% of the patients (95%) • The findings were:one patient with a brain tumor and another one ,normal NO SIGNIFICANT DIFERENCE P>0,208

  37. THE R.E.S.H. STUDY VASOPRESSOR DRUGS SPANISH GROUP OF SHOCK They were applied to a 42,8 % of the patients in shock (57,2%) CENTRAL VENOUS PRESSURE: It was messured in a 23,2% patients (76,8% ) NO SIGNIFICANT DIFFERENCE

  38. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK FLUIDOTHERAPY ADMINISTRATION • The fluidotherapy was administrated in a 69,8% at the E.D. and the other 30,2%, outside E.D. • The mortality among those, which the venous peripheral access where performance out of the E.D. was less than the other patients (32,6% in front of 42,9%). P<0,016 SIGNIFICANT DIFFERENCE

  39. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK . KIND OF FLUIDOTHERAPY SIGNIFICANT DIFFERENCE between glucose fluids and mortality in shock, p<0,006

  40. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK VOLUME ADMINISTRATED IN THE FIRST HOUR AFTER CONTACT WITH THE E.D. NO SIGNIFICANT DIFFERENCE

  41. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK WATER DIURESIS SIGNIFICANT DIFFERENCE between the less water diuresis during the first hour, after diagnosis and mortality in shock

  42. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK Among the séptic shock patients, the most frequent source were: Lung (44,1%) Kidney (25,7%) Colo-rectal (12,5%) Skin (3,1%) Central Nervous System (1,7%) Others (12,8%) INFECTION FOCUS

  43. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK ANTHIBIOTICS IT IS NECESSARY TO REPEAT THIS TOPIC, BECAUSE, THE SMALL NUMBER OF SUBJECTS COLLECTED. NO SIGNIFICANT DIFFERENCE

  44. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK VANCOMICINA5.0% NO SIGNIFICANT DIFFERENCE

  45. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK GLASGOW SCALE • Between 14-15: 62,7% • Among 13-7 : 25,7% • Among les than 7: 11,5%. SIGNIFICANT DIFFERENCE between the Glasgow scale and mortality in shock: p<0,004

  46. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK KIND OF SHOCK OUT SIDE E.D. INTO E.D.

  47. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK FOLOW UP ADMITTED TO AN INTERNAL MEDICINE FLOOR : 99,9% ADMITTED TO ICU: 31,9% DEATH :35,9% ALIVE: 64,1%.

  48. THE R.E.S.H. STUDY SPANISH GROUP OF SHOCK RANKIN SCORE NO SIGNIFICANT DIFFERENCE

  49. THE R.E.S.H. STUDY CONCLUSIONS SPANISH GROUP OF SHOCK • Patient with dyscomfort 2) Neoplasia 3) Chronical Bronchitis 4) Delay in filled capillary 5) Systolic blood pressure less than 110 mm Hg 6) Diastolic blood pressure less than 50 mm Hg 7) Respiratoy Rate more than 22 rates/min 8) Temperature less than 36ºC

  50. THE R.E.S.H. STUDY CONCLUSIONS II SPANISH GROUP OF SHOCK 8)Venous Access canalyzedout of the E.D. 9) ProthrombineActivity < 70% 10) Sodium>136 mmol/liter 11) Ph < 7,32 12) Bicarbonate <20 mg/cc 13) Lacticacid> 19 14) Abnormalfirst EKG(AF); thóraxradiography,(infiltrate); abdominal ultrasound

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