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Accuracy of Noninvasive and Invasive Point-of-Care Hemoglobin Measurement in the Emergency Department
Research Forum Abstracts Table 1. Group analysis of hemoglobin level derived by point of care HemoCue and laboratory CBC hemoglobin measurement. Group
# Patients
# Visits
HemoCue
CBC Hemoglobin
Difference
95% CI
30 77
41 612
8.559 (SD 2.023) 9.187 (SD 2.018)
8.707 (SD 1.866) 9.185 (SD 1.823)
0.148 (p¼0.730) 0.002 (p¼0.990)
1.004, 0.707 0.214, 0.217
Low-User (1 or less visit/year) High-User (>1 visit/year)
hemoglobin measurements is 0.008, and it is not significant with p¼0.9394. The 95% confidence interval of the mean difference is (0.217, 0.201). There were 30 patients in the low-user group and 77 patients in the high-user group. The HemoCue and CBC hemoglobin values are shown in the Table. There is no significant difference detected in either group between the hemoglobin level determined by HemoCue or CBC hemoglobin measurement. Conclusions: Hemoglobin measurements obtained from point-of-care HemoCue testing are highly comparable to hemoglobin values obtained from a CBC in the setting of sickle cell disease vaso-occlusive crisis.
104 105
Withdrawn Time to Treatment and Mortality in Acute Promyelocytic Leukemia
Haq SM, Willis Merriman K, Todd K/MD Anderson Cancer Center, Houston, TX
Background: Acute promyelocytic leukemia (APL), a subtype of acute myelogenous leukemia, is uniformly fatal if untreated. However, advances in treatment have markedly improved outcomes for this form of leukemia. Effective therapy is based on prompt recognition of the disease and urgent administration of all-trans retinoic acid (ATRA), a differentiating agent which leads to apoptosis of the malignant cells. National guidelines recommend immediate initiation of ATRA based treatment prior to confirmatory genetic testing. However, evidence is lacking as to whether APL treatment with ATRA is truly time sensitive. Study Objective: To evaluate the effect of time to ATRA treatment on 30-day mortality of patients with APL. Methods: All APL patients over a 5-year period, from 2007 to 2011, presenting to the emergency department (ED) at MD Anderson Cancer Center were identified using the International Classification of Diseases of Oncology histology code 98663. Patients with prior APL treatment or prior malignancies were excluded. Each patient’s chart was reviewed for administration of ATRA. Times from symptom onset to ED triage and the first dose of ATRA were recorded. Patient charts were also reviewed for age at diagnosis, sex, year of diagnosis, white blood cell count, platelet count, and coagulation times. 30 day mortality was recorded for each patient. Results: Eighty patients with a new diagnosis of APL as the first malignancy presented to the MD Anderson ED between 2007 and 2011, and all patients underwent treatment with ATRA. Four were excluded from analysis as time of symptoms onset was not available. The average patient age at diagnosis was 44 and 45% were male. The average times from onset of symptoms to ED triage and from ED triage to ATRA treatment were 17 days and 16.3 hours, respectively. Eighty-three percent of patients received ATRA treatment within 24 hours of ED presentation. Four patients died within 30 days, 3 from pulmonary hemorrhage and 1 from intracranial hemorrhage. When comparing patients who died within 30 days to the rest of the cohort, patients with early death had symptoms for four additional days. No additional differences were noted between the two groups. Conclusions: Time from symptoms onset to ED presentation was found to be associated with 30-day mortality. Strategies to detect patients at higher risk and education regarding symptoms may be of benefit, although identifying these variables would be difficult.
106
Accuracy of Noninvasive and Invasive Point-of-Care Hemoglobin Measurement in the Emergency Department
Wager A, Thomas AW, Sewatsky TP, Boas S, O‘keefe MF, Freeman K/University of Vermont, Burlington, VT
Study Objectives: Hemoglobin measurement is one of the most common tests performed in the emergency department (ED). Rapid, point-of-care measurement of hemoglobin with a finger sensor to detect light attenuation characteristics, may provide
Volume 62, no. 4s : October 2013
benefits to ED patients if the accuracy of this noninvasive measurement is comparable to invasive testing. The objective of this study was to compare noninvasive hemoglobin measurement with the Pronto-7 (SpHb) and capillary point-of-care measurement with HemoCue to reference values from a laboratory hematology analyzer (Hb). Methods: We studied the performance characteristics of point-of-care hemoglobin measurement in ED patients requiring a complete blood count for standard care. Eligible patients were hemodynamically stable and able to provide informed consent for enrollment prior to phlebotomy. A venous sample, analyzed with a hematology analyzer (Beckman Coulter LH 50, Beckman Coulter Inc.) and two capillary samples from a single finger stick, analyzed with a point-of-care device (Hemocue 201þ, HemoCue Inc.), were obtained from each patient. Additionally, two consecutive, SpHb spot check measurements were taken with an appropriately sized (small, medium or large) reusable sensor (rainbow 4D sensor, rev F) connected to a Pronto-7 (sw version 2317, Masimo Corp.). Blood collection for venous and capillary tests was performed within 15 min of noninvasive testing. The mean of the two values obtained from the Pronto-7 and HemoCue spot check devices were compared to the value from the hematology analyzer (Hb). Bias1 standard deviation (SD) and 95% limits of agreement were calculated for the SpHb and capillary measurement. Results: Of the 71 patients enrolled, 14 were excluded from analysis due to missing values (6 capillary, 5 Hb, 1 SpHb) or protocol deviations (2). Subjects ranged from 18 to 88 yrs and 59% were female. Subjects provided 57 sets of hemoglobin values. Hb values ranged from 7.7 to 16.6 g/dL. BiasSD compared to Hb were 1.11.3 g/dL for SpHb and 1.31.0 for capillary measurement. Limits of agreement were 3.6 to 1.4 g/dL for SpHb and -3.9 to 1.2 g/dL for capillary measurement. There were no significant differences in the bias or the limits of agreement between methods. Conclusions: Noninvasive hemoglobin measurement with the Pronto-7 had similar performance characteristics as capillary HemoCue measurements in ED patients. Noninvasive measurement provides benefits of patient comfort and reduced exposure of health care providers to biohazards such as sharps injury and blood borne pathogens. Our results suggest that the Pronto-7 may provide a clinically acceptable method to diagnose anemia, which may be useful for triage, screening, or continuous hemoglobin monitoring in the ED.
107
The Early Predictive Ability of Myoglobin versus Troponin in Patients Presenting to the Emergency Department With Suspected Acute Coronary Syndrome
Nale J, Lee D, Sud P, Chen A, Ward M, Kintzer E, Boccio E, Medairos R, Bilello L, Wu M/North Shore University Hospital, Manhasset, NY
Background: Myoglobin is a component of cardiac muscle that is released upon injury and has been used as a biomarker for cardiac injury. Older literature reported that myoglobin concentrations may rise prior to other commercially available biomarkers in the setting of an acute myocardial infarction and may be more sensitive in detecting recent cardiac injury. In our institution, we routinely include myoglobin assays along with assays for troponin and creatinine phosphokinase as a panel test as suggested by McCord in 2003. However, with the increasing sensitivity of troponin testing over the past decade, many institutions no longer use myoglobin testing to detect recent cardiac injury. Study Objective: To determine the utility of serum myoglobin levels versus troponin levels in detecting acute myocardial injury in patients presenting to the emergency department (ED) with symptoms suggestive of acute coronary syndrome. Methods: We performed an IRB-approved retrospective chart review of all ED patients who had cardiac biomarker tests performed over a nine-month period in 2012 at a suburban tertiary care hospital (an annual census over 85,000 patients). Subjects were identified through laboratory query of all patients who had successive cardiac biomarkers panels which included serial myoglobin and troponin tests obtained over two consecutive days. We obtained patient demographics, hospital course metrics, and discharge. We identified subjects who had an initial elevated myoglobin result with an initial normal troponin results. We specifically reviewed all charts who had elevated troponin testing within 24-48 hours. We used descriptive statistics to analyze the data.
Annals of Emergency Medicine S41
# Patients
# Visits
HemoCue
CBC Hemoglobin
Difference
95% CI
30 77
41 612
8.559 (SD 2.023) 9.187 (SD 2.018)
8.707 (SD 1.866) 9.185 (SD 1.823)
0.148 (p¼0.730) 0.002 (p¼0.990)
1.004, 0.707 0.214, 0.217
Low-User (1 or less visit/year) High-User (>1 visit/year)
hemoglobin measurements is 0.008, and it is not significant with p¼0.9394. The 95% confidence interval of the mean difference is (0.217, 0.201). There were 30 patients in the low-user group and 77 patients in the high-user group. The HemoCue and CBC hemoglobin values are shown in the Table. There is no significant difference detected in either group between the hemoglobin level determined by HemoCue or CBC hemoglobin measurement. Conclusions: Hemoglobin measurements obtained from point-of-care HemoCue testing are highly comparable to hemoglobin values obtained from a CBC in the setting of sickle cell disease vaso-occlusive crisis.
104 105
Withdrawn Time to Treatment and Mortality in Acute Promyelocytic Leukemia
Haq SM, Willis Merriman K, Todd K/MD Anderson Cancer Center, Houston, TX
Background: Acute promyelocytic leukemia (APL), a subtype of acute myelogenous leukemia, is uniformly fatal if untreated. However, advances in treatment have markedly improved outcomes for this form of leukemia. Effective therapy is based on prompt recognition of the disease and urgent administration of all-trans retinoic acid (ATRA), a differentiating agent which leads to apoptosis of the malignant cells. National guidelines recommend immediate initiation of ATRA based treatment prior to confirmatory genetic testing. However, evidence is lacking as to whether APL treatment with ATRA is truly time sensitive. Study Objective: To evaluate the effect of time to ATRA treatment on 30-day mortality of patients with APL. Methods: All APL patients over a 5-year period, from 2007 to 2011, presenting to the emergency department (ED) at MD Anderson Cancer Center were identified using the International Classification of Diseases of Oncology histology code 98663. Patients with prior APL treatment or prior malignancies were excluded. Each patient’s chart was reviewed for administration of ATRA. Times from symptom onset to ED triage and the first dose of ATRA were recorded. Patient charts were also reviewed for age at diagnosis, sex, year of diagnosis, white blood cell count, platelet count, and coagulation times. 30 day mortality was recorded for each patient. Results: Eighty patients with a new diagnosis of APL as the first malignancy presented to the MD Anderson ED between 2007 and 2011, and all patients underwent treatment with ATRA. Four were excluded from analysis as time of symptoms onset was not available. The average patient age at diagnosis was 44 and 45% were male. The average times from onset of symptoms to ED triage and from ED triage to ATRA treatment were 17 days and 16.3 hours, respectively. Eighty-three percent of patients received ATRA treatment within 24 hours of ED presentation. Four patients died within 30 days, 3 from pulmonary hemorrhage and 1 from intracranial hemorrhage. When comparing patients who died within 30 days to the rest of the cohort, patients with early death had symptoms for four additional days. No additional differences were noted between the two groups. Conclusions: Time from symptoms onset to ED presentation was found to be associated with 30-day mortality. Strategies to detect patients at higher risk and education regarding symptoms may be of benefit, although identifying these variables would be difficult.
106
Accuracy of Noninvasive and Invasive Point-of-Care Hemoglobin Measurement in the Emergency Department
Wager A, Thomas AW, Sewatsky TP, Boas S, O‘keefe MF, Freeman K/University of Vermont, Burlington, VT
Study Objectives: Hemoglobin measurement is one of the most common tests performed in the emergency department (ED). Rapid, point-of-care measurement of hemoglobin with a finger sensor to detect light attenuation characteristics, may provide
Volume 62, no. 4s : October 2013
benefits to ED patients if the accuracy of this noninvasive measurement is comparable to invasive testing. The objective of this study was to compare noninvasive hemoglobin measurement with the Pronto-7 (SpHb) and capillary point-of-care measurement with HemoCue to reference values from a laboratory hematology analyzer (Hb). Methods: We studied the performance characteristics of point-of-care hemoglobin measurement in ED patients requiring a complete blood count for standard care. Eligible patients were hemodynamically stable and able to provide informed consent for enrollment prior to phlebotomy. A venous sample, analyzed with a hematology analyzer (Beckman Coulter LH 50, Beckman Coulter Inc.) and two capillary samples from a single finger stick, analyzed with a point-of-care device (Hemocue 201þ, HemoCue Inc.), were obtained from each patient. Additionally, two consecutive, SpHb spot check measurements were taken with an appropriately sized (small, medium or large) reusable sensor (rainbow 4D sensor, rev F) connected to a Pronto-7 (sw version 2317, Masimo Corp.). Blood collection for venous and capillary tests was performed within 15 min of noninvasive testing. The mean of the two values obtained from the Pronto-7 and HemoCue spot check devices were compared to the value from the hematology analyzer (Hb). Bias1 standard deviation (SD) and 95% limits of agreement were calculated for the SpHb and capillary measurement. Results: Of the 71 patients enrolled, 14 were excluded from analysis due to missing values (6 capillary, 5 Hb, 1 SpHb) or protocol deviations (2). Subjects ranged from 18 to 88 yrs and 59% were female. Subjects provided 57 sets of hemoglobin values. Hb values ranged from 7.7 to 16.6 g/dL. BiasSD compared to Hb were 1.11.3 g/dL for SpHb and 1.31.0 for capillary measurement. Limits of agreement were 3.6 to 1.4 g/dL for SpHb and -3.9 to 1.2 g/dL for capillary measurement. There were no significant differences in the bias or the limits of agreement between methods. Conclusions: Noninvasive hemoglobin measurement with the Pronto-7 had similar performance characteristics as capillary HemoCue measurements in ED patients. Noninvasive measurement provides benefits of patient comfort and reduced exposure of health care providers to biohazards such as sharps injury and blood borne pathogens. Our results suggest that the Pronto-7 may provide a clinically acceptable method to diagnose anemia, which may be useful for triage, screening, or continuous hemoglobin monitoring in the ED.
107
The Early Predictive Ability of Myoglobin versus Troponin in Patients Presenting to the Emergency Department With Suspected Acute Coronary Syndrome
Nale J, Lee D, Sud P, Chen A, Ward M, Kintzer E, Boccio E, Medairos R, Bilello L, Wu M/North Shore University Hospital, Manhasset, NY
Background: Myoglobin is a component of cardiac muscle that is released upon injury and has been used as a biomarker for cardiac injury. Older literature reported that myoglobin concentrations may rise prior to other commercially available biomarkers in the setting of an acute myocardial infarction and may be more sensitive in detecting recent cardiac injury. In our institution, we routinely include myoglobin assays along with assays for troponin and creatinine phosphokinase as a panel test as suggested by McCord in 2003. However, with the increasing sensitivity of troponin testing over the past decade, many institutions no longer use myoglobin testing to detect recent cardiac injury. Study Objective: To determine the utility of serum myoglobin levels versus troponin levels in detecting acute myocardial injury in patients presenting to the emergency department (ED) with symptoms suggestive of acute coronary syndrome. Methods: We performed an IRB-approved retrospective chart review of all ED patients who had cardiac biomarker tests performed over a nine-month period in 2012 at a suburban tertiary care hospital (an annual census over 85,000 patients). Subjects were identified through laboratory query of all patients who had successive cardiac biomarkers panels which included serial myoglobin and troponin tests obtained over two consecutive days. We obtained patient demographics, hospital course metrics, and discharge. We identified subjects who had an initial elevated myoglobin result with an initial normal troponin results. We specifically reviewed all charts who had elevated troponin testing within 24-48 hours. We used descriptive statistics to analyze the data.
Annals of Emergency Medicine S41