Care Unit Length Of Stay Research Articles

Predicting Postoperative Complications, Intensive Care Unit Length of Stay, and Transfusion Requirements in Posterior Spinal Fusion for Adult Spinal Deformity using Artificial Intelligence

Predicting Postoperative Complications, Intensive Care Unit Length of Stay, and Transfusion Requirements in Posterior Spinal Fusion for Adult Spinal Deformity using Artificial Intelligence

Operational outcomes of propofol sedation versus fentanyl, midazolam and diphenhydramine sedation for endoscopies and colonoscopies at an academic medical center.

On July 1st, 2021, the University of Colorado Hospital (UCH) implemented new sedation protocols in the luminal gastrointestinal (GI) suite. GI proceduralist supervised, Nurse Administered Sedation with fentanyl, midazolam, and diphenhydramine (NAS) sedation was transitioned to Monitored Anesthesia Care with propofol under physician anesthesiologist supervision (MAC). To determine if there are statistically significant reductions in Sedation-Start to Scope-In time (SSSI) when using Monitored Anesthesia Care with propofol (MAC) versus Nurse Administered Sedation with fentanyl, midazolam, and diphenhydramine (NAS). Secondary objectives were to determine if statistically significant improvements to other operational times, quality measures, and satisfaction metrics were present. This study was a retrospective analysis of a natural experiment resultant of a change from NAS to MAC sedation protocols. Outcomes for NAS protocols from 1/1/21-6/30/21 were compared to outcomes of MAC protocols from the dates 8/1/21-10/31/21. Results were analyzed using Quasi-Poisson regression analysis and stratified based on upper GI, lower GI, and combined procedures. Patient demographic data including age, biological sex, comorbidities, and BMI, were adjusted for in the analysis. ASA matching was not performed as nursing sedation does not use ASA classifications. Pre-anesthesia co-morbidities were assessed via evaluation of a strict set of comorbidities abstracted from the electronic medical record. Perioperative operational outcomes include Sedation Start to Scope-In (SSSI), In-Room to Scope-In Time (IRSI), Scope Out to Out of Room (SOOR), Total Case Length (TCL), and Post Anesthesia Care Unit Length of Stay (PACU LOS). Quality outcomes include PACU Administered Medications (PAM), and Clinician Satisfaction Scores (CSS). A total of 5,582 gastrointestinal (GI) endoscopic cases (upper, lower, and combined endoscopies) were observed. Statistically significant decreases in SSSI of 2.5, 2.1, and 2.2 minutes for upper, lower, and dual GI procedures were observed when using MAC protocols. A statistically significant increase in satisfaction scores of 47.0 and 19.6 points were observed for nurses and proceduralists, respectively, when using MAC. MAC protocols for endoscopic GI procedures at UCH led to statistically significant decreases in the time required to complete procedures thus increasing operational efficiency.

Is the Patient State Index Recorded with the Sedline Sedation Monitor Correlated with the Duration of Emergence after Pediatric Surgery: An Exploratory, Single-Center, Blinded, Prospective Cohort Study

Introduction: Following surgery with general anesthesia, some children experience a prolonged emergence. We designed a prospective observational study in children undergoing general anesthesia who were monitored with the SedLine® Sedation Monitoring system (Masimo Corporation, Irvine, CA) to explore the hypothesis that the Patient State Index (PSI) obtained with this monitor could be inversely correlated with the duration of emergence after anesthesia. Materials and Methods: Prospective, observational single center study in a tertiary academic center in the United States. Fifty-six children between the ages of 1 and 12 years scheduled to undergo non-emergent surgery with general inhalational anesthesia were enrolled. Demographic and intraoperative characteristics were recorded. All caregivers were blinded to the PSI. Correlations were derived between PSI, duration of emergence, post-anesthesia care unit Length of Stay (LOS), and hospital LOS. PSI was analyzed in categories of <25, 25-50, and >50 both as absolute time spent in each category, and as the fraction of time compared to the length of the anesthetic. The development of Emergence Delirium (ED) was recorded as a secondary outcome variable. Results: The correlation coefficients between the PSI categories and the outcomes were weak (<0.3). Only two of the correlation coefficients reached statistical significance at p=0.05: fraction and absolute time spent in PSI category >50 and PACU length of stay, indicating that longer periods of PSI >50 during the anesthetic were associated with longer PACU LOS. Three patients (5%) developed ED. Conclusion: PSI measured with the SedLine monitor was not significantly correlated with the duration of emergence. There was a weak positive correlation between intraoperative time spent with PSI readings >50 and PACU LOS. Our sample did not have a high-enough event rate of ED to make statistical inferences about a correlation between PSI, ED and duration of emergence.

Influence of Congenital Heart Defect Types over Cardiopulmonary Bypass, Aortic Cross-Clamping, and Intensive Care Unit Length of Stay and Their Association with Genetic Factors

Aim: Surgical correction of congenital heart defects (CHD) often requires interruption of blood flow through cardiopulmonary bypass (CPB) and aortic cross-clamping (ACC), for which duration(s) are considered to be prognostic factors, along with intensive care unit (ICU) length of stay (ICULOS). The aim of this study was to evaluate these surgical prognostic factors in pediatric patients with different types of CHD regarding their type of lesion and associated genetic factors.
 Study Design: Cross-sectional cohort study with 307 pediatric patients.
 Place and Duration of Study: Pediatric Intensive Care Unit (ICU) of Hospital da Criança Santo Antônio, in Porto Alegre/RS, Brazil, from 2006-2009 (3 years)
 Methodology: After inclusion criteria, we studied 266 pediatric patients admitted for the first time in a reference cardiac pediatric ICU from Southern Brazil following cardiac surgery. Intraoperative prognostic factors such as duration of CPB, ACC and ICULOS, in addition to dysmorphological and cytogenetic examinations were compiled and analyzed. P-values of <0.05 were considered significant.
 Results: CPB time was associated to four outflow tract defects (Tetralogy of Fallot [ToF], transposition of the great arteries [TGA], double outlet right ventricle, and truncus arteriosus [TA]), atrioventricular septal defect, and hypoplastic left heart syndrome (HLHS) (P < 0.001). ACC duration was associated with three outflow tract defects (ToF, TGA, and TA) and HLHS (P < 0.001). Moreover, CPB and ACC times showed an association with cyanotic and complex heart defects, as well as prolonged ICULOS (P < 0.001). There was no relationship between these prognostic factors and syndromic aspects or cytogenetic findings.
 Conclusions: CHD type has an impact over CPB and ACC duration and ICULOS, whereas genetic factors are not associated with those prognostic factors.

Prediction of Intensive Care Unit Length of Stay in the MIMIC-IV Dataset

Accurately estimating the length of stay (LOS) of patients admitted to the intensive care unit (ICU) in relation to their health status helps healthcare management allocate appropriate resources and better plan for the future. This paper presents predictive models for the LOS of ICU patients from the MIMIC-IV database based on typical demographic and administrative data, as well as early vital signs and laboratory measurements collected on the first day of ICU stay. The goal of this study was to demonstrate a practical, stepwise approach to predicting patient’s LOS in the ICU using machine learning and early available typical clinical data. The results show that this approach significantly improves the performance of models for predicting actual LOS in a pragmatic framework that includes only data with short stays predetermined by a prior classification.

Impact of Fluid Balance on Intensive Care Unit Length of Stay in Critically Ill Trauma Patients.

There is significant data in the medical and surgical literature supporting the correlations between positive volume balance and negative outcomes such as AKI, prolonged mechanical ventilation, intensive care unit and hospital length of stay and increased mortality. This single-center, retrospective chart review included adult patients identified from a Trauma Registry database. The primary outcome was the total ICU LOS. Secondary outcomes include hospital LOS, ventilator-free days, incidence of compartment syndrome, acute respiratory distress syndrome (ARDS), renal replacement therapy (RRT), and days of vasopressor therapy. In general, baseline characteristics were similar between groups with the exception of mechanism of injury, FAST exam, and disposition from the ED. The ICU LOS was shortest in the negative fluid balance and longest in the positive fluid balance group (4 days vs 6 days, P = .001). Hospital LOS was also shorter in the negative balance group than that of the positive balance group (7 days vs 12 days, P < .001). More patients in the positive balance group experienced acute respiratory distress syndrome compared to the negative balance group (6.3% vs 0%, P = .004). There was no significant difference in the incidence of renal replacement therapy, days of vasopressor therapy, or ventilator-free days. A negative fluid balance at seventy-two hours was associated with a shorter ICU and hospital LOS in critically ill trauma patients. Our observed correlation between positive volume balance and total ICU days merits further exploration with prospective, comparative studies of lower volume resuscitation to key physiologic endpoints compared with routine standard of care.

CONTINUOUS FORMS OF INTRA-OPERATIVE ULTRAFILTRATION ENHANCE RECOVERY AFTER ADULT CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

CONTINUOUS FORMS OF INTRA-OPERATIVE ULTRAFILTRATION ENHANCE RECOVERY AFTER ADULT CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Comparison of Four Machine Learning Techniques for Prediction of Intensive Care Unit Length of Stay in Heart Transplantation Patients.

BackgroundPost-operative heart transplantation patients often require admission to an intensive care unit (ICU). Early prediction of the ICU length of stay (ICU-LOS) of these patients is of great significance and can guide treatment while reducing the mortality rate among patients. However, conventional linear models have tended to perform worse than non-linear models.Materials and MethodsWe collected the clinical data of 365 patients from Wuhan Union Hospital who underwent heart transplantation surgery between April 2017 and August 2020. The patients were randomly divided into training data (N = 256) and test data (N = 109) groups. 84 clinical features were collected for each patient. Features were validated using the Least Absolute Shrinkage and Selection Operator (LASSO) regression’s fivefold cross-validation method. We obtained Shapley Additive explanations (SHAP) values by executing package “shap” to interpret model predictions. Four machine learning models and logistic regression algorithms were developed. The area under the receiver operating characteristic curve (AUC-ROC) was used to compare the prediction performance of different models. Finally, for the convenience of clinicians, an online web-server was established and can be freely accessed via the website https://wuhanunion.shinyapps.io/PredictICUStay/.ResultsIn this study, 365 consecutive patients undergoing heart transplantation surgery for moderate (NYHA grade 3) or severe (NYHA grade 4) heart failure were collected in Wuhan Union Hospital from 2017 to 2020. The median age of the recipient patients was 47.2 years, while the median age of the donors was 35.58 years. 330 (90.4%) of the donor patients were men, and the average surgery duration was 260.06 min. Among this cohort, 47 (12.9%) had renal complications, 25 (6.8%) had hepatic complications, 11 (3%) had undergone chest re-exploration and 19 (5.2%) had undergone extracorporeal membrane oxygenation (ECMO). The following six important clinical features were selected using LASSO regression, and according to the result of SHAP, the rank of importance was (1) the use of extracorporeal membrane oxygenation (ECMO); (2) donor age; (3) the use of an intra-aortic balloon pump (IABP); (4) length of surgery; (5) high creatinine (Cr); and (6) the use of continuous renal replacement therapy (CRRT). The eXtreme Gradient Boosting (XGBoost) algorithm presented significantly better predictive performance (AUC-ROC = 0.88) than other models [Accuracy: 0.87; sensitivity: 0.98; specificity: 0.51; positive predictive value (PPV): 0.86; negative predictive value (NPV): 0.93].ConclusionUsing the XGBoost classifier with heart transplantation patients can provide an accurate prediction of ICU-LOS, which will not only improve the accuracy of clinical decision-making but also contribute to the allocation and management of medical resources; it is also a real-world example of precision medicine in hospitals.

Venous thromboembolism in COVID-19 patients and prediction model: a multicenter cohort study

BackgroundPatients with COVID-19 infection are commonly reported to have an increased risk of venous thrombosis. The choice of anti-thrombotic agents and doses are currently being studied in randomized controlled trials and retrospective studies. There exists a need for individualized risk stratification of venous thromboembolism (VTE) to assist clinicians in decision-making on anticoagulation. We sought to identify the risk factors of VTE in COVID-19 patients, which could help physicians in the prevention, early identification, and management of VTE in hospitalized COVID-19 patients and improve clinical outcomes in these patients.MethodThis is a multicenter, retrospective database of four main health systems in Southeast Michigan, United States. We compiled comprehensive data for adult COVID-19 patients who were admitted between 1st March 2020 and 31st December 2020. Four models, including the random forest, multiple logistic regression, multilinear regression, and decision trees, were built on the primary outcome of in-hospital acute deep vein thrombosis (DVT) and pulmonary embolism (PE) and tested for performance. The study also reported hospital length of stay (LOS) and intensive care unit (ICU) LOS in the VTE and the non-VTE patients. Four models were assessed using the area under the receiver operating characteristic curve and confusion matrix.ResultsThe cohort included 3531 admissions, 3526 had discharge diagnoses, and 6.68% of patients developed acute VTE (N = 236). VTE group had a longer hospital and ICU LOS than the non-VTE group (hospital LOS 12.2 days vs. 8.8 days, p < 0.001; ICU LOS 3.8 days vs. 1.9 days, p < 0.001). 9.8% of patients in the VTE group required more advanced oxygen support, compared to 2.7% of patients in the non-VTE group (p < 0.001). Among all four models, the random forest model had the best performance. The model suggested that blood pressure, electrolytes, renal function, hepatic enzymes, and inflammatory markers were predictors for in-hospital VTE in COVID-19 patients.ConclusionsPatients with COVID-19 have a high risk for VTE, and patients who developed VTE had a prolonged hospital and ICU stay. This random forest prediction model for VTE in COVID-19 patients identifies predictors which could aid physicians in making a clinical judgment on empirical dosages of anticoagulation.

Early Neurological Improvement Can Reduce Intensive Care Unit Length of Stay in Aneurysmal Subarachnoid Hemorrhage (P12-10.008)

Early Neurological Improvement Can Reduce Intensive Care Unit Length of Stay in Aneurysmal Subarachnoid Hemorrhage (P12-10.008)

Analyzing Relationships Between Economic and Neighborhood-Related Social Determinants of Health and Intensive Care Unit Length of Stay for Critically Ill Children With Medical Complexity Presenting With Severe Sepsis.

ObjectivesOf the Social Determinants of Health (SDoH), we evaluated socioeconomic and neighborhood-related factors which may affect children with medical complexity (CMC) admitted to a Pediatric Intensive Care Unit (PICU) in Shelby County, Tennessee with severe sepsis and their association with PICU length of stay (LOS). We hypothesized that census tract-level socioeconomic and neighborhood factors were associated with prolonged PICU LOS in CMC admitted with severe sepsis in the underserved community.MethodsThis single-center retrospective observational study included CMC living in Shelby County, Tennessee admitted to the ICU with severe sepsis over an 18-month period. Severe sepsis CMC patients were identified using an existing algorithm incorporated into the electronic medical record at a freestanding children's hospital. SDoH information was collected and analyzed using patient records and publicly available census-tract level data, with ICU length of stay as the primary outcome.Results83 encounters representing 73 patients were included in the analysis. The median PICU LOS was 9.04 days (IQR 3.99–20.35). The population was 53% male with a median age of 4.1 years (IQR 1.96–12.02). There were 57 Black/African American patients (68.7%) and 85.5% had public insurance. Based on census tract-level data, about half (49.4%) of the CMC severe sepsis population lived in census tracts classified as suffering from high social vulnerability. There were no statistically significant relationships between any socioeconomic and neighborhood level factors and PICU LOS.ConclusionPediatric CMC severe sepsis patients admitted to the PICU do not have prolonged lengths of ICU stay related to socioeconomic and neighborhood-level SDoH at our center. A larger sample with the use of individual-level screening would need to be evaluated for associations between social determinants of health and PICU outcomes of these patients.

Risk Factors for Longer Pediatric Intensive Care Unit Length of Stay Among Children Who Required Escalation of Care Within 24 Hours of Admission.

Children who require early escalation of care (EOC) to the pediatric intensive care unit (PICU) after floor admission have higher mortality and increased hospital length of stay (LOS) as compared with direct emergency department (ED) admissions. This study was designed to identify subgroups of patients within this cohort (EOC to PICU within 24 hours of hospital admission) who have worse outcomes (actual PICU LOS [aLOS] > predicted PICU LOS [pLOS]). This was a retrospective single-center cohort study. Patients who required EOC to PICU from January 2015 to December 2019 within 24 hours of admission were included. Postoperative patients, missing cause of EOC, and mortality were excluded. Predicted LOS was calculated based on Pediatric Risk of Mortality scores. Patients with aLOS > pLOS (group A) were compared with patients with aLOS ≤ pLOS (group B). Multivariable logistic regression was performed to adjust for confounders. Of 587 patients transferred to PICU after hospital admission during the study period, 286 patients met the study criteria (group A, n = 69; group B, n = 217). The 2 groups were similar in age, race, the severity of illness, and ED vitals and therapies. A higher proportion of patients in group B had EOC ≤ 6 hours of admission (51.1% vs 36.2%, P = 0.03), and a higher proportion in group A required Mechanical ventilation (56% vs 34%, P = 0.01). On multivariable regression, patients who required EOC to PICU after 6 hours after admission (adjusted odds ratio, 2.27; 95% confidence interval [CI] 1.2, 4.0), p,<0.01) and patients admitted to the floor from referral hospitals (adjusted odds ratio, 1.8; 95% confidence interval, 1.0-3.2), P = 0.04) had higher risk of greater than PLOS. Among patients who required EOC to PICU, risk factors associated with aLOS > pLOS were patients who required EOC to PICU longer than 6 hours after admission to the hospital and patients admitted to the floor as a transfer from referral hospitals.

Abstract TP124: Early Neurological Improvement Can Reduce Intensive Care Unit Length Of Stay In Aneurysmal Subarachnoid Hemorrhage

Introduction: Aneurysmal Subarachnoid Hemorrhage (aSAH) is often accompanied by an extended length of stay (LOS) in the intensive care unit (ICU), at tremendous cost to both the hospital system and the patient. We sought to determine predictors for ICU LOS in these patients. Methods: We performed a retrospective study of a cohort of consecutive patients with aSAH admitted to an academic referral center from 2016 to 2021. Multiple linear regression was performed in survivors to identify predictors for ICU LOS among factors present on admission and those related to hospital course. Results: In a cohort of 306 patients with confirmed aSAH, mean age was 57 years (SD 13.7), 61% were female and 70% were white. ICU LOS was longer for survivors (median 19 days, IQR 14-25) than for non-survivors (median 5 days, IQR 2-8; p&lt;0.001). For survivors (n=210), admission-related factors including Hunt and Hess grades 4 or 5 (4 additional days, 95% CI 0.5-7.5; p=0.027), hydrocephalus with external ventricular drain (EVD) requirement (9.2 additional days, 95% CI 5.7-12.8; p&lt;0.001), and coagulopathy (3.2 additional days, 95% CI 0.9-6.2; p=0.03) were associated with longer ICU LOS; however, early neurological improvement (defined as decrease in Hunt and Hess grades within first 3 days of admission) was associated with shorter ICU LOS (5.4 fewer days, 95% CI 2.7-8.5; p=0.001). Among hospital-related factors, symptomatic vasospasm (3.2 additional days, 95% CI 1.9-6.5; p=0.016), pneumonia (5.7 additional days, 95% CI 3.5-9.4; p= 0.001), and laryngeal edema requiring intubation or reintubation (4.3 additional days, 95% CI 0.7-7.8; p&lt;0.001) were associated with prolonged ICU LOS. Laboratory values from the emergency department and past medical history were not predictive for ICU LOS. Conclusion: Admission-related factors and in-hospital complications were more predictive for prolonged ICU LOS than past medical history or any laboratory values on admission. Early neurological improvement was associated with shorter ICU LOS which underscores the importance of early aggressive treatment measures in patients with aSAH.

Abstract WP125: Methamphetamine Associated Psychosis In Acute Stroke

Introduction: Methamphetamine, an addictive stimulant, may lead to psychosis of which little is known about the impact in acute stroke. Despite its short half-life, we hypothesize that methamphetamine use in acute stroke is associated with the development of psychosis and extends hospital length of stay (LOS). Methods: Single-center retrospective analysis (2016-2019) of consecutive adult patients admitted for acute ischemic stroke, intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (SAH), and transient ischemic attack (TIA) with methamphetamine detected on urine drug screen and were compared to those who did not. Psychosis was defined as disturbed thoughts or perceptions with abnormal psychomotor behavior. Psychosis onset and duration, clinical characteristics, total hospitalization time and intensive care unit (ICU) LOS, as well as psychotic treatment interventions were documented. Results: 138 patients were admitted for acute cerebrovascular events (87 ischemic strokes, 40ICH, 7 SAH, 2 TIAs). 69 patients tested positive for methamphetamine (68% male; mean age 53(range 26-68)) and were compared to 69 who did not (65% male, mean age 64 (range 30-93).Despite no differences in having any psychiatric illness history, 25% (17/69) of methamphetamine users experienced psychosis compared to only 3% (2/69) who did not test positive (p &lt;0.0002). Although there was no statistical difference in hospital LOS (3.6 days in methamphetamine positive versus 2.9 days ( p =.113)), substance use abusers had significantly longer ICU stays (48 hours versus 24 hours; p =.006). NIHSS and ICH Scores were not statistically different between those who tested positive or negative for methamphetamine. Conclusions: Methamphetamine use is strongly associated with developing psychosis and when present, leads to longer ICU stay.

Early Postoperative Extubation is Associated with Shorter Hospitalization and Improved Short-Term Survival in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is associated with significant operative time, hospital resources, and morbidity. We examine factors associated with hospital length of stay (LOS) and early overall survival (OS) after CRS/HIPEC. Patients who underwent CRS/HIPEC were evaluated for factors associated with LOS. Institutional learning curve influence was addressed by comparing early vs late cohorts. Variables with P < .200 after univariate analysis were considered for inclusion in multivariate linear regression modeling. Independent factors associated with OS were evaluated using the Kaplan-Meier method. Seventy patients underwent CRS/HIPEC (mean age 52.3years, 64.3% female, and 68.6% Caucasian). Presence of any surgical complication was found in 26 (37.1%), 28 (40%) remained intubated postoperatively, and the mean Peritoneal Carcinomatosis Index (PCI) score was 14.4 (10.4). Mean intensive care unit and hospital LOS were 2.9days (2.3) and 9.6days (3.6), respectively. After adjusting for covariates, only shorter time to postoperative ambulation (regression coefficient .92, P = .001) and early extubation (regression coefficient -1.90, P = .018) were associated with decreased hospital LOS on multivariate analysis. Immediate postoperative extubation conferred an independent early survival benefit on Kaplan-Meier analysis (mean OS 714.8 vs 473.4days, P = .010). There was no difference in hospital LOS or OS between early and late cohorts. Early postoperative extubation and shorter time to ambulation are associated with decreased hospital LOS. Moreover, CRS/HIPEC patients extubated immediately postoperatively have an early survival benefit. Every effort should be made to achieve early postoperative extubation and mobilization in CRS/HIPEC patients.

Crotalidae Polyvalent Immune Fab and Cost-Effective Management of Hospital Admissions for Snakebites.

Venomous snakebites are a common clinical scenario in the Southeastern United States. CroFab® (Crotalidae Polyvalent Immune Fab (Ovine), BTG, Wales, UK) antivenom is indicated in cases involving pit vipers and is known to be expensive. The treatment protocol for snakebites is based on clinically subjective measures triggering the application, or escalation of, antivenom administration. The purpose of this study is to characterize the use of CroFab at our institution and to evaluate the impact of its use regarding cost and overall outcomes. We suspect that it is often used but potentially less often needed. We hypothesized that CroFab use was associated with increased length of stay (LOS) without an observed difference in patient outcomes. A retrospective chart review of snakebite patients at our level-1 trauma center from 2000 to 2016 was performed. Snakebite location, snake species, number of vials of CroFab administered, hospital LOS, intensive care unit (ICU) LOS, and complications were identified for each patient. Patients were divided into CroFab (C) and no CroFab (NC) groups. One hundred ninety patients with venomous snakebites were included. 53.7% of patients received CroFab. There was no difference in the complication rate of C versus NC groups, (P = .1118). CroFab use was associated with longer hospital LOS (P < .0001) and ICU LOS (P < .0001). CroFab use was associated with increased LOS in our patient population. There was no difference in observed outcomes between the C and NC groups. These findings imply that CroFab is potentially over-used in our patient population.

Integration of Metabolomic and Clinical Data Improves the Prediction of Intensive Care Unit Length of Stay Following Major Traumatic Injury

Recent advances in emergency medicine and the co-ordinated delivery of trauma care mean more critically-injured patients now reach the hospital alive and survive life-saving operations. Indeed, between 2008 and 2017, the odds of surviving a major traumatic injury in the UK increased by nineteen percent. However, the improved survival rates of severely-injured patients have placed an increased burden on the healthcare system, with major trauma a common cause of intensive care unit (ICU) admissions that last ≥10 days. Improved understanding of the factors influencing patient outcomes is now urgently needed. We investigated the serum metabolomic profile of fifty-five major trauma patients across three post-injury phases: acute (days 0–4), intermediate (days 5–14) and late (days 15–112). Using ICU length of stay (LOS) as a clinical outcome, we aimed to determine whether the serum metabolome measured at days 0–4 post-injury for patients with an extended (≥10 days) ICU LOS differed from that of patients with a short (<10 days) ICU LOS. In addition, we investigated whether combining metabolomic profiles with clinical scoring systems would generate a variable that would identify patients with an extended ICU LOS with a greater degree of accuracy than models built on either variable alone. The number of metabolites unique to and shared across each time segment varied across acute, intermediate and late segments. A one-way ANOVA revealed the most variation in metabolite levels across the different time-points was for the metabolites lactate, glucose, anserine and 3-hydroxybutyrate. A total of eleven features were selected to differentiate between <10 days ICU LOS vs. >10 days ICU LOS. New Injury Severity Score (NISS), testosterone, and the metabolites cadaverine, urea, isoleucine, acetoacetate, dimethyl sulfone, syringate, creatinine, xylitol, and acetone form the integrated biomarker set. Using metabolic enrichment analysis, we found valine, leucine and isoleucine biosynthesis, glutathione metabolism, and glycine, serine and threonine metabolism were the top three pathways differentiating ICU LOS with a p < 0.05. A combined model of NISS and testosterone and all nine selected metabolites achieved an AUROC of 0.824. Differences exist in the serum metabolome of major trauma patients who subsequently experience a short or prolonged ICU LOS in the acute post-injury setting. Combining metabolomic data with anatomical scoring systems allowed us to discriminate between these two groups with a greater degree of accuracy than that of either variable alone.

Outcomes of Trauma Patients with Flail Chest and Surgical Rib Stabilization.

The goal of this project was to describe the current practices of this institution and identify which patients benefit from surgical stabilization of rib fractures (SSRF). A total of 1429 trauma patients admitted to our Level 1 center with rib fractures between January 1, 2014 and June 22, 2020 were retrospectively reviewed. Flail chest was observed in 43 (3.01%) patients. Surgical stabilization of rib fractures was pursued in 27 of all patients (1.89%). Twenty-four flail chest patients required intubation (ETT). Nineteen were not intubated (NoET). Of the ETT group, 8 underwent SSRF and 16 did not. Those who had SSRF had a shorter ventilator Length of Stay (7.1 vs 15.7d) and Intensive Care Unit Length of Stay (9.8 vs 11.9d). Surgical stabilization of rib fractures has shown success in managing flail chest. In intubated patients with flail chest, fixation seems to decrease Intensive Care Unit stays and the duration of ventilation. We believe we need to perform SSRF on more patients with flail chest.

Effects of Pre-Operative Risk Factors on Intensive Care Unit Length of Stay (ICU-LOS) in Major Oral and Maxillofacial Cancer Surgery.

Simple SummaryThis study aimed to investigate the effect of certain pre-operative parameters from the clinical routine directly on the post-operative intensive care unit (ICU)-length of stay (LOS) after major oral and maxillofacial cancer surgery. This study was performed to identify at-risk patients that are expected to need prolonged specialized care management post-operatively to these aforementioned operations. A homogenous cohort of 122 patients over a five year period was included in this study. At-risk patients are prone to need a significantly longer specialized care management than others. These patients are those with pre-operative severe renal dysfunction, peripheral vascular diseases and/or increasing heart failure stage categories. Confounding parameters that contribute to a prolonged specialized post-operative management in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.Objective: This study aimed to investigate the effect of certain pre-operative parameters directly on the post-operative intensive care unit (ICU)-length of stay (LOS), in order to identify at-risk patients that are expected to need prolonged intensive care management post-operatively. Material and Methods: Retrospectively, patients managed in an ICU after undergoing major oral and maxillofacial surgery were analyzed. Inclusion criteria entailed: age 18–90 years, major primary oral cancer surgery including tumor resection, neck dissection and microvascular free flap reconstruction, minimum operation time of 8 h. Exclusion criteria were: benign/borderline tumors, primary radiation, other defect reconstruction than microvascular, treatment at other centers. Separate parameters used within the clinical routine were set in correlation with ICU-LOS, by applying single testing calculations (t-tests, variance analysis, correlation coefficients, effect sizes) and a valid univariate linear regression model. The primary outcome of interest was ICU-LOS. Results: This study included a homogenous cohort of 122 patients. Mean surgery time was 11.4 (±2.2) h, mean ICU-LOS was 3.6 (±2.6) days. Patients with pre-operative renal dysfunction (p < 0.001), peripheral vascular disease-PVD (p = 0.01), increasing heart failure-NYHA stage categories (p = 0.009) and higher-grade categories of post-operative complications (p = 0.023) were identified as at-risk patients for a significantly prolonged post-operative ICU-LOS. Conclusions: At-risk patients are prone to need a significantly longer ICU-LOS than others. These patients are those with pre-operative severe renal dysfunction, PVD and/or high NYHA stage categories. Confounding parameters that contribute to a prolonged ICU-LOS in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.

Predicting Intensive Care Unit Length of Stay After Acute Type A Aortic Dissection Surgery Using Machine Learning.

Background: Patients with acute type A aortic dissection are usually transferred to the intensive care unit (ICU) after surgery. Prolonged ICU length of stay (ICU-LOS) is associated with higher level of care and higher mortality. We aimed to develop and validate machine learning models for predicting ICU-LOS after acute type A aortic dissection surgery.Methods: A total of 353 patients with acute type A aortic dissection transferred to ICU after surgery from September 2016 to August 2019 were included. The patients were randomly divided into the training dataset (70%) and the validation dataset (30%). Eighty-four preoperative and intraoperative factors were collected for each patient. ICU-LOS was divided into four intervals (<4, 4–7, 7–10, and >10 days) according to interquartile range. Kendall correlation coefficient was used to identify factors associated with ICU-LOS. Five classic classifiers, Naive Bayes, Linear Regression, Decision Tree, Random Forest, and Gradient Boosting Decision Tree, were developed to predict ICU-LOS. Area under the curve (AUC) was used to evaluate the models' performance.Results: The mean age of patients was 51.0 ± 10.9 years and 307 (87.0%) were males. Twelve predictors were identified for ICU-LOS, namely, D-dimer, serum creatinine, lactate dehydrogenase, cardiopulmonary bypass time, fasting blood glucose, white blood cell count, surgical time, aortic cross-clamping time, with Marfan's syndrome, without Marfan's syndrome, without aortic aneurysm, and platelet count. Random Forest yielded the highest performance, with an AUC of 0.991 (95% confidence interval [CI]: 0.978–1.000) and 0.837 (95% CI: 0.766–0.908) in the training and validation datasets, respectively.Conclusions: Machine learning has the potential to predict ICU-LOS for acute type A aortic dissection. This tool could improve the management of ICU resources and patient-throughput planning, and allow better communication with patients and their families.