Critical Care Admission Research Articles

Clinical risk calculators informing the decision to admit: A methodologic evaluation and assessment of applicability.

Clinical prediction and decision tools that generate outcome-based risk stratification and/or intervention recommendations are prevalent. Appropriate use and validity of these tools, especially those that inform complex clinical decisions, remains unclear. The objective of this study was to assess the methodologic quality and applicability of clinical risk scoring tools used to guide hospitalization decision-making. In February 2021, a comprehensive search was performed of a clinical calculator online database (mdcalc.com) that is publicly available and well-known to clinicians. The primary reference for any calculator tool informing outpatient versus inpatient disposition was considered for inclusion. Studies were restricted to the adult, acute care population. Those focused on obstetrics/gynecology or critical care admission were excluded. The Wasson-Laupacis framework of methodologic standards for clinical prediction rules was applied to each study. A total of 22 calculators provided hospital admission recommendations for 9 discrete medical conditions using adverse events (14/22), mortality (6/22), or confirmatory diagnosis (2/22) as outcomes of interest. The most commonly met methodologic standards included mathematical technique description (22/22) and clinical sensibility (22/22) and least commonly met included reproducibility of the rule (1/22) and measurement of effect on clinical use (1/22). Description of the studied population was often lacking, especially patient race/ethnicity (2/22) and mental or behavioral health (0/22). Only one study reported any item related to social determinants of health. Studies commonly do not meet rigorous methodologic standards and often fail to report pertinent details that would guide applicability. These clinical tools focus primarily on specific disease entities and clinical variables, missing the breadth of information necessary to make a disposition determination and raise significant validation and generalizability concerns.

260. Corticosteroid treatment in influenza virus and SARS-CoV-2 co-infected patients

Abstract Background Co-infections with SARS-CoV-2 and influenza virus may become more prevalent now that many countries are easing restrictions to reduce the spread of SARS-CoV-2. Co-infected patients are more likely to receive invasive mechanical ventilation (IMV) and have higher odds of in-hospital mortality. In the RECOVERY trial, dexamethasone was found to reduce the risk of 28-day mortality in hospitalised COVID-19 patients. On June 16, 2020, corticosteroids were included in clinical guidelines for the treatment of COVID-19 patients requiring supplemental oxygen. However, corticosteroid treatment in severe influenza virus infection may increase mortality. The effect of steroids in influenza and COVID-19 co-infected patients is unknown. Methods Adult patients with RT-PCR confirmed SARS-CoV-2 and influenza virus co-infection were evaluated. Patients without supplemental oxygen during admission were excluded. Patients who were hospitalised prior to June 16, 2020 were included in the ‘early’ group and patients who were hospitalised on or after June 16, 2020 were included in the ‘late’ group. Results 171 co-infected patients were included, 123 patients in the early group (table 1) and 48 in the late group (table 2). In the early group, 25 patients received steroids. In the late group, 40 patients received steroids. In the early group, the proportion of patients who were admitted to critical care was slightly lower in the group that received steroids. IMV was similar in both groups. In-hospital mortality was slightly higher in the group treated with steroids. In the late group, critical care admission and receipt of IMV were higher in the group not treated with corticosteroids than the group with corticosteroid treatment. In-hospital mortality was slightly lower in the group not treated with steroids. Conclusion There are differences between co-infected patients who were treated and not treated with corticosteroids and differences between the early and late groups. A limitation is that no dates were collected for the start of steroid treatment, making it impossible to draw conclusions on the causality of the need for IMV and treatment with steroids in this analysis. Future research should focus on the effect of steroids in COVID-19 and influenza co-infected patients. Disclosures Peter Openshaw, PhD, Bavarian Nordic: Advisor/Consultant|Cepheid: Advisor/Consultant|GlaxoSmithKline: Advisor/Consultant|Janssen: Advisor/Consultant|Pfizer: Advisor/Consultant Calum Semple, PhD, Integrum Scientific: Scientific Advisory Board|Integrum Scientific: Stocks/Bonds.

Monocyte distribution width as a pragmatic screen for SARS-CoV-2 or influenza infection

Monocyte distribution width (MDW) is a novel marker of monocyte activation, which is known to occur in the immune response to viral pathogens. Our objective was to determine the performance of MDW and other leukocyte parameters as screening tests for SARS-CoV-2 and influenza infection. This was a prospective cohort analysis of adult patients who underwent complete blood count (CBC) and SARS-CoV-2 or influenza testing in an Emergency Department (ED) between January 2020 and July 2021. The primary outcome was SARS-CoV-2 or influenza infection. Secondary outcomes were measures of severity of illness including inpatient hospitalization, critical care admission, hospital lengths of stay and mortality. Descriptive statistics and test performance measures were evaluated for monocyte percentage, MDW, white blood cell (WBC) count, and neutrophil to lymphocyte ratio (NLR). 3,425 ED patient visits were included. SARS-CoV-2 testing was performed during 1,922 visits with a positivity rate of 5.4%; influenza testing was performed during 2,090 with a positivity rate of 2.3%. MDW was elevated in patients with SARS-Cov-2 (median 23.0U; IQR 20.5–25.1) or influenza (median 24.1U; IQR 22.0–26.9) infection, as compared to those without (18.9U; IQR 17.4–20.7 and 19.1U; 17.4–21, respectively, P < 0.001). Monocyte percentage, WBC and NLR values were within normal range in patients testing positive for either virus. MDW identified SARS-CoV-2 and influenza positive patients with an area under the curve (AUC) of 0.83 (95% CI 0.79–0.86) and 0.83 (95% CI 0.77–0.88), respectively. At the accepted cut-off value of 20U for MDW, sensitivities were 83.7% (95% CI 76.5–90.8%) for SARS-CoV-2 and 89.6% (95% CI 80.9–98.2%) for influenza, compared to sensitivities below 45% for monocyte percentage, WBC and NLR. MDW negative predictive values were 98.6% (95% CI 98.0–99.3%) and 99.6% (95% CI 99.3–100.0%) respectively for SARS-CoV-2 and influenza. Monocyte Distribution Width (MDW), available as part of a routine complete blood count (CBC) with differential, may be a useful indicator of SARS-CoV-2 or influenza infection.

HPB P25 Incidence of pancreatitis induced vascular complications in a tertiary care hospital

Abstract Background Pancreatitis (AP) is a common cause of hospital admission, which can lead to vascular complications such as splanchnic venous thrombosis (SpVT), pseudoaneurysm and haemorhage. These complications can happen with both acute and chronic pancreatitis and can be associated with high morbidity and mortality. The aim of this study was to assess incidence of vascular complications in acute pancreatitis patients in a tertiary care hospital. Secondary aims included describing patient demographics, length of hospital stay, critical care admission, mortality, and assess the association between SpVT and pancreatic necrosis and mortality. Methods This study was done as part of year five elective project in University of Aberdeen Medical School. A retrospective study of acute pancreatitis patients who stayed in Aberdeen Royal Infirmary (ARI) or Dr. Gray's Hospital for ≥2 weeks and cases of mortality from acute pancreatitis irrespective of hospital stay between January 2018 to December 2019. Cases were identified from Health intelligence central data as per local governance protocol. Hospital electronic system (TrackCare) was used to review the clinical and radiological details and data was entered in SPSS software version 27 for analysis. Frequencies and percentages were shown for the categorical data and chi square test was used to compare the variables. A p value less than 0.05 was taken as statistically significant. Results Total 293 patients were admitted with acute pancreatitis during the study period. 52 patients met the inclusion criteria for our study. Of the 52 patients, 50 patients had a CT scan. There were 12 patients (24%) with evidence of vascular complications. 22% of patients had SVT and pseudoaneurysm was seen in 2% of cases. There was no case of haemorrhage. The overall mortality from AP during the study period was 6.5%. There was no statistically significant association between SVT and pancreatic necrosis or mortality. Conclusions Splanchnic venous thrombosis was a more frequent complication compared to pseudoaneurysm and haemorrhage in AP. There was no association between SVT and necrosis or mortality.

The Creation of a Critical Care Admission Pressure Injury Prevention Cart to Reduce Hospital-Acquired Pressure Injuries

The goal of this process improvement initiative is to reduce hospital-acquired pressure injuries related to Covid-19 with Critical Care patients. Critically ill and ventilated patients require prone position therapy and prolonged ventilator times place the patient at risk for hospital acquired conditions and pressure injuries. The Critical Care team created a Critical Care Admission Pressure Injury Prevention Cart that contains preventative dressings for all pressure areas at risk. The Critical Care Admission Pressure Injury Prevention Cart has significantly reduced the pressure injury rate. With the emergence of the pandemic and additional surges, pressure injuries continued to be on the rise due to prone position therapy. The Critical Care team worked with the system and developed prone position protocols, which included preventative dressings for all areas at risk. Prior to the implementation of the admission cart, Critical Care ended fiscal year 2022, quarter one, with fifty-three hospital acquired pressure injuries. Last December and early January 2022 there was another surge of Covid-19. The Critical Care team implemented the admission cart in January 2022. From January 2022 through September 2022, there has been an 98% reduction. The cart has been successful for Critical Care, and Baptist Hospital implemented the cart in all high acuity areas. This cart was a multidisciplinary practice, which consists of nursing, the wound and skin team, respiratory care, and leadership working together towards the goal of patient safety and pressure injury prevention.

Improving risk prediction model quality in the critically ill: data linkage study

Background A previous National Institute for Health and Care Research study [Harrison DA, Ferrando-Vivas P, Shahin J, Rowan KM. Ensuring comparisons of health-care providers are fair: development and validation of risk prediction models for critically ill patients. Health Serv Deliv Res 2015;3(41)] identified the need for more research to understand risk factors and consequences of critical care and subsequent outcomes. Objectives First, to improve risk models for adult general critical care by developing models for mortality at fixed time points and time-to-event outcomes, end-stage renal disease, type 2 diabetes, health-care utilisation and costs. Second, to improve risk models for cardiothoracic critical care by enhancing risk factor data and developing models for longer-term mortality. Third, to improve risk models for in-hospital cardiac arrest by enhancing risk factor data and developing models for longer-term mortality and critical care utilisation. Design Risk modelling study linking existing data. Setting NHS adult critical care units and acute hospitals in England. Participants Patients admitted to an adult critical care unit or experiencing an in-hospital cardiac arrest. Interventions None. Main outcome measures Mortality at hospital discharge, 30 days, 90 days and 1 year following critical care unit admission; mortality at 1 year following discharge from acute hospital; new diagnosis of end-stage renal disease or type 2 diabetes; hospital resource use and costs; return of spontaneous circulation sustained for &gt; 20 minutes; survival to hospital discharge and 1 year; and length of stay in critical care following in-hospital cardiac arrest. Data sources Case Mix Programme, National Cardiac Arrest Audit, UK Renal Registry, National Diabetes Audit, National Adult Cardiac Surgery Audit, Hospital Episode Statistics and Office for National Statistics. Results Data were linked for 965,576 critical care admissions between 1 April 2009 and 31 March 2016, and 83,939 in-hospital cardiac arrests between 1 April 2011 and 31 March 2016. For admissions to adult critical care units, models for 30-day mortality had similar predictors and performance to those for hospital mortality and did not reduce heterogeneity. Models for longer-term outcomes reflected increasing importance of chronic over acute predictors. New models for end-stage renal disease and diabetes will allow benchmarking of critical care units against these important outcomes and identification of patients requiring enhanced follow-up. The strongest predictors of health-care costs were prior hospitalisation, prior dependency and chronic conditions. Adding pre- and intra-operative risk factors to models for cardiothoracic critical care gave little improvement in performance. Adding comorbidities to models for in-hospital cardiac arrest provided modest improvements but were of greater importance for longer-term outcomes. Limitations Delays in obtaining linked data resulted in the data used being 5 years old at the point of publication: models will already require recalibration. Conclusions Data linkage provided enhancements to the risk models underpinning national clinical audits in the form of additional predictors and novel outcomes measures. The new models developed in this report may assist in providing objective estimates of potential outcomes to patients and their families. Future work (1) Develop and test care pathways for recovery following critical illness targeted at those with the greatest need; (2) explore other relevant data sources for longer-term outcomes; (3) widen data linkage for resource use and costs to primary care, outpatient and emergency department data. Study registration This study is registered as NCT02454257. Funding details This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 39. See the NIHR Journals Library website for further project information.

THE USE OF METARAMINOL AS A VASOPRESSOR IN CRITICALLY UNWELL PATIENTS: A NARRATIVE REVIEW AND A SURVEY OF UK PRACTICE

<h3>Background</h3> Major international guidelines state that norepinephrine should be used as the first-line vasopressor to achieve adequate blood pressure in patients with hypotension or shock. However, recent observational studies report that in the United Kingdom and Australia, metaraminol is often used as a first-line medication for cardiovascular support. <h3>Aim of the study</h3> The aim of this study was to carry out a systematic review of metaraminol use for the management of shock in critically unwell patients and carry out a survey evaluating whether UK critical care units use metaraminol and under which circumstances. <h3>Methods</h3> A systematic review literature search was conducted. We investigated 30 departments, representing small (< 10 beds), medium (10-20 beds), and large (> 20 beds) units, and both teaching and non-teaching hospitals, using a semi-structured narrative interview and a pre-defined list of questions. <h3>Results</h3> We received 26 responses from the 30 hospitals we contacted, representing 10% of UK adult critical care units. Of these 4 were small, 10 were medium, and 12 were large units. The surveyed units had a collective total of 34206 annual admissions, representing 17% of the UK total. The average number of admissions per small unit was 419/year, medium unit 757/year and larger unit 2080/year. In total, 88% of the units (23/26 hospitals) used metaraminol prior to critical care admission. In 70% of the hospitals, metaraminol was used on the wards or in the emergency departments. In 70% of the cases, metaraminol was used to manage hypotension due to any cause. Most hospitals (67%, 15/23) continued metaraminol infusion in the critical care unit. Almost half of the respondents explained that infusion was time-limited (usually 12–24 hours) with a subsequent change to norepinephrine. Approximately 2/3 of hospitals used metaraminol as the first-line vasopressor in critical care. The systematic literature review revealed several case reports and only two studies conducted in the last 20 years investigating the effect of metaraminol as a stand-alone vasopressor. Both studies focused on different aspects of metaraminol use, therefore it was not feasible to carry out a full systematic review. The narrative review has demonstrated the lack of robust evidence to support the use of metaraminol in critically ill patients. Even though the pharmacodynamic properties of metaraminol provide a rationale for its use but there is no evidence to evaluate its impact on important patient outcomes, such as the length of vasopressor support, complications associated with its use, morbidity, and mortality. <h3>Conclusions</h3> Metaraminol was the first-line vasopressor in a representative sample of UK critical care units. We identified no randomised trials describing clinical outcomes of metaraminol use, meaning the benefits and risks of this treatment are uncertain. Further observational studies and prospective randomised controlled trials are warranted to inform evidence-based practice for patient benefit.

Incidence of unplanned intensive care unit admission following surgery and associated factors in Amhara regional state hospitals

Unplanned postoperative critical care admission poses a potential risk to patients and places unanticipated pressure on clinical services and it has become an important parameter to assess patient safety in perioperative services. This study was aimed to determine the incidence of unplanned intensive care unit admission following surgery and the associated factors. A multi-center cross-sectional study was conducted on postoperative patients admitted to the ICU of three hospitals located in the Amhara region. Data were collected via a structured survey tool and analyzed using SPSS version 23 software with binary logistic regression analysis. The statistical significance to identify patient, anesthetic and surgical related factors in the preoperative, intraoperative, and postoperative period was < 0.05 for multivariable regression with a 95% confidence interval. Predominantly patients were admitted to the ICU in an unplanned manner. ASA status, preoperative hemoglobin (Hgb) level, intraoperative estimated blood loss, and adverse events occurring in the operating room were significantly associated with intensive care unit admission following surgery. Patients who had a low preoperative Hgb value were 35.1 times more likely to be admitted to the intensive care unit in an unplanned manner compared with their counterparts [(Adjust odds ratio (AOR) 35.16; CI 12.82, 96.44)]. Patients with ASA II and III were 19.4 and 16.2 times more likely to be admitted to ICU in an unplanned way compared to patients who had ASA I physical status [(AOR 51.79; CI 8.28, 323.94) (AOR 67.8 CI 14.68, 313.53)]. Unplanned ICU admission after surgery was high in this study, suggesting poor perioperative planning, risk stratification, and optimization of patients.

Predictors and risk factors for admission to critical care in cervicofacial infections: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infections carry significant morbidity. Patients present on a broad spectrum of severity, with some requiring outpatient management and others admission to higher level care. Recognition of risk factors is helpful in decision making regarding the need for admission to higher level care. Prospective data were captured on 1002 patients in 25 centres across 17 regions of the United Kingdom (UK) by the Maxillofacial Trainee Research Collaborative (MTReC). Patients admitted to critical care were compared with those who received ward-level care. Multivariate and receiver operating characteristic curve analyses were used to identify predictors for critical care admission. Our results show that the best predictor for critical care admission is the presence of three or more features of airway compromise (AUC 0.779), followed by C-reactive protein (CRP) >100 mg/L (OR 2.70; 95% CI 1.59 to 4.58; p < 0.005), submandibular space involvement (OR 3.82; 95% CI 1.870 to 7.81; p = 0.003), white cell count (WCC) >12 × 109/ dl (1.05; 95% CI 1.01 to 1.10; p = 0.03), and positive systemic inflammatory response syndrome criteria (OR 2.78; CI 1.35 to 5.80; p = 0.006). Admission to critical care is multifactorial, however, the presence of three or more features of airway compromise is the best predictor. Awareness of this alongside other key clinical findings in cervicofacial infections may allow for the early recognition of patients who may require escalation to critical care.

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

Health-related quality of life, one-year costs and economic evaluation in extracorporeal membrane oxygenation in critically ill adults

Purpose: This study reports on survival and health related quality of life (HRQOL) after extracorporeal membrane oxygenation (ECMO) treatment and the associated costs in the first year.Materials and Methods: Prospective observational cohort study patients receiving ECMO in the intensive care unit during August 2017 and July 2019. We analyzed all healthcare costs in the first year after index admission. Follow-up included a HRQOL analysis using the EQ-5D-5L at 6 and 12 months.Results: The study enrolled 428 patients with an ECMO run during their critical care admission. The one-year mortality was 50%. Follow up was available for 124 patients at 12 months. Survivors reported a favorable mean HRQOL (utility) of 0.71 (scale 0–1) at 12 months of 0.77. The overall health status (VAS, scale 0–100) was reported as 73.6 at 12 months. Mean total costs during the first year were $204,513 ± 211,590 with hospital costs as the major factor contributing to the total costs. Follow up costs were $53,752 ± 65,051 and costs of absenteeism were $7317 ± 17,036.Conclusions: At one year after hospital admission requiring ECMO the health-related quality of life is favorable with substantial costs but considering the survival might be acceptable. However, our results are limited by loss of follow up. So it may be possible that only the best-recovered patients returned their questionnaires. This potential bias might lead to higher costs and worse HRQOL in a real-life scenario.

Did Physicians Have a Role to Play in National Blood Crisis?

Background: The pandemic of COVID-19 (Coronavirus disease 2019) impacted the practices of blood product procurement and transfusion in multiple ways, including failed blood donation drives, staffing limitations and low donor turnout. On January 1, 2022, the American Red Cross declared the worst national blood crisis in over a decade. The effect was most notable on the community medical centers with limited resources in securing products for blood transfusion. However, evidence is lacking for the usage of blood products in a community teaching hospital during this pandemic. Study Design and Methods: We aimed to contrast the adherence to restrictive transfusion practice in the COVID era with the pre-COVID era irrespective of COVID-19 diagnosis. We performed a retrospective observational study involving packed red blood cell (PRBC) transfusions in patients from June 2020 to August 2020 (COVID era) and September 2019 to November 2019 (pre-COVID era). Patients with hemoglobinopathies were excluded. A detailed chart review to include the number of PRBC transfusions, documented indication for transfusion and it was also determined if transfusions met restrictive blood transfusion criteria (as per guidelines from the Association for the Advancement of Blood & Biotherapies (AABB)) (Table 1). Demographic data included age, gender, history of coronary artery disease (CAD) or prior gastrointestinal bleed, use of antiplatelet and anticoagulation, use of deep vein thrombosis prophylaxis inpatient, and diagnosis on admission. Chi-square was applied to test the statistical association between qualitative variables and Unpaired t-test/Mann Whitney U test was applied to test the mean difference of quantitative. The level of significance was set at 5%. Results: A total of 215 patients were screened and 208 met our inclusion criteria. There were 108 PRBC transfusions in the COVID era group and 100 PRBC transfusions in the pre-COVID era group, with equal distribution in both groups for age, sex, ethnicity and prior gastrointestinal bleed. The leading diagnosis on admission in both COVID era and pre-COVID era groups was acute hypoxia (53.7% and 36% p<0.001), followed by gastrointestinal bleeding. Lower proportion of patients receiving transfusion were on anticoagulant or antiplatelet therapy in COVID era group as compared to pre-COVID era (antiplatelet: 6.2% vs 19%, p<0.001 and anticoagulant: 12.1% vs 27%, p<0.001), though COVID era group had lower fraction of patients receiving pharmacological prophylaxis for deep vein thrombosis (DVT) (13.9% vs 29%, p<0.001). There was a higher percentage of transfusions in critical care units in the COVID era group than pre-COVID era group (38.9% vs 22%, p<0.008). Documented indications for transfusions in both groups were hemoglobin < 7 (47.2% vs 43%), acute coronary syndrome (ACS) or history of CAD (12% vs 11%), active bleed (35.2% vs 35%) and down trending hemoglobin (5.6% vs 11%). Restrictive transfusion criteria were met in only 67% vs 79% in COVID era and pre-COVID era transfusion cases respectively (p=0.008). Subgroup analysis of documented indications for transfusion among both groups is displayed in Graph 1. Conclusions: As evident from our results, the COVID era group despite having comparable, if not fewer risk factors associated with blood loss, received blood transfusion with less stringent adherence to restrictive blood transfusion guidelines. COVID pandemic had a significant impact on the landscape of blood transfusion and our study brought to light the physician's role in more liberal use of blood products. Due to a higher number of critical care admissions and the morbidity/mortality during this pandemic, compel physicians to have a more liberal mindset towards blood transfusions. However, given the acute shortage of blood products it is vital that we adhere to restrictive blood transfusion guidelines. In view of the ongoing National Blood Crisis, please visit RedCrossBlood.org or call 1-800-RED CROSS (1-800-733-2767) to donate blood. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Intensive care unit requirements in patients treated with immune checkpoint inhibitors.

To determine the proportion of emergency patients treated with immune checkpoint inhibitors (ICIs) that require critical care admission and their requirements. Prospective case series. Analysis of acutely unwell patients treated with ICIs attending a tertiary UK cancer hospital between May 2018 and May 2022. The primary outcome measure was the percentage of patients treated with ICI therapy requiring ICU admission. The secondary outcome measure was whether this need was driven by an immune-mediated toxicity. Eighteen (1.2%) patients of the 1561 acutely admitted patients treated with ICI therapy required an admission to ICU. Ten (55.5%) patients were admitted due to an immune-mediated toxicity; four due to pneumonitis and four due to myasthenia gravis. Seven of 10 survived their ICU admission with 6 surviving at least 6-month post-ICU discharge. Only a small minority of emergency admissions in patients treated with ICIs require admission to ICU. This series adds further evidence that patients with organ failure due to immune-mediated toxicity may achieve good outcomes from ICU admission.

Critical care in obstetrics: Clinical audit in the Republic of Ireland, 2014–2016

IntroductionAdmission to an Intensive Care Unit (ICU) in obstetrics is often used as a proxy for maternal near miss/severe maternal morbidity (MNM/SMM) events. Understanding incidence and management of pregnant or postpartum patients requiring critical care (CC) is thus important for continued improvement of maternity care. This study aims to describe provision of critical care in obstetrics in the Republic of Ireland. Material and methodsThe national clinical audit on critical care included 15 of 19 maternity units in Ireland (2014–2016). 960 pregnant or postpartum (within 42 days) individuals who required CC were included. Data were reported on all cases requiring level 2 or level 3 CC. We calculated basic descriptive statistics for diagnosis and process of care variables, and compared characteristics of women requiring level 2 care to those requiring level 3. Outcomes included diagnoses necessitating critical care; additional complications; level of care required; care process outcomes such as length of stay, consultation with non-obstetric specialties, location of maternal critical care, and neonatal care provision. ResultsOverall, the rate of critical care in obstetrics for these hospitals was 1 in 131 live births; 900 of the 960 cases required level 2 care only. Hypertensive disorders contributed to the need for critical care for 1 in 242; hemorrhage, 1 in 422; and infections, 1 in 926. A substantial minority (15.7%) had more than one diagnosis, accounting for 40% of level 3 care. Serious complications were rare (eg, hysterectomy, 1 in 3846). Parity, hospital size, and identification as high-risk antenatally (<50% cases) were associated with requiring level 3 care. Critical care was provided in multiple locations, including ICUs, HDUs, and operating theatres. Only 23.8% of patients received CC in an ICU, suggesting ICU admission is not an ideal method for identifying severe maternal morbidity. ConclusionsWe reported rates of critical care admission and primary diagnoses within the range of other published estimates, but huge variability exists in the literature, and within our data. ICU admission in and of itself iss not a reliable proxy for having received level 2 or 3 obstetric critical care in Ireland.

Clinician preference instrumental variable analysis of the effectiveness of magnesium supplementation for atrial fibrillation prophylaxis in critical care

Atrial fibrillation is a frequently encountered condition in critical illness and causes adverse effects including haemodynamic decompensation, stroke and prolonged hospital stay. It is a common practice in critical care to supplement serum magnesium for the purpose of preventing episodes of atrial fibrillation. However, no randomised studies support this practice in the non-cardiac surgery critical care population, and the effectiveness of magnesium supplementation is unclear. We sought to investigate the effectiveness of magnesium supplementation in preventing the onset of atrial fibrillation in a mixed critical care population. We conducted a single centre retrospective observational study of adult critical care patients. We utilised a natural experiment design, using the supplementation preference of the bedside critical care nurse as an instrumental variable. Using routinely collected electronic patient data, magnesium supplementation opportunities were defined and linked to the bedside nurse. Nurse preference for administering magnesium was obtained using multilevel modelling. The results were used to define "liberal" and "restrictive" supplementation groups, which were inputted into an instrumental variable regression to obtain an estimate of the effect of magnesium supplementation. 9114 magnesium supplementation opportunities were analysed, representing 2137 critical care admissions for 1914 patients. There was significant variation in magnesium supplementation practices attributable to the individual nurse, after accounting for covariates. The instrumental variable analysis showed magnesium supplementation was associated with a 3% decreased relative risk of experiencing an atrial fibrillation event (95% CI − 0.06 to − 0.004, p = 0.03). This study supports the strategy of routine supplementation, but further work is required to identify optimal serum magnesium targets for atrial fibrillation prophylaxis.

OC-022 MAINTAINING AN ELECTIVE ABDOMINAL WALL RECONSTRUCTION SERVICE DURING THE COVID 19 PANDEMIC

Abstract Aim Elective surgery services suffered significantly due to the COVID-19 pandemic. The aim of this study was to analyse the impact and outcomes of abdominal wall reconstruction (AWR) performed during the COVID-19 pandemic, assessing safety and sustainability. Material and Methods A retrospective review of all patients undergoing AWR in a single NHS trust, multiple surgeons, between 23rd March 2020 and 22rd March 2022, the 2 years following U.K. Government imposed lockdown, was undertaken and compared with the pre-pandemic AWR activity. Procedures were initially undertaken at a cold site and when demonstrated to be safe, main site operating restarted. The primary outcome was 90 day mortality, secondary outcomes of COVID-19 infection within 7 days, length of stay, critical care requirement, and complication rate. Results In the study period, 173 patients underwent AWR, compared with 99 cases in a single year preceding lockdown. 90 day mortality rate was zero. No patients returned positive COVID tests to the trust within 7 days of AWR, and no patients were readmitted for COVID related symptoms. Critical care admission was required in 7 patients, 3 of these were planned admissions pre-operatively. The surgical site occurrence rate was 9.8% (17), infection 5.8% (10), seroma 2.3% (4) and haematoma 1.7% (3). There were no recurrences reported, with follow up ranging between 1 and 18 months. Conclusion Continuing AWR services during the COVID pandemic is feasible and safe. Peri-operative COVID infection rates are low, critical care requirements minimal, and there is no impact on patient morbidity or mortality.

Pregnancy outcomes after SARS-CoV-2 infection in periods dominated by delta and omicron variants in Scotland: a population-based cohort study

Evidence suggests that the SARS-CoV-2 omicron (B.1·1.529) is associated with lower risks of adverse outcomes than the delta (B.1.617.2) variant among the general population. However, little is known about outcomes after omicron infection in pregnancy. We aimed to assess and compare short-term pregnancy outcomes after SARS-CoV-2 delta and omicron infection in pregnancy. We did a national population-based cohort study of women who had SARS-CoV-2 infection in pregnancy between May 17, 2021, and Jan 31, 2022. The primary maternal outcome was admission to critical care within 21 days of infection or death within 28 days of date of infection. Pregnancy outcomes were preterm birth and stillbirth within 28 days of infection. Neonatal outcomes were death within 28 days of birth, and low Apgar score (<7 of 10, for babies born at term) or neonatal SARS-CoV-2 infection in births occurring within 28 days of maternal infection. We used periods when variants were dominant in the general Scottish population, based on 50% or more of cases being S-gene positive (delta variant, from May 17 to Dec 14, 2021) or S-gene negative (omicron variant, from Dec 15, 2021, to Jan 31, 2022) as surrogates for variant infections. Analyses used logistic regression, adjusting for maternal age, deprivation quintile, ethnicity, weeks of gestation, and vaccination status. Sensitivity analyses included restricting the analysis to those with first confirmed SARS-CoV-2 infection and using periods when delta or omicron had 90% or more predominance. Between May 17, 2021, and Jan 31, 2022, there were 9923 SARS-CoV-2 infections in 9823 pregnancies, in 9817 women in Scotland. Compared with infections in the delta-dominant period, SARS-CoV-2 infections in pregnancy in the omicron-dominant period were associated with lower maternal critical care admission risk (0·3% [13 of 4968] vs 1·8% [89 of 4955]; adjusted odds ratio 0·25, 95% CI 0·14-0·44) and lower preterm birth within 28 days of infection (1·8% [37 of 2048] vs 4·2% [98 of 2338]; 0·57, 95% CI 0·38-0·87). There were no maternal deaths within 28 days of infection. Estimates of low Apgar scores were imprecise due to low numbers (5 [1·2%] of 423 with omicron vs 11 [2·1%] of 528 with delta, adjusted odds ratio 0·72, 0·23-2·32). There were fewer stillbirths in the omicron-dominant period than in the delta-dominant period (4·3 [2 of 462] per 1000 births vs 20·3 [13 of 639] per 1000) and no neonatal deaths during the omicron-dominant period (0 [0 of 460] per 1000 births vs 6·3 [4 of 626] per 1000 births), thus numbers were too small to support adjusted analyses. Rates of neonatal infection were low in births within 28 days of maternal SARS-CoV-2 infection, with 11 cases of neonatal SARS-CoV-2 in the delta-dominant period, and 1 case in the omicron-dominant period. Of the 15 stillbirths, 12 occurred in women who had not received two or more doses of COVID-19 vaccination at the time of SARS-CoV-2 infection in pregnancy. All 12 cases of neonatal SARS-CoV-2 infection occurred in women who had not received two or more doses of vaccine at the time of maternal infection. Findings in sensitivity analyses were similar to those in the main analyses. Pregnant women infected with SARS-CoV-2 were substantially less likely to have a preterm birth or maternal critical care admission during the omicron-dominant period than during the delta-dominant period. Wellcome Trust, Tommy's charity, Medical Research Council, UK Research and Innovation, Health Data Research UK, National Core Studies-Data and Connectivity, Public Health Scotland, Scottish Government Health and Social Care, Scottish Government Chief Scientist Office, National Research Scotland.

Polypharmacy and Healthcare Service Use Among Prescription Opioid Poisoning Cases Age 50+

Objectives: To examine relationships between polypharmacy and level of healthcare service use among prescription opioid poisoning cases age 50 and older. Methods: Data came from the American Association of Poison Control Center’s National Poison Data System, 2015-2020. We used multinomial logistic regression to examine the study questions. Results: Of the 77 946 cases with prescription opioid exposures, 64.5% were managed at a healthcare facility (HCF). Of HCF-managed cases, 41.2% were treated/evaluated and released and 21.3% and 37.5% were admitted for noncritical care and critical care, respectively. Medications for cardiovascular disease, benzodiazepines, other types of sedatives/hypnotics, antipsychotics, muscle relaxants, acetaminophen, and gabapentin were associated with increased risk of admission to both noncritical and critical care compared to treatment/evaluation and release. Acetaminophen use had the highest relative risk ratios (RRRs) for noncritical care (1.70, 95% CI = 1.51-1.91) and critical care (1.56, 95% CI = 1.39-1.76). Each additional medication/substance used was associated with 1.14 (95% CI = 1.11-1.17) and 1.19 (95% CI = 1.16-1.22) greater risk of noncritical and critical care admissions, respectively. Conclusions: Among older-adult poison control center cases for prescription opioid exposures, co-use of several commonly prescribed/used medicines was associated with increased risk of admissions to both noncritical and critical care units. Careful monitoring of medication use among older adults who use prescription opioids may reduce the risk of unintentional and intentional opioid poisoning.

Embedded point of care randomisation for evaluating comparative effectiveness questions: PROSPECTOR-critical care feasibility study protocol

IntroductionMany routinely administered treatments lack evidence as to their effectiveness. When treatments lack evidence, patients receive varying care based on the preferences of clinicians. Standard randomised controlled trials are unsuited...

Impact of vaccination on COVID-19-associated admissions to critical care in England: a study of population linked data with quantitative bias analysis for linkage error.

ObjectivesTo explore associations between COVID-19 vaccination and admission to critical care with COVID-19 in England, by age group, dose, and over time. ApproachWe conducted a population cohort study by linking the Case Mix Programme national clinical audit of adult intensive care to the National Immunisation Management System, combined with population denominators from the Office for National Statistics. We compared patient characteristics and estimated rates of critical care admission by vaccination status and age group and explored variation in admission rates and relative protection over time. Finally, we used quantitative bias analysis to explore sensitivity to potential linkage error. ResultsBetween 1 May and 15 December 2021 (England’s Delta wave), 11,431 patients were admitted to adult critical care units in England with COVID-19, of whom 10,141 were included in the cohort. Vaccinated patients were older, with higher levels of severe comorbidity and immunocompromise. Unvaccinated patients were greatly overrepresented, with people who had received two or more doses being at least 92% less likely to be admitted compared with those who were unvaccinated, for all ages, once the second dose had been rolled out. Those aged 50 years or older who had received a booster/third dose were 98-99% less likely to be admitted compared with unvaccinated. Our analysis was robust to linkage error, but closely related analyses could have been exquisitely sensitive to missed links. ConclusionOur findings are consistent with a high degree of vaccine-acquired protection against critical care admission, with little waning in the first 6-9 months for those aged under 70. While our analysis was robust to linkage error, significant care is warranted with related analyses of linked vaccination and outcome databases.