First Hour Of Admission Research Articles

Prevalence of low central venous oxygen saturation in the first hours of intensive care unit admission and associated mortality in septic shock patients: a prospective multicentre study.

IntroductionIn septic shock patients, the prevalence of low (<70%) central venous oxygen saturation (ScvO2) on admission to the intensive care unit (ICU) and its relationship to outcome are unknown. The objectives of the present study were to estimate the prevalence of low ScvO2 in the first hours of ICU admission and to assess its potential association with mortality in patients with severe sepsis or septic shock.MethodsThis was a prospective, multicentre, observational study conducted over a one-year period in ten French ICUs. Clinicians were asked to include patients with severe sepsis or septic shock preferably within 6 hours of ICU admission and as soon as possible without changing routine practice. ScvO2 was measured at inclusion and 6 hours later (H6), by blood sampling.ResultsWe included 363 patients. Initial ScvO2 below 70% was present in 111 patients and the pooled estimate for its prevalence was 27% (95% Confidence interval (95%CI): 18% to 37%). At time of inclusion, among 166 patients with normal lactate concentration (≤2 mmol/L), 55 (33%) had a low initial ScvO2 (<70%), and among 136 patients who had already reached the classic clinical endpoints for mean arterial pressure (≥65 mmHg), central venous pressure (≥8 mmHg), and urine output (≥0.5 mL/Kg of body weight), 43 (32%) had a low initial ScvO2 (<70%). Among them, 49% had lactate below 2 mmol/L. The day-28 mortality was higher in case of low initial ScvO2 (37.8% versus 27.4%; P = 0.049). When adjusted for confounders including the Simplified Acute Physiology Score and initial lactate concentration, a low initial ScvO2 (Odds ratio (OR) = 3.60, 95%CI: 1.76 to 7.36; P = 0.0004) and a low ScvO2 at H6 (OR = 2.18, 95%CI: 1.12 to 4.26; P = 0.022) were associated with day-28 mortality by logistic regression.ConclusionsLow ScvO2 was common in the first hours of admission to the ICU for severe sepsis or septic shock even when clinical resuscitation endpoints were achieved and even when arterial lactate was normal. A ScvO2 below 70% in the first hours of ICU admission and six hours later was associated with day-28 mortality.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0609-7) contains supplementary material, which is available to authorized users.

Agitation onset, frequency, and associated temporal factors in critically ill adults.

Agitation is a frequent complication in critically ill adults, can result in life-threatening events for patients or care providers, and extends the hospital length of stay, thereby increasing hospital costs. To describe the incidence, onset, and temporal factors related to agitation in critically ill adults. Data were collected for the first 5 days of stay of all adult patients consecutively admitted to a medical respiratory intensive care unit and a surgical trauma intensive care unit during a 2-month period. Agitation was documented by using scores on the Richmond Agitation-Sedation Scale or notation of agitation in the medical record. The hour was used as the documentation epoch, and data were summarized by hour, 4-hour block, and day for each patient. Data were collected on 200 patients, 100 from each unit. Among the sample, 118 (59%) were agitated at some time during the 5 days. The overall agitation rate was 7.8% of the total hourly time. Mean onset of agitation was 11.6 hours from time of admission to the unit. Of the 118 patients who were agitated at some time, 102 (86%) had agitation on day 1. Compared with patients in the surgical trauma unit, patients in the medical respiratory unit had significantly more hours of agitation the first day and first hour of admission and significantly earlier onset of agitation. Agitation was present in more than one-half of the patients in the sample, typically developed on the first day, and involved consecutive days.

Selecting the Best Mortality Risk Scoring Systems in a PICU

Zanatta, Graziela de A. C. MD; Carvalho, Werther B. PhD; Delgado, Artur F. MD PhD Author Information

Snakebite Prognostic Factors: Leading Factors of Weak Therapeutic Response Following Snakebite Envenomation

Background: The goal of antivenom administration for snake-bitten patients is to achieve therapeutic response (initial control), which means reversal of the venom-induced effects through neutralizing the venom. The aim of this study was to identify snakebite prognostic factors of weak therapeutic response prior to antivenom administration. Methods: This was a retrospective study of patients with viperidae snakebite envenomation who were admitted to Mashhad Toxicology Centre during 2007-2011. Demographic features, clinical manifestations and snakebite severity score (SSS) were collected prior to antivenom administration. Total number of antivenom vials administered to achieve therapeutic response and duration of hospitalization were also recorded. Potential factors in snakebite prognosis were analyzed by comparing in two groups of achieving therapeutic response with less than 5 vials and over 5 to calculate odds ratio. Results: Total of 108 patients (male/female: 85/23) with mean (SD) age of 34.5 (17.0) were studied. The most common manifestations included fang marks (100%), pain (100%), ecchymosis (89%), swelling (83%), blister formation (48%) and thrombocytopenia (25%). In univariate analysis, thrombocytopenia (P=0.01), spontaneous bleeding (P=0.02), coagulopathic disturbances (P=0.007), swelling (P=0.003), progressive swelling (P=0.005), ecchymosis (P=0.05) and respiratory distress (P= 0.05) were significantly correlated to weak therapeutic response. Swelling and spontaneous bleeding were the strongest snakebite prognostic factors, as respectively they put the patients at 12.4 and 10.4 fold risks for difficult achievement of therapeutic response. Conclusions: In snakebite, some clinical manifestations in the first hours of admission and prior to antivenom administration are associated with weak therapeutic response. Identifying these prognostic factors, can assist health care providers to better estimate the patient’s needs and predict the final consequences.

Detección de necesidades de los familiares de pacientes ingresados en la Unidad de Ictus

ObjectivesTo identify the needs of the relatives of patients admitted to a Stroke Unit (Hospital 12 de Octubre). To determine areas for improvement in the nursing care currently provided to the family. MethodologyCross-sectional study. Study group: Primary caregivers of Stroke Unit patients. Period7 months. Location: Stroke Unit (Hospital 12 de Octubre). Dependent Variables: The need for information, safety and trust, accessibility to health personnel, emotional support, participation in care, physical comfort, personal attention. Independent Variables: Sociodemographic data, change of address due to hospitalisation, travel time to hospital, visits to stroke unit, inpatient days, perceived severity, presence of the family during the first hours of admission, attendance at a course for family members of stroke patients. Data Collection: Modified Molter questionnaire. Sample size: 66 families. Analysis: Descriptive statistics by frequency distribution, measures of central tendency and dispersion measures. Comparison of means for independent variables, dependent variables and one-way ANOVA. ConclusionsRelatives less than 50 years old require more emotional support. Relatives who are presence during hospital admittance are the ones who are more willing to participate in care.

The diagnostic and prognostic value of first hour glycogen phosphorylase isoenzyme BB level in acute coronary syndrome

Evaluating patients with symptoms suggestive of acute coronary syndrome (ACS) is a time consuming, expensive and problematic process in the emergency department. This study aimed to evaluate the diagnostic and prognostic value of glycogen phosphorylase isoenzyme-BB (GP-BB) in ACS. A total of 72 patients (mean age 61.8 ± 11.6 years) with ACS were enrolled. The ELISA method for determining GP-BB level was performed and considered positive at 〉 10 ng/mL. Duration of angina, type of ACS, demographic features, myoglobin, creatinine kinase and troponin T (cTnT) were also assessed. The cTnT levels eight hours after pain onset was considered the gold standard test for the diagnosis of myocardial infarction. The most sensitive biomarker at first hour of admission was GP-BB (95.8%). However, the specificity of GP-BB was low (43.7%). Receiver operating characteristics curve analysis of the GP-BB level for predicting myocardial infarction revealed the area under the curve value as 0.82 (SE 0.04; 95% CI 0.78-0.85). Positive treadmill exercise test (60% vs 17%, p = 0.047), coronary artery disease (CAD; 59% vs 19%, p = 0.007), percutaneous coronary intervention (44% vs 27%, p = 0.031) and 30-day mortality and/or readmission (33% vs 5%, p = 0.028) were found to be higher in unstable angina (UA) patients having GP-BB (+). GP-BB is considerably cardiosensitive at the first hour of admission in patients with ACS, but the specificity of GP-BB is lower and it is elevated in nearly half of the patients with UA. However, in this group, GP-BB predicts significant CAD and the combined end-point of mortality and re-hospitalization.

Updated American College of Critical Care Medicine-Pediatric Advanced Life Support Guidelines for Management of Pediatric and Neonatal Septic Shock

Shock is a major preventable cause of morbidity and mortality in children referred to emergency care. The recently updated American College of Critical Care Medicine guidelines for the management of newborns and children with septic shock emphasize the role of emergency care in improving survival and functional outcomes. Implementation of these guidelines of stepwise use of fluids, antibiotics, and, if necessary, inotropes within the first hour of admission to the emergency department can reduce mortality and neurological morbidity risks 2-fold. Therapies should be goal directed to maintain age-specific threshold heart rates and blood pressure as well as a capillary refill of less than 3 seconds or 2 seconds or less. Inotropes should be delivered through peripheral intravenous or intraosseous access when central access is unavailable because delay in inotrope delivery can greatly increase mortality risks. Emergency care systems should be organized to facilitate recognition, triage, and treatment of shock in the first hour. Emergency departments should be stocked with ready access to antibiotics, fluids, and inotrope infusions, and clinicians should be trained in the delivery of goal-directed fluid, antibiotics, and inotrope therapies in the first hour of resuscitation. For newborns, in addition to fluids, antibiotics, and inotropes, a prostaglandin infusion should be available within 10 minutes if duct-dependent congenital heart disease is a possibility.

An analysis of the length of hospital stay after acetaminophen overdose

Acetaminophen is one of the most commonly encountered medications in self-poisoning, with a high rate of morbidity. The prevalence and characteristics of acetaminophen intoxication associated with long hospital stay in patients are not well defined. This study aims to identify the clinical and demographic factors associated with the length of in-hospital stay (LOS), and to evaluate the effect of early treatment of acetaminophen overdose patients (≤8 hours) by intravenous N-acetylcysteine (IV-NAC) on hospital stay. This is a retrospective cohort study of hospital admissions for acetaminophen overdose conducted over a period of 5 years from 1 January 2004 to 31 December 2008. Patients were divided into two groups: LS group patients had a long hospital stay (> median hours stay in hospital) and SS group patients had a short hospital stay (≤ median hours stay in hospital). Variables were abstracted from medical records for comparison between the two groups. A total of 20 variables were identified for comparison. Parametric and non-parametric tests were used to test differences between groups depending on the normality of the data. SPSS 15 was used for data analysis. Of the 305 patients, 11 factors were identified in the univariate analysis as associated with LS. Three independent factors were found to be significant predictors of LS in the multivariate analysis. The factors associated with LS were seen among patients with a history of abdominal pain after ingestion of acetaminophen (p = 0.04), who were on IV-NAC administration (p < 0.001) and had an acutely depressed mood (p = 0.003). Late time to NAC infusion of more than 8 hours was associated with LS rather than SS (96 patients [57%] and 6 [24%], respectively; p = 0.003). Patients with long hospital stay have different clinical characteristics compared to patients with short hospital stay. We identified time to IV-NAC administration is a potentially modifiable factor that may lead to prolonged hospital stay. When risk assessment indicates that NAC is required, it is highly recommended that NAC be started in the first hours of admission to reduce the LOS.

A 28 Years Old Woman with Severe Headache and Few Episodes of Vomiting: A Case Report

Problem statement: Cryptococcosis neoformans is commonest central nervous system infection in individuals infected with HIV. Most of the patients infected with Cryptococcus neoformans present with headache and visual changes. Approach: A 28 year old woman presented to Emergency Department (ED) with a chief complaint of headache, fever and vomiting and developed seizures during the first hour of admission. Firstly, diagnosed as cryptococcal meningitis, then, because of having a low White Blood Cell count (WBC) and low Total Lymphocyte Count (TLC) she was checked for HIV Ab and P24 Ag. Results: A diagnosis of HIV was made then her family members were checked for HIV and they were also HIV positive. Patient was discharged with a two month course of Fluconazole and after completion of antifungal treatment, Antiretroviral Treatment (HAART) was started. Conclusion: This case indicated that Cryptococcosis neoformans may develop in Immune-deficient patients, so complete laboratory workup and high index of suspicion to HIV should be under diagnosis.

Quantifying variation of paediatric length of stay among intensive care units in Australia and New Zealand

ObjectiveTo quantify variation of mean paediatric length of stay (LoS) among intensive care units (ICUs) in Australia and New Zealand.MethodRetrospective data from Australian and New Zealand institutions that admitted children...

Validation of CRIB II for prediction of mortality in premature babies

Validation of Clinical Risk Index for Babies (CRIB II) score in predicting the neonatal mortality in preterm neonates < or = 32 weeks gestational age. Prospective cohort study. Tertiary care neonatal unit. 86 consecutively born preterm neonates with gestational age < or = 32 weeks. The five variables related to CRIB II were recorded within the first hour of admission for data analysis. The receiver operating characteristics (ROC) curve was used to check the accuracy of the mortality prediction. HL Goodness of fit test was used to see the discrepancy between observed and expected outcomes. A total of 86 neonates (males 59.6% mean birthweight: 1228 +/- 398 grams; mean gestational age: 28.3 +/- 2.4 weeks) were enrolled in the study, of which 17 (19.8%) left hospital against medical advice (LAMA) before reaching the study end point. Among 69 neonates completing the study, 24 (34.8%) had adverse outcome during hospital stay and 45 (65.2%) had favorable outcome. CRIB II correctly predicted adverse outcome in 90.3% (Hosmer Lemeshow goodness of fit test P=0.6). Area under curve (AUC) for CRIB II was 0.9032. In intention to treat analysis with LAMA cases included as survivors, the mortality prediction was 87%. If these were included as having died then mortality prediction was 83.1%. The CRIB II score was found to be a good predictive instrument for mortality in preterm infants < or = 32 weeks gestation.

Standard Examination System for Laparoscopy in Penetrating Abdominal Trauma

The high missed occult small bowel injuries (SBI) associated with laparoscopy in trauma (LIT) is a major reason why some surgeons still preclude LIT today. No standardized laparoscopic examination for evaluation of the peritoneal cavity is described for trauma. The objective of this article is to verify if a systematic standardized laparoscopic approach could correctly identify SBI in the peritoneal cavity for penetrating abdominal trauma (PAT). Victims with PAT were evaluated in a prospective, nonrandomized study. A total of 75 hemodynamically stable patients with suspected abdominal injuries were operated by LIT and converted to laparotomy if criteria were met: SBI and lesions to blind spot zones--retroperitoneal hematoma, injuries to segments VI or VII of the liver, or injuries to the posterior area of the spleen. Inclusion criteria were equivocal evidence of abdominal injuries or peritoneal penetration; systolic blood pressure >90 mm Hg and <3 L of IV fluids in the first hour of admission; Glasgow Coma Scale score >12; and age >12 years. Exclusion criteria were back injuries; pregnancy; previous laparotomy; and chronic cardiorespiratory disease. Sixty patients were males and there were 38 stab wounds and 37 gunshot wounds. No SBI was missed, but a pancreatic lesion was undiagnosed due to a retroperitoneal hematoma. Twenty patients (26.6%) were converted. Unnecessary laparotomies were avoided in 73.33%. Therapeutic LIT was possible in 22.7%. Accuracy was 98.66% with 97.61% sensitivity and 100% specificity. Standard systematic laparoscopic exploration was 100% effective to detect SBI in the peritoneal cavity. Conversion from LIT to laparotomy should be done if injuries to blind spot zones are found which are poorly evaluated by LIT. Therapeutic LIT is feasible in PAT.

Parada cardíaca: presentación mortal de una miocarditis viral

Myocarditis is an inflammatory disease of the myocardium accompanied by necrosis of myocytes. The main causes are viral infections. The clinical presentation varies from mild forms to devastating ones which usually begin with trivial symptoms with progression, in some cases, to death. We report the case of an 18 month-old male toddler consulting for asthenia and anorexia for the last 24 h and a previous history of respiratory tract infection with high fever in the last week. Upon arrival at the emergency room and during the first hours of admission, physical examination was perfectly normal. Later, his general state gradually deteriorated,with biochemical disturbances (metabolic acidosis, renal failure and hyperglycaemia) and, eventually, a sudden cardiac arrest, with no response to cardiopulmonary resuscitation manoeuvres.

Intraabdominal Hypertension and the Abdominal Compartment Syndrome in Burn Patients

Severe burns represent a devastating injury that induces profound systemic inflammation requiring large volumes of resuscitative fluids. The consequent massive swelling and peritoneal ascites raises intraabdominal pressures (IAP) to supraphysiologic levels commensurate with intraabdominal hypertension (IAH) and with the abdominal compartment syndrome (ACS) if consistently associated with IAP >20 mmHg and associated with new organ failure. Severe burn injuries are an example of the secondary ACS (secondary ACS), wherein there has been no primary inciting intraperitoneal injury, yet severe IAH/ACS develops, setting the stage for progressive multiorgan dysfunction. These definitions along with practice management guidelines have recently been promulgated by the World Society of the Abdominal Compartment Syndrome (WSACS) in an effort to standardize terminology and communication regarding IAH/ACS in critical care. It is currently unknown whether these syndromes are iatrogenic consequences of excessive or poorly managed fluid resuscitation or unavoidable sequelae of the primary injury. It occurs frequently with burns of >60% body surface area, especially with associated inhalational injury, delayed resuscitation, and abdominal wall injuries. IAH/ACS is often a hyperacute phenomenon that occurs within the first hours of admission and thereafter with any complication requiring aggressive fluid resuscitation. Despite a number of noninvasive management strategies, interventions such as percutaneous peritoneal drainage and, ultimately, decompressive laparotomy are often required once the ACS is established. Whether novel resuscitation strategies can avoid or minimize IAH/ACS is unproven at present and requires further study. Truly understanding postburn ACS may require further insights into the basic mechanisms of injury and resuscitation.

Is supratentorial pressure difference clinically relevant? Analysis of 55 consecutive cases by bilateral intracranial pressure monitoring

Objective: The purpose of this study is to explore the possibilities of an early warning system by measuring intracranial pressure differences in order to prevent secondary insults to the injured brain.Methods: Fifty-five cases with a Glasgow coma scale (GCS) score 8 or below who presented with intracranial hypertension due to various intracranial pathologies underwent bilateral intraparenchymatous intracranial pressure (ICP) monitorization in an attempt to find out the existence of interhemispheric pressure differences. ICP values were recorded every 30 minutes during the first 24 hour interval. Patients were stratified into two groups as diffuse and focal according to the magnitude of their pathologies. Focal cases were also grouped according to lesion size and/or midline shift.Results: ICP differences that necessitated changes in the treatment were found at different time intervals in patients with focal lesions, but these did not reach statistical significance within the whole group (p>0.05). There were significant percentage differences between focal I and II groups in correlation with lesion side and non-lesion side within the first 4.5 hours (p<0.05). There was a significant difference within the first 3 hours between diffuse and focal II groups (p<0.05).Discussion: In patients with focal lesions, although more pronounced in focal II group, apparent pressure differences between two hemispheres within the first hours of admission were found. These pressure differences were related to the volume of the intracranial pathology. ICP monitorization from the lesion side is reasonable as an early forewarning procedure and this might prevent the development of secondary insults by providing the exact ICP values of the patients.

The influence of chronic health conditions on susceptibility to severe acute illness of children treated in PICU

Our study aimed to assess differences in the susceptibility to severe acute illness in children with and without chronic health conditions treated in a pediatric intensive care unit (PICU). Data on age, gender, need for ventilator support, length of stay, as well as other parameters for the Paediatric Index of Mortality (PIM2) score were collected. Data were analyzed and compared across three patient groups: those with a neurodevelopmental disability, those with a chronic condition other than a neurodevelopmental disability, and those with no chronic condition. Reasons for admission of patients were classified according to the Australia and New Zealand Paediatric Intensive Care Registry (ANZPIC Registry) diagnostic codes. In the multidisciplinary, seven-bed, level I PICU of the Split University Hospital, the admission data were collected prospectively for 591 consecutively admitted patients aged<or=18 years. Patients with a neurodevelopmental disability had a significantly higher rate of respiratory-related admissions compared to patients with other chronic health conditions and those with no chronic condition (chi2=33.72, P<0.001). There was a significant difference in the age at admission (f=6.04, P=0.003), median length of stay (f=7.94, P<0.001), need for ventilation during the first hour of admission (chi2=14.74, P<0.001) and PICU mortality (chi2=9.91, P=0.007) of patients with neurodevelopmental disabilities, compared to the other two groups of patients. Children with neurodevelopmental disabilities are more susceptible to acute illness compared to children with other chronic health conditions and those with no chronic condition.

Valor de la leucopenia durante la primera hora como marcador pronóstico en la enfermedad meningococcica

Objective: To stablish the temporal course of the white cell blood count (WBC) in patients with meningococcal infection during the first 24 hours after hospital admission and to evaluate the role of leukopenia in the first hour as a mortality risk factor. Design: Non-blind, non-analytical, prospective cohort study in the paedriatric ICU of a general hospital. All patients with meningococcal infection presenting between 1999 and 2002 were included. The WBC count was measured at the time of admission, and at 1, 6, 12 and 24 hours after admission. Leukopenia was defined as a WBC < 5,000/mm3. Results: 75 children, aged between 3 months to 12 years, were recruited. 56% of cases were confirmed by meningococcal culture. The mortality was 6.7%, all presenting with purpura fulminans. At admission 15% (11/75) had leukopenia, and 17% (13/75) after 1 hour. 22% of non-leukopenic patients had a decrease in the WBC count, but did not reach the leukopenic level. At the time of admission 69% of leukopenic children were hypotensive compared with 17% of non-leukopenic children (RR = 3.9 p < 0.001). The 5 children who died all showed leukopenia (5/13 38%) at 1 hour, while none of children with a normal WBC died. (RR = 2.07, p < 0.001, sensitivity 100% and negative predictive value 100%). The WBC nadir occurred after the first hour of admission, median 2,100/mm3 range 1,200-3,100/mm3. Conclusions: Leukopenia in meningococcal infections during the first hour of admission in the ITU doubles the risk of dying.

Early identification of sepsis and mortality risks through simple, rapid clot-waveform analysis. Implications of lipoprotein-complexed C reactive protein formation.

To determine if the rapid waveform profile of the activated partial thromboplastin time (aPTT) assay, which detects lipoprotein-complexed C reactive protein (LCCRP) formation, predicts sepsis and mortality in critically ill patients. Observational, cohort study. General intensive therapy unit (ITU) of a tertiary care hospital. A total of 1187 consecutive patients admitted to the ITU. Activated partial thromboplastin time transmittance waveform analysis was performed within the first hour of admission to the ITU. The degree of change causing a biphasic waveform was quantified through the drop in light transmittance level. Three hundred forty-six patients had a biphasic waveform on admission to the ITU with a mortality rate of 44% compared with 26% for those with normal waveforms. Logistic regression models showed direct correlation between the likelihood for sepsis and in-patient mortality with increasing waveform abnormalities. The mortality fraction was 0.3 with normal waveforms versus 0.6 when the light transmittance decreased by 30%. The odds ratio (OR) for mortality and sepsis were 4.5 and 11, respectively, from the most abnormal to normal aPTT waveforms. These were comparable with APACHE II scores and superior to those estimated by CRP for mortality (OR 2.3) / sepsis (OR 6.4) prediction. Waveform analysis within the first hour of ITU admission is a single, simple and rapid method of identifying the risks of mortality and sepsis. Its measure of LCCRP formation shows superior prediction over CRP alone and it warrants further assessment as a tool to triage and target prompt, appropriate treatment in the ITU.

Prognostic Significance of Heart Rate Variability During the First 24 Hours of Acute Myocardial Infarction: A 5-Year Follow-up Study

Background: The prognostic value of heart rate variability (HRV) measured within the first 24 hours of acute myocardial infarction was assessed in 94 consecutive patients. Methods: The mean of standard deviation of normal R-R intervals for all 5-minute segments (SDNN index), the width of the R-R interval histogram at 10% and 50% of the peak, and three frequency-domain measures of HRV (low frequency [LF], high frequency [HF], and LF/HF ratio) were calculated from a continuous ECG recording taken within the first hours of admission and their prognostic value for long-term events was studied. Results: During the follow-up period (56.7 ± 5.9 months) 6 sudden and 7 nonsudden cardiac deaths occurred. Time-domain measurements of HRV were lower in patients with sudden death (SDNN index: 27.0 ± 20.2 vs 47.5 ± 20.7 ms in survivors, P < 0.001). LF and HF power, but not the LF/HF ratio, were also inversely associated with sudden death. No significant differences were found between survivors and patients with nonsudden cardiac death. After adjustment for other clinical covariates, LF and HF power remained significantly associated with sudden death. Conclusion: We conclude that heart rate variability measured within the first 24 hours of myocardial infarction is a strong predictor of sudden death during subsequent follow-up.

Predicting Delivery Within 48 Hours in Women Treated With Parenteral Tocolysis

In Brief Objective To develop a prediction rule using clinical admission characteristics for women treated with parenteral tocolysis for preterm labor who are at highest risk of delivery within 48 hours. Methods We performed a case-control study of patients treated with magnesium sulfate for idiopathic preterm labor. A case was defined as a patient who received magnesium sulfate tocolysis and delivered within 48 hours of admission. We selected a 48-hour delay to delivery as a clinically relevant endpoint for the maximization of steroid benefit. Controls were patients who received magnesium sulfate tocolysis and remained undelivered 48 hours after admission. Cases and controls were identified by merging a pharmacy billing database with International Classification of Disease codes for premature labor. Medical records were reviewed and risk factor information was obtained. We focused on risk factors within the first hour of admission, because our goal was to identify patients at high risk of delivery early in their hospital course. Backward stepwise logistic regression was used to develop explanatory and predictive models. The focus of the predictive model was to maximize the test's sensitivity and negative predictive value. Results We identified 50 cases and 150 controls. The following six variables were included in the initial multivariable models based on bivariate analyses: white blood cell count at least 14.0 (1000/μL), cervical dilation at least 2 cm, bleeding, substance abuse, parity, and previous abortion. A two-variable model containing cervical dilation and bleeding had an overall accuracy of 73%, sensitivity of 62%, and specificity of 76%, and it was as sensitive and specific as more complex models. Conclusion Cervical dilation of at least 2 cm and bleeding on admission had an overall accuracy of 73% in predicting the likelihood of delivery within 48 hours in women receiving magnesium sulfate. Cervical dilation of 2 cm or more and bleeding on admission predict likelihood of delivery within 48 hours in women receiving magnesium sulfate.