Transfer To Intensive Care Unit Research Articles

Association between hydroxyethyl starch 130/0.4 administration during noncardiac surgery and postoperative acute kidney injury: A propensity score-matched analysis of a large cohort in China

Study objectiveThe use of hydroxyethyl starch 130/0.4 has been linked to renal injury in critically ill patients, but its impact on surgical patients remains uncertain. DesignA retrospective cohort study. SettingThis study was conducted at one tertiary care hospital in China. PatientsWe evaluated the records of 51,926 Chinese adults who underwent noncardiac surgery from 2013 to 2022. Patients given a combination of hydroxyethyl starch 130/0.4 and crystalloids were propensity-matched at a 1: 1 ratio of baseline characteristics to patients given only crystalloids (11,725 pairs). InterventionsEligible patients were divided into those given a combination of hydroxyethyl starch 130/0.4 and crystalloid during surgery and a reference crystalloid group consisting of patients who were not given any colloid. MeasurementsThe primary outcome was the incidence of acute kidney injury. Secondarily, acute kidney injury stage, need for renal replacement therapy, intensive care unit transfer rate, and duration of postoperative hospitalization were considered. Main resultsAfter matching, hydroxyethyl starch use [8.5 (IQR: 7.5–10.0) mL/kg] did not increase the incidence of acute kidney injury compared with that in the crystalloid group [2.0 vs. 2.2%, OR: 0.90 (0.74–1.08), P = 0.25]. Nor did hydroxyethyl starch use worsen acute kidney injury stage [OR 0.90 (0.75–1.08), P = 0.26]. No significant differences between the fluid groups were observed in renal replacement therapy [OR 0.60 (0.41–0.90), P = 0.02)] or intensive care unit transfers [OR 1.02 (0.95–1.09), P = 0.53] after Bonferroni correction. Even in a subset of patients at high risk of renal injury, hydroxyethyl starch use was not associated with worse outcomes. ConclusionsHydroxyethyl starch 130/0.4 use was not significantly associated with a greater incidence of postoperative acute kidney injury compared to receiving crystalloid solutions only.

The current state of intensive care unit discharge practices - Results of an international survey study.

Increasing pressure on limited intensive care capacities often requires a subjective assessment of a patient's discharge readiness in the absence of established Admission, Discharge, and Transfer (ADT) guidelines. To avoid suboptimal care transitions, it is important to define clear guidelines for the admission and discharge of intensive care patients and to optimize transfer processes between the intensive care unit (ICU) and lower care levels. To achieve these goals, structured insights into usual ICU discharge and transfer practices are essential. This study aimed to generate these insights by focusing on involved stakeholders, established processes, discharge criteria and tools, relevant performance metrics, and current barriers to a timely and safe discharge. In 2022, a structured, web-based, anonymous cross-sectional survey was conducted, aimed at practicing ICU physicians, nurses, and bed coordinators. The survey consisted of 29 questions (open, closed, multiple choice, and scales) that were divided into thematic blocks. The study was supported by several national and international societies for intensive care medicine and nursing. A total of 219 participants from 40 countries (105 from Germany) participated in the survey. An overload of acute care resources with ~90% capacity utilization in the ICU and the general ward (GW) leads to not only premature but also delayed patient transfers due to a lack of available ward and intermediate care (IMC) beds. After multidisciplinary rounds within the intensive care team, the ICU clinician on duty usually makes the final transfer decision, while one-third of the panel coordinates discharge decisions across departmental boundaries. By the end of the COVID-19 pandemic, half of the hospitals had implemented ADT policies. Among these hospitals, nearly one-third of the hospitals had specific transfer criteria established, consisting primarily of vital signs and laboratory data, patient status and autonomy, and organization-specific criteria. Liaison nurses were less common but were ranked right after the required IMC capacities to bridge the care gap between the ICU and normal wards. In this study, 80% of the participants suggested that transfer planning would be easier if there was good transparency regarding the capacity utilization of lower care levels, a standardized transfer process, and improved interdisciplinary communication. To improve care transitions, transfer processes should be managed proactively across departments, and efforts should be made to identify and address care gaps.

Association between serum levels of GDF-15, suPAR, PIVKA-II, sdLDL and clinical outcomes in hospitalized COVID-19 patients.

To quantify the circulating levels of novel serum biomarkers including GDF-15, PIVKA-II, sdLDL, suPAR, and of CRP in hospitalized COVID-19 patients compared with healthy subjects, and to evaluate their association(s) with outcomes in COVID-19. We considered patients with confirmed COVID-19, hospitalized in an Internal Medicine ward. The clinical characteristics were collected, including the number and type of comorbidities. Serum levels of GDF-15, PIVKA-II, suPAR, sdLDL, as well as CRPwere measured. As outcomes, we considered Intensive Care Unit (ICU) transfer or death, as well as the length of stay (days) and in-hospital complications. Data were statistically analyzed, as appropriate, and a p value < 0.05 was considered significant. Ninety-three patients and 20 healthy controls were enrolled. COVID-19 patients vs. controls showed higher median levels of GDF-15 (p < 0.0001), PIVKA-II (p < 0.0001) and sdLDL (p = 0.0002), whereas no difference was observed for suPAR. In COVID-19 patients, the most frequent comorbidities were arterial hypertension (62.4%) and cardiovascular disease (30.1%). GDF-15 levels positively correlated with age (r = 0.433, p < 0.0001), and this correlation was confirmed for suPAR (r = 0.308, p = 0.003) and CRP (Rho = 0.40 p < 0.0001), but not for PIVKA-II and sdLDL. Higher GDF-15 levels were associated with a higher number of comorbidities (p = 0.021). The median length of stay was 22 (15; 30) days. During hospitalization, 15 patients (16%) were ICU transferred, and 6 (6.45%) died. GDF-15 serum levels correlated with the length of stay (rho = 0.27 p = 0.010), and were associated with ICU transfer or death (p = 0.003), as well as PIVKA-II (p = 0.038) and CRP (p < 0.001). Moreover, higher GDF-15 and PIVKA-II serum levels were associated with infectious complications (p = 0.008 and p = 0.017, respectively). In this cohort of hospitalized COVID-19 patients, novel inflammatory biomarkers, including GDF-15, suPAR and PIVKA II were associated with some patient's clinical characteristics, complications, and poor outcomes.

COVID-19 Hospitalization in Hawai'i and Patterns of Insurance Coverage, Race and Ethnicity, and Vaccination.

The people of Hawai'i have both high rates of health insurance and high levels of racial and ethnic diversity, but the degree to which insurance status and race and ethnicity contribute to health outcomes in COVID-19 remains unknown. To evaluate the associations of insurance coverage, race and ethnicity (using disaggregated race and ethnicity data), and vaccination with outcomes for COVID-19 hospitalization. This retrospective cohort study included hospitalized patients at a tertiary care medical center between March 2020 and March 2022. All patients hospitalized for acute COVID-19, identified based on diagnosis code or positive results on polymerase chain reaction-based assay for SARS-CoV-2, were included in analysis. Data were analyzed from May 2022 to May 2023. COVID-19 requiring hospitalization. Electronic medical record data were collected for all patients. Associations among race and ethnicity, insurance coverage, receipt of at least 1 COVID-19 vaccine, intensive care unit (ICU) transfer, in-hospital mortality, and COVID-19 variant wave (pre-Delta vs Delta and Omicron) were assessed using adjusted multivariable logistic regression. A total of 1176 patients (median [IQR] age of 58 [41-71] years; 630 [54%] male) were hospitalized with COVID-19, with a median (IQR) body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 (25-36) and Sequential Organ Failure Assessment score of 1 (0-2). The sample included 16 American Indian or Alaska Native patients, 439 Asian (not otherwise specified) patients, 15 Black patients, 66 Chinese patients, 246 Filipino patients, 76 Hispanic patients, 107 Japanese patients, 10 Korean patients, 299 Native Hawaiian patients, 523 Pacific Islander (not otherwise specified) patients, 156 Samoan patients, 5 Vietnamese patients, and 311 White patients (patients were able to identify as >1 race or ethnicity). When adjusting for age, BMI, sex, medical comorbidities, and socioeconomic neighborhood status, there were no differences in either ICU transfer (eg, Medicare vs commercial insurance: odds ratio [OR], 0.84; 95% CI, 0.43-1.64) or in-hospital mortality (eg, Medicare vs commercial insurance: OR, 0.85; 95% CI, 0.36-2.03) as a function of insurance type. Disaggregation of race and ethnicity revealed that Filipino patients were more likely to die in the hospital (OR, 1.79; 95% CI, 1.04-3.03; P = .03). When considering variant waves, mortality among Filipino patients was highest during the pre-Delta time period (OR, 2.72; 95% CI, 1.02-7.14; P = .04), when mortality among Japanese patients was lowest (OR, 0.19; 95% CI, 0.03-0.78; P = .04); mortality among Native Hawaiian patients was lowest during the Delta and Omicron period (OR, 0.35; 95% CI, 0.13-0.79; P = .02). Patients with Medicare, compared with those with commercial insurance, were more likely to have received at least 1 COVID-19 vaccine (OR, 1.85; 95% CI, 1.07-3.21; P = .03), but all patients, regardless of insurance type, who received at least 1 COVID-19 vaccine had reduced ICU admission (OR, 0.40; 95% CI, 0.21-0.70; P = .002) and in-hospital mortality (OR, 0.42; 95% CI, 0.21-0.79; P = .01). In this cohort study of hospitalized patients with COVID-19, those with government-funded insurance coverage (Medicare or Medicaid) had similar outcomes compared with patients with commercial insurance, regardless of race or ethnicity. Disaggregation of race and ethnicity analysis revealed substantial outcome disparities and suggests opportunities for further study of the drivers underlying such disparities. Additionally, these findings illustrate that vaccination remains a critical tool to protect patients from COVID-19 mortality.

Aminoglycoside utilization in elderly inpatients: Implications for renal health and adverse outcomes

BackgroundAminoglycosides, maintaining antimicrobial efficacy, are considered for combating multidrug-resistant pathogens. Their contemporary use, combined with vigilant preventive strategies, may not universally lead to lasting renal complications in elderly inpatients. MethodsThis study examined data from the National Health Insurance Registry Database, focusing on elderly inpatients (aged 60 and above) hospitalized between 2000 and 2017 due to pneumonia, urinary tract infections, or bacteremia. Patients treated with aminoglycosides were compared to those receiving other antibiotics. Patient follow-up continued until the occurrence of renal disease, death, or for three months post-discharge, based on diagnoses coded in the International Classification of Diseases. ResultsAmong 938,052 elderly inpatients admitted for infections, 29.19 % were prescribed aminoglycosides. Patients receiving aminoglycosides tended to be younger and had fewer associated health conditions compared to those treated with other antibiotics. The overall incidence of renal disease was 2.03 % during hospitalization and it increased to 17.45 % at the three-month follow-up. While no increased risk for renal disease was observed in the aminoglycoside group compared to other antibiotics, it correlated with higher rates of death and intensive care unit transfer. Specific comorbidities, such as diabetes mellitus, heart failure, and liver disease, exhibited a stronger association with the development of renal disease compared to aminoglycosides. ConclusionCurrent aminoglycoside use did not contribute to a higher incidence of lasting renal disease compared to other antibiotics but was linked to increased morbidity and mortality. Caution is crucial when administering aminoglycosides to elderly patients to prevent adverse outcomes.

An audit of the continuation and review of intensive care unit (ICU)-initiated medications post ICU discharge

Abstract Introduction Medication errors at transitions of care have widely been reported and the transition of a patient from intensive care unit (ICU) to ward level care has additional risk for error due to the complexity of the cohort. The continuation of ICU-initiated medications at ward level has been associated with adverse drug events, and error mitigation strategies need to be implemented at the point of discharge from ICU to facilitate deprescribing and medication optimisation. Pharmacists are in an excellent position to facilitate this medication optimisation at the point of ICU transfer. Aim This study aimed to evaluate the frequency that ICU-initiated medications are continued on discharge from ICU and subsequently reviewed at ward level in a large teaching hospital. Methods An audit was conducted as a prospective observational study over the period of June and July 2023. A pharmacist reviewed kardexes of patients that had been discharged from ICU to determine the prevalence of ICU-initiated medications that were continued post discharge. Medications continued were documented using an Excel spreadsheet on a password-protected computer. A pharmacist followed patients at day 7 post ICU discharge and an audit was conducted to document if these medications had been reviewed by primary teams. A medication was deemed to be reviewed by a primary team if discontinued on the kardex, a dose altered on the kardex or reference made to the medication in the medical notes. All patients discharged from ICU to ward level care were eligible to be included in the study. Results In total, 53 patients were eligible to be included in the study, of which 51 had ICU-initiated medications continued on discharge. No class of medication was found to be reviewed for all patients discharged on that class of medication. Over half of patients (52.9%) had stress ulcer prophylaxis medications continued, 39.2% had opioids continued and 33.3% had anti-delirium medications continued. No surgical patient had anti-delirium medications reviewed at ward level and surgical patients were found to be the largest cohort discharged on opioids but not reviewed at ward level. Conclusion This study has highlighted that not only are ICU-initiated mediations continued on discharge from ICU, but also that a high proportion of these medications are not reviewed at ward level by primary teams. This has further shown the requirement for pharmacist review and verification of kardexes prior to ICU discharge and the implementation of deprescribing protocols. The main limitation of the study was the small sample size of patients discharged from ICU during the study period. Future studies could focus on the impact that a pharmacist-led quality improvement initiative would have on the continuation and review of ICU-initiated medications on discharge from the ICU and the audit repeated over a longer period of time.

Antibiotic route and outcomes for children hospitalized with pneumonia.

Emerging evidence suggests that initial oral and intravenous (IV) antibiotics have similar efficacy in pediatric community-acquired pneumonia (CAP), but further data are needed. We determined the association between hospital-level initial oral antibiotic rates and outcomes in pediatric CAP. This retrospective cohort study included children hospitalized with CAP at 43 hospitals in the Pediatric Health Information System (2016-2022). Hospitals were grouped by whether initial antibiotics were given orally in a high, moderate, or low proportion of patients. Regression models examined associations between high versus low oral-utilizing hospitals and length of stay (LOS, primary outcome), intensive care unit (ICU) transfers, escalated respiratory care, complicated CAP, cost, readmissions, and emergency department (ED) revisits. Initial oral antibiotics were used in 16% (interquartile range: 10%-20%) of 30,207 encounters, ranging from 1% to 68% across hospitals. Comparing high versus low oral-utilizing hospitals (oral rate: 32% [27%-47%] and 10% [9%-11%], respectively), there were no differences in LOS, intensive care unit, complicated CAP, cost, or ED revisits. Escalated respiratory care occurred in 1.3% and 0.5% of high and low oral-utilizing hospitals, respectively (relative ratio [RR]: 2.96 [1.12, 7.81]), and readmissions occurred in 1.5% and 0.8% (RR: 1.68 [1.31, 2.17]). Initial oral antibiotics varied across hospitals without a difference in LOS. While high oral-utilizing hospitals had higher escalated respiratory care and readmission rates, these were rare, the clinical significance of these small differences is uncertain, and there were no differences in other clinically relevant outcomes. This suggests some children may benefit from initial IV antibiotics, but most would probably do well with oral antibiotics.

Stewardship Prompts to Improve Antibiotic Selection for Urinary Tract Infection

Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed. To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI. Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017-September 30, 2018) and 15-month intervention period (April 1, 2019-June 30, 2020). CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education. The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods. Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively. Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers. ClinicalTrials.gov Identifier: NCT03697096.

Stewardship Prompts to Improve Antibiotic Selection for Pneumonia

Pneumonia is the most common infection requiring hospitalization and is a major reason for overuse of extended-spectrum antibiotics. Despite low risk of multidrug-resistant organism (MDRO) infection, clinical uncertainty often drives initial antibiotic selection. Strategies to limit empiric antibiotic overuse for patients with pneumonia are needed. To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with pneumonia. Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time MDRO risk-based CPOE prompts; n = 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults (≥18 years) hospitalized with pneumonia. There was an 18-month baseline period from April 1, 2017, to September 30, 2018, and a 15-month intervention period from April 1, 2019, to June 30, 2020. CPOE prompts recommending standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics during the empiric period who have low estimated absolute risk (<10%) of MDRO pneumonia, coupled with feedback and education. The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy and safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies. Among 59 hospitals with 96 451 (51 671 in the baseline period and 44 780 in the intervention period) adult patients admitted with pneumonia, the mean (SD) age of patients was 68.1 (17.0) years, 48.1% were men, and the median (IQR) Elixhauser comorbidity count was 4 (2-6). Compared with routine stewardship, the group using CPOE prompts had a 28.4% reduction in empiric extended-spectrum days of therapy (rate ratio, 0.72 [95% CI, 0.66-0.78]; P < .001). Safety outcomes of mean days to ICU transfer (6.5 vs 7.1 days) and hospital length of stay (6.8 vs 7.1 days) did not differ significantly between the routine and CPOE intervention groups. Empiric extended-spectrum antibiotic use was significantly lower among adults admitted with pneumonia to non-ICU settings in hospitals using education, feedback, and CPOE prompts recommending standard-spectrum antibiotics for patients at low risk of MDRO infection, compared with routine stewardship practices. Hospital length of stay and days to ICU transfer were unchanged. ClinicalTrials.gov Identifier: NCT03697070.

Simulated impact of lift car sizes on transport of critical care patients: Informing the design of the New Dunedin Hospital.

The New Dunedin Hospital (NDH) is New Zealand's largest health infrastructure build. Here we describe the use of a simple simulation-based hospital design exercise to inform the appropriate lift car size for critical care intrahospital transfers in the NDH. The intensive care unit (ICU) user group tested a series of entries and exits of simulated complex patient transfers in mocked-up lift cars of three different dimensions. Time taken to enter and exit the lift were recorded, reflecting the relative difficulty of transfer. Qualitative assessments were made of ease and perceived safety of transfer. These simulations demonstrated that recommended standard patient lift cars, often proposed for critical care transfers, could not physically accommodate all complex ICU transfers. A size of 1800 mm wide (W) × 3000 mm deep (D) had the physical capacity to permit all simulated ICU transfers, but with staff and patient risk. As lift car size increased to 2200 mm W × 3300 mm D, the simulation demonstrated reduced transfer times, smoother entry and exit, improved access to the head end of the bed, and reduced risk of disconnection or dislodgement of lines and airway support. The resultant clinical recommendations for the dimensions of a critical care lift car surpass current international health architecture guidelines and may help to inform future updates. The NDH project benefited from an objective assessment of risk, in language familiar to clinicians and healthcare architects. The outcome was an upsizing of the two ICU-capable lifts.

Effect of extended precision nursing on neurobehavioral function and pregnancy outcome in patients with threatened abortion.

This study aimed to assess the impact of continuous precision nursing on neurobehavioral function and pregnancy outcomes in patients experiencing threatened abortion. A total of 130 patients with early threatened abortion admitted to our hospital between October 2020 and January 2023 were selected and categorized into 2 groups based on intervention methods. The control group received routine nursing intervention, whereas the observation group received continuous precision nursing intervention. Changes in affective status scores, SF-36 scores, knowledge mastery scores, and satisfaction scores in the neurobehavioral function test before and after intervention were recorded in both groups. Additionally, pregnancy outcomes, obstetric adverse reaction rates, and neonatal conditions were documented. Following intervention, scores for tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment gradually decreased in both groups, with significantly lower scores observed in the observation group compared to the control group (P < .05). SF-36 scores in 8 dimensions, including physical functioning, role-physical, bodily pain, and overall health rating, showed a gradual increase in both groups, with the observation group scoring higher than the control group (P < .05). Knowledge mastery and satisfaction scores also increased significantly after intervention, with the observation group surpassing the control group (P < .05). The observation group exhibited lower rates of abortion and premature birth, along with a higher rate of full-term pregnancy compared to the control group, with statistically significant differences (P < .05). Furthermore, the observation group displayed lower rates of adverse reactions and low birth weight infants, with significant differences compared to the control group (P < .05). No significant differences were observed in neonatal mortality and neonatal intensive care unit transfer rates between the observation and control groups (P > .05). Continuous precision nursing contributes to improved pregnancy outcomes for patients with threatened miscarriage within the first 12 weeks of pregnancy. This comprehensive care approach is associated with enhanced knowledge retention, protection of neurological function, and an overall improvement in quality of life.

Predicting delayed extubation and transfer to the intensive care unit in children undergoing posterior fusion surgery for scoliosis : Aretrospective observational study.

Delayed extubation and transfer to the intensive care unit (ICU) in children undergoing major scoliosis surgery may increase postoperative complications, prolong hospital stay, and increase medical expenses; however, whether achild will require delayed extubation or transfer to the ICU after scoliosis orthopedic surgery is not fully understood. In this study, we reviewed the risk factors for delayed extubation and transfer to the ICU after scoliosis orthopedic surgery in children. The electronic medical records of pediatric patients (≤ 18years) who underwent posterior spinal fusion surgery between January 2018 and November 2021 were reviewed and analyzed. Patient characteristics (age, sex, body mass index, American Society of Anesthesiologists, ASA, grade, preoperative lung function, and congenital heart disease), preoperative Cobb angle, scoliosis type, correction rate, vertebral fusion segments, pedicle screws, surgical osteotomy, intraoperative bleeding, intraoperative allogeneic transfusion, intraoperative hemoglobin changes, intraoperative mean arterial pressure changes, intraoperative tidal volume (ml/kg predicted body weight), surgical time, postoperative extubation, and transfer to the ICU were collected. The primary outcomes were delayed extubation and transfer to the ICU. Multivariate logistic regression models were used to determine the risk factors for delayed extubation and ICU transfer. Atotal of 246 children who satisfied the inclusion criteria were enrolled in this study, of whom 23(9.3%) had delayed extubation and 81(32.9%) were transferred to the ICU after surgery. High ASA grade (odds ratio [OR] 5.42; 95% confidence interval [CI] 1.49-19.78; p = 0.010), high Cobb angle (OR 1.04; 95% CI 1.02-1.07; p < 0.001), moderate to severe pulmonary dysfunction (OR 10.9; 95% CI 2.00-59.08; p = 0.006) and prolonged surgical time (OR 1.01; 95% CI 1.00-1.03; p = 0.040) were risk factors for delayed extubation. A high Cobb angle (OR 1.02; 95% CI 1.01-1.04; p = 0.004), high intraoperative bleeding volume (OR 1.06; 95% CI 1.03-1.10; p = 0.001), allogeneic transfusion (OR 3.30; 95% CI 1.24-8.83; p = 0.017) and neuromuscular scoliosis (OR 5.38; 95% CI 1.59-18.25; p = 0.007) were risk factors for transfer to the ICU. A high Cobb angle was arisk factor for both delayed extubation and ICU transfer. Age, sex, body mass index, number of vertebral fusion segments, correction rate, and intraoperative tidal volume were not associated with delayed postoperative extubation and ICU transfer. The most common risk factor for delayed extubation and ICU transfer in pediatric patients who underwent posterior spinal fusion was ahigh Cobb angle. Determining risk factors for apoor prognosis may help optimize perioperative respiratory management strategies and planning of postoperative care for children undergoing complicated spinal surgery.

Correlation between heart rate variability and perioperative neurocognitive disorders in patients undergoing non-cardiac surgery: A retrospective cohort study.

With the improvement of medical level, the number of elderly patients is increasing, and the postoperative outcome of the patients cannot be ignored. However, there have been no studies on the relationship between preoperative heart rate variability (HRV) and Perioperative Neurocognitive Disorders (PND). The purpose of this study was to explore the correlation between (HRV) and (PND), postoperative intensive care unit (ICU), and hospital stay in patients undergoing non-cardiac surgery. This retrospective analysis included 687 inpatients who underwent 24-hour dynamic electrocardiogram examination in our six departments from January 2021 to January 2022. Patients were divided into two groups based on heart rate variability (HRV): high and low. Possible risk factors of perioperative outcomes were screened using univariate analysis, and risk factors were included in multivariate logistic regression to screen for independent risk factors. The subgroup analysis was carried out to evaluate the robustness of the results. The nomogram of PND multi-factor logistic prediction model was constructed. The receiver operating characteristic (ROC) curve was drawn, and the calibration curve was drawn by bootstrap resampling 1000 times for internal verification to evaluate the prediction ability of nomogram. A total of 687 eligible patients were included. The incidence of low HRV was 36.7% and the incidence of PND was 7.6%. The incidence of PND in the low HRV group was higher than that in the high HRV group (11.8% vs 5.2%), the postoperative ICU transfer rate was higher (15.9% than 9.3%P = 0.009), and the hospital stay was longer [15 (11, 19) vs (13), 0.015]. The multivariable logistic regression analysis showed that after adjusting for other factors, decreased low HRV was identified as an independent risk factor for the occurrence of PND (Adjusted Odds Ratio = 2.095; 95% Confidence Interval: 1.160-3.784; P = 0.014) and postoperative ICU admission (Adjusted Odds Ratio = 1.925; 95% Confidence Interval: 1.128-3.286; P = 0.016). This study drew a nomogram column chart for a multivariate logistic regression model, incorporating age and HRV. The calibration curve shows that the predicted value of the model for the occurrence of cardio-cerebrovascular events is in good agreement with the actual observed value, with C-index of 0.696 (95% CI: 0.626 ~ 0.766). Subgroup analysis showed that low HRV was an independent risk factor for PND in patients with gastrointestinal surgery and ASA Ⅲ, aged ≥ 65 years. In patients undergoing non-cardiac surgery, the low HRV was an independent risk factor for PND and postoperative transfer to the ICU, and the hospitalization time of patients with low HRV was prolonged. Through establishing a risk prediction model for the occurrence of PND, high-risk patients can be identified during the perioperative period for early intervention.

Myosteatosis predicts postoperative complications and long-term survival in robotic gastrectomy for gastric cancer: A propensity score analysis.

Robotic gastrectomy is increasingly utilized for gastric cancer, but high morbidity remains a concern. Myosteatosis or low skeletal muscle density reflecting fatty infiltration, associates with complications after other cancer surgeries but has not been evaluated for robotic gastrectomy. This retrospective study analysed 381 patients undergoing robotic gastrectomy for gastric cancer from September 2019 to October 2022. Myosteatosis was quantified on preoperative computed tomography (CT) images at lumbar 3 (L3). Propensity score matching addressed potential confounding between myosteatosis and non-myosteatosis groups. Outcomes were postoperative complications, 30 days mortality, 30 days readmissions and survival. Myosteatosis was present in 33.6% of patients. Myosteatosis associated with increased overall (47.7% vs. 26.5%, p < 0.001) and severe complications (12.4% vs. 4.9%, p < 0.001). After matching, myosteatosis remained associated with increased overall complications, major complications, intensive care unit (ICU) transfer and readmission (all p < 0.05). Myosteatosis independently predicted overall [odds ratio (OR) = 2.86, 95% confidence interval (CI): 1.57-5.20, p = 0.001] and severe complications (OR = 4.81, 95% CI: 1.51-15.27, p = 0.008). Myosteatosis also associated with reduced overall (85.0% vs. 93.2%, p = 0.015) and disease-free survival (80.3% vs. 88.4%, p=0.029). On multivariate analysis, myosteatosis independently predicted poorer survival [hazard ratio (HR) = 2.83, 95% CI: 1.32-6.08, p=0.012] and disease-free survival (HR = 1.83, 95% CI: 1.01-3.30, p=0.032). Preoperative CT-defined myosteatosis independently predicts increased postoperative complications and reduced long-term survival after robotic gastrectomy for gastric cancer. Assessing myosteatosis on staging CT could optimize preoperative risk stratification.

The Association of Anticoagulation Intensity with Outcomes in Hospitalized COVID-19 Patients.

Venous thromboembolism (VTE) risk is increased in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A key question was whether increased intensity of anticoagulation would help prevent VTE and improve patient outcomes, including transfer to the intensive care unit (ICU) and mortality. At the start of the coronavirus disease-19 (COVID-19) pandemic, our institution, Boston Medical Center, instituted a VTE risk stratification protocol based on patients' initial D-dimer levels, medical history, and presence of thrombosis to determine whether they should receive standard-dose prophylaxis, high-dose prophylaxis, or therapeutic anticoagulation. We performed a retrospective observational cohort study examining the association of degree of anticoagulation with outcomes in 915 hospitalized COVID-19 patients hospitalized initially on the general inpatient wards between March 1,, 2020, and June 1, 2020. Patients directly hospitalized in the ICU were excluded. Most, 813 patients (89%), in our cohort were on standard-dose prophylaxis; 32 patients (3.5%) received high-dose prophylaxis; 70 patients (7.7%), were treated with therapeutic anticoagulation. VTE occurred in 45 patients (4.9%), and the overall in-hospital mortality rate was 5.4% (49 deaths). On multivariable analysis of clinical outcomes in relation to type of anticoagulation, in the high-dose prophylaxis group, there was a trend towards increased in-hospital mortality (odds ratio 2.4 (0.8-7.5, 95% CI)) and increased ICU transfer (odds ratio 2.2 (0.9-5.7, 95% CI)). Our results suggest that patients receiving high-dose prophylaxis had more severe disease that was not mitigated by intermediate-dose anticoagulation.

High-Intensity Care for Nursing Home Residents with Severe Dementia Hospitalized at the End of Life: A Mixed Methods Study

ObjectiveFor nursing home residents with severe dementia, high-intensity medical treatment offers little possibility of benefit but has the potential to cause significant distress. Nevertheless, mechanical ventilation and intensive care unit (ICU) transfers have increased in this population. We sought to understand how and why such care is occurring. DesignMixed methods study, with retrospective collection of qualitative and quantitative data. SettingDepartment of Veterans Affairs (VA) hospitals. MethodsUsing the Minimum Data Set, we identified veterans aged ≥65 years who had severe dementia, lived in nursing homes, and died in 2013. We selected those who underwent mechanical ventilation or ICU transfer in the last 30 days of life. We restricted our sample to patients receiving care at VA hospitals because these hospitals share an electronic medical record, from which we collected structured information and constructed detailed narratives of how medical decisions were made. We used qualitative content analysis to identify distinct paths to high-intensity treatment in these narratives. ResultsAmong 163 veterans, 41 (25.2%) underwent mechanical ventilation or ICU transfer. Their median age was 85 (IQR, 80–94), 97.6% were male, and 67.5% were non-Hispanic white. More than a quarter had living wills declining some or all treatment. There were 5 paths to high-intensity care. The most common (18 of 41 patients) involved families who struggled with decisions. Other patients (15 of 41) received high-intensity care reflexively, before discussion with a surrogate. Four patients had families who advocated repeatedly for aggressive treatment, against clinical recommendations. In 2 cases, information about the patient's preferences was erroneous or unavailable. In 2 cases, there was difficulty identifying a surrogate. Conclusions and ImplicationsOur findings highlight the role of surrogates’ difficulty with decision making and of health system–level factors in end-of-life ICU transfers and mechanical ventilation among nursing home residents with severe dementia.

Impact of preoperative sarcopenia on postoperative complications and prognosis in patients undergoing robotic gastric cancer surgery: A propensity score matching study

BackgroundSarcopenia, defined as decreased muscle mass and function, correlates with postoperative morbidity and mortality in cancer surgery. However, sarcopenia's impact specifically following robotic gastrectomy for gastric cancer has not been clearly defined. This study aimed to determine the influence of sarcopenia on short- and long-term clinical outcomes after robotic gastrectomy for gastric cancer. MethodsThis retrospective study analyzed 381 gastric cancer patients undergoing robotic gastrectomy. Sarcopenia was diagnosed by preoperative computed tomography (CT) body composition analysis. Propensity score matching created 147 pairs of sarcopenia and nonsarcopenia patients for comparison. Outcomes included postoperative complications, survival, inflammatory markers, length of stay, intensive care unit (ICU) transfer, and readmissions. ResultsSarcopenia patients exhibited significantly higher rates of overall (53.7% versus 21.1%, P < 0.001), serious (12.9% versus 4.1%, P = 0.007), and grade III–IV complications compared to nonsarcopenia pairs after matching. Sarcopenia independently predicted reduced 3-years overall (HR = 2.53, 95% CI: 1.19–5.40, P = 0.016) and disease-free survival (HR = 1.99, 95% CI: 1.09–3.66, P = 0.026). Sarcopenia patients also showed heightened postoperative leukocyte, neutrophil, platelet, platelet to lymphocyte ratio (PLR), systemic immune-inflammation index (SII), and monocyte to lymphocyte ratio (MLR) levels alongside suppressed lymphocytes, monocytes, and neutrophil to lymphocyte ratio (NLR). ConclusionPreoperative sarcopenia is correlated with increased postoperative complications and poorer long-term survival in gastric cancer patients undergoing robotic gastrectomy. Sarcopenia assessment can optimize preoperative risk stratification and perioperative management in this population.

Risk Factors and Clinical Prognosis Associated With RSV-ALRI Intensive Care Unit Admission in Children

Respiratory syncytial virus (RSV) is the leading cause of acute lower respiratory infections (ALRIs) in children <2 years of age. Currently, there are limited data on risk factors for very severe RSV-ALRI requiring intensive care unit (ICU) admission. We conducted a case-control study of children <2 years old admitted with RSV-ALRI to the Sydney Children's Hospital Network, comprising 2 large tertiary pediatric hospitals. Cases were children with laboratory-confirmed RSV-ALRI admitted to ICU, and controls were (1:2, matched on date of admission) children hospitalized with RSV-ALRI but not requiring ICU transfer. Data on risk factors were retrieved from the electronic medical record system. Adjusted odds ratios (aORs) with 95% confidence intervals (95% CI) associated with risk factors for ICU admission and the association with clinical and treatment factors were determined from logistic regression models. A total of 44 (44%) of 100 cases and 90 (48.1%) of 187 controls were male. Age <6 months and preterm births were associated with a 2.10-fold (95% CI: 1.14-3.79) and 2.35-fold (95% CI: 1.26-4.41) increased risk in ICU admissions, respectively. The presence of any chronic health condition was a significant risk factor for ICU admission. The clinical presentations on admission more commonly seen in cases were apnea (aOR: 5.01, 95% CI: 1.50-17.13) and respiratory distress (aOR: 15.91, 95% CI: 4.52-55.97). Cases were more likely to be hospitalized for longer duration and require respiratory support. Our results can be translated into a clinical risk algorithm to identify children at risk of very severe RSV disease.

Improved tracheostomy-dependent patient outcomes after implementation of the Pediatric Resident Education in Pulmonary (PREP) Boot Camp.

Children with tracheostomies are high risk for morbidity and mortality. Pediatric resident physicians are not routinely taught skills to care for this vulnerable patient population. Few reports link educational interventions to improved patient outcomes. This study evaluates the impact of an intensive educational training program on pediatric residents' observed skills and tracheostomy-dependent patient outcomes. Pediatric post-graduate year 2 (PGY2) resident physicians rotating through the inpatient pediatric pulmonology month at Children's Hospital Colorado July 2018-2019 participated in the Pediatric Resident Education in Pulmonary (PREP) Boot Camp, an intensive educational program with an interactive lecture and simulation experience on patients with tracheostomy-dependence. PGY2s who partook in PREP and PGY3s who rotated before PREP initiation were invited to be studied. Primary outcomes included: (1) resident skills assessed by direct observation during simulation encounters and (2) rates of intensive care unit (ICU) transfers in tracheostomy-dependent patients following acute events before and after introduction of PREP. We hypothesized that increased education would enhance resident skills and improve patient outcomes by decreasing the rate of ICU transfers. PGY2 residents retained skills learned during PREP up to 11 months following initial participation, and significantly outperformed their PGY3 counterparts. There was a significant decrease in ICU transfer rate in patients with tracheostomies admitted to the pulmonary team during the 19 months following initiation of PREP. Enhanced early education may improve resident physicians' ability to care for complex patients with tracheostomies and could improve outcomes in this high-risk population.

Impact of initial high flow nasal cannula flow rates on clinical outcomes in children with bronchiolitis.

Our aim was to evaluate the impact of the initial high flow nasal cannula (HFNC) flow rate on clinical outcomes in children with bronchiolitis. This secondary analysis of retrospective data included children <2 years who required HFNC for bronchiolitis between 10/01/2018-04/20/2019, and following implementation of a revised institutional bronchiolitis pathway between 10/01/2021-04/30/2022. The new pathway recommended weight-based initiation of HFNC at 1.5-2 L/kg/min. We evaluated the effect of low (<1.0 L/kg/min), medium (1-1.5 L/kg/min) and high (>1.5 L/kg/min) HFNC flow rates on need for positive pressure ventilation (PPV), intensive care unit (ICU) transfer, HFNC treatment time, and hospital length of stay (LOS). The majority of the 885 included children had low initial flow rates (low [n = 450, 50.8%], medium [n = 332, 37.5%] and high [n = 103, 11.7%]). There were no significant differences in PPV (high: 7.8% vs. medium: 9.3% vs. low: 8.2%, p = 0.8) or ICU transfers (high: 4.9% vs. medium: 6.0% vs. low: 3.8%, p = 0.3). The low flow group had a significantly longer median HFNC treatment time (High: 29 [18, 45] vs. medium: 29 [16, 50] vs. low: 39 [25, 63], p < .001) and hospital LOS (High: 41 [27, 59] vs. medium: 42 [29, 66] vs. low: 50 (39, 75), p < .001). Logistic and linear regression models did not demonstrate any associations between HFNC flow rates and PPV or hospital LOS. Initial HFNC flow rates were not associated with significant changes in clinical outcomes in children in children with bronchiolitis.