Unexpected Intensive Care Unit Admission Research Articles

Eleven years of experience in operating a pediatric rapid response system at a children's hospital in South Korea.

Various rapid response systems have been developed to detect clinical deterioration in patients. Few studies have evaluated single-parameter systems in children compared to scoring systems. Therefore, in this study we evaluated a single-parameter system called the acute response system (ARS). This retrospective study was performed at a tertiary children's hospital. Patients under 18 years old admitted from January 2012 to August 2023 were enrolled. ARS parameters such as systolic blood pressure, heart rate, respiratory rate, oxygen saturation, and whether the ARS was activated were collected. We divided patients into two groups according to activation status and then compared the occurrence of critical events (cardiopulmonary resuscitation or unexpected intensive care unit admission). We evaluated the ability of ARS to predict critical events and calculated compliance. We also analyzed the correlation between each parameter that activates ARS and critical events. The critical events prediction performance of ARS has a specificity of 98.5%, a sensitivity of 24.0%, a negative predictive value of 99.6%, and a positive predictive value of 8.1%. The compliance rate was 15.6%. Statistically significant increases in the risk of critical events were observed for all abnormal criteria except low heart rate. There was no significant difference in the incidence of critical events. ARS, a single parameter system, had good specificity and negative predictive value for predicting critical events; however, sensitivity and positive predictive value were not good, and medical staff compliance was poor.

Automated Electronic Frailty Index–Identified Frailty Status and Associated Postsurgical Adverse Events

ImportanceElectronic frailty index (eFI) is an automated electronic health record (EHR)–based tool that uses a combination of clinical encounters, diagnosis codes, laboratory workups, medications, and Medicare annual wellness visit data as markers of frailty status. The association of eFI with postanesthesia adverse outcomes has not been evaluated.ObjectiveTo examine the association of frailty, calculated as eFI at the time of the surgical procedure and categorized as fit, prefrail, or frail, with adverse events after elective noncardiac surgery.Design, Setting, and ParticipantsThis cohort study was conducted at a tertiary care academic medical center in Winston-Salem, North Carolina. The cohort included patients 55 years or older who underwent noncardiac surgery of at least 1 hour in duration between October 1, 2017, and June 30, 2021.ExposureFrailty calculated by the eFI tool. Preoperative eFI scores were calculated based on available data 1 day prior to the procedure and categorized as fit (eFI score: ≤0.10), prefrail (eFI score: >0.10 to ≤0.21), or frail (eFI score: >0.21).Main Outcomes and MeasuresThe primary outcome was a composite of the following 8 adverse component events: 90-item Patient Safety Indicators (PSI 90) score, hospital-acquired conditions, in-hospital mortality, 30-day mortality, 30-day readmission, 30-day emergency department visit after surgery, transfer to a skilled nursing facility after surgery, or unexpected intensive care unit admission after surgery. Secondary outcomes were each of the component events of the composite.ResultsOf the 33 449 patients (median [IQR] age, 67 [61-74] years; 17 618 females [52.7%]) included, 11 563 (34.6%) were classified as fit, 15 928 (47.6%) as prefrail, and 5958 (17.8%) as frail. Using logistic regression models that were adjusted for age, sex, race and ethnicity, and comorbidity burden, patients with prefrail (odds ratio [OR], 1.24; 95% CI, 1.18-1.30; P < .001) and frail (OR, 1.71; 95% CI, 1.58-1.82; P < .001) statuses were more likely to experience postoperative adverse events compared with patients with a fit status. Subsequent adjustment for all other potential confounders or covariates did not alter this association. For every increase in eFI of 0.03 units, the odds of a composite of postoperative adverse events increased by 1.06 (95% CI, 1.03-1.13; P < .001).Conclusions and RelevanceThis cohort study found that frailty, as measured by an automatically calculated index integrated within the EHR, was associated with increased risk of adverse events after noncardiac surgery. Deployment of eFI tools may support screening and possible risk modification, especially in patients who undergo high-risk surgery.

Incidence and Outcome of Reintubation in the Postanesthesia Care Unit: A Single-Center, Retrospective, Observational Matched Cohort Study in China

PurposeTo investigate the incidence and outcome of reintubation after planned extubation (RAP) in the postanesthesia care unit (PACU) in China. DesignA single-center, retrospective, 1:2 matched cohort study following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. MethodsAmong 121,965 patients in the PACU, 14 patients with RAP were included in this study from January 1, 2017 to December 31, 2019. PACU length of stay, postoperative length of stay in hospital, inpatient healthcare costs, and outcomes were compared between the RAP and the matched groups. FindingsThe incidence of RAP was 0.0115%. After propensity score matching, there were no statistically significant differences in age, sex, body mass index (BMI), elective/nonelective procedure, surgical classification, American Society of Anesthesiologists physical status, the duration of anesthesia, or the duration of surgical procedure between the two groups. PACU length of stay, postoperative length of stay in hospital, and inpatient healthcare costs significantly differed between the RAP group and the matched group (P < .01 for all). The percentage of patients with longer PACU length of stay in the RAP group was significantly higher than that in the matched group (92.86% vs 7.14%), with an odds ratio of 29.87 (95% confidence interval = 14.00-2,040.54, P < .001). ConclusionsDespite its low incidence, RAP in the PACU may be associated with life-threatening and severe complications with longer PACU length of stay, unexpected intensive care unit admission, longer hospitalization length, longer postoperative length of stay in hospital, and increased inpatient health costs. Appropriate timing of extubation and monitoring in the PACU can effectively prevent the occurrence of RAP and improve patient prognosis.

Does Operative Duration of Lobectomy for Early Lung Cancer Increase Perioperative Morbidity?

BackgroundLonger bariatric, colorectal, plastic, spine, and urologic operations increase complications and lengths of stay. We aimed to determine whether this is a risk factor for lung lobectomy morbidity. MethodsThe Society of Thoracic Surgeons General Thoracic Surgery Database was queried for early-stage non-small cell lung cancer lobectomy with surgical duration treated as a continuous variable. Univariate and multivariate analyses compared patient and clinical characteristics with perioperative outcomes and procedure durations. Robotic cases were combined with thoracoscopic cases for duration analyses into a minimally invasive group. All analyses were conducted in SAS v9.4 (SAS Institute, Cary, NC) at a significance level of .05. ResultsIn 17,852 patients mean duration of thoracotomy, thoracoscopy, and robotic lobectomies were 178 ± 84, 185 ± 73, and 214 ± 82 minutes, respectively (P < .001). The most common complications were prolonged air leak (12.3%), atrial fibrillation (12%), pneumonia (4.4%), and atelectasis requiring bronchoscopy (4.1%). Procedure duration was associated with increased odds of intraoperative packed red blood cell transfusion (P < .001) and length of stay > 5 days (P < .001) for both thoracotomy and minimally invasive lobectomy. Increased odds of pneumonia (P < .001), atelectasis (P < .001), and unexpected intensive care unit admission (P = .006) for thoracotomy lobectomy were associated with longer procedure duration. Increased lobectomy duration was not associated with readmission (P = .549) or 30-day mortality (P = .208). ConclusionsLonger early-stage lung cancer lobectomy durations are associated with postoperative morbidity and increased length of stay. Although the effects of protracted operation times on long-term survival are unknown, short-term mortality differences were not detected. Measures that decrease operative durations without sacrificing safety and oncologic outcome should be undertaken by surgeons and hospital systems.

ASO Visual Abstract: A Population-Based Analysis of Long-Term Outcomes Among Older Adults Requiring Unexpected Intensive Care Unit Admission After Cancer Surgery

ASO Visual Abstract: A Population-Based Analysis of Long-Term Outcomes Among Older Adults Requiring Unexpected Intensive Care Unit Admission After Cancer Surgery

A Population-Based Analysis of Long-Term Outcomes Among Older Adults Requiring Unexpected Intensive Care Unit Admission After Cancer Surgery.

High-intensity cancer surgery is increasingly common among older adults. However, these patients are at high-risk for unexpected intensive care unit (ICU) admissions after surgery. How these admissions impact older adults' long-term outcomes is unknown. We performed a population-based, cohort study of older adults (age ≥70years) who underwent high-intensity cancer surgery from 2007 to 2017. Analyses were performed to examine time alive and at home following surgery, defined as time from surgery to nursing home admission or death. Patients were followed for up to 5years. Extended Cox proportional hazards models examined the independent association between unexpected ICU admission (ICU admissions excluding routine postoperative monitoring) and remaining alive and at home. Subgroup analysis stratified patients by duration of mechanical ventilation (MV). Of 47,367 identified older adults, 7372 (15.6%) had an unexpected ICU admission. Patients with an unexpected ICU admission had a significantly lower probability of being alive and at home at 5 years (26.2%; 95% confidence interval [CI] 25.1-27.2%) compared with those without an unexpected admission (56.8%; 95% CI 56.3-57.4%). After adjusting for baseline characteristics, unexpected ICU admission remained associated with less time alive and at home. The elevated risk of death or nursing home admission persisted for 5years after surgery (years 2-5: hazard ratio [HR] 1.58, 95% CI 1.50-1.66). Duration of MV was inversely associated with time alive and at home. Older adults with an unexpected ICU admission after high-intensity cancer surgery are at increased risk for death or admission to a nursing home for at least 5years.

A Challenging Period After Repair: Etiology and Follow-Up Rates of the Patients With Cleft Lip and Palate in Intensive Care Unit.

The perioperative period is quite challenging because of the featured anatomical and clinical properties of the babies with cleft lip and palate (CLP). Therefore follow-up in the intensive care unit (ICU) is a crucial parameter for managing these patients. Although various studies in cleft literature, limited studies have analyzed the ICU admission rate and its etiology in the cleft population. At this point, the present study aims to reveal the etiology and rate of ICU admission of babies with an orofacial cleft to contribute to taking preventive precautions.The rate of primary CLP patients was 69.5% (937 of 1348 patients). Intensive care unit admission rate of primary CLP patients was 6.2% (n = 58). The expected and unexpected ICU admission rate was 4.8% and 1.4%, respectively. Of the patients admitted to the ICU, 53.4% (n = 31) were boys and 46.6% (n = 27) were girls. There was no statistically significant association between gender and ICU admission (P = 0.896). However, the association between cleft type and ICU follow-up was statistically significant (P < 0.001).The findings of the present study reveal the high ICU admission rate of cleft patients within all patients admitted to ICU. Due to many unique statuses of cleft babies, attentive assessment in the preoperative period and determining the postoperative need for ICU follow-up would contribute to preventing postoperative complications.

A clinical nomogram predicting unplanned intensive care unit admission after hip fracture surgery

BackgroundDespite the improvement of surgical procedures and perioperative management, a portion of patients were still at high risk for intensive care unit admission owing to severe morbidity after hip fracture surgeries. The purpose of this study was to analyze influencing factors and to construct a clinical nomogram to predict unscheduled intensive care unit admission among inpatients after hip fracture surgeries. MethodsWe enrolled a total of 1,234 hip fracture patients, with 40 unplanned intensive care unit admissions, from January 2011 to December 2018. Demographics, chronic coexisting conditions at admission, laboratory tests, and surgical variables were collected and compared between intensive care unit admission and nonadmission groups using univariate analysis. The optimal lasso model was refined to the whole data set, and multivariate logistic regression was used to assign relative weights. A nomogram incorporating these predictors was constructed to visualize these predictors and their corresponding points of the risk for unplanned intensive care unit admission. The model was validated temporally using an independent data set from January 2019 to December 2019 by receiver operating characteristic area under the curve analysis. ResultsIn the development group, we identified age, chronic heart failure, coronary heart disease, chronic obstructive pulmonary disease, Parkinson disease, and serum albumin and creatinine concentration were associated with unscheduled intensive care unit admission using multivariate analysis. The final model had an area under the curve of 0.854 (95% confidence interval, 0.742–0.966). The median calculated odds ratio of intensive care unit admission based on the nomogram was significantly higher for patients in the intensive care unit admission group than in the non-intensive care unit admission group (65.93% vs 0.02%, P < .01). The validation group proved its high predictive power with an area under the curve of 0.96 (95% confidence interval, 0.91–0.99). ConclusionIn this study, we identified several independent factors that may increase the risk for unexpected intensive care unit admission after hip fracture surgery and developed a clinical nomogram based on these variables. Preoperative evaluation using this nomogram might facilitate advanced intensive care unit resource management for high-risk patients whose conditions might easily deteriorate if not closely monitored in general wards after surgeries.

Pulmonary artery size on computed tomography is associated with major morbidity after pulmonary lobectomy

ObjectiveTo investigate the relationship of pulmonary artery diameter (PAD) measured by computed tomography (CT) with outcomes following lobectomy. MethodsRecords of patients undergoing pulmonary lobectomy for lung cancer between 2011 and 2018 were reviewed. Baseline characteristics and postoperative outcome data were derived from the institutional Society of Thoracic Surgeons database. Luminal diameter of the central pulmonary arteries and ascending aorta were measured on preoperative CTs. Logistic regression analyses were performed to test the association of PAD with complications. ResultsA total of 736 lobectomy patients were included, who had a preoperative CT scan (25% with contrast, 75% noncontrast) available for review. A total of 141 (19.2%) patients had an enlarged main PAD ≥30 mm, and 58 (7.9%) patients had a main PAD that was larger than the ascending aorta (PA/ascending aorta ratio > 1). The right or left PAD on the surgical side was associated with major complication (odds ratio per mm, 1.12; 95% confidence interval, 1.05-1.18; P < .001), unexpected intensive care unit admission (odds ratio per millimeter, 1.11; 95% confidence interval, 1.04-1.19; P = .002), and 30-day mortality (odds ratio per millimeter, 1.25; 95% confidence interval, 1.06-1.46; P = .007). On multivariable analysis, adjusted for cardiovascular comorbidities, pulmonary function, and the operative approach, surgical side PAD remained an independent factor associated with major complication. ConclusionsCT-based measurements of the PAD on the operative side may inform of the about the risk of major complications after lobectomy. Review of PA size on preoperative CT scans may help identify patients who would benefit from formal evaluation of PA pressures to improve the operative risk assessment.

No harm found when the scope of practice of nurse anesthetists is expanded to the whole process of anesthetic care and under indirect supervision of anesthesiologists: A time series study

BackgroundMore and more countries utilize nurse anesthetists as an anesthetic care provider to make up for the insufficiency of anesthesiologists. ObjectiveTo examine whether introducing nurse anesthetists with expanded scope of practice to anesthetic care would jeopardize the safety of patients and quality of anesthetic care. DesignThis observational study used an interrupted time series design. Setting(s)A metropolitan teaching cancer hospital located in Southwest China. Participants24290 patients with surgical procedures under general anesthesia from January 2015 to December 2017 were included. MethodsIn May 2016, nurse anesthetists with expanded scope of practice were introduced to anesthetic care. Administrative and medical record data were accessed to identify the occurrence of anesthetic outcomes including failed tracheal intubation and inability to ventilate with mask, aspiration, problem with airway in the post-anesthesia care room, hypothermia (temperature ≤ 35°C or chills), unplanned stay in the post-anesthesia care room longer than 3 hours, unexpected intensive care unit admission, reintubation, vascular and cardiopulmonary disorders and death. Statistical process control analysis was conducted to test special cause variation in outcomes over time. ResultsFindings demonstrated significant decrease in the proportion of patients staying in the post-anesthesia care room longer than 3 hours and with hypothermia following nurse anesthetists introduced to anesthetic care. Other anesthetic outcomes were not significantly changed. ConclusionsThe results demonstrate that involvement of nurse anesthetists with expanded scope of practice in anesthetic care did not jeopardize patients’ safety or quality of anesthesia. Moreover, it may have beneficial impact in preventing prolonged stay in the post-anesthesia care room and hypothermia. Further research is required to examine the impact of involvement of nurse anesthetists in anesthetic care across all clinical contexts.

Characteristics and Prognosis of Hospitalized Patients at High Risk of Deterioration Identified by the Rapid Response System: a Multicenter Cohort Study.

We aimed to investigate the characteristics and prognosis of high risk hospitalized patients identified by the rapid response system (RRS). A multicentered retrospective cohort study was conducted from June 2019 to December 2020. The National Early Warning Score (NEWS) was used for RRS activation. The outcome was unexpected intensive care unit (ICU) admission within 24 hours after RRS activation. The 11,459 patients with RRS activations were included. We found distinct clinical characteristics in patients who underwent ICU admission. All NEWS parameters were associated with the risk of unexpected ICU admission except body temperature. Body mass index, pulmonary disease, and cancer are related to the decreased risk of unexpected ICU admission. In conclusion, there were differences in clinical characteristics among high risk patients, and those differences were associated with unexpected ICU admissions. Clinicians should consider factors relating to unexpected ICU admission in the management of high risk patients identified by RRS.

Adoption of a Urologic Oncology Perioperative Surgical Home is Associated with Decreased Total Length of Stay: A Pilot Study.

Urologists partnered with anesthesiologists to implement a model of perioperative and postoperative care known as the multidisciplinary perioperative surgical home in order to improve the quality and efficiency of care. We describe early outcomes associated with implementation of the perioperative surgical home. Retrospective chart review was performed of patients at a single institution undergoing radical prostatectomy, radical cystectomy, partial nephrectomy and radical nephrectomy from January 2014 to March 2016. Outcomes measured were length of stay and 30-day reoperation, readmission, unexpected intensive care unit admission and mortality rates. Statistical analysis was performed using the independent samples Mann-Whitney U test and Fisher exact test with p <0.05 considered significant. Univariate and multivariate analyses were performed to determine whether implementation of the perioperative surgical home was associated with improved outcomes. Length of hospital stay decreased from 4.79 to 3.19 days and 30-day complication rate decreased from 15.3% to 5.7% after implementation of the perioperative surgical home (p <0.01 for both). There was no change in the 30-day readmission rate. On multivariate analysis surgery occurring after perioperative surgical home implementation was associated with decreased length of stay (p = 0.008). The direct cost savings resulting from this length of stay reduction totaled $1,245,585 for the study period. The adoption of a perioperative surgical home is associated with a significantly decreased postoperative hospital stay and 30-day complication rate for urologic oncology cases.

Preoperative risk factors for unexpected postoperative intensive care unit admission: A retrospective case analysis

IntroductionThe purpose of this retrospective case–control study was to investigate preoperative risk factors for unexpected postoperative intensive care unit (ICU) admissions in patients undergoing non-emergent surgical procedures in a tertiary medical centre. MethodsA medical record review of adult patients undergoing elective non-cardiac and non-transplant major surgical procedures during the period of January 2011 through December 2015 in the operating rooms of a large university hospital was carried out. The primary outcome assessed was unexpected ICU admission, with mortality as a secondary outcome. Demographic data, length of hospital and ICU stay and preoperative comorbidities were also obtained as exposure variables. Propensity score matching was then employed to yield a study and control group. ResultsThe group of patients who met inclusion criteria in the study and the control group that did not require ICU admission were obtained, each containing 1191 patients after propensity matching. Patients with acute and/or chronic kidney injury (odds ratio (OR) 2.20 [1.75–2.76]), valvular heart disease (OR: 1.94 [1.33–2.85]), peripheral vascular disease (PVD) (OR: 1.41 [1.02–1.94]) and congestive heart failure (CHF) (OR: 1.80 [1.31–2.46]) were all associated with increased unexpected ICU admission. History of cerebrovascular accident (CVA) (OR: 3.03 [1.31–7.01]) and acute and/or chronic kidney injury (OR: 1.62 [1.12–2.35]) were associated with increased mortality in all patients; CVA was also associated with increased mortality (OR: 3.15 [1.21–8.20]) specifically in the ICU population. ConclusionsCHF, acute/chronic kidney injury, PVD and valve disease were significantly associated with increased unexpected ICU admission; patients with CVA suffered increased mortality when admitted to the ICU.

Analysis of Unplanned Intensive Care Unit Admissions in Postoperative Pediatric Patients.

Currently, there are only a few retrospective, single-institution studies that have addressed the prevalence and risk factors associated with unplanned admissions to the pediatric intensive care unit (ICU) after surgery. Based on the limited amount of studies, it appears that airway and respiratory complications put a child at increased risk for unplanned ICU admission. A more extensive and diverse analysis of unplanned postoperative admissions to the ICU is needed to address risk factors that have yet to be revealed by the current literature. To establish a rate of unplanned postoperative ICU admissions in pediatric patients using a large, multi-institution data set and to further characterize the associated risk factors. Data from the National Anesthesia Clinical Outcomes Registry were analyzed. We recorded the overall risk of unplanned postoperative ICU admission in patients younger than 18 years and performed univariate and multivariate logistic regression analysis to identify the associated patient, surgical, and anesthetic-related characteristics. Of the 324 818 cases analyzed, 211 reported an unexpected ICU admission. There was an increased likelihood of unplanned postoperative ICU in infants (age <1 year) and children who were classified as American Society of Anesthesiologists physical status classification of III or IV. Likewise, longer case duration and cases requiring general anesthesia were also associated with unplanned ICU admissions. This study establishes a rate of unplanned ICU admission following surgery in the heterogeneous pediatric population. This is the first study to utilize such a large data set encompassing a wide range of practice environments to identify risk factors leading to unplanned postoperative ICU admissions. Our study revealed that patient, surgical, and anesthetic complexity each contributed to an increased number of unplanned ICU admissions in the pediatric population.

Patients Hospitalized in General Wards via the Emergency Department: Early Identification of Predisposing Factors for Death or Unexpected Intensive Care Unit Admission—A Historical Prospective

Background. To identify, upon emergency department (ED) admission, predictors of unexpected death or unplanned intensive care/high dependency units (ICU/HDU) admission during the first 15 days of hospitalization on regular wards. Methods. Prospective cohort study in a medical-surgical adult ED in a teaching hospital, including consecutive patients hospitalized on regular wards after ED visit, and identification of predictors by logistic regression and Cox proportional hazards model. Results. Among 4,619 included patients, 77 (1.67%) target events were observed: 32 unexpected deaths and 45 unplanned transfers to an ICU/HDU. We identified 9 predictors of the target event including the oxygen administration on the ED, unknown current medications, and use of psychoactive drug(s). All predictors put the patients at risk during the first 15 days of hospitalization. A logistic model for hospital mortality prediction (death of all causes) still comprised oxygen administration on the ED, unknown current medications, and the use of psychoactive drug(s) as risk factors. Conclusion. The “use of oxygen therapy on the ED,” the “current use of psychoactive drug(s)”, and the “lack of knowledge of current medications taken by the patients” were important predisposing factors to severe adverse events during the 15 days of hospitalization on regular wards following the ED visit.

Accuracy of an expanded early warning score for patients in general and trauma surgery wards

Early warning scores (EWS) may aid the prediction of major adverse events in hospitalized patients. Recently, an expanded EWS was introduced in the Netherlands. The aim of this study was to assess the relationship between this EWS and the occurrence of major adverse clinical events during hospitalization of patients admitted to a general and trauma surgery ward. This was a prospective cohort study of consecutive patients admitted to the general and trauma surgery ward of a university medical centre (March-September 2009). Follow-up was limited to the time the patient was hospitalized. Logistic regression analysis was used to assess the relationship between the EWS and the occurrence of the composite endpoint consisting of death, reanimation, unexpected intensive care unit admission, emergency surgery and severe complications. Performance of the EWS was analysed using sensitivity, specificity, predictive values and receiver operating characteristic (ROC) curves. A total of 572 patients were included. During a median follow-up of 4 days, 46 patients (8.0 per cent) reached the composite endpoint (two deaths, two reanimations, 17 intensive care unit admissions, 44 severe complications, one emergency operation). An EWS of at least 3, adjusted for baseline American Society of Anesthesiology classification, was associated with a significantly higher risk of reaching the composite endpoint (odds ratio 11·3, 95 per cent confidence interval (c.i.) 5·5 to 22·9). The area under the ROC curve was 0·87 (95 per cent c.i. 0·81 to 0·93). When considering an EWS of at least 3 to be a positive test result, sensitivity was 74 per cent and specificity was 82 per cent. An EWS of 3 or more is an independent predictor of major adverse events in patients admitted to a general and trauma surgery ward.

Avoiding airway obstruction after pediatric adenotonsillectomy

Objective To evaluate the efficacy of a protocol designed to prevent post-adenotonsillectomy airway obstruction in small children with obstructive sleep apnea. Design Computerized retrospective review of single surgeon case series. Setting Tertiary children's medical center. Methods Children with sleep study proven obstructive sleep apnea or children under the age of 3 years with clinically suspected obstructive sleep apnea were treated according to a protocol that included: (1) rapid bloodless tonsillectomy; (2) repeated release of the tonsillar retractor; (3) avoidance of uvular edema; (4) routine intra-operative intranasal oxymetazoline, and placement of nasal airway; (5) extended recovery room observation. Primary outcome measures were (1) avoidance of unexpected intensive care unit admission; (2) post-extubation pulmonary edema; (3) aspiration pneumonia. Results During the period March 2004–August 2007, 864 children underwent adenotonsillectomy by a single surgeon—604 for the indication of obstructive sleep apnea or adenotonsillar hypertrophy with obstruction. Two hundred and ten were under the age of 3 years or had sleep study proven obstructive sleep apnea. There were two unexpected admissions to the pediatric intensive care unit for persistent upper airway obstruction—none required intubation. No child developed post-obstructive pulmonary edema. Three children were treated for infiltrates consistent with aspiration pneumonitis. Conclusion Most cases of post-extubation pulmonary edema and pneumonia can be avoided in young children and those with mild-to-moderate obstructive sleep apnea following a protocol that anticipates and avoids precipitating causes of upper airway obstruction.

The impact of introducing medical emergency team system on the documentations of vital signs

ObjectiveTo study the rate of documentation of vital signs in the period before the occurrence of an adverse event or emergency team call and to measure the effect of introducing the medical emergency team (MET) system on the rate of such documentation. MethodsDuring a cluster, randomised trial of the MET in 23 Australian hospitals, we collected the data on lowest systolic blood pressure, highest and lowest respiratory rate and heart rate from 15min to 24h before an adverse event (cardiac arrest, death or unexpected intensive care unit admission) or emergency team call. We derived the document of these vital signs (yes/no) from the numerical values recorded. We used analytically weighted and random-effect regression models to examine the association between non-documented (missing) vital signs, hospital characteristics and MET allocation, and to examine their trend over time. ResultsWe found marked variability in documentation, with a high proportion of missing vital signs in some hospitals. Close to 77% of patients suffering adverse events had at least one vital sign missing immediately before the event. Allocation to a MET system was associated with significantly increased documentation of respiratory rate and blood pressure before emergency team review (P<0.01) as well as an improvement in documentation over time (P<0.01). At all stages and for both MET and control hospitals, the respiratory rate was the least commonly documented vital sign (P<0.01). ConclusionsThe documentation of vital signs in the period before adverse events was commonly incomplete with a particular deficiency in the documentation of the respiratory rate. Introduction of a MET system was associated with improvement in the rate of documentation of vital signs.

Risk factors and prognostic predictors of unexpected intensive care unit admission within 3 days after ED discharge

Objective Our objective was to investigate the risk factors and prognostic predictors of unexpected intensive care unit (ICU) admission within 3 days after emergency department (ED) discharge. Methods From January 1, 2001, through December 31, 2005, patients admitted to the ICU unexpectedly within 3 days after being discharged from the ED were enrolled. Medical records of these patients were retrospectively reviewed. We categorized each patient's characteristics into dichotomous groups and used the χ 2 test to identify risk factors for unexpected ICU admission within 3 days after ED discharge. A multiple logistic regression was applied to examine possible independent predictors of poor prognoses. Results During the study period, 365 321 patients visited our ED; 241(0.07%) were unexpectedly admitted to the ICU within 3 days after being discharged from the ED. Mean patient age was 74.2 ± 16.4 years. The rate of ICU admissions caused by medical error was 0.019% ± 0.004% of all visits and 29.0% ± 5.7% of all unexpected ICU admissions. The overall mortality rate was 19.9% (48/241). Risk factors for unexpected ICU admission within 3 days after discharge from the ED were age of 65 years or older (odds ratio [OR], 5.4; 95% confidence interval [CI], 4.0-7.4), ambulance transport (OR, 5.1; 95% CI, 3.9-6.5), no accompanying family (OR, 3.5; 95% CI, 2.7-4.5), nonambulatory status (OR, 4.2; 95% CI, 2.9-5.0), not living at home (OR, 2.5; 95% CI, 1.9-3.3), Medicaid insurance (OR, 3.6; 95% CI, 2.8-4.7), and emergency stay of more than 24 hours (OR, 4.4; 95% CI, 3.4-5.7). The independent predictors of mortality were age of 65 years or older (OR, 2.4; 95% CI, 1.7-3.6), multiple comorbidities (OR, 4.0; 95% CI, 1.8-8.5), medical error leading to ICU admission (OR, 3.9; 95% CI, 1.8-8.3), and Acute Physiology and Chronic Health Evaluation II score of 20 or higher (OR, 2.9; 95% CI, 1.1-7.8). Conclusions In our study, the risk factors and prognostic predictors of unexpected ICU admission within 3 days after ED discharge were identified. Based on these risk and prognostic prediction factors, further strategies for decreasing the incidence of serious adverse events of ED-discharged patients can be implemented.

Consultations médicales préopératoires: conséquence sur la prise en charge périopératoire et les suites opératoires

This study was designed to assess the effect of preoperative medical consults on both perioperative management and surgical outcome. The charts of 387 consecutive patients over the age of 50 undergoing non-cardiac, elective surgery during a six-week period were retrospectively examined. Patient factors including age, ASA status, gender, type of surgery, outcome (death, unexpected intensive care unit admission or uncomplicated discharge), presence of medical consult, and, in those cases where a medical consult was present, stated reason for the consult, the ordering physician, and recommendations of the consultant, were recorded. 138 patients receiving medical consults (35.7%) were identified (a total of 146 consults). The most common stated purpose of the consults examined was "preoperative evaluation." In only five consults (3.4%) did the consultant identify a new finding. Sixty-two consults (42.5%) contained no recommendations. There was no statistically significant difference in outcome between those patients who received a medical consult and those who did not. A review of 146 medical consults suggests that the majority of such consults give little advice that truly impacts either perioperative management or outcome of surgery.