Use Of Invasive Interventions Research Articles

Pain management after microtia repair with costal cartilage: De-escalation and opioid use reduction

ObjectiveComplex and invasive postoperative pain regimens for microtia reconstruction with costal cartilage are often utilized. These generate added costs and invasiveness. We evaluated the effectiveness of a de-escalated pain regimen without use of invasive interventions. MethodsCase series of patients who underwent stage 1 microtia reconstruction with a modified Nagata/Firmin technique from 2017 to 2020 at a pediatric tertiary care hospital. Patients received intraoperative bupivacaine intercostal blocks and scheduled acetaminophen. Adjunct medications administered and pain scores (Wong-Baker FACES and FLACC-Face, Legs, Activity, Cry, Consolability) at intervals 2–72 h postoperatively were recorded. Narcotic use, peak and median pain scores, and length of stay were compared with published values. ResultsTwenty patients were included. Mean age of 12 and length of stay of 2.8 days. Average postoperative FACES scores between 0 and 72 h ranged between 0.7 and 4.0. The average peak pain score was 6.1 (±2.0). FLACC scores were low. Narcotics (0.59 ±0 .35 Morphine Milligram Equivalents/kg) were given to 17 patients. Compared to Shaffer et al. (paravertebral catheter-based infusion), total narcotics use (p = 0.03), peak pain (p = 0.0001), and length of stay (p = 0.001) were less. Compared to Woo et al. (intercostal catheter-based infusion), median pain scores at identical time intervals were lower (p = 0.04). ConclusionIntraoperative intercostal nerve blocks followed by scheduled, weight-based acetaminophen, adjunctive medications (ibuprofen and lidocaine patches), and rescue narcotics are effective in managing pain following microtia repair with autologous costal cartilage. It results in decreased narcotic usage, shorter length of stay, and lower pain scores compared to more complex regimens.

Effects of Hospice Care for Terminal Head and Neck Cancer Patients: A Nationwide Population-Based Matched Cohort Study

Background: Head and neck cancer was the fourth-most common cause of cancer death among Taiwanese men in 2018. Hospice care has been proven to reduce the use of invasive medical interventions and expenditures in caring for cancer patients. Aim: This study examined the effects of hospice care for terminal head and neck cancer patients. Design: A matched cohort study was used to compare the use of invasive interventions and expenditures among hospice care and nonhospice care patients. Setting/Participants: The investigated patients consisted of patients who died of head and neck cancer in Taiwan from 2004 to 2013 and were included in the Registry for Catastrophic Illness Patients in Taiwan and the Taiwan National Health Research Insurance Database. Results: A total of 45,948 terminal head and neck cancer patients were identified, and 9883 patients remained in each group after matching for comorbidities. After that matching, the rates of intensive care unit admission (23.9% vs. 38.94%, p < 0.0001), endotracheal intubation (10.05% vs. 31.32%, p < 0.0001), cardiopulmonary resuscitation (2.93% vs. 20.18%, p < 0.0001), defibrillation (0.51% vs. 4.36%. p < 0.0001), ventilator use (21.92% vs. 46.47%, p < 0.0001), blood transfusion (71.25% vs. 73.45%, p = 0.006), and hemodialysis (1.06% vs. 3.26%. p < 0.0001) were significantly lower in the hospice group than the nonhospice group, although the rates of parenteral nutrition for the two groups were similar (7.74% vs. 7.97%, p = 0.5432). The mean medical expenditure per person in the six months before death was 460,531 New Taiwan Dollar (NTD) for the nonhospice group and 389,079 NTD for those provided hospice care for more than three months, which was the lowest amount among various hospice enrollment durations. Conclusions: Hospice care can effectively reduce the use of invasive medical interventions in caring for terminal head and neck cancer patients and may improve their quality of death. Moreover, hospice care enrollment for more than three months can save on unnecessary medical expenditures for terminal head and neck cancer patients.

Withholding or withdrawing invasive interventions may not accelerate time to death among dying ICU patients.

BackgroundCritically ill patients may die despite invasive intervention. In this study, we examine trends in the application of two such treatments over a decade, namely, endotracheal ventilation and vasopressors and inotropes administration, as well as the impact of these trends on survival durations in patients who die within a month of ICU admission.MethodsWe considered observational data available from the MIMIC-III open-access ICU database and collected within a study period between year 2002 up to 2011. If a patient had multiple admissions to the ICU during the 30 days before death, only the first stay was analyzed, leading to a final set of 6,436 unique ICU admissions during the study period. We tested two hypotheses: (i) administration of invasive intervention during the ICU stay immediately preceding end-of-life would decrease over the study time period and (ii) time-to-death from ICU admission would also decrease, due to the decrease in invasive intervention administration. To investigate the latter hypothesis, we performed a subgroups analysis by considering patients with lowest and highest severity. To do so, we stratified the patients based on their SAPS I scores, and we considered patients within the first and the third tertiles of the score. We then assessed differences in trends within these groups between years 2002–05 vs. 2008–11.ResultsComparing the period 2002–2005 vs. 2008–2011, we found a reduction in endotracheal ventilation among patients who died within 30 days of ICU admission (120.8 vs. 68.5 hours for the lowest severity patients, p<0.001; 47.7 vs. 46.0 hours for the highest severity patients, p = 0.004). This is explained in part by an increase in the use of non-invasive ventilation. Comparing the period 2002–2005 vs. 2008–2011, we found a reduction in the use of vasopressors and inotropes among patients with the lowest severity who died within 30 days of ICU admission (41.8 vs. 36.2 hours, p<0.001) but not among those with the highest severity. Despite a reduction in the use of invasive interventions, we did not find a reduction in the time to death between 2002–2005 vs. 2008–2011 (7.8 days vs. 8.2 days for the lowest severity patients, p = 0.32; 2.1 days vs. 2.0 days for the highest severity patients, p = 0.74).ConclusionWe found that the reduction in the use of invasive treatments over time in patients with very poor prognosis did not shorten the time-to-death. These findings may be useful for goals of care discussions.

Surveillance of community-acquired pneumonia in critically ill patients

Background: In this study, we aimed to investigate the epidemiology, causative agents and outcomes of severe community-acquired pneumonia (CAP) in Hong Kong. Also, the risk factors for mortality would be identified. Methods: This is a retrospective cohort study of patients with severe CAP admitted to an adult ICU in a tertiary hospital. The study period was from January 2010 to December 2014. The following patient data were extracted from the medical records: (I) demographic data; (II) comorbidities; (III) the APACHE IV scores; (IV) probable causative agents; (V) laboratory results; (VI) use of invasive interventions; (VII) outcomes in term of mortality and length of stay. Multivariate regression analysis was used to assess the impact of independent variables on hospital mortality. Results: Totally 390 patients were admitted to ICU for severe CAP. We were able to obtain the causative pathogens in about 60% of patients. Bacterial infection was identified in 154 patients and 88 patients suffered from viral infection. Twenty-seven of them suffered from co-infection of bacteria and viruses. Streptococcus pneumoniae was the most commonly isolated organism and accounted for almost 40% of the bacterial pneumonia. Gram-negative organisms constituted about 45% of bacterial chest infection. The common agents included Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter baumannii. Approximately 70% of viral infection was caused by influenza A infection, followed by influenza B and parainfluenza. Atypical pneumonia only contributed to a minority of CAP, of about 2%. Legionella pneumophila was the most common organism. The overall ICU and hospital mortality rate was 23.1% and 34.6%, respectively, with mean ICU stay of 11.3 days and mean hospital stay of 28.7 days. The hospital survivors had shorter ICU and hospital length of stay. The mortality rates for CAP caused by bacteria, viruses and atypical organisms were 44.3%, 24.4% and 10.0%, respectively (P Conclusions: CAP is an important cause of admission to our ICU with significant mortality. Etiological organisms could be identified in about 60% of CAP. Streptococcus pneumoniae was the most common bacterial agent and most viral infections were caused by influenza A. Atypical bacteria accounted for only a minority of CAP. Pneumococcal and influenza immunization may be effective to reduce the incidence and severity of CAP.

Major Abdominal Surgery in Nursing Home Residents

To determine surgical risk in nursing home residents undergoing major abdominal surgery. Recent studies suggest that surgery can be performed safely in the very old. Surgical risk in nursing home residents is poorly understood. We used national Medicare claims and the nursing home Minimum Data Set (1999-2006) to identify nursing home residents undergoing surgery (surgery for bleeding duodenal ulcer, cholecystectomy, appendectomy, and colectomy, n = 70,719). We compared operative mortality and use of invasive interventions (mechanical ventilation, intravascular hemodynamic monitoring, feeding tube placement, tracheostomy, and vena cava filters) among nursing home residents to rates among noninstitutionalized Medicare enrollees age 65 and older undergoing the same procedures. (n = 1,060,389). We adjusted for patient characteristics using logistic regression. Operative mortality among nursing home residents was substantially higher than among noninstitutionalized Medicare enrollees for all procedures (surgery for bleeding duodenal ulcer, 42% versus 26%, adjusted odds ratio (AOR) 1.79; colectomy, 32% versus 13%, AOR 2.06; appendectomy, 12% versus 2%, AOR 3.27; cholecystectomy, 11% versus 3%, AOR 2.65; P < 0.001 for all comparisons). Overall, invasive interventions were more common among nursing home residents than controls (ranging from 18% and 5%, respectively, for cholecystectomy to 55% and 43%, respectively, for surgery for bleeding duodenal ulcer, P < 0.0001 for all comparisons). Nursing home residents experience substantially higher rates of mortality and invasive interventions after major surgery than other Medicare beneficiaries that are independent of age and measured comorbidities. Our data suggest that the risks of major surgery are substantially higher in nursing home residents and this information should inform decisions of physicians and patients and their families.

Health care–associated infections in the neonatal intensive care unit

Neonates represent a unique and highly vulnerable patient population. Advances in medical technology that have occurred over the last few decades have improved the survival and quality of life for neonates, particularly those infants born with extreme prematurity or with congenital defects. Although immunologic immaturity and altered cutaneous barriers play some role in the vulnerability of neonates to nosocomial infections, clearly, therapeutic interventions that have proven to be lifesaving for these fragile infants also appear to be associated with the majority of infectious complications resulting in neonatal morbidity and mortality. Rates of infections in neonatal intensive care units (NICUs) have varied from 6% to 40% of neonatal patients, with the highest rates in those facilities having larger proportions of very low-birth-weight infants (birthweight ≤1000 grams) or neonates requiring surgery. Efforts to protect the vulnerable NICU infants include the following: (1) optimal infection control practices, especially good hand hygiene and good nursery design; (2) prudent use of invasive interventions with particular attention to early removal of invasive devices after they are no longer essential; and (3) judicious use of antimicrobial agents, with an emphasis on targeted (narrow spectrum) rather than broad-spectrum antibiotics and appropriate indications (proven or suspected bacterial infections).