Objective To evaluate the effects of intraoperative protective ventilation on major postoperative respiratory complications and to define safe intraoperative mechanical ventilator settings that do ...not translate into an increased risk of postoperative respiratory complications.Design Hospital based registry study.Setting Academic tertiary care hospital and two affiliated community hospitals in Massachusetts, United States.Participants 69 265 consecutively enrolled patients over the age of 18 who underwent a non-cardiac surgical procedure between January 2007 and August 2014 and required general anesthesia with endotracheal intubation.Interventions Protective ventilation, defined as a median positive end expiratory pressure (PEEP) of 5 cmH2O or more, a median tidal volume of less than 10 mL/kg of predicted body weight, and a median plateau pressure of less than 30 cmH2O.Main outcome measure Composite outcome of major respiratory complications, including pulmonary edema, respiratory failure, pneumonia, and re-intubation.Results Of the 69 265 enrolled patients 34 800 (50.2%) received protective ventilation and 34 465 (49.8%) received non-protective ventilation intraoperatively. Protective ventilation was associated with a decreased risk of postoperative respiratory complications in multivariable regression (adjusted odds ratio 0.90, 95% confidence interval 0.82 to 0.98, P=0.013). The results were similar in the propensity score matched cohort (odds ratio 0.89, 95% confidence interval 0.83 to 0.97, P=0.004). A PEEP of 5 cmH2O and median plateau pressures of 16 cmH2O or less were associated with the lowest risk of postoperative respiratory complications.Conclusions Intraoperative protective ventilation was associated with a decreased risk of postoperative respiratory complications. A PEEP of 5 cmH2O and a plateau pressure of 16 cmH2O or less were identified as protective mechanical ventilator settings. These findings suggest that protective thresholds differ for intraoperative ventilation in patients with normal lungs compared with those used for patients with acute lung injury.
Administration of intravenous crystalloid solutions is a fundamental therapy for sepsis, but the effect of crystalloid composition on patient outcomes remains unknown.
To compare the effect of ...balanced crystalloids versus saline on 30-day in-hospital mortality among critically ill adults with sepsis.
Secondary analysis of patients from SMART (Isotonic Solutions and Major Adverse Renal Events Trial) admitted to the medical ICU with an
code for sepsis, using multivariable regression to control for potential confounders.
Of 15,802 patients enrolled in SMART, 1,641 patients were admitted to the medical ICU with a diagnosis of sepsis. A total of 217 patients (26.3%) in the balanced crystalloids group experienced 30-day in-hospital morality compared with 255 patients (31.2%) in the saline group (adjusted odds ratio aOR, 0.74; 95% confidence interval CI, 0.59-0.93;
= 0.01). Patients in the balanced group experienced a lower incidence of major adverse kidney events within 30 days (35.4% vs. 40.1%; aOR, 0.78; 95% CI, 0.63-0.97) and a greater number of vasopressor-free days (20 ± 12 vs. 19 ± 13; aOR, 1.25; 95% CI, 1.02-1.54) and renal replacement therapy-free days (20 ± 12 vs. 19 ± 13; aOR, 1.35; 95% CI, 1.08-1.69) compared with the saline group.
Among patients with sepsis in a large randomized trial, use of balanced crystalloids was associated with a lower 30-day in-hospital mortality compared with use of saline.Clinical trial registered with www.clinicaltrials.gov (NCT02444988).
Increased intravascular volume has been associated with protection from acute kidney injury (AKI), but in patients with congestive heart failure, venous congestion is associated with increased AKI. ...We tested the hypothesis that intraoperative venous congestion is associated with AKI after cardiac surgery.
In patients enrolled in the Statin AKI Cardiac Surgery trial, venous congestion was quantified as the area under the curve (AUC) of central venous pressure (CVP) >12, 16, or 20 mm Hg during surgery (mm Hg min). AKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria and urine concentrations of tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 (TIMP-2⋅IGFBP7), a marker of renal stress. We measured associations between venous congestion, AKI and TIMP-2⋅IGFBP7, adjusted for potential confounders. Values are reported as median (25th–75th percentile).
Based on KDIGO criteria, 104 of 425 (24.5%) patients developed AKI. The venous congestion AUCs were 273 mm Hg min (81–567) for CVP >12 mm Hg, 66 mm Hg min (12–221) for CVP >16 mm Hg, and 11 mm Hg min (1–54) for CVP >20 mm Hg. A 60 mm Hg min increase above the median venous congestion AUC above each threshold was independently associated with increased AKI (odds ratio=1.06; 95% confidence interval CI, 1.02–1.10; P=0.008; odds ratio=1.12; 95% CI, 1.02–1.23; P=0.013; and odds ratio=1.30; 95% CI, 1.06–1.59; P=0.012 for CVP>12, >16, and >20 mm Hg, respectively). Venous congestion before cardiopulmonary bypass was also associated with increased TIMP-2⋅IGFBP7 measured during cardiopulmonary bypass and after surgery, but neither venous congestion after cardiopulmonary bypass nor venous congestion throughout surgery was associated with postoperative TIMP-2⋅IGFBP7.
Intraoperative venous congestion was independently associated with increased AKI after cardiac surgery.
The High Luminosity LHC (HL-LHC) project aims at accumulating 3000 fb -1 in the years 2023-2035, i.e., ten times more w.r.t. the nominal LHC performance expected for 2010-2021. One key element to ...reach this challenging performance is a new insertion region to reduce the beam size in the interaction point by approximately a factor two. This requires larger aperture magnets in the region spanning from the interaction point to the matching section quadrupoles. This aperture has been fixed to 150 mm for the inner triplet quadrupoles in 2012. In this paper, we give a first baseline of the interaction region. We discuss the main motivations that lead us to choose the technology, the combination of fields/gradients and lengths, the apertures, the quantity of superconductor, and the operational margin. Key elements are also the constraints given by the energy deposition in terms of heat load and radiation damage; we present the main features related to shielding and heat removal.
Timely discharge to post-acute care (PAC) settings, such as skilled nursing facilities, requires early identification of eligible patients. We sought to develop and internally validate a model which ...predicts a patient's likelihood of requiring PAC based on information obtained in the first 24 h of hospitalization.
This was a retrospective observational cohort study. We collected clinical data and commonly used nursing assessments from the electronic health record (EHR) for all adult inpatient admissions at our academic tertiary care center from September 1, 2017 to August 1, 2018. We performed a multivariable logistic regression to develop the model from the derivation cohort of the available records. We then evaluated the capability of the model to predict discharge destination on an internal validation cohort.
Age (adjusted odds ratio AOR, 1.04 per year; 95% Confidence Interval CI, 1.03 to 1.04), admission to the intensive care unit (AOR, 1.51; 95% CI, 1.27 to 1.79), admission from the emergency department (AOR, 1.53; 95% CI, 1.31 to 1.78), more home medication prescriptions (AOR, 1.06 per medication count increase; 95% CI 1.05 to 1.07), and higher Morse fall risk scores at admission (AOR, 1.03 per unit increase; 95% CI 1.02 to 1.03) were independently associated with higher likelihood of being discharged to PAC facility. The c-statistic of the model derived from the primary analysis was 0.875, and the model predicted the correct discharge destination in 81.2% of the validation cases.
A model that utilizes baseline clinical factors and risk assessments has excellent model performance in predicting discharge to a PAC facility.
The goal of this study was to determine whether CYP2D6 metabolizer status within the ondansetron‐treated pediatric tonsillectomy population is associated with risk of postoperative nausea and ...vomiting (PONV) in the post‐anesthesia care unit. We conducted a retrospective cohort study of pediatric patients (<18 years) who underwent tonsillectomy and received ondansetron on the day of the procedure. Data were obtained from BioVU, an institutional biobank that links DNA to de‐identified electronic health record data. Subjects were tested for 10 CYP2D6 allelic variants and copy number variation, and genotype data translated into CYP2D6 metabolizer status. The cohort included 652 individuals, 105 (16.1%) of whom had PONV. Rates of PONV were similar across groups: ultrarapid metabolizers (UMs), 1 of 9 (11.1%); normal metabolizers (NMs), 64 of 354 (18.1%); intermediate metabolizers (IMs), 33 of 234 (14.1%); poor metabolizers (PMs), 6 of 39 (15.4%); and ambiguous phenotypes, 1 of 16 (6.3%). In multivariable analysis adjusted for age, sex, and time under anesthesia, CYP2D6 metabolizer status was not associated with PONV, with an odds ratio of 1.37 (95% confidence interval 0.9, 2.1) when comparing PM/IM versus NM/UM. In this large pediatric population, no significant differences were detected for PONV based on CYP2D6 metabolizer status. Further investigation is needed to determine mechanisms for ondansetron inefficacy in children.
BACKGROUND:The allocation of intensive care unit (ICU) beds for postoperative patients is a challenging daily task that could be assisted by the real-time detection of ICU needs. The goal of this ...study was to develop and validate an intraoperative predictive model for unplanned postoperative ICU use.
METHODS:With the use of anesthesia information management system, postanesthesia care unit, and scheduling data, a data set was derived from adult in-patient noncardiac surgeries. Unplanned ICU admissions were identified (4,847 of 71,996; 6.7%), and a logistic regression model was developed for predicting unplanned ICU admission. The model performance was tested using bootstrap validation and compared with the Surgical Apgar Score using area under the curve for the receiver operating characteristic.
RESULTS:The logistic regression model included 16 variablesage, American Society of Anesthesiologists physical status, emergency case, surgical service, and 12 intraoperative variables. The area under the curve was 0.905 (95% CI, 0.900–0.909). The bootstrap validation model area under the curves were 0.513 at booking, 0.688 at 3 h before case end, 0.738 at 2 h, 0.791 at 1 h, and 0.809 at case end. The Surgical Apgar Score area under the curve was 0.692. Unplanned ICU admissions had more ICU-free days than planned ICU admissions (5 vs. 4; P < 0.001) and similar mortality (5.6 vs. 6.0%; P = 0.248).
CONCLUSIONS:The authors have developed and internally validated an intraoperative predictive model for unplanned postoperative ICU use. Incorporation of this model into a real-time data sniffer may improve the process of allocating ICU beds for postoperative patients.
Abstract
Background
Pediatric patients have increasing rates of hospital-associated venous thromboembolism (HA-VTE), and while several risk-prediction models have been developed, few are designed to ...assess all general pediatric patients, and none has been shown to improve patient outcomes when implemented in routine clinical care.
Methods
The Children’s Likelihood Of Thrombosis (CLOT) trial is an ongoing pragmatic randomized trial being conducted starting November 2, 2020, in the inpatient units at Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, TN, USA. All admitted patients who are 21 years of age and younger are automatically enrolled in the trial and randomly assigned to receive either the current standard-of-care anticoagulation practice or the study intervention. Patients randomized to the intervention arm are assigned an HA-VTE risk probability that is calculated from a validated VTE risk-prediction model; the model is updated daily with the most recent clinical information. Patients in the intervention arm with elevated risk (predicted probability of HA-VTE ≥ 0.025) have an additional review of their clinical course by a team of dedicated hematologists, who make recommendations including pharmacologic prophylaxis with anticoagulation, if appropriate. The anticipated enrollment is approximately 15,000 patients. The primary outcome is the occurrence of HA-VTE. Secondary outcomes include initiation of anticoagulation, reasons for not initiating anticoagulation among patients for whom it was recommended, and adverse bleeding events. Subgroup analyses will be conducted among patients with elevated HA-VTE risk.
Discussion
This ongoing pragmatic randomized trial will provide a prospective assessment of a pediatric risk-prediction tool used to identify hospitalized patients at elevated risk of developing HA-VTE.
Trial registration
ClinicalTrials.gov NCT04574895. Registered on September 28, 2020. Date of first patient enrollment: November 2, 2020.
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