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Deasy A, O'Sullivan EP. Capnography: A Fundamental in Safe Airway Management. Int Anesthesiol Clin 2024; 62:29-36. [PMID: 39233569 DOI: 10.1097/aia.0000000000000453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Affiliation(s)
- Alison Deasy
- Department of Anaesthesiology and Intensive Care, St James's Hospital, Dublin, Ireland
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2
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Upadhyay P, Hicks MH, Khanna AK. Enhanced monitoring for postoperative hospital wards - Evidence to implementation. Indian J Anaesth 2024; 68:511-513. [PMID: 38903260 PMCID: PMC11186533 DOI: 10.4103/ija.ija_360_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 06/22/2024] Open
Affiliation(s)
- Prateek Upadhyay
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Megan Henley Hicks
- Anesthesiology, Section on Cardiac Anesthesiology and Critical Care Medicine, Atrium Health Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Ashish K. Khanna
- Anesthesiology, Section on Critical Care Medicine, Atrium Health Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA and Outcomes Research Consortium, Cleveland, OH, USA
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3
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Bruck O, Naofal A, Senussi MH. Lung, Pleura, and Diaphragm Point-of-Care Ultrasound. Semin Ultrasound CT MR 2024; 45:120-131. [PMID: 38244897 DOI: 10.1053/j.sult.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Thoracic Ultrasonography involves the ultrasonographic examination of the lungs, pleura, and diaphragm. This provides a plethora of clinical information during the point of care assessment of patients. The air filled lungs create consistent artifacts and careful examination and understanding of these artefactual signs can provide useful information on underlying clinicopathologic states. This review aims to provide a review of the ultrasound signs and features that can be seen in horacic ultrasonography and summarize the clinical evidence to support its use.
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Affiliation(s)
- Or Bruck
- Baylor College of Medicine, Houston, TX
| | | | - Mourad H Senussi
- Baylor College of Medicine, Houston, TX; Texas Heart Institute, Houston, TX.
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Tanaka H, Yokose M, Takaki S, Mihara T, Saigusa Y, Goto T. Measurement accuracy of a microwave doppler sensor beneath the mattress as a continuous respiratory rate monitor: a method comparison study. J Clin Monit Comput 2024; 38:77-88. [PMID: 37792139 DOI: 10.1007/s10877-023-01081-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/19/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE Non-contact continuous respiratory rate monitoring is preferred for early detection of patient deterioration. However, this technique is under development; a gold standard respiratory monitor has not been established. Therefore, this prospective observational method comparison study aimed to compare the measurement accuracy of a non-contact continuous respiratory rate monitor, a microwave Doppler sensor positioned beneath the mattress, with that of other monitors. METHODS The respiratory rate of intensive care unit patients was simultaneously measured using a microwave Doppler sensor, capnography, thoracic impedance pneumography, and a piezoelectric sensor beneath the mattress. Bias and 95% limits of agreement between the respiratory rate measured using capnography (standard reference) and that measured using the other three methods were calculated using Bland-Altman analysis for repeated measures. Clarke error grid (CEG) analysis evaluated the sensor's ability to assist in correct clinical decision-making. RESULTS Eighteen participants were included, and 2,307 data points were analyzed. The bias values (95% limits of agreement) of the microwave Doppler sensor, thoracic impedance pneumography, and piezoelectric sensor were 0.2 (- 4.8 to 5.2), 1.5 (- 4.4 to 7.4), and 0.4 (- 4.0 to 4.8) breaths per minute, respectively. Clinical decisions evaluated using CEG analyses were correct 98.1% of the time for the microwave Doppler sensor, which was similar to the performance of the other devices. CONCLUSION The microwave Doppler sensor had a small bias but relatively low precision, similar to other devices. In CEG analyses, the risk of each monitor leading to inadequate clinical decision-making was low. TRIAL REGISTRATION NUMBER UMIN000038900, February 1, 2020.
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Affiliation(s)
- Hiroyuki Tanaka
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Masashi Yokose
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Shunsuke Takaki
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Takahiro Mihara
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, Japan
| | - Yusuke Saigusa
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
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Gifford A, Butcher B, Chima RS, Moore L, Brady PW, Zackoff MW, Dewan M. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. J Hosp Med 2023; 18:978-985. [PMID: 37792360 DOI: 10.1002/jhm.13216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/11/2023] [Accepted: 09/16/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Optimal design of healthcare spaces can enhance patient care. We applied design thinking and human factors principles to optimize communication and signage on high risk patients to improve situation awareness in a new clinical space for the pediatric ICU. OBJECTIVE To assess the impact of these tools in mitigating situation awareness concerns within the new clinical space. We hypothesized that implementing these design-informed tools would either maintain or improve situation awareness. DESIGN, SETTINGS, AND PARTICIPANTS A 15-week design thinking process was employed, involving research, ideation, and refinement to develop and implement new situation awareness tools. The process included engagement with interprofessional clinical teams, scenario planning, workflow mapping, iterative feedback collection, and collaboration with an industry partner for signage development and implementation. INTERVENTION Improved and updated communication devices and bedside mitigation plans. MAIN OUTCOME AND MEASURES Process metrics included individual and shared situation awareness of PICU care teams and our patient outcome metric was the rate of cardiopulmonary resuscitation (CPR) events pre- and post-transition. RESULTS When evaluating all patients, shared situation awareness for accurate high-risk status improved from 81% pre-transition to 92% post-transition (p = .006). When assessing individual care team roles, accuracy of patient high-risk status improved from 88% to 95% (p = .05) for RNs, 85% to 96% (p = .003) for residents, and 88% to 95% (p = .03) for RTs. There was no change in the rate of CPR events following the transition.
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Affiliation(s)
| | - Bain Butcher
- College of Design, Art, Architecture, and Planning, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ranjit S Chima
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lindsey Moore
- Pediatric Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick W Brady
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Matthew W Zackoff
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Maya Dewan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Wollner EA, Nourian MM, Bertille KK, Wake PB, Lipnick MS, Whitaker DK. Capnography-An Essential Monitor, Everywhere: A Narrative Review. Anesth Analg 2023; 137:934-942. [PMID: 37862392 DOI: 10.1213/ane.0000000000006689] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
Capnography is now recognized as an indispensable patient safety monitor. Evidence suggests that its use improves outcomes in operating rooms, intensive care units, and emergency departments, as well as in sedation suites, in postanesthesia recovery units, and on general postsurgical wards. Capnography can accurately and rapidly detect respiratory, circulatory, and metabolic derangements. In addition to being useful for diagnosing and managing esophageal intubation, capnography provides crucial information when used for monitoring airway patency and hypoventilation in patients without instrumented airways. Despite its ubiquitous use in high-income-country operating rooms, deaths from esophageal intubations continue to occur in these contexts due to incorrect use or interpretation of capnography. National and international society guidelines on airway management mandate capnography's use during intubations across all hospital areas, and recommend it when ventilation may be impaired, such as during procedural sedation. Nevertheless, capnography's use across high-income-country intensive care units, emergency departments, and postanesthesia recovery units remains inconsistent. While capnography is universally used in high-income-country operating rooms, it remains largely unavailable to anesthesia providers in low- and middle-income countries. This lack of access to capnography likely contributes to more frequent and serious airway events and higher rates of perioperative mortality in low- and middle-income countries. New capnography equipment, which overcomes cost and context barriers, has recently been developed. Increasing access to capnography in low- and middle-income countries must occur to improve patient outcomes and expand universal health care. It is time to extend capnography's safety benefits to all patients, everywhere.
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Affiliation(s)
- Elliot A Wollner
- From the Department of Anaesthesia and Perioperative Medicine, Peter MacCallum Cancer Center, Melbourne, Victoria, Australia
- Center for Health Equity in Surgery and Anesthesia (CHESA), University of California, San Francisco, California
| | - Maziar M Nourian
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ki K Bertille
- Centre Hospitalier Universitaire Pédiatrique Charles de Gaulle, Ouagadougou, Burkina Faso
| | - Pauline B Wake
- School of Medicine and Health Sciences, University of Papua New Guinea
| | - Michael S Lipnick
- Department of Anesthesia and Perioperative Medicine, Center for Health Equity in Surgery and Anesthesia (CHESA), University of California, San Francisco, California
| | - David K Whitaker
- Department of Anaesthesia and Intensive Care, Manchester Royal Infirmary, United Kingdom
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Khanna AK, O'Connell NS, Ahuja S, Saha AK, Harris L, Cusson BD, Faris A, Huffman CS, Vallabhajosyula S, Clark CJ, Segal S, Wells BJ, Kirkendall ES, Sessler DI. Incidence, severity and detection of blood pressure and heart rate perturbations in postoperative ward patients after noncardiac surgery. J Clin Anesth 2023; 89:111159. [PMID: 37295123 DOI: 10.1016/j.jclinane.2023.111159] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/22/2023] [Accepted: 05/28/2023] [Indexed: 06/12/2023]
Abstract
STUDY OBJECTIVE We sought to determine changes in continuous mean and systolic blood pressure and heart rate in a cohort of non-cardiac surgical patients recovering on the postoperative ward. Furthermore, we estimated the proportion of vital signs changes that would remain undetected with intermittent vital signs checks. DESIGN Retrospective cohort. SETTING Post-operative general ward. PATIENTS 14,623 adults recovering from non-cardiac surgical procedures. INTERVENTIONS & MEASUREMENTS Using a wireless, noninvasive monitor, we recorded postoperative blood pressure and heart rate at 15-s intervals and encouraged nursing intervention as clinically indicated. MAIN RESULTS 7% of our cohort of 14,623 patients spent >15 sustained minutes with a MAP <65 mmHg, and 23% had MAP <75 mmHg for 15 sustained minutes. Hypertension was more common, with 67% of patients spending at least 60 sustained minutes with MAP >110 mmHg. Systolic pressures <90 mmHg were present for 15 sustained minutes in about a fifth of all patients, and 40% of patients had pressures >160 mmHg sustained for 30 min. 40% of patients were tachycardic with heart rates >100 beats/min for at least continuous 15 min and 15% of patients were bradycardic at a threshold of <50 beats/min for 5 sustained minutes. Conventional vital sign assessments at 4-h intervals would have missed 54% of mean pressure episodes <65 mmHg sustained >15 min, 20% of episodes of mean pressures >130 mmHg sustained >30 min, 36% of episodes of heart rate > 120 beats/min sustained <10 min, and 68% of episodes of heart rate sustained <40 beats per minute for >3 min. CONCLUSIONS Substantial hemodynamic disturbances persisted despite implementing continuous portable ward monitoring coupled with nursing alarms and interventions. A significant proportion of these changes would have gone undetected using traditional intermittent monitoring. Better understanding of effective responses to alarms and appropriate interventions on hospital wards remains necessary.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Nathaniel S O'Connell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Sanchit Ahuja
- Outcomes Research Consortium, Cleveland, OH, USA; Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH and Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Amit K Saha
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Lynnette Harris
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Bruce D Cusson
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Ann Faris
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Center for Nursing Research, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA.
| | - Carolyn S Huffman
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Center for Nursing Research, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA.
| | - Saraschandra Vallabhajosyula
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA; Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Clancy J Clark
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Scott Segal
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Brian J Wells
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Center for Biomedical Informatics, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Eric S Kirkendall
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Center for Healthcare Innovation, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
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Singh S, Laud PW, Crotty BH, Nanchal RS, Hanson R, Penlesky AC, Fletcher KE, Stadler ME, Dong Y, Nattinger AB. Effect of Implementing a Commercial Electronic Early Warning System on Outcomes of Hospitalized Patients. Am J Med Qual 2023; 38:229-237. [PMID: 37678301 DOI: 10.1097/jmq.0000000000000147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Despite the widespread adoption of early warning systems (EWSs), it is uncertain if their implementation improves patient outcomes. The authors report a pre-post quasi-experimental evaluation of a commercially available EWS on patient outcomes at a 700-bed academic medical center. The EWS risk scores were visible in the electronic medical record by bedside clinicians. The EWS risk scores were also monitored remotely 24/7 by critical care trained nurses who actively contacted bedside nurses when a patient's risk levels increased. The primary outcome was inpatient mortality. Secondary outcomes were rapid response team calls and activation of cardiopulmonary arrest (code-4) response teams. The study team conducted a regression discontinuity analysis adjusting for age, gender, insurance, severity of illness, risk of mortality, and hospital occupancy at admission. The analysis included 53,229 hospitalizations. Adjusted analysis showed no significant change in inpatient mortality, rapid response team call, or code-4 activations after implementing the EWS. This study confirms the continued uncertainty in the effectiveness of EWSs and the need for further rigorous examinations of EWSs.
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Affiliation(s)
- Siddhartha Singh
- Collaborative for Healthcare Delivery Sciences, Medical College of Wisconsin, Milwaukee, WI
- Froedtert and The Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Purushottam W Laud
- Collaborative for Healthcare Delivery Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Bradley H Crotty
- Collaborative for Healthcare Delivery Sciences, Medical College of Wisconsin, Milwaukee, WI
- Froedtert and The Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Rahul S Nanchal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Ryan Hanson
- Collaborative for Healthcare Delivery Sciences, Medical College of Wisconsin, Milwaukee, WI
- Froedtert and The Medical College of Wisconsin, Milwaukee, WI
| | - Annie C Penlesky
- Collaborative for Healthcare Delivery Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Kathlyn E Fletcher
- Collaborative for Healthcare Delivery Sciences, Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Michael E Stadler
- Froedtert and The Medical College of Wisconsin, Milwaukee, WI
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI
| | - Yilu Dong
- Collaborative for Healthcare Delivery Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Ann B Nattinger
- Collaborative for Healthcare Delivery Sciences, Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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Barata F, Cleres D, Tinschert P, Iris Shih CH, Rassouli F, Boesch M, Brutsche M, Fleisch E. Nighttime Continuous Contactless Smartphone-Based Cough Monitoring for the Ward: Validation Study. JMIR Form Res 2023; 7:e38439. [PMID: 36655551 PMCID: PMC9989914 DOI: 10.2196/38439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/17/2022] [Accepted: 01/17/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Clinical deterioration can go unnoticed in hospital wards for hours. Mobile technologies such as wearables and smartphones enable automated, continuous, noninvasive ward monitoring and allow the detection of subtle changes in vital signs. Cough can be effectively monitored through mobile technologies in the ward, as it is not only a symptom of prevalent respiratory diseases such as asthma, lung cancer, and COVID-19 but also a predictor of acute health deterioration. In past decades, many efforts have been made to develop an automatic cough counting tool. To date, however, there is neither a standardized, sufficiently validated method nor a scalable cough monitor that can be deployed on a consumer-centric device that reports cough counts continuously. These shortcomings limit the tracking of coughing and, consequently, hinder the monitoring of disease progression in prevalent respiratory diseases such as asthma, chronic obstructive pulmonary disease, and COVID-19 in the ward. OBJECTIVE This exploratory study involved the validation of an automated smartphone-based monitoring system for continuous cough counting in 2 different modes in the ward. Unlike previous studies that focused on evaluating cough detection models on unseen data, the focus of this work is to validate a holistic smartphone-based cough detection system operating in near real time. METHODS Automated cough counts were measured consistently on devices and on computers and compared with cough and noncough sounds counted manually over 8-hour long nocturnal recordings in 9 patients with pneumonia in the ward. The proposed cough detection system consists primarily of an Android app running on a smartphone that detects coughs and records sounds and secondarily of a backend that continuously receives the cough detection information and displays the hourly cough counts. Cough detection is based on an ensemble convolutional neural network developed and trained on asthmatic cough data. RESULTS In this validation study, a total of 72 hours of recordings from 9 participants with pneumonia, 4 of whom were infected with SARS-CoV-2, were analyzed. All the recordings were subjected to manual analysis by 2 blinded raters. The proposed system yielded a sensitivity and specificity of 72% and 99% on the device and 82% and 99% on the computer, respectively, for detecting coughs. The mean differences between the automated and human rater cough counts were -1.0 (95% CI -12.3 to 10.2) and -0.9 (95% CI -6.5 to 4.8) coughs per hour within subject for the on-device and on-computer modes, respectively. CONCLUSIONS The proposed system thus represents a smartphone cough counter that can be used for continuous hourly assessment of cough frequency in the ward.
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Affiliation(s)
- Filipe Barata
- Center for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland
| | - David Cleres
- Center for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland
| | - Peter Tinschert
- Center for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland.,Resmonics AG, Zurich, Switzerland
| | - Chen-Hsuan Iris Shih
- Center for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland.,Resmonics AG, Zurich, Switzerland
| | - Frank Rassouli
- Lung Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | | | - Martin Brutsche
- Lung Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Elgar Fleisch
- Center for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland.,Center for Digital Health Interventions, Institute of Technology Management, University of St. Gallen, St. Gallen, Switzerland
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10
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Respiratory Monitoring after Opioid-Sparing Bariatric Surgery in Patients with Obstructive Sleep Apnea (OSA). SURGERIES 2023. [DOI: 10.3390/surgeries4010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Introduction with Aim: Postoperative respiratory depression can complicate a patient’s recovery after surgery. A predictive score (PRODIGY) was recently proposed to evaluate the risk of opioid-induced postoperative respiratory depression. For the first time, we applied this score to a cohort of patients receiving bariatric surgery, stratified by Obstructive Sleep Apnea (OSA) status. In addition, we recorded continuous postoperative capnography to evaluate respiratory depression and apnea episodes (Respiratory Events, RE). Materials and Methods: The present study was approved by our IRB and comprised continuous surveillance of respiratory variables during postoperative recovery (in PACU) after robotic bariatric surgery. We utilized continuous capnography and pulse oximetry (Capnostream 35, Medtronic Inc., and Profox Respiratory Oximetry software). Preoperative preparation included OSA evaluation for all bariatric patients, additional sleep studies for severe OSA grades, and evaluation of risk for respiratory depression (low, intermediate, or high) using the published PRODIGY score. In addition, we evaluated patients by OSA status. All patients received multimodal intraoperative non-opioid anesthesia from the same team. After surgery, all patients received continuous respiratory surveillance in PACU (average duration exceeding 140 min). Respiratory depression events were scored using a modified list of the five standard published categories. Events were measured according to analysis of continuously recorded tracing of the compiled respiratory variables by observers kept blind from the study patient’s group. Results: Of the 80 patients evaluated (18 male), 56 had obstructive sleep apnea and were using CPAP at home (OSA); 24 did not. OSA patients received CPAP via an oronasal mask or a nasal pillow pressure support immediately after arriving in PACU, utilizing their at-home settings. We encountered 115 respiratory depression events across 48 patients. The most frequent respiratory event recorded was a transient desaturation (as low as 85%), which usually lasted 20–30 sec and resolved spontaneously in 3 to 5 min; most episodes followed small boluses of IV opioid analgesia administered during recovery, on demand. All episodes resolved spontaneously without any nursing or medical intervention. OSA patients had significantly more events than non-OSA patients (1.84 (1.78–1.9) mean events vs. 0.50 (0.43–0.57) for non-OSA, p = 0.0002). The level of PRODIGY score (low, intermediate, or high), instead, was not predictive of the number of events when we treated this variable as continuous (p = 0.39) or categorical (high vs. low, p = 0.65, and intermediate vs. low, p = 0.17). Conclusions: We attribute these novel results, showing a lack of respiratory events requiring intervention, to opioid-free anesthesia, early CPAP utilization, and head-up positioning on admission to PACU. Furthermore, all these patients had light postoperative narcotic requirements. Finally, an elevated PRODIGY score in our patients did not sufficiently predict respiratory events, but OSA status alone did. Key Points Summary: We investigated the incidence of Respiratory Events (RE) in Obstructive Sleep Apnea patients after surgery (56 patients) and compared them to similar patients without OSA (24 patients). All patients received identical robotic-assisted surgery and low- or no-opiate anesthesia. Patients were pre-screened with the standard published PRODIGY scores and were monitored after PACU arrival with continuous oximetry and capnography (Capnostream 35 and Profox analysis). OSA patients showed more RE than non-OSA (1.8 vs. 0.5, p = −0.0002). However, patients with elevated PRODIGY scores did not develop more frequent RE compared to patients with low scores. We attribute these novel results to opioid-sparing anesthesia/analgesia and immediate CPAP utilization on admission to PACU.
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11
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Javanbakht M, Moradi-Lakeh M, Mashayekhi A, Atkinson J. Continuous Monitoring of Respiratory Rate with Wearable Sensor in Patients Admitted to Hospital with Pneumonia Compared with Intermittent Nurse-Led Monitoring in the United Kingdom: A Cost-Utility Analysis. PHARMACOECONOMICS - OPEN 2022; 6:73-83. [PMID: 34387850 PMCID: PMC8363094 DOI: 10.1007/s41669-021-00290-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 06/01/2023]
Abstract
BACKGROUND Respiratory rate (RR) is one of the most important physiologic measures for predicting patients' deterioration of clinical condition and final prognosis. In several studies, RR has been the most important predictor of patients' prognoses. OBJECTIVES The objective of this study was to conduct a cost-utility analysis to estimate the cost and effectiveness of automatic respiratory rate monitoring (ARRM) with a non-invasive sensor (RespiraSense™) plus intermittent nurse-led RR monitoring (ARRM strategy) compared with intermittent nurse-led RR monitoring (IM strategy) in patients admitted to hospital in the UK with pneumonia. METHODS A decision analytic model was developed based on a hypothetical cohort of patients who were admitted to hospital with pneumonia. After admission, the patients could be monitored with either ARRM or IM strategies. The outcomes of interest included total costs and total effectiveness of each strategy, including length of stay (LoS) in hospital, LoS in intensive care unit, quality-adjusted life-years (QALYs), deaths, and incremental cost per QALY gained. An incremental cost of £20,000 or less per QALY gained was considered cost effective. A lifetime time horizon (38 years) was used to capture the long-term benefits. Probabilistic and deterministic sensitivity analyses were performed. RESULTS Total costs of patient care in ARRM and IM strategies were £1986.9 million and £2079.4 million, respectively. Total incremental QALYs lived were 3548 higher in the intervention arm (ARRM), meaning that the ARRM strategy was dominant (i.e., less costly [£92.6 million less] and more effective). The results were stable in probabilistic and most of the deterministic sensitivity analyses. Results from threshold analysis indicated that a minimum of 7 and 10% improvement in percentage of early detection of respiratory compromise is required for ARRM to become cost effective and cost saving, respectively. CONCLUSIONS Our results indicate that ARRM using RespiraSense, in addition to intermittent nurse-led monitoring of RR, in patients admitted to the hospital with pneumonia could be a cost-saving and cost-effective intervention if the minimum clinical thresholds are met.
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Affiliation(s)
- Mehdi Javanbakht
- Optimax Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Chilworth Hampshire, UK
| | | | - Atefeh Mashayekhi
- Optimax Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Chilworth Hampshire, UK
| | - Jowan Atkinson
- Device Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Chilworth, Hampshire, UK
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Rivas E, Cohen B, Pu X, Xiang L, Saasouh W, Mao G, Minko P, Mosteller L, Volio A, Maheshwari K, Sessler DI, Turan A. Pain and Opioid Consumption and Mobilization after Surgery: Post Hoc Analysis of Two Randomized Trials. Anesthesiology 2022; 136:115-126. [PMID: 34780602 DOI: 10.1097/aln.0000000000004037] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Early mobilization is incorporated into many enhanced recovery pathways. Inadequate analgesia or excessive opioids may restrict postoperative mobilization. The authors tested the hypotheses that in adults recovering from abdominal surgery, postoperative pain and opioid consumption are inversely related to postoperative mobilization, and that postoperative mobilization is associated with fewer potentially related complications. METHODS The authors conducted a subanalysis of two trials that enrolled adults recovering from abdominal surgery. Posture and movement were continuously monitored for 48 postoperative hours using noninvasive untethered monitors. Mobilization was defined as the fraction of monitored time spent sitting or standing. RESULTS A total of 673 patients spent a median [interquartile range] of 7% [3 to 13%] of monitored time sitting or standing. Mobilization time was 1.9 [1.0 to 3.6] h/day for patients with average pain scores 3 or lower, but only 1.2 [0.5 to 2.6] h/day in those with average scores 6 or greater. Each unit increase in average pain score was associated with a decrease in mobilization time of 0.12 (97.5% CI, 0.02 to 0.24; P = 0.009) h/day. In contrast, there was no association between postoperative opioid consumption and mobilization time. The incidence of the composite of postoperative complications was 6.0% (10 of 168) in the lower mobilization quartile, 4.2% (7 of 168) in the second quartile, and 0% among 337 patients in the highest two quartiles (P = 0.009). CONCLUSIONS Patients recovering from abdominal surgery spent only 7% of their time mobilized, which is considerably less than recommended. Lower pain scores are associated with increased mobility, independently of opioid consumption. Complications were more common in patients who mobilized poorly. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Eva Rivas
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department of Anesthesia, Hospital Clinic of Barcelona, August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - Barak Cohen
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Division of Anesthesia, Critical Care and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Xuan Pu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Li Xiang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Wael Saasouh
- Department of Anesthesiology, Henry Ford Health System, Detroit, Michigan
| | - Guangmei Mao
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Paul Minko
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | | | - Andrew Volio
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
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13
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Khanna AK, Saager L, Bergese SD, Jungquist CR, Morimatsu H, Uezono S, Ti LK, Soto R, Jiang W, Buhre W. Opioid-induced respiratory depression increases hospital costs and length of stay in patients recovering on the general care floor. BMC Anesthesiol 2021; 21:88. [PMID: 33743588 PMCID: PMC7980593 DOI: 10.1186/s12871-021-01307-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Opioid-induced respiratory depression is common on the general care floor. However, the clinical and economic burden of respiratory depression is not well-described. The PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial created a prediction tool to identify patients at risk of respiratory depression. The purpose of this retrospective sub-analysis was to examine healthcare utilization and hospital cost associated with respiratory depression. METHODS One thousand three hundred thirty-five patients (N = 769 United States patients) enrolled in the PRODIGY trial received parenteral opioids and underwent continuous capnography and pulse oximetry monitoring. Cost data was retrospectively collected for 420 United States patients. Differences in healthcare utilization and costs between patients with and without ≥1 respiratory depression episode were determined. The impact of respiratory depression on hospital cost per patient was evaluated using a propensity weighted generalized linear model. RESULTS Patients with ≥1 respiratory depression episode had a longer length of stay (6.4 ± 7.8 days vs 5.0 ± 4.3 days, p = 0.009) and higher hospital cost ($21,892 ± $11,540 vs $18,206 ± $10,864, p = 0.002) compared to patients without respiratory depression. Patients at high risk for respiratory depression, determined using the PRODIGY risk prediction tool, who had ≥1 respiratory depression episode had higher hospital costs compared to high risk patients without respiratory depression ($21,948 ± $9128 vs $18,474 ± $9767, p = 0.0495). Propensity weighted analysis identified 17% higher costs for patients with ≥1 respiratory depression episode (p = 0.007). Length of stay significantly increased total cost, with cost increasing exponentially for patients with ≥1 respiratory depression episode as length of stay increased. CONCLUSIONS Respiratory depression on the general care floor is associated with a significantly longer length of stay and increased hospital costs. Early identification of patients at risk for respiratory depression, along with early proactive intervention, may reduce the incidence of respiratory depression and its associated clinical and economic burden. TRIAL REGISTRATION ClinicalTrials.gov , NCT02811302 .
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Affiliation(s)
- Ashish K Khanna
- Wake Forest School of Medicine, Winston-Salem, NC, USA. .,Outcomes Research Consortium, Cleveland, OH, USA.
| | - Leif Saager
- Universitätsmedizin Göttingen, Göttingen, Germany
| | | | | | | | | | - Lian Kah Ti
- National University of Singapore, Singapore, Singapore
| | - Roy Soto
- Beaumont Hospital, Royal Oak, MI, USA
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14
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Khanna AK, Bergese SD, Jungquist CR, Morimatsu H, Uezono S, Lee S, Ti LK, Urman RD, McIntyre R, Tornero C, Dahan A, Saager L, Weingarten TN, Wittmann M, Auckley D, Brazzi L, Le Guen M, Soto R, Schramm F, Ayad S, Kaw R, Di Stefano P, Sessler DI, Uribe A, Moll V, Dempsey SJ, Buhre W, Overdyk FJ. Prediction of Opioid-Induced Respiratory Depression on Inpatient Wards Using Continuous Capnography and Oximetry: An International Prospective, Observational Trial. Anesth Analg 2020; 131:1012-1024. [PMID: 32925318 PMCID: PMC7467153 DOI: 10.1213/ane.0000000000004788] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Opioid-related adverse events are a serious problem in hospitalized patients. Little is known about patients who are likely to experience opioid-induced respiratory depression events on the general care floor and may benefit from improved monitoring and early intervention. The trial objective was to derive and validate a risk prediction tool for respiratory depression in patients receiving opioids, as detected by continuous pulse oximetry and capnography monitoring. METHODS PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) was a prospective, observational trial of blinded continuous capnography and oximetry conducted at 16 sites in the United States, Europe, and Asia. Vital signs were intermittently monitored per standard of care. A total of 1335 patients receiving parenteral opioids and continuously monitored on the general care floor were included in the analysis. A respiratory depression episode was defined as respiratory rate ≤5 breaths/min (bpm), oxygen saturation ≤85%, or end-tidal carbon dioxide ≤15 or ≥60 mm Hg for ≥3 minutes; apnea episode lasting >30 seconds; or any respiratory opioid-related adverse event. A risk prediction tool was derived using a multivariable logistic regression model of 46 a priori defined risk factors with stepwise selection and was internally validated by bootstrapping. RESULTS One or more respiratory depression episodes were detected in 614 (46%) of 1335 general care floor patients (43% male; mean age, 58 ± 14 years) continuously monitored for a median of 24 hours (interquartile range [IQR], 17-26). A multivariable respiratory depression prediction model with area under the curve of 0.740 was developed using 5 independent variables: age ≥60 (in decades), sex, opioid naivety, sleep disorders, and chronic heart failure. The PRODIGY risk prediction tool showed significant separation between patients with and without respiratory depression (P < .001) and an odds ratio of 6.07 (95% confidence interval [CI], 4.44-8.30; P < .001) between the high- and low-risk groups. Compared to patients without respiratory depression episodes, mean hospital length of stay was 3 days longer in patients with ≥1 respiratory depression episode (10.5 ± 10.8 vs 7.7 ± 7.8 days; P < .0001) identified using continuous oximetry and capnography monitoring. CONCLUSIONS A PRODIGY risk prediction model, derived from continuous oximetry and capnography, accurately predicts respiratory depression episodes in patients receiving opioids on the general care floor. Implementation of the PRODIGY score to determine the need for continuous monitoring may be a first step to reduce the incidence and consequences of respiratory compromise in patients receiving opioids on the general care floor.
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Affiliation(s)
- Ashish K. Khanna
- From the Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Outcomes Research Consortium, Cleveland, Ohio
| | - Sergio D. Bergese
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, Ohio
- Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook, New York
| | | | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | | | - Simon Lee
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | - Lian Kah Ti
- Department of Anaesthesia, National University of Singapore, Singapore
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Robert McIntyre
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Carlos Tornero
- Department of Anesthesiology, Resuscitation and Pain Therapeutics, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Leif Saager
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Toby N. Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Maria Wittmann
- Department of Anaesthesiology, University Hospital Bonn, Bonn, Germany
| | - Dennis Auckley
- Division of Pulmonary, Critical Care, and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Luca Brazzi
- Department of Anesthesia, Intensive Care and Emergency, University of Turin, Turin, Italy
| | - Morgan Le Guen
- Department of Anaesthesiology, Hôpital Foch, Suresnes, France
| | - Roy Soto
- Department of Anesthesiology, Beaumont Hospital, Royal Oak, Michigan
| | - Frank Schramm
- Department of Anesthesiology, Providence Regional Medical Center, Everett, Washington
| | - Sabry Ayad
- Cleveland Clinic Foundation, Outcomes Research Consortium, Cleveland, Ohio
| | - Roop Kaw
- Cleveland Clinic Foundation, Outcomes Research Consortium, Cleveland, Ohio
| | - Paola Di Stefano
- Medtronic Core Clinical Solutions, Study and Scientific Solutions, Rome, Italy
| | - Daniel I. Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alberto Uribe
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, Ohio
| | - Vanessa Moll
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | - Susan J. Dempsey
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- University of California, Los Angeles, School of Nursing, Los Angeles, California
| | - Wolfgang Buhre
- Department of Anesthesiology, University Medical Center, Maastricht, the Netherlands
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15
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Weingarten TN, Morimatsu H, Fiorda-Diaz J, Bergese SD, Ariyoshi M, Sprung J, Dahan A, Overdyk FJ. New-Onset Atrial Fibrillation Detected by Continuous Capnography Monitoring: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e925510. [PMID: 32948738 PMCID: PMC7521464 DOI: 10.12659/ajcr.925510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Case series Patients: Male, 75-year-old • Male, 72-year-old Final Diagnosis: Atrial fibrillation Symptoms: Apnea • atrial fibrillation Medication: — Clinical Procedure: — Specialty: Anesthesiology
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University, Okayama City, Okayama, Japan
| | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sergio D Bergese
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, NY, USA.,Department of Anesthesiology, Stony Brook Medicine, Stony Brook, NY, USA
| | - Makiko Ariyoshi
- Department of Anesthesiology and Resuscitology, Okayama University, Okayama City, Okayama, Japan
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Frank J Overdyk
- Department of Anesthesiology, Trident Health System, Charleston, SC, USA
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16
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Bedoya AD, Bhavsar NA, Adagarla B, Page CB, Goldstein BA, MacIntyre NR. Unanticipated Respiratory Compromise and Unplanned Intubations on General Medical and Surgical Floors. Respir Care 2020; 65:1233-1240. [PMID: 32156789 PMCID: PMC7906607 DOI: 10.4187/respcare.07438] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unanticipated respiratory compromise that lead to unplanned intubations is a known phenomenon in hospitalized patients. Most events occur in patients at high risk in well-monitored units; less is known about the incidence, risk factors, and trajectory of patients thought at low risk on lightly monitored general care wards. The aims of our study were to quantify demographic and clinical characteristics associated with unplanned intubations on general care floors and to analyze the medications administered, monitoring strategies, and vital-sign trajectories before the event. METHODS We performed a multicenter retrospective cohort study of hospitalized subjects on the general floor who had unanticipated, unplanned intubations on general care floors from August 2014 to February 2018. RESULTS We identified 448 unplanned intubations. The incidence rate was 0.420 per 1,000 bed-days (95% CI 0.374-0.470) in the academic hospital and was 0.430 (95% CI 0.352-0.520) and 0.394 per 1,000 bed-days (95% CI 0.301-0.506) at our community hospitals. Extrapolating these rates to total hospital admissions in the United States, we estimate 64,000 events annually. The mortality rate was 49.1%. Within 12 h preceding the event, 35.3% of the subjects received opiates. All received vital-sign assessments. Most were monitored with pulse oximetry. In contrast, 2.5% were on cardiac telemetry, and only 4 subjects used capnography; 53.7% showed significant vital-sign changes in the 24 h before the event. However, 46.3% had no significant change in any vital signs. CONCLUSIONS Our study showed unanticipated respiratory compromise that required an unplanned intubation of subjects on the general care floor, although not common, carried a high mortality. Besides pulse oximetry and routine vital-sign assessments, very little monitoring was in use. A significant portion of the subjects had no vital-sign abnormalities leading up to the event. Further research is needed to determine the phenotype of the different etiologies of unexpected acute respiratory failure to identify better risk stratification and monitoring strategies.
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Affiliation(s)
- Armando D Bedoya
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Nrupen A Bhavsar
- Division of General Internal Medicine, Department of Medicine, Duke University
| | | | | | - Benjamin A Goldstein
- Duke Clinical Research Institute
- Department of Biostatistics and Bioinformatics, Duke University
| | - Neil R MacIntyre
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University, Durham, North Carolina
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17
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Cumpstey AF, Oldman AH, Smith AF, Martin D, Grocott MP. Oxygen targets in the intensive care unit during mechanical ventilation for acute respiratory distress syndrome: a rapid review. Cochrane Database Syst Rev 2020; 9:CD013708. [PMID: 32870512 PMCID: PMC8133396 DOI: 10.1002/14651858.cd013708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Supplemental oxygen is frequently administered to patients with acute respiratory distress syndrome (ARDS), including ARDS secondary to viral illness such as coronavirus disease 19 (COVID-19). An up-to-date understanding of how best to target this therapy (e.g. arterial partial pressure of oxygen (PaO2) or peripheral oxygen saturation (SpO2) aim) in these patients is urgently required. OBJECTIVES To address how oxygen therapy should be targeted in adults with ARDS (particularly ARDS secondary to COVID-19 or other respiratory viruses) and requiring mechanical ventilation in an intensive care unit, and the impact oxygen therapy has on mortality, days ventilated, days of catecholamine use, requirement for renal replacement therapy, and quality of life. SEARCH METHODS We searched the Cochrane COVID-19 Study Register, CENTRAL, MEDLINE, and Embase from inception to 15 May 2020 for ongoing or completed randomized controlled trials (RCTs). SELECTION CRITERIA Two review authors independently assessed all records in accordance with standard Cochrane methodology for study selection. We included RCTs comparing supplemental oxygen administration (i.e. different target PaO2 or SpO2 ranges) in adults with ARDS and receiving mechanical ventilation in an intensive care setting. We excluded studies exploring oxygen administration in patients with different underlying diagnoses or those receiving non-invasive ventilation, high-flow nasal oxygen, or oxygen via facemask. DATA COLLECTION AND ANALYSIS One review author performed data extraction, which a second review author checked. We assessed risk of bias in included studies using the Cochrane 'Risk of bias' tool. We used the GRADE approach to judge the certainty of the evidence for the following outcomes; mortality at longest follow-up, days ventilated, days of catecholamine use, and requirement for renal replacement therapy. MAIN RESULTS We identified one completed RCT evaluating oxygen targets in patients with ARDS receiving mechanical ventilation in an intensive care setting. The study randomized 205 mechanically ventilated patients with ARDS to either conservative (PaO2 55 to 70 mmHg, or SpO2 88% to 92%) or liberal (PaO2 90 to 105 mmHg, or SpO2 ≥ 96%) oxygen therapy for seven days. Overall risk of bias was high (due to lack of blinding, small numbers of participants, and the trial stopping prematurely), and we assessed the certainty of the evidence as very low. The available data suggested that mortality at 90 days may be higher in those participants receiving a lower oxygen target (odds ratio (OR) 1.83, 95% confidence interval (CI) 1.03 to 3.27). There was no evidence of a difference between the lower and higher target groups in mean number of days ventilated (14.0, 95% CI 10.0 to 18.0 versus 14.5, 95% CI 11.8 to 17.1); number of days of catecholamine use (8.0, 95% CI 5.5 to 10.5 versus 7.2, 95% CI 5.9 to 8.4); or participants receiving renal replacement therapy (13.7%, 95% CI 5.8% to 21.6% versus 12.0%, 95% CI 5.0% to 19.1%). Quality of life was not reported. AUTHORS' CONCLUSIONS We are very uncertain as to whether a higher or lower oxygen target is more beneficial in patients with ARDS and receiving mechanical ventilation in an intensive care setting. We identified only one RCT with a total of 205 participants exploring this question, and rated the risk of bias as high and the certainty of the findings as very low. Further well-conducted studies are urgently needed to increase the certainty of the findings reported here. This review should be updated when more evidence is available.
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Affiliation(s)
- Andrew F Cumpstey
- Critical Care Research Group, University Hospital of Southampton, Southampton, UK
| | - Alex H Oldman
- Anaesthetics and Intensive Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Andrew F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - Daniel Martin
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Michael Pw Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Southampton, UK
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18
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Smischney NJ, Kashyap R, Khanna AK, Brauer E, Morrow LE, Seisa MO, Schroeder DR, Diedrich DA, Montgomery A, Franco PM, Ofoma UR, Kaufman DA, Sen A, Callahan C, Venkata C, Demiralp G, Tedja R, Lee S, Geube M, Kumar SI, Morris P, Bansal V, Surani S. Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study. PLoS One 2020; 15:e0233852. [PMID: 32866219 PMCID: PMC7458292 DOI: 10.1371/journal.pone.0233852] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/13/2020] [Indexed: 02/05/2023] Open
Abstract
Objective Hypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation. Methods A multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure <65 mmHg; 2) systolic blood pressure <80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation. Results Post-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure <65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients’ pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients’ risk of hypotension. Conclusions A novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients. Study registration Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.
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Affiliation(s)
- Nathan J. Smischney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- HEModynamic and AIRway Management (HEMAIR) Study Group, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
| | - Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- HEModynamic and AIRway Management (HEMAIR) Study Group, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Ashish K. Khanna
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio, United States of America
- Department of Anesthesia, Section on Critical Care Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Ernesto Brauer
- Department of Critical Care Medicine, Aurora Health Care, Milwaukee, Wisconsin, United States of America
| | - Lee E. Morrow
- Department of Critical Care Medicine, Creighton University, Omaha, Nebraska, United States of America
| | - Mohamed O. Seisa
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- HEModynamic and AIRway Management (HEMAIR) Study Group, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Darrell R. Schroeder
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Daniel A. Diedrich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- HEModynamic and AIRway Management (HEMAIR) Study Group, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Ashley Montgomery
- Department of Anesthesia and Critical Care Medicine, University of Kentucky, Lexington, Kentucky, United States of America
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, United States of America
| | - Uchenna R. Ofoma
- Division of Critical Care Medicine, Geisinger Health System, Danville, Pennsylvania, United States of America
| | - David A. Kaufman
- Section of Pulmonary, Critical Care, and Sleep Medicine, Bridgeport Hospital/Yale New Haven Health, Bridgeport, Connecticut, United States of America
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic, Scottsdale, Arizona, United States of America
| | - Cynthia Callahan
- Department of Critical Care Medicine, Berkshire Medical Center, Pittsfield, Massachusetts, United States of America
| | - Chakradhar Venkata
- Department of Critical Care Medicine, Mercy Hospital, St. Louis, Missouri, United States of America
| | - Gozde Demiralp
- Department of Anesthesia and Critical Care Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Rudy Tedja
- Department of Critical Care Medicine, Memorial Medical Center, Modesto, California, United States of America
| | - Sarah Lee
- Division of Pulmonary, Critical Care & Sleep Medicine, Detroit Medical Center, Detroit, Michigan, United States of America
| | - Mariya Geube
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Santhi I. Kumar
- Department of Critical Care Medicine, Kerk School University of Southern California, Los Angeles, California, United States of America
| | - Peter Morris
- Department of Anesthesia and Critical Care Medicine, University of Kentucky, Lexington, Kentucky, United States of America
| | - Vikas Bansal
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, United States of America
| | - Salim Surani
- Department of Critical Care Medicine, Corpus Christi Medical Center, Corpus Christi, Texas, United States of America
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Affiliation(s)
- Ashish K Khanna
- From the Center for Critical Care, Department of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Berg KM, Donnino MW, Andersen LW, Moskowitz A, Grossestreuer AV. Acute respiratory compromise on hospital wards: Association between recent ICU discharge and outcome. Resuscitation 2019; 144:40-45. [PMID: 31513866 PMCID: PMC7371260 DOI: 10.1016/j.resuscitation.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/15/2019] [Accepted: 09/01/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Acute respiratory compromise (ARC), respiratory distress requiring emergent assisted ventilation, has a mortality of 20-40%. The relationship between recent discharge from an intensive care unit (ICU) and outcomes of patients suffering ARC on hospital wards is not well known. We hypothesized that a significant percentage of ARC events would occur in patients recently discharged from an ICU, that these patients would have worse outcomes than those without prior ICU stays, and that weekend ICU discharge would be associated with higher than expected post-ICU ARC frequency. METHODS Using the Get-With-The-Guidelines-Resuscitation ARC registry, we included adult, index ARC events occurring on hospital wards. Our primary analysis used multivariable logistic regression accounting for clustering by hospital to examine the association between prior ICU discharge and survival after an ARC event. RESULTS Of 11,800 ARCs, 937 (8%) occurred within two calendar days and 1010 (9%) >two calendar days after an ICU discharge. Patients with ICU discharge within two days had higher survival compared to those with no prior ICU stay (odds ratio 1.28 (95% CI: 1.11-1.48, p = 0.001)). Survival was not different in those with an ICU discharge more than two days prior and no prior ICU stay. Patients with ARC within two days of ICU discharge were not more likely to have left the ICU on a weekend. CONCLUSIONS Contrary to our hypothesis, discharge from an ICU within two calendar days was associated with better odds for survival compared to no prior ICU discharge or ICU discharge more than two days prior.
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Affiliation(s)
- Katherine M Berg
- Divsion of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States.
| | - Michael W Donnino
- Divsion of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Lars W Andersen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Denmark
| | - Ari Moskowitz
- Divsion of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Anne V Grossestreuer
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
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Khanna AK, Hoppe P, Saugel B. Automated continuous noninvasive ward monitoring: future directions and challenges. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:194. [PMID: 31146792 PMCID: PMC6543687 DOI: 10.1186/s13054-019-2485-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/20/2019] [Indexed: 02/06/2023]
Abstract
Automated continuous noninvasive ward monitoring may enable subtle changes in vital signs to be recognized. There is already some evidence that automated ward monitoring can improve patient outcome. Before automated continuous noninvasive ward monitoring can be implemented in clinical routine, several challenges and problems need to be considered and resolved; these include the meticulous validation of the monitoring systems with regard to their measurement performance, minimization of artifacts and false alarms, integration and combined analysis of massive amounts of data including various vital signs, and technical problems regarding the connectivity of the systems.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Phillip Hoppe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Bernd Saugel
- Outcomes Research Consortium, Cleveland, OH, USA. .,Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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Friedman B, Fuckert D, Jahrsdoerfer M, Magness R, Patterson ES, Syed R, Zaleski JR. Identifying and Monitoring Respiratory Compromise: Report from the Rules and Algorithms Working Group. Biomed Instrum Technol 2019; 53:110-123. [PMID: 30901250 DOI: 10.2345/0899-8205-53.2.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Assessing the efficacy of the new protocol for chest compressions before definitive cardiac arrest in emergency medical service-witnessed adult out-of-hospital cardiac arrests. Resuscitation 2018; 130:92-98. [DOI: 10.1016/j.resuscitation.2018.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/07/2018] [Accepted: 07/09/2018] [Indexed: 12/15/2022]
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Jeffery AD, Dietrich MS, Fabbri D, Kennedy B, Novak LL, Coco J, Mion LC. Advancing In-Hospital Clinical Deterioration Prediction Models. Am J Crit Care 2018; 27:381-391. [PMID: 30173171 DOI: 10.4037/ajcc2018957] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Early warning systems lack robust evidence that they improve patients' outcomes, possibly because of their limitation of predicting binary rather than time-to-event outcomes. OBJECTIVES To compare the prediction accuracy of 2 statistical modeling strategies (logistic regression and Cox proportional hazards regression) and 2 machine learning strategies (random forest and random survival forest) for in-hospital cardiopulmonary arrest. METHODS Retrospective cohort study with prediction model development from deidentified electronic health records at an urban academic medical center. RESULTS The classification models (logistic regression and random forest) had statistical recall and precision similar to or greater than those of the time-to-event models (Cox proportional hazards regression and random survival forest). However, the time-to-event models provided predictions that could potentially better indicate to clinicians whether and when a patient is likely to experience cardiopulmonary arrest. CONCLUSIONS As early warning scoring systems are refined, they must use the best analytical methods that both model the underlying phenomenon and provide an understandable prediction.
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Affiliation(s)
- Alvin D Jeffery
- Alvin D. Jeffery is a medical informatics fellow at the US Department of Veterans Affairs, Tennessee Valley Health-care System, Nashville, Tennessee, and a postdoctoral research fellow, Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee. Mary S. Dietrich is a professor of statistics and measurement, Schools of Medicine (Biostatistics, Vanderbilt-Ingram Cancer Center, Psychiatry) and Nursing, Vanderbilt University. Daniel Fabbri is an assistant professor, Department of Biomedical Informatics, Vanderbilt University. Betsy Kennedy is a professor, School of Nursing, Vanderbilt University. Laurie L. Novak is an assistant professor and Joseph Coco is a senior application developer, Department of Biomedical Informatics, Vanderbilt University. Lorraine C. Mion is a professor, College of Nursing, The Ohio State University, Columbus, Ohio.
| | - Mary S Dietrich
- Alvin D. Jeffery is a medical informatics fellow at the US Department of Veterans Affairs, Tennessee Valley Health-care System, Nashville, Tennessee, and a postdoctoral research fellow, Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee. Mary S. Dietrich is a professor of statistics and measurement, Schools of Medicine (Biostatistics, Vanderbilt-Ingram Cancer Center, Psychiatry) and Nursing, Vanderbilt University. Daniel Fabbri is an assistant professor, Department of Biomedical Informatics, Vanderbilt University. Betsy Kennedy is a professor, School of Nursing, Vanderbilt University. Laurie L. Novak is an assistant professor and Joseph Coco is a senior application developer, Department of Biomedical Informatics, Vanderbilt University. Lorraine C. Mion is a professor, College of Nursing, The Ohio State University, Columbus, Ohio
| | - Daniel Fabbri
- Alvin D. Jeffery is a medical informatics fellow at the US Department of Veterans Affairs, Tennessee Valley Health-care System, Nashville, Tennessee, and a postdoctoral research fellow, Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee. Mary S. Dietrich is a professor of statistics and measurement, Schools of Medicine (Biostatistics, Vanderbilt-Ingram Cancer Center, Psychiatry) and Nursing, Vanderbilt University. Daniel Fabbri is an assistant professor, Department of Biomedical Informatics, Vanderbilt University. Betsy Kennedy is a professor, School of Nursing, Vanderbilt University. Laurie L. Novak is an assistant professor and Joseph Coco is a senior application developer, Department of Biomedical Informatics, Vanderbilt University. Lorraine C. Mion is a professor, College of Nursing, The Ohio State University, Columbus, Ohio
| | - Betsy Kennedy
- Alvin D. Jeffery is a medical informatics fellow at the US Department of Veterans Affairs, Tennessee Valley Health-care System, Nashville, Tennessee, and a postdoctoral research fellow, Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee. Mary S. Dietrich is a professor of statistics and measurement, Schools of Medicine (Biostatistics, Vanderbilt-Ingram Cancer Center, Psychiatry) and Nursing, Vanderbilt University. Daniel Fabbri is an assistant professor, Department of Biomedical Informatics, Vanderbilt University. Betsy Kennedy is a professor, School of Nursing, Vanderbilt University. Laurie L. Novak is an assistant professor and Joseph Coco is a senior application developer, Department of Biomedical Informatics, Vanderbilt University. Lorraine C. Mion is a professor, College of Nursing, The Ohio State University, Columbus, Ohio
| | - Laurie L Novak
- Alvin D. Jeffery is a medical informatics fellow at the US Department of Veterans Affairs, Tennessee Valley Health-care System, Nashville, Tennessee, and a postdoctoral research fellow, Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee. Mary S. Dietrich is a professor of statistics and measurement, Schools of Medicine (Biostatistics, Vanderbilt-Ingram Cancer Center, Psychiatry) and Nursing, Vanderbilt University. Daniel Fabbri is an assistant professor, Department of Biomedical Informatics, Vanderbilt University. Betsy Kennedy is a professor, School of Nursing, Vanderbilt University. Laurie L. Novak is an assistant professor and Joseph Coco is a senior application developer, Department of Biomedical Informatics, Vanderbilt University. Lorraine C. Mion is a professor, College of Nursing, The Ohio State University, Columbus, Ohio
| | - Joseph Coco
- Alvin D. Jeffery is a medical informatics fellow at the US Department of Veterans Affairs, Tennessee Valley Health-care System, Nashville, Tennessee, and a postdoctoral research fellow, Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee. Mary S. Dietrich is a professor of statistics and measurement, Schools of Medicine (Biostatistics, Vanderbilt-Ingram Cancer Center, Psychiatry) and Nursing, Vanderbilt University. Daniel Fabbri is an assistant professor, Department of Biomedical Informatics, Vanderbilt University. Betsy Kennedy is a professor, School of Nursing, Vanderbilt University. Laurie L. Novak is an assistant professor and Joseph Coco is a senior application developer, Department of Biomedical Informatics, Vanderbilt University. Lorraine C. Mion is a professor, College of Nursing, The Ohio State University, Columbus, Ohio
| | - Lorraine C Mion
- Alvin D. Jeffery is a medical informatics fellow at the US Department of Veterans Affairs, Tennessee Valley Health-care System, Nashville, Tennessee, and a postdoctoral research fellow, Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee. Mary S. Dietrich is a professor of statistics and measurement, Schools of Medicine (Biostatistics, Vanderbilt-Ingram Cancer Center, Psychiatry) and Nursing, Vanderbilt University. Daniel Fabbri is an assistant professor, Department of Biomedical Informatics, Vanderbilt University. Betsy Kennedy is a professor, School of Nursing, Vanderbilt University. Laurie L. Novak is an assistant professor and Joseph Coco is a senior application developer, Department of Biomedical Informatics, Vanderbilt University. Lorraine C. Mion is a professor, College of Nursing, The Ohio State University, Columbus, Ohio
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Overdyk FJ, Broens SJL. Continuous Pulse Oximetry Does Not Measure Blood Pressure. Anesth Analg 2018; 126:1089-1090. [PMID: 29337728 DOI: 10.1213/ane.0000000000002783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Frank J Overdyk
- Roper St. Francis Health System, Charleston, South Carolina, Leiden University Medical Center, Leiden, the Netherlands
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Pediatric In-Hospital Acute Respiratory Compromise: A Report From the American Heart Association's Get With the Guidelines-Resuscitation Registry. Pediatr Crit Care Med 2017; 18:838-849. [PMID: 28492403 PMCID: PMC5581225 DOI: 10.1097/pcc.0000000000001204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The main objectives of this study were to describe in-hospital acute respiratory compromise among children (< 18 yr old), and its association with cardiac arrest and in-hospital mortality. DESIGN Observational study using prospectively collected data. SETTING U.S. hospitals reporting data to the "Get With The Guidelines-Resuscitation" registry. PATIENTS Pediatric patients (< 18 yr old) with acute respiratory compromise. Acute respiratory compromise was defined as absent, agonal, or inadequate respiration that required emergency assisted ventilation and elicited a hospital-wide or unit-based emergency response. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was in-hospital mortality. Cardiac arrest during the event was a secondary outcome. To assess the association between patient, event, and hospital characteristics and the outcomes, we created multivariable logistic regressions models accounting for within-hospital clustering. One thousand nine hundred fifty-two patients from 151 hospitals were included. Forty percent of the events occurred on the wards, 19% in the emergency department, 25% in the ICU, and 16% in other locations. Two hundred eighty patients (14.6%) died before hospital discharge. Preexisting hypotension (odds ratio, 3.26 [95% CI, 1.89-5.62]; p < 0.001) and septicemia (odds ratio, 2.46 [95% CI, 1.52-3.97]; p < 0.001) were associated with increased mortality. The acute respiratory compromise event was temporally associated with a cardiac arrest in 182 patients (9.3%), among whom 46.2% died. One thousand two hundred eight patients (62%) required tracheal intubation during the event. In-hospital mortality among patients requiring tracheal intubation during the event was 18.6%. CONCLUSIONS In this large, multicenter study of acute respiratory compromise, 40% occurred in ward settings, 9.3% had an associated cardiac arrest, and overall in-hospital mortality was 14.6%. Preevent hypotension and septicemia were associated with increased mortality rate.
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Moskowitz A, Andersen LW, Karlsson M, Grossestreuer AV, Chase M, Cocchi MN, Berg K, Donnino MW. Predicting in-hospital mortality for initial survivors of acute respiratory compromise (ARC) events: Development and validation of the ARC Score. Resuscitation 2017; 115:5-10. [PMID: 28267618 DOI: 10.1016/j.resuscitation.2017.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 11/25/2022]
Abstract
AIM Acute respiratory compromise (ARC) is a common and highly morbid event in hospitalized patients. To date, however, few investigators have explored predictors of outcome in initial survivors of ARC events. In the present study, we leveraged the American Heart Association's Get With The Guidelines®-Resuscitation (GWTG-R) ARC data registry to develop a prognostic score for initial survivors of ARC events. METHODS Using GWTG-R ARC data, we identified 13,193 index ARC events. These events were divided into a derivation cohort (9807 patients) and a validation cohort (3386 patients). A score for predicting in-hospital mortality was developed using multivariable modeling with generalized estimating equations. RESULTS The two cohorts were well balanced in terms of baseline demographics, illness-types, pre-event conditions, event characteristics, and overall mortality. After model optimization, nine variables associated with the outcome of interest were included. Age, hypotension preceding the event, and intubation during the event were the greatest predictors of in-hospital mortality. The final score demonstrated good discrimination in both the derivation and validation cohorts. The score was also very well calibrated in both cohorts. Observed average mortality was <10% in the lowest score category of both cohorts and >70% in the highest category, illustrating a wide range of mortality separated effectively by the scoring system. CONCLUSIONS In the present study, we developed and internally validated a prognostic score for initial survivors of in-hospital ARC events. This tool will be useful for clinical prognostication, selecting cohorts for interventional studies, and for quality improvement initiatives seeking to risk-adjust for hospital-to-hospital comparisons.
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Affiliation(s)
- Ari Moskowitz
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA, United States.
| | - Lars W Andersen
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States; Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mathias Karlsson
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States; Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anne V Grossestreuer
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States; University of Pennsylvania, Department of Emergency Medicine, Philadelphia, PA, United States
| | - Maureen Chase
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States
| | - Michael N Cocchi
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States; Beth Israel Deaconess Medical Center, Department of Anesthesia Critical Care and Pain Medicine, Division of Critical Care, United States
| | - Katherine Berg
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA, United States
| | - Michael W Donnino
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA, United States; Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States
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29
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Karlsson CM, Donnino MW, Kirkegaard H, Cocchi MN, Chase M, Andersen LW. Acute Respiratory Compromise in the Emergency Department: A Description and Analysis of 3571 Events from the Get With the Guidelines-Resuscitation ® Registry. J Emerg Med 2017; 52:393-402. [PMID: 28108054 DOI: 10.1016/j.jemermed.2016.11.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/16/2016] [Accepted: 11/30/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Respiratory events requiring the use of assisted ventilation are relatively common in the emergency department (ED), and can be associated with substantial morbidity and mortality. OBJECTIVE The aim of this study was to describe and elucidate patient and event characteristics associated with mortality and progression to cardiac arrest in ED patients with acute respiratory compromise. METHODS Data were obtained from the multicenter Get With the Guidelines-Resuscitation® registry. We included patients with acute respiratory compromise defined as absent, agonal, or inadequate respiration that required emergency assisted ventilation. All adult patients between January 2005 and December 2014 with an index event in the ED were included. We used multivariable logistic regression models to assess the association between patient and event characteristics and in-hospital mortality, with cardiac arrest during the event as a secondary outcome. RESULTS A total of 3571 events were included. The in-hospital mortality was 34%. Twelve percent of events progressed to cardiac arrest, with a subsequent 82% in-hospital mortality. When adjusting for patient and event characteristics, we found no temporal changes in in-hospital mortality from 2005 to 2014. Several characteristics were associated with increased mortality, such as pre-event hypotension, septicemia, and acute stroke. Similarly, multiple characteristics, including pre-event hypotension, were associated with progression to cardiac arrest. CONCLUSIONS Patient with acute respiratory compromise in the ED had an in-hospital mortality of 34% in the current study. These patients also have a high risk of progressing to cardiac arrest, with a subsequent increase in in-hospital mortality to 82%. Potentially reversible characteristics, such as hypotension before the event, showed a strong association to in-hospital mortality, along with multiple other patient and event characteristics.
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Affiliation(s)
- Carl Mathias Karlsson
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Michael W Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Michael N Cocchi
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, Massachusetts
| | - Maureen Chase
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Lars W Andersen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
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