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Li Y, Lighthall G. Factors associated with 30- and 90-day mortality in intubations among critically ill patients. Acta Anaesthesiol Scand 2024; 68:206-213. [PMID: 37802764 DOI: 10.1111/aas.14334] [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: 03/29/2023] [Revised: 08/02/2023] [Accepted: 09/15/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Emergency intubations are commonly associated with adverse events when performed in critically ill patients. A detailed look at intubation factors and their association with procedural success and mortality has yet to be fully conducted. METHODS A total of 299 successive intubations at a tertiary Veteran Affair hospital were analyzed. Situational factors, personnel involved, intubation indications, induction agents, and airway management techniques were prospectively collected and entered into univariable and multivariable analyses to identify factors associated with procedural difficulty and mortality. RESULTS The use of paralytics was associated with easier intubations (OR: 0.31, 95% CI: 0.11-0.87, p = .03). The use of direct laryngoscopy or video laryngoscopy had no significant association with difficult intubation. Factors associated with increased 30-day mortality were cardiac arrest (OR: 7.90, 95% CI: 2.77-22.50, p < .001), hypoxia as indication for intubation (OR: 2.31, 95% CI: 1.23-4.35, p = .009), and nadir SpO2 < 90% (OR: 2.70, 95% CI: 1.01-7.21, p = .048). Presence of an attending anesthesiologist during intubation was associated with a lower 30-day mortality (OR: 0.11, 95% CI: 0.04-0.29, p < .001). Factors associated with increased 90-day mortality were cardiac arrest (OR: 6.57, 95% CI: 2.23-19.34, p = .001), hypoxia as indication for intubation (OR: 1.97, 95% CI: 1.10-3.55, p = .023), and older age (OR: 1.38, 95% CI: 1.07-1.78, p = .013). Similarly, presence of an attending anesthesiologist was found to be associated with a lower 90-day mortality (OR: 0.19, 95% CI: 0.07-0.50, p = .001). CONCLUSION Cardiovascular and respiratory instability were associated with increased 30- and 90-day mortality. Presence of an attending anesthesiologist was associated with a better survival following intubation outside operating room.
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Affiliation(s)
- Yi Li
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Geoffrey Lighthall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Anesthesiology, Palo Alto Veterans Affairs Medical Center, Stanford, California, USA
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Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure. Ann Emerg Med 2020; 76:751-756. [PMID: 32747084 DOI: 10.1016/j.annemergmed.2020.05.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Indexed: 11/21/2022]
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Udelsman BV, Moseley ET, Sudore RL, Keating NL, Lindvall C. Deep Natural Language Processing Identifies Variation in Care Preference Documentation. J Pain Symptom Manage 2020; 59:1186-1194.e3. [PMID: 31926970 DOI: 10.1016/j.jpainsymman.2019.12.374] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/24/2019] [Accepted: 12/26/2019] [Indexed: 12/18/2022]
Abstract
CONTEXT Documentation of care preferences within 48 hours of admission to an intensive care unit (ICU) is a National Quality Forum-endorsed quality metric for older adults. Care preferences are poorly captured by administrative data. OBJECTIVES Using deep natural language processing, our aim was to determine the rate of care preference documentation in free-text notes and to assess associated patient factors. METHODS Retrospective review of notes by clinicians using a deep natural language processing to identify care preference documentation, including goals-of-care and treatment limitations, within 48 hours of ICU admission within five ICUs (medical, cardiac, surgery, trauma surgery, and cardiac surgery) for adults 75 years and older. Covariates included demographics, ICU type, sequential organ failure assessment score, and need for mechanical ventilation. RESULTS Deep natural language processing reviewed 11,575 clinician notes for 1350 ICU admissions. Median patient age was 84.0 years (interquartile range 78.0-88.4). Overall, 64.7% had documentation of care preferences. Patients with documentation were older (85 vs. 83 years; P < 0.001) and more often female (53.8% vs. 43.4%; P < 0.001). In adjusted analysis, rates of care preference documentation were higher for older patients, females, nonelective admissions, and admissions to the medical vs. the cardiac or surgical ICUs (all P ≤ 0.01). CONCLUSION Care preference documentation within 48 hours was absent in more than one-third of ICU admissions among patients aged 75 years and older and was more likely to occur in medical vs. cardiac or surgical ICUs.
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Affiliation(s)
| | - Edward T Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, USA; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, USA
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George N, Jambaulikar GD, Sanders J, Ouchi K. A Time-to-Death Analysis of Older Adults after Emergency Department Intubation. J Palliat Med 2019; 23:401-405. [PMID: 31369301 DOI: 10.1089/jpm.2018.0632] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: Older adults frequently report a preference to "trial" intubation and mechanical ventilation (MV) if faced with life-threatening respiratory failure. Understanding the anticipated outcome of unplanned MV is key to structuring a time-limited trial of treatment. Objective: To characterize the time-to-death (TTD) among adults 65 years of age and older, who undergo emergency intubation and MV. Design: Retrospective cohort study. Setting/Subjects: All patients 65 years of age and older, who underwent emergency department (ED) intubation from 2008 to 2015, from 417 hospitals were included. Measurements: The primary outcome was TTD after emergency intubation. Results: We identified 41,463 ED encounters. The median TTD was three days (interquartile range, IQR, 1-8). There was a statistically significant change in the median TTD by age decile, with the shortest TTD, two days, in the oldest age group (p < 0.001). TTD was shortest among those with myocardial infarction (one day, IQR 4) and sepsis (two days, IQR 5). Bivariate analysis comparing TTD by Charleston Comorbidity Index (CCI) revealed a trend of increasing TTD with increasing CCI score among decedents. Patients with a CCI of 0 had a median TTD of one day (IQR 4), whereas the median TTD among those with a CCI >4 was four days (IQR 9). Conclusions: In a large, nationally representative cohort of older adults undergoing ED intubation, the median time from intubation to death was short; however, the length of time between intubation and death varied considerably by principal diagnosis. This information will help guide providers' prognostication after emergency intubation and enhance serious illness conversations by informing expectations. Tweet: Thirty-five percent of older adults die after ED intubation-most only survive two or three days after intubation.
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Affiliation(s)
- Naomi George
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Justin Sanders
- Department of Palliative Care and Psychosocial Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Palliative Care and Psychosocial Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
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Peyrony O, Dumas G, Legay L, Principe A, Franchitti J, Simonetta M, Verrat A, Amami J, Milacic H, Bragança A, Gillet A, Resche-Rigon M, Fontaine JP, Azoulay E. Central venous oxygen saturation is not predictive of early complications in cancer patients presenting to the emergency department. Intern Emerg Med 2019; 14:281-289. [PMID: 30306323 DOI: 10.1007/s11739-018-1966-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/06/2018] [Indexed: 12/14/2022]
Abstract
Central venous oxygen saturation (ScvO2) is easily observable in oncology patients with long-term central venous catheters (CVC), and has been studied as a prognostic factor in patients with sepsis. We sought to investigate the association between ScvO2 and early complications in cancer patients presenting to the ED. We prospectively enrolled adult cancer patients with pre-existing CVC who presented to the ED. ScvO2 was measured on their CVC. The outcome was admission to the intensive care unit (ICU) or mortality by day 7. ScvO2 was first studied as a continuous variable (%) with a ROC analysis and as a categorical variable (cut-off at < 70%) with a multivariate analysis. A total of 210 cancer patients were enrolled. At baseline, ScvO2 showed no significant difference between patients who were admitted to the ICU or died before day 7, and patients who did not (67%; IQR 62-68% vs. 71%; IQR 65-78% respectively, P = 0.3). The ROC analysis showed the absence of discrimination accuracy for ScvO2 to predict the outcome (AUC = 0.56). By multivariate analysis, ScvO2 < 70% was not associated with the outcome (OR 1.67; 95% CI 0.64-4.36). Variables that were associated with ICU admission or death by day 7 included a shock-index (heart rate/systolic blood pressure) > 1 and a performance status > 2 (OR 4.76; 95% CI 1.81-12.52 and OR 6.23, 95% CI 2.40-16.17, respectively). This study does not support the use of ScvO2 to risk stratify cancer patients presenting to the ED.
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Affiliation(s)
- Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
| | - Guillaume Dumas
- Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Léa Legay
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Alessandra Principe
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jessica Franchitti
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Marie Simonetta
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Anne Verrat
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jihed Amami
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Hélène Milacic
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Adélia Bragança
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Ariane Gillet
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Matthieu Resche-Rigon
- Biostatistics and Medical Information Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS-INSERM-UMR1153), ECSTRRA Team, Paris, France
- Paris Diderot University, Paris, France
| | - Jean-Paul Fontaine
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Elie Azoulay
- Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS-INSERM-UMR1153), ECSTRRA Team, Paris, France
- Paris Diderot University, Paris, France
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