LASER FLARE PHOTOMETRY IN PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT: An Evaluation of 2,487 Cases.

PURPOSE: Exploratory analysis associated with the prospective, multicenter, randomized PRIVENT trial. To characterize the associations between laser flare photometry and anatomical and epidemiological features of rhegmatogenous retinal detachment (RRD). METHODS: The authors measured laser flare values of all 3,048 prescreened patients excluding those with comorbidities. A mixed regression analysis evaluated the strength of the influencing factors like age, sex, lens status, and presence and extent of RRD on laser flare. RESULTS: Rhegmatogenous retinal detachment was more frequent in men (65.8%) than in women (34.2%, P < 0.001) and in right (52%) than in left eyes (48%, P = 0.045). Phakic RRD affected less quadrants and was less likely to be associated with macula-off status than pseudophakic RRD (48.4% vs. 58.0% macula off, 23% vs. 31% ≥3 quadrants, P < 0.001). Laser flare of affected eyes was significantly higher compared with fellow eyes (12.6 ± 15.2 vs. 8.3 ± 7.4 pc/ms, P < 0.001). The factors age, sex, lens status, presence of RRD, and the number of quadrants affected were independent influencing factors on laser flare. R 2 was 0.145 for phakic and 0.094 for pseudophakic eyes. CONCLUSION: The results indicate that there may be more factors affecting laser flare than previously assumed. This might limit flare as predictive value for PVR and retinal redetachment.

Arduino-Based Readout Electronics for Nuclear and Particle Physics.

Open Hardware-based microcontrollers, especially the Arduino platform, have become a comparably easy-to-use tool for rapid prototyping and implementing creative solutions. Such devices in combination with dedicated front-end electronics can offer low-cost alternatives for student projects, slow control and independently operating small-scale instrumentation. The capabilities can be extended to data taking and signal analysis at mid-level rates. Two detector realizations are presented, which cover the readouts of proportional counter tubes and of scintillators or wavelength-shifting fibers with silicon photomultipliers (SiPMs). The SiPMTrigger realizes a small-scale design for coincidence readout of SiPMs as a trigger or veto detector. It consists of a custom mixed signal front-end board featuring signal amplification, discrimination and a coincidence unit for rates of up to 200 kHz. The nCatcher transforms an Arduino Nano to a proportional counter readout with pulse shape analysis: time over threshold measurement and a 10-bit analog-to-digital converter for pulse heights. The device is suitable for low-to-medium-rate environments up to 5 kHz, where a good signal-to-noise ratio is crucial. We showcase the monitoring of thermal neutrons. For data taking and slow control, a logger board is presented that features an SD card and GSM/LoRa interface.

A NOVEL EQUATION SUCCESSFULLY CALCULATES TIDAL VOLUMES FOR LUNG PROTECTIVE VENTILATION.

BACKGROUND: Early application of low-tidal-volume ventilation (LTVV) has been associated with improved outcomes in the emergency department (ED) and intensive care unit (ICU), but is not consistently applied. The perceived complexity of calculating an ideal body weight (IBW)-based tidal volume (Vt) may contribute to this disparity. We hypothesized that a simplified equation could successfully predict LTVV. OBJECTIVE: To create a memorable, single-step, sex-independent equation to estimate LTVV based on height. METHODS: We conducted a retrospective observational cohort study of patients who received mechanical ventilation (MV) at 2 EDs from January 2016 to June 2019. Data were abstracted by automatic query. Patients < 18 years old, < 60 inches in height, and with implausible or incomplete data were excluded. LTVV was defined as ≤ 8 mL/kg IBW. We created a formula predicting a 6-8-mL/kg IBW Vt. We applied this formula to a population of ICU patients in the same health care system who received MV from January 2017 to December 2019 using the same exclusion criteria. The outcome was whether the equation predicted a 6-8-mL/kg IBW Vt. RESULTS: A total of 982 ED patients were included; 753 (76.7%) had an initial Vt < 8 mL/kg IBW. The equation Vt = 20*(Ht-60) + 300 was derived. A total of 3720 ICU patients were included. The Vt equation successfully predicted a Vt of 6-8 mL/kg IBW in 3720 (100%) of ICU patients. CONCLUSIONS: A novel equation successfully predicted a 6-8-mL/kg IBW Vt in a cohort of patients with height ≥ 60 inches.

The Association of Preoperative Hematocrit With Adverse Events Following Exploratory Laparotomy in Septic Patients: A Retrospective Analysis.

BACKGROUND: Sepsis continues to be the leading cause of death in intensive care units and surgical patients comprise almost one third of all sepsis patients. Anemia is a modifiable risk factor for worse postoperative outcomes in sepsis patients. Here we aim to evaluate the association of preoperative anemia and postoperative mortality in sepsis patients undergoing exploratory laparotomy. METHODS: The National Surgical Quality Improvement Program registry was used to query for preoperative sepsis patients undergoing exploratory laparotomy between 2014 and 2016. Preoperative hematocrit was stratified into 4 categories: ≥30% to polycythemia, <21%, 21 and less than 30%, and polycythemia. The primary outcome was 30-day mortality. Multivariable logistic regression was used to evaluate the association of preoperative hematocrit with primary and secondary endpoints. The multivariable analysis included preoperative hematocrit, gender, age, BMI, smoking status, functional status, hypertension, steroid use, bleeding disorder, and sepsis. The odds ratio (OR) with associated 95% confidence interval (CI) is reported for all outcomes. A p-value of less than <0.05 was considered statistically significant. RESULTS: The unadjusted 30-day death rate was the highest for patients with preoperative hematocrit <21% (p < 0.001) compared to the other hematocrit cohorts. The odds of 30-day death was significantly increased for patients with preoperative hematocrit <21% (OR 2.39 95% CI: 1.28-4.49, p = 0.006) and 21-30% (OR 1.35, 95% CI: 1.05 -1.72, p = 0.017) compared to patients with preoperative hematocrit of ≥30% and less than polycythemic ranges (reference cohort). CONCLUSION: Preoperative anemia in sepsis patients undergoing surgery can lead to increased mortality, postoperative complications, and length of hospital stay. Diagnosing sepsis early in the hospital course can allow physicians more time to titrate anticoagulation medications and treat preoperative anemia.

Discounting Behavior in Problem Gambling.

Problem gamblers discount delayed rewards more rapidly than do non-gambling controls. Understanding this impulsivity is important for developing treatment options. In this article, we seek to make two contributions: First, we ask which of the currently debated economic models of intertemporal choice (exponential versus hyperbolic versus quasi-hyperbolic) provides the best description of gamblers' discounting behavior. Second, we ask how problem gamblers differ from habitual gamblers and non-gambling controls within the most favored parametrization. Our analysis reveals that the quasi-hyperbolic discounting model is strongly favored over the other two parametrizations. Within the quasi-hyperbolic discounting model, problem gamblers have both a significantly stronger present bias and a smaller long-run discount factor, which suggests that gamblers' impulsivity has two distinct sources.

Oscillatory brain activity associated with skin conductance responses in the context of risk.

Understanding the neural correlates of risk-sensitive skin conductance responses can provide insights into their connection to emotional and cognitive processes. To provide insights into this connection, we studied the cortical correlates of risk-sensitive skin conductance peaks using electroencephalography. Fluctuations in skin conductance responses were elicited while participants played a threat-of-shock card game. Precise temporal information about skin conductance peaks was obtained by applying continuous decomposition analysis on raw electrodermal signals. Shortly preceding skin conductance peaks, we observed a decrease in oscillatory power in the frequency range between 3 and 17 Hz in occipitotemporal cortical areas. Atlas-based analysis indicated the left lingual gyrus as the source of the power decrease. The oscillatory power averaged across 3-17 Hz showed a significant negative relationship with the skin conductance peak amplitude. Our findings indicate a possible interaction between attention and threat perception.NEW & NOTEWORTHY We studied neural oscillations associated with risk-sensitive skin conductance responses. Going beyond previous studies, we applied methods with high-temporal resolution to account for the temporal properties of the sympathetic activity. Preceding skin conductance peaks, we observed decreased occipital cortex oscillatory power and a relationship between the oscillatory power decrease and the skin conductance peak amplitude. Our study suggests an interaction between attention and emotion such as threat perception reflected in skin conductance responses.

A Point-Based Risk Calculator Predicting Mortality in Patients That Developed Postoperative Sepsis.

BACKGROUND: Predicting the mortality from post-operative sepsis remains a continuing problem. We built a statistical model using national data to predict mortality in patients who developed post-operative sepsis. METHODS: This is a retrospective study using the American College of Surgeons National Quality Surgical Improvement Program database, in which we gathered data from adult patients between 2011 and 2016 who experienced postoperative sepsis. We designed a predictive model using multivariable logistic regression on a training set and validated the model on a separate test set. RESULTS: There were 128,325 patients included in the final dataset, in which 18,499 (14.4%) died within 30-days of surgery. The model consisted of 10 covariates: American Society of Anesthesiologists Physical Status classification score, preoperative sepsis, age, chronic obstructive pulmonary disease, postoperative myocardial infarction, postoperative stroke, postoperative acute renal failure, transfusion requirement, and infection type. A point-based risk calculator was developed, which had an area under the receiver operating characteristics curve of 0.819 (95% confidence interval 0.814-0.823). CONCLUSION: Although further work is needed to confirm and validate our model on external datasets, our scoring system provides a novel way to measure mortality in septic post-operative patients.

Improving Surgical Start Times by Improving Wayfinding.

PURPOSE: This performance improvement project was undertaken to reduce costly delays in first-case, operating room (OR) start times. DESIGN: Two Plan, Do, Study, Act (PDSA) cycles. METHODS: In PDSA 1, student nurses observed 30 patients' paths of travel from hospital entrance to OR and documented time spent at key stopping points. Directional signs were placed after PDSA 1. PDSA 2 consisted of an electronic medical record (EMR) review of pre- and postsignage cases (n = 492 and n = 538 respectively). FINDINGS: In the initial PDSA cycle (n = 30), one reason for delay was the time patients spent finding the preoperative area (POA). Signage was placed at strategic points noted to confuse patients. PDSA cycle 2 found median presignage POA arrival times (34 minutes) were significantly higher than postsignage POA arrival times (20 minutes) (U = 51,618.0, z = -16.934, P < .001). CONCLUSIONS: Delayed wayfinding contributed to delayed OR starts but improved with appropriate signage.

Enhancing Patients' Wayfinding and Visitation Experience Improves Quality of Care.

PURPOSE: To understand the impact of wayfinding challenges on patient hospital visitation experience, organizational costs, and emerging technology trends that may alleviate wayfinding challenges. DESIGN: A review of literature on the relationship of wayfinding to patient's hospital visitation experience. METHODS: A literature search identifying issues associated with wayfinding challenges in complex health care facilities was conducted. Case examples are provided to illustrate that the removal of barriers can improve the wayfinding experience. This review also informs technology trends that may effectively facilitate wayfinding in complex health care facilities. FINDINGS: Large hospital complexes exhibit many characteristics comparable to the physical features of a city environment. These complexities present challenges to patients to navigate to their destinations. An effective wayfinding system is a collection of tools that combines permanent signage, printed information, landmarks, architectural features and design elements, and human interactions. Navigational technology modeling holds the promise to aid patients and individuals with visual and cognitive challenges to find their way to their desired destinations effectively and efficiently, and improves their quality of life. CONCLUSIONS: Improved patient travel time correlates to reduce idled nursing time, with cost savings accrued to organization. Research shows that wayfinding mobile applications hold the promise of improving patients' hospital visitation experience.

A Predictive Model for Determining Patients Not Requiring Prolonged Hospital Length of Stay After Elective Primary Total Hip Arthroplasty.

BACKGROUND: Hospital length of stay (LOS) is an important quality metric for total hip arthroplasty. Accurately predicting LOS is important to expectantly manage bed utilization and other hospital resources. We aimed to develop a predictive model for determining patients who do not require prolonged LOS. METHODS: This was a retrospective single-institution study analyzing patients undergoing elective unilateral primary total hip arthroplasty from 2014 to 2016. The primary outcome of interest was LOS less than or equal to the expected duration, defined as ≤3 days. Multivariable logistic regression was performed to generate a model for this outcome, and a point-based calculator was designed. The model was built on a training set, and performance was assessed on a validation set. The area under the receiver operating characteristic curve and the Hosmer-Lemeshow test were calculated to determine discriminatory ability and goodness-of-fit, respectively. Predictive models using other machine learning techniques (ridge regression, Lasso, and random forest) were created, and model performances were compared. RESULTS: The point-based score calculator included 9 variables: age, opioid use, metabolic equivalents score, sex, anemia, chronic obstructive pulmonary disease, hypertension, obesity, and primary anesthesia type. The area under the receiver operating characteristic curve of the calculator on the validation set was 0.735 (95% confidence interval, 0.675-0.787) and demonstrated adequate goodness-of-fit (Hosmer-Lemeshow test, P = .37). When using a score of 12 as a threshold for predicting outcome, the positive predictive value was 86.1%. CONCLUSIONS: A predictive model that can help identify patients at higher odds for not requiring a prolonged hospital LOS was developed and may aid hospital administrators in strategically planning bed availability to reduce both overcrowding and underutilization when coordinating with surgical volume.

Thirty-Day Unplanned Reintubation Following Pleurodesis: A Retrospective National Registry Analysis.

OBJECTIVE: To examine risk factors associated with 30-day unplanned reintubation after pleurodesis. DESIGN: A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program surgical outcomes registry. SETTING: United States hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. PARTICIPANTS: The study comprised 2,358 patients who underwent video-assisted thorascopic surgery for pleurodesis from 2007 to 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The final sample included 2,358 cases, of which 93 (3.9%) required 30-day unplanned reintubation. Cases with 30-day unplanned reintubation, compared to those without, had higher unadjusted rates of American Society of Anesthesiologists physical status (ASA PS) score ≥4 (54.8% v 27.2%), preoperative dyspnea (71% v 57%), congestive heart failure (14% v 5.4%), functional dependence (28% v 10.3%), and diabetes mellitus (29% v 17.8%) (all p < 0.05). Patients with 30-day reintubation experienced higher unadjusted rates of 30-day outcomes including mortality (50.5% v 10.1%), pneumonia (28% v 4.9%), ventilator dependence (50.5% v 10.1%), sepsis (7.5% v 1.9%), myocardial infarction (5.4% v 0.1%), cardiac arrest (18.3% v 0.6%), transfusion (14% v 4.5%), and reoperation (15.1% v 3.2%) (all p < 0.05). The odds of 30-day unplanned reintubation were increased significantly on multivariable analysis for patients with ASA PS score ≥4, functional dependence, disseminated cancer, renal dialysis, and weight loss (all p < 0.05). CONCLUSION: Given the dearth of population-based studies addressing risk factors of reintubation after pleurodesis, this study suggests further review of preoperative optimization, which is required to improve patient outcomes and safety.

Peripartum Cardiomyopathy: Current Options for Treatment and Cardiovascular Support.

Peripartum cardiomyopathy is a rare form of acute heart failure but the major cause of all deaths in pregnant patients with heart failure. Improved survival rates in recent years, however, emphasize the importance of early recognition and initiation of heart failure treatment. This article, therefore, attempts to raise awareness among cardiac and obstetric anesthesiologists as well as intensivists of this often fatal diagnosis. This review summarizes theories of the pathophysiology and outcome of peripartum cardiomyopathy. Based on the most recent literature, it further outlines diagnostic criteria and treatment options including medical management, mechanical circulatory support devices, and heart transplantation. Earlier recognition of this rare condition and a new generation of mechanical circulatory devices has contributed to the improved outcome. More frequently, patients in cardiogenic shock who fail medical management are successfully bridged to recovery on extracorporeal circulatory devices or survive with a long-lasting implantable ventricular assist device. The outcome of transplanted patients with peripartum cardiomyopathy, however, is worse compared to other recipients of heart transplants and warrants further investigation in the future.

Outdoor Walking Training Compared To Cycle Ergometer Training in Severe COPD: A Randomized Controlled Feasibility Trial.

Exercise can improve walking capacity in persons with chronic obstructive pulmonary disease (COPD). However, most endurance training programs use cycle ergometers. The objectives of this study were: (i) to evaluate the feasibility of a randomized controlled trial (RCT) comparing outdoor walking training (OWT) to cycle ergometer training (CT) during inpatient rehabilitation in persons with severe COPD; (ii) to estimate the effect of OWT and CT on health-related quality of life, physical capacity and physical activity; and (iii) to estimate the required sample size for a RCT. A single-blind randomized controlled feasibility trial was conducted with three months' follow-up in the rehabilitation center in Walenstadtberg, Switzerland. Sixteen patients were included in the study, which had a recruitment rate of 33% (16/48). Patients were allocated to an OWT (n = 8) or CT (n = 8) group. Participants completed 75% of scheduled training and the follow-up rate was 75%. All participants in the OWT group were satisfied with the training. The OWT group had better health-related quality of life after three weeks' training compared to the CT group (p = 0.042, 95% confidence interval (95% CI) 1.06-49.94, effect size (d)=1.19). No exacerbations occurred in the OWT group, but three occurred in the CT group after three months' follow-up. There was no significant difference in the other outcomes. In conclusion, the study design and the OWT are feasible. Health-related quality of life improved in the OWT group compared to the CT group after three weeks' inpatient rehabilitation. A minimum of 46 participants is needed for a RCT. Trial registration: www.who.int/trialsearch DRKS00010977.

The Association of Preoperative Hematocrit and Transfusion with Mortality in Patients Undergoing Elective Non-cardiac Surgery.

BACKGROUND: Patients with anemia frequently undergo surgery, as it is unclear at what threshold clinicians should consider delaying surgery for preoperative anemia optimization. The primary objective of this study was to determine whether there is an association of varying degrees of anemia and transfusion with 30-day mortality. METHODS: This is a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2013. Cohorts were analyzed based on preoperative hematocrit range-patients with: (1) no anemia, (2) hematocrit ≥33% and <36% in females or <39% in males, (3) hematocrit ≥30% and <33%, (4) hematocrit ≥27% and <30%, (5) hematocrit ≥24% and <27%, and (6) hematocrit ≥21% and less than 24%. Multivariable logistic regression was used to analyze the association of anemia and transfusion with 30-day in-hospital mortality. RESULTS: The odds for 30-day mortality increased incrementally as the hematocrit ranges decreased, in which preoperative hematocrit between 21 and 24% had the highest odds for this outcome (odds ratio [OR] 6.50, p < 0.0001) compared to the reference group (no anemia). The use of transfusion increased the odds of mortality even further (OR 5.57, p < 0.0001). Among patients that received an intra-/postoperative transfusion, preoperative anemia was not predictive of mortality. CONCLUSIONS: Healthcare providers making preoperative clinical decisions for patients undergoing elective surgery should consider the degree of preoperative anemia and likelihood of perioperative transfusion.

A Dedicated Acute Pain Service Is Associated With Reduced Postoperative Opioid Requirements in Patients Undergoing Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: The Acute Pain Service (APS) was initially introduced to optimize multimodal postoperative pain control. The aim of this study was to evaluate the association between the implementation of an APS and postoperative pain management and outcomes for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS: In this propensity-matched retrospective cohort study, we performed a before-after study without a concurrent control group. Outcomes were compared among patients undergoing CRS-HIPEC when APS was implemented versus historical controls (non-APS). The primary objective was to determine if there was a decrease in median total opioid consumption during postoperative days 0-3 among patients managed by the APS. Secondary outcomes included opioid consumption on each postoperative day (0-6), time to ambulation, time to solid intake, and hospital length of stay. RESULTS: After exclusion, there were a total of 122 patients, of which 51 and 71 were in the APS and non-APS cohort, respectively. Between propensity-matched groups, the median (quartiles) total opioid consumption during postoperative days 0-3 was 27.5 mg intravenous morphine equivalents (MEQs) (7.6-106.3 mg MEQs) versus 144.0 mg MEQs (68.9-238.3 mg MEQs), respectively. The median difference was 80.8 mg MEQs (95% confidence interval, 46.1-124.0; P < .0001). There were statistically significant decreases in time to ambulation and time to solid diet intake in the APS cohort. CONCLUSIONS: After implementing the APS, CRS-HIPEC patients had decreased opioid consumption by >50%, as well as shorter time to ambulation and time to solid intake. Implementation of an APS may improve outcomes in CRS-HIPEC patients.

Perioperative Risk Factors Associated With Postoperative Unplanned Intubation After Lung Resection.

OBJECTIVE: Postoperative respiratory failure requiring reintubation is associated with a significant increase in mortality. However, perioperative risk factors and their effects on unplanned 30-day reintubation and postoperative outcomes after unplanned reintubation following lung resection are not described well. The aim of this study was to determine whether certain comorbidities, demographic factors, and postoperative outcomes are associated with 30-day reintubation after thoracic surgery. DESIGN: This was a retrospective observational study using multivariable logistic regression to identify preoperative risk factors and consequences of unplanned 30-day reintubation. SETTING: Multi-institutional, prospective, surgical outcome-oriented database study. PARTICIPANTS: Using the American College of Surgeons National Surgical Quality Improvement Program database, video-assisted thorascopic surgery and thoracotomy lung resections (lobectomy, wedge resection, segmentectomy, bilobectomy, pneumonectomy) were analyzed by Common Procedural Terminology codes from the years 2007 to 2016 in 16,696 patients undergoing thoracic surgery. INTERVENTION: None. MEASUREMENT AND MAIN RESULTS: The final analysis included 16,696 patients, of who 593 (3.5%) underwent unplanned reintubation. Among the final study population, 137 (23%) of unplanned intubations occurred within 24 hours postoperatively and the median (25%, 75% quartile) day of reintubation was day 3 (2, 8 days). The final multivariable logistic regression analysis suggested that age, American Society of Anesthesiologists physical status classification score ≥4, dyspnea with moderate exertion and at rest, history of chronic obstructive pulmonary disease, male sex, smoking, functional dependence, steroid use, open thoracotomies, increased operation time, and preoperative laboratory results (albumin and hematocrit) were associated with unplanned intubation after lung resection (p < 0.05). Unplanned intubation was associated significantly with 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay (p < 0.05). CONCLUSIONS: Nonmodifiable and modifiable preoperative risk factors were associated with increased odds of unplanned reintubation. Patients who experienced unplanned intubation were at considerable risk for 30-day mortality, reoperation, postoperative blood transfusion, and increased hospital length of stay.

Pulmonary Artery Catheter Placement Aided by Transesophageal Echocardiography versus Pressure Waveform Transduction.

OBJECTIVE: To compare pulmonary artery catheter (PAC) placement by transesophageal echocardiography combined with pressure waveform transduction versus the traditional technique of pressure waveform transduction alone. DESIGN: A prospective, randomized trial. SETTING: Single university hospital. PARTICIPANTS: Forty-eight patients with chronic thromboembolic pulmonary hypertension (CTEPH) scheduled for pulmonary thromboendarterectomy. INTERVENTIONS: PACs were placed in 48 patients with CTEPH scheduled for pulmonary thromboendarterectomy by either a combined approach (eg, transesophageal echocardiography [TEE] and pressure waveform transduction) or by pressure waveform transduction alone. MEASUREMENTS AND MAIN RESULTS: Successful placement of the PAC via a combined technique or pressure waveform transduction alone was timed, number of attempts recorded, and final location noted. The final location of the pressure waveform-guided catheters was the proximal right pulmonary artery in 6 of 24 cases (25%), whereas the combined method resulted in successful placement in the proximal right pulmonary artery in 24 of 24 cases (100%). The pressure waveform technique resulted in a mean time to placement and mean number of attempts of 74 seconds and 1.70 attempts, respectively. The combined approach resulted in a mean time to placement and mean number of attempts of 89 seconds and 1.79 attempts, respectively. The combined method resulted in placement in the proximal right pulmonary artery significantly more often than the pressure-only method but did not reduce significantly the number of attempts or time required to place the catheter successfully. Additionally, among those cases that required more than 1 attempt or manipulation, there was no difference in the time to successful placement or the number of attempts required for successful placement. CONCLUSION: TEE guidance during PAC insertion was hypothesized to result in a higher success rate, precise placement, and shorter times to placement. One hundred percent of the PACs inserted with TEE guidance were positioned successfully in the proximal right pulmonary artery, which is the institutional preference. Although the combined technique resulted in greater precision, the clinical significance of this is unknown. The time to placement benefit was not confirmed by this study.

Transport of Critically Ill Cardiovascular Patients.

Intra-hospital transport (IHT) of intensive care unit (ICU) patients is associated with a 30% to 60% incidence of adverse events (AEs). This prospective observational study collected data from 200 patient transports from a 24-bed cardiovascular intensive care unit (ICU) between July 2017 and December 2017. Phase 1 of the study focused on identifying and correcting deficiencies in nurses' knowledge regarding IHT. Phase 2 observed the occurrence and type of AEs during the IHT of ICU patients with and without physician accompaniment. The preeducation mean nursing knowledge score was 30.8 ± 10.2 (scale 0-100), and postcurriculum test mean score was 80 ± 20.2 (p < .001). In a series of 200 ICU transports, the incidence of AEs was 21.5% (n = 43). In patients who were unstable prior to transport, there was no difference in complications with or without a physician present (p = 0.40, χ = 0.696, odds ratio = 0.643, 95% confidence interval: 0.245-1.96). Patient needs during transport were met with preexisting orders or treatment orders received telephonically. Nurses' knowledge of transport standards improved significantly with education. Physician presence did not affect outcomes. The interventions needed to respond to complications did not require physician presence. In this cohort, there was no statistically significant benefit from physician attendance in transport.

Postoperative mortality and morbidity following non-cardiac surgery in a healthy patient population.

PURPOSE: Perioperative mortality ranges from 0.4% to as high as nearly 12%. Currently, there are no large-scale studies looking specifically at the healthy surgical population alone. The primary objective of this study was to report 30-day mortality and morbidity in healthy patients and define any risk factors. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) dataset, all patients assigned an American Society of Anesthesiologists physical status (ASA PS) classification score of 1 or 2 were included. Further patients were excluded if they had a comorbidity or underwent a procedure not likely to classify them as ASA PS 1 or 2. Multivariable logistic regression was performed to identify predictors of the outcomes, in which odds ratios (OR) and 95% confidence intervals (95% CI) were reported. RESULTS: There were 687,552 healthy patients included in the final analysis. Following surgery, 0.7, 7.0, and 0.7 per 1000 persons experienced 30-day mortality, sepsis, and stroke or myocardial infarction, respectively. Healthy patients greater than 80 years of age had the highest odds for mortality (OR 17.7, 95% CI 12.4-25.1, p < 0.001). Case duration was associated with increased mortality, especially in cases greater than or equal to 6 h (OR 3.0, 95% CI 2.0-4.5, p < 0.001). CONCLUSIONS: Thirty-day mortality and morbidity is, as expected, lower in the healthy surgical population. Age may be an indication to further risk stratify patients that are ASA PS 1 or 2 to better reflect perioperative risk.

Dependent functional status is associated with unplanned postoperative intubation after elective cervical spine surgery: a national registry analysis.

PURPOSE: The impact of preoperative functional status on 30-day unplanned postoperative intubation and clinical outcomes among patients who underwent cervical spine surgery is not well-described. We hypothesized that functional dependence is associated with 30-day unplanned postoperative intubation and that among the reintubated cohort, functional dependence is associated with adverse postoperative clinical outcomes after cervical spine surgery. METHODS: Utilizing the 2007-2016 American College of Surgeons National Surgical Quality Improvement Program database, we identified adult elective anterior and posterior cervical spine surgery patients by Current Procedural Terminology codes. We performed (1) a Cox Proportional Hazard analysis for the following outcomes: reintubation, prolonged ventilator use, and pneumonia and (2) an adjusted logistic regression analysis among patients that required postoperative reintubation to evaluate the association of functional status with adverse postoperative outcomes. RESULTS: The sample size was 26,263, of which 550 (2.1%) were functionally dependent. The adjusted model suggested that when compared with functionally independent patients, dependent patients were at increased risk of unplanned 30-day intubation (HR 2.05, 95% CI 1.26-3.34; P = 0.003). The adjusted risk of 30-day postoperative pneumonia was significantly higher in patients with functional dependence (HR 1.61, 95% CI 1.02-2.54, P = 0.036). Among patients that required postoperative reintubation, the odds of 30-day mortality was significantly higher in patients with functional dependence (OR 5.82, 95% CI 1.59-23.4, P < 0.001). CONCLUSION: Preoperative functional dependence is a good marker for estimating postoperative unplanned intubation following cervical spine surgery.