Early Cardiac Evaluation, Abnormal Test Results, and Associations with Outcomes in Patients with Acute Brain Injury Admitted to a Neurocritical Care Unit.

Background: to examine factors associated with cardiac evaluation and associations between cardiac test abnormalities and clinical outcomes in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (sICH), and traumatic brain injury (TBI) requiring neurocritical care. Methods: In a cohort of patients ≥18 years, we examined the utilization of electrocardiography (ECG), beta-natriuretic peptide (BNP), cardiac troponin (cTnI), and transthoracic echocardiography (TTE). We investigated the association between cTnI, BNP, sex-adjusted prolonged QTc interval, low ejection fraction (EF < 40%), all-cause mortality, death by neurologic criteria (DNC), transition to comfort measures only (CMO), and hospital discharge to home using univariable and multivariable analysis (adjusted for age, sex, race/ethnicity, insurance carrier, pre-admission cardiac disorder, ABI type, admission Glasgow Coma Scale Score, mechanical ventilation, and intracranial pressure [ICP] monitoring). Results: The final sample comprised 11,822 patients: AIS (46.7%), sICH (18.5%), SAH (14.8%), and TBI (20.0%). A total of 63% (n = 7472) received cardiac workup, which increased over nine years (p < 0.001). A cardiac investigation was associated with increased age, male sex (aOR 1.16 [1.07, 1.27]), non-white ethnicity (aOR), non-commercial insurance (aOR 1.21 [1.09, 1.33]), pre-admission cardiac disorder (aOR 1.21 [1.09, 1.34]), mechanical ventilation (aOR1.78 [1.57, 2.02]) and ICP monitoring (aOR1.68 [1.49, 1.89]). Compared to AIS, sICH (aOR 0.25 [0.22, 0.29]), SAH (aOR 0.36 [0.30, 0.43]), and TBI (aOR 0.19 [0.17, 0.24]) patients were less likely to receive cardiac investigation. Patients with troponin 25th-50th quartile (aOR 1.65 [1.10-2.47]), troponin 50th-75th quartile (aOR 1.79 [1.22-2.63]), troponin >75th quartile (aOR 2.18 [1.49-3.17]), BNP 50th-75th quartile (aOR 2.86 [1.28-6.40]), BNP >75th quartile (aOR 4.54 [2.09-9.85]), prolonged QTc (aOR 3.41 [2.28; 5.30]), and EF < 40% (aOR 2.47 [1.07; 5.14]) were more likely to be DNC. Patients with troponin 50th-75th quartile (aOR 1.77 [1.14-2.73]), troponin >75th quartile (aOR 1.81 [1.18-2.78]), and prolonged QTc (aOR 1.71 [1.39; 2.12]) were more likely to be associated with a transition to CMO. Patients with prolonged QTc (aOR 0.66 [0.58; 0.76]) were less likely to be discharged home. Conclusions: This large, single-center study demonstrates low rates of cardiac evaluations in TBI, SAH, and sICH compared to AIS. However, there are strong associations between electrocardiography, biomarkers of cardiac injury and heart failure, and echocardiography findings on clinical outcomes in patients with ABI. Findings need validation in a multicenter cohort.

Hospital Outcomes in Patients Who Developed Acute Respiratory Distress Syndrome After Community-Acquired Pneumonia.

Purpose: To identify risk factors for and outcomes in acute respiratory distress syndrome (ARDS) in patients hospitalized with community-acquired pneumonia (CAP). Methods: This is a retrospective study using the Premier Healthcare Database between 2016 and 2020. Patients diagnosed with pneumonia, requiring mechanical ventilation (MV), antimicrobial therapy, and hospital admission ≥2 days were included. Multivariable regression models were used for outcomes including in-hospital mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and days on MV. Results: 1924 (2.7%) of 72 107 patients with CAP developed ARDS. ARDS was associated with higher mortality (33.7% vs 18.9%; adjusted odds ratio 2.4; 95% confidence interval [CI] 2.16-2.66), longer hospital LOS (13 vs 9 days; adjusted incidence risk ratio (aIRR) 1.24; 95% CI 1.20-1.27), ICU LOS (9 vs 5 days; aIRR 1.51; 95% CI 1.46-1.56), more MV days (8 vs 5; aIRR 1.54; 95% CI 1.48-1.59), and increased hospitalization cost ($46 459 vs $29 441; aIRR 1.50; 95% CI 1.45-1.55). Conclusion: In CAP, ARDS was associated with worse in-patient outcomes in terms of mortality, LOS, and hospitalization cost. Future studies are needed to explore outcomes in patients with CAP with ARDS and explore risk factors for development of ARDS after CAP.

Burden of Ischemic and Hemorrhagic Stroke Across the US From 1990 to 2019.

Importance: Stroke is a leading cause of death and disability in the US. Accurate and updated measures of stroke burden are needed to guide public health policies. Objective: To present burden estimates of ischemic and hemorrhagic stroke in the US in 2019 and describe trends from 1990 to 2019 by age, sex, and geographic location. Design, Setting, and Participants: An in-depth cross-sectional analysis of the 2019 Global Burden of Disease study was conducted. The setting included the time period of 1990 to 2019 in the US. The study encompassed estimates for various types of strokes, including all strokes, ischemic strokes, intracerebral hemorrhages (ICHs), and subarachnoid hemorrhages (SAHs). The 2019 Global Burden of Disease results were released on October 20, 2020. Exposures: In this study, no particular exposure was specifically targeted. Main Outcomes and Measures: The primary focus of this analysis centered on both overall and age-standardized estimates, stroke incidence, prevalence, mortality, and DALYs per 100 000 individuals. Results: In 2019, the US recorded 7.09 million prevalent strokes (4.07 million women [57.4%]; 3.02 million men [42.6%]), with 5.87 million being ischemic strokes (82.7%). Prevalence also included 0.66 million ICHs and 0.85 million SAHs. Although the absolute numbers of stroke cases, mortality, and DALYs surged from 1990 to 2019, the age-standardized rates either declined or remained steady. Notably, hemorrhagic strokes manifested a substantial increase, especially in mortality, compared with ischemic strokes (incidence of ischemic stroke increased by 13% [95% uncertainty interval (UI), 14.2%-11.9%]; incidence of ICH increased by 39.8% [95% UI, 38.9%-39.7%]; incidence of SAH increased by 50.9% [95% UI, 49.2%-52.6%]). The downturn in stroke mortality plateaued in the recent decade. There was a discernible heterogeneity in stroke burden trends, with older adults (50-74 years) experiencing a decrease in incidence in coastal areas (decreases up to 3.9% in Vermont), in contrast to an uptick observed in younger demographics (15-49 years) in the South and Midwest US (with increases up to 8.4% in Minnesota). Conclusions and Relevance: In this cross-sectional study, the declining age-standardized stroke rates over the past 3 decades suggest progress in managing stroke-related outcomes. However, the increasing absolute burden of stroke, coupled with a notable rise in hemorrhagic stroke, suggests an evolving and substantial public health challenge in the US. Moreover, the significant disparities in stroke burden trends across different age groups and geographic locations underscore the necessity for region- and demography-specific interventions and policies to effectively mitigate the multifaceted and escalating burden of stroke in the country.

Early Beta-Blocker Utilization in Critically Ill Patients With Moderate-Severe Traumatic Brain Injury: A Retrospective Cohort Study.

BACKGROUND: There is limited evidence that beta-blockers may provide benefit for patients with moderate-severe traumatic brain injury (TBI) during the acute injury period. Larger studies on utilization patterns and impact on outcomes in clinical practice are lacking. OBJECTIVE: The present study uses a large, national hospital claims-based dataset to examine early beta-blocker utilization patterns and its association with clinical outcomes among critically ill patients with moderate-severe TBI. METHODS: We conducted a retrospective cohort study of the administrative claims Premier Healthcare Database of adults (≥17 years) with moderate-severe TBI admitted to the intensive care unit (ICU) from 2016 to 2020. The exposure was receipt of a beta-blocker during day 1 or 2 of ICU stay (BB+). The primary outcome was hospital mortality, and secondary outcomes were: hospital length of stay (LOS), ICU LOS, discharge to home, and vasopressor utilization. In a sensitivity analysis, we explored the association of beta-blocker class (cardioselective and noncardioselective) with hospital mortality. We used propensity weighting methods to address possible confounding by treatment indication. RESULTS: A total of 109 665 participants met inclusion criteria and 39% (n = 42 489) were exposed to beta-blockers during the first 2 days of hospitalization. Of those, 42% received cardioselective only, 43% received noncardioselective only, and 14% received both. After adjustment, there was no association with hospital mortality in the BB+ group compared to the BB- group (adjusted odds ratio [OR] = 0.99, 95% confidence interval [CI] = 0.94, 1.04). The BB+ group had longer hospital stays, lower chance of discharged home, and lower risk of vasopressor utilization, although these difference were clinically small. Beta-blocker class was not associated with hospital mortality. CONCLUSION: In this retrospective cohort study, we found variation in use of beta-blockers and early exposure was not associated with hospital mortality. Further research is necessary to understand the optimal type, dose, and timing of beta-blockers for this population.

Association of Early Dexmedetomidine Utilization With Clinical Outcomes After Moderate-Severe Traumatic Brain Injury: A Retrospective Cohort Study.

BACKGROUND: Traumatic brain injury (TBI) is an expensive and common public health problem. Management of TBI oftentimes includes sedation to facilitate mechanical ventilation (MV) for airway protection. Dexmedetomidine has emerged as a potential candidate for improved patient outcomes when used for early sedation after TBI due to its potential modulation of autonomic dysfunction. We examined early sedation patterns, as well as the association of dexmedetomidine exposure with clinical and functional outcomes among mechanically ventilated patients with moderate-severe TBI (msTBI) in the United States. METHODS: We conducted a retrospective cohort study using data from the Premier dataset and identified a cohort of critically ill adult patients with msTBI who required MV from January 2016 to June 2020. msTBI was defined by head-neck abbreviated injury scale (AIS) values of 3 (serious), 4 (severe), and 5 (critical). We described early continuous sedative utilization patterns. Using propensity-matched models, we examined the association of early dexmedetomidine exposure (within 2 days of intensive care unit [ICU] admission) with the primary outcome of hospital mortality and the following secondary outcomes: hospital length of stay (LOS), days on MV, vasopressor use after the first 2 days of admission, hemodialysis (HD) after the first 2 days of admission, hospital costs, and discharge disposition. All medications, treatments, and procedures were identified using date-stamped hospital charge codes. RESULTS: The study population included 19,751 subjects who required MV within 2 days of ICU admission. The patients were majority male and white. From 2016 to 2020, the annual percent utilization of dexmedetomidine increased from 4.05% to 8.60%. After propensity score matching, early dexmedetomidine exposure was associated with reduced odds of hospital mortality (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.47-0.74; P < .0001), increased risk for liberation from MV (hazard ratio [HR], 1.20; 95% CI, 1.09-1.33; P = .0003), and reduced LOS (HR, 1.11; 95% CI, 1.01-1.22; P = .033). Exposure to early dexmedetomidine was not associated with odds of HD (OR, 1.14; 95% CI, 0.73-1.78; P = .56), vasopressor utilization (OR, 1.10; 95% CI, 0.78-1.55; P = .60), or increased hospital costs (relative cost ratio, 1.98; 95% CI, 0.93-1.03; P = .66). CONCLUSIONS: Dexmedetomidine is being utilized increasingly as a sedative for mechanically ventilated patients with msTBI. Early dexmedetomidine exposure may lead to improved patient outcomes in this population.

Safety, Efficacy, and Clinical Outcomes of Dexmedetomidine for Sedation in Traumatic Brain Injury: A Scoping Review.

Dexmedetomidine is a promising alternative sedative agent for moderate-severe Traumatic brain injury (TBI) patients. Although the data are limited, the posited benefits of dexmedetomidine in this population are a reduction in secondary brain injury compared with current standard sedative regimens. In this scoping review, we critically appraised the literature to examine the effects of dexmedetomidine in patients with moderate-severe TBI to examine the safety, efficacy, and cerebral and systemic physiological outcomes within this population. We sought to identify gaps in the literature and generate directions for future research. Two researchers and a librarian queried PubMed, Embase, Scopus, and APA PsycINFO databases. Of 920 studies imported for screening, 11 were identified for inclusion in the review. The primary outcomes in the included studied were cerebral physiology, systemic hemodynamics, sedation levels and delirium, and the presence of paroxysmal sympathetic hyperactivity. Dexmedetomidine dosing ranged from 0.2 to 1 ug/kg/h, with 3 studies using initial boluses of 0.8 to 1.0 ug/kg over 10 minutes. Dexmedetomidine used independently or as an adjunct seems to exhibit a similar hemodynamic safety profile compared with standard sedation regimens, albeit with transient episodes of bradycardia and hypotension, decrease episodes of agitation and may serve to alleviate symptoms of sympathetic hyperactivity. This scoping review suggests that dexmedetomidine is a safe and efficacious sedation strategy in patients with TBI. Given its rapid onset of action and anxiolytic properties, dexmedetomidine may serve as a feasible sedative for TBI patients.

Association of Early Dexmedetomidine Utilization With Clinical and Functional Outcomes Following Moderate-Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study.

OBJECTIVE: To examine early sedation patterns, as well as the association of dexmedetomidine exposure, with clinical and functional outcomes among mechanically ventilated patients with moderate-severe traumatic brain injury (msTBI). DESIGN: Retrospective cohort study with prospectively collected data. SETTING: Eighteen Level-1 Trauma Centers, United States. PATIENTS: Adult (age > 17) patients with msTBI (as defined by Glasgow Coma Scale < 13) who required mechanical ventilation from the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using propensity-weighted models, we examined the association of early dexmedetomidine exposure (within the first 5 d of ICU admission) with the primary outcome of 6-month Glasgow Outcomes Scale Extended (GOS-E) and the following secondary outcomes: length of hospital stay, hospital mortality, 6-month Disability Rating Scale (DRS), and 6-month mortality. The study population included 352 subjects who required mechanical ventilation within 24 hours of admission. The initial sedative medication was propofol for 240 patients (68%), midazolam for 59 patients (17%), ketamine for 6 patients (2%), dexmedetomidine for 3 patients (1%), and 43 patients (12%) never received continuous sedation. Early dexmedetomidine was administered in 77 of the patients (22%), usually as a second-line agent. Compared with unexposed patients, early dexmedetomidine exposure was not associated with better 6-month GOS-E (weighted odds ratio [OR] = 1.48; 95% CI, 0.98-2.25). Early dexmedetomidine exposure was associated with lower DRS (weighted OR = -3.04; 95% CI, -5.88 to -0.21). In patients requiring ICP monitoring within the first 24 hours of admission, early dexmedetomidine exposure was associated with higher 6-month GOS-E score (OR 2.17; 95% CI, 1.24-3.80), lower DRS score (adjusted mean difference, -5.81; 95% CI, -9.38 to 2.25), and reduced length of hospital stay (hazard ratio = 1.50; 95% CI, 1.02-2.20). CONCLUSION: Variation exists in early sedation choice among mechanically ventilated patients with msTBI. Early dexmedetomidine exposure was not associated with improved 6-month functional outcomes in the entire population, although may have clinical benefit in patients with indications for ICP monitoring.

Maternal Morbidity According to Mode of Delivery Among Pregnant Patients With Pulmonary Hypertension.

BACKGROUND: Patients with pulmonary hypertension have a high risk of maternal morbidity and mortality. It is unknown if a trial of labor carries a lower risk of morbidity in these patients compared to a planned cesarean delivery. The objective of this study was to examine the association of delivery mode with severe maternal morbidity events during delivery hospitalization among patients with pulmonary hypertension. METHODS: This retrospective cohort study used the Premier inpatient administrative database. Patients delivering ≥25 weeks gestation from January 1, 2016, to September 30, 2020, and with pulmonary hypertension were included. The primary analysis compared intended vaginal delivery (ie, trial of labor) to intended cesarean delivery (intention to treat analysis). A sensitivity analysis was conducted comparing vaginal delivery to cesarean delivery (as treated analysis). The primary outcome was nontransfusion severe maternal morbidity during the delivery hospitalization. Secondary outcomes included blood transfusion (4 or more units) and readmission to the delivery hospital within 90 days from discharge from delivery hospitalization. RESULTS: The cohort consisted of 727 deliveries. In the primary analysis, there was no difference in nontransfusion morbidity between intended vaginal delivery and intended cesarean delivery groups (adjusted odds ratio [aOR], 0.75; 95% confidence interval [CI], 0.49-1.15). In secondary analyses, intended cesarean delivery was not associated with blood transfusion (aOR, 0.71; 95% CI, 0.34-1.50) or readmission within 90 days (aOR, 0.60; 95% CI, 0.32-1.14). In the sensitivity analysis, cesarean delivery was associated with a 3-fold higher risk of nontransfusion morbidity compared to vaginal delivery (aOR, 2.64; 95% CI, 1.54-3.93), a 3-fold higher risk of blood transfusion (aOR, 3.06; 95% CI, 1.17-7.99), and a 2-fold higher risk of readmission within 90 days (aOR, 2.20; 95% CI, 1.09-4.46) compared to vaginal delivery. CONCLUSIONS: Among pregnant patients with pulmonary hypertension, a trial of labor was not associated with a higher risk of morbidity compared to an intended cesarean delivery. One-third of patients who required an intrapartum cesarean delivery had a morbidity event, demonstrating the increased risk of adverse events in this group.

Malnutrition and Adverse Outcomes After Surgery for Head and Neck Cancer.

Importance: Patients with head and neck cancer (HNC) have an increased risk of malnutrition, partly due to disease location and treatment sequelae. Although malnutrition is associated with adverse outcomes, there is little data on the extent of outcomes and the sociodemographic factors associated with malnutrition in patients with HNC. Objectives: To investigate the association of race, ethnicity, and payer type with perioperative malnutrition in patients undergoing HNC surgery and how malnutrition affects clinical outcomes. Design, Setting, and Participants: This retrospective cohort study used data from the Premier Healthcare Database to assess adult patients who had undergone HNC surgery from January 2008 to June 2020 at 482 hospitals across the US. Diagnosis and procedure codes were used to identify a subset of patients with perioperative malnutrition. Patient characteristics, payer types, and hospital outcomes were then compared to find associations among race, ethnicity, payer type, malnutrition, and clinical outcomes using multivariable logistic regression models. Analyses were performed from August 2022 to January 2023. Exposures: Race, ethnicity, and payer type for primary outcome, and perioperative malnutrition status, race, ethnicity, and payer type for secondary outcomes. Main Outcomes and Measures: Perioperative malnutrition status. Secondary outcomes were discharge to home after surgery, hospital length of stay (LOS), total cost, and postoperative pulmonary complications (PPCs). Results: The study population comprised 13 895 adult patients who had undergone HNC surgery during the study period; they had a mean (SD) age of 63.4 (12.1) years; 9425 male (67.8%) patients; 968 Black (7.0%), 10 698 White (77.0%), and 2229 (16.0%) individuals of other races; and 887 Hispanic (6.4%) and 13 008 non-Hispanic (93.6%) individuals. Among the total sample, there were 3136 patients (22.6%) diagnosed with perioperative malnutrition. Compared with White patients and patients with private health insurance, the odds of malnutrition were higher for non-Hispanic Black patients (adjusted odds ratio [aOR], 1.31; 95% CI, 1.11-1.56), Medicaid-insured patients (aOR, 1.68; 95% CI, 1.46-1.95), and Medicare-insured patients (aOR, 1.24; 95% CI, 1.10-1.73). Black patients and patients insured by Medicaid had increased LOS, costs, and PPCs, and lower rates of discharge to home. Malnutrition was independently associated with increased LOS (ß, 5.20 additional days; 95% CI, 4.83-5.64), higher costs (ß, $15 722 more cost; 95% CI, $14 301-$17 143), increased odds of PPCs (aOR, 2.04; 95% CI, 1.83-2.23), and lower odds of discharge to home (aOR, 0.34; 95% CI, 0.31-0.38). No independent association between malnutrition and mortality was observed. Conclusions and Relevance: This retrospective cohort study found that 1 in 5 patients undergoing HNC surgery were malnourished. Malnourishment disproportionately affected Black patients and patients with Medicaid, and contributed to longer hospital stays, higher costs, and more postoperative complications.

Exploring phenotype-based ventilator parameter optimization to mitigate postoperative pulmonary complications: a retrospective observational cohort study.

PURPOSE: To identify tidal volume (VT) and positive end-expiratory pressure (PEEP) associated with the lowest incidence and severity of postoperative pulmonary complications (PPCs) for each phenotype based on preoperative characteristics. METHODS: The subjects of this retrospective observational cohort study were 34,910 adults who underwent surgery, using general anesthesia with mechanical ventilation. Initially, the least absolute shrinkage and selection operator regression was employed to select relevant preoperative characteristics. Then, the classification and regression tree (CART) was built to identify phenotypes. Finally, we computed the area under the receiver operating characteristic curves from logistic regressions to identify VT and PEEP associated with the lowest incidence and severity of PPCs for each phenotype. RESULTS: CARTs classified seven phenotypes for each outcome. A probability of the development of PPCs ranged from the lowest (3.51%) to the highest (68.57%), whereas the probability of the development of the highest level of PPC severity ranged from 3.3% to 91.0%. Across all phenotypes, the VT and PEEP associated with the most desirable outcomes were within a small range of VT 7-8 ml/kg predicted body weight with PEEP of between 6 and 8 cmH2O. CONCLUSIONS: The ranges of optimal VT and PEEP were small, regardless of the phenotypes, which had a wide range of risk profiles.

Severe Maternal Morbidity According to Mode of Delivery Among Pregnant Patients With Cardiomyopathies.

BACKGROUND: Women with cardiomyopathies are at risk for pregnancy complications. The optimal mode of delivery in these patients is guided by expert opinion and limited small studies. OBJECTIVES: The objective of this study is to examine the association of delivery mode with severe maternal morbidity events during delivery hospitalization and readmissions among patients with cardiomyopathies. METHODS: The Premier inpatient administrative database was used to conduct a retrospective cohort study of pregnant patients with a diagnosis of a cardiomyopathy. Utilizing a target trial emulation strategy, the primary analysis compared outcomes among patients exposed to intended vaginal delivery vs intended cesarean delivery (intention to treat). A secondary analysis compared outcomes among patients who delivered vaginally vs by cesarean (as-treated). Outcomes examined were nontransfusion severe maternal morbidity during the delivery hospitalization, blood transfusion, and readmission. RESULTS: The cohort consisted of 2,921 deliveries. In the primary analysis (intention to treat), there was no difference in nontransfusion morbidity (adjusted OR [aOR]: 1.17; 95% CI: 0.91-1.51), blood transfusion (aOR: 1.27; 95% CI: 0.81-1.98), or readmission (aOR: 1.03; 95% CI: 0.73-1.44) between intended vaginal delivery and intended cesarean delivery. In the as-treated analysis, cesarean delivery was associated with a 2-fold higher risk of nontransfusion morbidity (aOR: 2.44; 95% CI: 1.85-3.22) and blood transfusion (aOR: 2.26; 95% CI: 1.34-3.81) when compared with vaginal delivery. CONCLUSIONS: In patients with cardiomyopathies, a trial of labor does not confer a higher risk of maternal morbidity, blood transfusion, or readmission compared with planned cesarean delivery.

Early enteral nutrition is associated with improved outcomes in critically ill mechanically ventilated medical and surgical patients.

BACKGROUND AND AIMS: Data suggest that guidelines for enteral nutrition (EN) initiation are not closely followed in clinical practice. In addition, critically ill mechanically ventilated (MV) patients have varying metabolic needs, which often increase and persist over time, requiring personalized nutrition intervention. While both over- and under-nutrition can impact patient outcomes, recent data suggest that targeted early EN delivery may reduce mortality and improve clinical outcomes. This study examined if early EN improves clinical outcomes and decreases costs in critically ill patients on MV. METHODS: Data from a nationwide administrative-financial database between 2018 and 2020 was utilized to identify eligible adult critical care patients. Patients who received EN within 3 days after intubation (early EN) were compared to patients who started EN after 3 days of intubation (late EN). Outcomes of interest included hospital mortality, discharge disposition, hospital and intensive care unit (ICU) length of stay (LOS), MV days, and total cost. After inverse-probability-of-treatment weighting, outcomes were modeled using a nominal logistic regression model for hospital mortality and discharge disposition, a linear regression model for cost, and Cox proportional-hazards model for MV days, hospital and ICU LOS. RESULTS: A total of 27,887 adult patients with early MV were identified, of which 16,772 (60.1%) received early EN. Regression analyses showed that the early EN group had lower hospital mortality (OR = 0.88, 95% CI, 0.82 to 0.94), were more likely to be discharged home (OR = 1.47, 95% CI 1.38 to 1.56), had fewer MV days (HR = 1.23, 95% CI, 1.11 to 1.37), shorter hospital LOS (HR = 1.43, 95% CI, 1.33 to 1.54) and ICU LOS (HR = 1.36, 95% CI, 1.27 to 1.46), and lower cost (-$21,226; 95% CI, -$23,605 to -$18,848) compared to the late EN group. CONCLUSIONS: Early EN within 3 days of MV initiation in real-world practice demonstrated improved clinical and economic outcomes. These data suggest that early EN is associated with decreased hospital mortality, increased discharge to home, and decreased hospital and ICU LOS, time on MV, and cost compared to delayed initiation of EN; highlighting the importance of early EN to optimize utcomes ando support the recovery of critically ill patients on MV.

Association of Early Beta-Blocker Exposure and Functional Outcomes in Critically Ill Patients With Moderate to Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study.

OBJECTIVES: We aimed to 1) describe patterns of beta-blocker utilization among critically ill patients following moderate-severe traumatic brain injury (TBI) and 2) examine the association of early beta-blocker exposure with functional and clinical outcomes following injury. DESIGN: Retrospective cohort study. SETTING: ICUs at 18 level I, U.S. trauma centers in the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. PATIENTS: Greater than or equal to 17 years enrolled in the TRACK-TBI study with moderate-severe TBI (Glasgow Coma Scale of <13) were admitted to the ICU after a blunt TBI. INTERVENTIONS: None. MEASUREMENTS: Primary exposure was a beta blocker during the first 7 days in the ICU, with a primary outcome of 6-month Glasgow Outcome Scale-Extended (GOSE). Secondary outcomes included: length of hospital stay, in-hospital mortality, 6-month and 12-month mortality, 12-month GOSE score, and 6-month and 12-month measures of disability, well-being, quality of life, and life satisfaction. MAIN RESULTS: Of the 450 eligible participants, 57 (13%) received early beta blockers (BB+ group). The BB+ group was on average older, more likely to be on a preinjury beta blocker, and more likely to have a history of hypertension. In the BB+ group, 34 participants (60%) received metoprolol only, 19 participants (33%) received propranolol only, 3 participants (5%) received both, and 1 participant (2%) received atenolol only. In multivariable regression, there was no difference in the odds of a higher GOSE score at 6 months between the BB+ group and BB- group (odds ratio = 0.86; 95% CI, 0.48-1.53). There was no association between BB exposure and secondary outcomes. CONCLUSIONS: About one-sixth of subjects in our study received early beta blockers, and within this group, dose, and timing of beta-blocker administration varied substantially. No significant differences in GOSE score at 6 months were demonstrated, although our ability to draw conclusions is limited by overall low total doses administered compared with prior studies.

Change to Mixed-Lipid Emulsion From Soybean Oil-Based Lipid Emulsion in Pediatric Patients.

Importance: Critically ill pediatric patients often require parenteral nutrition (PN) in the intensive care unit (ICU). Literature suggests mixed lipid emulsions (LE) with soybean oil reduction strategies may improve outcomes. Objective: To examine the association of a hospital-wide switch to a mixed-lipid formula (4-OLE) with pediatric outcomes. Design, Setting, and Participants: Retrospective cohort study at a large US academic referral center. Pediatric patients aged 1 month to 17 years requiring parenteral nutrition from May 2016 to September 2019 were included. Data were analyzed from October 2020 to February 2023. Exposure: In 2017, Duke University Health System fully converted to a soybean oil/MCT/olive/fish oil lipid (4-OLE) from pure soybean oil-based LE in pediatric patients. Pediatric patients before the change (Intralipid [IL] group) were compared with patients after (4-OLE group). Main Outcomes and Measures: Clinical outcomes were compared between treatment periods via multivariable regression models. The primary outcome was hospital length of stay (LOS). Fourteen secondary outcomes included hospital mortality of any cause, 30-day or 90-day readmission, pneumonia, urinary tract infections (UTIs), total caloric delivery, and liver function tests (aspartate aminotransferase, alanine transaminase, alkaline phosphatase, and total bilirubin). Results: A total of 684 children dependent on PN were identified (342 were critically ill), with 30% (206 children) in the preswitch (IL) period and 70% (478 children) in the postswitch (4-OLE) period; 123 were male (59.7%). In comparing IL vs 4-OLE, there was a significant difference in median (IQR) age (4.0 [1.2-13.0] vs 3.0 [0.8-9.0] years, respectively; P = .04), without difference in body mass index or baseline comorbidities except for significant differences in cancer diagnosis (26 patients in the IL group [12.6%] vs 29 patients in the 4-OLE group [6.1%]; P = .004) and chronic obstructive pulmonary disease (24 patients in the IL group [11.7%] vs 30 patients in the 4-OLE group [6.3%]; P = .02). In the all children cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.05-0.78), and reduced UTI risk (OR, 0.33; 95% CI, 0.18-0.64). In the ICU cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.78-0.83), and reduced UTI risk (OR, 0.23; 95% CI, 0.11-0.51). Other secondary outcomes were not significant. Conclusions and Relevance: In this observational study of clinical outcomes among children dependent on PN, a switch to 4-OLE in a large academic hospital was associated with a significant decrease in hospital LOS in ICU and non-ICU patients. These findings suggest switching to a soy-LE sparing strategy using 4-OLE is feasible, safe, and associated with improved clinical outcomes in pediatric PN patients.

The Quality Improvement Fellow: Educating on Making the Difference.

The critical care medicine (CCM) fellowship is an opportunity for advanced anesthesiology trainees to refine their quality improvement (QI) skills. However, the short training period and inconsistent curricula make this challenging. The QI fellow (QIF) is described as an education program to provide consistent QI training during the CCM fellowship. The QIF is a mentored position to help manage data review, QI conferences, and improvement efforts within the CCM Division. The curriculum is focused on a QI education framework and mentored experiential learning. The QIF program is an opportunity for education and mentorship in the role of a CCM operational leader.

An Analysis of Outcomes Following a Central Line Associated Blood Stream Infections (CLABSI) Reduction Quality Improvement Project in a Tertiary Care Center.

Central Line Associated Blood Stream Infections (CLABSI) continue to be a significant complication for hospitalized patients. Hospitals have used various strategies to reduce CLABSI events due to the significant complications and associated costs. In this QI analysis, we examined the impact of a CLABSI reduction quality improvement project within a single ICU at a tertiary care medical center. Absolute CLABSI counts were compared between this ICU and other health system ICUs that did not implement the bundle. A sustained reduction in absolute CLABSI counts to or near zero was observed over 17 months after implementation. ICUs not performing the interventions during this time consistently reported ≥ 2 CLABSI per month. Further analysis is needed to assess causality and the generalizability of bundle components to other ICUs. These findings may provide other health systems with additional strategies to prevent CLABSI and provide consistent, evidence-based supportive care to critically ill patients.

Propensity score methods in observational research: brief review and guide for authors.

Causal inference in observational research requires a careful approach to adjustment for confounding. One such approach is the use of propensity score analyses. In this editorial, we focus on the role of propensity score-based methods in estimating causal effects from non-randomised observational data. We highlight the details, assumptions, and limitations of these methods and provide authors with guidelines for the conduct and reporting of propensity score analyses.