Patient, Operator, and Procedural Characteristics of Guidewire Retention as a Complication of Vascular Catheter Insertion.

Guidewire retention after intravascular catheter insertion is considered a "never event." Prior reports attribute this complication to various characteristics including uncooperative patients, operator inexperience, off-hour or emergent insertion, and underutilization of ultrasound guidance. In this descriptive analysis of consecutive events, we assessed the frequency of patient, operator, and procedural factors in guidewire retention. DESIGN: Pre-specified observational analysis as part of a quality improvement study of consecutive guidewire retention events across a multihospital health system from August 2007 to October 2015. SETTING: Ten hospitals within the Cleveland Clinic Health System in Ohio, United States. PATIENTS: Consecutive all-comers who experienced guidewire retention after vascular catheter insertion. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were manually obtained from the electronic medical records and reviewed for potential contributing factors for guidewire retention, stratified into patient, operator, and procedural characteristics. A total of 24 events were identified. Overall, the median age was 74 years, 58% were males, and the median body mass index was 26.5 kg/m2. A total of 12 (50%) individuals were sedated during the procedure. Most incidents (10 [42%]) occurred in internal jugular venous access sites. The majority of cases (13 [54%]) were performed or supervised by an attending. Among all cases, three (12%) were performed by first-year trainees, seven (29%) by residents, three (12%) by fellows, and four (17%) by certified nurse practitioners. Overall, 16 (67%) events occurred during regular working hours (8 amto 5 pm). In total, 22 (92%) guidewires were inserted nonemergently, with two (8%) during a cardiac arrest. Ultrasound guidance was used in all but one case. CONCLUSIONS: Guidewire retention can occur even in the presence of optimal patient, operator, and procedural circumstances, highlighting the need for constant awareness of this risk. Efforts to eliminate this important complication will require attention to issues surrounding the technical performance of the procedure.

Outcomes Associated with ICU Telemedicine and Other Risk Factors in a Multi-Hospital Critical Care System: A Retrospective, Cohort Study for 30-Day In-Hospital Mortality.

Introduction: Intensive care unit telemedicine (ICU-TM) is expanding due to increasing demands for critical care, but impact on outcomes remains controversial. This study evaluated the association of ICU-TM and other clinical factors with 30-day, in-hospital mortality. Methods: This retrospective, cohort study included 151,780 consecutive ICU patients admitted to nine hospitals in the Cleveland Clinic Health System from 2010 to 2020. Patients were identified from an institutional datamart and Acute Physiology and Chronic Health Evaluation IV (APACHE IV) registry. Primary outcome was 30-day in-hospital mortality. Analyses included multivariate logistic regression modeling, and survival analysis. Results: Overall, unadjusted 30-day, in-hospital mortality incidence was significantly different with (5.6%) or without ICU-TM (7.2%), and risk ratio was 0.78 (95% confidence interval [CI] 0.75-0.81) (p < 0.0001). Mortality rate for ICU-TM and no ICU-TM was 2.4/1,000 versus 3.2/1,000 patient days, respectively (p < 0.0001). Multivariate logistic regression showed that ICU-TM was associated with reduced 30-day mortality (odds ratio 0.78, 95% CI 0.72-0.83). Increased risk was seen with cardiac arrest admissions, males, acute stroke, weekend admission, emergency admission, race (non-white), sepsis, APACHE IV score, ICU length of stay (LOS), and the interaction term, emergency surgical admissions. Reduced risk was associated with hospital LOS, surgical admission, and the interaction terms (weekend admissions with ICU-TM and after-hour admissions with ICU-TM). The model c-statistic was 0.77. Median ICU and hospital lengths of stay were significantly reduced with ICU-TM, with no difference in 48-h mortality or 48-h mortality rate. Conclusion: ICU telemedicine exposure appears to be one of several operational and clinical factors associated with reduced 30-day, in-hospital mortality.

Beyond the Nuts and Bolts: Tele-Critical Care Patients, Workflows, and Activity Patterns.

Background: Tele-critical care (TCC) adoption has been slow since its emergence in the early 2000s. The COVID-19 pandemic has renewed interest in telemedicine and may spur expansion or development of new TCC programs. This narrative addresses the Cleveland Clinic TCC service, (eHospital) to promote exchange of ideas to continually optimize the practice for current and future users. Methods: A descriptive narrative methodology is used in this report. Results: Cleveland Clinic's eHospital was established in 2014 to support nighttime critical care across system hospitals. It encompasses a tiered system of two-way audiovisual communication, telemetry, software platform that integrates the electronic health record, and a proprietary risk stratification algorithm for targeted electronic surveillance. The TCC team includes intensivists, advanced care providers, and registered nurses. Three coverage models evolved depending on onsite clinician availability. More than 133,000 patients have been served by eHospital to date, and span the typical spectrum of critical illness. Along with universal monitoring, ∼18% of patients received active interventions, the most common of which are categorized. Patterns of activity, typical workflows, and adaptations of bedside best practices are also described. Bookending the work shift are sign outs focused on pending critical issues, unstable patients, and those who can be triaged out of the intensive care unit. In between, TCC teams round periodically and interact with bedside teams. Conclusions: TCC adoption has proceeded slowly. Some acceleration is anticipated in a post-COVID-19 pandemic world. Our experience highlights operational practices that can facilitate successful TCC practice.

External Validation of the Cardiac Surgery Score in a Quaternary Hospital in the United States of America.

BACKGROUND: The Cardiac Surgery Score (CASUS) was developed to assist in predicting post-cardiac surgery mortality using parameters measured in the intensive care unit. It is calculated by assigning points to ten physiologic variables and adding them to obtain a score (additive CASUS), or by logistic regression to weight the variables and estimate the probability of mortality (logistic CASUS). Both additive and logistic CASUS have been externally validated elsewhere, but not yet in the United States of America (USA). This study aims to validate CASUS in a quaternary hospital in the USA and compare the predictive performance of additive to logistic CASUS in this setting. METHODS: Additive and logistic CASUS (postoperative days 1-5) were calculated for 7098 patients at Cleveland Clinic from January 2015 to February 2017. 30-day mortality data were abstracted from institutional records and the Death Registries for Ohio State and the Centers for Disease Control. Given a low event rate, model discrimination was assessed by area under the curve (AUROC), partial AUROC (pAUC), and average precision (AP). Calibration was assessed by curves and quantified using Harrell's Emax, and Integrated Calibration Index (ICI). RESULTS: 30-day mortality rate was 1.37%. For additive CASUS, odds ratio for mortality was 1.41 (1.35-1.46, P <0.001). Additive and logistic CASUS had comparable pAUC and AUROC (all >0.83). However, additive CASUS had greater AP, especially on postoperative day 1 (0.22 vs. 0.11). Additive CASUS had better calibration curves, and lower Emax, and ICI on all days. CONCLUSIONS: Additive and logistic CASUS discriminated well for postoperative 30-day mortality in our quaternary center in the USA, however logistic CASUS under-predicted mortality in our cohort. Given its ease of calculation, and better predictive accuracy, additive CASUS may be the preferred model for postoperative use. Validation in more typical cardiac surgery centers in the USA is recommended.

Association between limiting the number of open records in a tele-critical care setting and retract-reorder errors.

BACKGROUND: Wrong patient selection errors may be tracked by retract-reorder (RAR) events. The aim of this quality improvement study was to assess the impact of reducing the number of concurrently open electronic health records from 4 to 2 on RAR errors generated by a tele-critical care service. METHODS: The study encompassed 32 months before and 21 months after restriction. Chi-Square test of proportions and T statistical process control chart for rare events were used. RESULTS: There were 156 318 orders with 57 RAR errors (36.5/100 000 orders) before restriction, and 122 587 orders with 34 errors (27.7/100 000 orders) after. Rates were not statistically different (P = .20), but analysis was underpowered. When plotted on a T control chart, random variation was detected between RAR errors. CONCLUSION: We found no significant difference in RAR errors in the tele-critical care setting after open record limitation. Other strategies should be studied to reduce wrong patient selection errors.

Association of Unit-Level Telecritical Care Intensity of Service and Length of Stay in the Intensive Care Unit.

Background:Telecritical care (TCC) has been shown to improve outcomes in the intensive care unit (ICU). A TCC was developed and implemented a nocturnal TCC across 10 ICUs in our Health System. TCC coverage patterns and level of involvement vary among ICUs. We identified an opportunity to determine the impact of TCC involvement on the ICU length of stay (LOS).Objective:The primary objective of this study was to assess if intensity of service provided by TCC impacts ICU LOS.Methods:This retrospective review was conducted for all patients admitted to covered ICUs during a 2-year period. ICUs were stratified by the coverage model provided by the TCC and the count of orders placed by the TCC served as a surrogate for intensity of service. Confounding variables were abstracted from the Acute Physiology and Chronic Health Evaluation (APACHE) databases. Spearman's rank correlation coefficient was used to measure the strength of the relationship between ICU LOS and TCC order volume. A linear regression model was used to describe the relationship between order volume and ICU LOS, while adjusting for confounding variables.Results:There is a strong negative relationship between TCC order volume and ICU LOS, as shown by the Spearman rank correlation coefficient of -0.818. The associated p-value of 0.0038 supports the strength of this relationship.Conclusion:Our results demonstrate the impact of nocturnal TCC involvement in patient care. As TCC order volume per ICU admission increases, ICU LOS decreases. We interpret this as an indication for deeper involvement between the TCC team and any on-site providers.

Limiting the number of open charts does not impact wrong patient order entry in the emergency department.

OBJECTIVE: We sought to examine the impact of limiting the number of open active charts on wrong patient order entry events among 13 emergency departments (EDs) in a large integrated health system. METHODS: A retrospective chart review of all orders placed between September 2017 and September 2019 was conducted. The rate of retract and reorder events was analyzed with no overlap in both the period pre- and post-intervention period. Secondary analysis of error rate by clinician type, clinician patient load, and time of day was performed. RESULTS: The order retraction rate was not improved pre- and post-intervention. Retraction rates varied by clinician type with residents retracting more often than physicians (odds ratio [OR] = 1.443 [1.349, 1.545]). Advanced practice providers also showed a slightly higher rate than physicians (OR = 1.114 [1.071, 1.160]). Pharmacists showed very low rates compared to physicians (OR = 0.191 [0.048, 0.764]). Time of day and staffing ratios appear to be a factor with wrong patient order entry rates slightly lower during the night (1900-0700) than the day (OR 0.958 [0.923, 0.995]), and increasing slightly with every additional patient per provider (OR 1.019 [1.005, 1.032]). The Academic Medical Center had more retractions that the other EDs. OR for the various ED types compared to the Academic Medical Center included Community (OR 0.908 [0.859, 0.959]), Teaching Hospitals (OR 0.850 [0.802, 0.900]), and Freestanding (OR 0.932 [0.864, 1.006]). CONCLUSIONS: Limiting the number of open active charts from 4 to 2 did not significantly reduce the incidence of wrong patient order entry. Further investigation into other factors contributing to order entry errors is warranted.

Application of Unit-Level Cost Transparency, Education, Enhanced Audit, and Feedback of Anonymized Peer Ranking to Promote Judicious Use of 25% Albumin in Critical Care Units.

Objective: Hyperoncotic 25% albumin is widely used for fluid resuscitation in intensive care units. However, this practice remains controversial. By 2012 in our intensive care unit, annual 25% albumin expenditures had steadily increased to exceed $1 million. This prompted efforts to promote more judicious use. Design: Prospective time series cohort analysis using statistical process control charts. Setting: Seventy-six-bed quaternary level cardiovascular surgical intensive care unit (CVICU), organized into 6 adjacent units. Patients: Adult cardiac, thoracic, and vascular surgery patients admitted postoperatively to the CVICU during the study period. Interventions: Over 12 months starting March 2013, we sequentially implemented unit-level 25% albumin cost transparency, provider education, and individualized audit and feedback of anonymized peer ranking of albumin prescriptions. Measurements and Main Results: C control charts were used for analysis of monthly unit-level direct albumin costs for 20 months. Balance measures including red cell transfusions, number of diagnoses of pleural effusions, and length of stay were also tracked. Monthly average albumin expenditures had decreased 61% by December 2014, and there was no evidence of adverse changes in any of the balance measures. These reductions have been sustained. Conclusion: Sequential implementation of multimodal strategies can alter clinician practices to achieve substantial unit-level reduction in 25% albumin utilization without harm to patients.

Evaluation of Albumin 25% Use in Critically Ill Patients at a Tertiary Care Medical Center.

Background: Albumin 25% has been studied and has demonstrated benefit in a limited number of patient populations. The use of albumin 25% is associated with higher costs compared with crystalloid therapy. The aim of this study was to describe the prescribing practices of albumin 25% at a tertiary-care medical center and identify opportunities for restriction criteria related to its use to help generate cost savings. Methods: This evaluation was a retrospective, noninterventional, descriptive study of albumin 25% use between June 2015 and February 2016. Inclusion criteria consisted of patients ≥18 years old and who received at least one dose of albumin 25% while admitted to a Cleveland Clinic main campus intensive care unit (ICU). Inclusion was restricted to 150 randomly selected patients. Results: A total of 539 albumin 25% orders were placed for the 150 included patients. The cardiovascular ICU more frequently prescribed albumin 25% compared with the medical, surgical, neurosciences, and coronary ICUs (51% vs 23% vs 11% vs 9% vs 6%, respectively). Although the cardiovascular surgery ICU most frequently prescribed albumin 25% compared with other ICUs, the medical ICU prescribed a larger total quantity of albumin 25% compared with the cardiovascular, surgical, neurosciences, and coronary ICUs (8705 g vs 7275 g vs 3205 g vs 2162 g vs 625 g, respectively). The majority of patients (61%) did not have an indication listed for albumin 25% use and only 9% of patients were prescribed for indications supported by primary literature. Of the patients prescribed albumin for other indications not supported by primary literature (30%), the most common reasons for albumin 25% were hypotension, acute kidney injury, and volume resuscitation. The median cost per patient of albumin 25% was $417 with a total cost of $122 164 for the cohort. Only 19% of the total cost aligned with dosing regimens evaluated in primary literature. Conclusion: Prescribing patterns of albumin 25% at a tertiary academic medical center do not align with indications supported by primary literature. These findings identified a major opportunity for prescriber education and implementation of restriction criteria to target cost savings.

The cost-effectiveness of epidural, patient-controlled intravenous opioid analgesia, or transversus abdominis plane infiltration with liposomal bupivacaine for postoperative pain management.

STUDY OBJECTIVE: Intravenous patient-controlled opioid analgesia (IVPCA), epidural analgesia and transversus abdominis plane (TAP) infiltrations are frequently used postoperative pain management modalities. The aim of this study was to conduct a cost-effectiveness analysis comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively in patients undergoing major lower abdominal surgery. DESIGN: Retrospective cost effectiveness analysis. SETTING: Operating room. PATIENTS: We obtained data on major lower-abdominal surgeries performed under general anesthesia on adult patients between January 2012 and July 2014. INTERVENTIONS: A cost-effectiveness analysis was comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively. MEASUREMENTS: A decision analytic model was used to estimate the health outcomes for patients undergoing major lower abdominal surgery. The primary outcome was time-weighted pain from 0 to 72 h after surgery, as measured by numerical rating scale pain scores. The analysis was conducted from the perspective of the hospital as the party responsible for most costs related to surgery. MAIN RESULTS: From the base case analysis, IVPCA was the optimal strategy regarding cost and effect. TAP with LB, however, was only narrowly dominated, while epidural was clearly dominated. From the sensitivity analysis at willingness-to-pay (WTP) of $150, IV PCA and TAP infiltration were each the optimal strategy for approximately 50% of the iterations. At WTP of $10,000, epidural was only the optimal strategy in 10% of the iterations. CONCLUSIONS: This is the first study in the literature to compare the cost-effectiveness of epidural, IVPCA, and TAP infiltrations with LB. Within reasonable WTP values, there is little differentiation in cost-effectiveness between IVPCA and TAP infiltration with LB. Epidural does not become a cost-effective strategy even at much higher WTP values.

Acute kidney injury in postoperative shock: is hyperoncotic albumin administration an unrecognized resuscitation risk factor?

BACKGROUND: The use of hyperoncotic albumin (HA) for shock resuscitation is controversial given concerns about its cost, effectiveness, and potential for nephrotoxicity. We evaluated the association between early exposure to hyperoncotic albumin (within the first 48 h of onset of shock) and acute organ dysfunction in post-surgical patients with shock. METHODS: This retrospective, cohort study included 11,512 perioperative patients with shock from 2009 to 2012. Shock was defined as requirement for vasopressors to maintain adequate mean arterial pressure and/or elevated lactate (> 2.2 mmol/L). Subsets of 3600 were selected after propensity score and exact matching on demographics, comorbidities, and treatment variables (> 30). There was a preponderance of cardiac surgery patients. Proportional odds logistic regression, multivariable logistic regression or Cox proportional hazard regression models measured association between hyperoncotic albumin and acute kidney injury (AKI), hepatic injury, ICU days, and mortality. RESULTS: Hyperoncotic albumin-exposed patients showed greater risk of acute kidney injury compared to controls (OR 1.10, 95% CI 1.04, 1.17. P = 0.002), after adjusting for imbalanced co-variables. Within matched patients, 20.3%, 2.9%, and 4.4% of HA patients experienced KDIGO stages 1-3 AKI, versus 19.6%, 2.5%, and 3.0% of controls. There was no difference in hepatic injury (OR 1.16; 98.3% CI 0.85, 1.58); ICU days, (HR 1.05; 98.3% CI 1.00, 1.11); or mortality, (OR 0.88; 98.3% CI 0.64, 1.20). CONCLUSIONS: Early exposure to hyperoncotic albumin in postoperative shock appeared to be associated with acute kidney injury. There did not appear to be any association with hepatic injury, mortality, or ICU days. The clinical and economic implications of this finding warrant further investigation.

Telemedicine/Virtual ICU: Where Are We and Where Are We Going?

Intensive care unit telemedicine (tele-ICU) is technology enabled care delivered from off-site locations that was developed to address the increasing complexity of patients and insufficient supply of intensivists. Although tele-ICU deployment is increasing, it continues to cover only a small proportion of ICU patients. This is primarily due to expense, with first-year costs exceeding $50,000 per bed. Meta-analyses of outcomes indicate survival benefits and quality improvements, albeit with significant heterogeneity. Depending on the context, a wide range of estimated incremental cost-effectiveness ratios reflects variable effects on cost and outcomes, such as mortality or length of stay. Tele-ICUs may fit within a hybrid model of care to complement high-intensity ICU staff coverage. However, more research is required to foster consensus and determine best practices. This review summarizes data on tele-ICU structure, operations, outcomes, and costs. Evidence was extracted from meta-analyses, with secondary data from Cleveland Clinic's tele-ICU experience.

Sinking Skin Flap Syndrome After Decompressive Craniectomy: A Case Report.

Sinking skin flap syndrome is a rare complication of decompressive craniectomy characterized by a sunken skin flap, neurological deterioration, and paradoxical herniation of the brain. An absent cranium allows for external compression via atmospheric pressure, causing alterations in cerebral blood flow, cerebral spinal fluid flow, and glucose metabolism, which ultimately leads to cortical dysfunction. This case report describes a patient with relatively early onset of variable neurological symptoms and imaging correlation, leading to a diagnosis and definitive therapeutic intervention with cranioplasty. Prompt recognition is critical to avoid potentially devastating neurological outcomes in this rare, but underreported condition.

Evaluation of Prophylactic Antibiotic Use for Delayed Sternal Closure After Cardiothoracic Operation.

BACKGROUND: Clinical practice guidelines provide recommendations for surgical prophylaxis in patients undergoing cardiothoracic procedures. However, currently no recommendations guide the management of antibiotic prophylaxis in patients who require delayed sternal closure after cardiothoracic operation. METHODS: This is a single-center, retrospective analysis. Data were extracted from The Society of Thoracic Surgery database and electronic medical record from July 2011 through January 2016. Patients included are adults (≥18 years old) after cardiothoracic operation with delayed sternal closure. RESULTS: A total of 167 patients were included for analysis. The majority of patients (131, 78.4%) were continued on routine antibiotics and 36 patients (21.6%) were switched to broad-spectrum antibiotics for prophylaxis. Of patients on routine antibiotic prophylaxis, 6 (4.6%) experienced a sternal surgical site infection, whereas 3 patients (8.3%) switched to broad-spectrum agents before chest closure experienced a sternal surgical site infection (p = 0.407). Eleven patients (6.6%) received an abbreviated duration of antibiotics, 52 patients (31.1%) were continued on antibiotics until the time of sternal closure, and 104 patients (62.3%) were continued on antibiotics past the time of sternal closure. The incidence of infection based on duration of prophylactic antibiotic was 0, 1 (1.9%), and 8 (7.7%), respectively (p = 0.352). CONCLUSIONS: Substantial variation was found in the duration and selection of antibiotic prophylaxis for patients with delayed sternal closure after cardiothoracic operation. Broad-spectrum antimicrobial agents and extended durations of antibiotic prophylaxis were not associated with benefits in the incidence of sternal wound infection and may increase the risk of adverse effects.

Estimating the number of difficult airway carts needed in an operating suite: Resource planning without compromising patient safety.

STUDY OBJECTIVE: To determine the number of difficult airway (DA) carts required based on the number of anesthetising locations and patients risk of DA. DESIGN: Binomial distributions. SETTING AND PATIENTS: Various hypothetical settings and patient cohorts. INTERVENTIONS AND MEASUREMENTS: Binomial distributions were used to calculate the number of distinct combinations of DAs by number of anesthetising locations assuming an average risk of 10%. The 'at least' number of DAs was calculated using cumulative probabilities of having exactly two plus more than 2 DAs up to the total number of simultaneously started anesthetising locations or until the cumulative probability exceeds the 50% threshold, therefore being more likely than not. MAIN RESULTS: The probability of encountering concurrent DAs increases as the number of simultaneously started anesthetising locations increases. For at least 2 concurrent DAs, the probability first exceeds 50% at 17 locations. The corresponding thresholds for at least 3 and 4 concurrent DAs, are 27 and 37 locations respectively. The probability of at least 2 concurrent DAs will exceed 50% when approximately 17 anesthetising sites are started simultaneously and a 10% worst case risk is assumed. CONCLUSIONS: With continuing resource constraints, proper planning of human and capital resources for DAs needs to be addressed without compromising patient safety. It is recommended that every block of 15-20 sites be equipped with a DA cart, that anaesthesia groups develop and rehearse DA algorithms with available equipment, and that preoperative anaesthesia clinics be used to identify DA therefore providing logistical leverage.

Validation and Extension of the Prolonged Mechanical Ventilation Prognostic Model (ProVent) Score for Predicting 1-Year Mortality after Prolonged Mechanical Ventilation.

RATIONALE: Prognostic models can inform management decisions for patients requiring prolonged mechanical ventilation. The Prolonged Mechanical Ventilation Prognostic model (ProVent) score was developed to predict 1-year mortality in these patients. External evaluation of such models is needed before they are adopted for routine use. OBJECTIVES: The goal was to perform an independent external validation of the modified ProVent score and assess for spectrum extension at 14 days of mechanical ventilation. METHODS: This was a retrospective cohort analysis of patients who received prolonged mechanical ventilation at the University of Iowa Hospitals. Patients who received 14 or more days of mechanical ventilation were identified from a database. Manual review of their medical records was performed to abstract relevant data including the four model variables at Days 14 and 21 of mechanical ventilation. Vital status at 1 year was checked in the medical records or the social security death index. Logistic regressions examined the associations between the different variables and mortality. Model performance at 14 to 20 days and 21+ days was assessed for discrimination by calculating the area under the receiver operating characteristic curve, and calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. MEASUREMENTS AND MAIN RESULTS: A total of 180 patients (21+ d) and 218 patients (14-20 d) were included. Overall, 75% were surgical patients. One-year mortality was 51% for 21+ days and 32% for 14 to 20 days of mechanical ventilation. Age greater than 65 years was the strongest predictor of mortality at 1 year in all cohorts. There was no significant difference between predicted and observed mortality rates for patients stratified by ProVent score. There was near-perfect specificity for mortality in the groups with higher ProVent scores. Areas under the curve were 0.69 and 0.75 for the 21+ days and the 14 to 20 days cohorts respectively. P values for the Hosmer-Lemeshow statistics were 0.24 for 21+ days and 0.22 for 14 to 20 days. CONCLUSIONS: The modified ProVent model was accurate in our cohort. This supports its geographic and temporal generalizability. It can also accurately identify patients at risk of 1-year mortality at Day 14 of mechanical ventilation, but additional confirmation is required. Further studies should explore the implications of adopting the model into routine use.

Delayed presentation of nitroprusside-induced cyanide toxicity.

Cyanide toxicity is a rare complication of sodium nitroprusside that can be difficult to diagnose in critically ill patients. We describe a case of cyanide toxicity after cardiac surgery that presented as lactic acidosis after discontinuation of nitroprusside.

Economic trends from 2003 to 2010 for perioperative myocardial infarction: a retrospective, cohort study.

BACKGROUND: Perioperative myocardial infarction (PMI) is a major surgical complication that is costly and causes much morbidity and mortality. Diagnosis and treatment of PMIs have evolved over time. Many treatments are expensive but may reduce ancillary expenses including the duration of hospital stay. The time-dependent economic impact of novel treatments for PMI remains unexplored. The authors thus evaluated absolute and incremental costs of PMI over time and discharge patterns. METHODS: Approximately 31 million inpatient discharges were analyzed between 2003 and 2010 from the California State Inpatient Database. PMI was defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Propensity matching generated 21,637 pairs of comparable patients. Quantile regression modeled incremental charges as the response variable and year of discharge as the main predictor. Time trends of incremental charges adjusted to 2012 dollars, mortality, and discharge destination was evaluated. RESULTS: Median incremental charges decreased annually by $1,940 (95% CI, $620 to $3,250); P < 0.001. Compared with non-PMI patients, the median length of stay of patients who experienced PMI decreased significantly over time: yearly decrease was 0.16 (0.10 to 0.23) days; P < 0.001. No mortality differences were seen; but over time, PMI patients were increasingly likely to be transferred to another facility. CONCLUSIONS: Reduced incremental cost and unchanged mortality may reflect improving efficiency in the standard management of PMI. An increasing fraction of discharges to skilled nursing facilities seems likely a result from hospitals striving to reduce readmissions. It remains unclear whether this trend represents a transfer of cost and risk or improves patient care.