A Controlled Study in CPR-Survival in Propensity Score Matched Full-Code and Do-Not-Resuscitate ICU Patients.

BACKGROUND: Cardiopulmonary Resuscitation (CPR) causes significant injuries and increased cost among transiently resuscitated patients that do not survive their hospitalizations. Descriptive studies show zero and near-zero percent survival for CPR recipients with high Apache II scores. Despite these factors, no controlled studies exist in CPR to guide patient selection for CPR candidacy. Our objective was therefore to perform a controlled study in CPR to inform recommendations for CPR candidacy. We hypothesize that the protective effects of CPR decrease as illness severity increases, and that Full-Code status provides no survival benefit over Do-Not-Resuscitate (DNR) status for patients with the highest predicted mortality by Apache IV score. METHODS: We performed propensity-score matched survival analyses between Full-Code and DNR patients after stratifying by predicted mortality quartiles using Apache IV scores. Primary outcomes were mortality hazard ratios. Secondary outcomes were Median Survival Differences, ICU LOS, and tracheostomy rates. RESULTS: Among 17,710 propensity-score matched ICU encounters, DNR status was associated with greater mortality in the first through third predicted mortality quartiles. There was no difference in survival outcomes in the fourth quartile (HR 0.99, p = .96). There was a stepwise decrease in the mortality hazard ratio for DNR patients as quartiles increased. CONCLUSION: Full-Code status provides no survival benefit over DNR status in individuals with greater than 75% predicted mortality by Apache IV score. There is a stepwise decrease in survival benefit for Full-Code patients as predicted mortality increases. We propose that it is reasonable to consider a very high predicted mortality by Apache IV score a contraindication to CPR given the lack of survival benefit seen in these patients. Larger studies with similar methods should be performed to reinforce or refute these findings.

Association of peripartum synthetic oxytocin administration and depressive and anxiety disorders within the first postpartum year.

BACKGROUND: Due to its potent effects on social behavior, including maternal behavior, oxytocin has been identified as a potential mediator of postpartum depression and anxiety. The objective of this study was to examine the relationship between peripartum synthetic oxytocin administration and the development of depressive and anxiety disorders within the first year postpartum. We hypothesized that women exposed to peripartum synthetic oxytocin would have a reduced risk of postpartum depressive and anxiety disorders compared with those without any exposure. METHODS: Population-based data available through the Massachusetts Integrated Clinical Academic Research Database (MiCARD) were used to retrospectively (2005-2014) examine this relationship and calculate the relative risk of peripartum synthetic oxytocin for the development of postpartum depressive and anxiety disorders in exposed (n = 9,684) compared to unexposed (n = 37,048) deliveries. RESULTS: Among deliveries to women with a history of prepregnancy depressive or anxiety disorder, exposure to peripartum oxytocin increased the risk of postpartum depressive or anxiety disorder by 36% (relative risk (RR): 1.36; 95% confidence interval (95% CI): 1.20-1.55). In deliveries to women with no history of prepregnancy depressive or anxiety disorder, exposure to peripartum oxytocin increased the risk of postpartum depressive or anxiety disorder by 32% compared to those not exposed (RR: 1.32; 95% CI: 1.23-1.42). CONCLUSIONS: Contrary to our hypothesis, results indicate that women with peripartum exposure to synthetic oxytocin had a higher relative risk of receiving a documented depressive or anxiety disorder diagnosis or antidepressant/anxiolytic prescription within the first year postpartum than women without synthetic oxytocin exposure.

Proton pump inhibitors increase the severity of hepatic encephalopathy in cirrhotic patients.

BACKGROUND: Liver cirrhosis is the late stage of hepatic fibrosis and is characterized by portal hypertension that can clinically lead to decompensation in the form of ascites, esophageal/gastric varices or encephalopathy. The most common sequelae associated with liver cirrhosis are neurologic and neuropsychiatric impairments labeled as hepatic encephalopathy (HE). Well established triggers for HE include infection, gastrointestinal bleeding, constipation, and medications. Alterations to the gut microbiome is one of the leading ammonia producers in the body, and therefore may make patients more susceptible to HE. AIM: To investigate the relationship between the use of proton pump inhibitors (PPIs) and HE in patients with cirrhosis. METHODS: This is a single center, retrospective analysis. Patients were included in the study with an admitting diagnosis of HE. The degree of HE was determined from subjective and objective portions of hospital admission notes using the West Haven Criteria. The primary outcome of the study was to evaluate the grade of HE in PPI users versus non-users at admission to the hospital and throughout their hospital course. Secondary outcomes included rate of infection, gastrointestinal bleeding within the last 12 mo, mean ammonia level, and model for end-stage liver disease scores at admission. RESULTS: The HE grade at admission using the West Haven Criteria was 2.3 in the PPI group compared to 1.7 in the PPI nonuser group (P = 0.001). The average length of hospital stay in PPI group was 8.3 d compared to 6.5 d in PPI nonusers (P = 0.046). Twenty-seven (31.8%) patients in the PPI user group required an Intensive Care Unit admission during their hospital course compared to 6 in the PPI nonuser group (16.7%) (P = 0.138). Finally, 10 (11.8%) patients in the PPI group expired during their hospital stay compared to 1 in the PPI nonuser group (2.8%) (P = 0.220). CONCLUSION: Chronic PPI use in cirrhotic patients is associated with significantly higher average West Haven Criteria for HE compared to patients that do not use PPIs.

Video capsule endoscopy as a tool for evaluation of obscure overt gastrointestinal bleeding in the intensive care unit.

BACKGROUND AND STUDY AIMS: Video capsule endoscopy (VCE) is a minimally invasive tool that helps visualize the gastrointestinal tract from the esophagus to the right colon without the need for sedation or preparation. VCE is safe with very few contraindications. However, its role and safety profile in the intensive care unit (ICU) population have not been reported. The aim of this study is to evaluate the safety, efficacy, and feasibility of VCE use in ICU patients. PATIENTS AND METHODS: We conducted a single-center retrospective observational study of patients who underwent VCE for evaluation of obscure overt gastrointestinal bleeding in the ICU between 2008 and 2016. RESULTS: This study included 48 patients who were admitted to the UMass Memorial Medical Center ICUs for gastrointestinal bleeding. VCE was successfully completed in 43/48 (90 %) patients. The entire length of small bowel could be evaluated in 75 % and the source of bleeding was identified in 44 % of the patients. The most commonly identified source of bleeding included small bowel angioectasias, duodenal erosions/ulcers, and small bowel polyps. No major complications could be attributed to the VCE. Only 1 capsule was retained after 2 wk; however, there was no incidence of bowel obstruction, perforation, or capsule aspiration. CONCLUSIONS: This observational retrospective study demonstrates that VCE may be a safe, feasible, and effective diagnostic tool in evaluation of gastrointestinal bleeding in the ICU population with few complications. VCE may be a safe diagnostic prelude and be a guide to the correct therapeutic procedure if needed, in the context of patients who are seriously ill.