Predictors for Tracheostomy with External Validation of the Stroke-Related Early Tracheostomy Score (SETscore).

BACKGROUND AND PURPOSE: Ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients often require endotracheal intubation (EI) and mechanical ventilation (MV). Predicting the need for prolonged EI and timing of tracheostomy (TR) is challenging. While TR is performed for about 10-15% of patients in the general intensive care unit (ICU), the rate in the neurological ICU and for stroke patients ranges between 15 and 35%. Thus, we performed an external validation of the recently published SETscore. METHODS: This is a retrospective review for all patients with IS, non-traumatic ICH, and SAH who required intubation within 48 h of admission to the neurological ICU. We compared the SETscore between tracheostomized versus successfully extubated patients, and early TR (within 7 days) versus late TR (after 7 days). RESULTS: Out of 511 intubated patients, 140 tracheostomized and 105 extubated were included. The sensitivity for a SETscore > 10 to predict the need for TR was 81% (95% CI 74-87%) with a specificity of 57% (95% CI 48-67%). The score had moderate accuracy in correctly identifying those requiring TR and those successfully extubated: 71% (95% CI 65-76%). The AUC of the score was 0.74 (95% CI 0.68-0.81). Multivariable logistic regression models were used to identify other independent predictors of TR. After including body mass index (BMI), African American (AA) race, ICH and a positive sputum culture in the SETscore, sensitivity, specificity, overall accuracy, and AUC improved to 90%, 78%, 85%, and 0.89 (95% CI 0.85-0.93), respectively. In our cohort, performing early TR was associated with improvement in the ICU median length of stay (LOS) (15 vs 20.5 days; p = 0.002) and mean ventilator duration (VD) (13.4 vs 18.2 days; p = 0.005) in comparison to late TR. CONCLUSIONS: SETscore is a simple score with a moderate accuracy and with a fair AUC used to predict the need for TR after MV for IS, ICH, and SAH patients. Our study also demonstrates that early TR was associated with a lower ICU LOS and VD in our cohort. The utility of this score may be improved when including additional variables such as BMI, AA race, ICH, and positive sputum cultures.

Evaluation of the Safety of Rapid Administration of Undiluted High-Dose Intravenous Levetiracetam.

Background: Intravenous (IV) levetiracetam (LEV) is an antiseizure medication traditionally given as an intermittent infusion to mitigate potential adverse effects given its acidic formulation. The process of compounding may lead to delays in treating status epilepticus, which is why administration of undiluted doses is of interest. Prior studies have shown safety of IV doses from 1000 mg to 4500 mg; however, assessments of adverse side effects outside IV site reactions have not been studied. Methods: A retrospective analysis was completed with patients who received 1500 mg doses of undiluted IV LEV. We included patients ≥ 18 years old that received at least 1 dose of IV LEV 1500 mg from January 2018 to February 2021. Study end points included assessment of hemodynamic disturbance (bradycardia [HR less than 50 beats per minute] or hypotension [SBP less than 90 mmHg] within 1 hour or documented infusion reaction within 12 hours of LEV. Descriptive statistics were utilized. Results: A total 213 doses of 1500 mg of IV LEV were administered to 107 patients. Peripheral lines were used for 85.9% of doses. Approximately half of doses (57) were administered to patients on the general wards, with the remainder in the intensive care unit or emergency department. Two patients (1.9%) experienced bradycardia; however, 1 patient had pre-existing bradycardia. Three patients (3.8%) experienced hypotension; however, those patients were receiving vasopressors prior to the dose. There were no cases of infusion reaction. Conclusion: Undiluted, rapid administration of IV LEV 1500 mg was well tolerated and safe.

Long-term outcomes of anterior spinal fusion with instrumentation for thoracolumbar and lumbar curves in adolescent idiopathic scoliosis.

STUDY DESIGN: A retrospective review of the long-term clinical and radiographic outcomes of anterior spinal fusion with instrumentation for thoracolumbar and lumbar curves in adolescent idiopathic scoliosis (AIS). OBJECTIVE: To evaluate a group of patients based on Scoliosis Research Society (SRS)-30 and Oswestry data as well as radiographic and magnetic resonance imaging (MRI) and report the results of long-term follow-up of this surgical treatment for this particular curve pattern in AIS. SUMMARY OF BACKGROUND DATA: Anterior spinal fusion with instrumentation has been used for many years in the treatment of thoracolumbar and lumbar curves in AIS. However, the long-term radiographic and functional outcomes of this procedure are not well known. METHODS: During 1984 to 1995, 31 patients with the diagnosis of AIS underwent anterior spinal instrumentation and fusion for thoracolumbar or lumbar scoliosis at our institution. A retrospective review of this patient group was performed to evaluate patient satisfaction, functional outcome, curve progression, implant failure, and disc degeneration. Radiographs and lumbar MRIs were obtained along with SRS-30 Questionnaire and Oswestry Disability Index data. RESULTS: Eighteen patients were available for review. Average follow-up for this study was 16.97 years. Based on SRS-30 and the Oswestry Disability Index data, most patients had good function scores and acceptable pain levels. Radiographs demonstrated no progression of the thoracolumbar or thoracic curves. Implant failure was identified in 2 patients. Radiographic changes of early degenerative disc disease were identified in most patients but had no correlation with SRS or Oswestry data. These degenerative changes were evident on both radiographs and MRI. CONCLUSION: The anterior approach in the treatment of thoracolumbar and lumbar curves in AIS offers good long-term functional outcomes for patients. Despite expected degenerative changes, patients scored well on the SRS and Oswestry tests, and were able to pursue careers and family activities.