Risk Factors and Outcomes Associated With Re-Intubation Secondary to Respiratory Failure in Patients With COVID-19 ARDS.

BACKGROUND: COVID-19 is associated with variable symptoms and clinical sequelae. Studies have examined the clinical course of these patients, finding a prolonged need for invasive ventilation and variable re-intubation rates. However, no research has investigated factors and outcomes related to re-intubation secondary to respiratory failure among patients with COVID-19 with ARDS. METHODS: We conducted a single-center, retrospective study on subjects intubated for ARDS secondary to COVID-19. The primary outcome was re-intubation status; secondary outcomes were hospital and ICU stay and mortality. Data were analyzed using between-group comparisons using chi-square testing for categorical information and Student t test for quantitative data. Univariate and multivariate logistic regression was performed to determine factors related to re-intubation and mortality as dependent variables. RESULTS: One hundred and fourteen subjects were included, of which 32% required re-intubation. No between-group differences were detected for most demographic variables or comorbidities. No differences were detected in COVID-19 treatments, noninvasive respiratory support, mechanical circulatory support, or duration of ventilation. Midazolam (odds ratio [OR] 5.55 [95% CI 1.83-16.80], P = .002), fentanyl (OR 3.64 [95% CI 1.26-10.52], P = .02), and APACHE II scores (OR 1.08 [95% CI 1.030-1.147], P = .005) were independently associated with re-intubation (area under the curve = 0.81). Re-intubated subjects had extended hospital (36.7 ± 22.7 d vs 26.1 ± 12.1 d, P = .01) and ICU (29.6 ± 22.4 d vs 15.8 ± 10.4 d, P < .001) stays. More subjects died who failed extubation (49% vs 3%, P < .001). Age (OR 1.07 [95% CI 1.02-1.23], P = .005), male sex (OR 4.9 [95% CI 1.08-22.35], P = .041), positive Confusion Assessment Method for the ICU (CAM-ICU) (OR 5.43 [95% CI 1.58-18.62], P = .007), and re-intubation (OR 12.75 [95% CI 2.80-57.10], P < .001) were independently associated with death (area under the curve = 0.93). CONCLUSIONS: Midazolam, fentanyl, and higher APACHE II scores were independently associated with re-intubation secondary to respiratory failure in subjects with COVID-19-related ARDS. Furthermore, age, male sex, positive CAM-ICU, and re-intubation were independently associated with mortality. Re-intubation also correlated with prolonged hospital and ICU stay.

Blunt Cardiac Injury in Patients With Sternal Fractures.

Background Blunt cardiac injury (BCI) is a possible consequence of sternal fractures (SF). There is a scarcity of studies addressing BCI in patients with different types of SF and with pre-existing cardiac conditions. The goal of this study was to delineate diagnostic patterns of BCI in different cohorts of SF patients. Methods This retrospective cohort study included 380 blunt trauma patients admitted to two level 1 trauma centers between January 2015 and March 2020 with radiologically confirmed SF. Electrocardiography, cardiac enzymes and echocardiography were evaluated for BCI diagnosis. Analyzed variables included: age, comorbidities, injury severity score, Glasgow coma score, type of SF (isolated, combined, displaced), incidence of traumatic brain injury, co-injuries, retrosternal hematoma, intensive care unit admissions, hospital lengths of stay, and mortality. Results In 380 SF patients there were 250 (66%) females and 130 (34%) males and the mean age was 63 years old. Electrocardiography was done in all patients, cardiac enzymes in 234 (62%) and echocardiography in 181 (48%). BCI was diagnosed in 19 (5%) of patients, all having combined SF. BCI patients had higher injury severity score (mean 18.4) and 14 (74%) had pulmonary co-injuries. Multivariable analysis confirmed pulmonary co-injuries as a statistically significant predictor of BCI (p<0.001). BCI patients compared to no BCI patients had all three tests (electrocardiography, cardiac enzymes and echocardiography) performed statistically more often (90% vs 36%, p<0.001). SF patients with pre-injury cardiac comorbidities had similar incidence of BCI as without cardiac comorbidities (5% vs 6%, p=0.6). In SF patients with traumatic brain injury, cardiac enzymes (troponin, creatine kinase) were elevated significantly more often compared to patients without traumatic brain injury (58% vs 38%, p=0.02). SF displacement or retrosternal hematoma presence were not associated with BCI. Mortality in SF patients with BCI versus without was not statistically different (16 vs 9%, p=0.4). Conclusions Blunt cardiac injury is rare in patients with SF. Higher degree of BCI suspicion must be applied in combined SF patients, especially those with pulmonary co-injuries. Cardiac comorbidities did not affect the rate of BCI. Echocardiography for BCI diagnosis is essential in SF patients with traumatic brain injury, as cardiac enzymes may be less informative, however is less important in isolated SF patients. Performing all three diagnostic tests in combined SF patients improves the accuracy of BCI diagnosis.

Sternal fractures in blunt trauma patients.

PURPOSE: Sternal fractures (SF) are commonly associated with other injuries and their incidence is on the rise. The aim was to evaluate injury characteristics and outcomes in patients with all types of SF after blunt trauma. METHODS: Retrospective analysis of 380 SF patients from two Level 1 trauma centers was performed. Patients were compared in various combinations: geriatric versus non-geriatric, isolated sternal fractures (ISF) versus combined sternal fractures (CSF), sternal body versus manubrium, displaced versus non-displaced, and with retrosternal hematoma versus without. Analyzed variables included: age, gender, race, comorbidities, mechanism of injury (MOI), injury severity score (ISS), Glasgow Coma Score (GCS), type and location of SF, concomitant fractures of ribs, vertebrae, clavicles and scapulae, co-injuries, rates of surgical stabilization, mechanical ventilation requirements, intensive care unit (ICU) admission, ICU length of stay (ICULOS), hospital LOS (HLOS), complications, and mortality. RESULTS: ISF constituted 17.9% of all patients with no mortality. CSF patients constituted 82.1%, had more ICU admissions, longer ICULOS/HLOS and 9.3% mortality (all p < 0.001). Geriatric SF had more concomitant rib fractures and 12.9% mortality. Concomitant fractures of ribs were present in 56.7% and had higher ICU admissions, ICULOS and complications compared to SF patients with concomitant vertebrae fractures diagnosed in 38.2%. CONCLUSION: SF are present in 2.1% of admissions to trauma centers. Geriatric patients account for half of SF patients and have higher mortality. Concomitant fractures of ribs are present in half and vertebrae fractures in one-third of the SF patients. CSF portend higher mortality and pulmonary co-injuries. The high incidence of concomitant rib and vertebra fractures requires additional diagnostic and treatment considerations.

Impact of insurance status, hospital ownership type, and children's hospital designation on outcomes for pediatric neurosurgery patients following spasticity procedures in the USA.

PURPOSE: This study aims to examine the relationship between insurance status, hospital ownership type, and children's hospital designation with outcomes for pediatric patients undergoing neurosurgical treatment for spasticity. METHODS: This retrospective cohort study utilized the Healthcare Cost and Utilization Project Kids' Inpatient Database and included 11,916 pediatric patients (≤ 17 years of age) who underwent neurosurgical treatment for spasticity between 2006 and 2012 using ICD-9-CM procedure codes. RESULTS: Uninsured patients had a significantly shorter hospital length of stay compared to Medicaid patients (-1.42 days, P = 0.030) as did privately insured patients (-0.74 days; P = 0.035). Discharge disposition and inpatient mortality rate were not associated with insurance status. There were no significant associations with hospital ownership type. Free-standing children's hospitals retained patients significantly longer compared to non-children's hospitals (+1.48 days; P = 0.012) and had a significantly higher likelihood of favorable discharge disposition (P = 0.004). Mortality rate was not associated with children's hospital designation. CONCLUSION: Pediatric patients undergoing neurosurgical treatment for spasticity were more likely to stay in the hospital longer if they were insured by Medicaid or treated in a free-standing children's hospital. In addition, patients in free standing children's hospitals were more likely to be discharged with a favorable disposition.