Peripheral arterial catheter securement and catheter survival in the pediatric intensive care unit.

BACKGROUND: Peripheral arterial catheters (PACs), and their associated complications, are common in the pediatric intensive care unit (PICU). Accidental catheter displacement and non-functional PACs are the most common complications, and this may be related to inadequate catheter securement. There is mixed guidance on the best way to secure PACs to prevent complications. The authors hypothesized that sutures would not be associated with a decreased risk of malfunction or accidental removal. METHODS: This was a single center retrospective cohort study at a quaternary-care PICU. PICU patients with a peripheral arterial catheter placed in the PICU from 7/2020 to 1/2023 were included. The primary outcome was unplanned PAC removal. A univariate and multivariate Cox proportional hazards regression analysis was performed, using patient weight, sedation, paralytic, and role of the proceduralist as covariates. The secondary outcome was survival probability. A log-rank test was used to compare survival curves. RESULTS: Of 761 PACs that met inclusion criteria in 437 unique patients, 599 were sutured (78.7%) and 162 were un-sutured (21.3%). In 257 cases (33.8%), the PAC had an unplanned removal. Among all PACs, the median duration of PAC placement was 5.3 days (IQR 2.1-10.5 days). There was an unplanned removal rate of 42.2% (68) in the un-sutured group and 31.4% (188) in the sutured group (p < 0.001). In multivariable analysis, sutured PACs were also associated with a lower rate of unplanned removal (hazard ratio, 0.59; 95% CI, 0.44-0.78). Use of continuous sedation was also associated with an increased risk of unplanned removal of PACs (hazard ratio, 1.54; 95% CI, 1.10-2.16). There was a 50% survival probability at 13.3 days for un-sutured PACs and 23.7 days for sutured PACs. CONCLUSIONS: Suturing is associated with fewer unplanned removals and longer catheter survival, compared to un-sutured PACs in pediatric patients.

Hypertonic Saline Versus Other Intracranial-Pressure-Lowering Agents for Patients with Acute Traumatic Brain Injury: A Systematic Review and Meta-analysis.

Acute traumatic brain injury (TBI) is a major cause of mortality and disability worldwide. Intracranial pressure (ICP)-lowering is a critical management priority in patients with moderate to severe acute TBI. We aimed to evaluate the clinical efficacy and safety of hypertonic saline (HTS) versus other ICP-lowering agents in patients with TBI. We conducted a systematic search from 2000 onward for randomized controlled trials (RCTs) comparing HTS vs. other ICP-lowering agents in patients with TBI of all ages. The primary outcome was the Glasgow Outcome Scale (GOS) score at 6 months (PROSPERO CRD42022324370). Ten RCTs (760 patients) were included. Six RCTs were included in the quantitative analysis. There was no evidence of an effect of HTS on the GOS score (favorable vs. unfavorable) compared with other agents (risk ratio [RR] 0.82, 95% confidence interval [CI] 0.48-1.40; n = 406; 2 RCTs). There was no evidence of an effect of HTS on all-cause mortality (RR 0.96, 95% CI 0.60-1.55; n = 486; 5 RCTs) or total length of stay (RR 2.36, 95% CI - 0.53 to 5.25; n = 89; 3 RCTs). HTS was associated with adverse hypernatremia compared with other agents (RR 2.13, 95% CI 1.09-4.17; n = 386; 2 RCTs). The point estimate favored a reduction in uncontrolled ICP with HTS, but this was not statistically significant (RR 0.52, 95% CI 0.26-1.04; n = 423; 3 RCTs). Most included RCTs were at unclear or high risk of bias because of lack of blinding, incomplete outcome data, and selective reporting. We found no evidence of an effect of HTS on clinically important outcomes and that HTS is associated with adverse hypernatremia. The included evidence was of low to very low certainty, but ongoing RCTs may help to the reduce this uncertainty. In addition, heterogeneity in GOS score reporting reflects the need for a standardized TBI core outcome set.

An analysis of a new rapid difficult airway response team in a vertically built children's hospital.

BACKGROUND: Intrahospital transport is associated with adverse events. This challenge is amplified during airway management. Although difficult airway response teams have been described, little attention has been paid to patient transport during difficult airway management versus the alternative of managing patient airways without moving the patient. This is especially needed in a 22-floor vertical hospital. HYPOTHESIS: Development of a rapid difficult airway response team and an associated difficult airway cart will allow for the ability to manage difficult airways in the patient's primary location. METHODS: A retrospective chart review of all rapid difficult airway response activations from December 18, 2019 to December 31, 2021 was performed to determine the number of airways secured in the patient's primary location (primary outcome). Secondary outcomes included length of time until airway securement, airway device used, number of attempts, complications, use of front of neck access, and mortality. RESULTS: There were 96 rapid difficult airway response activations in a 2-year period, with 18 activations deemed inappropriate. Of the 78 indicated rapid difficult airway response deployments, all activations resulted in a secure airway, and 76 (97.4%) of cases had an airway secured in the patient's primary location. The mean time to airway securement was 17.1 min (standard deviation 18.8 min). The most common methods of airway securement were direct laryngoscopy (42.3%, 33/78) and video laryngoscopy (29.5%, 23/78). The mean number of attempts by the rapid difficult airway response team was 1.4. There were no documented cases requiring front of neck access. The Cormack-Lehane airway grade at time of intubation was I-II in 83.3% (65/78) of activations. Rapid difficult airway response activation resulted in 16 cases of cardiac arrest and 4 patient deaths within 48 h. CONCLUSIONS: A rapid difficult airway response team allows a large majority of patients' airways to be managed and secured in the patient's primary hospital location. Future directions include reducing time to airway securement and identifying factors associated with cardiac arrest.

Sex and age effects on risk of non-traumatic subarachnoid hemorrhage: Retrospective cohort study of 124,234 cases using electronic health records.

OBJECTIVES: The epidemiology of non-traumatic subarachnoid hemorrhage (SAH) is unclear. This study describes the antecedent characteristics of SAH patients, compares the risk of SAH between women and men, and explores if this changes with age. MATERIALS AND METHODS: Retrospective cohort study using an electronic health records network based in the USA (TriNetX). All patients aged 18-90y with at least one healthcare visit were included. Antecedent characteristics of SAH patients (ICD-10 code I60) were measured. The incidence proportion and the relative risk between women and men, were estimated overall, in the 55-90y age group, and in five-year age categories. RESULTS: Of 58.9 million eligible patients, with 190.8 million person-years of observations, 124,234 (0.21%; 63,467 female, 60,671 male) had a first SAH, with a mean age of 56.8 (S.D. 16.8) y (women: 58.2 [16.2] y, men 55.3 [17.2] y). 9,758 SAH cases (7.8%) occurred in people aged 18-30y. Prior to the SAH, an intracranial aneurysm had been diagnosed in 4.1% (women: 5.8% men: 2.5%), hypertension in 25.1% and nicotine dependence in 9.1%. Overall, women had a lower risk of SAH compared to men (RR 0.83, 95% CI 0.83-0.84), with a progressive increase in risk ratio across age groups: from RR 0.36 (0.35-0.37) in people aged 18-24y, to RR 1.07 (1.01-1.13) aged 85-90y. CONCLUSIONS: Men are at greater risk of SAH than women overall, driven by younger adult age groups. Women are at greater risk than men only in the over 75-year age groups. The excess of SAH in young men merits investigation.

National Survey of Combined Pediatrics-Anesthesiology Residents and Graduates: Factors Contributing to Changing Career Aspirations Over Time.

BACKGROUND: The Dual Pathway for Certification in Pediatrics and Anesthesiology was created in 2011 to develop leaders in caring for children with complex medical and surgical conditions. While existing dual-trained practitioners report continued practice in both pediatric anesthesiology (PA) and pediatric critical care medicine (PCCM), recent surveys of dual pathway trainees have shown that only one-quarter still currently plan to pursue training in PCCM, a change from their initial plans to complete training in both PA and PCCM. The aim of this study was to further characterize the motivations driving shifts in career trajectory during training as well as factors affecting the combined training experience. METHODS: We conducted an online mixed-methods survey of all individuals who had matriculated at 1 of the 7 Accreditation Council for Graduate Medical Education-accredited combined pediatrics-anesthesiology residencies from 2011 to 2018. The survey consisted of a 30-item questionnaire addressing training experience, anticipated career trajectory, and respondent demographics. Descriptive statistics were used for closed-format questions. Responses to open-ended questions were systematically analyzed through inductive iterative review by 2 of the authors to elicit a set of overarching themes. RESULTS: We achieved a response rate of 85% (n = 53/62) with respondents from 7 of 7 combined residency programs. When asked about career goals, the majority of respondents planned to pursue both PA and PCCM (60%, n = 32) at the start of residency. However, at the time of survey completion, the percentage of respondents who were still planning to (or had already completed) train in both PA and PCCM had decreased to 23% (n = 12). Factors such as lifestyle and length of training contributed more to career choices during/after training compared to before residency. Thematic analysis of open-ended questions regarding transition between specialties, impact of dual training, and general comments revealed 3 major themes: (1) challenges of transitioning between specialties, (2) dual training is mutually beneficial, and (3) the need for an established fellowship training pathway. CONCLUSIONS: While there is continued interest in dual training in PA/PCCM for residents who enter the combined pediatrics-anesthesiology residency, factors such as duration of training and lifestyle become more important during residency and alter their career trajectories, often away from PCCM. Optimization of dual-subspecialty fellowship training will be critical to sustaining interest in dual-subspecialty training in PA/PCCM.

Early brain injury and cognitive impairment after aneurysmal subarachnoid haemorrhage.

The first 72 h following aneurysm rupture play a key role in determining clinical and cognitive outcomes after subarachnoid haemorrhage (SAH). Yet, very little is known about the impact of so called "early brain injury" on patents with clinically good grade SAH (as defined as World Federation of Neurosurgeons Grade 1 and 2). 27 patients with good grade SAH underwent MRI scanning were prospectively recruited at three time-points after SAH: within the first 72 h (acute phase), at 5-10 days and at 3 months. Patients underwent additional, comprehensive cognitive assessment 3 months post-SAH. 27 paired healthy controls were also recruited for comparison. In the first 72 h post-SAH, patients had significantly higher global and regional brain volume than controls. This change was accompanied by restricted water diffusion in patients. Persisting abnormalities in the volume of the posterior cerebellum at 3 months post-SAH were present to those patients with worse cognitive outcome. When using this residual abnormal brain area as a region of interest in the acute-phase scans, we could predict with an accuracy of 84% (sensitivity 82%, specificity 86%) which patients would develop cognitive impairment 3 months later, despite initially appearing clinically indistinguishable from those making full recovery. In an exploratory sample of good clinical grade SAH patients compared to healthy controls, we identified a region of the posterior cerebellum for which acute changes on MRI were associated with cognitive impairment. Whilst further investigation will be required to confirm causality, use of this finding as a risk stratification biomarker is promising.

Musculoskeletal complications following critical illness: A scoping review.

PURPOSE: To explore the extent to which musculoskeletal (MSK) complications have been reported following critical illness, identifying evidence gaps and providing recommendations for future research. MATERIALS AND METHODS: We searched five databases from January 1st 2000 to March 31st 2021. We included published original research reporting MSK complications in patients discharged from hospital following an admission to an intensive care unit (ICU). Two reviewers independently screened English language articles for eligibility. Data extracted included the MSK area of investigation and MSK outcome measures. The overall quality of study was evaluated against standardised reporting guidelines. RESULTS: 4512 titles were screened, and 32 met the inclusion criteria. Only one study included was interventional, with the majority being prospective cohort studies (n = 22). MSK complications identified included: muscle weakness or atrophy, chronic pain, neuromuscular dysfunction, peripheral joint impairment and fracture risk. The quality of the overall reporting in the studies was deemed adequate. CONCLUSIONS: We identified a heterogenous body of literature reporting a high prevalence of a variety of MSK complications extending beyond muscle weakness, therefore future investigation should include evaluations of more than one MSK area. Further investigation of MSK complications could inform the development of future post critical illness rehabilitation programs.

Brain injury after cardiac arrest.

As more people are surviving cardiac arrest, focus needs to shift towards improving neurological outcomes and quality of life in survivors. Brain injury after resuscitation, a common sequela following cardiac arrest, ranges in severity from mild impairment to devastating brain injury and brainstem death. Effective strategies to minimise brain injury after resuscitation include early intervention with cardiopulmonary resuscitation and defibrillation, restoration of normal physiology, and targeted temperature management. It is important to identify people who might have a poor outcome, to enable informed choices about continuation or withdrawal of life-sustaining treatments. Multimodal prediction guidelines seek to avoid premature withdrawal in those who might survive with a good neurological outcome, or prolonging treatment that might result in survival with severe disability. Approximately one in three admitted to intensive care will survive, many of whom will need intensive, tailored rehabilitation after discharge to have the best outcomes.

Medium-term effects of SARS-CoV-2 infection on multiple vital organs, exercise capacity, cognition, quality of life and mental health, post-hospital discharge.

BACKGROUND: The medium-term effects of Coronavirus disease (COVID-19) on organ health, exercise capacity, cognition, quality of life and mental health are poorly understood. METHODS: Fifty-eight COVID-19 patients post-hospital discharge and 30 age, sex, body mass index comorbidity-matched controls were enrolled for multiorgan (brain, lungs, heart, liver and kidneys) magnetic resonance imaging (MRI), spirometry, six-minute walk test, cardiopulmonary exercise test (CPET), quality of life, cognitive and mental health assessments. FINDINGS: At 2-3 months from disease-onset, 64% of patients experienced breathlessness and 55% reported fatigue. On MRI, abnormalities were seen in lungs (60%), heart (26%), liver (10%) and kidneys (29%). Patients exhibited changes in the thalamus, posterior thalamic radiations and sagittal stratum on brain MRI and demonstrated impaired cognitive performance, specifically in the executive and visuospatial domains. Exercise tolerance (maximal oxygen consumption and ventilatory efficiency on CPET) and six-minute walk distance were significantly reduced. The extent of extra-pulmonary MRI abnormalities and exercise intolerance correlated with serum markers of inflammation and acute illness severity. Patients had a higher burden of self-reported symptoms of depression and experienced significant impairment in all domains of quality of life compared to controls (p<0.0001 to 0.044). INTERPRETATION: A significant proportion of patients discharged from hospital reported symptoms of breathlessness, fatigue, depression and had limited exercise capacity. Persistent lung and extra-pulmonary organ MRI findings are common in patients and linked to inflammation and severity of acute illness. FUNDING: NIHR Oxford and Oxford Health Biomedical Research Centres, British Heart Foundation Centre for Research Excellence, UKRI, Wellcome Trust, British Heart Foundation.

Phase dynamics of cerebral blood flow in subarachnoid haemorrhage in response to sodium nitrite infusion.

Aneurysmal subarachnoid haemorrhage (SAH) is a devastating subset of stroke. One of the major determinates of morbidity is the development of delayed cerebral ischemia (DCI). Disruption of the nitric oxide (NO) pathway and consequently the control of cerebral blood flow (CBF), known as cerebral autoregulation, is believed to play a role in its pathophysiology. Through the pharmacological manipulation of in vivo NO levels using an exogenous NO donor we sought to explore this relationship. Phase synchronisation index (PSI), an expression of the interdependence between CBF and arterial blood pressure (ABP) and thus cerebral autoregulation, was calculated before and during sodium nitrite administration in 10 high-grade SAH patients acutely post-rupture. In patients that did not develop DCI, there was a significant increase in PSI around 0.1 Hz during the administration of sodium nitrite (33%; p-value 0.006). In patients that developed DCI, PSI did not change significantly. Synchronisation between ABP and CBF at 0.1 Hz has been proposed as a mechanism by which organ perfusion is maintained, during periods of physiological stress. These findings suggest that functional NO depletion plays a role in impaired cerebral autoregulation following SAH, but the development of DCI may have a distinct pathophysiological aetiology.

Thrombotic and haemorrhagic complications in critically ill patients with COVID-19: a multicentre observational study.

BACKGROUND: Optimal prophylactic and therapeutic management of thromboembolic disease in patients with COVID-19 remains a major challenge for clinicians. The aim of this study was to define the incidence of thrombotic and haemorrhagic complications in critically ill patients with COVID-19. In addition, we sought to characterise coagulation profiles using thromboelastography and explore possible biological differences between patients with and without thrombotic complications. METHODS: We conducted a multicentre retrospective observational study evaluating all the COVID-19 patients received in four intensive care units (ICUs) of four tertiary hospitals in the UK between March 15, 2020, and May 05, 2020. Clinical characteristics, laboratory data, thromboelastography profiles and clinical outcome data were evaluated between patients with and without thrombotic complications. RESULTS: A total of 187 patients were included. Their median (interquartile (IQR)) age was 57 (49-64) years and 124 (66.3%) patients were male. Eighty-one (43.3%) patients experienced one or more clinically relevant thrombotic complications, which were mainly pulmonary emboli (n = 42 (22.5%)). Arterial embolic complications were reported in 25 (13.3%) patients. ICU length of stay was longer in patients with thrombotic complications when compared with those without. Fifteen (8.0%) patients experienced haemorrhagic complications, of which nine (4.8%) were classified as major bleeding. Thromboelastography demonstrated a hypercoagulable profile in patients tested but lacked discriminatory value between those with and without thrombotic complications. Patients who experienced thrombotic complications had higher D-dimer, ferritin, troponin and white cell count levels at ICU admission compared with those that did not. CONCLUSION: Critically ill patients with COVID-19 experience high rates of venous and arterial thrombotic complications. The rates of bleeding may be higher than previously reported and re-iterate the need for randomised trials to better understand the risk-benefit ratio of different anticoagulation strategies.

The Impact of Airway Technique on Anesthesia Control Time.

Few studies have examined the impact of video laryngoscopy (VL) on operating room efficiency. We hypothesized that VL reduces anesthesia control time (ACT), a metric of anesthesia efficiency, compared with fiberoptic intubation (FOI) in potentially difficult airways, but that direct laryngoscopy (DL) remains more efficient in routine cases. We performed a multi-institutional, retrospective chart review of anesthetic cases from 2015 to 2016. Cases were compared based on choice of airway technique (laryngeal mask airway [LMA], DL, VL or FOI) and ACT. Generalized linear models with gamma distribution and log link were then used to model the data to control for variables including ASA physical status (PS), Mallampati (MP) score, body mass index, and presence of a trainee. ACT was analyzed for 32,542 cases. LMA insertion was associated with a median ACT of 10 min (CI 8-14 min), DL 14 min (CI 11-18 min), VL 17 min (CI 13-21 min) and FOI 20 min (CI 14.5-26 min). Modeling confirmed these results when controlling for variables expected to increase the ACT. However, modeling also revealed that presence of a trainee minimizes the increase in ACT for cases using VL or FOI. Use of VL in patients with a high MP score may improve anesthesia efficiency in the operating room. ASA PS, MP score, and presence of a trainee are all associated with an increased ACT. Trainee presence with both FOI and VL was associated with reduced increases in ACT for these devices.

Calcium channel blockade with nimodipine reverses MRI evidence of cerebral oedema following acute hypoxia.

Acute cerebral hypoxia causes rapid calcium shifts leading to neuronal damage and death. Calcium channel antagonists improve outcomes in some clinical conditions, but mechanisms remain unclear. In 18 healthy participants we: (i) quantified with multiparametric MRI the effect of hypoxia on the thalamus, a region particularly sensitive to hypoxia, and on the whole brain in general; (ii) investigated how calcium channel antagonism with the drug nimodipine affects the brain response to hypoxia. Hypoxia resulted in a significant decrease in apparent diffusion coefficient (ADC), a measure particularly sensitive to cell swelling, in a widespread network of regions across the brain, and the thalamus in particular. In hypoxia, nimodipine significantly increased ADC in the same brain regions, normalizing ADC towards normoxia baseline. There was positive correlation between blood nimodipine levels and ADC change. In the thalamus, there was a significant decrease in the amplitude of low frequency fluctuations (ALFF) in resting state functional MRI and an apparent increase of grey matter volume in hypoxia, with the ALFF partially normalized towards normoxia baseline with nimodipine. This study provides further evidence that the brain response to acute hypoxia is mediated by calcium, and importantly that manipulation of intracellular calcium flux following hypoxia may reduce cerebral cytotoxic oedema.

Shoulder Impairment Following Critical Illness: A Prospective Cohort Study.

OBJECTIVES: Identify the prevalence of shoulder impairment in ICU survivors within 6 months of discharge from ICU. Evaluate the impact of shoulder impairment on upper limb functional status in patients treated on an ICU. Identify risk factors for the development of shoulder impairment. DESIGN: Prospective cohort study. SETTING: A tertiary care medical-surgical-trauma ICU at a U.K. hospital over 18 months, with a further 6-month follow-up after hospital discharge. SUBJECTS: Adult patients with an ICU length of stay of greater than 72 hours with no preexisting or new neurologic or traumatic upper limb injury. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients underwent targeted shoulder assessments (pain, range of movement, Constant-Murley Score, shortened version of the disabilities of the arm, shoulder, and hand [DASH] score [QuickDASH] score) at hospital discharge, 3 and 6 months after hospital discharge. Assessments were undertaken on 96 patients, with 62 patients attending follow-up at 3 months and 61 patients at 6 months. Multivariate regression analysis was used to investigate risk factors for shoulder impairment. ICU-related shoulder impairment was present in 67% of patients at 6 months following discharge from hospital. Upper limb dysfunction occurred in 46%, with 16% having severe dysfunction (equivalent to shoulder dislocation). We were unable to identify specific risk factors for shoulder impairment. CONCLUSIONS: Shoulder impairment is a highly prevalent potential source of disability in ICU survivors. This persists at 6 months after discharge with a significant impact on upper limb function. More research is needed into potential mechanisms underlying shoulder impairment and potential targeted interventions to reduce the prevalence.

An adherent tissue-inspired hydrogel delivery vehicle utilised in primary human glioma models.

A physical hydrogel cross-linked via the host-guest interactions of cucurbit[8]uril and utilised as an implantable drug-delivery vehicle for the brain is described herein. Constructed from hyaluronic acid, this hydrogel is biocompatible and has a high water content of 98%. The mechanical properties have been characterised by rheology and compared with the modulus of human brain tissue demonstrating the production of a soft material that can be moulded into the cavity it is implanted into following surgical resection. Furthermore, effective delivery of therapeutic compounds and antibodies to primary human glioblastoma cell lines is showcased by a variety of in vitro and ex vivo viability and immunocytochemistry based assays.