Nighttime Extubation Does Not Increase Risk of Reintubation, Length of Stay, or Mortality: Experience of a Large, Urban, Teaching Hospital.

BACKGROUND: In the intensive care unit (ICU), extubation failure has been associated with greater resource utilization and worsened clinical outcomes. Most recently, nighttime extubation (NTE) has been reported as a risk factor for increased ICU and hospital mortality. We hypothesized that, in a large, urban, university-affiliated hospital with multidisciplinary assessment for extubation, rigorously protocolized extubation algorithms, and expert airway managers available at all times of day for assessment of high-risk extubations, NTE would not confer additional risk of adverse clinical outcomes. METHODS: This was a retrospective cohort study of mechanically ventilated adults at a single university-affiliated hospital. NTE was defined as occurring between 7:00 PM and 6:59 AM the following day. All data were extracted from the institution's electronic medical record. Multivariable regression analyses were used to assess associations between NTE and reintubation, ICU and hospital length of stay (LOS), and mortality with adjustments for demographic and clinical covariates defined a priori. Palliative, unplanned, and routine postoperative extubations were excluded in sensitivity analyses. RESULTS: Of 2241 patients, 204 of 2241 (9.1%) underwent NTE. The rates of reintubation (NTE 6.9% versus daytime extubation [DTE] 12.4%; adjusted odds ratio [95% confidence interval {CI}], 0.78 [0.43-1.41]; P = .41) and in-hospital mortality (NTE 3.4% versus DTE 5.9%; adjusted odds ratio [95% CI], 0.72 [0.28-1.84]; P = .49) were not found to differ. NTE, compared to DTE, was associated with shorter duration of mechanical ventilation (median [interquartile range], 1 [0-1] days vs 2 [1-4] days; adjusted ratio of geometric means [RGMs] [95% CI], 0.64 [0.54-0.70]; P < .001), ICU (2 [1-5] days vs 4 [2-10] days; adjusted RGMs [95% CI], 0.65 [0.57-0.75]; P < .001), and hospital LOS (6 [3-18] days vs 13 [6-25] days; adjusted RGMs [95% CI], 0.64 [0.56-0.74]; P < .001). These results were unchanged in sensitivity analyses. CONCLUSIONS: Patients who underwent NTE were not at increased risk of reintubation or in-hospital mortality. In addition, NTE was associated with a shortened duration of mechanical ventilation and hospital LOS. In health care systems with similar critical care delivery models, NTE may coincide with reduced resource utilization in appropriately selected patients.

Process Optimization and Digital Quality Improvement to Enhance Timely Initiation of Epidural Infusions and Postoperative Pain Control.

BACKGROUND: Although intraoperative epidural analgesia improves postoperative pain control, a recent quality improvement project demonstrated that only 59% of epidural infusions are started in the operating room before patient arrival in the postanesthesia care unit. We evaluated the combined effect of process and digital quality improvement efforts on provider compliance with starting continuous epidural infusions during surgery. METHODS: In October 2014, we instituted 2 process improvement initiatives: (1) an electronic order queue to assist the operating room pharmacy with infusate preparation; and (2) a designated workspace for the storage of equipment related to epidural catheter placement and drug infusion delivery. In addition, we implemented a digital quality improvement initiative, an Anesthesia Information Management System-mediated clinical decision support, to prompt anesthesia providers to start and document epidural infusions in pertinent patients. We assessed anesthesia provider compliance with epidural infusion initiation in the operating room and postoperative pain-related outcomes before (PRE: October 1, 2012 to September 31, 2014) and after (POST: January 1, 2015 to December 31, 2016) implementation of the quality improvement initiatives. RESULTS: Compliance with starting intraoperative epidural infusions was 59% in the PRE group and 85% in the POST group. After adjustment for confounders and preintervention time trends, segmented regression analysis demonstrated a statistically significant increase in compliance with the intervention in the POST phase (odds ratio, 2.78; 95% confidence interval, 1.73-4.49; P < .001). In the PRE and POST groups, cumulative postoperative intravenous opioid use (geometric mean) was 62 and 34 mg oral morphine equivalents, respectively. A segmented regression analysis did not demonstrate a statistically significant difference (P = .38) after adjustment for preintervention time trends. CONCLUSIONS: Process workflow optimization along with Anesthesia Information Management System-mediated digital quality improvement efforts increased compliance to intraoperative epidural infusion initiation. Adjusted for preintervention time trends, these findings coincided with a statistically insignificant decrease in postoperative opioid use in the postanesthesia care unit during the POST phase.

Idiopathic Interstitial Pneumonia Associated With Autoantibodies: A Large Case Series Followed Over 1 Year.

BACKGROUND: Some patients with autoimmune characteristics and idiopathic interstitial pneumonia, particularly usual interstitial pneumonia (UIP), do not fit neatly into the category of connective tissue disease-associated interstitial lung disease (CTD-ILD), idiopathic pulmonary fibrosis (IPF), or recently proposed yet to be validated criteria for interstitial pneumonia with autoimmune features (IPAF). Outcomes of these patients are unknown. METHODS: This was a retrospective single-center study. Analyses of variance compared differences in mean change in FVC and diffusion capacity (Dlco) over 1 year among 124 well-defined patients (20 patients with positive autoantibodies with or without symptoms of connective tissue disease [AI-ILD], 15 patients with IPAF, 36 patients with CTD-ILD, and 53 patients with IPF with negative CTD serologies [Lone-IPF]). RESULTS: Of the patients, 75% with AI-ILD, 33% with IPAF, and 33% with CTD-ILD had UIP. Initial FVC and Dlco were similarly moderately reduced across groups. Mean change in FVC over 12 months was as follows: -60 mL (IPAF), -110 mL (AI-ILD), -10 mL (CTD-ILD), and -90 mL (Lone-IPF) (P = .52). Mean change in Dlco was as follows: 2.39 mL/mm Hg/min (IPAF), -1.15 mL/mm Hg/min (AI-ILD), -0.27 mL/mm Hg/min (CTD-ILD), and -1.05 mL/mm Hg/min (Lone-IPF) (P < .001). By pattern of disease, the mean change in FVC was as follows: -140 mL (UIP), 10 mL (nonspecific interstitial pneumonia), and 12 mL (unclassifiable/other) (P = .001). CONCLUSIONS: No clinically significant differences in pulmonary function to distinguish between patients with AI-ILD, IPAF, CTD-ILD, and Lone-IPF were observed after 1 year. Longer periods of follow-up are needed to understand the outcomes of these patients. It is not yet clear whether AI-ILD is a distinct phenotype or a variant of the newly proposed entity IPAF.

Continuous intraoperative epidural infusions affect recovery room length of stay and analgesic requirements: a single-center observational study.

PURPOSE: Continuous intraoperative epidural analgesia may improve post-operative pain control and decrease opioid requirements. We investigate the effect of epidural infusion initiation before or after arrival in the post-anesthesia care unit on recovery room duration and post-operative opioid use. METHODS: We performed a retrospective chart review of abdominal, thoracic and orthopedic surgeries where an epidural catheter was placed prior to surgery at the University of Washington Medical Center during a 24 month period. RESULTS: Patients whose epidural infusions were started prior to PACU arrival (Group 2: n = 540) exhibited a shorter PACU length of stay (p = .004) and were less likely to receive intravenous opioids in the recovery room (34 vs. 48%; p < .001) compared to patients whose infusions were started after surgery (Group 1: n = 374). Although the highest patient-reported pain scores were lower in Group 2 (5.3 vs. 6.0; p = .030), no differences in the pain scores prior to PACU discharge were observed. CONCLUSION: Intraoperative continuous epidural infusions decrease PACU LOS as discharge criteria for patient-reported NRS pain scores are met earlier.

The Effect of Hyponatremia and Sodium Variability on Outcomes in Adults with Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Hyponatremia is common in patients with subarachnoid hemorrhage, but its effect on outcomes remains contentious. Fluctuation in sodium has been reported to negatively affect perioperative outcomes in general surgical patients, but not specifically in patients with a subarachnoid hemorrhage. The primary aim was to describe the relationship between 1) hyponatremia and 2) sodium fluctuations during intensive care and neurologic outcome at hospital discharge. METHODS: Adults with aneurysmal subarachnoid hemorrhage between January 2012 and September 2013 were retrospectively reviewed. Data were collected for admission to day 14 of intensive care or death. Severity of illness was assessed by Hunt and Hess grade and simplified acute physiology score. Hyponatremia was defined as any measurement <135 mEq/L. Sodium variability was categorized as a maximum change of <6, 6-12, or >12 mEq/L during intensive care. Neurologic outcomes at discharge were assessed by modified Rankin Scale. The relationship between sodium and outcome was assessed by ordinal logistic regression. RESULTS: A total of 198 patients were included. After adjustment for Hunt and Hess grade, severity of systemic illness, patient age, surgical intervention, and whether or not the hyponatremia was treated with additional sodium, hyponatremia was not associated with worse neurologic outcomes. More patients with sodium variability of 6-12 and >12 mEq/L had cerebral infarction than those with variability <6 mEq/L and had modified Rankin Scale scores of 2-3 and 4-6, respectively (P = 0.001). CONCLUSIONS: Sodium fluctuation, not hyponatremia, is associated with worse neurologic outcome in patients with aneurysmal subarachnoid hemorrhage. This is in contradistinction to current teaching and warrants further examination.

Ventilation by mask before and after the administration of neuromuscular blockade: a pragmatic non-inferiority trial.

BACKGROUND: Test ventilating prior to administration of neuromuscular blockade (NMB) in order to avoid a cannot intubate-cannot ventilate situation is a classic anesthesia teaching. The primary aim of our study was to show that facemask ventilation (FMV) after NMB was not inferior to FMV prior to NMB with respect to exhaled gas volumes before and after their administration. METHODS: This study was approved by the University of Washington Human Subjects Division (Seattle, Washington, USA). Written informed consent was obtained from all patients. Measurements of tidal volume (Vte) as well as other respiratory parameters during FMV were made for 60 s after induction of anesthesia and again after NMB. Difficult, impossible, inadequate, and dead-space only mask ventilation was graded using published definitions. Difficult intubation was defined as >2 attempts at intubation. The primary outcome was non-inferiority in Vte during both study periods defined as a mean difference of <50 mL. Multivariate analysis was performed to assess for interaction between operator experience, patient risk factors for difficult mask ventilation, exhaled volumes, and use of airway adjuncts. RESULTS: Two-hundred and ten patients were studied. Overall, FMV improved after NMBD. The mean (SD) Vte in mL/breath increased from 399 (169) to 428 (166) (mean dif. 30 mL, p = 0.001) and the minute ventilation in L/min from 5.6 (2.5) to 6.3 (2.5) (mean dif. 0.6, p < 0.001). No patient who was difficult to ventilate after induction became impossible after NMB. DISCUSSION: In patients at risk for or judged to be a difficult FMV by clinical grading scales, tidal volumes improved after administration of NMBDs. None of these patients exhibited a decline in ventilation or became impossible to ventilate after NMBDs. Several limitations are noted, including the use of hand-delivered breaths and inability to account for time-related changes in ventilation conditions independent of NMBDs. CONCLUSION: We conclude that FMV is no worse after NMB than before and is likely to improve airway conditions. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02237443 . Registered August 28, 2014.

Modulation of P-glycoprotein at the Human Blood-Brain Barrier by Quinidine or Rifampin Treatment: A Positron Emission Tomography Imaging Study.

Permeability-glycoprotein (P-glycoprotein, P-gp), an efflux transporter at the human blood-brain barrier (BBB), is a significant obstacle to central nervous system (CNS) delivery of P-gp substrate drugs. Using positron emission tomography imaging, we investigated P-gp modulation at the human BBB by an approved P-gp inhibitor, quinidine, or the P-gp inducer, rifampin. Cerebral blood flow (CBF) and BBB P-gp activity were respectively measured by administration of (15)O-water followed by (11)C-verapamil. In a crossover design, healthy volunteers received quinidine and 11-29 days of rifampin treatment during different study periods. CBF and P-gp activity was measured in the absence (control; prior to quinidine treatment) and presence of P-gp modulation. At clinically relevant quinidine plasma concentrations, P-gp inhibition resulted in a 60% increase in (11)C-radioactivity distribution across the human BBB as measured by the brain extraction ratio (ER) of (11)C-radioactivity. Furthermore, the magnitude of BBB P-gp inhibition by quinidine was successfully predicted by a combination of in vitro and macaque data, but not by rat data. Although our findings demonstrated that quinidine did not completely inhibit P-gp at the human BBB, it has the potential to produce clinically significant CNS drug interactions with P-gp substrate drugs that exhibit a narrow therapeutic window and are significantly excluded from the brain by P-gp. Rifampin treatment induced systemic CYP3A metabolism of (11)C-verapamil; however, it reduced the ER by 6%. Therefore, we conclude that rifampin, at its usual clinical dose, cannot be used to induce P-gp at the human BBB to a clinically meaningful extent and is unlikely to cause inadvertent BBB-inductive drug interactions.

Retrospective investigation of the effects and efficiency of self-ligating and conventional brackets.

INTRODUCTION: The purpose of this retrospective cohort study was to assess the effects and efficiency of self-ligating brackets compared with conventional brackets. A secondary purpose was to identify the pretreatment factors associated with the choice of self-ligating or conventional brackets. METHODS: The subjects were treated by 2 private practitioners who used both self-ligating and conventional brackets in their practices. The self-ligating subjects were consecutively identified (treatment completed between January 2011 and April 2012), and then an age- and sex-matched control group was chosen from the same office. The outcome measures were changes in arch dimensions, changes in mandibular incisor inclinations, final peer assessment rating (PAR) scores, percentages of PAR reduction, overall treatment times, total number of visits, and number of emergency visits. All cast and cephalometric measurements were performed on digital records in a blinded manner. Two calibrated assessors measured the PAR scores. RESULTS: The final sample comprised 74 patients from clinician 1 and 34 patients from clinician 2. The practitioners had significant differences for several treatment parameters; therefore, the data from the 2 clinicians were analyzed separately. For clinician 1, no significant differences were observed between the self-ligating and conventional groups, other than increased arch length in the self-ligating group. The self-ligation patients treated by clinician 2 demonstrated significant increases in transverse dimensions, lower percentages of reduction in PAR scores, shorter treatment times, fewer visits, and more wire-sliding emergencies than the conventional bracket group. CONCLUSIONS: Although some significant findings were observed, the small sample and the lack of consistent findings between the 2 clinicians made it difficult to draw strong conclusions.

Hypoglossal nerve palsy after airway management for general anesthesia: an analysis of 69 patients.

Isolated hypoglossal nerve palsy (HNP), or neurapraxia, a rare postoperative complication after airway management, causes ipsilateral tongue deviation, dysarthria, and dysphagia. We reviewed the pathophysiological causes of hypoglossal nerve injury and discuss the associated clinical and procedural characteristics of affected patients. Furthermore, we identified procedural factors potentially affecting HNP recovery duration and propose several measures that may reduce the risk of HNP. While HNP can occur after a variety of surgeries, most cases in the literature were reported after orthopedic and otolaryngology operations, typically in males. The diagnosis is frequently missed by the anesthesia care team in the recovery room due to the delayed symptomatic onset and often requires neurology and otolaryngology evaluations to exclude serious etiologies. Signs and symptoms are self-limited, with resolution occurring within 2 months in 50% of patients, and 80% resolving within 4 months. Currently, there are no specific preventive or therapeutic recommendations. We found 69 cases of HNP after procedural airway management reported in the literature from 1926 to 2013.

Medicaid and privately financed orthodontic patients have similar occlusal and psychosocial outcomes.

OBJECTIVE: This study compares occlusal and psychosocial outcomes from comprehensive orthodontic treatment in Medicaid (MC) and privately financed (private pay, PP) patients. METHODS: Two cohorts received comprehensive orthodontics: MC (n = 66); PP (n = 60). A calibrated, blinded examiner scored dental casts at baseline (pretreatment, T1) and after completing 2 years of treatment (posttreatment, T2) using the Peer Assessment Rating (PAR) and the Index of Complexity, Outcome, and Need (ICON). The prevalence of patients in the validated ICON categories for treatment need, complexity, and improvement were calculated. Questionnaires to assess body image (BI) and expectations/experiences were administered. Occlusal measures at T2 were compared after adjustment for baseline characteristics. Psychosocial measures were compared between and within groups. Occlusal and psychosocial associations were evaluated. RESULTS: MC was 1.3 years younger (P < 0.001) and had worse malocclusions at baseline (PAR 32 versus 25; P < 0.001); (ICON 64 versus 56; P = 0.06). After adjustment for age and initial severity, estimated average differences between groups at T2 (MC-PP) were slight: 1.5 [95 percent confidence interval (CI) -2.9, 5.9] and 2.4 (95 percent CI -4.4, 8.9) for PAR and ICON, respectively. More PP completed treatment under 2 years (85 percent versus 62 percent; P = 0.03). At baseline, both groups needed treatment, but MC malocclusions were more complex (P = 0.05). At T2, both groups were acceptable and there were no differences in ICON improvement categories. Group differences in psychosocial measures and associations between psychosocial and occlusal measures were evident in the "teeth" domain but weak or lacking elsewhere. CONCLUSIONS: Occlusal and psychosocial outcomes from orthodontics in MC and PP were comparable, despite worse MC malocclusions at baseline.

Effects of bronchoconstriction, minute ventilation, and deep inspiration on the composition of exhaled breath condensate.

BACKGROUND: Exhaled breath condensate (EBC) is composed of droplets of airway surface liquid (ASL) diluted by water vapor. The goal of this study was to determine if the composition of EBC is affected by changes in airway caliber, minute ventilation, or forceful exhalation, factors that may differ among subjects with asthma in cross-sectional studies. METHODS: In a group of subjects with asthma, we measured the effects of the following: (1) a series of three deep-inspiration and forceful-exhalation maneuvers; (2) a doubling of minute ventilation; and (3) acute bronchoconstriction induced by methacholine on EBC volume, dilution of ASL, and concentration of cysteinyl leukotrienes (CysLTs). RESULTS: With the exception of an increase in EBC volume with increased minute ventilation, there were no significant changes in the volume, dilution, or levels of CysLTs in EBC introduced by each of these factors. The CIs surrounding the differences introduced by each factor showed that the maximum systematic errors due to these factors were modest. CONCLUSIONS: These results indicate that changes in airway caliber, minute ventilation, or breathing pattern among subjects with asthma do not significantly alter the measurements of mediator concentrations in EBC.

Efficacy of a computerized shade selection system in matching the shade of anterior metal-ceramic crowns--a pilot study.

OBJECTIVE: The purpose of this study was to determine whether anterior crowns fabricated using a computerized shade selection system (ShadeScan, Cynovad) (experimental procedure) match adjacent teeth better than anterior crowns fabricated using conventional shade prescription and clinical slides (control). METHOD AND MATERIALS: Five subjects who required a crown to restore a maxillary central incisor were selected. Two metal-ceramic crowns were fabricated for each incisor, 1 using the experimental procedure and 1 using the control method. The shade selection method to be used for the first and second crowns was randomly assigned. The duration of each procedure was recorded. Each restoration was tried-in in a double-blind manner and evaluated for its level of match to adjacent teeth using modified Ryge criteria. Data were analyzed within each subject using descriptive statistics and paired t test (alpha = .05). RESULTS: In 40% of the cases, both procedures did equally well. In the remaining 60% of the cases the control procedure (two-thirds of the cases) performed better than the experimental procedure (one-third of the cases). Duration of the control procedure was 14.4 +/- 5 minutes, and the experimental procedure was 5.2 +/- 3.3 minutes. A paired t test showed the difference was significant (P = .0045). CONCLUSION: The level of matching of crowns fabricated with the ShadeScan system was not different from crowns fabricated using the control. However, it took significantly less time to record the shade with the ShadeScan system.

Effect of aging on the response of ghrelin to acute weight loss.

OBJECTIVES: To determine whether the failure of the orexigenic hormone ghrelin to increase as it normally does with weight loss contributes to impaired weight recovery in older persons. DESIGN: Prospective diet intervention study. SETTING: University of Washington Medical Center from 2001 through 2005. PARTICIPANTS: Twenty-one younger (18-35) and 18 older (> or =70) men and women. INTERVENTION: Two weeks of a weight-maintaining diet were followed in sequence by 2 weeks of 30% calorie restriction, then 4 weeks of ad libitum food intake. MEASUREMENTS: Twenty-four-hour plasma ghrelin levels, dual x-ray absorptiometry scan for body composition, resting energy expenditure, and calorie intakes were measured. RESULTS: Both younger and older subjects lost weight with calorie restriction and failed to fully regain their baseline weight. The older adults trended toward increasing their calorie intake above their baseline level during the ad libitum period (111+/-66 kcal, P=.11), whereas the younger individuals did not (-236+/-95 kcal, P=.02). There was no statistically significant difference between the two cohorts in 24-hour ghrelin levels before or after calorie restriction. Ghrelin levels in the two cohorts increased equivalently after calorie restriction and decreased after ad libitum food consumption resumed. CONCLUSION: Ghrelin levels in healthy older individuals respond appropriately in a compensatory manner to changes in body weight and calorie intake.