Unexpected Shocks From a Subcutaneous Implantable Cardioverter-Defibrillator Despite Attempted Reprogramming and Magnet Use: A Case Report.

We present the case of a patient with a subcutaneous implantable cardioverter-defibrillator (S-ICD) in situ. Device interrogation and reprogramming were unsuccessful due to a software mismatch between the device and programmer. The device manufacturer recommended magnet application to suspend antitachycardia therapy. Despite using this strategy, the S-ICD discharged multiple times. The S-ICD has unique perioperative considerations for the anesthesiologist. This case provides an example of the complexity of electrophysiologic devices in current use and the necessity of the anesthesia provider to stay up to date with evolving device management strategies.

Associations Between Opioid Prescribing Patterns and Overdose Among Privately Insured Adolescents.

OBJECTIVES: Little is known about the risk for overdose after opioid prescription. We assessed associations between the type of opioid, quantity dispensed, daily dose, and risk for overdose among adolescents who were previously opioid naive. METHODS: Retrospective analysis of 1 146 412 privately insured adolescents ages 11 to 17 years in the United States captured in the Truven MarketScan commercial claims data set from January 2007 to September 2015. Opioid overdose was defined as any emergency department visit, inpatient hospitalization, or outpatient health care visit during which opioid overdose was diagnosed. RESULTS: Among our cohort, 725 participants (0.06%) experienced an opioid overdose, and the overall rate of overdose events was 28 events per 100 000 observed patient-years. Receiving ≥30 opioid tablets was associated with a 35% increased risk for overdose compared to receiving ≤18 tablets (hazard ratio [HR] = 1.35; 95% confidence interval: 1.05-1.73; P = .02). Daily prescribed opioid dose was not independently associated with an increased risk for overdose. Tramadol exposure was associated with a 2.67-fold increased risk for opioid overdose compared to receiving oxycodone (adjusted HR = 2.67; 95% confidence interval: 1.90-3.75; P < .0001). Adolescents with preexisting mental health conditions demonstrated increased risk for overdose, with HRs ranging from 1.65 (anxiety) to 3.09 (substance use disorders). CONCLUSIONS: One of 1600 (0.06%) previously opioid-naive adolescents who received a prescription for opioids experienced an opioid overdose a median of 1.75 years later that resulted in medical care. Preexisting mental health conditions, use of tramadol, and higher number of dispensed tablets (>30 vs <18) were associated with an increased risk of opioid overdose.

Impact of Clinical Guidelines on Revisits After Ambulatory Pediatric Adenotonsillectomy.

BACKGROUND: Pediatric adenotonsillectomies are common and carry known risks of potentially severe complications. Complications that require a revisit, to either the emergency department or hospital readmission, increase costs and may be tied to lower reimbursements by federal programs. In 2011 and 2012, recommendations by pediatric and surgical organizations regarding selection of candidates for ambulatory procedures were issued. We hypothesized that guideline-associated changes in practice patterns would lower the odds of revisits. The primary objective of this study was to assess whether the odds of a complication-related revisit decreased after publication of guidelines after accounting for preintervention temporal trends and levels. The secondary objective was to determine whether temporal associations existed between guideline publication and characteristics of the ambulatory surgical population. METHODS: This study employs an interrupted time series design to evaluate the longitudinal effects of clinical guidelines on revisits. The outcome was defined as revisits after ambulatory tonsillectomy for privately insured patients. Data were sourced from the Truven Health Analytics MarketScan database, 2008-2015. Revisits were defined by the most prevalent complication types: hemorrhage, dehydration, pain, nausea, respiratory problem, infection, and fever. Time periods were defined by surgeries before, between, and after guidelines publication. Unadjusted odds ratios estimated associations between revisits and clinical covariates. Multivariable logistic regression was used to estimate the impact of guidelines on revisits. Differences in revisit trends among pre-, peri-, and postguideline periods were tested using the Wald test. Results were statistically significant at P < .005. RESULTS: A total of 326,993 surgeries met study criteria. The absolute revisit rate increased over time, from 5.9% (95% confidence interval [CI], 5.8-6.0) to 6.7% (95% CI, 6.6-6.9). The proportion of young children declined slightly, from 6.4% to 5.9% (P < .001). The proportion of patients having a tonsillectomy in an ambulatory surgery center increased (16.5%-31%; P < .001), as did the prevalence of obstructive sleep apnea (7.0%-14.0%; P < .001) and sleep-disordered breathing (20.6%-35.0%; P < .001). In a multivariable logistic regression model adjusted for age, sex, comorbidities, and surgical location, odds of a revisit increased during the preguideline period (0.4% increase per month; 95% CI, 0.24%-0.54%; P < .001). This monthly increase did not continue after guidelines (P = .002). CONCLUSIONS: While odds of a postoperative revisit did not decline after guideline publication, there was a significant difference in trend between the pre- and postguideline periods. Changes in the ambulatory surgery population also suggest at least partial adherence to guidelines.

Variability in opioid prescribing for children undergoing ambulatory surgery in the United States.

STUDY OBJECTIVE: We attempted to describe the opioid prescribing patterns for ambulatory pediatric surgery in the United States from 2007 to 2014. DESIGN: Retrospective database review. SETTING: Operating room ambulatory encounters as determined by the Truven Health Marketscan Commercial Claims and Encounters database. PATIENTS: A total of 929,874 ambulatory surgical encounters were identified in patients <18years of age and, of these, 439,286 encounters generated an analgesic prescription. INTERVENTIONS: N/A MEASUREMENTS: The analgesic prescription was described in terms of the type of opioid along with the inclusion of acetaminophen and/or NSAIDs. MAIN RESULTS: The probability of receiving a post-operative analgesic prescription increased with age, ranging from 18.2% of infants to 71.7% of teens. Acetaminophen with codeine (APAP/C) was the most common drug for infants (63.8%), while acetaminophen with hydrocodone (APAP/H) was the most common analgesic prescription for teens (53.6%). APAP/C and APAP/H were the predominant drugs used for all procedure types. CONCLUSIONS: Substantial variability in analgesic prescribing at the level of the procedure performed, both in terms of the probability of receiving a prescription and in which drugs were prescribed. We observed significant age and procedure-based variability in opioid prescribing following pediatric ambulatory surgery.

Associations Between Age and Dosing of Volatile Anesthetics in 2 Academic Hospitals.

BACKGROUND: The inverse relationship between age and dose requirement for potent volatile anesthetics is well established, but the question of whether anesthetic providers consider this relationship in practice remains unanswered. We sought to determine whether there is an association between patient age and the mean dose of volatile anesthetic delivered during maintenance of anesthesia. METHODS: This was a retrospective cross-sectional study of patients receiving a single potent volatile anesthetic at 2 academic hospitals using data recorded in an anesthesia information management system. Multivariate linear models were constructed at each hospital to examine the relationship between age and mean minimum alveolar concentration (MAC) fraction delivered during the maintenance of anesthesia. RESULTS: A total of 7878 cases at the 2 hospitals were included for analysis. For patients aged <65 years, we observed decreasing doses of volatile anesthetics as age increased. Per decade, mean delivered MAC fraction decreased by an estimated 1.8% (95% confidence interval, 1.5-2.2, P < 0.0001), smaller than the 6.7% decrease suggested by previous studies of human anesthetic requirements. At age >65 years, the magnitude of the inverse association between age and MAC fraction was higher (3.8% decrease per decade; 95% confidence interval, 2.9-4.7). CONCLUSIONS: Increasing age is associated with decreased absolute doses of potent volatile anesthetics, an association that seems to strengthen as patients enter the geriatric age range. The observed decreases in absolute anesthetic dose were less than those predicted by previous research and therefore represent an overall increase in "age-adjusted dose" as patients grow older.

Validity of exchangeable solute balance as a measure of blood volume in neurologically injured adults.

BACKGROUND: Daily weight (DW) and examination of fluid balances (FB) are commonly used in assessments of extracellular fluid (ECF) and circulating blood volume (BV). We hypothesized that a calculated total body exchangeable solute, the main determinant of the ECF, would have high agreement and correlation with actual BV. METHODS: The University of Washington IRB approved the study. We included a sample of consecutive adult patients in whom a BV was measured, while in the neuroscience intensive care units of a large academic medical center. BV was measured as part of routine care using iodinated (131)I albumin injection and the BVA-100 (Daxor Corp, New York, NY, USA). Total body exchangeable solute was estimated at the time of BV measurement by multiplying the calculated total body water by the sum of the sodium plus potassium and chloride measured in plasma. The correlation between the change in DW, FB (adjusted for insensible fluid loss), exchangeable solute, and BV was performed using linear regression with adjustment for number of days between admit and BV measurement, and capillary leak. Errors were computed using robust variance estimation. RESULTS: 55 patients had BV tests available, and 43 of them had subarachnoid hemorrhage. Total body exchangeable solute strongly correlated with BV (r = 0.75, 95% CI 0.63-0.84, p < 0.01 for Na(+)/K(+), and r = 0.71, 95% CI 0.58-0.81, p < 0.01 for Cl(-)). DW (r = 0.21) and FB (r = 0.11) were not correlated with BV. CONCLUSIONS: Total body exchangeable solute appears to be a valid and reliable measure of BV and can be calculated using information readily available at the bedside. The value of having this information automatically calculated and available at the bedside should be explored.

National variability in intracranial pressure monitoring and craniotomy for children with moderate to severe traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI) is a significant cause of mortality and disability in children. Intracranial pressure monitoring (ICPM) and craniotomy/craniectomy (CRANI) may affect outcomes. Sources of variability in the use of these interventions remain incompletely understood. OBJECTIVE: To analyze sources of variability in the use of ICPM and CRANI. METHODS: Retrospective cross-sectional study of patients with moderate/severe pediatric TBI with the use of data submitted to the American College of Surgeons National Trauma Databank. RESULTS: We analyzed data from 7140 children at 156 US hospitals during 7 continuous years. Of the children, 27.4% had ICPM, whereas 11.7% had a CRANI. Infants had lower rates of ICPM and CRANI than older children. A lower rate of ICPM was observed among children hospitalized at combined pediatric/adult trauma centers than among children treated at adult-only trauma centers (relative risk = 0.80; 95% confidence interval 0.66-0.97). For ICPM and CRANI, 18.5% and 11.6%, respectively, of residual model variance was explained by between-hospital variation in care delivery, but almost no correlation was observed between within-hospital tendency toward performing these procedures. CONCLUSION: Infants received less ICPM than older children, and children hospitalized at pediatric trauma centers received less ICPM than children at adult-only trauma centers. In addition, significant between-hospital variability existed in the delivery of ICPM and CRANI to children with moderate-severe TBI.

Oxygen and pulse oximetry in childhood pneumonia: a survey of healthcare providers in resource-limited settings.

Globally, pneumonia is the leading cause of death in children <5 years of age. Hypoxemia, a frequent complication of pneumonia, is a risk factor for death. To better understand the availability of oxygen and pulse oximetry, barriers to use and provider perceptions and practices regarding their role in childhood pneumonia, we conducted a survey using a convenience sampling strategy targeting clinicians working in resource-limited countries. Most respondents were physicians from public district and provincial hospitals with access to oxygen and pulse oximetry; however, reported therapeutic use for childhood pneumonia was low. Common barriers included insufficient supply, competition for use, lack of policies, guidelines and training and perceived high cost. Despite the frequency of hypoxemia, the inaccuracy of clinical predictors, the poor outcome hypoxemia portends and the effectiveness of pulse oximetry and oxygen in childhood pneumonia, our data indicate that these tools may be underused in resource-limited settings.

Unnecessary care for bronchiolitis decreases with increasing inpatient prevalence of bronchiolitis.

OBJECTIVE: To measure the association between inpatient bronchiolitis prevalence (IBP) and the delivery of unnecessary tests and treatments to patients hospitalized with bronchiolitis. METHODS: A multicenter, retrospective, cohort study was performed using the Pediatric Hospital Information System database. All patients 2 months to 2 years of age hospitalized with bronchiolitis during 2004-2008 at participating pediatric hospitals were included. Main outcome measures were the probability of receiving potentially unnecessary care for bronchiolitis, including steroids, intravenously administered antibiotics, chest or neck radiographs, and any laboratory tests during hospitalization. RESULTS: During winter months, with each 1% absolute increase in IBP, patients were less likely to receive steroids (incidence rate ratio: 0.968 [95% confidence interval: 0.960-0.976]; P < .001), radiographs (incidence rate ratio: 0.988 [95% confidence interval: 0.984-0.992]; P < .001), and laboratory tests (incidence rate ratio: 0.992 [95% confidence interval: 0.988-0.995]; P < .001). During summer months, similar associations were observed for steroids and radiographs. No association between IBP and antibiotic use was observed during either time period. CONCLUSIONS: The frequency with which several types of unnecessary care were delivered to patients with bronchiolitis seemed to decrease with increasing IBP. This finding suggests that an association exists between contextual information and care delivery during the management of acute illness, and it highlights the importance of such information for delivery of high-quality health care.

Investigating a pediatric hospital's response to an inpatient census surge during the 2009 H1N1 influenza pandemic.

BACKGROUND: On November 4, 2009, the 250-bed Seattle Children's Hospital (SCH) identified a surge in its census--245 inpatients, well above the average midnight census of 207. In response, SCH activated its pandemic influenza surge plan in an effort to decrease the inpatient census. Within 16 hours, 51 patients (20.4% of total bed capacity) had been discharged, and inpatient census at SCH decreased to 222 patients. METHODS: As part of a quality improvement project, SCH's response to the surge was investigated, with data drawn from interviews, a review of records created in the course of the surge plan implementation, an e-mail survey of attending physicians responsible for patient discharges, and models examining predictors of hospital discharges. FINDINGS: Analysis of three years of hospital data (2007-2009) indicated that the high census on November 4 was an uncommon but not unprecedented occurrence. In addition, there was a clear positive association between an evening's census and the number of discharges during the following 24 hours. SCH discharged essentially the same number of patients on November 4 as on previous high-census days when the surge plan was not activated, suggesting that the surge plan did not succeed in creating excess discharges. CONCLUSIONS: Increasingly, evidence indicates that care quality depends on the degree to which hospital resources are sufficient to meet demand. Reverse triage, at least as implemented by SCH on November 4, 2009, is unlikely to represent an effective solution to surge outside of a disaster setting because of its requirement for centralized decision making. SCH has incorporated the results of this review into the way that it collects and analyzes data, manages flow, and responds to inpatient surges.

Diagnostic utility of B-type natriuretic peptide in critically ill patients with pulmonary edema: a prospective cohort study.

INTRODUCTION: Distinguishing pulmonary edema due to acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS) from hydrostatic or cardiogenic edema is challenging in critically ill patients. B-type natriuretic peptide (BNP) can effectively identify congestive heart failure in the emergency room setting but, despite increasing use, its diagnostic utility has not been validated in the intensive care unit (ICU). METHODS: We performed a prospective, blinded cohort study in the medical and surgical ICUs at the University of Chicago Hospitals. Patients were eligible if they were admitted to the ICU with respiratory distress, bilateral pulmonary edema and a central venous catheter suggesting either high-pressure (cardiogenic) or low-pressure (ALI/ARDS) pulmonary edema. BNP levels were measured within 48 hours of ICU admission and development of pulmonary edema and onward up to three consecutive days. All levels were drawn simultaneously with the measurement of right atrial or pulmonary artery wedge pressure. The etiology of pulmonary edema--cardiogenic or ALI/ARDS--was determined by three intensivists blinded to BNP levels. RESULTS: We enrolled a total of 54 patients (33 with ALI/ARDS and 21 with cardiogenic edema). BNP levels were lower in patients with ALI/ARDS than in those with cardiogenic edema (496 +/- 439 versus 747 +/- 476 pg/ml, P = 0.05). At an accepted cutoff of 100 pg/ml, specificity for the diagnosis of ALI/ARDS was high (95.2%) but sensitivity was poor (27.3%). Cutoffs at higher BNP levels improved sensitivity at considerable cost to specificity. Invasive measures of filling pressures correlated poorly with initial BNP levels and subsequent day BNP values fluctuated unpredictably and without correlation with hemodynamic changes and net fluid balance. CONCLUSION: BNP levels drawn within 48 hours of admission to the ICU do not reliably distinguish ALI/ARDS from cardiogenic edema, do not correlate with invasive hemodynamic measurements, and do not track predictably with changes in volume status on consecutive daily measurements.

Attenuating mutations in the P/C gene of human parainfluenza virus type 1 (HPIV1) vaccine candidates abrogate the inhibition of both induction and signaling of type I interferon (IFN) by wild-type HPIV1.

Recombinant human parainfluenza virus type 1 (HPIV1) and mutants containing point and deletion (Delta) mutations in the P/C gene (r-CDelta10-15HNT553A, r-CR84G, r-CF170S and r-CDelta170), which have previously been evaluated as HPIV1 vaccine candidates, were evaluated for their effect on the type I interferon (IFN) response in vitro. HPIV1 wt infection inhibited the IFN response by inhibiting IFN regulatory factor-3 (IRF-3) activation and IFN production in A549 cells and IFN signaling in Vero cells. In contrast, r-CR84G, r-CF170S and r-CDelta170 were defective for inhibition of IRF-3 activation and IFN production and r-CF170S and r-CDelta170 did not inhibit IFN signaling. Thus, HPIV1 antagonizes the IFN response at both the level of induction and signaling, and antagonism at both levels was disrupted by mutations in the P/C gene. Because CF170S affects C and not P, the anti-IFN function can be attributed to the C proteins. These data, in the context of previous in vivo studies, suggest that the loss of antagonism of the IFN response at both the level of induction and signaling, observed with the P/C mutants, r-CF170S and r-CDelta170, was necessary for significant attenuation in African green monkeys (AGMs).