Socioeconomic Disparities in Pediatric Traumatic Brain Injury Transfer Patterns: An Analysis of Area Deprivation Index and Clinical Outcomes.

BACKGROUND: Traumatic brain injury (TBI) poses a significant health burden, particularly among pediatric populations, leading to long-term cognitive, physical, and psychosocial impairments. Timely transfer to specialized trauma centers is crucial for optimal management, yet the influence of socioeconomic factors, such as the Area Deprivation Index (ADI), on transfer patterns remains understudied. METHODS: A retrospective study was conducted on pediatric TBI patients presenting to a Level I Pediatric Trauma Center between January 2012 and July 2023. Transfer status, distance, mode of transport, and clinical outcomes were analyzed in relation to ADI. Statistical analyses were performed using Student t-test and analysis of variance. RESULTS: Of 359 patients, 53.5% were transferred from outside hospitals, with higher ADI scores observed in transfer patients (P<0.01). Air transport was associated with greater distances traveled and higher ADI compared to ground ambulance (P<0.01). Despite similarities in injury severity, intensive care unit admission rates differed between transfer modes, with no significant impact on mortality. CONCLUSIONS: High ADI patients were more likely to be transferred, suggesting disparities in access to specialized care. Differences in transfer modes highlight the influence of socioeconomic factors on logistical aspects. While transfer did not independently impact outcomes, disparities in intensive care unit admission rates were observed, possibly influenced by injury severity. Integrating socioeconomic data into clinical decision-making processes can inform targeted interventions to optimize care delivery and improve outcomes for all pediatric TBI patients. Prospective, multicenter studies are warranted to further elucidate these relationships.

Risk Factors for Postoperative Unplanned Reintubation in a Cohort of Patients Undergoing General Anesthesia.

Background Unplanned post-operative reintubation (UPR) is a complication of general anesthesia (GA) that can be associated with worsened outcomes. Objective Evaluate characteristics associated with UPR in patients undergoing procedures under GA. Methods Patients over the age of 18 undergoing surgical procedures under GA were extracted from our institution's electronic medical record. Patient baseline, procedural, and anesthesia characteristics were evaluated for associations with UPR. Results In 29,284 surgical procedures undergoing GA, there were 29 (0.1%) patients that required UPR. The most common surgical service with UPR was otolaryngology; the most common surgical positioning was supine. When controlling for operative time and case complexity, UPR was predicted by high-dose opioids, defined as opioid administration greater than the 75th percentile of our institutional cohort. Prolonged operative time, estimated blood loss (EBL), body mass index (BMI), extubation time after reversal, or age were not independently associated with UPR. Conclusion Our analysis revealed that high-dose opioid administration is independently associated with intraoperative UPR. Awareness of patients at the highest risk for UPR along with provider education regarding techniques to avoid respiratory depression in this patient population is essential in reducing patient morbidity and mortality. This knowledge will help guide perioperative physicians in medical optimization, appropriate selection of intraoperative analgesics, and cautious extubation criteria to ensure patient safety.

Risk factors for posttraumatic hydrocephalus after decompressive hemicraniectomy in pediatric patients with traumatic brain injury.

OBJECTIVE: Traumatic brain injuries (TBIs) play a significant role in pediatric mortality and morbidity. Decompressive hemicraniectomy (DHC) is a treatment option for severe pediatric TBI (pTBI) not amenable to medical management of intracranial pressure. Posttraumatic hydrocephalus (PTH) is a known sequela of DHC that may lead to further injury and decreased capacity for recovery if not identified and treated. The goal of this study was to characterize risk factors for PTH after DHC in patients with pTBI by using the Kids' Inpatient Database (KID). METHODS: The records collected in the KID from 2016 to 2019 were queried for patients with TBI using International Classification of Diseases, 10th Revision codes. Data defining demographics, complications, procedures, and outcomes were extracted. Multivariate regression was used to identify risk factors associated with PTH. The authors also investigated length of stay and hospital charges. RESULTS: Of 68,793 patients with pTBI, 848 (1.2%) patients underwent DHC. Prolonged mechanical ventilation (PMV) was required in 475 (56.0%) patients with pTBI undergoing DHC. Three hundred (35.4%) patients received an external ventricular drain (EVD) prior to DHC. PTH was seen in 105 (12.4%), and 50 (5.9%) received a ventriculoperitoneal shunt. DHC before hospital day 2 was negatively associated with PTH (OR 0.464, 95% CI 0.267-0.804; p = 0.006), whereas PMV (OR 2.204, 95% CI 1.344-3.615; p = 0.002) and EVD placement prior to DHC (OR 6.362, 95% CI 3.667-11.037; p < 0.001) were positively associated with PTH. PMV (OR 7.919, 95% CI 2.793-22.454; p < 0.001), TBI with subdural hematoma (OR 2.606, 95% CI 1.119-6.072; p = 0.026), and EVD placement prior to DHC (OR 4.575, 95% CI 2.253-9.291; p < 0.001) were independent predictors of ventriculoperitoneal shunt insertion. The mean length of stay and total hospital charges were significantly increased in patients with PMV and in those with PTH. CONCLUSIONS: PMV, presence of subdural hematoma, and EVD placement prior to DHC are risk factors for PTH in patients with pTBI who underwent DHC. Higher healthcare resource utilization was seen in patients with PTH. Identifying risk factors for PTH may improve early diagnosis and efficient resource utilization.

Mandatory Grand Rounds Evaluations: More Data, Less Information.

AIMS: For several years, physicians have been required to evaluate a continuing medical education (CME) session before receiving a certificate of participation from an accredited provider. The mandatory nature of these evaluations has led to a high number of evaluations that offer information of questionable utility. MATERIAL AND METHODS: We asked our CME evaluation vendor Eeds for all of the CME evaluation timestamps for our grand rounds from August 5 to September 16, 2020. We obtained time-stamped evaluation data from our CME services vendor and compared the times that sessions were evaluated to the start and completion times of those CME sessions. RESULTS: While almost all attendees completed electronic evaluations, 8% did so before the start of the session and half did so before its completion. CONCLUSIONS: Making evaluations mandatory has had the effect of lowering the quality of the data thus obtained. In an age that has been described as the "graying of grand rounds," there are more effective strategies to enhance educational value and learner satisfaction.

A patient reads the medical literature.

A 45-year-old male with no significant past medical history presented with a lump in his right groin. Outpatient computed tomography imaging ordered by his primary care physician demonstrated moderate right inguinal hernia containing nonobstructed distal descending/proximal sigmoid colon. Surgical repair of the hernia was recommended and the patient was referred for consultation with a general surgeon. The patient then conducted a search of current medical literature and, upon reflection, refused to let the consulted surgeon operate upon him. After identifying a significantly more experienced surgeon, the patient underwent office consultation and, later, uneventful surgical repair of his inguinal hernia. To follow is a case description with a review of the relevant literature read by the patient that informed his decision to be operated upon only by a more senior general surgeon.

Early Detection and Management of Massive Intraoperative Pulmonary Embolism in a Patient Undergoing Repair of a Traumatic Acetabular Fracture.

A 73-year-old male with history of hyperlipidemia and osteoarthritis was transferred from an outside hospital after a fall from a ladder at home. He sustained a severe right sided acetabular fracture involving the femoral head, requiring operative repair. Preoperative evaluation was unremarkable except for oxygen saturation < 95 %. After induction of anesthesia and surgical positioning, the patient went into cardiac arrest. After intraoperative cardiopulmonary resuscitation (CPR) and placement on extracorporeal membrane oxygenation (ECMO), the patient stabilized. Cardiac catheterization revealed a large left pulmonary embolism. Here, we discuss the etiology and management of intraoperative pulmonary embolism.

General Anesthesia During Endovascular Stroke Therapy Does Not Negatively Impact Outcome.

OBJECTIVE: Recent randomized trials have demonstrated that endovascular therapy improves outcomes in patients with an acute ischemic stroke from a large vessel occlusion. Subgroup analysis of the Multicenter Randomized CLinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN) study found that patients undergoing general anesthesia (GA) for the procedure did worse than those with nongeneral anesthesia (non-GA). Current guidelines now suggest that we consider non-GA over GA, without large, randomized trials specifically designed to address this issue. We sought to review our experience and outcomes in a program where we routinely use GA in patients undergoing mechanical thrombectomy with similar techniques. METHODS: Patients with anterior circulation strokes who received intravenous tissue plasminogen activator (IV-tPA) and endovascular stroke therapy were included in the analysis. The National Institutes of Health Stroke Scale (NIHSS) on admission and discharge and modified Rankin scale scores at discharge were recorded and compared with the outcome measurements of MR CLEAN. RESULTS: Sixty patients were identified: 39 males and 21 females with a mean age of 62 (range of 29-88). Forty-seven patients were transferred from outside primary stroke centers, while 13 patients presented directly to our institution. Median NIHSS on admission was 15. The median time of symptom onset to endovascular therapy was 265 minutes, with an interquartile range of 81 minutes. Using the thrombolysis in cerebral infarction (TICI) scale, recanalization of TICI 2b-3 was achieved in 76.4% of recorded patients (42/55 recorded). At discharge, mortality was 16.7% (10/60), median NIHSS was 5, and 38.3% (23/60) of patients had a modified Rankin Scale score of 0-2. CONCLUSIONS: General anesthesia does not worsen outcome in patients undergoing mechanical thrombectomy when compared to historical subgroups. Despite a longer time from symptom onset to treatment, our outcomes for patients receiving GA compare favorably to the GA and non-GA groups in MR CLEAN.

PSEUDOCHOLINESTERASE DEFICIENCY IN A OCTOGENARIAN UNDERGOING TOTAL INTRAVENOUS ANESTHESIA; IMPLICATIONS FOR NEUROMONITORING.

Pseudocholinesterase deficiency manifests as prolonged motor blockade after the administration of succinylcholine. A previously unknown homozygous form of the disease, became apparent during a lumbar laminectomy seriously limiting the ability to monitor motor evoked potentials and perform electromyelography (EMG). Moreover, concerns were raised as to how the enzyme deficiency would affect the metabolism of remifentanil and other esters during a total intravenous anesthetic. We present the perioperative management of the patient and a literature review of the syndrome. The patient provided written permission for the authors to publish this report. At our institution, IRB review and approval is not required for a single case report.

Accidental tracheal extubation of a patient in the prone position.

While undergoing emergency C6-C7 corpectomy and anterior and posterior fusion, our prone patient in whom airway management had been difficult experienced unplanned tracheal extubation. Herein, we describe emergency airway management including reintubation and provide suggestions for airway management in the prone-positioned patient.