Nisha Rathi

Body position and obstructive sleep apnea in 8–12-month-old infants

AIM To determine the association between body position and obstructive events during sleep as determined by polysomnography (PSG) in infants of ages 8-12 months with obstructive sleep apnea (OSA). METHODS Consecutive nocturnal polysomnograms (NPSGs) of 50 children ages 8-12 months old referred to the sleep disorders center between 1 January 2003 and 1 June 2006 for possible sleep-disordered breathing were retrospectively reviewed. Data on total obstructive apnea index (AI), total obstructive apnea-hypopnea index (AHI), AI by body position, AHI by body position, rapid eye movement (REM) and non-REM sleep AHI and REM and non-REM AI were recorded. RESULTS The mean age was 9.5+/-1.9S.D. months and 46% of the patients were females. There were no significant differences between the mean non-supine AHI (2.0+/-5.1) and supine AHI (2.5+/-5.4), p=0.63. When comparing specific body positions, there were also no significant differences between the mean supine AHI (2.5+/-5.4), prone AHI (2.9+/-7.3), left-lateral decubitus AHI (1.1+/-6.1), or the right-lateral decubitus AHI (2.5+/-7.6), p=0.71. Additionally, there were also no significant differences between the mean non-supine AI (0.7+/-2.9) and supine AI (1.4+/-3.0), p=0.23, and no differences between the supine AI (0.7+/-2.9), prone AI (1.0+/-2.9), left-lateral decubitus AI (0.3+/-2.9) or the right-lateral decubitus AI (1.1+/-3.0), p=0.44. Children spent an average of 50% of their total sleep time supine. OSA was significantly worse in REM sleep as compared to non-REM sleep (REM AHI 4.3+/-7.3 versus non-REM AHI 1.4+/-3.9, p=0.015; REM AI 5.1+/-4.9 versus non-REM AI 1.5+/-4.9, p<0.001). Mean time in REM sleep was 26% (range 5-42%). CONCLUSIONS There was no significant effect of body position on sleep-disordered breathing in 8-12 months old infants, although REM sleep represented a significant risk factor for OSA.

Low-, medium- and high-dose steroids with or without aminocaproic acid in adult hematopoietic SCT patients with diffuse alveolar hemorrhage

Diffuse alveolar hemorrhage (DAH) is a poorly understood complication of transplantation carrying a high mortality. Patients commonly deteriorate and require intensive care unit (ICU) admission. Treatment with high-dose steroids and aminocaproic acid (ACA) has been suggested. The current study examined 119 critically ill adult hematopoietic transplant patients treated for DAH. Patients were subdivided into low-, medium- and high-dose steroid groups with or without ACA. All groups had similar baseline characteristics and severity of illness scores. Primary objectives were 30, 60, 100 day, ICU and hospital mortality. Overall mortality (n=119) on day 100 was high at 85%. In the steroids and ACA cohort (n=82), there were no significant differences in 30, 60, 100, day, ICU and hospital mortality between the dosing groups. In the steroids only cohort (n=37), the low-dose steroid group had a lower ICU and hospital mortality (P=0.02). Adjunctive treatment with ACA did not produce differences in outcomes. In the multivariate analysis, medium- and high-dose steroids were associated with a higher ICU mortality (P=0.01) as compared with the low-dose group. Our data suggest that treatment strategies may need to be reanalyzed to avoid potentially unnecessary and potentially harmful therapies.

Does Thrombolysis Have a Place in the Cardiopulmonary Resuscitation of Patients With Acute Pulmonary Embolism? A Case of Successful Thrombolysis During Pulmonary Embolism Induced Cardiopulmonary Arrest.

Objective:Pulmonary embolism often causes cardiac arrest. When this occurs, thrombolytic therapy is not routinely administered. There are multiple reasons for this, including difficulty with rapidly adequately diagnosing the embolus, the lack of good data supporting the use of thrombolytics during resuscitation, the belief that thrombolytic therapy is ineffective once a patient has already arrested, the difficulty of obtaining thrombolytics at the bedside rapidly enough to administer during a code, and the increased risks of bleeding, particularly with ongoing chest compressions. In this case report, we present a patient who was successfully treated with thrombolytic therapy during pulmonary embolism–induced cardiopulmonary arrest and discuss the role of thrombolytics in cardiopulmonary resuscitation. Design:Case report. Setting:Surgical ICU in a comprehensive cancer center. Patient:A 56-year-old man who developed hypotension, dyspnea, hypoxia, and pulseless electrical activity 10 days after resection of a benign colon lesion with a right hemicolectomy and primary end-to-end anastomosis. Interventions:After a rapid bedside echocardiogram suggesting pulmonary embolus, thrombolytic therapy was administered during cardiopulmonary resuscitative efforts. Measurements and Main Results:The patient had a return of spontaneous circulation and showed improvement in repeat echocardiographic imaging. He had a prolonged course in the ICU and hospital, but eventually made an essentially complete clinical recovery. Conclusion:As bedside echocardiographic technology becomes more rapidly and readily available, the rapid diagnosis of pulmonary embolism and use of thrombolytics during cardiopulmonary resuscitation may need to be more routinely considered a potential therapeutic adjunctive measure.

Place of Death among Hospitalized Patients with Cancer at the End of Life

BACKGROUND The majority of hospital deaths in the United States occur after ICU admission. The characteristics associated with the place of death within the hospital are not known for patients with cancer. OBJECTIVE The study objective was to identify patient characteristics associated with place of death among hospitalized patients with cancer who were at the end of life. METHODS A retrospective cohort study design was implemented. Subjects were consecutive patients hospitalized between 2003 and 2007 at a large comprehensive cancer center in the United States. Multinomial logistic regression analysis was used to identify patient characteristics associated with place of death (ICU, hospital following ICU, hospital without ICU) among hospital decedents. RESULTS Among 105,157 hospital discharges, 3860 (3.7%) died in the hospital: 42% in the ICU, 14% in the hospital following an ICU stay, and 44% in the hospital without ICU services. Individuals with the following characteristics had an increased risk of dying in the ICU: nonlocal residence, newly diagnosed hematologic or nonmetastatic solid tumor malignancies, elective admission, surgical or pediatric services. A palliative care consultation on admission was associated with dying in the hospital without ICU services. CONCLUSIONS Understanding existing patterns of care at the end of life will help guide decisions about resource allocation and palliative care programs. Patients who seek care at dedicated cancer centers may elect more aggressive care; thus the generalizability of this study is limited. Although dying in a hospital may be unavoidable for patients who have uncontrolled symptoms that cannot be managed at home, palliative care consultations with patients and their families in advance regarding end-of-life preferences may prevent unwanted admission to the ICU.

Two Decades of ICU Utilization and Hospital Outcomes in a Comprehensive Cancer Center.

Objective:To investigate ICU utilization and hospital outcomes of oncological patients admitted to a comprehensive cancer center. Design:Observational cohort study. Setting:The University of Texas MD Anderson Cancer Center. Patients:Consecutive adults with cancer discharged over a 20-year period. Interventions:None. Measurements and Main Results:The Cochran-Armitage test for trend was used to evaluate ICU utilization and hospital mortality rates by primary service over time. A negative binomial log linear regression model was fitted to the data to investigate length of stay over time. Among 387,306 adult hospitalized patients, the ICU utilization rate was 12.9%. The overall hospital mortality rate was 3.6%: 16.2% among patients with an ICU stay and 1.8% among non-ICU patients. Among those admitted to the ICU, the mean (SD) admission Sequential Organ Failure Assessment score was 6.1 (3.8) for all ICU patients: 7.3 (4.4) for medical ICU patients and 4.9 (2.8) for surgical ICU patients. Hematologic disorders were associated with the highest hospital mortality rate in ICU patients (42.8%); metastatic disease had the highest mortality rate in non-ICU patients (4.2%); sepsis, pneumonia, and other infections had the highest mortality rate for all inpatients (8.5%). Conclusions:This study provides a longitudinal view of ICU utilization rates, hospital and ICU length of stay, and severity-adjusted mortality rates. Although the data arise from a single institution, it encompasses a large number of hospital admissions over two decades and can serve as a point of comparison for future oncological studies at similar institutions. More studies of this nature are needed to determine whether consolidation of cancer care into specialized large-volume facilities may improve outcomes, while simultaneously sustaining appropriate resource utilization and reducing unnecessary healthcare costs.

962: USE OF ORDER SETS TO IMPROVE SEDATION AND ANALGESIA PRACTICES IN AN ONCOLOGY INTENSIVE CARE UNIT.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) stratified by response to iNO therapy. We hypothesized that iNO response (20% OI decrease in 6 hours) was associated with survival and duration of mechanical ventilation. Methods: Retrospective observational study of a cohort of children with ARDS (Berlin definition) admitted to the Children’s Hospital of Philadelphia PICU July 2011-June 2016 and exposed to iNO within 3 days of ARDS onset. Cox proportional hazard evaluated association between iNO response and mortality. Competing risk regression assessed association between iNO response and duration of ventilation, with successful extubation as primary outcome and death as competing risk. Models were adjusted for potential confounders. Results: 161 patients met inclusion criteria and were classified as responders (n=98) or nonresponders (n=63). There was no difference between groups in demographics, evidence of pulmonary hypertension, or ARDS etiology/severity. Cox regression showed no association between iNO response and mortality. However, competing risk regression demonstrated iNO response to be associated with shorter duration of mechanical ventilation (SHR 1.65, 95% CI 1.18–2.30, p=0.003), after adjusting for severity of illness/hypoxemia, and immunocompromise. Responders also had significantly less exposure to extracorporeal membrane oxygenation (ECMO, 6% vs 17%, p=0.034) and high-frequency oscillatory ventilation (HFOV, 26% vs 41%, p=0.039). Conclusions: While response to iNO was not associated with mortality, it correlated with shorter duration of ventilation and reduced exposure to ECMO and HFOV. Future trials of iNO in pediatric ARDS should stratify analyses by oxygenation response to iNO.

862: MEASURING ETT CARINA DISTANCE USING THE AIRWAVE DEVICE IN PATIENTS IDENTIFIED AS A DIFFICULT AIRWAY.

(p<0.01).Overall, elective surgery hospital mortality decreased from 1.78% in Phase 1 to 1.44% in Phase 2 (NS). Conclusions: The strategy of safely moving surgical elective patients from ICU to IMCU has been successful. The majority of the elective surgical cases now go directly to IMCU and overall HLOS is lower by transitioning patients to IMCU post operatively instead of ICU. There are positive trends for decreases in transfers from IMCU to ICU and morality rates. Though the Intermediate Care Unit concept is popular, the literature on safety and efficient remains mixed. We attribute our improvement to careful planning, good case selection and monitoring.

P143: Body Position and Obstructive Sleep Apnea in Infants

OBJECTIVES: Determine the association between body position and obstructive events during sleep as determined by polysomnography (PSG) in infants aged 8-12 months with obstructive sleep apnea (OSA). METHODS: Consecutive nocturnal polysomnograms (NPSGs) of 50 children ages 8 to 12 months old referred to the sleep disorders center between January 1, 2003 and June 1, 2006 for possible sleep disordered breathing were retrospectively reviewed; 46% of the patients were female, and the mean age was 9.5 months. Total obstructive apnea-hypopnea index (OAHI), OAHI by body position, and REM and nonREM sleep OAHI were recorded. RESULTS: There were no significant differences between the mean supine OAHI (2.1 /-SD 4.7) and the mean nonsupine OAHI (2.0 /5.3), p 0.90. Children spent an average of 50% of their total sleep time supine. OSA was significantly worse in REM sleep (OAHI 4.3 /7.3) than in non-REM sleep (OAHI 1.4 /3.9), p 0.015. Mean time in REM sleep was 30% (range 5% to 42%). CONCLUSIONS: There was no significant effect of body position on OSA in 8 – 12 month old infants, although REM sleep represented a significant risk factor.