In Response.

Triaging acute chest syndrome clinical decision-making using bedside SaO2/FiO2 ratio.

Exploring Entrustment: Housestaff Autonomy and Patient Readmission

Opioid misuse constitutes a health care crisis in Canada, and coprescription of opioids with sedatives has been associated with adverse events. Opioids and sedatives are frequently administered in the intensive care unit (ICU). The rate of continuation of opioid-sedative combinations after an ICU admission at the study institution was unknown. To determine the rates of opioid and sedative coprescriptions following an ICU admission and to identify factors associated with continuation of hospital-initiated opioid-sedative coprescriptions at ICU transfer and hospital discharge. This retrospective chart review involved patients admitted to ICUs at a tertiary care centre between April 1, 2018, and March 31, 2019. Baseline characteristics were obtained from a clinical database and medication information from medication reconciliation forms. An opioid coprescription was defined as prescription of an opioid in combination with a sedative (benzodiazepine, z-drug, gabapentinoid, tricyclic antidepressant, or antipsychotic), and hospital-initiated coprescriptions encompassed various predefined scenarios of therapy started or modified before ICU transfer. Factors associated with hospital-initiated opioid coprescription were analyzed by multivariable logistic regression. A total of 735 patients met the inclusion criteria. At ICU transfer, 23.0% (169/735) of the patients had an opioid coprescription, and 87.0% (147/169) of these coprescriptions were hospital-initiated. At hospital discharge, 8.6% (44/514) of the patients had an opioid coprescription, and 56.8% (25/44) of these coprescriptions were hospital-initiated. Male sex, home opioid coprescription, surgical patient, prolonged hospital stay, and in-hospital death were significantly associated with hospital-initiated opioid coprescription at the time of ICU transfer. Home opioid coprescription was significantly associated with opioid coprescription at the time of hospital discharge. Hospital-initiated opioid coprescriptions accounted for the majority of opioid coprescriptions at ICU transfer and hospital discharge. Pharmacists should assess all opioid coprescriptions to determine whether discontinuation and/or dose reduction is appropriate.

Introduction: Patients with chronic kidney disease (CKD), especially in advanced stages, face elevated risks for sedation- and analgesia-related adverse events when managed outside intensive care units (ICUs). These events often present atypically and can progress severely, yet risk factors for ICU transfer in this population remain poorly characterized, complicating timely escalation decisions. Methods: We performed a systematic review of 28 studies (39 adult cases) from 2007 to 2024 across seven countries. Included patients had CKD and experienced sedation-/analgesia-related complications in non-ICU settings. Analyses were conducted using Google Colab; our protocol is registered to OSF. Using age- & sex-adjusted meta-regression, we examined associations between clinical and pharmacologic factors and ICU transfer. Results: Demographics (age 68±14 years; 59% male), CKD stage distribution (41% ESRD, 21% CKD 5, 18% CKD 4, 18% CKD 3, 15% unclassified), drug exposures, polypharmacy, comorbidities, complication types, and ICU transfers. Sedation-related complications occurred in 69% of cases. Neurologic complications dominated (46%), followed by metabolic (27%), cardiac (19%), and respiratory (12%). Opioids were implicated in 59% of events, with local anesthetics and NMDA antagonists also involved. ICU transfer was necessary in 29%, usually due to respiratory failure, hemodynamic instability, or severe neurotoxicity. Three independent predictors of ICU transfer emerged: ESRD/CKD5 vs. CKD 3–4 (adjusted odds ratio 3.1, [95% CI] 1.2–8.0, p=0.02), opioid exposure (2.8, [1.1–7.3], p=0.04), and poly-sedation (2.7, [1.0–7.0], p=0.05). Age and sex were not independently linked to ICU transfer. Although 82% of patients recovered, 18% suffered significant morbidity or death. Recovery was least common in ESRD patients exposed to opioids and polypharmacy (60% vs. 88%, p=0.03). In 18% of cases, sedatives were employed to manage refractory symptoms, highlighting treatment complexity. Conclusions: Nearly 1 in 3 sedation-related complications required ICU care, driven by kidney disease severity, opioid use, and sedative polypharmacy. These findings emphasize the importance of proactive monitoring, cautious drug selection, and prompt critical care involvement to minimize avoidable critical illness in this vulnerable group.

Forming a Partnership to Save Lives

Intravenous Fluid Replacement Therapy and Hospital Outcomes for Vaso-Occlusive Episodes in Patients with Sickle Cell Disease

Purpose Bronchiolitis guidelines recommend intermittent pulse oximetry monitoring for stable infants. Continuous pulse oximetry can lead to harm for some infants with bronchiolitis but is still frequently used in emergency departments (EDs) for infants who do not require oxygen supplementation. Measuring continuous pulse oximetry use from medical charts can be challenging. This study aimed to (1) develop a feasible method for documenting the use of continuous pulse oximetry in infants with bronchiolitis and (2) explore factors influencing its use in this population. Methods We conducted a cross-sectional observational study in a tertiary pediatric ED. Infants 60 days and 12 months old with possible bronchiolitis and not requiring oxygen were included. The patients were recruited from January 11 to March 21, 2023. Research assistants directly observed the use of pulse oximetry monitors. The primary outcome was the proportion of infants placed on continuous pulse oximetry. The secondary outcomes included disease severity, admission, unplanned return visits, the use of supplemental oxygen, and the need for investigationsand interventions. Results Eighteen infants were included in this study, with six (33.3%) placed on continuous pulse oximetry. The median disease severity score was similar between infants who were continuously monitored (6.5 (IQR 5.3, 10.8)) and those in the intermittent pulse oximetry group (4.5 (IQR 2, 9)). Infants in the continuous pulse oximetry group underwent more investigations and interventions than those in the intermittent pulse oximetry group: chest radiograph and bloodwork in 50% versus 8.3%, antibiotics in 33.3% versus 8.3%, bronchodilators in 33.3% versus 16.7%, and steroids in 16.7% versus 0%. In the continuous pulse oximetry group, four infants (66.7%), all of whom were placed on supplemental oxygen, were admitted, compared to one infant (8.3%) in the intermittent pulse oximetry group. Conclusion The decision to use continuous pulse oximetry may be influenced by provider characteristics. Objectiveparameters should be developed to guide its applicationand minimize potential harms associated with it.

Clinical practice guidelines for managing infants and children hospitalized for bronchiolitis recommend only obtaining intermittent or "spot check" pulse oximetry readings for those who show clinical improvement. The effect of such monitoring is currently unknown. To determine the effect of intermittent vs continuous pulse oximetry monitoring on hospital length of stay among nonhypoxemic infants and young children hospitalized for bronchiolitis. Randomized, parallel-group, superiority clinical trial of otherwise healthy infants and children 2 years of age or younger hospitalized for bronchiolitis during the period from 2009 to 2014 at 1 of 4 children's hospitals in the United States. Parents or guardians were blinded to allocation assignment until informed consent was obtained; study personnel and outcome assessors were not. Patients were randomly assigned to undergo continuous or intermittent pulse oximetry monitoring (ie, pulse oximetry measurements were obtained along with a scheduled check of vital signs or for clinical suspicion of deterioration) during hospitalization when oxygen saturation levels were 90% or higher. Length of hospital stay was the primary outcome. Secondary outcome measures included duration of supplemental oxygen use and rate of escalation of care (defined as transfer to an intensive care unit). A total of 449 infants and young children were screened for inclusion; 288 infants and young children were excluded, resulting in 161 patients who were enrolled in the study (80 patients underwent continuous monitoring, and 81 patients intermittent). The mean length of stay did not differ based on pulse oximetry monitoring strategy (48.9 hours [95% CI, 41.3-56.5 hours] for continuous monitoring vs 46.2 hours [95% CI, 39.1-53.3 hours] for intermittent monitoring; P = .77). The rates of escalation of care and duration of supplemental oxygen use did not differ between groups. Intermittent pulse oximetry monitoring of nonhypoxemic patients with bronchiolitis did not shorten hospital length of stay and was not associated with any difference in rate of escalation of care or use of diagnostic or therapeutic measures. Our results suggest that intermittent pulse oximetry monitoring can be routinely considered in the management of infants and children hospitalized for bronchiolitis who show clinical improvement. clinicaltrials.gov Identifier: NCT01014910.

We appreciate the interest Dr. and Mrs. Rampil have taken in our recent article in Anesthesiology.1As highlighted in their letter, the introduction of surveillance monitoring, as commonly used in the intensive care unit or the operating room, into the general-care setting (a traditionally unmonitored environment) does break new ground. It provides tremendous opportunities for research, education, and improvement in patient safety.In our article, we demonstrated a reduction in intensive care unit transfers by almost 50% and a decrease in rescue events by 65%; in our view, these are meaningful changes. Although we did see a statistically significant reduction in mortality, we deemphasized that change because of a possible small number effect. Even though Dr. and Mrs. Rampil are concerned about adequate power, the study's sample size with 19,070 patient days analyzed was clearly sufficient; indeed, as stated above, we chose to not emphasize some changes (such as mortality), even though they were statistically significant.We do agree that a reduction in intensive care unit transfers and rescue events are proxy outcomes as a measure of escalation in care and that better surveillance prompts earlier intervention, which leads to a reduction in escalation in care. Our interpretation is indeed, as hypothesized by the Rampils, that improved monitoring leads to an increase in early interventions and thus prevents adverse events and an escalation in care. Nursing interventions, such as those triggered by the monitoring system, were by protocol. A measure of these early interventions may be desirable, but we had decided that if a clear link could be established between the introduction of the system and a decrease in escalation of care, we may conclude that it is due to earlier interventions without measuring them directly.We are continuously monitoring overall patient satisfaction, as well as nurse satisfaction, with Patient Surveillance. Patient satisfaction has not changed with the introduction of Patient Surveillance on the unit we reported on, nor on two more surgical units that the system has been introduced to since, while nurse satisfaction has increased.Abenstein and Narr2stated in an accompanying editorial to our article, “Early intervention guided by this system reduced the need for patient rescue interventions, including Intensive Care Unit transfers. These results could have important implications for hospital wards throughout the country.” We entirely agree and would like to point out that much work remains to be done in the area of Patient Surveillance. Our publication was a first step in that direction. We hope that anesthesiologists, given their expertise in patient safety and monitoring, will be at the forefront of these exciting developments.*Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire. andreas.h.taenzer@dartmouth.edu

Surgeons' Perceptions of the Causes of Preventable Harm in Arterial Surgery: A Mixed-Methods Study

ObjectiveTo analyze the factors associated with intraoperative hypothermia (IHC) in elderly patients undergoing total joint replacement under general anesthesia based on preoperative nutritional status, intraoperative fluid administration volume, operating room temperature, and anesthesia duration, and to construct and validate a risk prediction model.MethodsA retrospective study was conducted on 120 elderly patients who underwent joint replacement surgery at our hospital between March 2023 and March 2025. All patient data were obtained from the electronic medical record system, and patients were divided into an IHC group and a non-IHC group based on whether they experienced IHC. Patient-related data were collected and compared. Selection operator (LASSO) regression analysis and multivariate logistic analysis were performed to identify risk factors for IHC in elderly patients undergoing joint replacement surgery. A prediction model was established using R software and validated.ResultsA total of 120 elderly patients who underwent joint replacement surgery at our hospital were included in this study. According to medical record system records, 21 patients developed IHC, accounting for 17.50%, and were included in the IHC group. Ninety-nine patients did not develop IHC, accounting for 82.50%, and were included in the non-IHC group. There were significant statistical differences between the IHC group and the non-IHC group in terms of BMI, intraoperative fluid administration volume, operating room temperature, anesthesia duration, serum albumin (ALB), and total protein (TP; p < 0.05). After LASSO regression analysis, none of the above indicators exhibited multicollinearity or overfitting. Logistic regression analysis revealed that intraoperative fluid administration volume and anesthesia duration were risk factors for IHC in elderly joint replacement surgery patients (OR = 1.002, 142.629, p < 0.05), Operating room temperature and ALB were protective factors for IHC in elderly joint replacement surgery patients (OR = 0.626, 0.712, p < 0.05); Based on the results of the logistic regression analysis, a risk prediction model for IHC in elderly joint replacement surgery patients was constructed using a nomogram. The ROC curve showed an AUC value of 0.994 (95% CI: 0.985–1.000). While this indicates excellent discriminative ability in the current cohort, we acknowledge that such a high value may reflect overfitting due to the limited sample size. External validation is required to confirm the model’s generalizability. The calibration curve indicated that the model’s predicted results were well aligned with the actual occurrence of IHC in patients. The Cox-Snell R2 was 0.89, Nagelkerke R2 was 0.538, Brier Score was 0.027, model fit p-value was 1.00, and the statistic was 0.08. The clinical decision curve was generally above the two extreme curves, indicating that the factors included in the nomogram have a high net benefit in predicting IHC occurrence in patients.ConclusionThere are numerous factors associated with the occurrence of IHC in elderly patients undergoing joint replacement surgery, primarily including intraoperative fluid administration volume, operating room temperature, anesthesia duration, and ALB. The risk prediction nomogram model constructed based on these factors demonstrates certain predictive value for the risk of IHC occurrence. Clinically, early screening of high-risk populations and implementation of targeted nursing interventions hold significant implications for clinical outcomes.

ObjectivesTo gain an in-depth understanding of the experience of elderly joint replacement patients in making surgical decisions and to identify the needs of patients in the decision-making process.DesignA qualitative study, semistructured interviews were used and analysed by Colaizzi’s seven-step method.SettingThis study was conducted in the orthopaedics department of a tertiary hospital in Wuhan.ParticipantsEligible participants were aged 60 years or older, scheduled for elective joint replacement surgery, cognitively intact and voluntarily consented to participate in the study.ResultsWe conducted interviews with a total of 25 elderly patients who underwent joint replacement surgery. This study reveals three themes and eight subthemes regarding the surgical decision-making experiences of elderly patients undergoing joint replacement. The three themes summarise three stages of the decision-making experience, respectively, trade-offs before decisions, feelings during decision-making and expectations after the decision. In the first stage, three subthemes were identified: (1) weighing the surgical risks and benefits, (2) assessment of medical proficiency and (3) low patient involvement in decision-making. In the second stage, three subthemes emerged: (1) internal fear, (2) self-doubt and (3) a heavy burden. In the third stage, two subthemes were identified: (1) a recovery process filled with confidence and (2) a desire for improved quality of life.ConclusionsThis study delves deep into the experiences of elderly patients undergoing joint replacement surgery during the surgical decision-making process. It provides a theoretical basis for decision-making assistance for elderly joint replacement patients, which is conducive to reducing patients’ decision-making conflicts and enhancing their decision-making capabilities.

Rupture of abdominal aortic aneurysm remains a fatal event in up to 65% of cases and emergency open surgery (ruptured open aneurysm repair or rOAR) has a great intraoperative mortality of about 30-50%. The introduction of endovascular repair of abdominal aortic aneurysm (ruptured endovascular aneurysm repair or rEVAR) has rapidly challenged the conventional approach to this catastrophic event. The purpose of this systematic review is to compare the outcomes of open surgical repair and endovascular interventions. A literature search was performed using Medline, Scopus, and Science Direct from August 2010 to March 2017 using keywords identified and agreed by the authors. Randomized trials, cohort studies, and case-report series were contemplated to give a breadth of clinical data. Ninety-three studies were included in the final analysis. Thirty-five (50.7%) of the listed studies evaluating the within 30 days mortality rates deposed in favor of rEVAR, while the others (comprising all four included RCTs) failed detecting any difference. Late mortality rates were found to be lower in rEVAR group in seven on twenty-seven studies (25.9%), while one (3.7%) reported higher mortality rates following rEVAR performed before 2005, one found lower incidence of mortality at 6 months in the endovascular group but higher rates in the same population at 8 years of follow-up, and the remaining (66.7%) (including all three RCTs) failed finding any benefit of rEVAR on rOAR. A lower incidence of complications was reported by thirteen groups (46.4%), while other thirteen studies did not find any difference between rEVAR and rOAR. Each of these two conclusions was corroborated by one RCTs. Other two studies (7.2%) found higher rates of tracheostomies, myocardial infarction, and acute tubular necrosis or respiratory, urinary complications, and acute renal failure respectively in rOAR group. The majority of studies (59.0%, 72.7%, and 89.3%, respectively) and all RCTs found significantly lower rates of length of hospitalization, intensive care unit transfer, and blood loss with or without transfusion need in rEVAR group. The large majority of the studies did not specified neither the type nor the brands of employed stent grafts. The bulk of evidence regarding the comparison between endovascular and open surgery approach to RAAA points to: 1) non-inferiority of rEVAR in terms of early (within 30 days) and late mortality as well as rate of complications and length of hospitalization, with trends of better outcomes associated to the endovascular approach; 2) significantly better outcomes in terms of intensive care unit transfer and blood loss with or without transfusion need in the rEVAR group. These conclusions reflect the results of the available RCTs included in the present review. Thus rEVAR can be considered a safe method in treating RAAA and we suggest that it should be preferred when technically feasible. However, more RCTs are needed in order to give strength of these evidences, bring to definite clinical recommendations regarding this subject, and assess the superiority (if present) of one or more brands of stent grafts over the others.

BACKGROUND: Atrioventricular nodal reentrant tachycardia (AVNRT) is considered a sporadic disease occurring in ≈22.5 cases per 10 000 in the general population.We define the prevalence and characteristics of familial AVNRT among patients who underwent radiofrequency ablation. METHODS AND RESULTS:Ablation reports of all patients with familial AVNRT (at least 2 first-degree family members) who underwent radiofrequency ablation in our institution and in another hospital were reviewed.There were 1587 patients from our institution, of whom 20 had ≥1 first-degree relatives with AVNRT.This indicates a familial AVNRT prevalence of 127 cases per 10 000 (95% confidence interval, 82-196/10 000).First-degree relatives of patients with AVNRT presented a hazard ratio of at least 3.6 for exhibiting AVNRT compared with the general population.After inclusion of 4 families with familial AVNRT who underwent ablation at another hospital our population study comprised a total of 24 families (50 patients) with AVNRT.Patients at ablation were younger in the familial AVNRT group when compared with the sporadic AVNRT group (44.2±19 versus 54.8±18 years old, P=0.0001).The male/female ratio was similar, with female predominance.The supraventricular tachycardia mechanism was typical slow/fast reentry in most cases in both groups.The most common familial relationship in our 24 families included a parent and a child in 67% of cases and less often 2 siblings (29%).CONCLUSIONS: Familial AVNRT prevalence is higher than previously believed suggesting that this arrhythmia may have a genetic component.Autosomal dominance with incomplete penetrance is the most likely mode of inheritance.

In the February 2010 issue, the article “Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: A before-and-after concurrence study” (Taenzer AH, Pyke JB, McGrath SP, Blike GT: Anesthesiology 2010; 112:282–7. doi: 10.1097/ALN.0b013e3181ca7a9b) contains an error in the denominator label for rates of rescue events presented. The correct denominator label is patient days, not discharges. This error does not alter the findings of the study. Clarification of the terminology, however, will allow other organizations implementing the same or similar technology to improve understanding of their comparative performance.The authors regret the error.