Evaluation of levetiracetam for early post-traumatic seizure prophylaxis: A level II trauma center experience

IntroductionTraumatic brain injury (TBI) can induce early or late post-traumatic seizures (PTS). While PTS incidence is low, prophylaxis is used despite a lack of consensus on agent or duration. Levetiracetam (LEV) for early PTS prophylaxis is preferred due to its safety and efficacy. The purpose of this study was to evaluate LEV for early PTS prophylaxis.Methods and materialsA single-center, retrospective chart review of TBI patients ≥18 years who received LEV for early PTS prophylaxis between August 2018–July 2019. The primary outcome was LEV duration. Secondary outcomes were incidence of seizure, intensive care unit (ICU) and hospital length of stay (LOS).ResultsOf the 137 included, mean age was 59 ± 20 years and 69.3% were male. The mean admission GCS was 13 ± 4 and 77.4% had mild TBI. Median LEV duration was 7 (IQR 4–10) days and 13.9% met recommended 7-day duration. Those prescribed LEV >7 days had more than twice the median LEV duration than those prescribed ≤7 days [10.25 (8.5–15.5) vs 4 (1.5–4.5) days, p < 0.0001]. Electroencephalography-confirmed PTS occurred in 2.2%, with an early PTS incidence of 0.73%. Median ICU and hospital LOS were 2 (IQR 1–7) and 7 (IQR 3–16) days, respectively.ConclusionsThe incidence of PTS was low as most patients in our study had mild or moderate TBI. Early PTS prophylaxis with LEV for 7 days is appropriate, although the majority of patients did not meet the recommended duration. Efforts to standardize and implement PTS prophylaxis protocols are needed.     

Dexmedetomidine versus propofol for prolonged sedation in critically ill trauma and surgical patients

Backgroundand Purpose: Currently, dexmedetomidine versus propofol has primarily been studied in medical and cardiac surgery patients with outcomes indicating safe and effective sedation. The purpose of this study was to assess the efficacy of dexmedetomidine versus propofol for prolonged sedation in trauma and surgical patients.MethodsThis was a single-center prospective study conducted in the Trauma/Surgical Intensive Care Unit (ICU) at a Level I academic trauma center. It included patients 18 years of age or older requiring mechanical ventilation who were randomly assigned based on unit bed location to receive either dexmedetomidine or propofol. The primary outcome was duration of mechanical ventilation. Secondary outcomes included mortality; proportion of time in target sedation; incidence of delirium, hypotension, and bradycardia; and ICU and hospital length of stay (LOS).ResultsA total of 57 patients were included. Baseline characteristics were similar between groups. There was no significant difference in duration of mechanical ventilation (median [IQR]) between the dexmedetomidine (78.5[125] hours) and propofol (105[130] hours; p = 0.15) groups. There was no difference between groups in ICU mortality, ICU and hospital LOS, or incidence of delirium. Safety outcomes were also similar. Patients in the dexmedetomidine group spent a significantly greater percentage of time in target sedation (98[8] %) compared to propofol group (92[10] %; p = 0.02).ConclusionsOur results suggest that, similar to medical and cardiac surgery patients, dexmedetomidine and propofol are safe and effective sedation agents in critically ill trauma and surgical patients; however, dexmedetomidine achieves target sedation better than propofol for this specific population.     

Quetiapine therapy in critically injured trauma patients is associated with an increased risk of pulmonary complications

BackgroundThe aim of this study was to evaluate quetiapine-associated pulmonary complications (PC) in critically injured trauma patients.MethodsInjured adults admitted during 2016 to the ICU at a Level I trauma center were analyzed. Outcomes were evaluated by competing risks survival analysis.ResultsOf 254 admissions, 40 (15.7%) had PC and 214 (84.3%) were non-events. PC patients were more severely injured, had longer hospital stays and were more likely to die. Patients administered quetiapine were more likely to develop PC and acquire PC earlier than those without quetiapine. Quetiapine was a positive risk factor for PC (sHR 2.24, p = 0.013). Stratification by ventilator use revealed non-ventilated patients administered quetiapine had the highest risk for PC (sHR 4.66, p = 0.099).ConclusionsQuetiapine exposure in critically injured trauma patients was associated with increased risk of PC. Guidelines for treatment of delirium with quetiapine in critically injured trauma patients should account for this risk.     

Early prediction of delirium upon intensive care unit admission: Model development,validation, and deployment

Study objectiveTo develop, validate, and deploy models for predicting delirium in critically ill adult patients as early as upon intensive care unit (ICU) admission.DesignRetrospective cohort study.SettingSingle university teaching hospital in Taipei, Taiwan.Patients6238 critically ill patients from August 2020 to August 2021.MeasurementsData were extracted, pre-processed, and split into training and testing datasets based on the time period. Eligible variables included demographic characteristics, Glasgow Coma Scale, vital signs parameters, treatments, and laboratory data. The predicted outcome was delirium, defined as any positive result (a score ≥ 4) of the Intensive Care Delirium Screening Checklist that was assessed by primary care nurses in each 8-h shift within 48 h after ICU admission. We trained models to predict delirium upon ICU admission (ADM) and at 24 h (24H) after ICU admission by using logistic regression (LR), gradient boosted trees (GBT), and deep learning (DL) algorithms and compared the models' performance.Main resultsEight features were extracted from the eligible features to train the ADM models, including age, body mass index, medical history of dementia, postoperative intensive monitoring, elective surgery, pre-ICU hospital stays, and GCS score and initial respiratory rate upon ICU admission. In the ADM testing dataset, the incidence of ICU delirium occurred within 24 h and 48 h was 32.9% and 36.2%, respectively. The area under the receiver operating characteristic curve (AUROC) (0.858, 95% CI 0.835–0.879) and area under the precision-recall curve (AUPRC) (0.814, 95% CI 0.780–0.844) for the ADM GBT model were the highest. The Brier scores of the ADM LR, GBT, and DL models were 0.149, 0.140, and 0.145, respectively. The AUROC (0.931, 95% CI 0.911–0.949) was the highest for the 24H DL model and the AUPRC (0.842, 95% CI 0.792–0.886) was the highest for the 24H LR model.ConclusionOur early prediction models based on data obtained upon ICU admission could achieve good performance in predicting delirium occurred within 48 h after ICU admission. Our 24-h models can improve delirium prediction for patients discharged >1 day after ICU admission.     

The incidence,clinical characteristics,and outcome of polytrauma patients with the combination of pulmonary contusion,flail chest and upper thoracic spinal injury

BackgroundChest trauma was the third most common cause of death in polytrauma patients, accounting for 25% of all deaths from traumatic injury. Chest trauma involves in injury to the bony thorax, intrathoracic organs and thoracic medulla. This study aimed to investigate the incidence, clinical characteristics, and outcome of polytrauma patients with pulmonary contusion, flail chest and upper thoracic spinal injury.MethodsPatients who met inclusion criteria were divided into groups: Pulmonary contusion group (PC); Pulmonary contusion and flail chest group (PC + FC); Pulmonary contusion and upper thoracic spinal cord injury group (PC + UTSCI); Thoracic trauma triad group (TTT): included patients with flail chest, pulmonary contusion and the upper thoracic spinal cord injury coexisted. Outcomes were determined, including 30-day mortality and 6-month mortality.ResultsA total 84 patients (2.0%) with TTT out of 4176 polytrauma patients presented to Tongji trauma center. There was no difference in mean ISS among PC + FC group, PC + UTSCI group and TTT group. Patients with TTT had a longer ICU stay (21.4 days vs. 7.5 and 6.2; p<0.01), relatively higher 30-day mortality (40.5% vs. 6.0% and 4.3%; p<0.01), and especially higher 6-month mortality (71.4% vs. 6.5%, 13.0%; p<0.01), compared to patients with PC + FC or with PC + UTSCI. The leading causes of death for patients with TTT were ARDS (44.1%) and pulmonary infection (26.5%) during first 30 days after admission. For those patients who died later than 30 days during the 6 months, the predominant underlying cause of death was MOF (53.8%).ConclusionsLethal triad of thoracic trauma (LTTT) were described in this study, which consisting of pulmonary contusion,flail chest and the upper thoracic spine cord injury. Like the classic “lethal triad”, there was a synergy between the factors when they coexist, resulting in especially high mortality rates. Polytrauma patients with LTTT were presented relatively high 30-day mortality and 6 months mortality. We should pay much more attention to the patients with LTTT for further minimizing complications and mortality.     

Delirium in hospitalised adults with acute burns – A systematic review

IntroductionDelirium is a potentially modifiable, acutely altered mental state, commonly characterised as a hospital-acquired complication. Studies of adult inpatients with acute burns with and without delirium identify causative risks related to the injury or treatment and outcomes related to the patient and healthcare system. We compare patients with and without delirium, providing a high-level quantitative synthesis of delirium risks and outcomes to inform guidelines and future research.MethodsA systematic review, meta-analysis and GRADE evaluation of risks and outcomes associated with delirium in adults with acute burns was conducted using PRISMA guidelines and PROSPERO protocol CRD42021283055. The Newcastle-Ottawa Scale was used to assess quality.ResultsInvestigators reviewed ten studies. ASA score ≥ 3, Total Body Surface Area Percentage (TBSA)> 10%, surgery done, ICU admission, hospital and also Intensive Care Unit (ICU) lengths of stay all had statistically significant associations with delirium, with low-very low certainty on GRADE evaluation. Limitations were heterogeneous studies, review methodology and study bias.ConclusionDelirium represents a significant risk to comorbid patients with burns that are hospitalised, receive ICU care, and surgery. Further research is indicated to precisely categorise delirium along the clinical journey to identify modifiable factors, prevention, and proactive therapy.     

The influence of orthopedic surgery on the incidence of post-operative delirium in geriatric patients: results of a prospective observational study

BackgroundPostoperative delirium (PD) is a major concern in geriatric patients undergoing orthopedic surgery. This prospective observational study aims to examine the incidence of PD, to identify intervention-specific risk factors and to investigate the influence of orthopedic surgery on delirium.MethodsFrom 2019 to 2020, 132 patients ≥70 years of age with endoprosthetic (Group E) or spinal surgery (Group S) were included. Upon admission, the ISAR score, the Nursing Delirium Screening Scale, potential risk factors, the ASA score, duration of surgery, type of anesthesia, blood loss, and hemoglobin drop were recorded. For risk factor analysis patients were grouped into Group D (delirium) and Group ND (no delirium). Primary endpoint was the occurrence of PD.ResultsOf 132 patients, 50 were included in Group E and 82 in Group S. Mean age and ISAR score were not significantly different between groups. Delirium rate in Group E and S was 12% vs. 18% (p = 0.3). Differences could be observed between Group D and ND in duration of surgery (173 min vs. 112 min, p = 0.02), postoperative hemoglobin drop (3.2 g/dl vs. 2.3 g/dl; p = 0.026), history of PD (23% vs. 11%, p = 0.039) and use of isoflurane (6 vs. 2). Type of surgery was not an independent risk factor (p = 0.26).ConclusionSpecific type of orthopedic surgery is not an independent risk factor for PD. Prevention of PD should focus on duration of surgery and blood loss, particularly in patients with a history of PD. A possible delirogenic potential of isoflurane should be further studied.     

Impact of service delivery factors on patient outcomes in emergency general surgery

BackgroundEmergency general surgery (EGS) is a high-risk process and is associated with poor outcomes and high mortality. This study aimed to evaluate the service delivery factors in a tertiary referral centre which may influence patient outcomes in emergency general surgery.MethodsData on consecutive patients undergoing emergency laparotomy in a tertiary referral centre were prospectively collected from July 2017–July 2018. An extensive review of patient charts and IT systems was performed to extract demographic, clinical and care pathway data. Transfers for surgery from within the institution or within the centralised hospital network were recorded.ResultsThe unadjusted 30-day mortality rate in 163 patients undergoing emergency laparotomy was 13%. On multivariate analysis, 30-day mortality was significantly associated with p-POSSUM predicted mortality (p = 0.003), p-POSSUM predicted morbidity (p = 0.01), SORT mortality (p = 0.004), ICU admission (p = 0.02), ASA grade (p < 0.001) and transfer from non-surgical services (p < 0.001). 19.2% of patients were transferred from a referring hospital for emergency laparotomy. There was no association between inter-hospital transfer and 30-day mortality while increased mortality was observed in patients admitted to non-surgical services who required laparotomy (p < 0.001).ConclusionInter-hospital transfer for emergency laparotomy was not associated with increased mortality. Increased mortality was observed in patients admitted to non-surgical services who subsequently required emergency laparotomy. Configuration of emergency general surgery services must accommodate safe and effective transfer of patients, both between and within hospitals.     

Optimal interval and duration of CAM-ICU assessments for delirium detection after cardiac surgery

Study objectiveOur goal was to determine when postoperative delirium first occurs, and to assess evaluation strategies that reliably detect delirium with lowest frequency of testing’.DesignThis was a retrospective study that used a database from a five-center randomized trial.SettingPostoperative cardiothoracic ICU and surgical wards.ParticipantAdults scheduled for elective coronary artery bypass and/or valve surgery.Intervention and measurementsPostoperative delirium was assessed using CAM-ICU questionnaires twice daily for 5 days or until hospital discharge. Data were analyzed using frequency tables and Kaplan-Meier time-to-event estimators, the latter being used to summarize time to first positive CAM-ICU over POD1–5 for all patients for various evaluation strategies, including all assessments, only morning assessment, and only afternoon assessments. Sensitivity for various strategies were compared using McNemar's test for paired proportions.Main resultsA total of 95 of 788 patients (12% [95% CI, 10% to 15%]) had at least 1 episode of delirium within the first 5 postoperative days. Among all patients with delirium, 65% were identified by the end of the first postoperative day. Delirium was detected more often in the mornings (10% of patients) than evenings (7% of patients). Compared to delirium assessments twice daily for five days, we found that twice daily assessments for 4 days detected an estimated 97% (95% CI 91%, 99%) of delirium. Measurements twice daily for three days detected 90% (82%, 95%) of delirium.ConclusionsPostoperative delirium is common, and CAM-ICU assessments twice daily for 4 days, versus 5 days, detects nearly all delirium with 20% fewer assessments. Four days of assessment may usually be sufficient for clinical and research purposes.     

The survival benefit of low molecular weight heparin over unfractionated heparin in pediatric trauma patients

IntroductionVenous thromboembolism (VTE) prophylaxis in pediatric patients is controversial and is mainly dependent on protocols derived from adult practices. Our study aimed to compare outcomes among pediatric trauma patients who received low molecular weight heparin (LMWH) compared to those who received unfractionated heparin (UFH).MethodsWe performed 2 years (2015–2016) retrospective analysis of the Pediatrics ACS-TQIP database. Pediatric trauma patients (age ≤ 17) who received thromboprophylaxis with either LMWH or UFH were included. Patients were stratified into three age groups. Analysis of each subgroup and the entire cohort was performed. Outcome measures included VTE events (deep vein thrombosis [DVT] and pulmonary embolism [PE]), hospital and ICU length of stay (LOS) among survivors, and mortality. Propensity score matching was used to match the two cohorts LMWH vs UFH.ResultsA matched cohort of 1,678 pediatric trauma patients was analyzed. A significant difference in survival, DVT events, and in-hospital LOS was seen in the age groups above 9 years. Overall, the patients who received LMWH had lower mortality (1.4% vs 3.6%, p < 0.01), DVT (1.7% vs 3.7%, p < 0.01), and hospital LOS among survivors (7 days vs 9 days, p < 0.01) compared to those who received UFH. There was no significant difference in the ICU LOS among survivors and the incidence of PE between the two groups.ConclusionLMWH is associated with increased survival, lower rates of DVT, and decreased hospital LOS compared to UFH among pediatric trauma patients age 10–17 years.Level of EvidenceLevel III Prophylactic.Study TypeProphylactic.     

Prehospital personnel discretion pediatric trauma team activations: Too much of a good thing?

PurposeTrauma team activation is essential to provide rapid assessment of injured patients, however excessive utilization can overburden systems. We aimed to identify predictors of over triage and evaluate impact of prehospital personal discretion trauma activations on the over triage rate.MethodsRetrospective comparative study of pediatric trauma patients (<18 years) evaluated after activation of the trauma team to those evaluated as a trauma consult treated between 2010 and 2013. Cohort matching of trauma activated and consult patients was done on the basis of patients’ age and ISS.Results1363 patients including 359 trauma team activations were evaluated. Median age was 6 years, Injury Severity Score (ISS) 4, 116 (8.5%) required operative intervention and 20 (1.4%) died.Matched analysis using age and ISS showed trauma activated patients were more likely to have penetrating MOI (4.7% vs.1.7%; p = 0.03) and need ICU admission(32.9% vs.16.7%; p = 0.0001). State of Florida discrete criteria based trauma activated patients when compared to paramedic discretion activations had a higher ISS (9 vs.5; p = 0.014), need for ICU admission (36.5% vs.20.4%; p = 0.004), ICU LOS(2 vs.0 days; p = 0.02), hospital LOS(2 vs.2 days; p = 0.014) and higher likelihood of death(4.9% vs.0%;p = 0.0001). Moreover, paramedic discretion trauma activated patients were similar to trauma consult patients in terms of ISS score(p = 0.86), need for ICU admission(p = 0.86), operative intervention(p = 0.86), death(p = 0.86) and hospital LOS(p = 0.86), with a considerably higher cost of care(p = 0.0002).ConclusionDiscrete criteria-based trauma team activations appear to more reliably identify patients likely to benefit from initial multidisciplinary management.     

Acute surgical admissions at the end of life–an analysis of non-operative hospital deaths

BackgroundPatients with advanced illnesses are often admitted with acute surgical emergencies. There is currently no evidence characterising such admissions. We aimed to evaluate emergency patients, managed non-operatively, who died during the same admission.MethodsThis single-centre retrospective, observational study collected data points for a 12 month period including age, prior documented do not resuscitate order (DNAR), existing cancer, Charlson Comorbidity Index, frailty, surgical diagnosis, interval from admission to death and care given. Patients who underwent surgical intervention were excluded. Non-parametric tests were used for statistical analysis.ResultsA total of 72 patients were included in this study, of which 68.1% died within 6 days of admission (median 4.0 days). Patients with visceral perforation, obstruction, bowel ischaemia or known malignancy were more likely to die within 6 days than those with pancreatitis, sepsis or new malignancy (median 2 vs 7 days, p < 0.001). Patients with frailty (2 vs 4 days, p = 0.017) and existing DNAR (3 vs 4 days, p = 0.048) died more rapidly than those without. Age and comorbidity index did not impact time to death.ConclusionFrailty, surgical diagnosis and existing DNAR were predictors of shorter admission to death interval, while age and comorbidity index were not. This has implications on inpatient palliative care service planning.     

The impact of obesity on polytraumatized patients with operatively treated fractures

IntroductionThe objective of this study was to evaluate the effect of obesity on outcomes following operative treatment of fractures in obese polytrauma patients.MethodsThis was a prospective cohort study at a level I trauma centre from January 2014 until December 2017. The eligibility criteria were adult (age >= 18 years) polytrauma patients who presented with at least one orthopaedic fracture that required operative fixation. Polytrauma was defined as having an Injury Severity Score (ISS) >= 16. Out of 891 patients, a total of 337 were included with 85 being obese. The primary outcome variable was the total hospital length of stay in days. The secondary outcome variables were the number of patients who had an intensive care unit (ICU) admission, the ICU length of stay in days, the number of patients who had mechanical ventilation, the duration of mechanical ventilation in days, perioperative complications, and mortality.ResultsObesity was associated with increased total hospital stay (36 vs. 27 days; P<0.001), increased ICU stay (13 vs. 8 days; P = 0.04), increased ICU admissions (83.5% vs. 68.6%; P = 0.008) and increased incidence of mechanical ventilation (64.7% vs. 43.7%; P = 0.001). These findings remained statistically significant following adjusted regression models for age, gender, ISS, and injuries sustained. However, the mechanical ventilation duration was not significantly different between both groups on adjusted and unadjusted analyses. However, an increase per unit BMI significantly increases the duration of mechanical ventilation (P = 0.02). In terms of complications, obesity was only associated with an increase in acute renal failure (ARF) on unadjusted analyses (P = 0.004). Whereas, adjusted logistic regression demonstrated that an increase per BMI unit led to a significant increase in the odds ratio for wound infection (P = 0.03) and ARF (P = 0.024).ConclusionsThis study displayed that obesity was detrimental to polytrauma patients with operatively treated fractures leading to prolonged hospital and ICU length of stay. This highlights the importance of optimizing trauma care for obese polytraumatized patients to reduce morbidity. With 41.1% of our population being obese, obesity presents a unique challenge in the care of polytrauma patients which mandates further research in improving health care for this population group.     

Predictors of discharge against medical advice in adult trauma patients

BackgroundPatients who leave against medical advice (AMA) have higher readmission rates and mortality. However, little is known about the characteristics of trauma patients that leave AMA. The purpose of this study was to identify predictors for leaving AMA in adult trauma patients.MethodsThe Trauma Quality Improvement Program database was queried between 2010 and 2016 for patients ≥18 years of age presenting after trauma. Two groups were compared: those who left AMA and those that did not. Bivariate analysis using Chi-squared and Mann–Whitney U tests was performed. A multivariable logistic regression analysis was performed to identify predictors for leaving AMA.ResultsOf 1,403,466 trauma patients identified, 10,659 (0.76%) left AMA. Patients that left AMA were younger (median age, 48 vs. 53 years-old, p < 0.001), more often male (82.1% vs. 62.8%, p < 0.001), more likely to be black (23.6% vs. 14.9%, p < 0.001), and more likely to be uninsured (27.0% vs. 12.3%, p < 0.001). Patients leaving AMA were more likely to test positive for alcohol (36.1% vs. 17.4%, p < 0.001) or drug use (36.0% vs. 17.2%, p < 0.001) at time of admission. On multivariable logistic regression, the strongest predictors for leaving AMA were: no insurance (OR 2.00, CI 1.88–2.14, p < 0.001), alcohol use (OR 1.85, CI 1.74–1.96, p < 0.001) or drug use (OR 1.83, CI 1.72–1.94, p < 0.001), male gender (OR 1.83, CI 1.71–1.97, p < 0.001), and stab mechanism of injury (OR 1.58, CI 1.43–1.73, p < 0.001).ConclusionIn adult trauma patients, male gender, stab mechanism of injury, being uninsured, and alcohol/drug use were strong predictors of leaving AMA. The risk factors identified may help in developing strategies aimed at preventing trauma patients from leaving AMA.     

Are there variations in timing to tracheostomy in a tertiary academic medical center?

BackgroundIt is unclear what drives variation in timing to tracheostomy among different patients.MethodsAge, ethnicity, admission service, and income were retrospectively collected for patients undergoing tracheostomy in a Level 1 trauma center from 2007 to 2017. The primary outcome was time to tracheostomy with early tracheostomy (ET) or late tracheotomy (LT) defined as 3–7 or ≥ 10 days post-intubation, respectively. Secondary outcomes included length of stay (LOS), ventilator associated pneumonia, and mortality.ResultsAmong 1,640 patients, more men had ET compared to women (30% vs 28%; p = 0.05). The mean time to tracheostomy was 11.2 ± 7.7 days. Neurology and trauma patients had significantly shorter time to tracheostomy compared to other services. Age, ethnicity, and income showed no differences in timing to tracheostomy. Patients who underwent LT had a longer LOS (46 vs 32 days, p < 0.01) and higher mortality (19% vs 13% p < 0.01). Conclusions: There were no disparities in timing to tracheostomy based on age, ethnicity, or income. We detected a hesitation in performing tracheostomies by certain providers with shorter LOS and improved mortality in ET.     

Association between obstructive sleep apnea and atrial fibrillation and delirium after cardiac surgery. Sub-analysis of DECADE trial

BackgroundAtrial fibrillation and delirium are common complications after cardiac surgery. Both are associated with increased Intensive Care Unit (ICU) and hospital length of stay, functional decline, 30-day mortality and increase in health care costs. Obstructive Sleep Apnea (OSA) induces deleterious effects in the cardiovascular and nervous systems. We hypothesized that adult patients with preoperative OSA have a higher incidence of postoperative atrial fibrillation and delirium than patients without OSA, after cardiac surgery.MethodsSub-analysis of the DECADE trial at Cleveland Clinic hospitals. Our exposure was OSA, defined by STOP-BANG questionnaire score higher than 5 and/or a preoperative diagnosis of OSA. The primary outcome was atrial fibrillation, defined by clinician diagnosis or documented arrhythmia. The secondary outcome was delirium assessed twice during the initial five postoperative days using the Confusion Assessment Method for ICU. We assessed the association between OSA, and atrial fibrillation and delirium using a logistic regression model adjusted for confounders using inverse probability of treatment weighting.Results590 patients were included in the final analysis. 133 were diagnosed with OSA and 457 had no OSA. Satisfactory balance between groups for most confounders (absolute standardized difference < 0.10) was achieved after weighting. The atrial fibrillation incidence was 37% (n = 49) in the patients with OSA and 33% (n = 150) in the non-OSA patients. OSA was not associated with atrial fibrillation with an estimated odds ratio of 1.22 (95% CI: 0.75,1.99;p = 0.416). The delirium incidence was 17% (n = 22) in patients with OSA and 15% (n = 67) in the non-OSA patients. OSA was not associated with delirium with an estimated odds ratio of 0.93 (95% CI: 0.51,1.69;p = 0.800).ConclusionIn adult patients having cardiac surgery, OSA is not associated with a higher incidence of postoperative atrial fibrillation and delirium. These results suggest different prominent factors rather than OSA affect the incidence of these postoperative outcomes.     

The effect of dexmedetomidine on delirium and agitation in patients in intensive care: systematic review and meta-analysis with trial sequential analysis

Delirium is common in intensive care patients. Dexmedetomidine is increasingly used for sedation in this setting, but its effect on delirium remains unclear. The primary aim of this review was to examine whether dexmedetomidine reduces the incidence of delirium and agitation in intensive care patients. We sought randomised clinical trials in MEDLINE, EMBASE, PubMed and CENTRAL from their inception until June 2018. Observational studies, case reports, case series and non-systematic reviews were excluded. Twenty-five trials including 3240 patients were eligible for inclusion in the data synthesis. In the patients who received dexmedetomidine (eight trials, 1425 patients), delirium was reduced, odds ratio (95%CI) 0.36 (0.26–0.51), p < 0.001 and high quality of evidence. The use of dexmedetomidine was associated with a reduced incidence of agitation, OR (95%CI) 0.34 (0.20–0.59), p < 0.001, moderate quality of evidence. Patients who were randomly assigned to dexmedetomidine had a significantly higher incidence of bradycardia, OR (95%CI) 2.18 (1.46–3.24), p < 0.001, moderate quality of evidence; and hypotension, OR (95%CI) 1.89 (1.48–2.41), p < 0.001, high quality of evidence. We found no evidence of an effect on mortality, OR (95%CI) 0.86 (0.66–1.10), p = 0.23, moderate quality of evidence. The trial sequential analyses for the incidence of delirium, bradycardia and hypotension was conclusive but not for the incidence of agitation and mortality. In summary, this meta-analysis suggests that dexmedetomidine reduces the incidence of delirium and agitation in intensive care patients. The general quality of evidence ranged from moderate to high.     

Efficacy and safety of haloperidol for delirium prevention in adult patients: An updated meta-analysis with trial sequential analysis of randomized controlled trials

Study objectiveTo identify the efficacy and safety of haloperidol prophylaxis in adult patients with a high risk for delirium.DesignA meta-analysis with trial sequential analysis of randomized controlled trials.InterventionA comprehensive search was performed in PubMed, the ISI Web of Knowledge, the Cochrane Library, and Embase databases from inception through to March 2019.Citation screening, data abstraction and quality assessment were performed in duplicate. Meta-analysis with trial sequential analysis (TSA) were used to assess the primary and secondary outcomes. In addition, we used the Grading of Recommendations Assessment Development and Evaluation (GRADE) to evaluate the certainty of the body of evidence.Main resultsWe appraised 8 RCTs involving 3034 patients that that were in compliance with inclusion and exclusion criterion. Pooled analyses indicated patients receiving haloperidol prophylaxis and placebo or normal saline did not significantly differ in incidence of delirium (relative risk [RR] = 0.90, 95% confidence interval [CI] = 0.70 to 1.15), with TSA inconclusive. Notably, compared with the control group, use of haloperidol significantly decreased the duration of delirium (Mean difference [MD] −0.94; 95% CI −1.82 to −0.06 days), with a marked heterogeneity. Additionally, haloperidol prophylaxis does not significantly affect duration of mechanical ventilation, length of intensive care unit (ICU) stay, length of hospital stay and mortality. In terms of safety profiles, haloperidol was not associated with increased risk for QTc prolongation, extrapyramidal symptoms, or adverse events. GRADE indicated the level of evidence was very low for a benefit from haloperidol prophylaxis.ConclusionsThe results of our meta-analysis suggested the use of prophylactic haloperidol compared with placebo had no beneficial impacts on incidence of delirium, duration of mechanical ventilation, length of intensive care unit (ICU) stay, length of hospital stay and mortality in adult patients. It appeared to have a positive effect on duration of delirium, while with a significant heterogeneity. These findings do not support the routine usage of haloperidol for delirium prevention.Trial registration: PROSPERO registration number: CRD42018100511. Registered on 17 July 2018.     

Orthopaedic trauma during COVID-19: Is patient care compromised during a pandemic?

BackgroundThe Coronavirus disease-2019 (COVID-19) placed unprecedented pressure on the healthcare system. Many institutions implemented a government-mandated restructured set of safety and administrative protocols to treat urgent orthopaedic trauma patients. The objective of this study was to compare two cohorts of patients, a COVID group and non-COVID control group, and to evaluate the effectiveness of safety measures outlined in the Rutgers Orthopaedic Trauma Patient Safety Protocol (ROTPSP). Secondary outcomes were to elucidate risk factors for complications associated with fractures and COVID-19.MethodsPatients treated for orthopaedic traumatic injuries were retrospectively identified between March and May 2020, and compared to a series of patients from the same time period in 2018. Main outcome measures included surgical site infections (SSI), length of stay (LOS), post-operative LOS (poLOS), presentation to OR time (PORT), and length of surgery.ResultsAfter review, 349 patients (201 non-COVID, 148 COVID) undergoing 426 surgeries were included. Average LOS (11.91 days vs. 9.27 days, p = 0.04), poLOS (9.68 days vs. 7.39 days, p = 0.03), and PORT (30.56 vs. 25.59 h, p < 0.01) was significantly shorter in the COVID cohort. There were less SSI in the COVID group (5) compared to the non-COVID group (14) (p = 0.03). Overall complications were significantly lower in the COVID group. Patients receiving Cepheid tests had significantly shorter LOS and poLOS compared to patients receiving the RNA and DiaSorin tests (p < 0.01 and p < 0.01, respectively). The Cepheid test carried the best benefit-to-cost ratio, 0.10, p < 0.05.ConclusionThe restructuring of care protocols caused by COVID-19 did not negatively impact perioperative complication rates, PORT or LOS. Cepheid COVID test type administered upon admission plays an integral role in a patient's hospital course by reducing both length of stay and hospital costs. This information demonstrates we can continue to treat orthopaedic trauma patients safely during the COVID-19 pandemic by utilizing strict safety protocols.