238 Measuring Childbirth Outcomes Using Administrative and Birth Certificate Data
Currently available outcome measures for obstetrical care are limited because they are not risk adjusted. In the absence of risk adjustment, differences in hospital outcomes may be due to differences in hospital case mix rather than differences in hospital quality. The purpose of this study was to develop a risk-adjusted composite measure of severe maternal morbidity and severe newborn morbidity based on administrative and birth certificate data for 883,121 deliveries in 2011 and 2012. The incidence of severe maternal morbidity was 1.53% and the incidence of severe newborn morbidity was 3.67%. Adjusted severe maternal morbidity rates were 2.81% in low-performance hospitals, 1.49% in average-performance hospitals, and 0.91% in high-performance hospitals. Adjusted rates of severe newborn morbidity were 5.67% in low-performance hospitals, 2.67% in average-performance hospitals, and 1.98% in high-performance hospitals. Because hospital risk-adjusted rates of severe maternal morbidity were poorly correlated with hospital risk-adjusted rates of severe newborn morbidity, maternal and newborn outcomes should be reported jointly. See the accompanying Editorial View on page 223.
328 Prophylactic Haloperidol Effects on Long-term Quality of Life in Critically Ill Patients at High Risk for Delirium: Results of the REDUCE Study
The REDUCE study, a large multicenter double-blind randomized controlled trial involving intensive care unit patients at high risk for delirium, found that prophylactic haloperidol had no effects on survival and incidence and duration of delirium in critically ill patients. Because many intensive care unit survivors suffer from long-term impairment of physical, cognitive, or mental health status, a preplanned secondary analysis of long-term outcomes of the REDUCE study determined the effects of prophylactic haloperidol on long-term quality of life in 887 patients 6 months after intensive care unit admission. Long-term quality of life, measured using the Short Form-12 questionnaire, did not differ between the haloperidol and placebo groups 6 months after intensive care unit admission. The secondary aim of this analysis determined factors associated with changes in long-term quality of life of intensive care unit survivors. Age, medical and trauma admission, quality of life score at baseline, risk for delirium score, and the number of sedation-induced coma days were significantly associated with a decline in long-term quality of life.
279 Discharge Readiness after Propofol with or without Dexmedetomidine for Colonoscopy: A Randomized Controlled Trial
The hypothesis that sedation with a combination of propofol and low-dose dexmedetomidine would be noninferior to a combination of propofol and placebo was tested in a randomized controlled trial of 101 patients having ambulatory elective colonoscopies. The primary outcome was the percentage of patients in each group who were ready for discharge within 30 min of procedure end time, defined as a score greater than or equal to 9 on the Modified Post Anesthesia Discharge Scoring System scale. Noninferiority would be shown by the probability that the percentage of patients being discharged within 30 min from the end of the procedure would be within the 20% margin of clinical importance for the two groups. While 44 of 50 (88%) subjects receiving propofol-placebo met validated discharge criteria within 30 min from procedure end time, only 26 of 51 (51%) subjects receiving propofol-dexmedetomidine did. For the 30-min discharge outcome, the 90% Farrington-Manning CI for the risk difference between study arms was 0.204 to 0.501. Delay in discharge readiness was primarily due to inability to ambulate.
369 Impact of an Opioid Safety Initiative on Patients Undergoing Total Knee Arthroplasty: A Time Series Analysis
An opioid safety initiative was implemented across the Veterans Health Administration in fiscal year 2013. This ecological study used retrospective group-level data to examine the effect of the opioid safety initiative on eight pain scores and analgesic prescriptions before and after total knee arthroplasty. Measurements were made at the group level every month. Time series analyses were conducted to examine trends for the 28,509 patients treated over a 27-month period after implementation versus trends forecasted using data from the 31,547 patients treated over the 45-month period before implementation. In robust time series analyses, chronic postoperative and chronic preoperative opioid prescriptions were substantially decreased compared to forecasted trends (reductions of 20% and 13%, respectively), while mean postoperative minus preoperative pain scores increased at the population level from 0.65 to 0.81, by 0.16 points (95% CI, 0.05 to 0.27), on the 11-point numeric rating scale. Time-series analysis confirmed significant increases in preoperative and postoperative prescriptions for gabapentinoids, acetaminophen, and nonsteroidal anti-inflammatory drugs.
356 Dextromethorphan Analgesia in a Human Experimental Model of Hyperalgesia
Neuropathic pain, which presents abnormal pain manifestations including allodynia and hyperalgesia, is associated with central sensitization involving N-methyl-d-aspartate receptors. In the freeze-injury hyperalgesia model, a cold burn leads to development of both primary hyperalgesia and secondary hyperalgesia, which develops away from the site of injury without apparent tissue modification and is associated with central sensitization and activation of N-methyl-d-aspartate receptors in the spinal cord. Dextromethorphan, which is an N-methyl-d-aspartate receptor antagonist, is antihyperalgesic in preclinical pain models. The hypothesis that dextromethorphan is also antihyperalgesic in humans was tested using the freeze-injury pain model in a randomized, double-blind, placebo-controlled, crossover trial of 30-mg doses of oral dextromethorphan in 20 male volunteers. Dextromethorphan decreased the secondary hyperalgesia induced by the model and reversed peripheral and central neuronal sensitization. Because dextromethorphan had no intrinsic antinociceptive effect in acute pain on healthy skin, N-methyl-d-aspartate receptors may need to be sensitized by pain for dextromethorphan to be effective. See the accompanying Editorial View on page 233.
344 Lung Pharmacokinetics of Tobramycin by Intravenous and Nebulized Dosing in a Mechanically Ventilated Healthy Ovine Model
For most bacterial pneumonia, the lung interstitium is considered to be the site of infection and adequate interstitial space fluid antibiotic concentrations are important for drug effect. Despite systemic antibiotic therapy, therapeutic failure is common, perhaps due to poor lung penetration and resulting low interstitial space fluid antibiotic concentrations. Increasing systemic antibiotic doses to increase interstitial space fluid antibiotic concentrations could lead to toxicities, such as nephrotoxicity. The hypothesis that nebulized tobramycin will achieve higher pulmonary interstitial space fluid concentrations with lesser systemic concentrations compared to IV tobramycin was tested in 10 anesthetized and mechanically ventilated ewes with healthy lungs. Nebulized tobramycin produced higher peak lung interstitial space fluid concentrations, as well as higher initial epithelial lining fluid concentrations, with lower plasma concentrations than were observed after IV administration due to more extensive lung penetration. Epithelial lining fluid antibiotic concentrations poorly predicted interstitial space fluid antibiotic concentrations. See the accompanying Editorial View on page 229.
410 Adjunctive Corticosteroid Treatment in Septic Shock (Clinical Focus Review)
Although the anti-inflammatory effects of corticosteroids are well established, by 2017 the question of whether corticosteroid treatment produces benefit in septic shock remained unanswered despite more than 20 randomized trials and 11 systematic reviews and meta-analyses. Since then, two large scale randomized controlled trials have added new data to inform opinion. This Clinical Focus Review considers the biologic rationale for adjunctive use of corticosteroids in the treatment of septic shock, the background to the recent trials, the current state of the evidence, and ongoing areas of uncertainty in this field. It concludes the weight of evidence suggests adjunctive corticosteroid therapy may be associated with either no or, at most, a small reduction in mortality, but there is clear evidence of benefit seen in the patient-centered outcomes of time to withdrawal of ventilation and time in the intensive care unit as well as a faster reversal of shock. Suggestions are provided for clinicians who wish to commence adjunctive corticosteroid treatment for patients with septic shock.
426 Failure to Rescue as a Surgical Quality Indicator: Current Concepts and Future Directions for Improving Surgical Outcomes (Review Article)
Postoperative complications are common adverse events after surgical procedures. Over the past decade, several specific postoperative complications have become the focus of quality improvement initiatives. However, a notable challenge when focusing on postoperative complications as a quality target is that they still can, and do, occur even when timely and appropriate perioperative care is provided. Failure to rescue, or the death of a patient after one or more potentially treatable complications, could be a more appealing target for surgical quality improvement initiatives because it is based on the premise that prompt recognition and treatment of complications can profoundly affect a patient’s eventual outcome. This review provides a conceptual framework for understanding failure to rescue, discusses various patient- and system-level factors associated with failure to rescue, delineates possible reasons failure to rescue has become recognized as an important quality indicator, and proposes future directions of scientific inquiry aimed at developing effective interventions that can be broadly implemented to improve surgical outcomes across all hospitals.