Intermittent Phosphate Usage for Pediatric Diabetic Ketoacidosis in the Setting of a Phosphate Shortage

2019 ◽  
pp. 001857871986764
Author(s):  
Christopher T. Campbell ◽  
Sarah Gattoline ◽  
Brian Kelly
Keyword(s):  
Length Of Stay ◽  
Diabetic Ketoacidosis ◽  
Group Versus ◽  
Potassium Phosphate ◽  
Hospital Length Of Stay ◽  
Continuous Group ◽  
Continuous Administration ◽  
Improvement Project ◽  
Total Phosphate ◽  
Number Of Patients

Purpose: Hypophosphatemia during pediatric diabetic ketoacidosis (DKA) is often replaced through a continuous infusion of intravenous (IV) fluids with potassium phosphate. In 2012, during an IV potassium phosphate shortage, providers were directed to oral replacement strategies to restrict IV products to those patients with severe hypophosphatemia. Intermittent oral and IV as needed doses for low phosphate levels replaced continuous administration in pediatric DKA. The purpose of this quality-improvement project was to determine whether the implemented IV phosphate restrictions resulted in less IV phosphate usage with no change in clinically relevant outcomes. Methods: In a retrospective chart analysis, pediatric patients less than 18 years of age admitted with a DKA diagnosis from June 2011 to December 2016 were divided into 2 groups: continuous and intermittent phosphate administration. Patients were excluded if they received both therapies. The primary outcome was the difference in IV phosphate administered. Secondary outcomes included the following: total phosphate received, the number of patients requiring as needed doses, phosphate levels at admission and discharge from pediatric intensive care unit (PICU), hospital length of stay, and PICU length of stay. Results: Phosphate restrictions resulted in a significantly lower usage of IV phosphate products in the intermittent group versus the continuous group (38.5 vs. 0 mmol, P < .0001). While total phosphate replacement was similar, intermittent phosphate administration was also associated with significantly lower minimum and discharge phosphate levels. Conclusions: During a phosphate salt shortage, restriction of continuous phosphate replacement in pediatric DKA management can reduce the amount of IV phosphate products used without any clinically meaningful change in outcomes.

Balanced Crystalloid Versus Normal Saline as Resuscitative Fluid in Diabetic Ketoacidosis

2022 ◽  
pp. 106002802110636
Author(s):  
Adriana R. Carrillo ◽  
Kirsten Elwood ◽  
Chris Werth ◽  
Jessica Mitchell ◽  
Preeyaporn Sarangarm
Keyword(s):  
Length Of Stay ◽  
Serum Creatinine ◽  
Diabetic Ketoacidosis ◽  
Fluid Resuscitation ◽  
Normal Saline ◽  
Group Versus ◽  
Hospital Length Of Stay ◽  
Maximum Serum ◽  
Significant Difference ◽  
Balanced Crystalloid

Background: Large volume resuscitation with normal saline (NS) may be associated with iatrogenic hyperchloremia and renal injury. Objective: The purpose of this study was to assess clinical outcomes associated with the use of Lactated Ringer’s (LR) compared to NS as resuscitative fluid in diabetic ketoacidosis (DKA). Methods: Single-center, retrospective analysis of patients admitted for DKA. The primary objective of this study was to evaluate the incidence of iatrogenic hyperchloremia associated with fluid resuscitation using balanced crystalloid compared to NS. Results Iatrogenic hyperchloremia occurred more frequently in the NS group compared to the LR group (74.4% vs 64.2%; P = 0.05). Mean maximum serum chloride was higher in the NS group (115.7 mmol/L vs 113.7 mmol/L; P = 0.004). Incidence of hypernatremia was higher in the NS group (18.3% vs 9.3%; P = 0.02). There was no significant difference in the incidence of AKI; however, mean change in serum creatinine at 48 hours showed a significantly greater decrease in the LR group (-0.15 mg/dL vs -0.04 mg/dL; P = 0.002). No significant differences were found in intensive care unit (ICU) length of stay or total hospital length of stay. Conclusion and Relevance This study found a statistically significant reduction in the incidence of iatrogenic hyperchloremia with the use of LR compared to NS as fluid resuscitation in DKA. Serum creatinine was more improved in the LR group versus NS group at 48 hours. Preferential use of balanced crystalloid for fluid resuscitation in DKA may reduce incidence of hyperchloremia and support renal recovery in this population.

30-Day Outcomes for Total Ankle Arthroplasty in Patients With Anemia

2021 ◽  
pp. 107110072110175
Author(s):  
Jordan R. Pollock ◽  
Matt K. Doan ◽  
M. Lane Moore ◽  
Jeffrey D. Hassebrock ◽  
Justin L. Makovicka ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Univariate Analysis ◽  
Hospital Length ◽  
Total Ankle Arthroplasty ◽  
Hospital Length Of Stay ◽  
Preoperative Anemia ◽  
Improvement Project ◽  
Average Hospital ◽  
Ankle Arthroplasty ◽  
Reoperation Rates

Background: While anemia has been associated with poor surgical outcomes in total knee arthroplasty and total hip arthroplasty, the effects of anemia on total ankle arthroplasty remain unknown. This study examines how preoperative anemia affects postoperative outcomes in total ankle arthroplasty. Methods: A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from 2011 to 2018 for total ankle arthroplasty procedures. Hematocrit (HCT) levels were used to determine preoperative anemia. Results: Of the 1028 patients included in this study, 114 patients were found to be anemic. Univariate analysis demonstrated anemia was significantly associated with an increased average hospital length of stay (2.2 vs 1.8 days, P < .008), increased rate of 30-day readmission (3.5% vs 1.1%, P = .036), increased 30-day reoperation (2.6% vs 0.4%, P = .007), extended length of stay (64% vs 49.9%, P = .004), wound complication (1.75% vs 0.11%, P = .002), and surgical site infection (2.6% vs 0.6%, P = .017). Multivariate logistic regression analysis found anemia to be significantly associated with extended hospital length of stay (odds ratio [OR], 1.62; 95% CI, 1.07-2.45; P = .023) and increased reoperation rates (OR, 5.47; 95% CI, 1.15-26.00; P = .033). Anemia was not found to be a predictor of increased readmission rates (OR, 3.13; 95% CI, 0.93-10.56; P = .066) or postoperative complications (OR, 1.27; 95% CI, 0.35-4.56; P = .71). Conclusion: This study found increasing severity of anemia to be associated with extended hospital length of stay and increased reoperation rates. Providers and patients should be aware of the increased risks of total ankle arthroplasty with preoperative anemia. Level of Evidence: Level III, retrospective comparative study.

Ketamine as an Analgesic Adjuvant in Adult Trauma Intensive Care Unit Patients With Rib Fracture

2018 ◽  
Vol 52 (9) ◽  
pp. 849-854 ◽  
Author(s):  
Mary K. Walters ◽  
Joseph Farhat ◽  
James Bischoff ◽  
Mary Foss ◽  
Cory Evans
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Length Of Stay ◽  
Group Versus ◽  
Standard Of Care ◽  
Pain Scale ◽  
Rib Fracture ◽  
Hospital Length Of Stay ◽  
Control Group ◽  
Opioid Use

Background: Rib fracture associated pain is difficult to control. There are no published studies that use ketamine as a therapeutic modality to reduce the amount of opioid to control rib fracture pain. Objective: To examine the analgesic effects of adjuvant ketamine on pain scale scores in trauma intensive care unit (ICU) rib fracture. Methods: This retrospective, case-control cohort chart review evaluated ICU adult patients with a diagnosis of ≥1 rib fracture and an Injury Severity Score >15 during 2016. Patients received standard-of-care pain management with the physician’s choice analgesics with or without ketamine as a continuous, fixed, intravenous infusion at 0.1 mg/kg/h. Results: A total of 15 ketamine treatment patients were matched with 15 control standard-of-care patients. Efficacy was measured via Numeric Pain Scale (NPS)/Behavioral Pain Scale (BPS) scores, opioid use, and ICU and hospital length of stay. Safety of ketamine was measured by changes in vital signs, adverse effects, and mortality. Average NPS/BPS, severest NPS/BPS, and opioid use were lower in the ketamine group than in controls (NPS: 4.1 vs 5.8, P < 0.001; severest NPS: 7.0 vs 8.9, P = 0.004; opioid use: 2.5 vs 3.5 mg morphine equivalents/h/d, P = 0.015). No difference was found between the cohort’s length of stay or mortality. Average diastolic blood pressure was higher in the treatment group versus the control group (75.3 vs 64.6 mm Hg, P = 0.014). Conclusion: Low-dose ketamine appears to be a safe and effective adjuvant option to reduce pain and decrease opioid use in rib fracture.

Intraoperative Implementation of a Tissue Sealant on All Lung Surgery Patients: A Quality Improvement Project

2015 ◽  
Vol 8 (1) ◽  
pp. 125-129
Author(s):  
Stephanie Cain ◽  
Richard Anderson ◽  
Patricia Stockert ◽  
Suzanne Brown ◽  
Jane Blood-Siegfried
Keyword(s):  
Length Of Stay ◽  
Chest Tube ◽  
Length Of Hospital Stay ◽  
Clinical Problem ◽  
Hospital Length Of Stay ◽  
Air Leak ◽  
Improvement Project ◽  
Air Leaks ◽  
Pulmonary Surgery ◽  
Tissue Sealant

More than 200,000 patients undergo pulmonary surgery annually. Air leaks after pulmonary surgery are a common complication and represent a substantial clinical problem. Air leaks can increase chest tube time, increase pain, reduce mobility, and increase hospital length of stay. The application of a synthetic surgical lung sealant (SLS) to lung surfaces during surgery in patients at risk for an air leak has been advocated to reduce these complications.The aim of the project was to reduce or eliminate air leaks, decrease chest tube time, and decrease length of stay by applying an FDA-approved tissue sealant during all pulmonary surgeries. The population of focus were adult pulmonary surgery patients undergoing pulmonary surgery.Data were collected on 146 patients: 72 patients the year prior to the intervention and 74 the year after implementation of the intervention. The incidence of air leak was significantly lower; the number of comorbidities was statistically higher in the group following implementation. There were, however, no significant differences in chest tube duration and length of hospital stay. The use of lung sealant on all patients undergoing pulmonary surgery had a positive outcome without any adverse effects and is now standard of practice.

Clinical pathway for the Fontan patient to standardise care and improve outcomes

2020 ◽  
Vol 30 (9) ◽  
pp. 1247-1252
Author(s):  
Sarah M. Lagergren ◽  
Megan Jensen ◽  
Bryan Beaven ◽  
Suma Goudar
Keyword(s):  
Length Of Stay ◽  
Clinical Pathway ◽  
Patient Population ◽  
Fontan Procedure ◽  
Diuretic Therapy ◽  
The United States ◽  
Hospital Length Of Stay ◽  
Fluid Restriction ◽  
Fontan Patient ◽  
Improvement Project

AbstractIntroduction:The Fontan procedure is the final stage of surgical palliation for the children with functionally single ventricle anatomy. The post-operative medical management of this patient population can be variable and hospital length of stay prolonged. The purpose of this quality improvement project was to determine if the implementation of an evidence-based clinical pathway for post-operative management of the Fontan patient at a large Midwestern academic paediatric medical centre would standardise care and decrease length of stay.Materials and methods:The clinical pathway was developed using key components from three published pathways for the Fontan procedure from other paediatric institutions across the United States. Components of the clinical pathway included (1) supplemental oxygen until pleural drainage tubes are removed, (2) fluid restriction to 80% daily maintenance and a prescribed low-fat diet, (3) aggressive and standardised diuretic therapy while inpatient and (4) central venous access. The pathway was trialed using Plan-Do-Study-Act cycles in 2016, implemented in 2017 and sustained in 2018–2019. A retrospective electronic medical record review was performed to compare key outcomes from pre-pathway (2014–2015, 37 patients) with post-pathway implementation (2017–2018, 30 patients).Results:Adherence to the pathway was nearly 100% with a statistically significant decrease in length of stay from 12 to 9 days (p = 0.007) and no increase in readmissions.Conclusion:Standardising care can improve clinical and financial outcomes for the Fontan patient population without negatively impacting quality of care, thus providing a positive benefit to the healthcare institution, industry and patient.

It is Not Just Cosmesis: Straight Laparoscopy with Stoma Site Extraction Improves Outcomes in Ulcerative Colitis Patients Undergoing Total Colectomy

2019 ◽  
Vol 85 (10) ◽  
pp. 1194-1197
Author(s):  
Ino Chough ◽  
Karen Zaghiyan ◽  
Gayane Ovsepyan ◽  
Phillip Fleshner
Keyword(s):  
Ulcerative Colitis ◽  
Length Of Stay ◽  
Group Versus ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Study Cohort ◽  
Class Iii ◽  
Total Abdominal Colectomy ◽  
Postoperative Length ◽  
The Mean

Minimally invasive approaches to total abdominal colectomy (TAC) in ulcerative colitis (UC) patients include straight laparoscopy (SL), hand-assisted laparoscopic surgery (HALS), and robotics. In this study, short-term outcomes of patients undergoing SL and HALS TAC were compared. Prospectively collected data on UC patients undergoing TAC were tabulated. The study cohort included 36 (27%) patients in the SL group and 95 (73%) patients in the HALS group. The groups were comparable in terms of preoperative characteristics and demographics. The mean operative time was 151 (range, 73–225) minutes in the SL group versus 164 (range, 103–295) minutes in the HALS group ( P = 0.09). Total 48-hour IV morphine use was 30 (range, 0–186) mg in the SL group compared with 56 (0–275) mg in the HALS group ( P < 0.01). Although overall morbidity was comparable between the groups, Clavien-Dindo Class III complications did not occur in any of the SL group patients versus 11 (11%) of the HALS group patients ( P = 0.03). The postoperative length of stay was 3 (3–21) days in the SL group versus 5 (3–15) days in the HALS group ( P < 0.01). Compared with HALS, SL is associated with lower postoperative narcotic use and hospital length of stay in UC patients undergoing TAC.

scholarly journals MP023: Reasons for referral and hospitalization among emergency department patients with syncope

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S74-S74
Author(s):  
O. Cook ◽  
M.A. Mukarram ◽  
M. Rahman ◽  
S. Kim ◽  
K. Arcot ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Improve Patient Safety ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Cardiac Monitoring ◽  
Inpatient Cost ◽  
Monitoring Strategy ◽  
Potential Cost ◽  
Cardiac Syncope ◽  
Number Of Patients

Introduction: Syncope can be caused by serious life-threatening conditions not obvious during the initial ED assessment leading to wide variations in management. We aimed to identify the reasons for consultations and hospitalizations, outcomes, and the potential cost savings if an outpatient cardiac monitoring strategy were developed. Methods: We conducted a prospective cohort study of adult syncope patients at 5 academic EDs over 41 months. We collected baseline characteristics, reasons for consultation and hospitalization, hospital length of stay and average total inpatient cost. Adjudicated 30-day serious adverse events (SAEs) included death, myocardial infarction, arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage and procedural intervention. We used descriptive statistics with 95% CI. Results: Of the 4,064 patients enrolled (mean age 53.1 years, 55.9% female), 3,255 (80.1%) were discharged from the ED, 209 (5.2%) had a SAE identified in the ED, 600 (14.8%) with no SAE were referred for consultation in the ED and 299 (7.4%) were hospitalized: 55.5% of referrals and 55.2% of hospitalizations were for suspected cardiac syncope (46.5% admitted for cardiac monitoring of whom 71.2% had no cause identified). SAE among groups were 9.7% in total; 2.5% discharged by ED physician; 3.4% discharged by consultant from ED; 21.7% as inpatient and 4.8% following discharge from hospital. The mean hospital length of stay for cardiac syncope was 6.7 (95%CI 5.8, 7.7) days with total estimated costs of $7,925 per patient (95% CI: 7434, 8417). Conclusion: Suspected cardiac syncope, particularly arrhythmia, was the major reason for ED referral and hospitalization. The majority of patients hospitalized for cardiac monitoring had no identified cause. An important number of patients suffered SAE, particularly arrhythmias outside the hospital. These findings highlight the need to develop a robust syncope prediction tool and a remote cardiac monitoring strategy to improve patient safety while saving substantial health care resources.

Predictors of intensive care unit and hospital length of stay in diabetic ketoacidosis

2002 ◽  
Vol 17 (4) ◽  
pp. 207-211 ◽  
Author(s):  
Amado X. Freire ◽  
Guillermo E. Umpierrez ◽  
Bekele Afessa ◽  
Kashif A. Latif ◽  
Lisa Bridges ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Length Of Stay ◽  
Diabetic Ketoacidosis ◽  
Hospital Length ◽  
Hospital Length Of Stay

S111 – Monitoring Frequency: A Determinant in Free Tissue Transfer

2008 ◽  
Vol 139 (2_suppl) ◽  
pp. P114-P114
Author(s):  
Joshua D Hornig
Keyword(s):  
Length Of Stay ◽  
Group Versus ◽  
Free Tissue Transfer ◽  
Hospital Length Of Stay ◽  
Complication Rates ◽  
Success Rates ◽  
Minimal Group ◽  
Tissue Transfer ◽  
Flap Loss ◽  
Flap Monitoring

Objectives 1) To compare the success rates of free tissue transfer (FTT) between a cohort of patients who underwent frequent scheduled checks to a cohort who received checks on an as-needed basis. 2) To compare the overall flap survival, ICU stay, in-hospital stay, complications, and cost. Methods Patients meeting the criteria for free tissue transfer were divided into 2 cohorts: minimal FTT monitoring and frequent scheduled FTT monitoring. In August 2005, frequent scheduled flap monitoring was instituted. The study was set up to identify if this method impacted overall patient outcomes. The 2 groups were compared over several dimensions: overall flap outcome, total vs. partial flap loss, length of stay in hospital, revision procedures, and complications. Results A total of 212 patients were identified. 107 of the patients were in the frequent, scheduled group and 105 were in the minimal group. The overall FTT success rates were significantly higher in the frequently scheduled group versus the minimal group (100% vs 89%). The rates of partial flap loss and total flap loss were higher in the minimal group (11% vs 4%). The overall length of stay in the hospital, length of stay in the ICU, and complication rates were nonsignificant between the 2 groups. However, the number of revision procedures were significantly lower in the frequently scheduled FTT group. Conclusions The implementation of frequent scheduled flap monitoring significantly improves free tissue transfer survival in head and neck patients and decreases the number of revision procedures that need to be performed.

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