Off-hours admission to pediatric intensive care and mortality. (Betters)

McCrory MC, Gower EW, Simpson SL, Nakagawa TA, Mou SS, Morris PE. Off-hours admission to pediatric intensive care and mortality. Pediatrics. 2014 Nov;134(5):e1345-53.

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BACKGROUND: Critically ill patients are admitted to the pediatric ICU at all times, while staffing and other factors may vary by day of the week or time of day. The purpose of this study was to evaluate whether admission during off-hours is independently associated with mortality in PICUs.

METHODS: A retrospective cohort study of admissions of patients <18 years of age to PICUs was performed using the Virtual PICU Systems (VPS, LLC) database. “Off-hours” was defined as nighttime (7:00 pm to 6:59 am) or weekend (Saturday or Sunday any time). Mixed-effects multivariable regression was performed by using Pediatric Index of Mortality 2 (PIM2) to adjust for severity of illness. Primary outcome was death in the pediatric ICU.

RESULTS: Data from 234 192 admissions to 99 PICUs from January 2009 to September 2012 were included. When compared with regular weekday admissions, off-hours admissions were less likely to be elective, had a higher risk for mortality by PIM2, and had a higher observed ICU mortality (off-hours 2.7% vs weekdays 2.2%; P < .001). Multivariable regression revealed that, after adjustment for other significant factors, off-hours admission was associated with lower odds of mortality (odds ratio, 0.91; 95% confidence interval, 0.85-0.97; P = .004). Post hoc multivariable analysis revealed that admission during the morning period 6:00 am to 10:59 am was independently associated with death (odds ratio, 1.27; 95% confidence interval, 1.16-1.39; P < .0001).

CONCLUSIONS: Off-hours admission does not independently increase odds of death in the PICU. Admission from 6:00 am to 10:59 am is associated with increased risk for death and warrants further investigation in the PICU population.



More harm than good: Antiseizure prophylaxis after traumatic brain injury does not decrease seizure rates but may inhibit functional recovery. (Petrillo)

Bhullar IS, Johnson D, Paul JP, Kerwin AJ, Tepas JJ 3rd, Frykberg ER. More harm than good: Antiseizure prophylaxis after traumatic brain injury does not decrease seizure rates but may inhibit functional recovery. J Trauma Acute Care Surg. 2014 Jan;76(1):54-61.

BACKGROUND: The purposes of this study were to examine the current Brain Trauma Foundation recommendation for antiseizure prophylaxis with phenytoin during the first 7 days after traumatic brain injury (TBI) in preventing seizures and to determine if this medication affects functional recovery at discharge.

METHODS: The records of adult (age ≥ 18 years) patients with blunt severe TBI who remained in the hospital at least 7 days after injury were retrospectively reviewed from January 2008 to January 2010. Clinical seizure rates during the first 7 days after injury and functional outcome at discharge were compared for the two groups based on antiseizure prophylaxis, no prophylaxis (NP) versus phenytoin prophylaxis (PP). Statistical analysis was performed using χ.

RESULTS: A total of 93 adult patients who met the previously mentioned criteria were identified (43 [46%] NP group vs. 50 [54%] PP group). The two groups were well matched. Contrary to expectation, more seizures occurred in the PP group as compared with the NP group; however, this did not reach significance (PP vs. NP, 2 [4%] vs. 1 [2.3%], p = 1). There was no significant difference in the two groups (PP vs. NP) as far as disposition are concerned, mortality caused by head injury (4 [8%] vs. 3 [7%], p = 1), discharge home (16 [32%] vs. 17 [40%], p = 0.7), and discharge to rehabilitation (30 [60%] vs. 23 [53%], p = 0.9). However, with PP, there was a significantly longer hospital stay (PP vs. NP, 36 vs. 25 days, p = 0.04) and significantly worse functional outcome at discharge based on Glasgow Outcome Scale (GOS) score (PP vs. NP, 2.9 vs. 3.4, p < 0.01) and modified Rankin Scale score (2.3 ± 1.7 vs. 3.1 ± 1.5, p = 0.02).

CONCLUSION: PP may not decrease early posttraumatic seizure and may suppress functional outcome after blunt TBI. These results need to be verified with randomized studies before recommending changes in clinical practice and do not apply to penetrating trauma.

LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemiologic study, level III.

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