OBJECTIVES:Mean arterial pressure (MAP) after cardiac surgery may contribute to acute kidney injury (AKI). The authors sought to identify threshold MAP values during the first 24 hours postoperatively below or above which the risk of AKI increased. DESIGN:Retrospective cohort study. SETTING:Single academic medical center. PARTICIPANTS:One thousand three hundred sixty-eight adult patients undergoing cardiac surgery from October 2020 to September 2022. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Using minute-by-minute MAP values during the first 24 hours postoperatively, the authors created 7 mutually exclusive MAP range bands (<55, 55-59, 60-64, 65-69, 70-74, 75-79, and ≥80 mmHg); the primary exposure was defined as the total number of minutes a patient spent within each MAP range band throughout this period. The primary outcome was AKI, identified between 24 hours and 7 days postoperatively. Multivariable logistic regression models quantified the association between increasing time spent in each MAP range band during the first 24 hours postoperatively, relative to a reference range band of 65 to 69 mmHg, and AKI. The mean patient age was 63.9 years (standard deviation, 12.8 years), with 1,313,568 observed MAP data points from 1,895,133 intensive care unit person-minutes during the first 24 hours postoperatively. After prespecified exclusions, AKI occurred in 190 patients (15.3%). There was no association between increasing time spent in any MAP range band, relative to time spent between 65 and 69 mmHg, and AKI. For example, the odds ratio for AKI per 15 minutes with MAP of 60 to 64 mmHg was 0.98 (95% confidence interval [CI], 0.88-1.08), and the odds ratio with MAP of 55 of 59 mmHg was 1.03 (95% CI, 0.93-1.13). CONCLUSIONS:This study was unable to demonstrate an association between increasing time spent in any MAP range band during the first 24 hours postoperatively and AKI.

OBJECTIVE:To develop a parsimonious, interpretable, and accurate model for predicting discharge for premature infants in the NICU-a model suitable for prospective evaluation and integration into clinical workflows. STUDY DESIGN:Using routinely available electronic health record data, we developed and validated NEOnatal Reliable Estimation of Approaching Discharge in Young Infants (NEO-READY), a daily-updating model that predicts the likelihood of discharge within 5 days for premature infants. RESULTS:Data from 702 infants were used to develop the model, and data from 201 infants were used for temporal external validation. The model included 13 predictors and two interaction terms and demonstrated excellent discrimination across development (AUC = 0.88, 95% CI 0.87-0.90) and validation (0.90, 0.88-0.91) cohorts. CONCLUSION:This work represents step 1 toward our long-term goal: integrating the NEO-READY model into clinical workflows as part of a comprehensive strategy to improve discharge preparedness, reduce discharge delays, and optimize NICU resources.

Background Contact precautions are used commonly to prevent nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE). Whether targeted contact precautions are as effective at preventing nosocomial infection as contact precautions for all patients with MRSA and VRE is uncertain. Research Question Compared with standard contact precautions, are targeted contact precautions able to reduce the number of days patients spend in contact precautions and are they as effective at preventing hospital-acquired infection with MRSA and VRE? Study Design and Methods A pragmatic, single-center, single-cluster, crossover pilot and feasibility trial in which all adults admitted to a single medical ICU alternated every 2 months between targeted and standard contact precautions for MRSA and VRE for a total of 8 months. In targeted periods, patients received contact precautions only for highly transmissible MRSA or VRE infections, including open wounds, uncontrolled diarrhea, or pneumonia. In standard periods, patients received contact precautions for any MRSA or VRE infection or colonization. The primary pilot outcome was hospital-acquired infection with MRSA or VRE. The primary feasibility outcome was the number of patients per day removed from contact precautions in the targeted group. Results The trial enrolled 2,230 adults. During targeted months, 0.56 additional patients/d remained without contact precautions. Thirteen hospital-acquired infections with MRSA or VRE occurred during targeted months compared with 13 infections during standard months (P = .95). MRSA acquisition was higher in the targeted group (6.5% vs 3%; P = .03). Interpretation Our results show that despite a slight reduction in patient-days spent with contact precautions during the targeted contact precautions periods, no statistically significant difference was found in hospital-acquired MRSA or VRE infections when comparing targeted with standard contact precautions in this pilot trial. Larger, multicenter trials should examine the benefits and risks of these interventions. Clinical Trial Registration ClinicalTrials.gov; No.: NCT03268122; URL: www.clinicaltrials.gov

Background Patients with sepsis frequently require invasive mechanical ventilation. How oxygenation during mechanical ventilation affects clinical outcomes for patients with sepsis remains uncertain. Research Question To evaluate the effects of different oxygen saturation targets on clinical outcomes for patients with sepsis receiving mechanical ventilation. Study Design and Methods We performed a secondary analysis of the Pragmatic Investigation of optimaL Oxygen Targets (PILOT) trial dataset among patients who met criteria for sepsis by the Sepsis-3 definition at the time of enrollment. We compared patients randomized to a lower oxygen saturation target (90%; range, 88–92%), an intermediate target (94%; range, 92–96%), and a higher target (98%; range, 96–100%) with regard to the outcomes of 28-day in-hospital mortality and ventilator-free days to study day 28. Results Of 2541 patients in the PILOT dataset, 805 patients with sepsis were included in the current analysis. In-hospital mortality by day 28 did not differ significantly between the lower target group (48%; 95% confidence interval [CI], 42% to 54%), the intermediate target group (50%; 95% CI, 43% to 56%), and the higher target group (51%; 95% CI, 45% to 56%) (P = 0.83). The number of ventilator-free days to day 28 did not significantly differ between the trial groups, with a mean of 9.9 (standard deviation [SD], 11.8) in the lower oxygen saturation target group, 9.5 (SD, 11.2) in the intermediate group, and 9.4 (SD, 11.4) in the higher group (P = 0.65). Interpretation Among mechanically ventilated patients with sepsis in a large, randomized trial, the incidence of 28-day in-hospital mortality was not statistically significantly different between the use of a lower, intermediate, or higher oxygen target. However, the confidence intervals included treatment effects that would be clinically meaningfully and further randomized trials of oxygen targets in sepsis are required. Referenced trial name Pragmatic Investigation of optimaL Oxygen Targets Trial (PILOT) ClinicalTrials.gov number NCT03537937 URL: https://clinicaltrials.gov/study/NCT03537937

BACKGROUND:Balanced crystalloid solutions may improve clinical outcomes compared with saline for some critically ill adults, but it is unclear whether differences in composition between balanced crystalloid solutions affect outcomes. RESEARCH QUESTION:Does the choice of balanced crystalloid solutions (Normosol-R vs lactated Ringers) impact acid-base status, organ function, or outcomes for critically ill adults? STUDY DESIGN AND METHODS:This pragmatic, cluster-randomized, multiple-crossover trial at an academic medical center in the United States compared the use of Normosol-R vs lactated Ringers among critically ill adults. The primary outcome was the plasma bicarbonate (HCO3-) concentration between enrollment and 7 days. Secondary outcomes included receipt of kidney replacement therapy and death by day 30. RESULTS:Between June 1, 2018, and January 31, 2019, 2,084 patients were enrolled. The median age was 59 years, 1,006 patients (48.3%) were female, and the median Sequential Organ Failure Assessment score was 5 (interquartile range, 3-8). HCO3- concentration between enrollment and 7 days did not differ between the Normosol-R and lactated Ringers groups (mean difference, -0.12 mmol/dL; 95% CI, -0.61 to 0.36; P = .61). A total of 58 patients (6.0%) in the Normosol-R group and 47 patients (5.0%) in the lactated Ringers group received new kidney replacement therapy (absolute risk difference, 1.0%; 95% CI, -1.2% to 3.1%). Death by day 30 occurred in 172 patients (16.3%) in the Normosol-R group and 164 patients (16.0%) in the lactated Ringers group (absolute risk difference, 0.3%; 95% CI, -2.9% to 3.6%). INTERPRETATION:Among critically ill adults, the use of Normosol-R for IV fluid therapy did not affect plasma HCO3- concentrations or clinical outcomes compared with lactated Ringers. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov; No.: NCT03537898; URL: www. CLINICALTRIALS:gov.

Background  A common cause of preventable harm is the failure to detect and appropriately respond to clinical deterioration. Timely intervention is needed, particularly in medically complex patients, to mitigate the effects of adverse events, disease progression, and medical error. This challenging problem requires clinical surveillance, early recognition, timely notification of the appropriate clinicians, and effective intervention. Objectives  We determined the feasibility of designing, developing, and implementing the tools and processes to create a surveillance-and-risk prediction system to detect clinical deterioration in cancer outpatients. Methods  We used systems engineering and iterative human-centered design to develop a functional prototype of a surveillance-and-risk prediction system. The system includes passive surveillance involving wearable sensors, active surveillance involving patient event and symptom reporting as well as extraction of selected patient data from the electronic health record (EHR), a predictive model, and communication of estimated risk to clinicians. System usability was evaluated using patient and clinician interviews and clinician ratings using the System Usability Scale (SUS). Results  Fifty of 71 recruited patients enrolled in the feasibility study. Patient-reported outcome measures and clinical data extracted from the EHR were the best predictors of a patient's 7-day risk of experiencing unplanned treatment events (UTEs, i.e., emergency room visits, hospital admissions, or major treatment changes). Deep learning neural network models using these predictors demonstrated modest performance in predicting 7-day UTE risk (PROMS, F-measure: 0.900, area under the receiver operating characteristic curve [AUC-ROC]: 0.983; clinical data from EHR F-measure: 0.625, AUC-ROC: 0.983). Patient risk scores were communicated to clinicians using a risk communication prototype rated favorably by clinicians with a SUS score of 76 out of 100 (median = 80; range: 60-85). Conclusion  We demonstrate the feasibility of a surveillance-and-risk prediction system for detecting and reporting clinical deterioration in cancer outpatients. Future research is needed to fully implement and evaluate system adoption and effectiveness under different clinical situations.

BACKGROUND:Perioperative hyperglycemia is associated with adverse patient outcomes including surgical site infections. This study examined whether an automated insulin dosing reminder is associated with a lower risk for postoperative hyperglycemia and other secondary and safety outcomes in patients at high risk for intraoperative hyperglycemia. METHODS:The authors conducted a pragmatic trial using a sequential and repeated crossover design between October 5, 2022, and October 26, 2023. They sequentially assigned anesthesia providers to receive either an automated insulin dosing reminder (intervention) or a glucose check reminder (routine care) periodically throughout surgery for a consecutive sample of adult patients at high risk for intraoperative hyperglycemia undergoing major surgery at their quaternary medical center. The primary outcome was hyperglycemia (glucose greater than 180 mg/dl) at the first postoperative measurement 3 h or less postoperatively. The primary analysis studied the association between automated insulin dosing reminder and postoperative hyperglycemia adjusted for demographics, surgery characteristics, preoperative glucose, time period, and the interaction of intervention and time period. RESULTS:A total of 4,558 cases qualified for primary analysis: 2,611 cases in the routine care group and 1,947 cases in the intervention group. A total of 970 (37%) and 675 (35%) cases, respectively, experienced the primary outcome. The authors found no evidence of an association between treatment and postoperative hyperglycemia in the overall study period (odds ratio [OR], 0.90; 95% CI, 0.78 to 1.03; P = 0.165). There was no evidence of difference in intraoperative glucose monitoring (OR, 0.99; 95% CI, 0.83 to 1.19; P = 0.369) and intraoperative insulin use (OR, 1.00; 95% CI, 0.83 to 1.20; P = 0.995). The odds of surgical site infections were higher in the intervention group (overall unadjusted OR, 2.52; 95% CI, 1.37 to 4.64; P = 0.006). No difference in safety endpoints was observed between groups. CONCLUSIONS:Among surgical patients at high risk of intraoperative hyperglycemia, an automated insulin dosing reminder did not improve glycemic control or other outcomes compared with a glucose check reminder.

BACKGROUND:Despite widespread adoption of ketamine into enhanced recovery after surgery (ERAS) protocols, research regarding its specific impact on perioperative outcomes is limited. This pragmatic, randomised, double-blind, placebo-controlled, single-cluster trial evaluated the impact of ketamine on postoperative outcomes in patients undergoing major abdominal surgery within an established ERAS protocol. METHODS:Male and female patients, aged ≥18 yr, were randomised to ketamine or saline placebo bolus at induction of general anaesthesia, followed by an intraoperative and postoperative infusion for 48 h. The primary outcome was hospital length of stay. Secondary outcomes included total opioid consumption and the incidences of side-effects and adverse events. RESULTS:A total of 1522 patients were included. In covariate adjusted analyses, ketamine administration did not decrease length of stay (odds ratio [OR] 1.21; 95% confidence interval [CI] 1.00-1.47) or opioid consumption (OR 0.85; 95% CI 0.71-1.01) compared with placebo. Patients receiving ketamine experienced higher odds of ICU transfer (OR 2.03; 95% CI 1.14-3.63) and lower odds of meeting early discharge milestones (OR 0.68; 95% CI 0.50-0.93). Rapid response activation (OR 1.51; 95% CI 0.85-2.68) and ileus requiring nasogastric decompression (OR 1.26; 95% CI 0.87-1.84) were similar between groups. Patients receiving ketamine experienced higher rates of debilitating dizziness (OR 6.05; 95% CI 3.02-12.11), debilitating hallucinations (OR 2.69; 95% CI 1.09-6.65), and other severe side-effects (OR 1.94; 95% CI 1.27-2.96). CONCLUSIONS:The addition of ketamine to a multimodal abdominal ERAS protocol provided no significant benefits and was associated with worse perioperative outcomes. CLINICAL TRIAL REGISTRATION:NCT04625283.

Background: The COVID-19 pandemic highlighted the impact of acute respiratory illnesses on long-term morbidity. However, the long-term morbidity associated with non-COVID-19 pneumonia is unclear, particularly in patients who are receiving mechanical ventilation. Research Question: What is the burden of 12-month long-term cognitive impairment (LTCI), functional impairment, psychological distress, and quality of life in critically ill patients receiving mechanical ventilation for non-COVID-19 pneumonia? Study Design and Methods: This single-site prospective cohort study enrolled patients with non-COVID-19 pneumonia receiving mechanical ventilation in the emergency department and ICUs from June 18, 2018, through August 30, 2021. Global cognition at 12 months was measured by the Montreal Cognitive Assessment for the Blind, with higher scores representing better cognition. Secondary outcomes were basic and instrumental activities of daily living (ADLs), psychological distress (posttraumatic stress disorder [PTSD], depression, and anxiety), and quality of life. Results: Of 408 patients with non-COVID-19 pneumonia (63.4%), 96 patients survived and completed the 12-month follow-up. Among survivors of non-COVID-19 pneumonia, 57.3% met the criteria for LTCI, 13.5% showed executive dysfunction, 17.7% showed impairments in at least 1 basic ADL, 51.0% showed impairments in at least 1 instrumental ADL, 44.0% demonstrated physical disability, 17.8% met the criteria for PTSD, 37.8% met the criteria for depression, 46.7% met the criteria for anxiety, and 19.4% rated their quality of life as poor at 12 months. Interpretation: A substantial proportion of patients with non-COVID-19 pneumonia receiving mechanical ventilation met criteria for LTCI. Additionally, many demonstrated difficulty performing ADLs, showed physical disability, and experienced psychological sequelae, leading to poor quality of life at 12 months. Interventions designed to reduce these adverse outcomes are needed.

BACKGROUND:We assessed the association between education-based interventions, the frequency of train-of-four (TOF) monitoring, and postoperative outcomes. METHODS:We studied adults undergoing noncardiac surgery from February 1, 2020 through October 31, 2021. Our education-based interventions consisted of 3 phases. An interrupted time-series analysis, adjusting for patient- and procedure-related characteristics and secular trends over time, was used to assess the associations between education-based interventions and the frequency of TOF monitoring, postoperative pulmonary complications (PPCs), 90-day mortality, and sugammadex dosage. For each outcome and intervention phase, we tested whether the intervention at that phase was associated with an immediate change in the outcome or its trend (weekly rate of change) over time. In a sensitivity analysis, the association between education-based interventions and postoperative outcomes was adjusted for TOF monitoring. RESULTS:Of 19,422 cases, 11,636 (59.9%) had documented TOF monitoring. Monitoring frequency increased from 44.2% in the first week of preintervention stage to 83.4% in the final week of the postintervention phase. During the preintervention phase, the odds of TOF monitoring trended upward by 0.5% per week (odds ratio [OR], 1.005; 95% confidence interval [CI], 1.002-1.007). Phase 1 saw an immediate 54% increase (OR, 1.54; 95% CI, 1.33-1.79) in the odds, and the trend OR increased by 3% (OR, 1.03; 95% CI, 1.01-1.05) to 1.035, or 3.5% per week (joint Wald test, P < .001). Phase 2 was associated with a further immediate 29% increase (OR, 1.29; 95% CI, 1.02-1.64) but no significant association with trend (OR, 0.96; 95% CI, 0.93-1.01) of TOF monitoring (joint test, P = .04). Phase 3 and postintervention phase were not significantly associated with the frequency of TOF monitoring (joint test, P = .16 and P = .61). The study phases were not significantly associated with PPCs or sugammadex administration. The trend OR for 90-day mortality was larger by 24% (OR, 1.24; 95% CI, 1.06-1.45; joint test, P = .03) in phase 2 versus phase 1, from a weekly decrease of 8% to a weekly increase of 14%. However, this trend reversed again at the transition from phase 3 to the postintervention phase (OR, 0.82; 95% CI, 0.68-0.99; joint test, P = .05), from a 14% weekly increase to a 6.2% weekly decrease in the odds of 90-day mortality. In sensitivity analyses, adjusting for TOF monitoring, we found similar associations between study initiatives and postoperative outcomes. TOF monitoring was associated with lower odds of PPCs (OR, 0.69; 95% CI, 0.55-0.86) and 90-day mortality (OR, 0.79; 95% CI, 0.63-0.98), but not sugammadex dosing (mean difference, -0.02; 95% CI, -0.04 to 0.01). CONCLUSIONS:Our education-based interventions were associated with both TOF utilization and 90-day mortality but were not associated with either the odds of PPCs or sugammadex dosing. TOF monitoring was associated with reduced odds of PPCs and 90-day mortality.

Study objective: In 2018, the American Society of Anesthesiologists stated that student registered nurse anesthetists (SRNAs) "are not yet fully qualified anesthesia personnel." It remains unclear, however, whether postprocedural outcomes are affected by SRNAs providing anesthesia care under the medical direction of anesthesiologists, as compared with medically directed anesthesiology fellows or residents, or certified registered nurse anesthetists (CRNAs). We therefore aimed to examine whether medically directed SRNAs serving as inroom anesthesia providers impact surgical outcomes. Design: Retrospective, matched -cohort analysis. Setting: Adult patients (>= 18 years old) undergoing inpatient surgery between 2000 and 2017 at a tertiary academic medical center. Patients: 15,365 patients exclusively cared for by medically directed SRNAs were matched to 15,365 cared for by medically directed CRNAs, anesthesiology residents, and/or fellows. Interventions: None. Measurements: The primary composite outcome was postoperative occurrence of in -hospital mortality and six categories of major morbidities (infectious, bleeding, serious cardiac, gastrointestinal, respiratory, and urinary complications). In -hospital mortality was analyzed as the secondary outcome. Main results: In all, 30,730 cases were matched using propensity score matching to control for potential confounding. The primary outcome was identified in 2295 (7.5%) cases (7.5% with exclusive medically directed SRNAs vs 7.4% with medically directed CRNAs, residents and/or fellows; relative risk, 1.02; 95% CI, 0.94-1.11). Thus, our effort to determine noninferiority (10% difference in relative risk) with other providers was inconclusive (P = .07). However, the medically directed SRNA group (0.8% [118]) was found to be noninferior (P < .001) to the matched group (1.0% [156]) on in -hospital mortality (relative risk, 0.75; 95% CI, 0.59-0.96). Conclusions: Among 30,730 patients undergoing inpatient surgery at a single hospital, findings were inconclusive regarding whether exclusive medically directed SRNAs as in -room providers were noninferior to other providers. The use of medically directed SRNAs under this staffing model should be subject to further review.

BACKGROUND:Hospitalization rates for childhood pneumonia vary widely. Risk-based clinical decision support (CDS) interventions may reduce unwarranted variation. METHODS:We conducted a pragmatic randomized trial in two US pediatric emergency departments (EDs) comparing electronic health record (EHR)-integrated prognostic CDS versus usual care for promoting appropriate ED disposition in children (<18 years) with pneumonia. Encounters were randomized 1:1 to usual care versus custom CDS featuring a validated pneumonia severity score predicting risk for severe in-hospital outcomes. Clinicians retained full decision-making authority. The primary outcome was inappropriate ED disposition, defined as early transition to lower- or higher-level care. Safety and implementation outcomes were also evaluated. RESULTS:The study enrolled 536 encounters (269 usual care and 267 CDS). Baseline characteristics were similar across arms. Inappropriate disposition occurred in 3% of usual care encounters and 2% of CDS encounters (adjusted odds ratio: 0.99, 95% confidence interval: [0.32, 2.95]). Length of stay was also similar and adverse safety outcomes were uncommon in both arms. The tool's custom user interface and content were viewed as strengths by surveyed clinicians (>70% satisfied). Implementation barriers include intrinsic (e.g., reaching the right person at the right time) and extrinsic factors (i.e., global pandemic). CONCLUSIONS:EHR-based prognostic CDS did not improve ED disposition decisions for children with pneumonia. Although the intervention's content was favorably received, low subject accrual and workflow integration problems likely limited effectiveness. Clinical Trials Registration: NCT06033079.

Study objective: Explore validation of a model to predict patients' risk of failing extubation, to help providers make informed, data-driven decisions regarding the optimal timing of extubation. Design: We performed temporal, geographic, and domain validations of a model for the risk of reintubation after cardiac surgery by assessing its performance on data sets from three academic medical centers, with temporal validation using data from the institution where the model was developed. Setting: Three academic medical centers in the United States. Patients: Adult patients arriving in the cardiac intensive care unit with an endotracheal tube in place after cardiac surgery. Interventions: Receiver operating characteristic (ROC) curves and concordance statistics were used as measures of discriminative ability, and calibration curves and Brier scores were used to assess the model's predictive ability. Measurements: Temporal validation was performed in 1642 patients with a reintubation rate of 4.8%, with the model demonstrating strong discrimination (optimism-corrected c-statistic 0.77) and low predictive error (Brier score 0.044) but poor model precision and recall (Optimal F1 score 0.29). Combined domain and geographic validation were performed in 2041 patients with a reintubation rate of 1.5%. The model displayed solid discriminative ability (optimism-corrected c-statistic = 0.73) and low predictive error (Brier score = 0.0149) but low precision and recall (Optimal F1 score = 0.13). Geographic validation was performed in 2489 patients with a reintubation rate of 1.6%, with the model displaying good discrimination (optimism-corrected c-statistic = 0.71) and predictive error (Brier score = 0.0152) but poor precision and recall (Optimal F1 score = 0.13). Main results: The reintubation model displayed strong discriminative ability and low predictive error within each validation cohort. Conclusions: Future work is needed to explore how to optimize models before local implementation.

Background:Cerebral vasospasm (CV) is a feared complication occurring in 20-40% of patients following subarachnoid hemorrhage (SAH) and is known to contribute to delayed cerebral ischemia. It is standard practice to admit SAH patients to intensive care for an extended period of vigilant, resource-intensive, clinical monitoring. We used machine learning to predict CV requiring verapamil (CVRV) in the largest and only multi-center study to date. Methods:SAH patients admitted to UCLA from 2013-2022 and a validation cohort from VUMC from 2018-2023 were included. For each patient, 172 unique intensive care unit (ICU) variables were extracted through the primary endpoint, namely first verapamil administration or ICU downgrade. At each institution, a light gradient boosting machine (LightGBM) was trained using five- fold cross validation to predict the primary endpoint at various timepoints during hospital admission. Receiver-operator curves (ROC) and precision-recall (PR) curves were generated. Results:A total of 1,750 patients were included from UCLA, 125 receiving verapamil. LightGBM achieved an area under the ROC (AUC) of 0.88 an average of over one week in advance, and successfully ruled out 8% of non-verapamil patients with zero false negatives. Minimum leukocyte count, maximum platelet count, and maximum intracranial pressure were the variables with highest predictive accuracy. Our models predicted "no CVRV" vs "CVRV within three days" vs "CVRV after three days" with AUCs=0.88, 0.83, and 0.88, respectively. For external validation at VUMC, 1,654 patients were included, 75 receiving verapamil. Predictive models at VUMC performed very similarly to those at UCLA, averaging 0.01 AUC points lower. Conclusions:We present an accurate (AUC=0.88) and early (>1 week prior) predictor of CVRV using machine learning over two large cohorts of subarachnoid hemorrhage patients at separate institutions. This represents a significant step towards optimized clinical management and improved resource allocation in the intensive care setting of subarachnoid hemorrhage patients.

Background and aim Oral iron therapy is effective in treating iron deficiency anemia in outpatient pregnant women but has not been studied in inpatient pregnant women. We aimed to evaluate the effect of oral iron therapy versus no therapy during hospitalization on maternal and neonatal outcomes in women with anemia who are hospitalized for pregnancy-related morbidities (i.e., preterm premature rupture of membranes, preterm labor, pre-eclampsia, abnormal placentation, or fetal monitoring). Methods A retrospective, single -center study was conducted in hospitalized pregnant women (2018 to 2020) with inpatient stays of more than three days. The primary outcome was a change in hemoglobin level from admission to delivery in women treated with oral iron compared with those left untreated. Secondary outcomes included the total amount of iron administered before delivery, the time interval from admission to delivery, and neonatal effects. Results Two hundred sixty-three women were admitted, 79 women had anemia, and 29 (36.7%) received at least one dose of oral iron. Baseline patient characteristics were similar between groups. The median (interquartile range) dose of iron in the oral iron group was 1185.0 (477.0, 1874.0) mg. Neither absolute hemoglobin before delivery (control group: 10.0 +/- 1.2 g/dL; iron group: 10.1 +/- 1.1 g/dL; p=0.774) nor change in hemoglobin from admission to delivery (control group: -0.1 +/- 1.1 g/dL vs. iron group: 0.4 +/- 1.1 g/dL; p=0.232) differed between groups. Women in the control group had shorter length of stay (LOS) median (IQR) than women in the iron group (control group: 7.1 (5.0, 13.7) days; iron group: 11.4 (7.4, 25.9) days; p=0.03). There were no differences in maternal mode of delivery, though each group had high rates of cesarean delivery (control group: 53.7%; iron group: 72.4%; p=0.181). There were no differences in estimated blood loss at delivery (control group: 559 +/- 401; iron group: 662.1 +/- 337.4; p=0.264) in either group. Neonatal birthweight (control group: 1.9 +/- 0.7 kg; iron group: 1.9 +/- 0.7 kg; p=0.901), birth hemoglobin (control group: 16.3 +/- 2.2 g/dL; iron group: 16 +/- 2.2 g/dL; p=0.569), neonatal intensive care unit (NICU) admission (control group: 93.3%; iron group: 84.8%; p=0.272 ), or neonatal death (control group: 8.9%; iron group: 3%; p=0.394) were not different between groups. Conclusions Oral iron administered to anemic inpatient pregnant women was not associated with higher hemoglobin concentrations before delivery. Lack of standardized iron regimens and short hospital stays may contribute to the inefficacy of oral iron for this inpatient pregnant population. The small sample size and retrospective nature of this study are limiting factors in drawing conclusive evidence from this study.

The role of informatics in public health has increased over the past few decades, and the coronavirus disease 2019 (COVID-19) pandemic has underscored the critical importance of aggregated, multicenter, high-quality, near-real-time data to inform decision-making by physicians, hospital systems, and governments. Given the impact of the pandemic on perioperative and critical care services (eg, elective procedure delays; information sharing related to interventions in critically ill patients; regional bed-management under crisis conditions), anesthesiologists must recognize and advocate for improved informatic frameworks in their local environments. Most anesthesiologists receive little formal training in public health informatics (PHI) during clinical residency or through continuing medical education. The COVID-19 pandemic demonstrated that this knowledge gap represents a missed opportunity for our specialty to participate in informatics-related, public health-oriented clinical care and policy decision-making. This article briefly outlines the background of PHI, its relevance to perioperative care, and conceives intersections with PHI that could evolve over the next quarter century.

Rationale: Among mechanically ventilated critically ill adults, the PILOT (Pragmatic Investigation of Optimal Oxygen Targets) trial demonstrated no difference in ventilator-free days among lower, intermediate, and higher oxygen-saturation targets. The effects on long-term cognition and related outcomes are unknown.Objectives: To compare the effects of lower (90% [range, 88-92%]), intermediate (94% [range, 92-96%]), and higher (98% [range, 96-100%]) oxygen-saturation targets on long-term outcomes.Methods: Twelve months after enrollment in the PILOT trial, blinded neuropsychological raters conducted assessments of cognition, disability, employment status, and quality of life. The primary outcome was global cognition as measured using the Telephone Montreal Cognitive Assessment. In a subset of patients, an expanded neuropsychological battery measured executive function, attention, immediate and delayed memory, verbal fluency, and abstraction.Measurements and Main Results: A total of 501 patients completed follow-up, including 142 in the lower, 186 in the intermediate, and 173 in the higher oxygen target groups. Median (interquartile range) peripheral oxygen saturation values in the lower, intermediate, and higher target groups were 94% (91-96%), 95% (93-97%), and 97% (95-99%), respectively. Telephone Montreal Cognitive Assessment score did not differ between lower and intermediate (adjusted odds ratio [OR], 1.36 [95% confidence interval (CI), 0.92-2.00]), intermediate and higher (adjusted OR, 0.90 [95% CI, 0.62-1.29]), or higher and lower (adjusted OR, 1.22 [95% CI, 0.83-1.79]) target groups. There was also no difference in individual cognitive domains, disability, employment, or quality of life.Conclusions: Among mechanically ventilated critically ill adults who completed follow-up at 12 months, oxygen-saturation targets were not associated with cognition or related outcomes.