OBJECTIVES:In the PICU, predicting death within 1 hour after terminal extubation (TE) is valuable in augmenting family counseling and in identifying suitable candidates for organ donation after circulatory determination of death (DCDD). The objective of this study was to train and validate a machine learning model to predict death within 1 hour after TE. DESIGN:The Death One Hour After Terminal Extubation (DONATE) database was generated using multicenter retrospective data from 2009 to 2021. Data covering demographics, clinical features, vital signs, laboratory values, ventilator settings, medications, and procedures were collected. Machine learning models were trained to predict whether a pediatric patient would die within 1 hour after TE and evaluated on a holdout set. SETTING:Ten U.S. PICUs. PATIENTS:Children and adolescents, 0-21 years old, who died after TE ( n = 957). INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:The final model was a parsimonious extra-trees model with 21 input features. It was trained on the 2009-2018 data from eight sites ( n = 634) and evaluated on a holdout set comprised of the 2019-2021 data of all ten sites ( n = 323), representing temporal and external validation. The area under the receiver operating characteristic curve and 95% CI was 0.84 (95% CI, 0.81-0.87). At a sensitivity of 90%, the positive predictive value (PPV) was 88%, the negative predictive value (NPV) was 70%, and the number needed to alert (NNA) was 1.14. Among potential organ donors, at the same sensitivity level, the PPV was 86%, the NPV was 74%, and the NNA was 1.17. CONCLUSIONS:Our model, trained and validated on multisite data, predicted whether a child will die within 1 hour of TE with high discrimination and a low false alarm rate. This finding has important applications to end-of-life counseling and institutional resource utilization when families wish to attempt DCDD.

OBJECTIVE:Emergent resuscitation of postoperative paediatric cardiac surgical patients requires specialised skills and multidisciplinary teamwork. Bedside resternotomy is a rare but life-saving procedure and few studies focus on ways to prepare providers and improve performance. We created a multidisciplinary educational intervention that addressed teamwork and technical skills. We aimed to evaluate the efficiency of the intervention to decrease time to perform critical tasks and improve caregiver comfort. METHODS:A simulation-based, in situ resternotomy educational intervention was implemented. Pre-intervention data were collected. Educational aids were used weekly during day and night nursing huddles over a three-month period. All ICU charge nurses had separate educational sessions with study personnel and were required to demonstrate competency in all the critical tasks. Post-intervention simulations were performed after intervention and at 6 months and post-intervention surveys were performed. RESULTS:A total of 186 providers participated in the intervention. There was a decrease in time to obtain defibrillator, setup resternotomy equipment and internal defibrillator paddles and deliver sedation and fluid (all p < 0.05). Time to escort family from the room and obtain blood was significantly decreased after intervention (p < 0.05). There was no difference in time to first dose of epinephrine, defibrillator pads on the patient, or time to call the cardiovascular surgeon or blood bank. Providers reported increased comfort in identifying equipment needed for resternotomy (p < 0.01) and setting up the internal defibrillator paddles (p < 0.01). CONCLUSIONS:Implementation of a novel educational intervention increased provider comfort and decreased time to perform critical tasks in an emergent resternotomy scenario.

Introduction: The doctrine of double effect provides an ethical framework for providers to titrate medications to patient comfort at the end-of-life even if doing so hastens death, but moral distress may result from perceived under- or over- treatment. Objective of this study was to describe the doses of opioids and benzodiazepines (BZD) administered to children around the time of Terminal Extubation (TE) and to identify their association with the time to death (TTD). Methods: Secondary analysis of data collected for the Death One Hour After Terminal Extubation (DONATE) study, which included retrospective data from 9 U.S. hospitals. Medications included total doses of opioids and BZD 24 hours before and 1 hour after TE. Correlations between drug doses and TTD in minutes were calculated, and multivariable linear regression was performed to determine their association with TTD after adjusting for age, sex, last Saturation/FiO2 (SF) ratio, inotrope requirement in last 24 hours, and last recorded Glasgow Coma Scale (GCS) score. Results: Analysis cohort included 680 patients between 0-21 years who died within 1 hour in ICU after TE (2010-2021). Median age of the study population was 2.1 (IQR 0.4, 11) years. The median TTD was 15 (IQR 8, 23) minutes. 40% (278/680) of patients received either opioids or BZD within one hour after TE, with the largest proportion receiving opioids only (23%, 159/680). Among patients who received medications, the median IV morphine equivalent (eq) within 1 hour after TE was 0.75 (IQR 0 .3, 1.8) mg/kg/hr (n=263), and median lorazepam eq was 0.22 (IQR 0.11, 0.44) mg/kg/hr (n=118). The median morphine eq and lorazepam eq rates after TE were 7.5-fold and 22-fold greater than the median pre-extubation rates, respectively. No significant direct correlation was observed between either opioid or BZD doses before or after TE and TTD. After adjusting for confounding variables regression analysis also failed to show any association between drug dose and TTD. Conclusions: Children after TE are often prescribed opioids and BZD. Time to death after TE is not associated with the dose of medication administered as part of comfort care. Providers should titrate analgesic and sedative/anxiolytic medications to patient comfort after terminal extubation.

Objectives:To describe the doses of opioids and benzodiazepines administered around the time of terminal extubation (TE) to children who died within 1 hour of TE and to identify their association with the time to death (TTD). Design:Secondary analysis of data collected for the Death One Hour After Terminal Extubation study. Setting:Nine U.S. hospitals. Patients:Six hundred eighty patients between 0 and 21 years who died within 1 hour after TE (2010-2021). Measurements and Main Results:Medications included total doses of opioids and benzodiazepines 24 hours before and 1 hour after TE. Correlations between drug doses and TTD in minutes were calculated, and multivariable linear regression performed to determine their association with TTD after adjusting for age, sex, last recorded oxygen saturation/Fio(2) ratio and Glasgow Coma Scale score, inotrope requirement in the last 24 hours, and use of muscle relaxants within 1 hour of TE. Median age of the study population was 2.1 years (interquartile range [IQR], 0.4-11.0 yr). The median TTD was 15 minutes (IQR, 8-23 min). Forty percent patients (278/680) received either opioids or benzodiazepines within 1 hour after TE, with the largest proportion receiving opioids only (23%, 159/680). Among patients who received medications, the median IV morphine equivalent within 1 hour after TE was 0.75 mg/kg/hr (IQR, 0.3-1.8 mg/kg/hr) (n = 263), and median lorazepam equivalent was 0.22 mg/kg/hr (IQR, 0.11-0.44 mg/kg/hr) (n = 118). The median morphine equivalent and lorazepam equivalent rates after TE were 7.5-fold and 22-fold greater than the median pre-extubation rates, respectively. No significant direct correlation was observed between either opioid or benzodiazepine doses before or after TE and TTD. After adjusting for confounding variables, regression analysis also failed to show any association between drug dose and TTD. Conclusions:Children after TE are often prescribed opioids and benzodiazepines. For patients dying within 1 hour of TE, TTD is not associated with the dose of medication administered as part of comfort care.

OBJECTIVE:Terminal extubation (TE) and terminal weaning (TW) during withdrawal of life-sustaining therapies (WLSTs) have been described and defined in adults. The recent Death One Hour After Terminal Extubation study aimed to validate a model developed to predict whether a child would die within 1 hour after discontinuation of mechanical ventilation for WLST. Although TW has not been described in children, pre-extubation weaning has been known to occur before WLST, though to what extent is unknown. In this preplanned secondary analysis, we aim to describe/define TE and pre-extubation weaning (PW) in children and compare characteristics of patients who had ventilatory support decreased before WLST with those who did not.DESIGN:Secondary analysis of multicenter retrospective cohort study.SETTING:Ten PICUs in the United States between 2009 and 2021.PATIENTS:Nine hundred thirteen patients 0-21 years old who died after WLST.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:71.4% ( n = 652) had TE without decrease in ventilatory support in the 6 hours prior. TE without decrease in ventilatory support in the 6 hours prior = 71.4% ( n = 652) of our sample. Clinically relevant decrease in ventilatory support before WLST = 11% ( n = 100), and 17.6% ( n = 161) had likely incidental decrease in ventilatory support before WLST. Relevant ventilator parameters decreased were F io2 and/or ventilator set rates. There were no significant differences in any of the other evaluated patient characteristics between groups (weight, body mass index, unit type, primary diagnostic category, presence of coma, time to death after WLST, analgosedative requirements, postextubation respiratory support modality).CONCLUSIONS:Decreasing ventilatory support before WLST with extubation in children does occur. This practice was not associated with significant differences in palliative analgosedation doses or time to death after extubation.

Abstract Background The Guillain-Barre Syndrome (GBS), also known as acute idiopathic polyneuritis, is a critical acquired condition associated with preceding nonspecific infection or triggering factors like trauma, surgery, or vaccination. GBS is currently the most frequent cause of acute flaccid paralysis in India. This study evaluates the short-term and in-hospital outcomes in different subtypes of GBS. Methods A prospective observational study was conducted at V.S. Hospital, Ahmedabad, from September 2015 to December 2017. Patients above the age of 12 were included. Patients having other underlying neurological conditions, as well as immunodeficiency disorders, were excluded. The patients were classified into different subtypes of GBS, and functional outcomes were recorded on admission and discharge according to Hughes Scoring System. All statistical analyses were performed by using SPSS software. Results Out of 50 patients, 35 (70%) were males. The mean age was of 37.18 +/− 18.35 years. 25 (50%) patients had a preceding infection. 88% of patients presented with cranial nerve (CN) involvement had a Hughes Score of >/= 3 (p = 0.0087). They had less improvement of Hughes Score on discharge (0.13 +/− 0.04) as compared to the patients without cranial nerve involvement (0.38 +/− 0.08) (p = 0.008). Respiratory involvement was associated with a higher Hughes Score (p = 0.005) on admission. 85% of patients diagnosed with an axonal subtype of GBS had a Hughes Score of >/= 3 (p = 0.06) compared to 74% patients with demyelinating subtype. Axonal subtype required double period (11 +/− 2.34) to show improvement as compared to demyelinating subtype (6 +/− 1.2) (p = 0.020). Irrespective of the subtypes, in two different treatment cohorts (PLEX vs IVIG), there was no difference in short term functional outcomes measured by improvement in the Hughes scores (p = 0.89). Conclusions Early cranial nerve and respiratory involvement in patients presenting with GBS are associated with poor outcomes warranting immediate critical care involvement. In our study, amongst all the subtypes, axonal had poor clinical outcomes. Further clinical trials on the Indian subpopulation will help us evaluate the impact of different treatment modalities on this disease.

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Coronavirus disease 2019 (COVID-19) has resulted in an unprecedented global healthcare crisis. One special population that poses a challenge is pregnant women with COVID-19. However, there is limited data on treatment options for severe coronavirus disease in pregnancy. Remdesivir, an antiviral drug, is currently being studied as a potential treatment of COVID-19 pneumonia. Nevertheless, pregnant women are also being excluded from various clinical trials for the disease. There are some studies mentioned in the literature which have shown no adverse effects of remdesivir during pregnancy. In this study, we present four serial cases of COVID-19 in pregnant women with moderate to severe symptoms who were treated with remdesivir. All of the them showed positive fetal outcome without any birth defects or malformations. However, further studies are necessary to evaluate the biosafety and effects of remdesivir in pregnant women.

Drug use pattern in the labor room and adherence to standard treatment guidelines: A prospective cross-sectional study in a tertiary care teaching hospital - IJOGR- Print ISSN No: - 2394-2746 Online ISSN No:- 2394-2754 Article DOI No:- 10.18231/j.ijogr.2019.070, Indian Journal of Obstetrics and Gynecology Research-Indi

Kapileshwarkar, Yamini; Cashen, Katherine; Shah, Jui; Tilford, Bradley Author Information

Background: The present study was undertaken to study the efficacy and safety of thiocolchicoside, a centrally acting skeletal muscle relaxant, GABA mimetic drug and pregabalin, an anti-epileptic, GABA mimetic drug in the treatment of acute non-specific low back pain. Methods: The study was carried out at the orthopaedic outpatient department of our hospital. 80 patients were included during the study period of two months. Out of the 80, 40 were given pregabalin 75 mg 1hs and the rest were given thiocolchicoside 8 mg bd by the prescribing doctor. Patients, aged between 18-60 years having non-radiating low back pain for less than 7 days were selected. The data was collected in a proforma which included the patient’s details and the prescribed drugs. The patients were also given notepads to record adverse effects. On day 1, the pain was measured on visual analogue scale. After a week, follow up was done and decrease in pain was measured on the visual analogue scale. Results: There was significant difference between pre and post visual analogue scale score in both the groups with a p-value of less than 0.0001. But the difference between the two groups was not statistically significant (p-value 0.0664). In both the groups, patients did not report any adverse effects. Pregabalin has a slower onset than thiocolchicoside however has better efficacy. In India, where the drug abuse risk is higher, pregabalin is a safer choice as skeletal muscle relaxants (thiocolchicoside) should not be given for more than a week. Conclusions: Pregabalin has better efficacy in treatment of acute non-specific low back pain as compared to thiocolchicoside.