Daily Anesthesiology Research Analysis

IMPORTANCE: The optimal airway management during pediatric in-hospital cardiac arrest (IHCA) is unknown. OBJECTIVE: To evaluate intubation trends during pediatric IHCA between 2000 and 2022, and determine the association of intra-arrest intubation with survival in a recent cohort of patients (2017-2022). DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study (analysis performed between June 2023 and October 2024) used data from the multicenter American Heart Association Get With The Guidelines-Resuscitation registry. Pediatric patients (<18 years) with IHCA from 2000 through 2022 were included. EXPOSURE: Intra-arrest endotracheal intubation. MAIN OUTCOMES AND MEASURES: The primary outcome was survival to hospital discharge. Intra-arrest intubation trends were assessed using nonparametric test for trend. A time-dependent propensity matched analysis assessed the association between intra-arrest intubation and hospital survival from 2017 through 2022. Each minute, patients intubated were matched with patients at risk of intubation using a propensity score, with forced matching on stratification variables and replacement of controls. Mixed-effects logistic regression assessed the association with survival outcomes, with subgroup analysis by age and illness category. RESULTS: The cohort included 3262 pediatric patients with IHCA (median age, 12.0 [IQR, 3.0-83.8] months; 1775 [54.4%] male) with no advanced airway at CPR onset. Return of spontaneous circulation was attained in 2413 patients (74.0%), and 1748 (53.6%) survived to hospital discharge. The intubation rate decreased over time (33 of 39 [84.6%] in 2000 to 112 of 168 [66.7%] in 2022; P < .001). In the 2017-2022 cohort, intubation vs nonintubation in each minute of CPR was associated with decreased discharge survival odds in unadjusted analysis (odds ratio [OR], 0.18; 95% CI, 0.14-0.24; P < .001) but not after matching (adjusted OR, 1.18; 95% CI, 0.90-1.53; P = .23). In children aged 8 years or older, after matching, intubation compared with nonintubation in each minute was associated with increased odds of discharge survival (adjusted OR, 1.91; 95% CI, 1.09-3.33; P = .02). CONCLUSIONS AND RELEVANCE: In this cohort study of pediatric patients with IHCA between 2017 and 2022 without an advanced airway at the start of CPR, no association was identified between intra-arrest tracheal intubation and hospital survival after time-dependent propensity score matching. In subgroup analysis, intra-arrest intubation in children 8 years or older was associated with higher survival odds. These findings may have important clinical implications for clinicians caring for children with IHCA and warrant further investigation into the physiologic and practical mechanisms of this association.

BACKGROUND: The Extracorporeal Life Support Organization recommends daily antithrombin monitoring and supplementation to achieve > 50%-80% activity during extracorporeal membrane oxygenation (ECMO). Evidence supporting this practice is uncertain, and whether it confers clinical benefit or harm is unclear. METHODS: This was a systematic review with meta-analysis to evaluate the safety and efficacy of antithrombin supplementation during ECMO. We systematically searched databases and registers for studies comparing patients on ECMO who received antithrombin supplementation to those who did not. Random effects meta-analysis was performed. Risk of bias was independently assessed by two investigators. A priori subgroup and sensitivity analyses were performed to explore reasons for heterogeneity. RESULTS: A total of 11 studies were identified. In the pooled meta-analysis, antithrombin supplementation resulted in no difference in bleeding events (OR 1.38, 95% CI, 0.88-2.17, p = 0.16), thrombotic events (OR 1.57, 95% CI, 0.84-2.90, p = 0.15), or mortality (OR 1.21, 95% CI, 0.81-1.81, p = 0.35) when compared to those who did not receive antithrombin. Subgroup analysis revealed no difference in bleeding events or mortality in pediatric or adult patients; however, pediatric patients that received antithrombin were more likely to experience a thrombotic event (OR 1.70, 95% CI, 1.51-1.91). Sensitivity analysis in only low risk of bias studies confirmed these findings. CONCLUSIONS: Antithrombin supplementation was not associated with differences in mortality or hemostatic outcomes during ECMO support and may be associated with harm in pediatric patients on ECMO.

BACKGROUND: Over 1 million hip and knee total joint arthroplasties (THA and TKA) are performed annually in the US. While major perioperative complications are relatively uncommon, they may substantially increase healthcare expenditures. The economic impact of individual complications, however, remains poorly defined. We aimed to assess the effect of major complications on hospital costs and length of stay (LOS). METHODS: We analyzed data from 2,361,402 THA/TKA patients in the Premier Healthcare claims database (2006-2022). The exposure was the occurrence of major postoperative complications (e.g. cardiac, pulmonary, renal, gastrointestinal, infectious, central nervous system, and thromboembolic complications), evaluated individually and in clusters (2 or ≥3 coinciding). The primary outcome was total cost of hospital stay. Generalized estimating equation models compared costs across groups, reported as percent change with 95% confidence intervals. RESULTS: Median costs without complications were $16,802 (IQR $13,731-$20,838) for TKA and $17,250 (IQR $14,072-$21,355) for THA. In TKA, highest costs occurred with ≥3 complications ($35,477, IQR $26,078-$52,071), sepsis ($30,633, IQR $21,748-$44,530), and myocardial infarction ($28,908, IQR $21,805-$38,744). Multivariable models confirmed the greatest adjusted increases with ≥3 complications (+136%), sepsis (+88%), and myocardial infarction (+73%) at the patient level. Frequent complications such as renal failure (+26%), pulmonary complications (+23%), and ICU admission (+61%) emerged as leading drivers of overall costs. LOS accounted for a substantial share of additional costs. CONCLUSIONS: In this large national cohort, perioperative complications substantially increased hospital costs, largely via prolonged LOS. Although sepsis, stroke, and myocardial infarction were most expensive per case, the overall healthcare burden was driven by frequent complications and resource use, including ICU admission, acute renal failure, pulmonary complications, mechanical ventilation, and concurrent complications. These findings suggest that targeting frequent complications and resource intensive care processes may yield the greatest impact on reducing hospital expenditures in arthroplasty surgery.