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Chao NT, Karwoski AS, Pitsenbarger LT, Som MN, Dunlap E, Nagarsheth KH. Preoperative Nil Per Os Duration Predicts Mortality and Ambulation Following Below-Knee Amputation. Am Surg 2024:31348241244633. [PMID: 38561237 DOI: 10.1177/00031348241244633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Routine use of nil per os (NPO) prior to procedures has been associated with dehydration and malnutrition leading to patient discomfort. We aim to examine how duration of NPO status affects postoperative outcomes in patients undergoing elective below-knee amputation (BKA). METHODS We performed a retrospective chart review of 92 patients who underwent elective BKA between 2014-2022 for noninfectious indications. We performed statistical analysis using Chi-square tests, t-tests, and linear/logistic regression with odds ratio using P < .05 as our significance level. RESULTS The mean age was 48.0 ± 16.7 years, and there were 64 (70%) male patients and 41 (45%) Black patients. Mean NPO duration was 12.9 ± 4.7 hours. Patients with longer NPO duration were associated with increased rates of postoperative stroke (P = .03). Patients with shorter NPO duration had significantly lower mean BUN on postoperative day (POD) 1 (14.5, P < .001) and POD 3 (14.1, P < .001) compared to preoperative mean BUN (16.8), however this normalized by POD 7 (19.2, P = .26). There were no changes in postoperative renal function based on baseline kidney disease status or associated with longer NPO duration. Shorter NPO duration was a predictor of increased likelihood of 1-year follow-up (OR: 2.9 [1.24-6.79], P = .01), independent ambulation (OR: 2.7 [1.03-7.34], P = .04), and decreased mortality (OR: .11 [.013-.91], P = .04). CONCLUSION While NPO duration does not appear to result in postoperative renal dysfunction, prolonged NPO duration predicts worse rates of follow-up, ambulation, and survival and is associated with increased stroke rates.
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Affiliation(s)
- Natalie T Chao
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Maria N Som
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eleanor Dunlap
- University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, Vascular Division, University of Maryland Medical Center, Baltimore, MD, USA
| | - Khanjan H Nagarsheth
- University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, Vascular Division, University of Maryland Medical Center, Baltimore, MD, USA
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Mehta PB, Kohn MA, Rov-Ikpah E, San Luis C, Johnson C, Lee G, Koliwad S, Rushakoff RJ. Novel Automated Self-adjusting Subcutaneous Insulin Algorithm Improves Glycemic Control and Physician Efficiency in Hospitalized Patients. J Diabetes Sci Technol 2024:19322968241232673. [PMID: 38454631 DOI: 10.1177/19322968241232673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Hyperglycemia occurs in 22% to 46% of hospitalized patients, negatively affecting patient outcomes, including mortality, inpatient complications, length of stay, and hospital costs. Achieving inpatient glycemic control is challenging due to inconsistent caloric intake, changes from home medications, a catabolic state in the setting of acute illness, consequences of acute inflammation, intercurrent infection, and limitations in labor-intensive glucose monitoring and insulin administration. METHOD We conducted a retrospective cross-sectional analysis at the University of California San Francisco hospitals between September 3, 2020 and September 2, 2021, comparing point-of-care glucose measurements in patients on nil per os (NPO), continuous total parenteral nutrition, or continuous tube feeding assigned to our novel automated self-adjusting subcutaneous insulin algorithm (SQIA) or conventional, physician-driven insulin dosing. We also evaluated physician efficiency by tracking the number of insulin orders placed or modified. RESULTS The proportion of glucose in range (70-180 mg/dL) was higher in the SQIA group than in the conventional group (71.0% vs 69.0%, P = .153). The SQIA led to a lower proportion of severe hyperglycemia (>250 mg/dL; 5.8% vs 7.2%, P = .017), hypoglycemia (54-69 mg/dL; 0.8% vs 1.2%, P = .029), and severe hypoglycemia (<54 mg/dL; 0.3% vs 0.5%, P = .076) events. The number of orders a physician had to place while a patient was on the SQIA was reduced by a factor of more than 12, when compared with while a patient was on conventional insulin dosing. CONCLUSIONS The SQIA reduced severe hyperglycemia, hypoglycemia, and severe hypoglycemia compared with conventional insulin dosing. It also improved physician efficiency by reducing the number of order modifications a physician had to place.
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Affiliation(s)
- Paras B Mehta
- Division of Endocrinology and Metabolism, University of California, San Francisco, CA, USA
| | - Michael A Kohn
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Esther Rov-Ikpah
- Institute of Nursing Excellence, University of California, San Francisco, CA, USA
| | - Craig San Luis
- Department of Clinical Systems, University of California, San Francisco, CA, USA
| | - Craig Johnson
- Department of Health Informatics, University of California, San Francisco, CA, USA
| | - Gwendolyn Lee
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Suneil Koliwad
- Division of Endocrinology and Metabolism, University of California, San Francisco, CA, USA
| | - Robert J Rushakoff
- Division of Endocrinology and Metabolism, University of California, San Francisco, CA, USA
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Ghimire A, Moharir A, Yamaguchi Y, Tram NK, Tobias JD. Preoperative gastric point-of-care ultrasound in nonelective surgical procedures in pediatric-aged patients. Saudi J Anaesth 2024; 18:17-22. [PMID: 38313729 PMCID: PMC10833037 DOI: 10.4103/sja.sja_379_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 02/06/2024] Open
Abstract
Background Airway management for nonelective surgical procedures in the setting of trauma, pain, and opioid use can be complicated by the potential for aspiration due to delayed gastric emptying. Point-of-care ultrasound (POCUS) remains a useful tool for evaluating gastric content and volume in various clinical settings. The authors evaluated gastric volume and content in children scheduled for urgent and semi-urgent procedures to assess their aspiration risk. Methods After obtaining consent, gastric POCUS was performed in the preoperative holding area for pediatric patients scheduled for both elective and nonelective surgery. Qualitative and quantitative measurements of the gastric antrum were taken, and the risk of gastric aspiration was calculated. Additional data collected included patient demographics, the type of surgery, nil per os (NPO) status at the time of surgery, NPO status at the time of injury, and administration of opioids. Results The study cohort included 100 patients ranging in age from 3 to 17 years old (mean age 9.2 years). Out of these 100 patients, gastric scanning was successfully conducted in 98 patients. Sixteen of fifty-nine nonelective patients (27%) had received opioids for pain control prior to surgery. Among the 34 patients who had suffered an acute injury, 7 (21%) had been NPO for <8 hours at the time of the injury. Ninety-nine out of hundred patients had been NPO for at least 6 hours at the time of the gastric ultrasound. Based on our gastric ultrasound findings, all patients who were appropriately NPO had either Grade 0 or Grade 1 risk for aspiration, indicating a low risk of aspiration. Conclusions The preliminary data show that when patients presenting for nonelective surgery are appropriately NPO, they may have a low risk of aspiration. This information may help guide the choice of anesthetic induction technique, particularly when concerns exist about the safety of a rapid sequence induction. It allows for a more stable and controlled induction of anesthesia.
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Affiliation(s)
- Anuranjan Ghimire
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
| | - Alok Moharir
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, Japan
| | - Yoshikazu Yamaguchi
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
- Department of Anesthesiology, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Nguyen K. Tram
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, Japan
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Japan
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, Japan
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Maeda K, Murotani K, Kamoshita S, Horikoshi Y, Kuroda A. Effect of parenteral energy or amino acid doses on in-hospital mortality, among patients with aspiration pneumonia: a cohort medical claims database study. J Gerontol A Biol Sci Med Sci 2021; 77:1683-1690. [PMID: 34626471 PMCID: PMC9373951 DOI: 10.1093/gerona/glab306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Indexed: 12/05/2022] Open
Abstract
Background This study examined the association between parenteral energy/amino acid doses and in-hospital mortality among inpatients on long-term nil per os (NPO) status, using a medical claims database in Japan. Methods Hospitalized patients with aspiration pneumonia, aged 65 and older, and on more than 7-day NPO status were identified in a medical claims database between January 2013 and December 2018. Using multivariate logistic regression and regression analyses, we examined the association between mean parenteral energy/amino acid doses and in-hospital mortality, and secondarily, the association between prognosis (in-hospital mortality, inability to receive full oral intake, readmission, and hospital stay length) and 4 groups of mean amino acid doses (no dose: 0 g/kg/day; very low dose: >0, ≤0.3 g/kg/day; low dose: >0.3, ≤0.6 g/kg/day; moderate dose: >0.6 g/kg/day). Results The analysis population included 20 457 inpatients (≥80 years: 78.3%). In total, 5 920 mortalities were recorded. Increased amino acid doses were significantly associated with reduced in-hospital mortality (p < .001). With a no dose reference level, the odds ratios (95% confidence interval) of in-hospital mortality adjusted for potential confounders were 0.78 (0.72–0.85), 0.74 (0.67–0.82), and 0.69 (0.59–0.81) for very low, low, and moderate amino acid doses, respectively. Additionally, patients prescribed amino acid dose levels more than 0.6 g/kg/day had shorter hospitalization periods than those prescribed none. Conclusions Increased amino acid doses were associated with reduced in-hospital mortality. Sufficient amino acid administration is recommended for patients with aspiration pneumonia requiring NPO status.
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Affiliation(s)
- Keisuke Maeda
- Department of Geriatric Medicine, National Center for Geriatrics and Gerontology, Morioka-cho, Obu-shi, Aichi-ken, Japan
| | - Kenta Murotani
- Biostatistics Center, Kurume University Graduate School of Medicine, Asahi-machi, Kurume, Japan
| | - Satoru Kamoshita
- Medical Affairs Department, Research and Development Center, Otsuka Pharmaceutical Factory, Inc., Kanda-Tsukasamachi, Chiyoda-ku, Tokyo, Japan
| | - Yuri Horikoshi
- Medical Affairs Department, Research and Development Center, Otsuka Pharmaceutical Factory, Inc., Kanda-Tsukasamachi, Chiyoda-ku, Tokyo, Japan
| | - Akiyoshi Kuroda
- Research and Development Center, Otsuka Pharmaceutical Factory, Inc., Kanda-Tsukasamachi, Chiyoda-ku, Tokyo, Japan
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Maeda K, Murotani K, Kamoshita S, Horikoshi Y, Kuroda A. Nutritional management in inpatients with aspiration pneumonia: a cohort medical claims database study. Arch Gerontol Geriatr 2021; 95:104398. [PMID: 33798999 DOI: 10.1016/j.archger.2021.104398] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/01/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND/OBJECTIVES This study aimed to describe real-world nutrition management patterns among inpatients hospitalized for aspiration pneumonia, using a medical claims database in Japan. METHODS Patients aged ≥65 years hospitalized for aspiration pneumonia treatment were identified in a medical claims database between January 2013 and December 2018, to evaluate nutrition management initiation and adjustment timing, factors associated with >7-days nil per os (NPO) status, prescribed nutrition doses, and types of parenteral nutrition solutions. Patients who received oral intake or enteral nutrition on the day of admission (Day 1) were excluded. RESULTS The analysis population included 72,315 inpatients. The median (first quartile, third quartile) initiation date of oral nutrition intake was Day 4 (3, 7) and 65.1% of patients received oral nutrition intake by Day 7. Factors associated with >7-day NPO included sex, BMI, treatment years, Barthel Index score, Japan Coma Scale score, and oxygen inhalation on the day of hospital admission. Amongst NPO patients on Day 7, only 5.3% were prescribed the recommended doses of ≥20 kcal/kg; 6.4% were prescribed ≥1.0 g/kg amino acids, and 5.7% were prescribed fat energy ratio at ≥15% of non-protein calories. Commonly prescribed parenteral nutrition solutions on Day 7 were carbohydrate/electrolyte solutions (52.8%) and peripheral parenteral nutrition solutions (49.0%). CONCLUSION Prescribed parenteral energy, amino acids, and fat during the NPO period were lower than the recommended doses in the majority of patients. Prescribing recommended doses of each of these component nutrients may be beneficial when managing parenteral nutrition of patients during NPO.
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Affiliation(s)
- Keisuke Maeda
- Department of Geriatric Medicine, National Center for Geriatrics and Gerontology, 7-430 Morioka-cho, Obu-shi, Aichi-ken, Japan.
| | - Kenta Murotani
- Biostatistics Center, Kurume University Graduate School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Satoru Kamoshita
- Medical Affairs Department, Otsuka Pharmaceutical Factory, Inc., 2-9 Kanda-Tsukasamachi, Chiyoda-ku, Tokyo, Japan
| | - Yuri Horikoshi
- Medical Affairs Department, Otsuka Pharmaceutical Factory, Inc., 2-9 Kanda-Tsukasamachi, Chiyoda-ku, Tokyo, Japan
| | - Akiyoshi Kuroda
- Medical Affairs Department, Otsuka Pharmaceutical Factory, Inc., 2-9 Kanda-Tsukasamachi, Chiyoda-ku, Tokyo, Japan
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McClunan K, Nel DG, Dhansay MA, van Niekerk E. Effect of Nutritional Intake on the Body Composition of HIV-Exposed and HIV-Unexposed Preterm and Low Birth Weight Infants. Breastfeed Med 2019; 14:144-153. [PMID: 30715911 DOI: 10.1089/bfm.2018.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Human breast milk (HBM) is considered inadequate in meeting protein requirements, especially for very low birth weight (VLBW) infants, which could affect body composition. OBJECTIVES The primary objective was to determine the effect of HBM on body composition of HIV-exposed and unexposed preterm VLBW and extremely low birth weight infants. The secondary objectives were to ascertain the effect breast milk fortification and days nil per os (NPO) have on body composition. MATERIALS AND METHODS A descriptive cross-sectional study was conducted. Preterm infants with a birth weight of ≤1,200 g were included. Infant nutritional intakes and body composition measurements were recorded during the 28-day follow-up period. RESULTS One hundred ten of 113 preterm infants received HBM and 91 infants received fortified HBM. HIV-exposed and unexposed infants receiving fortified HBM displayed differences in fat mass percentage (FM%) (0.88% versus 1.36%, p = 0.01; 0.97% versus 1.49%, p = 0.03) and fat-free mass percentage (FFM%) (98.98% versus 98.68%, p = 0.03; 99.02% versus 98.49%, p = 0.02) on days 21 and 28, respectively. Infants kept NPO displayed differences in FM% on days 7, 21, and 28 (0.9% versus 1.3%, p = 0.03; 0.99% versus 1.4%, p = 0.02; and 0.9% versus 1.6%, p = 0.0004) as well as differences in FFM% (99.1% versus 98.4%; p = 0.0005) on day 28 of life. CONCLUSION There were no significant differences in the body composition of infants who received HBM versus fortified HBM. However, significant differences in body composition were reported between HIV exposure groups for infants who received fortified HBM. Infants who were kept NPO were generally smaller, shorter, and had lower FM% and more FFM%.
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Affiliation(s)
- Klara McClunan
- 1 Division of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Daniel Gerhardus Nel
- 2 Department of Mathematical Sciences, Stellenbosch University, Cape Town, South Africa.,3 Department of Statistics and Actuarial Sciences, Stellenbosch University, Cape Town, South Africa
| | - Muhammad Ali Dhansay
- 4 Burden of Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Evette van Niekerk
- 1 Division of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Yang WC, Chang YJ, Lin YC, Chen CY, Peng YC, Wu HP. Survey of nil per os duration of patients admitted to the emergency department due to vomiting. Medicine (Baltimore) 2019; 98:e15087. [PMID: 30946363 PMCID: PMC6456003 DOI: 10.1097/md.0000000000015087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
During the acute phase of vomiting, even a small amount of water may not be tolerated by mouth. Early refeeding may cause re-vomiting in patients, whereas late refeeding may result in dehydration and hypoglycemia. Nil per os (NPO) may be generally recommended by primary physicians, but the appropriate NPO duration for these patients is still unclear.The study aimed to identify the ideal NPO duration for patients with acute vomiting.We prospectively recruited patients with vomiting who underwent NPO management and were administered antiemetic agents in the emergency department (ED) and the pediatric ED. The demographics, final diagnosis, clinical manifestations, medical management, NPO duration, and laboratory data were collected and analyzed to identify the ideal NPO durationA total of 304 patients with vomiting who were admitted in the ED were enrolled. The major diagnosis was acute gastroenteritis (AGE) (82.9%), followed by acute gastritis and colitis. Most patients were younger than 6 years (43.8%). Apart from abdominal pain and vomiting, nausea was the most common symptom (93.1%). NPO duration of 4 to 6 hours had the lowest rate of refeeding failure (3.7%) compared to the other NPO durations.For patients with acute vomiting who are admitted to the ED, NPO duration of 4 to 6 hours may be necessary and should be recommended by primary ED physicians.
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Affiliation(s)
- Wen-Chieh Yang
- Department of Pediatric Emergency China Medical University Children's Hospital, China Medical University
- Department of Medicine, College of Medicine, China Medical University
| | - Yu-Jun Chang
- Laboratory of Epidemiology and Biostastics, Changhua Christian Hospital
| | - Ya-Chun Lin
- Department of Nursing, Changhua Christian Hospital, Changhua
| | - Chun-Yu Chen
- Department of Pediatric Emergency China Medical University Children's Hospital, China Medical University
- Department of Medicine, College of Medicine, China Medical University
| | - Yi-Chin Peng
- Department of Pediatric Emergency China Medical University Children's Hospital, China Medical University
- Department of Medicine, College of Medicine, China Medical University
| | - Han-Ping Wu
- Department of Pediatric Emergency China Medical University Children's Hospital, China Medical University
- Department of Medicine, College of Medicine, China Medical University
- Department of Medical Research, China Medical University Children's Hospital, China Medical University, Taichung, Taiwan
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Yeh J, Brown ER, Kellogg KA, Donohue JE, Yu S, Gaies MG, Fifer CG, Hirsch JC, Aiyagari R. Utility of a clinical practice guideline in treatment of chylothorax in the postoperative congenital heart patient. Ann Thorac Surg 2013; 96:930-6. [PMID: 23915583 DOI: 10.1016/j.athoracsur.2013.05.058] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 05/08/2013] [Accepted: 05/17/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Chylothorax after congenital heart surgery is a common complication with associated morbidities, but consensus treatment guidelines are lacking. Variability exists in the duration of medical treatment and timing for surgical intervention. METHODS After institution of a clinical practice guideline for management of postoperative chylothorax at a single center, pediatric cardiothoracic intensive care unit (ICU) in June 2010, we retrospectively analyzed 2 cohorts of patients: those with chylothorax from January 2008 to May 2010 (early cohort; n=118) and from June 2010 to August 2011 (late cohort; n=45). Data collected included demographics, cardiac surgical procedure, treatments for chylothorax, bloodstream infections, hospital mortality, length of hospitalization, duration of mechanical ventilation, and device utilization. RESULTS There were no demographic differences between the cohorts. No differences were found in octreotide use or surgical treatments for chylothorax. Significant differences were found in median times to chylothorax diagnosis (9 in early cohort versus 6 days in late cohort, p=0.004), ICU length of stay (18 vs 9 days, p=0.01), hospital length of stay (30 vs 23 days, p=0.005), and total durations of mechanical ventilation (11 vs 5 days, p=0.02), chest tube use (20 vs 14 days, p=0.01), central venous line use (27 vs 15 days, p=0.001), and NPO status (9.5 vs 6 days, p=0.04). CONCLUSIONS Institution of a clinical practice guideline for treatment of chylothorax after congenital heart surgery was associated with earlier diagnosis, reduced hospital length of stay, mechanical ventilation, and device utilization for these patients.
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Affiliation(s)
- Jay Yeh
- Division of Pediatric Cardiology, Department of Cardiac Surgery, University of Michigan, C.S. Mott Children's Hospital Ann Arbor, Michigan 48109-4204, USA
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