Gopalratnam, Kavitha

Background: Pulmonary embolism (PE) is a major cause of morbidity and mortality accounting for 100,000 deaths per year in the United States and 5–10% of in-hospital deaths. There is sparse comparative data on readmission patterns in patients who undergo early versus late catheter directed thrombolysis (CDT) for acute PE. Research Question: Is the procedure day for acute PE associated with a difference in 30-day readmission rates? Study Design and Method: This study was performed by using the Nationwide Readmissions Database between 2016 and 2019. Patients with acute PE who underwent CDT were identified using codes from the International Classification of Diseases, 10th Edition (ICD 10). Results: The 30-day readmission rates were higher for patients who underwent CDT on Day 2 or afterwards compared to Day 1 and Day 0 (7.1% vs. 5.7% vs. 5.2%). Patients who had CDT on Day 2 or later had a higher rate of 30-day readmission mortality compared to those who had CDT on Day 1 or 0 (0.6% vs. 0.3% vs. 0.2%. The 30-day readmission rates for heart failure were higher among patients who had CDT on Day 2 compared to those who had CDT on Day 0 of admission (2% vs. 1.0% vs. 0.9%). Interpretation: Delayed CDT for acute PE was associated with increased rates of 30-day readmission, readmission mortality, and readmission for heart failure. These findings emphasize the need for earlier CDT for the treatment of acute PE.

Background: Patients with pulmonary hypertension (PH) who undergo endotracheal intubation have an increased risk of adverse outcomes, but little is known regarding prognostic factors and there is limited evidence to guide management. We sought to define characteristics, prognostic factors, and outcomes of critically ill patients with PH who underwent intubation. Study Design: We performed a single-center retrospective cohort study of critically ill patients with group 1, 3 or 4 PH who underwent intubation. Results: Eighty-one patients were included. Patients had a median age of 56 years (interquartile range 44-65) and were predominantly female (n = 53, 65%) and Caucasian (n = 71, 88%). Forty-five (56%) had group 1 PH while 25 (31%) had group 3 PH and 11 (14%) had group 4 PH. Patients were admitted to the hospital for right ventricular failure (n = 21, 25.6%), sepsis (n = 18, 22.2%), and respiratory failure (n = 19, 23.1%). Hypoxemic respiratory failure (n = 54, 66.7%) was the most common indication for intubation. In-hospital mortality was 30.9% and 1-year mortality was 48.2% . All patients (11 of 11, 100%) intubated electively for intensive care unit procedures survived to hospital discharge while only 1 of 6 (16.7%) intubated in the setting of a cardiac arrest survived. After adjusting for right ventricular systolic pressure, pre-intubation PaO 2 (odds ratio [OR] = 0.99, 95% confidence interval [CI] 0.97-1.00, P = .02) and postintubation PaO 2 (OR = 0.97 per 1mm Hg, 95% CI 0.95 to 0.99, P = .003), pH (OR = 0.49 per 0.1 increase, 95% CI 0.29 to 0.80, P = .005) and PaCO 2 (OR = 1.08 per 1mm Hg, 95% CI 1.02 to 1.14, P = .005) were significantly associated with in-hospital mortality. Results were similar when we excluded patients intubated electively or in the setting of cardiac arrest. Conclusions: Intubation in critically ill patients with PH is associated with significant in-hospital mortality and nearly 50% 1-year mortality. Potentially modifiable factors, such as peri-intubation gas exchange, are associated with an increased risk of death while other demographic and hemodynamic variables are not.