Cardiothoracic Intensive Care Unit Research Articles

The long-term conditional mortality rate in older ICU patients compared to the general population.

Understanding how preexisting comorbidities may interact with a critical illness is important for the assessment of long-term survival probability of older patients admitted to the ICU. The mortality after a first ICU admission in patients ≥ 55years old registered in the Swedish Intensive Care Registry was compared to age- and sex-matched individuals from the general population with a landmark after 1 year. The comparison was adjusted for age, sex, and baseline comorbidity using Cox regression. The 7-year study period included 140 008 patients, of whom 23% were 80 years or older. Patients surviving the first year remained at an increased risk compared to the general population, but much of this difference was attenuated after adjustment for baseline comorbidity (HR, 1.03; 95% CI 1.02-1.04). Excluding cardio-thoracic ICU admissions, the increased risk remained slightly elevated (adjusted HR, 1.15; 95% CI 1.13-1.16). Also, the subgroup ≥ 75years old surviving the first year returned to a mortality rate comparable to the general population (HR, 0.98; 95% CI 0.96-0.99). Stratified by admission diagnosis an increased mortality rate remained beyond the first year for acute-on-chronic respiratory failure (adjusted HR, 1.47; 95% CI 1.36-1.58) but not for other respiratory causes (adjusted HR, 1.03; 95% CI 0.99-1.07) or admission for septic shock (adjusted HR, 1.04; 95% CI 0.95-1.13). No substantial increased mortality rate was notable beyond the first year for other admission diagnoses. Older ICU patients that survive the first year after an ICU admission return to a mortality rate close to that of the general population having similar baseline comorbidity, but variability is seen depending on the ICU admission diagnosis. Trial registration ClinicalTrials.gov ID: NCT06234709, date 02/01/2024.

Assessing the Nursing Workload in the Cardiothoracic Intensive Care Unit: Comparative Study.

This study aimed to assess nursing workload in Cardiac Intensive Care Unit (CICU) after three cardiothoracic surgery procedures during first four postoperative days using Nursing Activities Score (NAS) and Nine Equivalents of Nursing Manpower Use Score (NEMS) systems, to compare their performance for that purpose and to investigate association between nursing workload and type of surgery. A comparative study. The research environment includes CICU of the University Hospital for Cardiovascular Diseases in Serbia. A total of 808 patients who underwent coronary, valvular, or combined surgery, resulting in 2282 filled NAS and NEMS pairs chart. Statistical analysis was performed using SPSS-19. The correlation between NAS and NEMS was tested by Spearman's correlation coefficient. Differences were considered statistically significant at p < 0.05. The lowest median of cumulative NAS 176 (175-257) and NEMS 76 (64-91) had coronary surgery patients, the highest NAS 224.5 (178-334.5) and NEMS 83 (69-121) had those with combined surgery; this difference was statistically significant (p < 0.001). The median of both scores decreased after surgery, with the following values from the first to the fourth postoperative day: NAS from 104 (102-105) to 81 (74-85) and NEMS from 46 (42-46) to 30 (30-37). The difference in mean values of both scores between the first and the fourth postoperative day was statistically significant (p < 0.001). NAS and NEMS were in a positive, strong correlation (r = 0.913; p < 0.005). Both scores can be used to measure nursing workload, identify the required number of nurses in CICU, and support task allocation. NAS may have an advantage because it better describes extensive postoperative monitoring and care needed for cardiac surgery patients. Nursing workload is associated with type of surgery, with the highest workload measured in patients who underwent combined surgery procedure and on the first postoperative day.

Mixed venous to arterial pCO2-gap is poorly correlated to cardiac index in 1526 pulmonary artery catheter monitored critically ill patients

Abstract Background The CO2 gap is the difference between mixed venous and arterial CO2, and can be estimated by the difference in partial pressure in CO2 (Pv-aCO2 or ∆PCO2). ∆PCO2 is affected by cardiac output (CO), CO2 production and solubility. The central venous-to-arterial CO2 gap has been proposed as a less invasive surrogate for P(v-a)CO2 and has been investigated as a measure of adequacy of resuscitation, and to guide sepsis management. Nevertheless, the CO2-gap as determinant of CO has never been thoroughly investigated in large cohort of critically ill ICU-patients. This study aims to investigate the relationship between ∆PCO2 and cardiac index (CI) in a retrospective cohort of critically ill patients in a large quaternary cardiothoracic intensive care unit. Methods Over 62 months, pulmonary artery catheter monitored critically ill patients were identified and their case files reviewed in retrospect. Extracorporeal membrane oxygenation (ECMO) patients were excluded. P(v-a)CO2 measurements were defined as mixed venous and arterial pCO2 measurements drawn simultaneously or within maximum 30 minutes together with PA-measurements. Correlation coefficients were calculated between P(v-a)CO2 and CI, serum lactate, mixed venous saturations (SvO2), cardiac power index (CPI), inotropic score (IS), central venous pressure (CVP) and minute expiratory volume (MV)(Table 1). We used receiver operator characteristic (ROC) curves to assess the diagnostic performance of P(v-a)CO2 as a surrogate for CI lower than 2,2L/min/m2. Multivariate linear regression analysis was performed with P(v-a)CO2 as an dependent variable. Results 4414 P(v-a)CO2 measurements were identified from 1526 patients. Median P(v-a)CO2 was 0,86 kPa (0,66-1,1) or 6.45 mmHg (4.95-8.25), and mean CI was 2.7l/min/m2 (2.2-3.2). Correlation coefficients of P(v-a)CO2 with the other variables remained poor (&amp;gt; 0,35). The area under the ROC curve for P(v-a)CO2 as a predictor of CI&amp;lt;2.2l/min/m2 was 0.65, p&amp;lt;0.0001 (Fig. 1B). A value of P(v-a)CO2 &amp;gt; 6.9 mmHg was found to have the highest sensitivity and specificity, with a poor performance of 61.21% sensitivity and 62.73% specificity. Conclusion This large retrospective study in 1526 critically ill cardiac ICU-patients did not demonstrate a strong relationship between P(v-a)CO2 and CI, nor with any other hemodynamic variable found in the ICU patient cohort studied (Table 1). This raises scepticism regarding the efficacy of P(v-a)CO2 as a physiological goal in guiding resuscitation and management of this precarious patient group. Therefore, we argue that the PA-catheter remains the cornerstone in assessing critically ill (cardiothoracic) ICU patients.

Exploring the experience of cardiothoracic ICU clinicians during the COVID-19 pandemic: A grounded theory study.

Prior to the COVID-19 pandemic a flexible approach to visiting was adopted by many Intensive Care Units in the United Kingdom. Due to the rapid spread globally of COVID-19, significant policy changes were put in place, including the restriction on visitors to patients in hospital. Evidence has emerged demonstrating the negative impact of these restrictions on patients with COVID-19, their families and the staff caring for them. However, there is limited data about the impact of these restrictions in the non-COVID ICU environment. This study aimed to explore the experiences of staff caring for non-COVID-19 patients in a cardiothoracic critical care unit during the COVID-19 pandemic. This qualitative research study adopted a grounded theory methodological approach. This methodology was used due to the unique situation, with no prior research available. We recruited healthcare staff that worked in a cardiothoracic critical care unit during the COVID-19 pandemic. Semi structured interviews were carried out, transcribed, and analysed. Using the data collected, a theory was constructed. Interviews were carried out with 20 healthcare staff from a range of professions including nurses, doctors, and allied health professionals. Following data analysis four main categories emerged from the data: impact and implementation of visiting restrictions; the dehumanisation of patients; end-of-life care and witnessing distress. From these four categories, a theory has emerged suggesting that healthcare staff in a non-covid ICU were regularly exposed to potentially moral injurious events, despite being shielded from caring for patients with COVID-19. This study provides a theory that healthcare staff caring for non-COVID-19 critical care patients during the period of visiting restrictions were exposed to potentially morally injurious events. Repeated exposure to potentially morally injurious events can lead to the development of moral injury and its adverse consequences. This study highlights the need to support all staff in the post COVID era, including those who worked in a non-COVID environment.

Comparison of four intensive care scores in prediction of outcome after Veno-Arterial ECMO: A single-center retrospective study

ObjectiveAssess the capability of APACHE-II (Acute Physiology and Chronic Health Evaluation II), SOFA (Sequential Organ Failure Assessment scores), Cardiac Surgery Score (CASUS), and SAVE (Survival After VA-ECMO) in predicting outcomes among a cohort of patients undergoing Veno-Arterial ECMO (VA-ECMO). DesignThis is an observational retrospective study of 142 patients who were admitted to the Cardiothoracic Intensive Care Unit (CTICU) after undergoing VA-ECMO insertion. SettingCTICU of a tertiary care center. ParticipantsAll patients admitted to the CTICU for a minimum duration of 24 h, post-VA ECMO insertion, between the years 2015 and 2022. InterventionsReview of electronic patient records. Measurements and ResultsScores for APACHE-II, SOFA, and CASUS were calculated 24 h after intensive care units (ICU) admission. The SAVE score was computed from the last available patient details within 24 h of ECMO insertion. Relevant demographic, clinical, and laboratory data for the study was retrieved from electronic patient records. Pre-ECMO serum levels of lactates and creatinine were significantly associated with mortality. Lower ECMO flow rates at 4 h and 12 h post-ECMO cannulation were significantly correlated with survival to discharge. The development of arrhythmias, acute kidney injury (AKI), and the need for continuous renal replacement therapy (CRRT) while on ECMO were significantly associated with mortality. The APACHE-II, SOFA, and CASUS scores, calculated at 24 h of ICU admission, were significantly higher amongst non-survivors. Following risk score categorization using receiver operating characteristic (ROC) curve analysis, it was found that APACHE-II, SOFA, and CASUS scores calculated at 24 h post-ICU admission after ECMO insertion demonstrated moderate predictive ability for mortality, whereas the SAVE score failed to predict mortality. APACHE-II > 27 (AUC of 0.66), calculated 24 h post-ICU admission after ECMO insertion, showed the greatest predictive ability for mortality. Multivariate logistic regression analysis of the four scores showed that APACHE-II > 27 and SOFA > 14, calculated 24 h post-ICU admission after ECMO insertion, were independently significantly predictive of mortality. ConclusionThe APACHE-II, SOFA, and CASUS, calculated at 24 h of ICU admission, were significantly higher among non-survivors compared to survivors. APACHE-II demonstrated the highest mortality predictive ability. APACHE-II scores of 27 or above, and SOFA scores of 14 or above, at 24 h of ICU admission after ECMO cannulation, can predict mortality and assist physicians in decision-making.

Thrombotic Safety of Angiotensin II for Distributive Shock in the Cardiothoracic Intensive Care Unit.

Background: Angiotensin II (ATII) has been shown in the literature to increase the risk of thrombosis. Little data exists in patients with mechanical circulatory support (MCS) due to exclusion from landmark trials. Objective: Evaluate the thrombotic risk of ATII in patients in the cardiothoracic intensive care unit (CTICU) with distributive shock. Methods: Retrospective study including adult patients admitted to the CTICU with temporary MCS. This study evaluated patients ≥18 years old on temporary MCS in the CTICU between September 1st, 2018 and August 30th, 2022. Patients that received ATII were compared to a control group for the outcome of an index thrombotic event. The outcomes were compared using the Fischer's exact or chi-squared test. Results: A total of 75 patients primarily admitted for cardiac surgery were included, of which 41 (54.7%) received ATII. The rates of overall thrombosis were higher in the ATII group compared to the control, though the outcome was not statistically significant (41.5% vs 20.6%; P = 0.05). Individual thrombotic components of the composite outcome were not statistically significant between groups. Conclusion: Numerically higher rates of thrombosis were seen in patients on MCS that received ATII, though the outcome was not statistically significant. This retrospective study provides a single-center, real-world safety perspective on the use of ATII in MCS.

Evaluation of T2 Magnetic Resonance (T2MR®) Technology for the Early Detection of ESKAPEc Pathogens in Septic Patients.

Bloodstream infections (BSIs) and sepsis are a major cause of morbidity and mortality. Appropriate early antibiotic therapy is crucial for improving the survival of patients with sepsis and septic shock. T2 magnetic resonance (T2MR®) technology may enable fast and sensitive detection of ESKAPEc pathogens directly from whole-blood samples. We aimed to evaluate concordance between the T2Bacteria® Panel and standard blood culture and its impact on antibiotic therapy decisions. We conducted a single-centre retrospective study on patients with sepsis-induced hypotension or septic shock admitted to general, post-operative/neurosurgical, and cardiothoracic Intensive Care Units who were tested with the T2Bacteria® Panel from January 2021 to December 2022. Eighty-five consecutively admitted patients were included, for a total of 85 paired tests. A total of 48 ESKAPEc pathogens were identified by the T2Bacteria® Panel. The concordance rate between the T2Bacteria® Panel and blood cultures was 81% (69/85), with 20 concordant-positive and 49 concordant-negative cases. For the 25 microorganisms grown from accompanying blood cultures, blood pathogen coverage by the T2Bacteria® Panel was 88%. In this cohort of severely ill septic patients, the T2Bacteria® Panel was highly concordant and was able to detect more ESKAPEc pathogens, with a significantly shorter turn-around time compared to conventional blood cultures. The T2Bacteria® Panel also significantly impacted decisions on antibiotic therapy.

Modernization of Cardiac Advanced Life Support: Role and Value of Cardiothoracic Anesthesiologist Intensivist in Post–Cardiac Surgery Arrest Resuscitation

Cardiac arrest in the post-operative cardiac surgery patient requires a unique set of management skills that deviates from traditional cardiopulmonary resuscitation and Advanced Cardiovascular Life Support (ACLS). Cardiac Advanced Life Support (CALS) was first proposed in 2005 to address these intricacies. The hallmark of CALS is early chest reopening and internal cardiac massage within five minutes of the cardiac arrest in patients unresponsive to basic life support. Since the introduction of CALS, the landscape of cardiac surgery has continued to evolve.Cardiac intensivists encounter more patients who undergo cardiac surgical procedures performed via minimally invasive techniques such as lateral thoracotomy or mini sternotomy, in which an initial bedside sternotomy for cardiac massage is not applicable. Given the heterogeneous nature of the patient population in the cardiothoracic intensive care unit (CTICU), personnel must expeditiously identify the most appropriate rescue strategy. As such, we have proposed a modified CALS approach to (1) adapt to a newer generation of cardiac surgery patients and (2) incorporate advanced resuscitative techniques. These include rescue-focused cardiac ultrasound to aid in the early identification of underlying pathology and guide resuscitation and early institution of extracorporeal cardiopulmonary resuscitation (ECPR) instead of chest re-opening. While these therapies are not immediately available in all cardiac surgery centers, we hope this creates a framework to revise guidelines to include these recommendations to improve outcomes and how cardiac anesthesiologist intensivists' evolving role can aid resuscitation.

Research report: Management of dysphagia using pharyngeal electrical stimulation in the general intensive care population - A service development.

Dysphagia places a substantial burden on the critically ill, affecting 12%-84% of this cohort, and is independently associated with worse outcomes. Pharyngeal electrical stimulation (PES-treatment) is a novel dysphagia therapy with an emerging evidence base. This retrospective observational study describes our dysphagia service and reports the use of PES-treatment as a standard of care in recovering critically ill patients at a single-site tertiary UK hospital. Patients admitted to Acute or Cardio-Thoracic adult intensive care units between 1st July 2017 and 30th June 2022 were routinely referred to Speech and Language Therapy (SLT) following tracheostomy, or suspected dysphonia/dysphagia. Clinical assessments and direct laryngeal visualisation using Fibreoptic Evaluation of Swallowing (FEES) were performed. Severe dysphagia was defined as Penetration-Aspiration Score of ⩾6 and patients were offered PES-treatment when staffing allowed. Of 289 patients with severe dysphagia, 19 underwent a course of PES-treatment with the remaining patients receiving standard care. PES-treatment patients were significantly less likely to remain nil-by-mouth (11.1% vs 62.5%, Chi2 p < 0.001) or to have an enteral feeding tube in situ at discharge from critical care (27.8% vs 62.5%, p = 0.006) than those receiving standard dysphagia care. Both groups demonstrated an improvement in Penetration-Aspiration Score at repeat FEES: PES-treatment mean difference -2.0 (p = 0.003); non-PES-treatment -1.68 (p < 0.001); (61% PES-treatment improved vs 40% non-PES-treatment, p = 0.09). Our observations suggest that PES may be effective in the general critical care population. PES may offer new treatment options for patients and healthcare staff managing severe dysphagia and its significant consequences.

Association of extreme hyperoxemic events and mortality in pediatric critical care: an observational cohort study.

Our aim was to confirm whether extreme hyperoxemic events had been associated with excess mortality in our diverse critical care population. Retrospective analysis of 9 years of data collected in the pediatric and cardiothoracic ICUs in Children's Hospital Los Angeles was performed. The analysis was limited to those mechanically ventilated for at least 24 h, with at least 1 arterial blood gas measurement. An extreme hyperoxemic event was defined as a PaO2 of ≥300 torr. Multivariable logistic regression was used to assess the association of extreme hyperoxemia events and mortality, adjusting for confounding variables. Selected a-priori, these were Pediatric Risk of Mortality III predicted mortality, general or cardiothoracic ICU, number of blood gas measurements, as well as an abnormal blood gas measurements (pH < 7.25, pH > 7.45, and PaO2 < 50 torr). There were 4,003 admissions included with a predicted mortality of 7.1% and an actual mortality of 9.7%. Their care was associated with 75,129 blood gas measurements, in which abnormal measurements were common. With adjustments for these covariates, any hyperoxemic event was associated with excess mortality (p < 0.001). Excess mortality increased with multiple hyperoxemic events (p < 0.046). Additionally, treatment resulting in SpO2 > 98% markedly increased the risk of a hyperoxemic event. Retrospective analysis of critical care admissions showed that extreme hyperoxemic events were associated with higher mortality. Supplemental oxygen levels resulting in SpO2 > 98% should be avoided.

Predictive Value of Ultrasonic Diaphragm Thickening Fraction on Successful Weaning in Postoperative Cardiothoracic Surgery Patients with Chronic Obstructive Pulmonary Disease (COPD)

Abstract Background The diaphragm is the most important muscle of respiration and is largely responsible for the change in the intra thoracic pressure. In mechanically ventilated patients, the diaphragm can develop atrophy and weakness leading to prolonged duration of mechanical ventilation. Many studies reported a high prevalence of diaphragm dysfunction during weaning, and it was found to be associated with poorer clinical outcomes. Objective To assess the predictive value of diaphragm thickening fraction (DTF) by bedside ultrasound on successful weaning in postoperative cardiothoracic surgery patients with COPD. Subjects and Methods This prospective study was conducted on 40 subjects at cardiothoracic ICU unit at Elmaadi Military hospital during the period from (September,2021) to (July,2022) after approval of the research Ethical committee at faculty of medicine, Ain shams university. Results Regarding the relation between the two studied groups and diaphragmatic thickness, the thickness was decreased in the failed group than the successful group during inspiration, expiration and thickness fraction %, with significant difference between two groups as p-Value was &amp;lt;0.05. There was an increase in the duration of ICU stay &amp; mechanical ventilation in the failed group compared to the successful group, with significant difference between two groups as p-Value was &amp;lt;0.05. Regarding the correlation between ICU stay &amp; mechanical ventilation and diaphragmatic thickness, there were negative correlation between ICU stay &amp; MV duration and all parameters of the diaphragmatic thickness, with significant difference as p-Value was &amp;lt;0.05. Conclusion Weaning success in mechanically ventilated postoperative cardiothoracic surgery patients with COPD can be predicted by ultrasonography-based evaluation of diaphragm function by analyzing diaphragmatic thickness fraction. It is a practical, feasible, non-invasive technique that may be used at the bedside to rule out diaphragmatic dysfunction.

Preoperative right ventricular strain as an early predictor of perioperative cardiac failure in patients undergoing mitral surgery: An exploratory study.

This study's primary purpose was to demonstrate the correlation of preoperative right ventricular free-wall longitudinal strain (RVFWLS) and pre-/postsurgical variation in strain (delta strain) with the clinical and echocardiographic diagnosis of right ventricular dysfunction. Its secondary purpose was to determine the correlation of RVFWLS and delta strain with length of stay (LOS) in the intensive care unit (ICU), ventilation days, trend of natriuretic peptide test. (NT-proBNP) and lactate in the first 48 h, incidence of acute renal failure, and 28-day mortality. Prospective observational study. Cardio-thoracic and Vascular Anaesthesia Department and ICU of the University Hospital Integrated Trust of Verona. Patients scheduled for mitral surgery. None. All clinical and transoesophageal echocardiographic (TEE) parameters were collected at baseline, before surgery (T1) and at admission in the ICU postsurgery (T2). During the postoperative period, the clinical and echocardiographic diagnoses of right, left, or biventricular dysfunction were evaluated. TEE parameters were evaluated by a cardiologist offline. The patients were divided into two subgroups according to the development of any type of ventricular dysfunction. No statistically significant differences emerged between the two groups. According to a logistic regression model, a T1-RVFWLS value of -15% appeared to predict biventricular dysfunction (sensitivity: 100%; specificity: 91.3%). No correlation between T1- or T2-RVFWLS and creatinine, hours of ventilation or ICU LOS was found. Our study introduces a new parameter that could be used in perioperative evaluations to identify patients at risk of postoperative biventricular dysfunction.

Effects of pay-for-performance based antimicrobial stewardship on antimicrobial consumption and expenditure: An interrupted time series analysis

ObjectivesTo evaluate the impact of pay-for-performance on antimicrobial consumption and antimicrobial expenditure in a large teaching hospital in Guangzhou, China. MethodsWe collected data from hospital information system from January 2018 through September 2022 in the inpatient wards. Antimicrobial consumption was evaluated using antibiotic use density (AUD) and antibiotic use rate (AUR). The economic impact of intervention was assessed by antimicrobial expenditure percentage. The data was analyzed using interrupted time series (ITS) analysis. ResultsFollowing the implementation of the intervention, immediate decreases in the level of AUD were observed in Department of Hematology Unit 3 (β = −66.93 DDDs/100PD, P = 0.002), Urology (β = −32.80 DDDs/100PD, P < 0.001), Gastrointestinal Surgery Unit 3 (β = −11.44 DDDs/100PD, P = 0.03), Cardiac Surgery (β = −14.30 DDDs/100PD, P = 0.01), ICU, Unit 2 (β = −81.91 DDDs/100PD, P = 0.02) and Cardiothoracic Surgery ICU (β = −41.52 DDDs/100PD, P = 0.05). Long-term downward trends in AUD were also identified in Organ Transplant Unit (β = −1.64 DDDs/100PD, P = 0.02). However, only Urology (β = −6.56 DDDs/100PD, P = 0.02) and Gastrointestinal Surgery Unit 3 (β = −8.50 %, P = 0.01) showed an immediate decrease in AUR, and long-term downward trends in AUR were observed in Pediatric ICU (β = −1.88 %, P = 0.05) and ICU Unit 1 (β = −0.55 %, P = 0.02). ConclusionThis study demonstrates that the adoption of pay-for-performance effectively reduces antibiotic consumption in specific departments of a hospital in Guangzhou in the short term. However, it is important to recognize that the long-term impact of such interventions is often limited. Additionally, it should be noted that the overall effectiveness of the intervention across the entire hospital was not significant.

Caregiver Satisfaction with Medical Providers' Communication: Comparison Between Spanish-Speaking Caregivers with Limited English Proficiency (LEP) and Caregivers Who Are English-Proficient (EP).

Barriers to communication have been observed with patients and families who prefer a language other than English for medical conversations, referred to as individuals with limited English proficiency (LEP). We used the pediatric Family Satisfaction with ICU 24R (FS-ICU) survey to assess communication satisfaction for English-proficient (EP) and Spanish-speaking LEP caregivers. We added additional questions related to attendance at morning rounds, frequency of provider updates, interpreter use, and general satisfaction with communication. This was a single-center, prospective, observational cohort study in the pediatric intensive care unit (PICU) and cardiothoracic intensive care unit (CICU) of a tertiary, academic, free-standing children's hospital. Caregivers of children < 18 years old admitted for at least 48 h to the PICU or CICU between June and September 2022 were eligible for enrollment. 24LEP and 74 EP caregivers completed the survey questions. The LEP group had lower household income and education levels and higher incidence of public insurance. FS-ICU scores for both LEP and EP caregivers suggested high satisfaction, without significant difference between the groups. However, qualitative analysis revealed dissatisfaction for LEP caregivers related to information, inclusion, and language barriers. EP caregivers had more positive references to information and emotional connection but indicated dissatisfaction around consistency and responsiveness. 18%of LEP caregivers reported regularly attending rounds, versus 67% of the EP group (p value < .001). 39% ofLEP versus 52% of EP caregivers reported multiple daily updates, although the difference was not statistically significant. 29% of LEP respondents reported nonfluent MD/NPs using an interpreter never, rarely, or some of the time. There was no difference in satisfaction scores between LEP and EP caregivers. LEP caregivers had lower socioeconomic status based on public insurance and reported income and education level. Qualitative data allowed more nuanced understanding of communication satisfaction, which correlated with LEP caregivers' reported lower attendance at morning rounds, inconsistent interpreter use, and a trend toward less frequent provider updates.

Effect of nitric oxide delivery via cardiopulmonary bypass circuit on postoperative oxygenation in adults undergoing cardiac surgery (NOCARD trial): a randomised controlled trial.

Cardiac surgery involving cardiopulmonary bypass induces a significant systemic inflammatory response, contributing to various postoperative complications, including pulmonary dysfunction, myocardial and kidney injuries. To investigate the effect of Nitric Oxide delivery via the cardiopulmonary bypass circuit on various postoperative outcomes. A prospective, single-centre, double-blinded, randomised controlled trial. Rabin Medical Centre, Beilinson Hospital, Israel. Adult patients scheduled for elective cardiac surgery were randomly allocated to one of the study groups. For the treatment group, 40 ppm of nitric oxide was delivered via the cardiopulmonary bypass circuit. For the control group, nitric oxide was not delivered. The primary outcome was the incidence of hypoxaemia, defined as a p a O2 /FiO 2 ratio less than 300 within 24 h postoperatively. The secondary outcomes were the incidences of low cardiac output syndrome and acute kidney injury within 72 h postoperatively. Ninety-eight patients were included in the final analysis, with 47 patients allocated to the control group and 51 to the Nitric Oxide group. The Nitric Oxide group exhibited significantly lower hypoxaemia rates at admission to the cardiothoracic intensive care unit (47.1 vs. 68.1%), P = 0.043. This effect, however, varied in patients with or without baseline hypoxaemia. Patients with baseline hypoxaemia who received nitric oxide exhibited significantly lower hypoxaemia rates (61.1 vs. 93.8%), P = 0.042, and higher p a O2 /FiO 2 ratios at all time points, F (1,30) = 6.08, P = 0.019. Conversely, this benefit was not observed in patients without baseline hypoxaemia. No significant differences were observed in the incidence of low cardiac output syndrome or acute kidney injury. No substantial safety concerns were noted, and toxic methaemoglobin levels were not observed. Patients with baseline hypoxaemia undergoing cardiac surgery and receiving nitric oxide exhibited lower hypoxaemia rates and higher p a O2 /FiO 2 ratios. No significant differences were found regarding postoperative pulmonary complications and overall outcomes. NCT04807413.

Newly qualified professional nurses' experiences providing postoperative care to children in CTICU.

It is challenging for newly qualified professional nurses (NQPNs) to care for children with congenital heart abnormalities following cardiac surgery in cardiothoracic critical care units. This population of nurses is allocated to critically ill children in the cardiothoracic intensive care unit (CTICU) even though they lack sufficient knowledge, experience and skills to care for these patients. This study explored, described and made recommendations to support NQPNs who provide postoperative care to children in a CTICU. A qualitative, exploratory, descriptive and contextual research design was used. Purposive sampling was employed, and in-depth individual phenomenological interviews were conducted with 10 NQPNs. Data were analysed according to Giorgio's descriptive phenomenological method, and measures to ensure trustworthiness and ethical principles were followed. The NQPNs cited their lack of knowledge and mentoring as the primary contributors to their perceived challenges. This population requires motivation, mentoring and empowerment to address this phenomenon. Professional nurses in CTICUs require a supportive work environment, with encouragement from colleagues, management and doctors. A lack of support compromises patient care outcomes and safety, resulting in litigation.Contribution:Recommendations are provided for nursing education, research and practice to empower NQPNs with knowledge and skills to work with children following cardiac surgery to avoid adverse events in the CTICU.

Opioid use following cardio-thoracic intensive care: risk factors and outcomes: a cohort study

Opioid misuse has become a serious public health problem. Patients admitted to cardio-thoracic critical care are usually exposed to opioids, but the incidence and effects of chronic opioid use are not known. The primary objective was to describe opioid use after admission to a cardio-thoracic intensive care unit. Secondary objectives were to identify factors associated with chronic opioid usage and analyze risk of death. This cohort study included all cardio-thoracic ICU care episodes in Sweden between 2010 and 2018. Among the 34,200 patients included in the final study cohort, 4050 developed persistent opioid use after ICU care. Younger age, preadmission opioid use, female sex, presence of comorbidities and earlier year of ICU admission were all found to be associated with persistent opioid use. The adjusted hazard ratio for mortality between 6 and 18 months after admission among individuals with persistent opioid use was 2.2 (95% CI 1.8–2.6; P < 0.001). For opioid-naïve patients before ICU admission, new onset of chronic opioid usage was significant during the follow-up period of 24 months. Despite the absence of conclusive evidence supporting extended opioid treatment, the average opioid consumption remains notably elevated twelve months subsequent to cardio-thoracic ICU care.

Bloodstream infections in cardiac intensive care units from a tertiary care center

Blood stream infections (BSIs) occur more frequently in patients hospitalized in Intensive care units (ICUs). Intravascular devices are the most frequent predisposing factor causing BSI. To compare the proportion, risk factors, microbiological profile of Blood stream Infections and Central line associated bloodstream infection in Cardiology Intensive care units (CICU) and Cardiothoracic Intensive care units (CTICU).This is a prospective study conducted by the Dept. of Microbiology along with Cardiology Intensive care unit(CICU), and Cardiothoracic Intensive care unit (CTICU) of a tertiary care centre, from June 1st 2017-Oct 312018.Laboratory confirmed BSIs (LCBSI’s), occurring more than 48hrs after ICU admission were included in the study. Identification of pathogens were done by standard methods.A total of 1640 blood cultures were analyzed (CICU=890,CTICU=750).73 Primary BSIs were observed with male preponderance.68/73 diagnosed to have non CLABSI (CTICU=35/68 51.4%, CICU=33/68, 48.5%) and 5/73 cases diagnosed to have CLABSI (CTICU=5/73, 6.84% CICU=0%) 47.94% of our isolates were Gram negative pathogens with as the predominant followed by 35.6% of Gram positive with as the major pathogen &amp; 16.4% were Candida spp. 20.5% were multi drug resistant and 10% were ESBL producers. Prevalence and incidence rates were high in CTICU (5.3% &amp; 1.5%) compared to CICU (3.7% &amp; 0%) of BSI &amp; CLABSI respectively.BSI is preventable costly complication that occur with greater frequency in the ICU settings. Strict adherence to Infection control measures such as hand hygiene, aseptic precautions during blood culture collection and bundle care measures can decrease the BSI and CLABSI incidence rates.

Effect of early enteral nutrition on short-term outcomes and survival in patients in the cardiothoracic intensive care unit: An inverse probability weighted retrospective study

ObjectivesThe merits of early enteral nutrition (EEN) in patients in the cardiothoracic intensive care unit (CTICU) remain unclear. This retrospective study aimed to address this issue. MethodsWe analyzed data from the MIMIC IV v2.0 database, including patients with a CTICU stay of ≥4 d. Patients were divided into early and delayed enteral nutrition (EN) groups. Differences in baseline data were corrected using an inverse probability weighting (IPW) approach. Generalized linear models (GLMs) were used to compare trends over time between groups, and survival effects were evaluated with weighted logistic and Cox regression, supplemented by weighted Kaplan–Meier curves. Subgroup analysis facilitated the exploration of potential interactions. ResultsThe study included 720 CTICU patients. Following IPW, all baseline variables were balanced. EEN led to shorter hospital and CTICU stays, lower incidence of respiratory and blood infections, and reduced total insulin usage in the first week of CTICU admission, albeit with an increased total gastric residual volume. Mortality risk between the groups did not significantly differ at 28 d or at 1 y. Excessive early energy and protein intake elevated the risk of 28-d mortality, but the relationship may not be linear. Overweight patients or those with fewer comorbidities had a higher mortality risk with EEN. ConclusionsEEN may improve short-term outcomes in CTICU patients without a clear survival benefit. Early high caloric and protein intake could lead to adverse outcomes, suggesting a careful evaluation for initiating EN in specific patients.

Implementation of a diagnostic stewardship intervention to improve blood-culture utilization in 2 surgical ICUs: Time for a blood-culture change.

We compared the number of blood-culture events before and after the introduction of a blood-culture algorithm and provider feedback. Secondary objectives were the comparison of blood-culture positivity and negative safety signals before and after the intervention. Prospective cohort design. Two surgical intensive care units (ICUs): general and trauma surgery and cardiothoracic surgery. Patients aged ≥18 years and admitted to the ICU at the time of the blood-culture event. We used an interrupted time series to compare rates of blood-culture events (ie, blood-culture events per 1,000 patient days) before and after the algorithm implementation with weekly provider feedback. The blood-culture event rate decreased from 100 to 55 blood-culture events per 1,000 patient days in the general surgery and trauma ICU (72% reduction; incidence rate ratio [IRR], 0.38; 95% confidence interval [CI], 0.32-0.46; P < .01) and from 102 to 77 blood-culture events per 1,000 patient days in the cardiothoracic surgery ICU (55% reduction; IRR, 0.45; 95% CI, 0.39-0.52; P < .01). We did not observe any differences in average monthly antibiotic days of therapy, mortality, or readmissions between the pre- and postintervention periods. We implemented a blood-culture algorithm with data feedback in 2 surgical ICUs, and we observed significant decreases in the rates of blood-culture events without an increase in negative safety signals, including ICU length of stay, mortality, antibiotic use, or readmissions.