Cardiothoracic Intensive Care Unit Research Articles

ScvO2 changes after red-blood-cell transfusion for anaemia in cardiothoracic and vascular ICU patients: an observational study.

Haemoglobin threshold for transfusion has been significantly decreased, but haemoglobin plasma concentration may not be sufficient to assess the need of red-blood-cell (RBC) transfusion. Central venous oxygen saturation (ScvO2 ) is a clue of metabolic matching between O2 transport and consumption, which could help to assess when transfusion is appropriate once anaemia has been diagnosed in ICU patients. Adult patients admitted consecutively to a cardiothoracic and vascular ICU were included in a prospective, observational and single-centre study over a 6-month period (September 2014 to February 2015), provided they were transfused with RBC. Patients with active bleeding or in unstable condition were excluded. Haemoglobin and ScvO2 were collected through a central venous catheter before and after transfusion. In order to identify a ScvO2 threshold, analysis of ScvO2 changes after transfusion was performed. Fifty-three patients received 100 RBC transfusions. Haemoglobin at the time of transfusion was 7·2g/dl [6·8-7·7], while ScvO2 was 66·9% [60-73]. A 5% increase in ScvO2 after transfusion has the best specificity and positive predictive values, with a ScvO2 threshold of 65%. After transfusion (RBC units, 2 [1-2]), ScvO2 increased only in patients with ScvO2 ≤65%, from 58% [53-62] to 69% [64-73] (P<0·001). In anaemic patients, RBC transfusion induced a significant increase in ScvO2 , provided it was low before transfusion. A 65% cut-off value of ScvO2 before transfusion showed good specificity and good positive predictive value for a 5% increase after transfusion.

Impact of a Monoplane Hemodynamic TEE (hTEE) Monitoring Device on Decision Making in a Heterogeneous Hemodynamically Unstable Intensive Care Unit Population: A Prospective, Observational Study

This prospective observational study was undertaken to evaluate the utility of a miniature transesophageal echocardiography probe (ImaCor hemodynamic [hTEE]) in the management of hemodynamically unstable intensive care unit patients with and without various forms of mechanical circulatory support. A prospective observational study. A single tertiary care cardiothoracic and surgical intensive care unit. Fifty-three cardiothoracic and surgical intensive care unit patients undergoing miniature transesophageal echocardiography examinations. All patients had hemodynamic instability as defined by necessity of mechanical circulatory support (MCS) devices or vasoactive medications. From April 2012 to February 2014, 53 hemodynamically unstable intensive care unit patients received an examination with the miniature transesophageal echocardiography probe when deemed necessary by the intensivist for rapid and/or ongoing transesophageal echocardiographic examinations. Twenty-eight of the examinations were performed in patients with MCS devices (53%). The remainder of examinations (n = 25, 47%) were performed in patients after other cardiothoracic surgery or noncardiac surgery with cardiac complications. The measured endpoint was determination of usefulness of management guidance due to the miniature transesophageal echocardiographic examination as assessed by the intensivist caring for the patient. The incidence of hTEE imaging provoking a change in management also was recorded. Overall, of the 53 examinations, 77% (n = 41) provided useful information to the management. Of the 25 examinations in patients without MCS, 92% (n = 23) of the examinations were useful in guiding management. Among the 28 examinations in patients with MCS devices, 64% (n = 18) of examinations were useful in guiding management (odds ratio = 0.156; 95% confidence interval, 0.015-0.899; p = 0.022). Eight of the 53 examinations (15%) were deemed to have "poor image quality" by the echocardiographer. Age, sex, and body mass index did not significantly affect the usefulness of the hTEE examinations. Examination of a heterogeneous hemodynamically unstable intensive care population with a miniature transesophageal echocardiography probe provided useful information beyond standard intensive care unit monitoring data, which influenced post-hTEE medical decision making. The examinations were more useful in patients without MCS devices than in those with MCS. Of the patients with MCS, patients with durable ventricular assist devices had the lowest rate of useful examinations.

Physicians Perceptions of Shared Decision-Making in Neonatal and Pediatric Critical Care.

Most children die in neonatal and pediatric intensive care units after decisions are made to withhold or withdraw life-sustaining treatments. These decisions can be challenging when there are different views about the child's best interest and when there is a lack of clarity about how best to also consider the interests of the family. To understand how neonatal and pediatric critical care physicians balance and integrate the interests of the child and family in decisions about life-sustaining treatments. Semistructured interviews were conducted with 22 physicians from neonatal, pediatric, and cardiothoracic intensive care units in a single quaternary care pediatric hospital. Transcribed interviews were analyzed using content and thematic analysis. We identified 3 main themes: (1) beliefs about child and family interests; (2) disagreement about the child's best interest; and (3) decision-making strategies, including limiting options, being directive, staying neutral, and allowing parents to come to their own conclusions. Physicians described challenges to implementing shared decision-making including unequal power and authority, clinical uncertainty, and complexity of balancing child and family interests. They acknowledged determining the level of engagement in shared decision-making with parents (vs routine engagement) based on their perceptions of the best interests of the child and parent. Due to power imbalances, families' values and preferences may not be integrated in decisions or families may be excluded from discussions about goals of care. We suggest that a systematic approach to identify parental preferences and needs for decisional roles and information may reduce variability in parental involvement.

P.2.a.002 - External validity of the forced swim test supported by meta-analysis of studies using different classes of antidepressant drugs

The use of extracorporeal life support (ECLS) worldwide has increased exponentially since 2009. The patient requiring ECLS demands an investment of hospital resources, including personnel. Educating bedside nurses to manage ECLS circuits broadens the availability of trained providers.Experienced cardiothoracic intensive care unit (CTICU) nurses underwent training to manage ECLS circuits, including volume assessment, treatment of arterial blood gas values, the physiology of ECLS, and recognition of common emergencies. In addition to lectures and a written examination, simulation using water circuits and an ICU model allowed assessment of skills and understanding of concepts. Performance assessments were completed regularly at the bedside, and skills revalidation occurred every 6 months. A sequential cohort of 40 patients was tracked over 1 year.Despite doubling the census of ECLS patients in 1 year, management by specially trained CTICU nurses has positively affected patient care and outcomes. At a single institution, 40 patients had a median of 6 days (interquartile range, 2 to 226 days) of support in 2014, leading to 767 patient-days of support. Survival to hospital discharge increased to 45% in 2014. Most survivors were weaned from support. Neurologic injury was the most common cause of death, followed by failure to qualify for advanced therapies.With on-going education and assessment, including crisis training, physiology, and cannulation strategies, CTICU nurses can safely operate ECLS circuits and can increase the availability of appropriately trained providers to accommodate the exponential increase in ECLS occurrences without negatively affecting outcomes and generally at a lower cost.

The Role of Extracorporeal Membrane Oxygenation Simulation Training at Extracorporeal Life Support Organization Centers in the United States.

Extracorporeal membrane oxygenation (ECMO) requires a multidisciplinary healthcare team. The Extracorporeal Life Support Organization publishes training guidelines but leaves specific requirements up to each institution. Simulation training has shown promise, but it is unclear how many institutions have incorporated simulation techniques into ECMO training to date. We sent an electronic survey to ECMO coordinators at Extracorporeal Life Support Organization sites in the United States. Participants were asked about training practices and the use of simulation for ECMO training. Descriptive results were reported as the percentage of total responses for each question. Logistic regression was used to identify characteristics associated with simulation use. Of 94 responses (62% response rate), 46% had an ECMO simulation program, whereas 26% report a program is in development. Most (61%) have been in operation for 2 to 5 years. Sixty-three percent use simulation for summative assessment, and 76% have multidisciplinary training. Access to a simulation center [odds ratio (OR) = 4.7, 95% confidence interval (CI) = 1.7-12.5], annual ECMO caseload of greater than 20 (OR = 2.5, 95% CI = 1.5-5.8), and having a pediatric cardiothoracic intensive care unit (OR = 2.8, 95% CI = 1.2-6.7) are each associated with increased likelihood of mannequin-based ECMO simulation. Common scenarios include pump failure (93%), oxygenator failure (90%), and circuit rupture (76%). Extracorporeal membrane oxygenation simulation is growing but remains in its infancy. Centers with access to a simulation center, higher caseloads, and pediatric cardiothoracic intensive care units are more likely to have ECMO simulation programs. Extracorporeal membrane oxygenation simulation is felt to be beneficial, and further work is needed to delineate best training practices for ECMO providers.

Glycaemic control in a cardiothoracic surgical population: Exploring the protocol-practice gap

Background . Glycaemic control constitutes an important component in the management of critically ill patients. As such, all healthcare workers involved in the management of critically ill patients need to ensure that it is achieved adequately. To avoid glucose variability and to maintain normoglycaemia, evidence-based protocols are implemented to guide clinical care. However, it has been suggested that with the use of protocoldirected therapy, protocol-practice gaps are common and therefore protocol adherence must be audited regularly. The aim of this study was to evaluate adherence to the glucose control protocol by nurses in the cardiothoracic intensive care unit (ICU) at a tertiary academic hospital. Methods . A retrospective study involving the review of ICU charts of all post-cardiac surgery patients ≥16 years admitted to the cardiothoracic ICU during March 2011. A convenience sampling method was used. Results . A total of 741 glucose readings for 22 patients were evaluated. The median (interquartile range) glucose reading was 7.8 mmol/L (6.7 - 9.3 mmol/L). Overall, 411 (55.5%) protocol violations were recorded and 629 (84.9%) of the total readings were abnormal. Protocol violations were similar between the day and night staff; 188 (54.7%) and 223 (58.5%) were recorded, respectively ( p =0.256). Of the readings, 464 (62.6%) were conducted by ICU-trained nurses and 245 (33.2%) by non-ICU-trained nurses. There were fewer protocol violations recorded by the ICU-trained nurses compared with the non-ICU-trained nurses, i.e. 53.3% and 63.7%, respectively ( p <0.05). Conclusion . Adherence to the glucose-control protocol was suboptimal. These results may suggest that the training and education of healthcare workers in implementing protocols is an ongoing and dynamic process, and that there is a need for the regular evaluation of protocol adherence in order to identify protocol-practice gaps.

Deployment of a Second Victim Peer Support Program: A Replication Study.

Background:The second victim phenomenon occurs when health-care providers experience significant professional distress (compassion dissatisfaction, burnout, secondary traumatic stress) and psychological distress (shame, anxiety, and depression) as a result of medical errors or adverse patient outcomes. Few hospitals have institution-wide systems in place to assist employees through the recovery process.Methods:At Nationwide Children’s Hospital (NCH), a peer-based support program called “YOU Matter” was executed and spread hospital-wide. The program emulated the framework and execution strategy designed by University of Missouri Health Care’s (MUHC) “forYOU” Team. Strategic elements of the program’s structure were reviewed and adapted for NCH with system-wide deployment and enhancement to include electronic peer support reporting. This article summarizes program implementation, management, and sustainment over the past 2 years.Results:By following University of Missouri Health Care’s model, we successfully deployed an institution-wide second victim program. Since the November 2013 initiation, we have documented 232 peer and 21 group encounters. High-risk clinical areas for second victimization at NCH included the emergency department (ED), pediatric intensive care unit (PICU), cardiothoracic intensive care unit (CTICU), and pharmacy department. Registered nurses (RNs) and licensed practical nurses (LPNs) have had the highest number of encounters necessitating second victim support (32%). Supported staff reported improved emotional state and improved return-to-work metrics.Conclusions:An organization’s culture of patient safety can be enhanced by ensuring staff psychological safety. Programs like “YOU Matter” and the “forYOU” Team are essential building blocks to improve the overall safety culture and quality of care. Implementation of “YOU Matter” at NCH validates the MUHC program and demonstrates its generalizability to other health-care institutions.

Patients Discharged From the Intensive Care Unit on a Dopamine Infusion—A Retrospective, Observational Study

To assess the safety of discharging cardiac surgical patients from the intensive care unit (ICU) to wards while the patients are still receiving a dopamine infusion. Retrospective, observational study. Cardiothoracic ICU of a tertiary academic hospital in the United Kingdom. The study comprised all cardiac surgical patients older than 18 years and admitted between September 1, 2015 and September 16, 2016 to the ICU and subsequently discharged to a surgical ward. Patients were divided in the following 2 groups: a dopamine group with patients discharged with a dopamine infusion and a control group with patients discharged without any dopamine infusion. None. The hospital mortality rate was comparable in both groups (0.7% in the dopamine group v 0.2% in the control group [p = 0.11]), despite that the median logistic EuroSCORE was significantly higher in the dopamine group (7.0 v 3.8 [p < 0.01]). The ICU readmission rate was higher in the dopamine group (6.6% v 2.4%; p < 0.01). ICU and hospital lengths of stay were longer in the dopamine group (1.7 v 0.9 days [p < 0.01] and 11.4 v 8.0 days [p < 0.01], respectively). Despite a higher ICU readmission rate, ICU discharge of patients on dopamine infusion was not associated with increased mortality.

Variability in Integrated Cardiothoracic Training Program Curriculum

Development of curricula that appropriately progress a resident from medical school graduate to fully trained cardiothoracic surgeon is a key challenge for integrated cardiothoracic training programs. This study examined variability and perceived challenges in integrated curricula. Responses to the 2016 TSDA/TSRA survey that accompanies the annual in-training exam taken by current cardiothoracic surgery residents were analyzed. Standard statistical methods were utilized to examine trends in participant responses. General surgery experience decreased with post-graduate year, whereas cardiac operative experience increased. Rotations in a wide variety of adjunct fields were common. The majority (87%) of respondents reported had dedicated cardiothoracic intensive care unit (ICU) rotations, and surgical ICU and cardiac care unit rotations were less common (68% and 42%, respectively). The most common surgical subspecialty rotations were vascular (94%) and acute care surgery (88%), with a wide range of clinical exposure (ie, 3-44 weeks for vascular). Importantly, 52% felt competition with general surgery residents for experience and 22.5% of general surgery rotations were at hospitals without general surgery residents. Perceived challenges included optimization of rotations (78%), faculty allowing residents to perform case components (60%), faculty teaching in the operating room (29%), and improving surgical experience on general surgery rotations (19%). Significant variation exists in integrated cardiothoracic surgery curricula. Optimization of rotations, access to surgical experience, and integration with general surgery appear to be the most significant perceived challenges. These data suggest that optimization of early clinical and surgical experience within institutions could improve trainee preparedness for senior cardiothoracic surgery training.

OP49, PP26 - Time to central venous catheter imaging on the Cardiothoracic Intensive Care Unit (CICU)

OP49, PP26 - Time to central venous catheter imaging on the Cardiothoracic Intensive Care Unit (CICU)

OP25 - Control of nosocomial outbreak due to multiresistant bacteria based on audit and education in a cardiothoracic intensive care unit

OP25 - Control of nosocomial outbreak due to multiresistant bacteria based on audit and education in a cardiothoracic intensive care unit

PP39 - Survival after prolonged ICU stay in patients who have had surgical resection of oesophageal squamous cell carcinoma

Oesophageal squamous-cell carcinoma (SCC) is associated with lifestyle-related behaviours (i.e. malnutrition, alcohol and tobacco), which also increase the risk of perioperative complications (1,2). Previously the impact of complications on survival has been explored in mixed SCC and adenocarcinoma populations with conflicting results. In the present study, the influence of perioperative complications on survival following open oesophageal resection was investigated exclusively in patients with SCC. In a retrospective observational study at the department of cardiothoracic surgery and intensive care unit (ICU) at Rigshospitalet, Copenhagen, Denmark, 133 patients were included. Patients undergoing open surgical resection from February 2010 to December 2015 were consecutively included. Pre- and perioperative clinical information, mortality and complications defined as a Clavien-Dindo classification >1 were registered. The overall survival was calculated from time of index surgery to the censoring date November 16 2016. Primary outcome was overall survival. Secondary outcomes were short-term survival (30 and 90 days respectively), long-term survival (excluding 30 days mortality) and postoperative complications. Eighty-nine patients experienced one or more postoperative complications. The most frequent was suspicion of infection requiring antibiotic treatment (56%) and among these 19% had sepsis. In addition atrial fibrillation (14%), delirium (12%), anastomotic leakage (11%) and chylothorax (6%) were among the most common complications. The incidence of postoperative complications was associated with a low haemoglobin level (P<0.001) and a low mean arterial pressure in the ICU (P=0.015) and during the operation (P=0.030). Short-term survival was not significantly different in patients with or without complications. However, long-term survival was significantly lower in patients with complications (log rank P=0.038). Patients with a length of stay in the ICU ≥ 20 days had a significantly lower overall survival (log rank P<0.001) (Figure 1). After one year 71% were dead, compared with 14% in the group requiring less than 20 days in the ICU. A univariate Cox regression analysis revealed that long-term survival was significantly worse in patients experiencing complications (HR: 2.07, 95% CI: 1.02-4.21, P=0.044), and overall survival was lower in patients admitted for ≥20 days in the ICU (HR: 6.97, 95% CI: 2.61-18.59, P<0.001). We found that survival was negatively affected by complications during the index hospitalisation for SCC resection and in patients requiring an ICU stay for 20 days or more. Additional follow-up studies are necessary to clearly identify markers for compassionate treatment in this high risk patient group. 1. Pennathur A, Gibson MK, Jobe BA, Luketich JD. Oesophageal carcinoma. Lancet (London, England). 2013; 381(9864): 400-12. 2. Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA: a cancer journal for clinicians. 2015; 65(2): 87-108.

Comparison of Effort of Breathing for Infants on Nasal Modes of Respiratory Support

To directly compare effort of breathing between high flow nasal cannula (HFNC), nasal intermittent mechanical ventilation (NIMV), and nasal continuous positive airway pressure (NCPAP). This was a single center prospective cross-over study for patients <6 months in the cardiothoracic or pediatric intensive care unit receiving nasal noninvasive respiratory support after extubation. We measured effort of breathing using esophageal manometry with pressure-rate product (PRP) on all 3 modes. NIMV synchrony was determined by comparing patient efforts (esophageal manometry) with mechanically delivered breaths (spirometry in ventilator circuit). On NIMV, PRP and synchrony was also measured after adding a nasal clip on 26 patients. Forty-two children were included. Median (IQR) age was 2 (0.5, 4) months. There was no difference in median PRP between HFNC 6 liters per minute, 355 (270,550), NIMV 12/5 cm H2O, 341 (235, 472), and NCPAP 5 cm H2O, 340 (245,506) (P?=?.33). Results were similar regardless of HFNC flow rate or NIMV inspiratory pressure. Median PRP on CPAP of 5 cm H2O prior to extubation 255 (176, 375) was significantly lower than all postextubation values (P?<?.002). On NIMV, less than 50% of patient efforts resulted in a ventilator breath, which was not improved with a nasal clip (P?>?.07)). However, as NIMV synchrony improved (>60%), PRP on NIMV was lower than on HFNC. For infants, effort of breathing is similar on HFNC, NIMV, and NCPAP after extubation, regardless of flow rate or inspiratory pressure. We speculate that bi-level NIMV may be superior if high levels of synchrony can be achieved.

Fluid Responsiveness After CArdiac Surgery (FRACAS): A Prospective Observational Study Using Peripheral Near-Infrared Spectroscopy

To describe tissue oxygen saturation (StO2) in response to a vascular occlusion test using thenar eminence and forearm near-infrared spectroscopy (NIRS) and the association with volume responsiveness after cardiac surgery. Single-center, prospective, observational cohort study. Cardiothoracic intensive care unit. Seventy-six post-cardiac surgical adults. Immediately before and 10 minutes after a 250-to-500 mL fluid bolus, StO2 was measured in response to a vascular occlusion test to calculate tissue deoxygenation (Rdes) and reoxygenation (Rres) rates. Concurrently, systemic hemodynamic, metabolic, and blood gas variables were collected. A total of 203 boluses were captured using thenar NIRS and 141 boluses using forearm NIRS. Approximately 25% of boluses increased cardiac output by ≥15% (volume responders). Thenar and forearm Rdes decreased in responders, but increased (thenar) or remained unchanged (forearm) in nonresponders. A logistic regression model of the association among StO2, Rdes and Rres, and volume responsiveness was significant for thenar measurements (p = 0.001) with an area under the receiver operating characteristic of 0.69 (95% confidence interval: 0.62-0.75). It also was significant (p = 0.02) for forearm measurements, with an area under the receiver operating characteristic of 0.71 (0.62-0.79). Rdes was an independent variable in both instances (odds ratio 0.31 [0.14-0.69], thenar; odds ratio 0.60 [0.45-0.80], forearm). Thenar and forearm NIRS variables were correlated poorly with cardiac output, stroke volume, systemic oxygen delivery and consumption index, mixed venous, and central venous oxygen saturation (Spearman׳s coefficients, r = 0.17-0.46, p < 0.002). In post-cardiac surgical patients, thenar and forearm NIRS variables were associated with volume responsiveness although not achieving precision necessary for clinical management.

A nursing protocol targeting risk factors for reducing postoperative delirium in patients following coronary artery bypass grafting: Results of a prospective before-after study

ObjectiveThe results of postoperative delirium (POD) warrant testing for prevention. The purpose of this study was to determine whether a nursing intervention targeting risk factors could decrease the incidence of POD among patients who had coronary artery bypass grafting (CABG) in China. MethodsA prospective before-after study was conducted between April 2014 and April 2015. A nursing delirium intervention protocol targeting risk factors for delirium was performed for 141 patients undergoing CABG in a cardiothoracic ICU from November 2014 to April 2015. Intervention consisted of screening for delirium risk factors, followed by targeted risk factor modification, including pain control, early catheter removal, patient orientation using the 5W1H procedure, increased family visits, minimizing care-related interruptions, comfortable nursing and monitoring for sleeping difficulties. Outcomes of the Intervention Group were compared with those of the Control Group for 137 CABG patients from April 2014 to October 2014. Delirium was assessed using the confusion assessment method for the intensive care unit (CAM-ICU). The sample size was justified by PASS2000, based on previous data of delirium incidence in our institution (30%). Main resultsDelirium incidence during the first seven postoperative days was significantly lower in the Intervention Group at 13.48% (19/141) vs. 29.93% (41/137) for the Control Group (χ2 = 11.112, P = 0.001). In addition, POD in the Intervention Group occurred between the 3rd and 6th postoperative days, while POD in the Control Group mainly occurred on the first three days postoperatively. Delirium in the Intervention Group occurred later than delirium in the Control Group (χ2 = 12.743, P < 0.001). Length of ICU stay was reduced significantly (Z = −6.026, P < 0.001). ConclusionThe application of a nursing protocol targeting risk factors in this study seems to be associated with a lower incidence of POD in patients after CABG. This finding suggests that managing the predictors properly is one of the effective strategies to prevent delirium.

The Effects of On-Pump and Off-Pump Coronary Artery Bypass Surgery on Respiratory Function in the Early Postoperative Period.

Respiratory complications are common after cardiac surgery and the use of extracorporeal circulation is one of the main causes of lung injury. We hypothesized a better postoperative respiratory function in off-pump coronary artery bypass grafting (OPCABG) as compared with "on-pump coronary artery bypass grafting" (ONCABG). This is a retrospective, single-center study at a cardiothoracic intensive care unit (ICU) in a tertiary university hospital. Consecutive data on 339 patients undergoing elective CABG (n = 215 ONCABG, n = 124 OPCABG) were collected for 1 year from the ICU electronic medical records. We compared respiratory variables (Pao2, Pao2/Fio2 ratio, Sao2, and Paco2) at 7 predefined time points (ICU admission, postoperative hours 1, 3, 6, 12, 18, and 24). We also evaluated time to extubation, rates of reintubation, and use of noninvasive ventilation (NIV). We used mixed-effects linear regression models (with time as random effect for clustering of repeated measures) adjusted for a predetermined set of covariates. The values of Pao2 and Pao2/Fio2 were significantly higher in the OPCABG group only at ICU admission (mean differences: 9.7 mm Hg, 95% confidence interval [CI] 3.1-16.2; and 27, 95% CI 6.1-47.7, respectively). The OPCABG group showed higher Paco2, overall ( P = .02) and at ICU admission (mean difference 1.8 mm Hg, 95% CI: 0.6-3), although mean values were always within normal range in both groups. No differences were seen in Sao2 values, time to extubation, rate of reintubation rate, and use of postoperative NIV. Extubation rate was higher in OPCABG only at postoperative hour 12 (92% vs ONCABG 82%, P = .02). The OPCABG showed only marginal improvements of unlikely clinical meaning in oxygenation as compared to ONCABG in elective low-risk patients.

The Utility of Nurse-Managed Extracorporeal Life Support in an Adult Cardiac Intensive Care Unit

The use of extracorporeal life support (ECLS) worldwide has increased exponentially since 2009. The patient requiring ECLS demands an investment of hospital resources, including personnel. Educating bedside nurses to manage ECLS circuits broadens the availability of trained providers. Experienced cardiothoracic intensive care unit (CTICU) nurses underwent training to manage ECLS circuits, including volume assessment, treatment of arterial blood gas values, the physiology of ECLS, and recognition of common emergencies. In addition to lectures and a written examination, simulation using water circuits and an ICU model allowed assessment of skills and understanding of concepts. Performance assessments were completed regularly at the bedside, and skills revalidation occurred every 6 months. Asequential cohort of 40 patients was tracked over 1 year. Despite doubling the census of ECLS patients in 1 year, management by specially trained CTICU nurses has positively affected patient care and outcomes. At a single institution, 40 patients had a median of 6 days (interquartile range, 2 to 226 days) of support in 2014, leading to 767 patient-days of support. Survival to hospital discharge increased to 45% in 2014. Most survivors were weaned from support. Neurologic injury was the most common cause of death, followed by failure to qualify for advanced therapies. With on-going education and assessment, including crisis training, physiology, and cannulation strategies, CTICU nurses can safely operate ECLS circuits and can increase the availability of appropriately trained providers to accommodate the exponential increase in ECLS occurrences without negatively affecting outcomes and generally at a lower cost.

Hemodynamic Effect of Different Doses of Fluids for a Fluid Challenge: A Quasi-Randomized Controlled Study.

The objectives of this study are to determine what is the minimal volume required to perform an effective fluid challenge and to investigate how different doses of IV fluids in an fluid challenge affect the changes in cardiac output and the proportion of responders and nonresponders. Quasi-randomized controlled trial. Cardiothoracic ICU, tertiary university hospital. Eighty postcardiac surgery patients. IV infusion of 1, 2, 3, or 4 mL/Kg (body weight) of crystalloid over 5 minutes. Mean systemic filling pressure measured using the transient stop-flow arm arterial-venous equilibrium pressure, arterial and central venous pressure, cardiac output (LiDCOplus; LiDCO, Cambridge, United Kingdom), and heart rate. The groups were well matched with respect to demographic and baseline physiologic variables. The proportion of responders increased from 20% in the group of 1 mL/kg to 65% in the group of 4 mL/kg (p = 0.04). The predicted minimal volume required for an fluid challenge was between 321 and 509 mL. Only 4 mL/Kg increases transient stop-flow arm arterial-venous equilibrium pressure beyond the limits of precision and was significantly associated with a positive response (odds ratio, 7.73; 95% CI, 1.78-31.04). The doses of fluids used for an fluid challenge modify the proportions of responders in postoperative patients. A dose of 4 mL/Kg increases transient stop-flow arm arterial-venous equilibrium pressure and reliably detects responders and nonresponders.

Delirium in Children After Cardiac Bypass Surgery.

To describe the incidence of delirium in pediatric patients after cardiac bypass surgery and explore associated risk factors and effect of delirium on in-hospital outcomes. Prospective observational single-center study. Fourteen-bed pediatric cardiothoracic ICU. One hundred ninety-four consecutive admissions following cardiac bypass surgery, 1 day to 21 years old. Subjects were screened for delirium daily using the Cornell Assessment of Pediatric Delirium. Incidence of delirium in this sample was 49%. Delirium most often lasted 1-2 days and developed within the first 1-3 days after surgery. Age less than 2 years, developmental delay, higher Risk Adjustment for Congenital Heart Surgery 1 score, cyanotic disease, and albumin less than three were all independently associated with development of delirium in a multivariable model (all p < 0.03). Delirium was an independent predictor of prolonged ICU length of stay, with patients who were ever delirious having a 60% increase in ICU days compared with patients who were never delirious (p < 0.01). In our institution, delirium is a frequent problem in children after cardiac bypass surgery, with identifiable risk factors. Our study suggests that cardiac bypass surgery significantly increases children's susceptibility to delirium. This highlights the need for heightened, targeted delirium screening in all pediatric cardiothoracic ICUs to potentially improve outcomes in this vulnerable patient population.

A Retrospective, Pilot Study of De Novo Antidepressant Medication Initiation in Intensive Care Unit Patients and Post-ICU Depression

Post-ICU Syndromes (PICS) remain a devastating problem for intensive care unit (ICU) survivors. It is currently unknown if de novo initiation of an antidepressant medication during ICU stay decreases the prevalence of post-ICU depression. We performed a retrospective, pilot study evaluating patients who had not previously been on an antidepressant medication and who were started on an antidepressant while in the trauma surgical, cardiothoracic, or medical intensive care unit (ICU). The PHQ-2 depression scale was used to ascertain the presence of depression after ICU discharge and compared this to historical controls. Of 2,988 patients admitted to the ICU, 69 patients had de novo initiation of an antidepressant medication and 27 patients were alive and available for study inclusion. We found the prevalence of depression in these patients to be 26%, which is not statistically different than the prevalence of post-ICU depression in historical controls [95% CI (27.6%, 51.6%)]. De novo initiation of an antidepressant medication did not substantially decrease the prevalence of post-ICU depression in this retrospective, pilot study.