Cardiovascular Intensive Care Unit Research Articles

Postcardiac Surgery Euglycemic Diabetic Ketoacidosis in Patients on Sodium-Glucose Cotransporter 2 Inhibitors

To evaluate sodium-glucose cotransporter 2 inhibitors (SGLT2i) use and complications (euglycemic diabetic ketoacidosis [eDKA] rate, mortality, infection, hospital, and cardiovascular intensive care unit [CVICU] length of stay [LOS]) in patients undergoing cardiac surgery. A retrospective study. At an academic university hospital. Adult patients undergoing cardiac surgery. SGLT2i use versus no SGLT2i use. The authors evaluated patients undergoing cardiac surgery within 24 hours of hospital admission (between February 2, 2019 to May 26, 2022) for SGLT2i prevalence and eDKA frequency. The outcomes were compared using Wilcoxon rank sum and chi-square testing as appropriate. The cohort included 1,654 patients undergoing cardiac surgery, of whom 53 (3.2%) were prescribed an SGLT2i before surgery; 8 (15.1%) of 53 had eDKA. The authors found no differences between patients with and without SGLT2i use in hospital LOS (median [IQR]: 4.5 [3.5-6.3] v 4.4 [3.4-5.6] days, p=0.46) or CVICU LOS (median [IQR]: 1.2 [1.0-2.2] v 1.1 [1.0-1.9] days, p=0.22), 30-day mortality (1.9% v 0.7%, p=0.31), or sternal infections (0.0% v 0.3%, p=0.69). Among patients prescribed an SGLT2i, those with and without eDKA had similar hospital LOS (5.1 [4.0-5.8] v 4.4 [3.4-6.3], p=0.76); however, CVICU LOS was longer in patients with eDKA (2.2 [1.5-2.9] v 1.2 [0.9-2.0], p=0.042). Mortality (0.0% v 2.2%, p=0.67) and wound infections (0.0% v 0.0%, p > 0.99) were similarly rare. Postoperative eDKA occurred in 15% of patients on an SGLT2i prior to cardiac surgery, and was associated with longer CVICU LOS. Future studies into SGLT2i management perioperatively are important.

Aspiration Pneumonitis.

Background: Aspiration pneumonitis also called as Mendelson's syndrome is a lung injury from acute inflammation that occurs after chemical burns in the airways and lung parenchyma, caused by the inhalation of gastric content. Depending on the quantity, nature of the aspirated material, and the host factors, the damage can lead to acute respiratory distress with a mortality rate up to 70%.
 Case report: A 73-year-old male, was admitted from the emergency department to cardiovascular surgery ICU, diagnosed with ruptured abdominal aortic aneurysm. The patient presented with severe hypotension, tachycardic with altered mental status and was immediately sent to the operating room. At the moment of shifting to the operating table, the patient had cardiocirculatory arrest, large amount of gastric content came out of the patient’s mouth. While the patient was assisted with chest compressions, suction was immediately done in the oropharyngeal cavity, the patient was intubated with direct laryngoscopy, the tube cuff had its adequate pressure assured to prevent further aspiration.Bronchial lavage was performed before patient ventilation. The cardiac rhythm was restored, and the surgical incision started. Within 30 minutes from the aspiration, during the surgery the patient appeared symptoms of Mendelson’s syndrome. The arterial blood gas test was presented with hypoxemia in 100% with retention. Empiric antibiotic and corticosteroid were administered. After the surgery the patient was transferred to the ICU and was ventilated according to the ARDS protocol. The patient had other complications during his stay in ICU and was extubated after nine days and was discharged home after 19 days.
 Discussion: Regardless of the measures taken to avoid aspiration pneumonia during emergency surgery, it is sometimes inevitable and it is important to know how to act and treat the patient according to the primary underlying condition.
 Conclusions: Treatment with early, empiric, broad-spectrum antibiotics should be administered then selection of pathogen specific antibiotics or decision to stop or continue the use of antibiotics is made based on quantitative bacteriology

Mobilization Levels of Cardiac Surgery Patients in the Early Postoperative Period

Introduction: Early mobilization after cardiac surgery positively affects the improvement of the physical, social, and psychological functions of patients. This study was carried out to evaluate the mobilization levels of cardiac surgery patients in the early postoperative period with the ICU-Mobility Scale (IMS). Methods: This descriptive and observational study was conducted with 104 patients and 15 nurses between February and June 2021 in a cardiovascular surgery intensive care unit in Turkey. Data were collected with an information form and the IMS. Results: A statistically significant relationship was found between the time the patients reached the 1st, 3rd, 4th, 6th, 7th, and 8th levels of the IMS in the intensive care unit and the American Society of Anesthesiologists (ASA) score, cardiopulmonary bypass time, aortic cross-clamping time, operation time, and intubation time (p < 0.05). In addition, nurses reported that they had a little difficulty and high satisfaction during the application of the scale. Conclusion: Mobilization after cardiac surgery is affected by some factors during and after surgery. The IMS is an inexpensive, easy, and effective method that can be used to evaluate and classify the mobilization levels of patients in the intensive care unit after cardiac surgery.

Comparison of Platelet Mass Index to Platelet Count as Transfusion Trigger in Neonatal Extracorporeal Membrane Oxygenation.

Platelet transfusions are routinely administered to neonates in intensive care units when there are concerns of bleeding, including high-risk situations like Extracorporeal Membrane Oxygenation (ECMO). Most platelets in ICUs are transfused prophylactically for thrombocytopenia based solely on the platelet count. Platelet Mass Index (PMI) has been proposed as an alternative to platelet count (PC) as a transfusion trigger. The objective of this study was to determine the relationship between PMI and platelet-specific maximal clot firmness (PMCF) in Rotational thromboelastometry (ROTEM), which gives an indication of platelet contribution to clot firmness and to investigate whether PMI may be a better choice as a trigger for platelet transfusions than PC. Retrospective review of medical records of neonates with congenital heart disease placed on ECMO support in the cardiovascular intensive care unit (CVICU) from 2015 to 2018 was conducted. Platelet count (PC), platelet mean volume (PMV), ROTEM parameters along with demographic data including gestation age, birth weight, gender and survival were collected. Mixed effects linear models with a first order autoregressive covariance structure were used to assess the associations of PMI, PC, and MPV against PMCF. In addition, generalized estimating equations with a first order auto-regressive covariance structure were used to compare odds of transfusion using PC versus PMI triggers. A total of 92 tests on consecutive days were obtained for 12 ECMO patients (5 male, GA = 38.1 ± 1.6 weeks, BW = 3.1 ± 0.4 kgs, mean ± SD). A variation of 40.1% in PMCF was explained by platelet count (p < 0.001) while 38.5% of the variation in PMCF was explained by PMI (p < 0.001). If the platelet transfusion trigger was PC < 100 x 103 platelets/µL vs. PMI < 800. Using the PC trigger yielded significantly higher odds of transfusion compared to the PMI trigger (odds ratio = 1.31, 95% confidence interval: 1.18 - 1.45, p < 0.001). While our study failed to demonstrate a superior correlation of PMI with PMCF than PC, our study did reveal that using PMI as transfusion trigger would result in significantly less platelet transfusions, when compared with the current practice of using PC as a trigger.

Characterization of early versus late opioid iatrogenic withdrawal syndrome in critically ill children transitioning from fentanyl -infusions to methadone.

Methadone is used to prevent opioid iatrogenic withdrawal syndrome (IWS) in children, but the optimal dose and overlap time with an opioid infusion have not been elucidated. The purpose was to compare clinical manifestations among patients who developed opioid IWS within 24 hours (early) versus ≥24 hours (late) of fentanyl discontinuation when enteral methadone was initiated. A retrospective, descriptive study. Pediatric and cardiovascular intensive care units at a tertiary care health system. Sixty-seven children received fentanyl infusions for ≥3 days and initiated on methadone prior to fentanyl discontinuation. The primary objective was to compare clinical characteristics between those with early versus late opioid IWS. Opioid IWS was defined as a Withdrawal Assessment Tool-1 score ≥3 within 5 days of fentanyl discontinuation. Secondary objectives included a comparison of time to IWS, clinical characteristics, and risk factors among patients with and without IWS. Fifty children (74.6 percent) developed opioid IWS within a median time of 3.5 hours. No differences were noted for those with and without IWS. Thirty-seven patients (74.0 percent) with IWS developed early IWS. A higher percentage of males in the late versus early group developed IWS, 100 percent versus 51.4 percent, p = 0.002. The median overlap time with methadone and fentanyl was shorter in the early versus late IWS group without reaching statistical significance, 27.5 versus 64.0 hours, p = 0.127. The majority developed opioid IWS, with most developing early IWS, despite methadone initiation. Future studies should evaluate the optimal methadone dosing and overlap time to prevent opioid IWS.

Usefulness of the Quick-Sepsis Organ Failure Assessment Score in Cardiovascular Intensive Care Unit to Predict Prognosis in Acute Coronary Syndrome

Triage of patients with acute coronary syndrome (ACS) at high risk of in-hospital complications is essential. In this study, we evaluated the quick sepsis organ failure assessment (qSOFA) score as a tool for predicting the prognosis of 964 patients admitted to the cardiovascular intensive care unit (CICU) with ACS over a 4-year period. In total, out of 964 patients included, with a percentage of 4.6% for 30-day mortality. The risk of 30-day mortality was independently associated with qSOFA ≥ 2 at admission (hazard ratio = 2.76, 95% CI 1.32-5.74, p = 0.007). For MACEs, qSOFA ≥ 2 at admission was a predictive factor with (odds ratio = 2.42, 95% CI 1.37–4.36, p = .002). A qSOFA ≥ 2 on admission had an AUC of 0.729 (95% CI [0.694, 0.762]), with a good specificity of 91.6%. For 30-day mortality, an AUC of 0.759 (95%CI [0.726, 0.792]) for cardiogenic shock with specificity of 92.5%. For MACEs, an AUC of 0.702 (95% CI [0.64, 0.700] with a specificity of 95%. Concerning the different scores tested, we found no significant difference between the Zwolle score and the qSOFA score for predicting prognosis, whereas the CADILLAC score was better than qSOFA for predicting 30-day mortality (AUC = 0.829 and De long test = 0.03). However, there was no difference between qSOFA and CADILLAC scores for predicting cardiogenic shock (De Long test at 0.08). This is the first study to evaluate qSOFA as a predictive score for 30-day mortality and MACEs, and the results are very encouraging, particularly for cardiogenic shock.

Predicting readmission to the cardiovascular intensive care unit using recurrent neural networks.

If a patient can be discharged from an intensive care unit (ICU) is usually decided by the treating physicians based on their clinical experience. However, nowadays limited capacities and growing socioeconomic burden of our health systems increase the pressure to discharge patients as early as possible, which may lead to higher readmission rates and potentially fatal consequences for the patients. Therefore, here we present a long short-term memory-based deep learning model (LSTM) trained on time series data from Medical Information Mart for Intensive Care (MIMIC-III) dataset to assist physicians in making decisions if patients can be safely discharged from cardiovascular ICUs. To underline the strengths of our LSTM we compare its performance with a logistic regression model, a random forest, extra trees, a feedforward neural network and with an already known, more complex LSTM as well as an LSTM combined with a convolutional neural network. The results of our evaluation show that our LSTM outperforms most of the above models in terms of area under receiver operating characteristic curve. Moreover, our LSTM shows the best performance with respect to the area under precision-recall curve. The deep learning solution presented in this article can help physicians decide on patient discharge from the ICU. This may not only help to increase the quality of patient care, but may also help to reduce costs and to optimize ICU resources. Further, the presented LSTM-based approach may help to improve existing and develop new medical machine learning prediction models.

Evaluation of healthcare-associated nosocomial infections in the pediatric cardiovascular surgery intensive care unit over the years.

Evaluation of healthcare-associated nosocomial infections in the pediatric cardiovascular surgery intensive care unit over the years.

Comparison of infrared tympanic and non-contact temporal artery thermometer in determining the body temperature of patients in cardiovascular surgical intensive care

Accurate measurement of body temperature is crucial post-cardiovascular surgery, given the intricate and high-risk nature of cardiovascular procedures. In this prospective observational study, the safety and efficacy of infrared tympanic thermometers (ITT) and non-contact infrared temporal artery thermometers (NCTAT) were assessed in intensive care patients recovering from cardiovascular surgery. Conducted at a state hospital in Istanbul from April to July 2016, the study included 60 eligible patients meeting the specified criteria. Results indicated a slightly higher body temperature measurement with ITT (36.42±0.72) compared to NCTAT (36.02±0.79). NCTAT and ITT values were found (right ear: bias =0.39°C, limits of agreement: -1.99°C to 1.21°C; left ear: bias =0.29°C, limits of agreement: -1.59°C to 1.01°C) in the statistical evaluation by Bland and Altman analysis method. Repeatability, intragroup correlation and scatter plots of both measuring devices did not show a significant difference. In conclusion, within the cardiovascular surgical intensive care unit, both types of thermometers prove suitable for body temperature measurement. Healthcare professionals can make informed choices between the two based on the distinct advantages and disadvantages associated with each device.

Effect of Admission and Discharge Times on Hospital Mortality in Patients With Sepsis.

To assess whether the time of admission/discharge time from the ICU and weekend admission are independently associated with hospital mortality in critically ill patients with sepsis. Retrospective study. Each 24-hour period (08:00 to 07:59 hr) was split into three time periods, defined as "day" (08:00 to 16:59 hr), "evening" (17:00 to 23:59 hr), and "night" (00:00 to 07:59 hr). Weekends were defined as 17:00 hours on Friday to 07:59 hours on Monday. Multivariate logistic regression models were conducted to assess the association between the ICU admission/discharge time, weekend admission, and hospital mortality. Single-center ICUs in China. Characteristics and clinical outcomes of 1,341 consecutive septic patients admitted to the emergency ICU, general ICU, or cardiovascular ICU in a tertiary teaching hospital were collected. None. ICU mortality rates were 5.8%, 11.9%, and 10.6%, and hospital mortality rates were 7.3%, 15.6%, and 17.1% during the day, evening, and night time, respectively. Hospital mortality was adjusted for patient to nurse (P/N) ratio, disease severity, Charlson index, age, gender, mechanical ventilation, and shock. Notably, ICU admission time and weekend admission were not predictors of mortality after adjustment. The P/N ratio at admission was significantly associated with mortality ( p < 0.05). The P/N ratio and compliance with the Surviving Sepsis Campaign (SSC) were significantly correlated. After risk adjustment for illness severity at time of ICU discharge and Charlson index, the time of discharge was no longer a significant predictor of mortality. ICU admission/discharge time and weekend admission were not independent risk factors of hospital mortality in critically ill patients with sepsis. The P/N ratio at admission, which can affect the compliance rate with SSC, was a predictor of hospital survival. Unstable state on transfer from the ICU was the main risk factor for in-hospital death. These findings may have implications for the management of septic patients.

Central catheter tip migration in critically ill patients.

Chest X-ray (CXR) is routinely required for assessing Central Venous Catheter (CVC) tip position after insertion, but there is limited data as to the movement of the tip location during hospitalization. We aimed to assess the migration of Central Venous Catheter (CVC) position, as a significant movement of catheter tip location may challenge some of the daily practice after insertion. Retrospective, single-center study, conducted in the Intensive Care and Cardiovascular Intensive Care Units in Tel Aviv Sourasky Medical Center 'Ichilov', Israel, between January and June 2019. We identified 101 patients with a CVC in the Right Internal Jugular (RIJ) with at least two CXRs during hospitalization. For each patient, we measured the CVC tip position below the carina level in the first and all consecutive CXRs. The average initial tip position was 1.52 (±1.9) cm (mean±SD) below the carina. The maximal migration distance from the initial insertion position was 1.9 (±1) cm (mean±SD). During follow-up of 2 to 5 days, 92% of all subject's CVCs remained within the range of the Superior Vena Cava to the top of the right atrium, regardless of the initial positioning. CVC tip position can migrate significantly during a patient's early hospitalization period regardless of primary location, although for most patients it will remain within a wide range of the top of the right atrium and the middle of the Superior Vena Cava (SVC), if accepted as well-positioned.

191: IMPACT OF AN ANTI-IMPULSE PHARMACOTHERAPY ORDER SET IN AORTIC SYNDROMES: INTERIM DATA

Introduction: Anti-impulse therapy is used to describe the strategy to rapidly manage heart rate and blood pressure control in patients presenting with acute aortic syndromes (AAS). Patients presenting with AAS that have delayed transition from intravenous (IV) to oral anti-impulse therapy may encounter increased medication costs and length of stay (LOS). The objective of this study is to determine how an anti-impulse pharmacotherapy order set impacts the transition from IV to oral therapy in medically managed AAS patients and the subsequent impact on length of stay (LOS). Methods: A single-center, retrospective chart review of adult patients admitted to the cardiovascular intensive care unit (CVICU) for medical management of AAS was conducted from December 2020 to May 2022. Prior to this study, an anti-impulse order set was implemented through the electronic health record on March 18, 2022. Data on duration of continuous IV anti-impulse medications were collected to compare patients treated pre- and post-order set implementation. Patient demographics, ICU LOS, hospital LOS, cost of anti-impulse therapy, and time to initiate enteral medications for heart rate and blood pressure control were also obtained. Results: There were 27 patients in the pre-implementation group and seven patients assessed to date in the post-implementation group. The cohort of patients included in this study had a median age of 68 (IQR 55-81), were primarily male (66.7%), and the majority were white (84.8%). Type B aortic dissections was the most common type of medically managed AAS (57.6%). Implementation of an order set resulted in a reduction of continuous IV beta-blocker median duration of therapy by 18.2 hours (49.9 hours pre-implementation vs 31.7 hours post-implementation). Median duration of IV vasodilator therapy was also reduced by 23.7 hours (48.3 hours pre-implementation vs. 24.6 hours post implementation). There was no difference in median ICU LOS, however, hospital LOS was decreased by 35 hours after order set implementation. Conclusions: Interim analysis of use of an anti-impulse order set appears to be associated with a decreased duration of continuous infusion IV beta-blockers and vasodilators resulting in quicker oral therapy stabilization and subsequent decreased hospital length of stay.

Regional citrate anticoagulation versus systemic heparin anticoagulation for continuous kidney replacement therapy in intensive care

PurposeMany intensive care units (ICUs) have transitioned from systemic heparin anticoagulation (SHA) to regional citrate anticoagulation (RCA) for continuous kidney replacement therapy (CKRT). We evaluated the clinical and health economic impacts of ICU transition to RCA. Materials and methodsWe surveyed all adult general ICUs in England and Wales to identify transition dates and conducted a micro-costing study in eight ICUs. We then conducted an interrupted time-series analysis of linked, routinely collected health records. ResultsIn 69,001 patients who received CKRT (8585 RCA, 60,416 SHA) in 181 ICUs between 2009 and 2017, transition to RCA was not associated with a change in 90-day mortality (adjusted odds ratio 0.98, 95% CI 0.89–1.08) but was associated with step-increases in duration of kidney support (0.53 days, 95% CI 0.28–0.79), advanced cardiovascular support (0.23 days, 95% CI 0.09–0.38) and ICU length of stay (0.86 days, 95% CI 0.24–1.49). The estimated one-year incremental net monetary benefit per patient was £ − 2376 (95% CI £ − 3841–£ − 911), with an estimated likelihood of cost-effectiveness of <0.1%. ConclusionsTransition to RCA was associated with significant increases in healthcare resource use, without corresponding clinical benefit, and is highly unlikely to be cost-effective over a one-year time horizon.

Validation of an Instrument to Measure Family Engagement in Acute Cardiac Care

BackgroundEngaging families in care leads to improved patient- and family-centreed outcomes and is recommended by cardiovascular societies. However, no validated tools are currently available to measure family engagement in acute cardiac care. We previously described the development of the FAMily Engagement (FAME) instrument. The purpose of this study is to validate the FAME instrument in acute cardiac care. MethodsThe FAME questionnaire was administered to family members of patients in a cardiovascular intensive care unit and ward at an academic tertiary care hospital in Montreal, Canada. After hospital discharge, we assessed family satisfaction in the intensive care unit (FS-ICU) and mental health (using the Hospital Anxiety and Depression Scale [HADS]). Higher FAME scores indicate increased care engagement. Reliability was assessed using internal consistency testing. Predictive validity was evaluated by assessing the relationship between the FAME score and the FS-ICU score and whether the FAME score was correlated with the HADS score. Convergent validity was assessed by comparing the FAME score with engagement elements of the FS-ICU score. ResultsA total of 160 family participants were included (age 54.8 ± 14.8 years; 66% women; 36% non-White). The most common relationships to the patient were spouse/partner and adult child (both n = 62; 39%). The mean FAME score was 70.8 ± 16.0. The FAME instrument had high internal consistency (Cronbach’s a = 0.86). The FAME score was associated with family satisfaction in the multivariable analysis (P < 0.001). No correlation occurred between FAME and HADS anxiety or depression scores. ConclusionsThe FAME tool demonstrated reliability and convergent and predictive validity in the acute care cardiac population. Further research is needed to explore whether selected engagement interventions can impact the FAME score favourably.

Activated 4-Factor Prothrombin Complex Concentrate as a Hemostatic Adjunct for Neonatal Cardiac Surgery: A Propensity Score-Matched Cohort Study.

Prothrombin complex concentrates are an emerging "off-label" therapy to augment hemostasis after cardiopulmonary bypass (CPB), but data supporting their use for neonatal cardiac surgery are limited. We retrospectively reviewed neonates undergoing open heart surgery with first-time sternotomy between May 2014 and December 2018 from a hospital electronic health record database. Neonates who received activated 4-factor prothrombin complex concentrate (a4FPCC) after CPB were propensity score matched (PSM) to neonates who did not receive a4FPCC (control group). The primary efficacy outcome was total volume (mL/kg) of blood products transfused after CPB, including the first 24 hours on the cardiovascular intensive care unit (CVICU). The primary safety outcome was the incidence of 7- and 30-day postoperative thromboembolism. Secondary outcomes included 24 hours postoperative chest tube output, time to extubation, duration of CVICU stay, duration of hospital stay, 30-day mortality, and incidence of acute kidney injury on postoperative day 3. We used linear regression modeling on PSM data for the primary efficacy outcome. For the primary safety outcome, we tested for differences using McNemar test on PSM data. For secondary outcomes, we used linear regression, Fisher exact test, or survival analyses as appropriate, with false discovery rate-adjusted P values. A total of 165 neonates were included in the final data analysis: 86 in the control group and 79 in the a4FPCC group. After PSM, there were 43 patients in the control group and 43 in the a4FPCC group. We found a statistically significant difference in mean total blood products transfused for the a4FPCC group (47.5 mL/kg) compared with the control group (63.7 mL/kg) for PSM patients (adjusted difference, 15.3; 95% CI, 29.4-1.3; P = .032). We did not find a statistically significant difference in 7- or 30-day thromboembolic rate, postoperative chest tube output, time to extubation, incidence of postoperative acute kidney injury (AKI), or 30-day mortality between the groups. The a4FPCC group had a significantly longer length of intensive care unit stay (32.9 vs 13.3 days; adjusted P = .049) and hospital stay (44.6 vs 24.1 days; adjusted P = .049) compared with the control group. We found that the use of a4FPCC as a hemostatic adjunct for post-CPB bleeding in neonatal cardiac surgery was associated with a decrease in mean total blood products transfused after CPB without an increased rate of 7- or 30-day postoperative thromboembolism. Our findings suggest that a4FPCCs can be considered as part of a hemostasis pathway for refractory bleeding in neonatal cardiac surgery.

Multi-Lobar Atelectasis in Children Receiving Venoarterial Extracorporeal Membrane Oxygenation for Cardiac Indications.

Respiratory complications are common in patients who require venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for cardiac indications. We aimed to examine the frequency and characteristics of patients who develop multi-lobar atelectasis early in the course of VA ECMO and to identify factors associated with its occurrence. We performed a single-center retrospective review of consecutive pediatric subjects on VA ECMO in the cardiovascular ICU from 2014 to 2019. Chest radiographs before VA ECMO initiation and daily for up to 5 d of VA ECMO support were reviewed. Multi-lobar atelectasis was defined as the collapse of ≥2 lobes of the same lung. Patients with multi-lobar atelectasis before or immediately after VA ECMO cannulation were excluded. Bivariate comparisons and multivariable logistic regression analyses were performed to identify factors independently associated with lung collapse. Results of the multivariable analysis are provided as odds ratio (OR) with 95% CI. We reviewed 119 VA ECMO runs in 101 unique subjects. Multi-lobar atelectasis occurred in 36 runs (30%), with an isolated collapse of the left lung occurring most frequently (no. runs = 20). VA ECMO runs complicated by multi-lobar atelectasis were significantly longer and associated with lower hospital survival (51% vs 77%, survival in subjects without multi-lobar atelectasis; P = .01). Multivariable logistic regression analysis identified a subsequent ECMO run during the same admission to be independently associated with multi-lobar atelectasis (OR 5.4, 95% CI 1.2-21.5). Subanalysis of the subjects with isolated left lung collapse revealed male sex (OR 8.9, 95% CI 1.6-48.2) and subsequent ECMO run during the same admission (OR 4.0, 95% CI 1.2-13.6) to be independently associated with this complication, and mechanical ventilation at least 12 h before ECMO may be protective (OR 0.22, 95% CI 0.07-0.76). Multi-lobar atelectasis commonly occurred in children who were receiving VA ECMO for cardiac failure and was associated with worse outcomes. Male patients, a subsequent VA ECMO run during the same hospitalization, and patients in whom mechanical ventilation was initiated shortly before ECMO cannulation may be at increased risk for this complication.

Cardiovascular Critical Care Training: A Collaboration between Intensivists and Cardiologists.

With growing patient complexity, the cardiovascular intensive care unit (CICU) of today has evolved substantially from the coronary care unit (CCU) of decades ago. The growing burden of noncardiac critical illness and highly specialized acute cardiovascular disease requires a degree of expertise beyond that afforded through a general cardiology training program. Therefore, the American Heart Association (AHA) has proposed a CICU staffing model to include dedicated cardiac intensivists; in the present day, "dual-trained" physicians are extremely sparse. Guidance on designing critical care fellowships for cardiologists is limited but will require collaboration between cardiologists and medical intensivists. Here, we review the evolution of the CICU, describe training pathways, and offer guidance on creating a cardiology critical care training program.

Abstract 14539: Interhospital Differences in the Use of Critical Care Therapies in Coronary Intensive Care Units and Its Association With In-Hospital Mortality: Insights From the Critical Care Cardiology Trials Network

Background: Previous studies have shown wide interhospital variation in cardiovascular intensive care unit (CICU) admission practices and use of critical care restricted therapies and monitoring (CCRx), but little is known about practice differences among tertiary and academic CICUs. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multicenter registry of tertiary and academic CICUs in the USA and Canada that contributed consecutive patient data in annual 2-month periods from 2017 to 2021. The analysis included 13,318 admissions across 28 sites and compared interhospital variability in CCRx and its association with in-hospital survival. Results: CCRx was provided to 61.4% (interhospital range 28.3 - 86.7%) of CICU patients. Admissions to CICUs in the highest tertile of CCRx utilization, compared with the lower tertile, had a greater burden of comorbidities; less frequently admitted patients with ACS (18.7% vs 35.8%); more frequently admitted cardiac arrest (4.9% vs 2.6%) or cardiogenic shock (5.8% vs 1.9%); and had higher median admission Sequential Organ Failure Assessment (SOFA) scores (5.0 vs 2.0), lactate (1.9 vs 1.8 mmol/L), and creatinine (1.3 vs 1.1 mg/dL) levels. Unadjusted in-hospital mortality varied widely between CICUs (median 12.6%; range 4.0-23.5%; p&lt;0.001). After adjustment for patient differences, the correlation between CICU provision of CCRx and in-hospital mortality was weak (r=0.287, p&lt;0.001). Conclusions: In a large registry of tertiary and academic CICUs, there was large interhospital variability in the provision of CCRx. The weak adjusted correlation with in-hospital mortality suggests that standardized CICU admission criteria could reduce disparities in admission practices and improve health-resource allocation. Figure 1: Unadjusted correlation between individual CICU utilization of critical care restricted therapies and in-hospital all-cause mortality

Abstract 11931: Plasma Volume Status at Cardiovascular Intensive Care Unit Discharge and Hospital Discharge is Associated With Overall Survival in Patients With Acute Decompensated Heart Failure

Background: Plasma volume status (PVS), a measure of plasma volume, has been evaluated as a prognostic marker for chronic heart failure. However, the significance of PVS in patients with acute decompensated heart failure (ADHF) admitted to the cardiovascular intensive care unit (CICU) remains unclear. Therefore, we examined the relationship between PVS and the long-term mortality. Method: Of 389 consecutive patients admitted to our CICU for ADHF from January 2018 to December 2020, a total of 206 patients (74.9 ± 12.9 years, 64.6% male) were enrolled, excluding those who received red blood cell transfusion, underwent dialysis, were discharged directly from the CICU, or died in the hospital. We measured PVS during the CICU stay and at discharge using the Kaplan-Hakim formula, and examined the association with all-cause mortality during the observation period (1037 days). Result: The group with decreasing PVS at 3 points, at admission to the CICU, at transfer to the GW, and at discharge, had a 3-year mortality rate of 0%. Cut-off values to predict long-term mortality were 10% and 9% for PVS at transfer to the GW and discharge according to ROC curve, respectively. All patients were divided into 2 groups by cut-off values, respectively, and the high PVS group had a significantly higher mortality rate (Figure 1, 2). In COX regression analysis, significant poor prognostic factors were PVS at transfer to the GW (HR=1.086 [1.04-1.13], P&lt;0.001), PVS at discharge (HR=1.073 [1.03-1.12], P&lt;0.001), and age (HR=1.052 [1.00-1.10], P=0.04). In multivariate analysis, PVS at discharge (HR=1.058 [1.00-1.12], P=0.048) was independent poor prognostic factor. Conclusions: In patients with ADHF who were admitted to the CICU, PVS at discharge may be useful in predicting prognosis. It is necessary to consider whether the treatment of heart failure that lowers PVS contributes to improved prognosis.

First 24-h Sardjito Cardiovascular Intensive Care (SCIENCE) admission risk score to predict mortality in cardiovascular intensive care unit (CICU)

Background and objectivesThe application of prognostic scoring systems to identify risk of death within 24 h of CICU admission has significant consequences for clinical decision-making. Previous score of parameters collected after 24 h was considered too late to predict mortality. As a result, we attempted to develop a CICU admission risk score to predict hospital mortality using indicators collected within 24 h. MethodsData were obtained from SCIENCE registry from January 1, 2021 to December 21, 2021. Outcomes of 657 patients (mean age 58.91 ± 12.8 years) were recorded retrospectively. Demography, risk factors, comorbidities, vital signs, laboratory and echocardiography data at 24-h of patient admitted to CICU were analysed by multivariate logistic regression to create two models of scoring system (probability and cut-off model) to predict in-hospital mortality of any cause. ResultsFrom a total of 657 patients, the hospital mortality was 15%. The significant predictors of mortality were male, acute heart failure, hemodynamic instability, pneumonia, baseline creatinine ≥1.5 mg/dL, TAPSE <17 mm, and the use of mechanical ventilator within first 24-h of CICU admission. Based on Receiver Operating Characteristic (ROC) curve analysis a cut off of ≥3 is considered to be a high risk of in-hospital mortality (sensitivity 75% and specificity 65%). ConclusionThe initial 24-h SCIENCE admission risk rating system can be used to predict in-hospital mortality in patients admitted to the CICU with a high degree of sensitivity and specificity,