Cardiovascular Surgery Intensive Care Unit Research Articles

Improvement in Diagnosis and Management of Nosocomial Pneumonias in a Cardiovascular Surgery Intensive Care Unit: A Multidisciplinary Approach.

While criteria for the diagnosis of nosocomial pneumonias exist, objective definitions are a challenge and there is no gold standard for diagnosis. We analyzed the impact of the implementation of a logical, consensus-based diagnostic and treatment protocol for managing nosocomial pneumonias in the cardiovascular surgery intensive care unit (CVS-ICU). We conducted a quasi-experimental, interrupted time series analysis to evaluate the impact of a diagnostic and treatment protocol for nosocomial pneumonias in the CVS-ICU. Impacts were measured relative to patient outcomes, diagnostic processes, and antimicrobial stewardship improvement. Descriptive statistics were used to analyze results. Overall, 35 pre-protocol and 39 post-protocol patients were included. Primary clinical variables suggesting pneumonia in pre- and post-protocol patients were new lung consolidation (50% vs. 71%), new leukocytosis (59% vs. 64%), and positive culture (32% vs. 55%). Appropriate diagnostic testing improved (23% vs. 54%, p = 0.008) after protocol implementation. The proportion of patients meeting the criteria for nosocomial pneumonia (77% vs. 87%) was not statistically significant, though more patients in the post-protocol group met probable diagnostic criteria (51% vs. 77%). Duration of therapy was not significantly different (6 days [IQR = 5.0, 10.0] vs. 7 days [IQR = 6.0, 9.0]). The implementation of a diagnostic and treatment protocol for management of nosocomial pneumonias in the CVS-ICU resulted in improved diagnostic accuracy, advanced antimicrobial and diagnostic stewardship efforts, and laboratory cost savings without an adverse impact on patient-centered outcomes.

Critical Care Alarm Fatigue and Monitor Customization: Alarm Frequencies and Context Factors.

Alarm fatigue among nurses working in the intensive care unit has garnered considerable attention as a national patient safety priority. A viable solution for reducing the frequency of alarms and unnecessary noise is intensive care unit alarm monitor customization. A 24-bed cardiovascular and thoracic surgery intensive care unit in a large academic medical center identified a high rate of alarms and associated noise as a problem contributing to nurse alarm fatigue. An alarm monitor quality improvement project used both alarm frequency and nurse surveys before and after implementation to determine the effectiveness of interventions. Multimodal interventions included nurse training sessions, informational flyers, organizational policies, and an alarm monitor training video. Unexpected results inspired an extensive investigation and secondary analysis, which included examining the data-capturing capabilities of the alarm monitors and the impact of context factors. Alarm frequencies unexpectedly increased after the intervention. The software data-capturing features of the alarm monitors for determining frequency did not accurately measure nurse interactions with monitors. Measured increases in patient census, nurse staffing, and data input from medical devices from before to after the intervention substantially affected project results. Alarm frequencies proved an unreliable measure of nurse skills and practices in alarm customization. Documented changes in context factors provided strong anecdotal evidence of changed circumstances that clarified project results and underscored the critical importance of contemporaneous collection of context data. Designs and methods used in quality improvement projects must include reliable outcome measures to achieve meaningful results.

Determinants of 30-day mortality in elderly patients admitted to a cardiovascular surgery intensive care unit.

This study aims to identify the factors influencing 30-day morbidity and mortality in patients aged 65 and older undergoing cardiovascular surgery. Data from 360 patients who underwent cardiac surgery between January 2012 and August 2021 in the Cardiovascular Surgery Intensive Care Unit (CVS ICU) were analyzed. Patients were categorized into two groups: "mortality+" (33 patients) and "mortality-" (327 patients). Factors influencing mortality, including preoperative, intraoperative, and postoperative risk factors, complications, and outcomes, were assessed. Significant differences were observed between the two groups in factors affecting mortality, including extubation time, ICU stay duration, blood transfusion, surgical reexploration, aortic clamp duration, glomerular filtration rate (GFR), blood urea nitrogen (BUN), creatinine, hemoglobin A1c (HbA1c) levels, and the lowest systolic blood pressure during the first 24 hours in the ICU (p<0.05). The "mortality+" group had longer extubation times and ICU stays, required more blood transfusions, and had higher BUN-creatinine ratios, but lower systolic blood pressures, GFR, and HbA1c levels. Mortality was also higher in patients needing noradrenaline infusions and those who underwent reoperation for bleeding (p<0.05). By optimizing preoperative renal function, minimizing extubation time, shortening ICU stays, and carefully managing blood transfusions, surgical reexplorations, aortic clamp duration, and HbA1c levels, we believe that the mortality rate can be reduced in elderly patients. Key strategies include shortening aortic clamp times, reducing perioperative blood transfusions, and ensuring effective bleeding control.

Analysis of the Training Needs of Nurses Working in a Cardiovascular Surgery Intensive Care Unit

Analysis of the Training Needs of Nurses Working in a Cardiovascular Surgery Intensive Care Unit

Determination of the cost of prolonged hospitalization in cardiovascular surgery intensive care unit to the institution

In the provision of health services, health institutions should be perceived as an enterprise to use limited resources most effectively and efficiently, evaluate them optimally and ensure production efficiency. Therefore, cost information enables the most efficient utilization of resources in hospital enterprises and allows managers to use decision-making mechanisms most accurately. This study was conducted to determine and compare the costs of prolonged hospitalizations in the cardiovascular surgery intensive care unit of a university hospital. Our study was descriptive and retrospective. The hospitalizations in the cardiovascular surgery intensive care unit of the hospital were analyzed according to the prolonged hospitalization criteria determined by the social security institution. 29 extended hospitalization patient bills were determined in three years. The mean age of the prolonged hospitalization of patients was 67 years, the duration of hospitalization was 680 days, and the mean hospitalization day was 18.64. The items with the highest expenditure in prolonged hospitalization of patients were determined as drug costs, general applications and intervention costs, medical consumables costs, and laboratory costs. The increase in costs during the hospitalization and treatment process is mainly due to medication, general practices, interventions, and medical consumables. Related decision-makers should make root-cause analyses, and plans should be made to reduce costs.

Application of health failure mode and effect analysis for the airbag pressure management of patients with artificial airways

To analyze the application effect of health failure mode and effect analysis (HFMEA) model in patients with artificial airways in the cardiovascular surgery intensive care unit (CSICU) by establishing a HFMEA project team, and to develop targeted improvement measures and processes. The patients undergoing cardiovascular surgeries and with established artificial airways in the Shandong Provincial Hospital Affiliated to Shandong First Medical University were recruited from October 2021 to March 2022. The enrolled patients were divided into the conventional management group and the HFMEA model management group according to random number table method. The conventional management group applied the conventional procedures for monitoring the air bag pressure. The HFMEA model management group used the HFMEA model to implement and improve the airbag pressure monitoring process. The efficacy of HFMEA was assessed by comparing the incidence of ventilator-associated pneumonia (VAP), the pass rate of airbag pressure monitoring, the duration of endotracheal intubation and the length of CSICU stay between two groups. The practicability of HFMEA model was evaluated by analyzing the theoretical assessment scores and practical skill scores of nurses and their satisfaction scores with HFMEA. Compared with the conventional management group, the patients in the HFMEA mode management group had a significantly higher rate of passing airbag pressure monitoring [94.99% (2 994/3 152) vs. 69.97% (1 626/2 324), P < 0.01], shorter duration of endotracheal intubation and length of CSICU stay [duration of endotracheal intubation (hours): 6 (7, 12) vs. 6 (8, 13), length of CSICU stay (hours): 40 (45, 65) vs. 41 (46, 85), both P < 0.05], but the incidences of VAP between the two groups were similar. The theoretical assessment scores and practical skill scores of nurses were significantly higher (theoretical assessment score: 44.47±2.72 vs. 37.59±6.56, practical skill score: 44.56±2.66 vs. 40.03±4.32, total score: 89.03±3.07 vs. 77.63±9.56, all P < 0.05) in the HFMEA mode management group. And the satisfaction scores with airbag pressure management were also significantly higher in the HFMEA mode management group (7.72±1.11 vs. 6.44±1.32, P < 0.05). The application of the HFMEA can improve the airbag pressure measures and standardize the monitoring procedures in patients with artificial airways, and reduce the risk of clinical nursing. It is safe and effective for patients with invasive mechanical ventilation in the CSICU.

Brain Death and Its Effect on Organ Donation: A 10-Year Analysis

Objective :Brain death can be defined as the irreversible loss of brain functions. It is evident that a delay occurred in the diagnosis of brain death will result in the loss of many cadaveric organs and thus, the number of patients waiting for organ transplantation will increase. Despite there being many studies in the literature about the diagnosis and difficulties of brain death, family interviews, and organ donation, the studies regarding the effects of the regulation change in Turkey on organ donation are limited. The present study includes 10-year retrospective data and it has been conducted to offer an insight to the scientists about the diagnosis of brain death and organ donation.&#x0D; Method: The study was conducted by using data obtained from the examination of the retrospective files of patients diagnosed with brain death between 2011 and 2021 at Pamukkale University, Faculty of Medicine after obtaining the approval of the ethics committee.&#x0D; Results: After the study was initiated, the files of 71 patients diagnosed with brain death between 2011 and 2021, were accessed. Due to the missing information in the files of 4 patients, these patients were excluded from the study. Of 67 patients with registered brain death, 36 were male (53.7%) and 31 were female (46.2%). The age average was 49.07. When the treatment units of these patients were evaluated, 50 patients (74.6%) diagnosed with brain death were treated at the neurosurgery intensive care unit, 7 (10.4%) at the neurology intensive care unit, 6 (9%) at the anesthesia intensive care unit, and 4 (6%) at the cardiovascular surgery intensive care unit.&#x0D; Conclusions:The study concluded that the importance of the diagnosis duration of brain death and the number of specialists who diagnosed brain death in the previous years may have affected this process. It is clear that the formal process, which changed after 2014, showed an acceleration in diagnosis. The importance of the interviews with family members besides the brain death diagnosis has emerged as a result of the study

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%.&#x0D; 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.&#x0D; 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.&#x0D; 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.

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.

Nozocomial Infections in Patients Under 1 Year of Age Hospitalized in Pediatric Cardiology and Cardiovascular Surgery Intensive Care Unit

Nozocomial Infections in Patients Under 1 Year of Age Hospitalized in Pediatric Cardiology and Cardiovascular Surgery Intensive Care Unit

Determination of Environmental Stressors Perceived by Patients Treated in the Cardiovascular Surgery Intensive Care Unit

Determination of Environmental Stressors Perceived by Patients Treated in the Cardiovascular Surgery Intensive Care Unit

Infection profile of patients with extracorporeal membrane oxygenation in paediatric cardiac surgery ICU.

We investigated the risk of increased nosocomial infections and the associated pathogens in patients who underwent paediatric cardiovascular surgery and were put on extracorporeal membrane oxygenation support. We studied the duration of extracorporeal membrane oxygenation use and other variables that may be associated with increased nosocomial infection risk. Patients who were treated with an extracorporeal membrane oxygenation in paediatric cardiovascular surgery ICU between 2010 and 2020 were included in this retrospective study. We analysed the site of infection and microbiological profile of infections occurring in these patients according to CDC and National Healthcare Safety Network criteria. The onset of infection development in patients after extracorporeal membrane oxygenation was found to be median 8 (3-15, 25-75 IQR) days in the whole group, and median 11 (3-16, 25-75 IQR) days in those who developed infection without being put on extracorporeal membrane oxygenation. When patients were divided into those with and without infection, duration of ICU was found to be 19 (16-28, IQR 25-75) days in patients with infection vs. 8 (2-16, IQR 25-75; p: <0.001) days in patients without infection. Duration of extracorporeal membrane oxygenation support was found to be 14 (10-25, IQR 25-75) days in patients with infection versus 5 (2-10, IQR 25-75; p: <0.001) days in patients without infection and total hospital stay was 26 (18-33, IQR 25-75) days in patients with infection versus 8 (2-23, IQR 25-75) days in those without infection. A total of 24 patients out of the 70 patients experienced 32 infectious episodes during extracorporeal membrane oxygenation support. Culture-positive infections were detected at a single site in 19 patients, and multiple sites in 5 patients. We propose that prolonged extracorporeal membrane oxygenation support is associated with an increased risk of infection. Although extracorporeal membrane oxygenation is a life-saving treatment method, prolonged extracorporeal membrane oxygenation may increase the development of infectious complications and the associated mortality and morbidity of the patient.

A 5-year analysis of Candida bloodstream infections in the paediatric cardiovascular surgery ICU of a tertiary care centre.

Candida infections have become one of the most common causes of morbidity and mortality in paediatric ICUs, especially following complex surgeries, all over the world. Therefore, we conducted a 5-year analysis of Candida bloodstream infections in our tertiary paediatric cardiovascular surgery ICU. One thousand nine hundred and thirty four children, 0-16-year-old, who underwent paediatric cardiovascular surgery between January 2016-June 2021 were enrolled in this retrospective study. Blood cultures obtained from 1056 patients, who needed mechanical ventilation and indwelling devices longer than 5 days and had the signs of infection according to Center for Disease Control criteria, were evaluated. The isolated pathogens were recorded. 137 with Candida bloodstream infections were reanalysed for their age, weight, cardiac pathologies, duration of mechanical ventilation, hospitalisation and antibiotic use. One hundred and thirty-seven out of one thousand and fifty six patients (12.9%) had Candida growth in their blood cultures. C. albicans (n: 50, 36.5%), C. parapsilosis (n: 20, 14.6%), C. tropicalis (n: 8, 5.8%), C. glabrata (n: 5, 3.7%), and other non-albicans Candida species (n: 54, 39.4%) were isolated. The patients with Candida bloodstream infections had lower age, longer duration of mechanical ventilation, longer length of hospital stay and antibiotic use (p-values<0.05). They had cardiac pathologies as atrioventricular septal defect (18.9%), transposition of great arteries (17.6%), tetralogy of Fallot (12.4%), transposition of great arteries + double outlet right ventricle, or total anomalous pulmonary venous return + atrioventricular septal defect (37.9%), and others. The Candida bloodstream infections mortality was 11.6% (16/137). The most common cause of Candida bloodstream infections in the last five years in our paediatric cardiovascular surgery ICU was non-albicans Candida species. Prolonged mechanical ventilation, hospitalisation and antibiotic use, low age, and weight were found as the main risk factors that raise the morbidity and mortality rates of Candida bloodstream infections.

Predicting the Response of Hydroxocobalamin in Postoperative Vasoplegia in Recipients of Cardiopulmonary Bypass

The primary aim of this study was to identify predictors of response to hydroxocobalamin. A retrospective cohort study. A single large academic medical center within the cardiovascular surgery intensive care unit. Postoperative cardiovascular surgery patients within 96 hours of cardiopulmonary bypass separation between May 7, 2018, and August 1, 2020. None. Of the 66 administrations, 43 administrations yielded hemodynamic improvements (65.2%). Comparing responders to nonresponders, nonresponders had a greater median cardiopulmonary bypass duration (223 v 131 minutes; p < 0.001) and a prolonged median cross-clamp time (153 v 77 minutes; p=0.014). Multivariate modeling demonstrated a reduction in the odds of being a responder by 57% for every 60 minutes of cardiopulmonary bypass duration (odds ratio, 0.43; 95% confidence interval, 0.28-0.68; p < 0.001), but there was no significant difference based on time from intensive care unit admission to hydroxocobalamin administration (odds ratio, 0.95; 95% confidence interval, 0.88-1.03; p=0.20). Shorter total bypass duration and more rapid utilization after bypass of hydroxocobalamin were associated with a higher likelihood of response to refractory vasoplegic shock.

Our clinical approach in the prevention of blood flow infection in pediatric cardiovascular surgery intensive care unit

Our clinical approach in the prevention of blood flow infection in pediatric cardiovascular surgery intensive care unit

Yoğun Bakım Ünitesi Mobilizasyon Ölçeğinin Türkçeye Uyarlama, Geçerlik ve Güvenirlik Çalışması: Metadolojik Çalışma

Objective: The aim of this study was to adapt the Intensive Care Units (ICU)-Mobility Scale which evaluates and classifies the mobilization status of ICU patients into Turkish. Material and Methods: A methodological and cross-sectional study design was used. This study was conducted in different types of ICU (Anesthesia ICU, Internal Medicine ICU, Neurology ICU, Coronary ICU, Cardiovascular Surgery ICU, and Neurosurgery ICU) of an Education and Research Hospital in İstanbul between June and August 2019 with a hundred patients receiving treatment. Data were collected using a questionnaire developed by the researchers and the ICU-Mobility Scale. For the validity of the scale, the language validity was tested. In order to determine its reliability, kappa inter-observer compliance analysis was performed. Results: Patients hospitalized in medical (65%) and surgical (35%) ICUs were involved in the study. Of the patients, 51% were female and 49% were male. The average age of the patients is 69.65±16.33 years. The language validity of the scale was ensured with World Health Organization's methods for the translation and adaptation of instruments developed in different languages. As a result of the kappa observer agreement, 0.846 (p˂0.001) was found to be high in reliability. The ICU-Mobility Scale was found to be valid and reliable in this study. Conclusion: Classification of types of mobilization is important in order to overcome barriers and standardize protocols that can be carried out. The ICU-Mobility Scale may be used to standardize and record the patients' mobility status in the ICU.

Impact of Bedside Re-Explorations in a Cardiovascular Surgery Intensive Care Unit Led by Surgeons.

Surgical re-explorations represent 3–5% of all cardiac surgery. Concerns regarding mortality and major morbidity of re-explorations in the intensive care unit (ICU) setting exist. We sought to investigate whether they may have different outcomes compared with those performed in the operating room (OR). Single center retrospective review of patients who underwent mediastinal re-exploration in the ICU or in the OR after cardiac surgery. Mediastinal re-explorations were also classified as: “planned” and “unplanned”. Primary outcome was 30-day mortality, secondary outcomes include deep sternal wound infection (DSWI), sepsis, ICU and hospital length of stay, prolonged intubation (>72 h), tracheostomy, pneumonia, acute kidney injury requiring dialysis and stroke. Between 2010 and 2019, 195 of 7263 patients (2.7%) underwent mediastinal re-exploration after cardiac surgery. More patients in the ICU group experienced two or more re-explorations (30.3% vs. 2.3%, p < 0.001), a higher incidence of postoperative pneumonia (22% vs. 7%, p = 0.004), prolonged intubation (46.8% vs. 19.8%, p < 0.001) and longer hospital stay (30.3 ± 34.2 vs. 20.8 ± 18.3 days, p = 0.014). There were no differences in mortality between ICU and OR (16.5% vs. 13.9%, p = 0.24) nor in sepsis (14.7% vs. 7%, p = 0.91) and DSWI rates (1.8% vs. 1.2%, p = 0.14). Re-explorations in the ICU were not associated with increased mortality, sepsis and mediastinitis rate.

Healthcare-associated Infections in Pediatric Cardiovascular Surgery Intensive Care Unit Between 2016-2020

Introduction: Healthcare-associated infections are the most common problem in intensive care unit world- wide. Children with congenital heart diseases have many complications such as developmental problems, respiratory tract infections, endocarditis, pneumonia and after long-term hospital and intensive care stays and surgeries patients become vulnerable to healthcare-associated infections. Patients and Methods: The study presents the frequency of infection, microorganisms in patients hospital- ized at Kartal Koşuyolu High Specialization Training and Research Hospital Pediatric Cardiovascular Surgery Intensive Care Unit between 2016-2020. Results: One hundred-eight healthcare-associated infections episodes were seen in 83 of 1920 patients hos- pitalized in Pediatric Cardiovascular Surgery Intensive Care Unit between 2016-2020. Healthcare-associated infections rates varied between 4.8% and 7.77% over the years. In the 5-year period, a total of 118 micro- organisms were detected. Among all microorganisms, Candida species (n= 43, 36.4%) ranked first. Central line-associated bloodstream infections 53 (49%), ventilator-associated pneumonia 40 (37%), surgical site in- fection 8 (6.5%), catheter-associated urinary tract infection 7 (6%). Conclusion: Healthcare-associated infections requires special attention in pediatric cardiovascular intensive care units. In order to prevent, innovations such as bundle applications should be implemented as well as personnel training.

The Effect of a Multifaceted Family Participation Program in an Adult Cardiovascular Surgery ICU.

To develop and implement a patient- and family-centered care program for patients in a cardiovascular surgery ICU. Prospective, pre- and postintervention evaluations were conducted. The cardiovascular surgery ICU was located in a tertiary hospital. Participants included 56 family members of patients in cardiovascular surgery ICU between May and July 2019. Providing personalized treatment plans for patients by: 1) providing an ICU diary, 2) communicating with the medical staff, 3) providing personal care using ICU visitation kit, and 4) guiding bedside range of motion exercises. The experimental group received a guided ICU diary and education program from a nurse, including the application of a family participation visitation program. Family members were provided with customized information from the ICU diary and communicated with the medical staff for approximately 10 minutes. Family members were instructed on how to perform personal care using an "ICU visitation kit" during visitation hours when permitted to participate in bedside activities for approximately 10-minute intervals. Scores for satisfaction with the provided care and information increased significantly for the experimental group compared with the control group (t = 8.62; p < 0.001). Anxiety levels decreased significantly after intervention in both groups (t = -7.05; p < 0.001 and t = -12.94; p < 0.001) with a significant association observed between group and time point (F = 20.50; p < 0.001). However, no significant change was observed in satisfaction with decision-making following intervention in either group, and no significant association was noted between groups and time points for this variable (F = 0.24; p = 0.626). This set of implemented family participation processes significantly improved satisfaction and reduced anxiety in family members of critically ill patients.