Cardiovascular Surgical Intensive Care Unit Research Articles

The role of serum magnesium in the prediction of acute kidney injury after total aortic arch replacement: A prospective observational study.

Considerable morbidity and death are associated with acute kidney damage (AKI) following total aortic arch replacement (TAAR). The relationship between AKI following TAAR and serum magnesium levels remains unknown. The intention of this research was to access the predictive value of serum magnesium levels on admission to the Cardiovascular Surgical Intensive Care Unit (CSICU) for AKI in patients receiving TAAR. From May 2018 to January 2020, a prospective, observational study was performed in the Guangdong Provincial People's Hospital CSICU. Patients accepting TAAR admitted to the CSICU were studied. The Kidney Disease: Improving Global Outcomes (KDIGO) definition of serum creatinine was used to define AKI, and KDIGO stages two or three were used to characterize severe AKI. Multivariable logistic regression and area under the curve receiver-operator characteristic curve (AUC-ROC) analysis were conducted to assess the predictive capability of the serum magnesium for AKI detection. Finally, the prediction model for AKI was established and internally validated. Of the 396 enrolled patients, AKI occurred in 315 (79.5%) patients, including 154 (38.8%) patients with severe AKI. Serum magnesium levels were independently related to the postoperative AKI and severe AKI (both, P < 0.001), and AUC-ROCs for predicting AKI and severe AKI were 0.707 and 0.695, respectively. Across increasing quartiles of serum magnesium, the multivariable-adjusted odds ratios (95% confidence intervals) of postoperative AKI were 1.00 (reference), 1.04 (0.50-2.82), 1.20 (0.56-2.56), and 6.19 (2.02-23.91) (P for Trend < 0.001). When serum magnesium was included to a baseline model with established risk factors, AUC-ROC (0.833 vs 0.808, P = 0.050), reclassification (P < 0.001), and discrimination (P = 0.002) were further improved. Serum magnesium levels on admission are an independent predictor of AKI. In TAAR patients, elevated serum magnesium levels were linked to an increased risk of AKI. In addition, the established risk factor model for AKI can be considerably improved by the addition of serum magnesium in TAAR patients hospitalized in the CSICU.

Agreement of continuous non-invasive arterial blood pressure monitoring (CNAP) and pulmonary artery catheter thermodilution method in estimating the hemodynamic parameters of post CABG patients

Abstract Background The use of hemodynamic parameters in monitoring patients after coronary artery bypass surgery is an essential element of clinical practice. It helps intensivist and physicians to properly manage patients after surgery where hemodynamic parameters are usually dynamic and complicated. Pulmonary artery guided thermodilution (PACT) has been the gold standard in assessing the adequacy of cardiac output, however, its invasive nature is also associated with more complex procedures and the risk of complications, including infections. With the emergence of new non-invasive hemodynamic monitoring devices such as the CNAP (continuous non-invasive arterial pressure), alternative methods for hemodynamic monitoring is now possible. Compared to invasive methods, it is easier to use with an error-free application, safer, less risk of infection and more cost effective. Purpose To determine the agreement of Continuous non-invasive arterial pressure (CNAP) and pulmonary artery guided thermodilution in monitoring the hemodynamic parameters of patients who underwent coronary artery bypass graft surgery. Methods This is a cross-sectional study conducted at the cardiovascular surgical intensive care unit and included 63 patients with Coronary artery disease who underwent elective coronary artery bypass graft surgery. Cardiac output, Cardiac Index, Stroke volume and Systemic vascular resistance were simultaneously obtained using both the CNAP and PACT. Three consecutive sets of measurements were recorded for each patient with a 3 hour interval; during arrival at the ICU, 3 hours post op, and 6 hours post op. Results The mean difference between PACT-CO and CNAP-CO was -0.81 L/min (SD -1.18 to -0.44) with a 95% limits of agreement of -3.74 to 2.11 L/min on the 0 hour, -0.81L/min (SD -1.22 to -0.41) with a 95% limits of agreement of -1.98 to 1.18 L/min on the 3rd hour, and -0.77L/min (SD -1.08 to -0.46) with a 95% limits of agreement of -3.22 to 1.68 L/min on the 6th hour post op. The results showed a significant difference between the PACT and CNAP. However, a positive correlation was noted between PACT-CO and CNAP-CO, the correlation coefficient on the 0, 3rd and 6th hour were 0.5384, 0.5158, and 0.6265 respectively. Conclusion CNAP derived hemodynamic parameters had a high mean difference compared to the PACT and there was no agreement between the two methods. However, it was able to have a positive correlation with the PACT, making it possible for the CNAP to track the hemodynamic changes during the post operative course.

Practice patterns in extracorporeal life support in tertiary cardiac intensive care units in north america: a survey-based analysis from the critical care cardiology trials network

Abstract Funding Acknowledgements Type of funding sources: None. Background The use of veno-arterial (VA) and veno-venous (VV) extracorporeal membrane oxygenation (ECMO) has significantly increased in the last decade. However, there is substantial variability in practice patterns between institutions. To date, the optimal ECMO program model is unclear and possible differences between ECMO centers in staffing, organization and team structure have been poorly characterized. Purpose Our aim was to describe contemporary practices of care for patients undergoing ECMO in tertiary cardiac centers in North America. Methods An 11-question anonymous survey was sent to all participating sites in the Critical Care Cardiology Trials Network (CCCTN), a prospective registry of advanced cardiac intensive care units (CICUs) in North America, coordinated by the TIMI Study Group. The survey evaluated ECMO staffing models, decision-making processes, cannulation and longitudinal care. Results The response rate was 100% (39/39) across CCCTN centers. The decision to proceed with VA ECMO was made as a team in 79% of the cases and in 58.3% of the VV ECMO cases, rather than by an individual specialty. An ECMO consult service was used in 67% of the centers, and integrated with the cardiogenic shock team in 58%. The most common specialty participating in the ECMO service was cardiothoracic surgery (CTS) (73.1%), followed by heart failure specialists (38.5%), with critical care cardiology (CCC) in only 23.1% of the centers (Figure 1A). In the majority of centers, VA ECMO cannulation was performed by CTS alone (46.2%), Interventional cardiology (IC) and CTS (38.5%), and IC alone (7.7%, Figure 1B). Cannulation for VA ECMO was not performed by intensivists at any center. VV ECMO cannulations were performed by CTS in 51.3%, intensivists in 17.9% and IC in 2.6% of the centers. VA ECMO patients were admitted to the cardiovascular surgical intensive care unit in 64.1% of centers, with 20.5 % admitted to the CICU (Figure 1C). VV ECMO patients were admitted to the cardiovascular surgical intensive care unit in 36.8% of sites, and the medical intensive care unit in 34.2%. The most common ECMO specialist model was having a perfusionist at the bedside, followed by nurse specialist (Figure 1D). Specialty services consulted within 24-48 hours of cannulation included physical therapy in 48.7%, palliative care in 30.8%, and bioethics in only 2.6% of centers. Simulation-based ECMO training is performed in 59% of the centers. Half (51.3%) of the centers perform ECPR, while 17.9% reported plans of developing a program. Conclusions Although there is significant variability in ECMO cannulation, location of care, staffing practices in advanced CICUs in North America, a multidisciplinary team approach is common in ECMO centers, with early involvement of physical therapy and palliative care specialists. Further research to establish the optimal model for ECMO programs is of high importance.

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.

In-Hospital Mortality Among Critically Ill Patients With Atrial Fibrillation (AF) Versus Patients Without AF

IntroductionAtrial fibrillation (AF) is one of the most frequent arrhythmias observed in the intensive care unit (ICU). The present study assessed AF as an independent risk factor for mortality among patients in the ICU setting.MethodologyA prospective cohort study was conducted at the medical ICU in a tertiary academic medical center from September 2020 to January 2021. All critically ill patients, irrespective of gender, who were admitted for at least two days in the ICU were eligible to partake in the study. Individuals in the cardiovascular surgical ICU and the trauma ICU were not eligible. Demographics, clinical history, the occurrence of AF, fluid input and output, echocardiography, drug history, and hospital mortality were recorded during the first week of admission. Patients were divided into two groups.ResultsPatients with AF had significantly higher in-hospital mortality, 27 (73%), and longer hospital stays (11.61 ± 7.01) as compared to patients who did not suffer from AF (p<0.0001). The mean length of stay in ICU was 10.32 ± 5.92 and the duration of mechanical ventilation was 7.05 ± 6.16 days in the AF group which was significantly higher than patients who did not have AF (p<0.0001). No significant difference was found in mortality rate between new-onset and recurrent AF among the patients; albeit the latter was higher (60% vs 81.8%, p=0.142).ConclusionThe present study indicated that AF was a predictor of mortality hence, associated with poor patient prognosis. The occurrence of AF was associated with high in-hospital mortality and longer hospital stay. Further large-scale studies should be conducted to explore other socio-demographic and clinical risk factors.

Pressure Injury Prevention for Complex Cardiovascular Patients in the Operating Room and Intensive Care Unit: A Quality Improvement Project.

PURPOSE:The purpose of our project was to examine the effect of an alternating pressure (AP) overlay on hospital-acquired pressure injury (HAPI) in high-risk cardiovascular surgical patients.PARTICIPANTS AND SETTING:This quality improvement (QI) initiative was conducted in a core group of 8 cardiovascular operating room (OR) suites and 1 cardiovascular surgical critical intensive care unit (ICU) in a large Indiana-based academic hospital. The sample comprised adult patients who underwent complex cardiovascular surgical procedures and those in the cardiovascular surgical ICU with extracorporeal membrane oxygenation (ECMO), ventricular assistive device (VAD), and undergoing heart and/or lung transplant, or open chest procedures.APPROACH:The AP overlay was placed on OR cardiovascular foam surfaces and on selected ICU support surfaces for patients who met inclusion criteria. We used a pre/postcomparative QI design to assess outcomes including OR-related HAPI rates, ICU aggregate unit HAPI data, related costs, and staff satisfaction during the 3-month project period.OUTCOMES:Operating room-related HAPIs were reduced from 8/71 (11%) preintervention to 0/147 (0%) postintervention (P = .008), resulting in a cost avoidance of $323,048 and positive staff satisfaction (mean = 3.85; 1- to 4-point Likert scale). No adverse outcomes occurred. Although not significant, ICU HAPI rates decreased from 10 to 7 pre/postintervention (P = .29), demonstrating a 14% HAPI reduction with a cost avoidance of $121,143. The ICU incidence density decreased from 3.57 to 3.24; however, there was no decrease in ICU monthly unit prevalence. Critical care staff satisfaction was positive (mean = 2.95; 1- to 4-point Likert scale) with most staff members preferring the AP overlay to a fluid immersion surface. A cost savings of 48% (AP overlay vs fluid immersion rental) was identified in the ICU.IMPLICATIONS FOR PRACTICE:We achieved fewer HAPIs and reduced costs and observed positive staff satisfaction, along with no adverse events with the use of the AP overlay. Further research is needed to determine the safety and efficacy of this device for this pressure injury prevention option for immobile patients in both the OR and the ICU.

Risk factors associated with longer stays in cardiovascular surgical intensive care unit after CABG

Monitoring ICU length of stay (LOS) after CABG and examining its risk factors can guide initiatives on the improvement of care. But few have evaluated this issue to include personal and clinical factors, and demands of ICU care. This study applied Donabedian model to identify risk factors for longer ICU stays after CABG. Lifestyle, clinical factors during and after CABG, TISS were viewed as structure factors, and infection and organ failures during ICU did as process factors. This retrospective cohort study used data via medical records at a medical center. A stratified randomized sample of 230 adults from a cohort of 690 isolated CABGs was to reflect the rate of 34.7% longer than 3-day-ICU LOS. The sample comprised of longer-stay group (n = 150) and shorter-stay group (n = 80). Hierarchical logistic regression analysis revealed that potential signs of infection (3-day average WBC higher than 10,000/μL, OR: 3.41 and the body temperature higher than 38 °C, OR:5.67) and acute renal failure (OR: 8.97) remained as the most significant predicted factors of stay longer than 3 ICU days. Along with higher TISS score within 24 hours (OR:1.06), structure factors of female gender (OR:4.16) smoking(OR: 4.87), higher CCI before surgery(OR:1.49), bypass during CABG (OR:3.51) had higher odds of risk to stay longer. Further quality improvement initiatives to shorten ICU stay after CABG may include the promotion of a smoking cessation program in clinical practice, and better management of the manpower allocation, infection control and renal failure.

Delirium in Cardiac and Cardiovascular Surgical Intensive Care Units.

Delirium is a common occurrence in cardiac and cardiovascular surgical intensive care units. Due to multiple confounding factors, this diagnosis remains challenging for medical professionals. Multiple theories exist regarding the pathophysiology of delirium, which include disruption of neurotransmitters as well as inflammation. Delirium has been associated with prolonged hospitalizations and an increase in mortality. Although there are widely used screening tools for delirium, none have been validated in this particular patient population. Limited treatments exist for delirium, so: both pharmacologic and nonpharmacologic preventative measures should be employed in this patient population.

Hospital acquired pressure injury prediction in surgical critical care patients

BackgroundHospital-acquired pressure injuries (HAPrIs) are areas of damage to the skin occurring among 5–10% of surgical intensive care unit (ICU) patients. HAPrIs are mostly preventable; however, prevention may require measures not feasible for every patient because of the cost or intensity of nursing care. Therefore, recommended standards of practice include HAPrI risk assessment at routine intervals. However, no HAPrI risk-prediction tools demonstrate adequate predictive validity in the ICU population. The purpose of the current study was to develop and compare models predicting HAPrIs among surgical ICU patients using electronic health record (EHR) data.MethodsIn this retrospective cohort study, we obtained data for patients admitted to the surgical ICU or cardiovascular surgical ICU between 2014 and 2018 via query of our institution's EHR. We developed predictive models utilizing three sets of variables: (1) variables obtained during routine care + the Braden Scale (a pressure-injury risk-assessment scale); (2) routine care only; and (3) a parsimonious set of five routine-care variables chosen based on availability from an EHR and data warehouse perspective. Aiming to select the best model for predicting HAPrIs, we split each data set into standard 80:20 train:test sets and applied five classification algorithms. We performed this process on each of the three data sets, evaluating model performance based on continuous performance on the receiver operating characteristic curve and the F1 score.ResultsAmong 5,101 patients included in analysis, 333 (6.5%) developed a HAPrI. F1 scores of the five classification algorithms proved to be a valuable evaluation metric for model performance considering the class imbalance. Models developed with the parsimonious data set had comparable F1 scores to those developed with the larger set of predictor variables.ConclusionsResults from this study show the feasibility of using EHR data for accurately predicting HAPrIs and that good performance can be found with a small group of easily accessible predictor variables. Future study is needed to test the models in an external sample.

Hospital-Acquired Pressure Injury Development Among Surgical Critical Care Patients Admitted With Community-Acquired Pressure Injury: A Retrospective Cohort Study.

Community-acquired pressure injuries (CAPIs) are present among approximately 3% to 8% of patients admitted to acute care hospitals. In the critical care population, little is known about hospital-acquired pressure injury (HAPI) development among patients with CAPIs because most studies exclude patients with CAPIs. The purpose of our study was to determine the incidence of HAPI development and the associated risk factors among surgical critical care patients with CAPIs. Retrospective cohort study. We used electronic health record data from adult critical care patients admitted to the surgical and cardiovascular surgical intensive care units (ICUs) at a level 1 trauma center and academic medical center between 2014 and 2018. Univariate analysis was used to compare patients with CAPIs who developed a HAPI and those who did not, as well as logistic regression analysis to identify independent risk factors for HAPIs among patients with CAPIs. Among 5101 patients admitted to 2 surgical critical care units, 167 (3%) patients were admitted with CAPIs. Hospital-acquired pressure injuries were 4 times more common among patients with CAPIs compared to patients without CAPIs. Among the 167 patients with CAPIs, 47 patients (28%) went on to also develop a HAPI, whereas in the 4934 patients without CAPIs, 352 patients (7%) went on to develop a HAPI. Findings from the multivariate logistic regression analysis (n = 151) showed that decreased serum albumin (odds ratio [OR] = 0.47; 95% confidence interval [CI], 0.25-0.85; P = .02) and excessively dry skin (OR = 2.6; 95% CI, 1.1-6.22; P = .03) were independent predictors of HAPI development among patients admitted with CAPIs. Results from our study show that patients with CAPIs are at high risk for developing a HAPI, particularly among patients with decreased serum albumin or excessively dry skin. Patients with excessively dry skin may benefit from the application of skin moisturizers.

Safe Ambulation of Critically Ill Cardiac Patients With Femoral Balloon Pumps: A Case Cohort Study

We sought to demonstrate the safety of ambulation of patients with intra-aortic balloon pumps (IABPs) inserted via the femoral approach in the setting of 1 cardiovascular surgical intensive care unit and 1 cardiac care unit. We studied 70 patients who had received femoral IABPs at our institution between December 2015 and June 2019 and who met standardized criteria for ambulation. These patients underwent initial standing trials with a specialty standing bed/tilt table and progressed to standing exercises and, ultimately, to ambulation (defined as covering a distance of at least 10 feet) with the physical therapist. A total of 323 sessions of ambulation were successfully performed in 70 patients with IABPs inserted via the femoral approach, for an average of 4.61 sessions per patient. The average ambulation session time was 45 minutes (3-62 minutes, covering a median distance of 420 ft [805 IQR]). Complications were defined as major or minor and were monitored for during and after ambulation. Major complications included limb ischemia, arterial dissection, aortic aneurysm, balloon rupture, significant hemodynamic compromise, and death. Minor complications included balloon migration, infection, paresthesia, changes in balloon augmentation, and hematoma at insertion site. No major complications were associated with ambulation, and only 11 minor complications were observed. The total complication rate was 3.40% for all ambulation sessions. Ambulation of selected patients with femoral IABPs appears to be a safe activity when using the enclosed protocol and selection process. Future studies are required to show that such activities decrease muscle deconditioning in these patients and enhance recovery.

Severe Impairment of Microcirculatory Perfused Vessel Density Is Associated With Postoperative Lactate and Acute Organ Injury After Cardiac Surgery

Resuscitation after cardiac surgery needs to address multiple pathophysiological processes that are associated with significant morbidity and mortality. Functional microcirculatory derangements despite normal systemic hemodynamics have been previously described but must be tied to clinical outcomes. The authors hypothesized that microcirculatory dysfunction after cardiac surgery would include impaired capillary blood flow and impaired diffusive capacity and that subjects with the lowest quartile of perfused vessel density would have an increased postoperative lactate level and acute organ injury scores. Prospective, observational study. A single, tertiary university cardiovascular surgical intensive care unit. 25 adults undergoing elective cardiac surgery requiring cardiopulmonary bypass. Sublingual microcirculation was imaged using incident dark field microscopy before and 2 to 4 hours after surgery in the intensive care unit. Compared with baseline measurements, postoperative vessel-by-vessel microvascular flow index (2.9 [2.8-2.9] v 2.5 [2.4-2.7], p < 0.0001) and perfused vessel density were significantly impaired (20.7 [19.3-22.9] v 16.3 [12.8-17.9], p < 0.0001). The lowest quartile of perfused vessel density (<12.8 mm/mm2) was associated with a significantly increased postoperative lactate level (6.0 ± 2.9 v 1.8 ± 1.2, p < 0.05), peak lactate level (7.6 ± 2.8 v 2.8 ± 1.5, p = 0.03), and sequential organ failure assessment (SOFA) score at 24 and 48 hours. In patients undergoing cardiac surgery, there was a significant decrease in postoperative microcirculatory convective blood flow and diffusive capacity during early postoperative resuscitation. Severely impaired perfused vessel density, represented by the lowest quartile of distribution, is significantly related to hyperlactatemia and early organ injury.

Diagnostic Performance of Cyclophilin A in Cardiac Surgery-Associated Acute Kidney Injury.

Acute kidney injury (AKI) is associated with increased morbidity and mortality and is frequently encountered in cardiovascular surgical intensive care units (CVS-ICU). In this study, we aimed at investigating the utility of cyclophilin A (CypA) for the early detection of postoperative AKI in patients undergoing cardiac surgery. This was a prospective observational study conducted in a CVS-ICU of a tertiary care university hospital. All prospective clinical and laboratory data were evaluated as predictors of AKI. Serum and urine CypA, as well as urine neutrophil gelatinase-associated lipocalin (uNGAL), were examined within 6 h after cardiac surgery. The discriminative power for the prediction of AKI was evaluated using the area under the receiver operator characteristic curve (AUROC). We found that both serum CypA and urine CypA were significantly higher in the AKI group than in the non-AKI group. For discriminating AKI and dialysis-requiring AKI, serum CypA demonstrated acceptable AUROC values (0.689 and 0.738, respectively). The discrimination ability of urine CypA for predicting AKI was modest, but it was acceptable for predicting dialysis-requiring AKI (AUROC = 0.762). uNGAL best predicted the development of AKI, but its sensitivity was not good. A combination of serum CypA and uNGAL enhanced the overall performance for predicting the future development of AKI and dialysis-requiring AKI. Our results suggest that CypA is suitable as a biomarker for the early detection of postoperative AKI in CVS–ICU. However, it has better discriminating ability when combined with uNGAL for predicting AKI in CVS-ICU patients.

Prospective validation and refinement of the APPROACH cardiovascular surgical intensive care unit readmission score

PurposeThe APPROACH cardiovascular surgical intensive care unit (CVICU) readmission score has excellent discrimination and calibration for CVICU readmission after discharge to a surgical ward; however, it has not been prospectively validated. Material and methodsIn a prospective consecutive cohort of 805 patients ≥18 years admitted to the CVICU after coronary artery bypass and/or valvular surgery, the APPROACH CVICU readmission score was calculated at the time of discharge to a surgical ward. The study compared observed versus predicted CVICU readmission and the model discrimination was evaluated using AUC c-index. The incremental prognostic utility of 6 pre-specified prospectively collected respiratory (re-intubation, tracheostomy, oxygen at discharge) and hemodynamic variables (heart rate, systolic blood pressure, inotropes at discharge) were tested using net reclassification index (NRI) and integrated discrimination improvement (IDI). ResultsA total of 37 (4.6%) patients were readmitted to the CVICU. The median CVICU length of stay (9.0 vs 2.0 days, p < .001) and all-cause in-hospital mortality (8.1% vs 0.4%, p < .001) was higher among readmitted patients. The model had good discrimination (c-index = 0.748). Systolic blood pressure at discharge yielded the largest improvement in model discrimination (c-index = 0.782; Hosmer-Lemshow p = .749). ConclusionsIn a prospective validation cohort, the APPROACH CVICU readmission risk score had good discrimination and could be operationalized in future research and clinical practice.

Application of Unit-Level Cost Transparency, Education, Enhanced Audit, and Feedback of Anonymized Peer Ranking to Promote Judicious Use of 25% Albumin in Critical Care Units.

Objective: Hyperoncotic 25% albumin is widely used for fluid resuscitation in intensive care units. However, this practice remains controversial. By 2012 in our intensive care unit, annual 25% albumin expenditures had steadily increased to exceed $1 million. This prompted efforts to promote more judicious use. Design: Prospective time series cohort analysis using statistical process control charts. Setting: Seventy-six-bed quaternary level cardiovascular surgical intensive care unit (CVICU), organized into 6 adjacent units. Patients: Adult cardiac, thoracic, and vascular surgery patients admitted postoperatively to the CVICU during the study period. Interventions: Over 12 months starting March 2013, we sequentially implemented unit-level 25% albumin cost transparency, provider education, and individualized audit and feedback of anonymized peer ranking of albumin prescriptions. Measurements and Main Results: C control charts were used for analysis of monthly unit-level direct albumin costs for 20 months. Balance measures including red cell transfusions, number of diagnoses of pleural effusions, and length of stay were also tracked. Monthly average albumin expenditures had decreased 61% by December 2014, and there was no evidence of adverse changes in any of the balance measures. These reductions have been sustained. Conclusion: Sequential implementation of multimodal strategies can alter clinician practices to achieve substantial unit-level reduction in 25% albumin utilization without harm to patients.

Evaluation of the increase in invasive device associated infections in cardiovascular surgical intensive care unit.

Infections related to the use of invasive instruments leads to the risk of treatment difficulties, prolonged hospitalization, increased health care costs, and increased mortality and morbidity rates. The present study examines the results of an infection surveillance study that showed an increased incidence of infections related to the use of invasive instruments in the cardiovascular surgery intensive care unit of the Ankara Training and Research Hospital and mitigating measures were taken following the surveillance program. Compared with previous surveillance data, an increase was observed in the incidence of infections related to the use of invasive instruments in cardiovascular surgery intensive care unit (CVS-ICU) during the first six months of 2014. A research team was formed comprising one infectious diseases and microbiology specialist, one cardiovascular surgeon, and two infection-control nurses. Patient data was collected. The compliance of the surgeons, nurses, and other health care professionals to the infection control measures was evaluated. The rate of ventilator-associated pneumonia was 8.20% and the rate of catheter-associated urinary tract infection was 4.47% in the CVS-ICU. There were missing or inadvertent practices regarding antibiotic prophylaxis, asepsis and antisepsis and isolation measures in patient preparation and patient care before and after the operations. The rate of inappropriate antibiotic as prolonged use was 72%. It is one of the basic tasks to take appropriate measures to prevent outbreaks of hospital infections. It is possible to prevent an outbreak of hospital infections only by the accurate analysis of data and establishing strict infection control procedures.

DSV-79 - Reduction of Catheter Related Bloodstream Infections (CRBI) Rates After Implementation of 2% Gluconate-Chlorhexidine-Impregnated Wipes (CHG Wipes) Daily Bathing in a Cardiovascular Surgical Intensive Care Unit (CSICU)

DSV-79 - Reduction of Catheter Related Bloodstream Infections (CRBI) Rates After Implementation of 2% Gluconate-Chlorhexidine-Impregnated Wipes (CHG Wipes) Daily Bathing in a Cardiovascular Surgical Intensive Care Unit (CSICU)

Determination of the risk factors that will play a role in the pressure sore prevalence and the development of pressure sore in patients hospitalized in a chest cardiovascular surgical intensive care unit

Determination of the risk factors that will play a role in the pressure sore prevalence and the development of pressure sore in patients hospitalized in a chest cardiovascular surgical intensive care unit

Visible but wide QRS complexes are associated with false asystole alarms

Alarm fatigue in the ICU setting has been well documented in the literature. The ICU's high-intensity environment requires staff's vigilant attention, and distraction from false and non-actionable alarms pulls staff away from important tasks, creates dissatisfaction, and is a potential patient safety risk if alarms are missed or ignored. This project was intended to improve patient safety by optimizing alarm systems in a cardiovascular surgical intensive care unit (CVSICU). Specific aims were to examine nurses' attitudes toward clinical alarm signals, assess nurses' ability to discriminate audible alarm signals, and implement a bundled set of best practices for monitor alarm reduction without undermining patient safety.CVSICU nurses completed an alarm perception survey and participated in alarm discriminability testing. Nurse survey data and baseline monitor alarm data were used to select targeted alarm reduction interventions, which were progressively phased in. Monitor alarm data and cardiorespiratory event data were trended over one year.Five of the most frequent CVSICU monitor alarm types—pulse oximetry, heart rate, systolic and diastolic blood pressure, pulse oximetry sensor, and ventricular tachycardia > 2—were targeted. After implementation, there was a 61% reduction in average alarms per monitored bed and a downward trend in cardiorespiratory events.To reduce alarm fatigue it is important to decrease alarm burden through targeted interventions. Methods to reduce non-actionable alarms include adding short delays to allow alarm self-correction, adjusting default alarm threshold limits, providing alarm notification through a secondary device, and teaching staff to optimize alarm settings for individual patients.

Clinical Reasoning and Collaboration for Functional Mobility and Ambulation Under Multiple Conditions of Concurrent CentriMag Ventricular Assistive Devices: A Case Report

Background: The CentriMag Extracorporeal Blood Pumping System is an effective means of temporary ventricular support for patients acutely decompensating from cardiac shock. Out-of-bed activities are not currently recommended by the manufacturer, leaving patients functionally limited and restricted to the intensive care unit (ICU). Purpose: This report aims to describe progression of functional mobility and ambulation with CentriMag ventricular assist device (VAD) equipment using appropriate clinical reasoning and multidisciplinary collaboration. Methods: Functional mobility activities were initiated on the first physical therapy (PT) session and progressed throughout the length of stay and included sit–stand transfers, bed–chair transfers, standing activities, and ambulation. Outcomes: The patient remained in the cardiovascular surgical ICU for 30 days and received PT for 13 total treatment sessions with 4 different physical therapists without adverse events. Out-of-bed activities were performed during all 13 PT sessions and the average session duration was 49.8 minutes. Ambulation was documented on 9/13 sessions and on the days the patient ambulated, and the average distance was approximately 183 feet. The patient was seen on 7 occasions with biventricular assist device CentriMag devices and 6 occasions with the concurrent CentriMag right VAD–HeartMate II left VAD. Discussion: As the technology and scope of application for VADs continues to progress, it is imperative that the acute care PT understands the complexities, risks, and benefits of functional mobility in critically ill patients. Conclusion: This report suggests that mobilization with CentriMag devices is feasible, without adverse events, using appropriate clinical decision-making, and suggests that patients who ambulate under multiple conditions of CentriMag VADs may demonstrate functional improvements.