Critical Care Resuscitation Unit Research Articles

Association between measures of resuscitation in the critical care resuscitation unit and in-hospital mortality among patients with sepsis.

We hypothesized that lactate clearance and reduction of the Sequential Organ Failure Assessment (SOFA) score during patients' critical care resuscitation unit (CCRU) stay would be associated with lower in-hospital mortality. This was a retrospective study of adult patients who had sepsis diagnoses and were admitted to the CCRU in 2018. Multivariable logistic regression analysis was performed to assess the association of clinical factors, lactate clearance, and SOFA reduction with hospital mortality. A total of 401 patients with lactate clearance data and 455 patients with SOFA score data were included in the study. The mean (SD) lactate and SOFA score on admission were 2.2 (1.8) mmol/L and 4.4 (4.3), respectively. Average lactate clearance was 0.1 (2.6) mmol/L, and average SOFA score reduction was 0.65 (5.9). Patients with a one point reduction in SOFA score during their CCRU stay had a 31% reduction of mortality (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.62-0.77, p<0.001). SOFA score reduction was associated with lower hospital mortality for both surgical patients (OR 0.69, 95% CI 0.58-0.81, p<0.001) and non-surgical patients (OR 0.71 95% CI 0.06-0.83, p<0.001). SOFA score reduction, but not lactate clearance during the CCRU stay, was associated with lower odds of in-hospital mortality. These findings suggest that resuscitative efforts leading to an early improvement in SOFA score may benefit patients with sepsis.

Role of the Critical Care Resuscitation Unit in a Comprehensive Stroke Center: Operations for Mechanical Thrombectomy During the Pandemic.

Standard of care for patients with acute ischemic stroke from large vessel occlusion (AIS-LVO) includes prompt evaluation for urgent mechanical thrombectomy (MT) at a comprehensive stroke center (CSC). During the start of the coronavirus 2019 pandemic (COVID-19), there were reports about disruption to emergency department (ED) operations and delays in management of patients with AIS-LVO. In this study we investigate the outcome and operations for patients who were transferred from different EDs to an academic CSC's critical care resuscitation unit (CCRU), which specializes in expeditious transfer of time-sensitive disease. This was a pre-post retrospective study using prospectively collected clinical data from our CSC's stroke registry. Adult patients who were transferred from any ED to the CCRU and underwent MT were eligible. We compared time intervals in the pre-pandemic (PP) period between January 2018- February 2020, such as ED in-out and CCRU arrival-angiography, to those during the pandemic (DP) between March 2020-May 31, 2021. We used classification and regression tree (CART) analysis to identify which time intervals, besides clinical factors, were associated with good neurological outcome (90-day modified Rankin scale 0-2). We analyzed 203 patients: 135 (66.5%) in the PP group and 68 (33.5%) in the DP group. Time from ED triage to computed tomography (difference 7 minutes, 95% confidence interval [CI] -12 to -1, P < 0.01) for the DP group was statistically longer, but ED in-out was similar for both groups. Time from CCRU arrival to angiography (difference 9 minutes, 95% CI 4-13, P < 0.01) for the DP group was shorter. Forty-nine percent of the DP group achieved mRS ≤ 2 vs 32% for the PP group (difference -17%, 95% CI -0.32 to -0.03, P < 0.01). The CART identified initial National Institutes of Health Stroke Scale, age, ED in-and-out time, and CCRU arrival-to-angiography time as important predictors of good outcome. Overall, the care process in EDs and at this single CSC for patients requiring MT were not heavily affected by the pandemic, as certain time metrics during the pandemic were statistically shorter than pre-pandemic intervals. Time intervals such as ED in-and-out and CCRU arrival-to-angiography were important factors in achieving good neurologic outcomes. Further study is necessary to confirm our observation and improve operational efficiency in the future.

Rearranging the furniture: A blueprint for reappropriating fixed resources to create an emergency department resuscitative care unit.

Emergency department (ED) care teams face challenges in providing timely, high-quality care to critically ill patients because of competing patient care priorities and a multitude of system strains, including patient boarding. Patients who are boarding in the ED experience increased morbidity and mortality, and this is particularly true for those who are critically ill. Geography-based models for critical care delivery in the ED range from resuscitation bays to full-fledged ED intensive care units. Studies have shown that such models can improve patient survival without affecting cost. Here, we describe how we reappropriated limited fixed resources to create a critical care resuscitation unit in a busy, urban, academic ED. Our objective is to provide a blueprint for similar models, paying particular attention to operations, clinical care, education, and financial stability.

The Impact of the Critical Care Resuscitation Unit on Quaternary Care Accessibility for Rural Patients: A Comparative Analysis.

Previous research suggests that patients from rural areas who are critically ill with complex medical needs or require time-sensitive subspecialty interventions face worse healthcare outcomes and delays in care when compared to those from urban areas. The critical care resuscitation unit (CCRU) at our quaternary care center was established to expedite the transfer of critically ill patients or those who need time-sensitive intervention. This study investigates if disparities exist in treatments and outcomes among patients transferred to the CCRU from rural versus urban hospitals. This is a retrospective study of adult, nontrauma patients admitted to the CCRU via interhospital transfer from outside facilities from January 1 to December 31, 2018. Patients transferred from within our institution or with missing clinical data were excluded. Multivariable logistic regressions were performed to measure the association between patients' demographic and clinical factors with in-hospital mortality. We analyzed 1381 nontrauma patients, and 484 (35%) were from rural areas. Median age was 59 [47-69], and 629 (46%) were female. Median sequential organ failure assessment was 3 ([1-6], p=0.062) for both patients transferred from urban and rural hospitals. There was no significant difference between groups with respect to most demographic and clinical factors, as well as types of interventions after CCRU arrival, including emergent surgical interventions within 12 hours of arrival at the CCRU. Rural patients were more likely to be transferred for care by the acute care emergency surgery service than were patients from urban areas and were transferred over a significantly greater distance (difference of 53 kilometers (km), 95% CI: -58.9-51.7 km, P < 0.001). Transfer from rural areas was not associated with increased odds of in-hospital mortality (OR: 0.90, 95% CI: 0.60, 1.36; P=0.63). Thirty-five percent of patients transferred to the CCRU came from rural areas, which house 25% of the state population of Maryland. Patients transferred from rural counties to the CCRU faced greater transport distances, but they received the same level of care upon arrival at the CCRU and had the same odds of in-hospital mortality as patients transferred from urban hospitals.

Population characteristics, healthcare pathways and outcomes of patients with cirrhosis hospitalized with overt hepatic encephalopathy in France: A study of the French Hospital‐Discharge Database

Hepatic encephalopathy (HE) is a severe complication of cirrhosis, independently associated with a poor survival. The objectives of this study were to describe the prevalence of overt hepatic encephalopathy (OHE) requiring hospitalization, and the healthcare pathways and outcomes of patients hospitalized for OHE in France. Data from the French Hospital‐Discharge Database (Programme de Medicalisation des Systemes d'information, PMSI) within the 5-year period from 2014 to 2018 were analysed. Since the disease lacks a PMSI code in the ICD-10, an identification algorithm was developed. The analysis identified 57,191 patients with OHE including 48,566 patients (85 %) who had been hospitalized twice or more during the study period. Each year, an average of over 20,000 patients were hospitalized in France for OHE as the primary or secondary reason for hospitalization. Among these patients, between 11,500 and 13,500 had been hospitalized at least twice in that year with an average of 3.4 hospitalisations per year. 25 % of admissions occurred following consultation at the emergency unit. Among hospitalisations, 15 % involved admission to the critical care resuscitation unit or intensive care. For all patients identified as suffering from OHE and hospitalized, the 5-year mortality was 46.5 % (26,621 patients). This pioneering study revealed that, in France, despite a probable underestimation of OHE episodes due to the lack of specific PMSI coding, the prevalence of OHE was very high, with frequent recurrences and readmissions, and high mortality.

Direct Discharge from the Critical Care Resuscitation Unit: Results from a Longitudinal Assessment.

The critical care resuscitation unit (CCRU) facilitates interhospital transfer (IHT) of critically ill patients for immediate interventions. Due to these patients' acuity, it is uncommon for patients to be directly discharged home from this unit, but it does happen on occasion. Since there is no literature regarding outcomes of patients being discharged from a resuscitation unit, our study investigated these patients' outcome at greater than 12 months after being discharged directly from the CCRU. We performed a retrospective cohort study of all adult patients directly discharged from the CCRU between January 01, 2017, and December 31, 2020. The primary outcome was number of ED visits or hospitalizations within 6 months. Secondary outcomes were number of ED visits or hospitalizations within 6, 12, and >12 months from CCRU discharge. We analyzed 145 patients' records. Mean age was 56 (standard deviation [SD] ± 19), with a majority being male (72%) and Caucasian (58%). The most common discharge destination was home (139 patients, 96% of total subjects) versus hospice (2%) or nursing facilities (2%). Most patients (55%) did not have any hospital revisits within the first 6 months of discharge, while 31% had 1-2 revisits, and 14% had ≥3 revisits. The most common discharge diagnoses were soft tissue infection (16.5%), aortic dissection (14%), and stroke (11%). Factors which were associated with a greater likelihood of any return hospital visit within 6 months receiving mechanical ventilation during CCRU stay (coefficient -2.23, 95% CI 0.01-0.87, P=0.036), while high hemoglobin on CCRU discharge was associated with no ED revisit (coeff. 0.42, 95% CI 1.15-2.06, P=0.004). Most patients who were discharged from the CCRU did not require any hospital revisits in the first 6 months. Requiring mechanical ventilation and having soft tissue infection were associated with high unplanned hospital revisits following discharge. Further research is needed to validate these findings.

Examining Predictors of Early Admission and Transfer to the Critical Care Resuscitation Unit.

Previous studies have demonstrated that rapid transfer to definitive care improves the outcomes for many time-sensitive conditions. The critical care resuscitation unit (CCRU) improves the operations of the University of Maryland Medical Center (UMMC) by expediting the transfers and resuscitations for critically ill patients who exceed the resources at other facilities. In this study we investigated CCRU transfer patterns to determine patient characteristics and logistical factors that influence bed assignments and transfer to the CCRU. We hypothesized that CCRU physicians prioritize transfer for critically ill patients. Therefore, those patients would be transferred faster. We performed a retrospective review of all non-traumatic adult patients transferred to the CCRU from other hospitals between January 1-December 31, 2018. The primary outcome was the interval from transfer request to CCRU bed assignment. The secondary outcome was the interval from transfer request to CCRU arrival. We used multivariate logistic regressions to determine associations with the outcomes of interest. A total of 1,741 patients were admitted to the CCRU during the 2018 calendar year. Of those patients, 1,422 were transferred from other facilities and were included in the final analysis. Patients' mean age was 57 ± 17 years with a median Sequential Organ Failure Assessment (SOFA) score of 3 [interquartile range 1-6]. Median time from transfer request to CCRU bed assignment was 8 (0-70) minutes. A total of 776 (55%) patients underwent surgical intervention after arrival. Using the median transfer request to bed assignment time, we found that patients requiring stroke neurology (odds ratio [OR] 5.49, 95% confidence interval [CI] 2.85-10.86), having higher SOFA score (OR 1.04, 95% CI 1.001-1.07), and needing an immediate operation (OR 2.85, 95% CI 1.98-4.13) were associated with immediate bed assignment time (≤8 minutes). Patients who were operated on (OR 0.74, 95% CI 0.55-0.99) were significantly less likely to have an immediate bed assignment time. The CCRU expedited the transfer of critically ill patients who needed urgent interventions from outside facilities. Higher SOFA scores and the need for urgent neurological or surgical intervention were associated with near-immediate CCRU bed assignment. Other institutions with similar models to the CCRU should perform studies to confirm our observations.

Most patients with non-hypertensive diseases at a critical care resuscitation unit require arterial pressure monitoring: a prospective observational study.

Blood pressure (BP) monitoring is essential for patient care. Invasive arterial BP (IABP) is more accurate than non-invasive BP (NIBP), although the clinical significance of this difference is unknown. We hypothesized that IABP would result in a change of management (COM) among patients with non-hypertensive diseases in the acute phase of resuscitation. This prospective study included adults admitted to the Critical Care Resuscitation Unit (CCRU) with non-hypertensive disease from February 1, 2019, to May 31, 2021. Management plans to maintain a mean arterial pressure >65 mmHg (1 mmHg=0.133 kPa) were recorded in real time for both NIBP and IABP measurements. A COM was defined as a discrepancy between IABP and NIBP that resulted in an increase/decrease or addition/discontinuation of a medication/infusion. Classification and regression tree analysis identified significant variables associated with a COM and assigned relative variable importance (RVI) values. Among the 206 patients analyzed, a COM occurred in 94 (45.6% [94/206]) patients. The most common COM was an increase in current infusion dosages (40 patients, 19.4%). Patients receiving norepinephrine at arterial cannulation were more likely to have a COM compared with those without (45 [47.9%] vs. 32 [28.6%], P=0.004). Receiving norepinephrine (relative variable importance [RVI] 100%) was the most significant factor associated with a COM. No complications were identified with IABP use. A COM occurred in 94 (45.6%) non-hypertensive patients in the CCRU. Receiving vasopressors was the greatest factor associated with COM. Clinicians should consider IABP monitoring more often in non-hypertensive patients requiring norepinephrine in the acute resuscitation phase. Further studies are necessary to confirm the risk-to-benefit ratios of IABP among these high-risk patients.

1157: EARLY INTERVENTION IN THE CRITICAL CARE RESUSCITATION UNIT AND MORTALITY AMONG PATIENTS WITH SEPSIS

Introduction: The Critical Care Resuscitation Unit (CCRU) at the University of Maryland Medical Center (UMMC) expedites the transfer of critically ill patients from other hospitals for early intervention, when there is no available intensive care (ICU) bed available. After stabilization, patients are transferred from the CCRU to an appropriate unit for longitudinal care. We hypothesized that early and effective interventions during the CCRU, defined as lactate clearance and Sequential Organ Failure Assessment (SOFA) score reduction for septic patients in the CCRU would be associated with decreased risk of hospital mortality. Methods: This was a retrospective study of adult patients with sepsis conditions and admitted to the CCRU between 01/01/2018 - 12/31/2018. Multivariate logistic regression was used to evaluate the association between lactate clearance and SOFA score reduction during CCRU stay and in-hospital mortality. Results: There were 604 patients admitted to the CCRU with a sepsis diagnosis. Eighteen (2.8%) patients who had Do Not Resuscitated order died during their CCRU stay, and were excluded. A total of 364 patients with full lactate clearance data and 493 patients with full SOFA data were included in our analysis. Mean age was 55 (±16) years, and median CCRU length of stay in the CCRU was 6.42 [3.21-18.53] hours. Among survivors, 290 (49%) patients required emergent surgical interventions within 12 hours of arrival. 61 (10%) patients were intubated, 42 (7.2%) patients were initiated on vasopressors in the CCRU, 17 (2.9%) patients cannulated for Extracorporeal Membrane Oxygenation. 524 (89%) patients survived. The average lactate and SOFA scores on admission were 2.2 (1.8) mmol/L and 4.2 (4.1), respectively. 146 (30%) had SOFA score reduction. Lactate clearance was not associated with reduced in-hospital mortality (OR 0.95, CI 0.77 - 1.16, p = 0.61), but each point of SOFA score reduction during the CCRU stay was associated with 13% reduced odds of hospital mortality (OR 0.87, CI 0.76 - 0.98, p = 0.029). Conclusions: The CCRU transferred approximately half of patients with sepsis for urgent surgical operation and during CCRU stay, 30% achieved SOFA reduction, which was associated with lower odds for hospital mortality. Further study with larger patient population is needed to confirm our study.

567: OUTCOME PREDICTORS FOR INTERHOSPITAL OBSTETRIC PATIENTS TRANSFERRED DIRECTLY TO INTENSIVE CARE UNITS

Introduction: Medical complications among pregnant peripartum patients are not common. However, certain disease such as obstetric hemorrhage or respiratory failure could be associated with poor outcome among obstetric patients whose biological systems are already stretched. When a peripartum patients encounter a severe medical condition, they are frequently transferred to a tertiary center for management of these patients’ complex conditions. Our study investigated the outcomes of the peripartum patients who were transferred from other hospitals (Interhospital transfer [IHT]) to the Intensive Care Unit at an academic quaternary center. Methods: We retrospectively analyzed all adult IHT peripartum patients to our institution’s ICU between Jan. 2017 to Dec. 2021. We presented descriptive analysis for our patients and used multivariable ordinal regressions for association between demographic, clinical factors, and patients’ length of stay (LOS) in the ICU (ICULOS), hospital (HLOS). Results: Among 1794 IHT peripartum patients, 59 patients were transferred directly to an ICU, 8 (13.6%) to Medical ICU, 2 (3.4%) Neuro ICU, 2 (3.4%) Surgical ICU and 47 (79.7%) to our Critical Care Resuscitation Unit. Patients’ mean (Standard Deviation) age was 32 (6) years, SOFA score 3 (3), APACHE II 8 (4), median Respiratory Oxygenation (ROx) index was 13 [Interquartile Range 4-22], and serum lactate 11 [9-15] mmol/L. Respiratory failure occurred in 19 (32%), postpartum hemorrhage 9 (15%), sepsis 8 (14%) patients. 16 (27%) patients were infected with COVID-19. 24 (41%) needed intubation, 13 (22%) vasopressor, 4 (7%) Extracorporeal Membrane Oxygenation. Median ICULOS and HLOS was 5 [2-12], 8 [5-17] days. Only 1 (1.7%) died, while 45 (76.3%) were discharged home directly. Having COVID-19 infection was associated with both ICULOS (Correlation Coefficient -2,23, OR 0.06, 95%CI 0.02-0.65, P = 0.016) and HLOS (Corr. Coeff. -2.75, OR 0.06, 95%CI 0.01-0.37, P = 0.002). Conclusions: Although severe medical conditions were uncommon among interhospital transferred peripartum patients, they could be severe, especially during the COVID-19 pandemic. Fortunately, the mortality rate for peripartum patients in our study was very low. Further studies with larger sample sizes are needed to confirm our observation.

Critical Care Resuscitation Unit Model Shows Benefit for Patients, Patient Flow Metrics, and the Medical System.

Critical Care Resuscitation Unit Model Shows Benefit for Patients, Patient Flow Metrics, and the Medical System.

Association between resuscitation in the critical care resuscitation unit and in-hospital mortality

IntroductionPatients who present in shock have high expected mortality and early resuscitation is crucial to improve their outcomes. The Critical Care Resuscitation Unit (CCRU) is a specialized unit at the University of Maryland Medical Center (UMMC) that prioritizes early resuscitation of critically ill patients. We hypothesized that lactate clearance and reduction of Sequential Organ Failure Assessment (SOFA) score during CCRU stay would be associated with lower in-hospital mortality. MethodsWe performed a retrospective analysis of adult patients who were admitted to the CCRU between 01/01/2018–12/31/2018 and had a diagnosis of severe shock, determined by serum lactate ≥4 mmol/L. We excluded patients who died during CCRU stay. We used multivariable logistic regression to evaluate the association between lactate clearance and reduction in SOFA scores during CCRU stay and in-hospital mortality. ResultsOut of 1740 patients admitted to the CCRU in 2018, 172 (10%) had serum lactate ≥4 mmol/L. Twenty-two (13%) patients died during their CCRU stay. Our primary analysis included 129 patients with lactate clearance data and 136 patients with SOFA data. Average patients' age was 54 years, and median length of stay in the CCRU was 6 h 55 min. The average lactate and SOFA score on admission were 7.4 (3.8) mmol/L and 8.3 (4.7), respectively. Average lactate clearance was 1.9 (3.1) and average SOFA score reduction was 0.2 (2.9). In multivariable logistic regressions evaluating SOFA score and lactate separately, SOFA score reduction during CCRU stay was associated with lower in-hospital mortality (OR 0.83, 95% CI: 0.70–0.97) but lactate clearance was not (OR 0.90, 95% CI 0.78–1.03). In forward stepwise multivariable analysis containing both SOFA score and lactate values, SOFA score clearance during CCRU stay was still associated with decreased in-hospital mortality (OR 0.84, 95% CI 0.72–0.98). ConclusionsCare in the CCRU is more effective at reducing lactate than SOFA scores in patients with severe shock. However, SOFA score reduction in the resuscitation phase during the CCRU stay was associated with decreased odds of in-hospital mortality in this group of patients. Further studies are necessary to confirm our observations.

Is the Critical Care Resuscitation Unit Sustainable: A 5-Year Experience of a Beneficial and Novel Model.

Background The 6-bed critical care resuscitation unit (CCRU) is a unique and specialized intensive care unit (ICU) that streamlines the interhospital transfer (IHT—transfer between different hospitals) process for a wide range of patients with critical illness or time-sensitive disease. Previous studies showed the unit successfully increased the number of ICU admissions while reducing the time of transfer in the first year of its establishment. However, its sustainability is unknown. Methods This was a descriptive retrospective analysis of adult, non-trauma patients who were transferred to an 800-bed quaternary medical center. Patients transferred to our medical center between January 1, 2014 and December 31, 2018 were eligible. We used interrupted time series (ITS) and descriptive analyses to describe the trend and compare the transfer process between patients who were transferred to the CCRU versus those transferred to other adult inpatient units. Results From 2014 to 2018, 50,599 patients were transferred to our medical center; 31,582 (62%) were non-trauma adults. Compared with the year prior to the opening of the CCRU, ITS showed a significant increase in IHT after the establishment of the CCRU. The CCRU received a total of 7,788 (25%) IHTs during this period or approximately 20% of total transfers per year. Most transfers (41%) occurred via ground. Median and interquartile range [IQR] of transfer times to other ICUs (156 [65–1027] minutes) were longer than the CCRU (46 [22–139] minutes, P < 0.001). For the CCRU, the most common accepting services were cardiac surgery (16%), neurosurgery (11%), and emergency general surgery (10%). Conclusions The CCRU increases the overall number of transfers to our institution, improves patient access to specialty care while decreasing transfer time, and continues to be a sustainable model over time. Additional research is needed to determine if transferring patients to the CCRU would continue to improve patients' outcomes and hospital revenue.

Invasive arterial blood pressure monitoring may aid in the medical management of hypertensive patients with acute aortic disease

IntroductionBlood pressure (BP) monitoring and management is essential in the treatment of acute aortic disease (AoD). Previous studies had shown differences between invasive arterial BP monitoring (ABPM) and non-invasive cuff BP monitoring (CBPM), but not whether ABPM would result in patients' change of clinical management. We hypothesized that ABPM would change BP management in AoD patients. MethodsThis was a prospective observational study of adult patients with AoD admitted to the Critical Care Resuscitation Unit from January 2019 to February 2021. Patients with AoD and both ABPM and CBPM measurements were included. Clinician's BP management goals were assessed in real time before and after arterial catheter placement according to current guidelines. We defined change of management as change of current antihypertensive infusion rate or adding a new agent. We used multivariable logistic and ordinal regressions to determine relevant predictors. ResultsWe analyzed 117 patients, and 56 (47%) had type A dissection. ABPM was frequently ≥10 mmHg higher than CBPM values. Among 40 (34%) patients with changes in management, 58% (23/40) had [ABPM-CBPM] differences ≥20 mmHg. ABPM prompted increasing current antihypertensive infusion in 68% (27/40) of patients. Peripheral artery disease (OR 13, 95% CI 1.18–50+) was associated with changes in clinical management, and ordinal regression showed hypertension and serum lactate to be associated with differences between ABPM and CBPM. ConclusionsABPM was frequently higher than CBPM, resulting in 34% of changes of management, most commonly increasing anti-hypertensive infusion rates.

Discrepancy Between Invasive and Noninvasive Blood Pressure Measurements in Patients with Sepsis by Vasopressor Status.

IntroductionBlood pressure (BP) monitoring is an essential component of sepsis management. The Surviving Sepsis Guidelines recommend invasive arterial BP (IABP) monitoring, although the benefits over non-invasive BP (NIBP) monitoring are unclear. This study investigated discrepancies between IABP and NIBP measurement and their clinical significance. We hypothesized that IABP monitoring would be associated with changes in management among patients with sepsis requiring vasopressors.MethodsWe performed a retrospective study of adult patients admitted to the critical care resuscitation unit at a quaternary medical center between January 1–December 31, 2017. We included patients with sepsis conditions AND IABP monitoring. We defined a clinically significant BP discrepancy (BPD) between NIBP and IABP measurement as a difference of > 10 millimeters of mercury (mm Hg) AND change of BP management to maintain mean arterial pressure ≥ 65 mm Hg.ResultsWe analyzed 127 patients. Among 57 (45%) requiring vasopressors, 9 (16%) patients had a clinically significant BPD vs 2 patients (3% odds ratio [OR] 6.4; 95% CI: 1.2–30; P = 0.01) without vasopressors. In multivariable logistic regression, higher Sequential Organ Failure Assessment (SOFA) score (OR 1.33; 95% CI: 1.02–1.73; P = 0.03) and serum lactate (OR 1.27; 95% CI: 1.003–1.60, P = 0.04) were associated with increased likelihood of clinically significant BPD. There were no complications (95% CI: 0–0.02) from arterial catheter insertions.ConclusionAmong our population of septic patients, the use of vasopressors was associated with increased odds of a clinically significant blood pressure discrepancy between IABP and NIBP measurement. Additionally, higher SOFA score and serum lactate were associated with higher likelihood of clinically significant blood pressure discrepancy. Further studies are needed to confirm our observations and investigate the benefits vs the risk of harm of IABP monitoring in patients with sepsis.

A Case Report on a Patient Whose Road Traffic Injury Severity Was Determined by the MAIS (Maximum Abbreviated Injury Scale) Score

Abstract There are numerous definitions and classifications of severe trauma. Due to the observed heterogeneity in the existing definitions and the lack of a uniform definition of serious bodily injury, in January 2013 the High Level Group on Road Safety EU (HLGRS) published the definition of serious bodily injury in road traffic as a non-fatal injury with Maximum Abbreviated Injury Scale (MAIS) between 3 and 6, including the limit values. However, determining the MAIS score is not easy even for doctors with many years of experience. A female patient, injured as a pedestrian in a traffic accident, was examined prehospitally, and was transported to the hospital in the optimal golden hour from the time of the injury. The patient was intubated and mechanically ventilated in the Critical Care Resuscitation Unit. After the entire diagnostic procedure, diagnoses were made according to the ICD classification of diseases. During further examination, each code of the diagnosis of the disease was assigned an AIS code and the highest AIS score - AIS 5 was determined, which indicated that the patient was critically injured. Our patient's MAIS score was 5. After 39 days she was discharged from hospital. The neurological findings at discharge corresponded to left hemiparesis – ASIA D impairment grade. In conclusion, a novelty in the assessment of severe bodily injury is the introduction of the AIS/MAIS score. However, to avoid a subjective assessment of these scores, AIS dictionaries should be obtained for physicians, or a software solution should be developed to convert ICD-10 diagnoses into the AIS / MAIS injury scale.

280 Arterial Line versus Noninvasive Blood Pressure Monitoring in Hypertensive Emergencies

Blood pressure (BP) monitoring is important for managing patients with hypertensive emergencies. Management of such conditions often involves relatively narrow and specific blood pressure windows. While invasive arterial blood pressure (IABP) monitoring is considered the gold standard method of BP measurement, its usefulness is unclear. Although previous studies demonstrated differences between IABP and NIBP values, few had assessed whether these differences would affect clinical management. Our study aimed to determine whether the difference between NIBP and IABP would change BP management in patients with hypertensive emergencies. This was a prospective observational study of adult patients with any hypertensive emergency admitted to the Critical Care Resuscitation Unit (CCRU) at a quaternary academic center from January 2019—April 2021. We included consecutive patients with diagnoses of ischemic stroke, acute aortic disease, spontaneous intracranial hemorrhage (sICH), etc, and who required arterial monitoring. We excluded patients who had hypertensive diagnoses but required vasopressors due to overtreatment of anti-hypertensive medications or those who had arterial catheters prior to arrival. All arterial catheters were inserted upon patients’ arrival per CCRU clinical policy. Patients who had IABP and NIBP in the same extremity and four consecutive measurements of each modality following arterial catheter placement were eligible. Before arterial catheter placement, we recorded in real time clinicians’ decisions to manage patients’ systolic BP (SBP) according to the NIBP values and current guidelines, for example maintaining SBP ≤160 mmHg for patients with sICH. After the arterial catheter was placed, we again recorded in real time clinicians’ management of patients’ arterial SBP. We defined change in clinical management as any difference in blood pressure management (eg, adding a new antihypertensive agent, increasing or decreasing dose). We used Classification and Regression Tree (CART) analysis to identify sensitive and specific clinical predictors of management differences. A total of 183 patients were identified and analyzed, 71 (39%) female. Mean age was 63 years (standard deviation [SD] 14), mean body mass index (BMI) was 29 (6). Mean difference between IABP and NIBP and was 11 mmHg (95% CI 5-17). One hundred and seventeen patients (64%) had difference >10 mmHg between the two modalities, while 70 (38%) had a difference >20 mmHg. Seventy-nine patients (43%) had a change in management after arterial catheters were inserted. The most important factors in predicting management change included mean SBP >148 mmHg. Subsequent important factors were BMI >21, difference in BP value [IABP – NIBP] >6 mmHg, and diagnoses of ruptured abdominal aortic aneurysm, ischemic stroke + alteplase, any aortic dissection. Arterial BP monitoring identified a change in clinical management in almost half of patients with hypertensive emergencies. Clinicians should consider using arterial BP monitoring more frequently in the management of hypertensive emergencies, especially when strict BP goals are warranted.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Transfer of Patients with Spontaneous Intracranial Hemorrhage who Need External Ventricular Drain: Does Admission Location Matter?

IntroductionPatients with spontaneous intracranial hemorrhage (sICH) are associated with high mortality and require early neurosurgical interventions. At our academic referral center, the neurocritical care unit (NCCU) receives patients directly from referring facilities. However, when no NCCU bed is immediately available, patients are initially admitted to the critical care resuscitation unit (CCRU). We hypothesized that the CCRU expedites transfer of sICH patients and facilitates timely external ventricular drain (EVD) placement comparable to the NCCU.MethodsThis is a pre-post study of adult patients transferred with sICH and EVD placement. Patients admitted between January 2011–July 2013 (2011 Control) were compared with patients admitted either to the CCRU or the NCCU (2013 Control) between August 2013–September 2015. The primary outcome was time interval from arrival at any intensive care units (ICU) to time of EVD placement (ARR-EVD). Secondary outcomes included time interval from emergency department transfer request to arrival, and in-hospital mortality. We assessed clinical association by multivariable logistic regressions.ResultsWe analyzed 259 sICH patients who received EVDs: 123 (48%) CCRU; 81 (31%) 2011 Control; and 55 (21%) in the 2013 Control. The groups had similar characteristics, age, disease severity, and mortality. Median ARR-EVD time was 170 minutes [106–311] for CCRU patients; 241 minutes [152–490] (p < 0.01) for 2011 Control; and 210 minutes [139–574], p = 0.28) for 2013 Control. Median transfer request-arrival time for CCRU patients was significantly less than both control groups. Multivariable logistic regression showed each minute delay in ARR-EVD was associated with 0.03% increased likelihood of death (odds ratio 1.0003, 95% confidence interval, 1.0001–1.006, p = 0.043).ConclusionPatients admitted to the CCRU had shorter transfer times when compared to patients admitted directly to other ICUs. Compared to the specialty NCCU, the CCRU had similar time interval from arrival to EVD placement. A resuscitation unit like the CCRU can complement the specialty unit NCCU in caring for patients with sICH who require EVDs.

772: Neurologic Status and Intubation in a Critical Care Resuscitation Unit for Mechanical Thrombectomy

Najafali, Daniel1; Panchal, Bhakti1; Vuong, Kim2; Ullah, Muhammad1; Karwoski, Allison1; Berman, Emilie1; Sahadzic, Iana1; Sapru, Mayga1; Cao, Tiffany1; Tiffany, Laura1; Patel, Priya3; Traynor, Timothy3; Woods, Nathaniel4; Yarbrough, Karen3; Phipps, Michael3; Morris, Nicholas5; Jindal, Gaurav3; Haase, Daniel3,6; Tran, Quincy3,7 Author Information

1102: How The Critical Care Resuscitation Unit Contributes to Critically Ill Transfer: A 5-Year Experience

1102: How The Critical Care Resuscitation Unit Contributes to Critically Ill Transfer: A 5-Year Experience