Decrease In Intensive Care Unit Length Research Articles

Perioperative Individualized Goal Directed Therapy for Cardiac Surgery: A Historical-Prospective, Comparative Effectiveness Study.

Introduction: Cardiac surgery patients are at increased risk for post-operative complications and prolonged length of stay. Perioperative goal directed therapy (GDT) has demonstrated utility for non-cardiac surgery, however, GDT is not common for cardiac surgery. We initiated a quality improvement (QI) project focusing on the implementation of a GDT protocol, which was applied from the immediate post-bypass period into the intensive care unit (ICU). Our hypothesis was that this novel GDT protocol would decrease ICU length of stay and possibly improve postoperative outcomes. Methods: This was a historical prospective, QI study for patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB). Integral to the QI project was education towards all associated providers on the concepts related to GDT. The protocol involved identifying patient specific targets for cardiac index and mean arterial pressure. These targets were maintained from the post-CPB period to the first 12 h in the ICU. Statistical comparisons were performed between the year after GDT therapy was launched to the last two years prior to protocol implementation. The primary outcome was ICU length of stay. Results: There was a significant decrease in ICU length of stay when comparing the year after the protocol initiation to years prior, from a median of 6.19 days to 4 days (2017 vs. 2019, p < 0.0001), and a median of 5.88 days to 4 days (2018 vs. 2019, p < 0.0001). Secondary outcomes demonstrated a significant reduction in total administered volumes of inotropic medication(milrinone). All other vasopressors demonstrated no differences across years. Hospital length of stay comparisons did not demonstrate a significant reduction. Conclusion: These results suggest that an individualized goal directed therapy for cardiac surgery patients can reduce ICU length of stay and decrease amount of inotropic therapy.

Trends of clinical outcomes in patients with a Traumatic Brain Injury (TBI) in Canada between 2006 and 2012

BackgroundTraumatic brain injuries (TBI) are the leading cause of death for people aged <40 years. In Canada, the structure of trauma care has evolved independently across provinces during the last decade. However, little is known about the evolution of clinical outcomes. We aimed to compare trends in hospital mortality, unplanned readmission, hospital length of stay (LOS) and intensive care unit (ICU) LOS for TBI between 2006 and 2012 across Canadian provinces. MethodsWe conducted a retrospective multicentre cohort study based on TBI admissions across Canadian level I and II trauma centres. Data were extracted from the National Trauma Registry linked to hospital discharge databases. All adults with an injury severity score ≥12 were included. Multilevel generalized linear models were used to evaluate trends in clinical outcomes. ResultsBetween 2006 and 2012, we observed a decrease in mortality in Canada (odd ratio [OR] = 0.95; 95% confidence intervals [CI] = 0.92–0.98) mostly driven by Ontario (OR = 0.95; 95% CI = 0.93–0.98). We observed a significant decrease in hospital length of stay in Canada (hazard ratio [HR]: hazard of being discharged alive from hospital = 1.02; 95% CI = 1.01–1.02) mostly driven by a decrease in Quebec (HR = 1.03; 95% CI = 1.01–1.04). We observed a decrease in ICU Length of stay only in Alberta (HR = 1.05; 95% CI = 1.01–1.09). No trend was observed for hospital readmissions. ConclusionWe observed significant decreases in mortality, hospital and ICU length of stay for TBI in Canada between 2006 and 2012 but only in certain provinces. This study may represent the first step towards a better understanding of the influence of trauma system configuration on the burden of injuries in Canada.

A Comparative Study to Evaluate the Efficacy of Butorphanol as an Adjuvant to Epidural Analgesia for Rib Fractures

Abstract Introduction: Pain management via epidural catheters have emerged as an optimal method of pain control in patients with rib fractures (RF). This study was done to evaluate the efficacy of butorphanol in this subset of patients. Materials and methods: Sixty patients were randomly allocated in two groups R (ropivacaine only) and B (ropivacaine with butorphanol). Group R patients received 0.2% ropivacaine epidurally (10 mL) while group B patients received 0.2% ropivacaine and 1 mg butorphanol epidurally (10 mL). Baseline respiratory rate, oxygen saturation, partial pressure of oxygen (PaO2), visual analog score (VAS), peak inspiratory flow rate (PIFR) were noted in both the groups. Results: There was significant increase in duration of analgesia and nonsignificant reduction in VAS score in group B, and nonsignificant decrease in invasive ventilation cases and significant reduction in length of intensive care unit (ICU) stay in group B. There were no significant adverse effects in both the groups except for nausea in group B. Conclusion: Butorphanol as an adjuvant to epidural analgesia leads to better oxygenation, decrease in length of ICU stay and duration of mechanical ventilation without increase in significant side effects.

Impact of Infectious Diseases Team Consultation on Antimicrobial Use, Length of Stay and Mortality

Infectious disease (ID) clinicians and multidisciplinary teams may have a beneficial impact on patient outcomes. This study was conducted to determine the impact of dedicated ID team rounding in an adult noncardiac intensive care unit (ICU) on antimicrobial costs, length of stay and mortality. The authors instituted dedicated ICU ID team rounds at a large tertiary care hospital ICU ("intervention"), with the ID team conducting rounds in the ICU every weekday. The authors compared the cost of antimicrobial agents, total hospital and ICU length of stay and inpatient mortality for the 6-month period before and after institution of these rounds between those seen versus those not seen by the ID team. Among 386 patients analyzed, 206 were admitted in the preintervention and 180 in the postintervention period. Among those seen by the ID team, there was an 18% decrease in total antimicrobial cost (P < 0.0001), 40% decrease in ICU length of stay (P = 0.1), 33% decrease in overall hospital length of stay (P = 0.03) and 34% decrease in mortality (0.04) from preintervention to postintervention period. Among those not seen by ID, there was a 39% decrease in cost among those not seen by ID (P < 0.0001), but length of ICU or hospital stay and mortality were not significantly different. Institution of dedicated ID team rounding in the ICU leads to substantial decreases in antimicrobial costs, hospital length of stay and inpatient mortality among those patients seen by the team.

Pharmacologic prevention and treatment of delirium in intensive care patients: A systematic review

PurposeThe purpose of the study is to determine if pharmacologic approaches are effective in prevention and treatment of delirium in critically ill patients. Materials and methodsWe performed a systematic search to identify publications (from January 1980 to September 2014) that evaluated the pharmacologic interventions to treat or prevent delirium in intensive care unit (ICU) patients. ResultsFrom 2646 citations, 15 studies on prevention (6729 patients) and 7 studies on treatment (1784 patients) were selected and analyzed. Among studies that evaluated surgical patients, the pharmacologic interventions were associated with a reduction in delirium prevalence, ICU length of stay, and duration of mechanical ventilation, but with high heterogeneity (respectively, I2 = 81%, P = .0013; I2 = 97%, P < .001; and I2 = 97%). Considering treatment studies, only 1 demonstrated a significant decrease in ICU length of stay using dexmedetomidine compared to haloperidol (Relative Risk, 0.62 [1.29-0.06]; I2 = 97%), and only 1 found a shorter time to resolution of delirium using quetiapine (1.0 [confidence interval, 0.5-3.0] vs 4.5 [confidence interval, 2.0-7.0] days; P = .001). ConclusionThe use of antipsychotics for surgical ICU patients and dexmedetomidine for mechanically ventilated patients as a preventive strategy may reduce the prevalence of delirium in the ICU. None of the studied agents that were used for delirium treatment improved major clinical outcome, including mortality.

Extubation in the operating room after cardiac surgery in children: a prospective observational study with multidisciplinary coordinated approach.

This prospective observational study was undertaken to determine the feasibility of extubation of children in the operating room after cardiac surgery. A prospective observational study compared with historic controls. A single tertiary care referral hospital. One thousand consecutive pediatric patients requiring cardiac surgery aged 1 day to 18 years. Patients with spinal deformity, neurologic problems, coagulopathy as diagnosed by high international normalized ratio (INR) more than 1.5, and patients preoperatively on mechanical ventilation were excluded from the study. Data were also reviewed for another 1,000 patients operated before the beginning of this study, which constituted historic controls. All 1,000 patients were considered as potential candidates for extubation in the operating room after cardiac surgery and managed by a combination of general anesthesia and neuraxial analgesia with a mixture of caudal morphine and dexmedetomidine, and extubation in the operating room was attempted after completion of the surgical procedure. These comprised the study group (SG). Data also were reviewed for another 1,000 patients before the beginning of this study when extubation in the operating room was not attempted and compared with this group to study the impact of extubation in the operating room on intensive care unit (ICU) stay and resource utilization. This data comprised the before-study group (BSG). Eight hundred seventy-one (87.1%) patients were extubated in the operating room. This included 40% of neonates and 70%, 85%, and 91% of patients aged between 1 and 3 months, 3 months to 1 year, and more than 1 year, respectively. Forty-five patients (4.5%) required re-intubation within 24 hours, and 9 patients died among those extubated in the OR, but for reasons thought not to be related to extubation. The ICU stay was significantly less in the study group (2.56±1.84 v 5.4±2.32 days, p<0.0001) as compared to before-study group (BSG). The number of patients in the ICU (34.76±3.19 v 59.98±4.92, p<0.0001) and the number of patients on a ventilator (5.1±1.24 v 24.5±2.88, p<0.0001) on a daily basis were significantly less in the study group, reflecting positive impact on resource utilization. Extubation in the operating room was successful in 87.1% of the patients without any increase in mortality and morbidity, but with a decrease in ICU length of stay and less use of hospital resources.

Education About Palliative Care in the Intensive Care Unit: Rediscovering Opportunity

Underlying palliative care is a philosophy that aligns patients' health care with what they deem most important. For patients in the final stages of life, this often includes the desire to avoid burdensome and high-intensity care. In the intensive care unit (ICU), where we see the highest acuity of illness, often there are many competing priorities. The principles of palliative care are vital in refocusing our attention on what matters most to the patient and his or her family. Because of the value of these principles, there is increasing interest in finding ways to improve education in palliative care and to integrate palliative care education into the ICU. To achieve this goal, 3 models for incorporating palliative care in the ICU have been proposed: the integrative model (education in primary palliative care skills for ICU clinicians); the consultative model (access to palliative care specialists); and the mixed model that uses both of these approaches simultaneously.1,2 It is increasingly clear that a mixed model, in which the education and deployment of palliative care specialists is combined with the education of all clinicians in basic principles of palliative care, is the optimal approach to address the diverse range of palliative care needs in the ICU.2

Effectiveness of Integration of Palliative Medicine Specialist Services into the Intensive Care Unit of a Community Teaching Hospital

Collaboration between palliative medicine and the intensive care unit (ICU) represents best practice and offers important benefits. However, achieving effective collaboration between these two specialties can be challenging. Assess effectiveness of integrating palliative medicine specialists in the ICU. Retrospective chart review. Of 201 patients who qualified for palliative consultation using a palliative screening tool, 92 were referred and 109 were not referred for palliative medicine consultation. The number of screening criteria met was similar between the two groups. Palliative medicine consult volume increased significantly compared with preintegration (7.7±3.4 versus 4.4±2.8 consults per month, p=0.04). No significant difference in hospital mortality was found between the referred and unreferred groups (32/92 [35%] versus 26/109 [24%], p=0.09). ICU length of stay was significantly shorter in the referred group (7 versus 11 days, p<0.001). Referred patients were more frequently enrolled in hospice compared with unreferred patients (32/92 [37%] versus 3/109 [3%], p<0.001). ICU physicians referred patients significantly more often for dementia and ventilator withdrawal (13/16, p=0.003; 24/29, p<0.001, respectively) and significantly less often for ICU stay longer than 10 days (21 versus 49, p=0.001). Integrating palliative medicine specialists into intensive care was associated with a significant increase in use of palliative medicine services and a significant decrease in ICU length of stay for referred patients without a significant increase in mortality. The screening tool effectively identified patients at high risk of death. Given the high mortality rate of the unreferred patients, the criteria could be more widely adopted by ICU physicians to consider expanding palliative medicine referrals.

WITHDRAWN. Surfactant therapy for bronchiolitis in critically ill infants.

Viral bronchiolitis is a common cause of respiratory failure in infants and children, and accounts for a significant portion of intensive care unit (ICU) admissions during seasonal epidemics. Currently there is no evidence to support the use of anything but supportive care for this disease. Surfactant is a potentially promising therapy; alterations in its composition have been described in bronchiolitis, and it may play a role in the host immunity for this disease. To assess the efficacy of exogenous surfactant for the treatment of bronchiolitis in mechanically ventilated infants and children. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2006, issue 1) which contains the Acute Respiratory Infections Group's Specialized Register; MEDLINE (1966 to Week 1, February 2006); and EMBASE (1990 to September 2005). Randomised controlled trials (RCTs) comparing surfactant with placebo or surfactant with no surfactant in mechanically ventilated infants and children with viral bronchiolitis. Two authors independently extracted data and assessed trial quality. Unpublished data were requested from trial authors when necessary. Three trials containing a total of 79 patients met the inclusion criteria. No mortality or adverse effects associated with surfactant administration were reported in any of these trials. In the three trials, use of surfactant was associated with a decrease in duration of mechanical ventilation by 2.6 days (95% confidence interval (CI) -5.34 to 0.18 days; P value 0.07) and a decrease in ICU length of stay by 3.3 days (95% CI -6.38 to -0.23 days; P value 0.04). In two studies with 59 patients, in which duration of mechanical ventilation in the control groups was more comparable, surfactant was associated with a decrease in ventilator days by 1.21 days (95% CI 0.75 to 1.67 days) and a decrease in ICU stay by 1.81 days (95% CI 1.19 days to 2.42 days). Individually the studies reported some short term benefit of surfactant on pulmonary mechanics and gas exchange. Available data on surfactant were not sufficient to provide reliable estimates of its effects in mechanically ventilated infants and children with bronchiolitis. Future studies should be adequately powered and will need to address unresolved questions regarding which surfactant preparation may be best suited for the treatment of bronchiolitis, the appropriate dose and administration interval, and how the choice of ventilator strategy may modify its effects.

Adequacy of Brain Oxygen Saturation for Goal-Directed Therapy

Adequacy of Brain Oxygen Saturation for Goal-Directed Therapy