Difference In ICU Length Of Stay Research Articles

Length of hospital and intensive care unit stay in patients with invasive candidiasis and/or candidemia treated with rezafungin: a pooled analysis of two randomised controlled trials.

Invasive candidiasis/candidemia (IC/C) is associated with a substantial health economic burden driven primarily by prolonged hospital stay. The once-weekly IV echinocandin, rezafungin acetate, has demonstrated non-inferiority to caspofungin in the treatment of IC/C. This paper reports a post hoc pooled exploratory analysis of length of stay (LoS) for hospital and intensive care unit (ICU) stays in two previously published clinical trials (ReSTORE [NCT03667690] and STRIVE [NCT02734862], that compared rezafungin with daily IV caspofungin (stable patients in the caspofungin group who met relevant criteria could step down to fluconazole after 3days or more). LoS outcomes were analysed descriptively in the pooled modified intention to treat (mITT) population (all patients who had a documented Candida infection in line with trial requirements and received at least one dose of study drug). In addition, to adjust for an imbalance between treatment groups in the proportion receiving mechanical ventilation at baseline, a generalised linear model with mechanical ventilation as a binary covariate was applied. Responses to an exploratory question in the phase 3 trial on possible earlier discharge with weekly rezafungin are also reported. 294 patients were included (rezafungin 139, caspofungin 155), of whom 126 (43%) had ICU admission. Patients treated with rezafungin had a numerically shorter LoS than with caspofungin in all analyses. Mean total LoS was 25.2days, vs 28.3days with caspofungin, and mean ICU LoS was 16.1 vs 21.6days for rezafungin and caspofungin, respectively. After adjustment for mechanical ventilation status the difference in ICU LoS was 4.1days, a relative difference of 24% (95% CI -11%, 72%). Physicians would have considered earlier discharge for 16% of patients (30/187) with weekly rezafungin, an average of 5-6days earlier. Rezafungin may enable shorter hospital and ICU LoS in IC/C compared with daily IV caspofungin, with accompanying savings in resource use. Further research is needed to confirm this in the real-world setting. NCT03667690 (ReSTORE; September 12, 2018); NCT02734862 (STRIVE; April 12, 2016).

Adoption of an Enhanced Recovery After Surgery Protocol Increases Cost of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy and Does not Improve Outcomes.

Enhanced recovery after surgery (ERAS) protocols have been shown to reduce length of stay (LOS) and complications. The impact of ERAS protocols on the cost of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has not been studied. We performed a retrospective cohort analysis of patients undergoing CRS-HIPEC from 2016-2022 at a single quaternary center. Propensity score matching was used to create pre-and post-ERAS cohorts. Cost, overall and serious complications, and intensive care unit (ICU) length of stay (LOS) between the two cohorts were compared using the Mann-Whitney U-test for continuous variables and χ2 test for categorical variables. Our final matched cohort consisted of 100 patients, with 50 patients in both the pre- and post-ERAS groups. After adjusting for patient complexity and inflation, the median total cost [$75,932 ($67,166-102,645) versus $92,992 ($80,720-116,710), p = 0.02] and operating room cost [$26,817 ($23,378-33,121) versus $34,434 ($28,085-$41,379), p < 0.001] were significantly higher in the post-ERAS cohort. Overall morbidity (n = 22, 44% versus n = 17, 34%, p = 0.40) and ICU length of stay [2 days (IQR 1-3) versus 2 days (IQR 1-4), p = 0.70] were similar between the two cohorts. A total cost increase of $22,393 [SE $13,047, 95% CI (-$3178 to $47,965), p = 0.086] was estimated after implementation of ERAS, with operating room cost significantly contributing to this increase [$8419, SE $1628, 95% CI ($5228-11,609), p < 0.001]. CRS-HIPEC ERAS protocols were associated with higher total costs due to increased operating room costs at a single institution. There was no significant difference in ICU LOS and complications after the implementation of the ERAS protocol.

Assessing glycemic variability in critically ill patients: A prospective cohort study comparing insulin infusion therapy with insulin sliding scale

Glycemic variability (GV) has been associated with an increased mortality rate among critically ill patients. The clinical outcomes of having less GV even with slight hyperglycemia are better than those having tight glycemic control but higher GV. Insulin infusion remains the preferred method to control stress hyperglycemia in critically ill patients. However, its impacts on GV and clinical outcomes in critically ill patients still need further investigation. This study intended to evaluate the impact of insulin infusion therapy (IIT) compared to the insulin sliding scale (ISS) on the extent of GV and explore its impact on the clinical outcomes for critically ill patients. A prospective, single-center observational cohort study was conducted at a tertiary academic hospital in Saudi Arabia between March 2021 and November 2021. The study included adult patients admitted to ICUs who received insulin for stress hyperglycemia management. Patients were categorized into two groups based on the regimen of insulin therapy during ICU stay (IIT versus ISS). The primary outcome was the GV between the two groups. Secondary outcomes were ICU mortality, the incidence of hypoglycemia, and ICU length of stay (LOS). A total of 381 patients were screened; out of them, eighty patients met the eligibility criteria. The distribution of patients having diabetes and a history of insulin use was similar between the two groups. The GV was lower in the IIT group compared to the ISS group using CONGA (− 0.65, 95% CI [− 1.16, − 0.14], p-value = 0.01). Compared with ISS, patients who received IIT had a lower incidence of hypoglycemia that required correction (6.8% vs 2.77%; p-value = 0.38). In contrast, there were no significant differences in ICU LOS and ICU mortality between the two groups. Our study demonstrated that the IIT is associated with decreased GV significantly in critically ill patients without increasing the incidence of severe hypoglycemia. There is no survival benefit with the use of the IIT. Further studies with larger sample size are required to confirm our findings and elaborate on IIT's potential effect in reducing ICU complications in critically ill patients.

Impact of a Divided Phenobarbital Load and Taper Compared With Lorazepam Symptom Triggered Therapy in Hospitalized Patients.

Benzodiazepines are the preferred treatment for alcohol withdrawal. Phenobarbital is an alternative in the setting of prescriber expertise or benzodiazepine contraindication. To evaluate the efficacy and safety of a phenobarbital dosing strategy aimed at treating a spectrum of alcohol withdrawal symptoms across various patient populations. Retrospective review of patients admitted with concerns of alcohol withdrawal between May 2018 and November 2022. Patients were separated into a before-after cohort of lorazepam or phenobarbital. The primary outcome was hospital length of stay (LOS). Secondary outcomes were intensive care unit (ICU) LOS, escalation of respiratory support, increased level of care (LOC), and incidence of delirium tremens and/or seizures. Two hundred and seventy-seven patients received lorazepam and 198 received phenobarbital. Hospital LOS was longer in the phenobarbital cohort compared with the lorazepam cohort (6.9 vs 9.3 days). There was no difference in ICU LOS. Level of care increases were fewer in the phenobarbital cohort (4 events vs 19 events). There were higher rates of non-invasive respiratory interventions in the lorazepam cohort and higher rates of mechanical ventilation in the phenobarbital cohort. Utilization of phenobarbital was attributed to a reduction in delirium tremens and seizures. This study is novel because of the broad application of a phenobarbital order set across multiple levels of care and patient admission diagnoses. A risk targeted split load intravenous phenobarbital order set can safely be administered to patients with fewer escalations of care, seizures, delirium tremens, and respiratory care escalation.

Evaluation of phenobarbital for prevention of alcohol withdrawal in trauma patients.

Up to 30% of trauma patients experience alcohol withdrawal syndrome (AWS) during their hospital admission, which is associated with worse outcomes. While benzodiazepines and phenobarbital are the mainstay of AWS management, there are limited data on the prevention of AWS. The objective was to evaluate the safety and efficacy of phenobarbital for the prevention of AWS. Adult patients admitted to a level 1 trauma center who received at least one dose of phenobarbital for the prevention of AWS between January 2019 and August 2021 were included. Patients were case matched to a control group managed with symptom-triggered therapy based on risk of AWS. Risk factors included sex, age, history of AWS/delirium tremens or withdrawal seizures, selected laboratory values, and screening questionnaires. The primary endpoint was the need for rescue therapy. Secondary endpoints included the time to rescue therapy, intensive care unit (ICU) length of stay (LOS), and hospital LOS. Overall, 110 patients were included with 55 patients in each group. The phenobarbital group had higher baseline Injury Severity Scores ( p = 0.03) and were more likely to be admitted to the ICU (44% vs. 24%; p = 0.03). The phenobarbital group required less rescue therapy (16% vs. 62%; p < 0.001) with a longer time to rescue therapy administration (26 vs. 11 hours; p = 0.01). The phenobarbital group had a longer hospital LOS (216 vs. 87 hours; p = 0.0001) but no difference in ICU LOS ( p = 0.36). There was no incidence of delirium tremens or seizures and no difference in intubation rates ( p = 0.68). There was no incidence of hypotension associated with phenobarbital. Patients managed with phenobarbital had a lower need for rescue therapy for AWS with no increased adverse effects. Further studies should evaluate a protocol to prevent alcohol withdrawal in the trauma population. Therapeutic/Care Management; Level III.

438 Benefits of Short- Versus Long-segment Fixation for the Treatment of Thoracolumbar Chance Fractures: A Comparison of Perioperative and Radiological Outcomes

INTRODUCTION: Discussion continues regarding optimal surgical management of thoracolumbar fractures. Some have indicated long-segment posterior fixation (LSPF) is favorable when evaluating implant stability, kyphotic deformity, and pain. However, most studies either included multiple fracture subtypes or focused on burst fractures. Short-segment fixation (SSPF) may be similarly effective for a subset of patients while minimizing surgical time and length of stay (LOS). This study reviews inpatient and follow-up outcomes of chance fractures managed with SSPF versus LSPF. METHODS: Retrospective review of 50 consecutive patients with thoracolumbar distraction injuries (AO B1 and B2) at a single center over a five-year period. Patients underwent pedicle fixation one level (SSPF) or two to three levels (LSPF) above and below the fracture. Patient demographics, preoperative characteristics, and perioperative outcomes were compared between groups. Radiological outcomes were assessed by measuring Cobb angles immediately postoperatively and up to 12 months postoperatively. RESULTS: There was a 31% reduction in mean surgical time for SSPF patients vs LSPF (134 vs 195 minutes, independent samples t test, p = 0.037) without a significant difference in ICU LOS (4.6 vs 4.8 days, independent samples t test, p = 0.947), hospital LOS (15 vs 14 days, independent samples t test, p = 0.865) or complication rates (2 of 35 vs 2 of 15 patients, Fisher’s Exact, p = 0.574). Longitudinal assessment of kyphosis by measuring Cobb angles immediately postoperatively and 2 - 4, 6, 8 - 12, and &gt; 12 months postoperatively showed no significant differences in radiological outcomes between groups. There was a trend toward an increased likelihood of discharge to home (Likelihood ratio = 5.299, ꭓ2 test, p = 0.032) with SSPF. CONCLUSIONS: SSPF is non-inferior to LSPF for thoracolumbar chance fractures while offering reduced surgery time. Our results additionally suggest SSPF may offer increased likelihood of discharge home.

The Impact of a Pharmacist-Driven Multicomponent Sleep-Promoting Protocol on Delirium in Critically Ill Patients

Background: Sleep deprivation is reported in 80% of patients in the intensive care unit (ICU) and is associated with delirium. Guidelines recommend implementing a sleep-promoting protocol in critically ill patients which may increase the quantity and quality of sleep and may decrease delirium. Our objective was to implement a pharmacist-led interdisciplinary sleep-promoting protocol and analyze its impact on delirium in ICU patients receiving mechanical ventilation (MV). Methods: The study involved pre-implementation education, protocol development, and post-implementation analysis. ICU pharmacists completed prospective patient chart reviews to reduce exposure to deliriogenic medications and assess the need for a pharmacologic sleep aid. The primary outcome was the incidence of delirium and delirium-free days. Secondary outcomes included ICU length of stay (LOS), incidence of MV, and pharmacist medication interventions. Results: Post-protocol patients (n = 185) had a higher incidence of delirium compared to pre-protocol patients (n = 237) (51.3% vs 39.0%; P = .01). Post-protocol patients had a higher average APACHE III score (P = <.001). Delirium-free days were not significantly different between groups (P = .97). Difference in ICU LOS was not significant (P = .80). More patients received MV post-protocol implementation (55.7% vs 36.1%; P < .001). Pharmacists documented a total of 113 medication interventions. Conclusion and Relevance: A pharmacist-led, ICU sleep-promoting protocol was successfully implemented but did not reduce the incidence of delirium or the administration of insomnia agents. Post-protocol patients had higher disease severity and were more likely to receive MV. Incidence of delirium was consistent with the national reported prevalence of ICU delirium. ICU pharmacists on all shifts had an active role in optimizing sleep.

Model-informed precision dosing of beta-lactam antibiotics and ciprofloxacin in critically ill patients: a multicentre randomised clinical trial

PurposeIndividualising drug dosing using model-informed precision dosing (MIPD) of beta-lactam antibiotics and ciprofloxacin has been proposed as an alternative to standard dosing to optimise antibiotic efficacy in critically ill patients. However, randomised clinical trials (RCT) on clinical outcomes have been lacking.MethodsThis multicentre RCT, including patients admitted to the intensive care unit (ICU) who were treated with antibiotics, was conducted in eight hospitals in the Netherlands. Patients were randomised to MIPD with dose and interval adjustments based on monitoring serum drug levels (therapeutic drug monitoring) combined with pharmacometric modelling of beta-lactam antibiotics and ciprofloxacin. The primary outcome was ICU length of stay (LOS). Secondary outcomes were ICU mortality, hospital mortality, 28-day mortality, 6-month mortality, delta sequential organ failure assessment (SOFA) score, adverse events and target attainment.ResultsIn total, 388 (MIPD n = 189; standard dosing n = 199) patients were analysed (median age 64 [IQR 55–71]). We found no significant differences in ICU LOS between MIPD compared to standard dosing (10 MIPD vs 8 standard dosing; IRR = 1.16; 95% CI 0.96–1.41; p = 0.13). There was no significant difference in target attainment before intervention at day 1 (T1) (55.6% MIPD vs 60.9% standard dosing; p = 0.24) or at day 3 (T3) (59.5% vs 60.4%; p = 0.84). There were no significant differences in other secondary outcomes.ConclusionsWe could not show a beneficial effect of MIPD of beta-lactam antibiotics and ciprofloxacin on ICU LOS in critically ill patients. Our data highlight the need to identify other approaches to dose optimisation.

Evaluating the Impact of Introducing Modified Early Warning Score to Identify Deteriorating Patients in the Wards at a Tertiary University Hospital - A before-after Study

BACKGROUND&#x0D; Modified early warning score (MEWS) is a scoring system being used in hospitals for the identification of patients who may deteriorate into medical emergencies or cardiac arrest. However, the mortality benefit of MEWS hasn’t been established. Also, there is limited data about the experience of MEWS being implemented in low-income countries. Hence, we conducted a before-after prospective observational study to evaluate the impact on ICU mortality post-introduction of the MEWS chart.&#x0D; METHODS&#x0D; MEWS before-after study is a single-centre prospective observational study in a tertiary university hospital conducted in the ICU at Kasturba Hospital, Manipal University, India. We trained ward nurses on MEWS and introduced the MEWS chart and compared the change in outcomes from two months prior (i.e. February-March 2018) to the subsequent two months (i.e. April-May 2018). The primary outcome measured was the ICU mortality between the samples. Our secondary outcomes were the length of stay (LOS) and hospital mortality. Student t-test was used to estimate the total sample size and we used the chi-square test for statistical analyses.&#x0D; RESULTS&#x0D; We enrolled 161 patients into each group and the patient demographics between groups did not show any statistically significant difference. The ICU mortality data did not show any statistically significant difference before the introduction of MEWS after using the chi-square test with a p-value of 0.33. There was no statistically significant difference in ICU LOS, ICU re-admission rates, hospital LOS, hospital mortality, bed occupancy rates, or incidence of CPR between the two periods.&#x0D; CONCLUSIONS&#x0D; Our study did not show a significant difference in the mortality after introduction of MEWS scoring charts to our wards. The introduction of critical care outreach services may improve the outcomes.

Effects of the Coronavirus Disease 2019 (COVID-19) Pandemic on Outcomes among Patients with Polytrauma at a Single Regional Trauma Center in South Korea

Purpose The coronavirus disease 2019 (COVID-19) pandemic has necessitated a redistribution of resources to meet hospitals’ service needs. This study investigated the impact of COVID-19 on a regional trauma center in South Korea. Methods We retrospectively reviewed cases of polytrauma at a single regional trauma center in South Korea between January 20 and September 30, 2020 (the COVID-19 period) and compared them to cases reported during the same time frame (January 20 to September 30) between 2016 and 2019 (the pre-COVID-19 period). The primary outcome was in-hospital mortality, and secondary outcomes included the number of daily admissions, hospital length of stay (LOS), and intensive care unit (ICU) LOS. Results The mean number of daily admissions decreased by 15% during the COVID-19 period (4.0±2.0 vs. 4.7±2.2, p=0.010). There was no difference in mechanisms of injury between the two periods. For patients admitted during the COVID-19 period, the hospital LOS was significantly shorter (10 days [interquartile range (IQR) 4–19 days] vs. 16 days [IQR 8–28 days], p&lt;0.001); however, no significant differences in ICU LOS and mortality were found. Conclusions The observations at Regional Trauma Center, Pusan National University Hospital corroborate anecdotal reports that there has been a decline in the number of patients admitted to hospitals during the COVID-19 period. In addition, patients admitted during the COVID-19 pandemic had a significantly shorter hospital LOS than those admitted before the COVID-19 pandemic. These preliminary data warrant validation in larger, multi-center studies.

Comparative study of high flow nasal catheter device and noninvasive positive pressure ventilation for sequential treatment in sepsis patients after weaning from mechanical ventilation in intensive care unit.

The hypoxemia condition after mechanical ventilation (MV) weaning is not rare among sepsis patients, so we compared the efficacy in two different intervention groups: high-flow nasal cannula device group and non-invasive positive pressure ventilation (NPPV) group. This is a retrospective cohort study. Participants were patients with sepsis receiving high-flow nasal catheter (HFNC) device or NPPV within 24 hours after weaning from MV. The primary outcome was tracheal re-intubation within 72 hours after extubation. Secondary outcomes included: oxygenation index, complication rate, patient comfort evaluation, HFNC/NPPV treatment time, ICU length of stay (LOS), ICU mortality, and in-hospital 28-day mortality. A total of 283 patients were included in the study with 167 in the HFNC group and 116 in the NPPV group. The re-intubation rates after extubation in both groups were respectively 4.2% and 5.2% without significant difference. Patients in the HFNC group experienced lower incidence of delirium, reflux aspiration, facial pressure ulcer and other complications, and higher score of patients comfort than that in the NPPV group. There was no significant difference in ICU LOS, ICU mortality and in-hospital 28-day mortality between the two groups. HFNC and NPPV have similar efficacy in the sequential treatment of sepsis patients after weaning from MV. Compared with NPPV, those extubated to HFNC had lower rate of complications such as reflux aspiration and facial pressure ulcers. The patients extubation to HFNC is more comfortable (and associated with less delirium) than to NPPV.

145-LB: Glycemic Control Is Not an Independent Predictor of Mortality or Length of Stay for Patients Hospitalized with Coronavirus 2019 (COVID-19)

Diabetes mellitus (DM) is an important prognostic factor for coronavirus 2019 (COVID-19). However, studies of hospital glycemic control and outcomes controlled for factors that affect morbidity and mortality in pneumonia (PNA) are limited. We conducted a multicenter retrospective cohort study of patients ≥ 18 years (N=108) admitted to either the ICU or noncritical units January 1, 2020 to September 29, 2020 with a clinical diagnosis or radiographic evidence of PNA, laboratory confirmation of COVID-19, and DM or newly diagnosed hyperglycemia, defined as admission plasma glucose &amp;gt; 126 mg/dL or one or more random plasma glucose measurements &amp;gt; 200 mg/dL. Co-primary endpoints were mortality, ICU length of stay (LOS), and total hospital LOS stratified by mean capillary blood glucose (CBG) for hospitalization. Endpoints were compared by logistic, linear, or Poisson regressions controlling for demographic variables, prehospital HbA1c, residence, pneumonia severity index score, Sequential Organ Failure Assessment score (ICU patients), pulmonary consultation, infectious diseases consultation, and study site. Patients treated with dexamethasone (N=42) were evaluated separately from untreated patients. There was no difference in mortality for patients with mean hospital CBG &amp;lt; 180 mg/dL (30.1%) or ≥ 180 mg/dL (20.0%, P=0.24). Median total hospital LOS was 8 (5-15) and 8 (6-16) days for patients with mean CBG &amp;lt; 180 mg/dL or ≥ 180 mg/dL, respectively (P=0.35), and there was no difference in ICU LOS by glycemic status (P=0.19). No measures of glycemic control were independent predictors of mortality or LOS in multivariable regression analyses, and results were unaffected by dexamethasone treatment status. In this study controlling for multiple validated PNA prognostic factors, hospital glycemic control did not have a significant effect on mortality or LOS for patients with DM or newly diagnosed hyperglycemia hospitalized with COVID-19. Disclosure M. G. Jakoby: None. V. Williams: None. S. Ward: None. S. K. Lee: None. M. Buhnerkempe: None. K. Izuora: None.

Comparison of blood cultures versus T2 Candida Panel in management of candidemia at a large community hospital.

The T2 Candida Panel (T2CP) has high sensitivity and specificity to detect candidemia. Its role in the diagnosis and management of candidemia compared to blood cultures (BC) remains unclear. The purpose of this study was to evaluate the T2CP versus BC in detecting and treating candidemia. A retrospective, observational cohort study was conducted to compare clinical outcomes in patients with candidemia identified by BC versus T2CP. Patients with a positive BC or T2CP for Candida spp. from January 2012 to August 2020 were grouped by initial method of detection (BC vs T2CP). Co-primary endpoints assessed included time to detection of candidemia and time to antifungal therapy. Key secondary endpoints included length of stay (LOS), ICU LOS, and mortality. One hundred sixty-three patients with a positive BC and 89 patients with a positive T2CP were included in the evaluation. The average time to detection of candidemia was significantly shorter in the T2CP group compared to BC group (9 vs 41h, p< 0.001). The time to antifungal was also significantly shorter in the T2CP group compared to the BC group (4 vs 37h, p < 0.001). However, LOS was significantly shorter in the BC positive group than the T2CP group with no difference in ICU LOS. There was no difference in in-hospital or 30-day mortality between the two groups. Of patients diagnosed with candidemia at our large community hospital, identification by T2CP led to faster detection and initiation of antifungal compared to blood cultures without improvement in LOS or mortality.

EFFECTS OF DISCONTINUING VS TAPERING VASOPRESSIN INFUSION ON HEMODYNAMIC RECOVERY IN VASODILATORY SHOCK

SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Vasopressin (AVP) discontinuation strategies vary significantly despite its widespread use as an adjunctive agent in the treatment of vasodilatory shock. Several studies have looked at clinical outcomes associated with the discontinuation sequence of norepinephrine and AVP; however, these studies do not specify AVP de-escalation strategy. The purpose of our study is to compare the effect of gradual taper (GT) versus abrupt discontinuation (ADC) on the rates of clinically significant hypotension in patients recovering from vasodilatory shock. METHODS: This is a single-center, retrospective chart review of critically ill adult patients admitted to medical and surgical intensive care units from January 2016 to December 2019. The inclusion criterion was the confirmed administration of AVP infusion as an adjunct to catecholamine-based vasopressor therapy for at least one hour. Exclusion criteria included a primary diagnosis of cardiogenic shock, treatment with vasopressin as a sole vasopressor agent, vasopressin use for diabetes insipidus or organ donation, or transition to comfort care. The primary endpoint was the incidence of clinically significant hypotension after the initiation of vasopressin titration. Clinically significant hypotension was defined as hypotension requiring an increase or re-initiation of vasopressin, increase or re-initiation of catecholamine vasopressor, administration of fluid bolus, or a combination of these interventions. Secondary endpoints included duration of therapy and the number of vasopressors required. Additionally, ICU length of stay (LOS) and in-hospital mortality were evaluated. RESULTS: Of the 259 patients screened, a total of 46 patients were analyzed (15 in GT and 31 in ADC). Overall, the ADC group had a higher incidence of clinically significant hypotension, but this difference did not reach statistical significance (51.6% vs 26.7%, p = 0.11). While there were no differences in demographics or SOFA scores, the GT group tended to be on more vasopressors (3 vs 2, p = 0.05). In addition, of the 11 patients who received phenylephrine, the duration of therapy (59 hours vs 5 hours, p = 0.008) and the maximum dose (380 mcg/min vs 100 mcg/min, p = 0.0226) was higher in the GT group. There were no differences in ICU LOS or mortality between the two groups. CONCLUSIONS: Our study shows that, upon shock recovery, the abrupt discontinuation of vasopressin infusion was associated with numerically higher rates of clinically significant hypotension than gradual taper, although not statistically significant. There were no significant differences in LOS or in-hospital mortality. A larger study is needed to confirm these findings. CLINICAL IMPLICATIONS: The abrupt discontinuation of vasopressin may be relatively safe as it did not increase LOS or mortality. However, a gradual taper approach may be preferred in more profound shock, given the reduced rate of rebound hypotension. DISCLOSURES: No relevant relationships by Ola Elnadoury, source=Web Response No relevant relationships by Bhaskara Garimella, source=Web Response No relevant relationships by Andrew Lehr, source=Web Response No relevant relationships by Anthony Lubinsky, source=Web Response

Healthcare Resource Utilization of Ceftolozane/Tazobactam Versus Meropenem for Ventilated Nosocomial Pneumonia from the Randomized, Controlled, Double-Blind ASPECT-NP Trial.

IntroductionHospital-acquired and ventilator-associated bacterial pneumonia (HABP and VABP) are associated with significant healthcare resource utilization (HCRU). This a priori, exploratory, secondary analysis from the ASPECT-NP clinical trial evaluated resource utilization among patients with ventilated HABP (vHABP)/VABP treated with ceftolozane/tazobactam or meropenem.MethodsThis analysis used data from the randomized, double-blind, noninferiority phase 3 ASPECT-NP trial of patients with vHABP/VABP randomized to receive ceftolozane/tazobactam 3 g (ceftolozane 2 g/tazobactam 1 g) or meropenem 1 g for 8–14 days. Day 28 outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, and time to mechanical ventilation extubation in the microbiological intention-to-treat (mITT) population and in an HCRU population. The HCRU population, a subset of patients from the mITT population that were alive at day 28, was used to remove resource use bias influenced by mortality rates.ResultsCeftolozane/tazobactam-treated versus meropenem-treated patients, respectively, had fewer deaths (20.1% vs. 25.5%), fewer hospital discharges (30.7% vs. 32.4%), and higher ICU discharges (60.0% vs. 58.3%) and extubations (51.9% vs. 48.2%) by day 28. In the HCRU population, adjusted LOS differences (95% confidence intervals) for ceftolozane/tazobactam compared with meropenem were 0.1 (− 1.4 to 1.6) hospitalization days, − 1.4 (− 2.9 to 0.2) ICU days, and − 0.9 (− 2.4 to 0.7) mechanical ventilation days. Patterns were similar among the VABP and Pseudomonas aeruginosa subgroups.ConclusionSimilar 28-day resource utilization outcomes were observed between ceftolozane/tazobactam and meropenem in the mITT population of patients from ASPECT-NP with vHABP/VABP due to gram-negative pathogens. ASPECT-NP was not powered to detect differences in resource utilization outcomes between treatment groups; however, numerical differences in ICU LOS and duration of mechanical ventilation were noted. Further study is needed to assess resource utilization in the real-world practice setting, especially among patients excluded from ASPECT-NP, including those with resistant P. aeruginosa infections.Trial RegistrationsClinicalTrials.gov: NCT02070757, registered February 25, 2014; EudraCT: 2012-002862-11.Electronic supplementary materialThe online version of this article (10.1007/s40121-020-00343-0) contains supplementary material, which is available to authorized users.

Efficacy of Oscillation and Lung Expansion in Reducing Postoperative Pulmonary Complication

Postoperative pulmonary complications (PPCs) cause high morbidity and mortality. Targeted treatment for patients at risk for PPCs can improve outcomes. This multicenter prospective trial examined the impact of oscillation and lung expansion (OLE) therapy, using continuous high-frequency oscillation and continuous positive expiratory pressure on PPCs in high-risk patients. In stage I, CPT and ICD codes were queried for patients (n= 210) undergoing thoracic, upper abdominal, or aortic open procedures at 3 institutions from December 2014 to April 2016. Patients were selected randomly. Age, comorbidities, American Society of Anesthesiologists physical status classification scores, and PPC rates were determined. In stage II, 209 subjects were enrolled prospectively from October 2016 to July 2017 using the same criteria. Stage II subjects received OLE treatment and standard respiratory care. The PPCs rate (prolonged ventilation, high-level respiratory support, pneumonia, ICU readmission) werecompared. We also compared ICU length of stay (LOS), hospital LOS, and mortality using t-tests and analysis of covariance. Data are mean ± SD. There were 419 subjects. Stage II patients were older (61.1 ± 13.7 years vs 57.4 ± 15.5 years; p < 0.05) and had higher American Society of Anesthesiologists scores. Treatment with OLE decreased PPCs from 22.9% (stage I) to 15.8% (stage II) (p < 0.01 adjusted for age, American Society of Anesthesiologists score, and operation time). Similarly, OLE treatment reduced ventilator time (23.7 ± 107.5 hours to 8.5 ± 27.5 hours; p < 0.05) and hospital LOS (8.4 ± 7.9 days to 6.8 ± 5.0 days; p < 0.05). No differences in ICU LOS, pneumonia, or mortality were observed. Aggressive treatment with OLE reduces PPCs and resource use in high-risk surgical patients.

High-dose versus low-dose opioid anesthesia in adult cardiac surgery: A meta-analysis

Study Objective.We performed a systematic comparison of high-dose and low-dose opioid anesthesia in cardiac surgery. DesignSystematic review and meta-analysis of randomized controlled trials (RCTs). SettingOperating room. Patients1400 adult patients undergoing cardiac surgery using general anesthesia. InterventionsAll RCTs comparing the effects of various doses of intravenous opioids (morphine, fentanyl, sufentanil, and remifentanil) during adult cardiac surgery using general anesthesia published until May 2018 (full-text English articles reporting data from human subjects) were included. MeasurementsPrimary outcome was intensive care unit (ICU) length of stay (LOS). Secondary outcomes were ventilation time, use of vasopressors, perioperative myocardial infarction, perioperative stroke, and hospital LOS. Main resultsEighteen articles were included (1400 patients). There was no difference in ICU LOS between studies using high or low dose of opioids (both short-acting and long-acting) (standard mean difference [SMD]−0.02, 95%CI: −0.15–0.11, P = 0.74). Similarly, there was no difference in secondary outcomes of ventilation time (SMD−0.27, 95%CI: −0.63–0.09, P = 0.14), use of vasopressors (OR 0.61, 95%CI: 0.29–1.30, P = 0.20), myocardial infarction (risk difference 0.00, 95% CI: −0.02–0.03, P = 0.70), stroke (RD 0.00, 95% CI: −0.01–0.01, P = 0.92) and hospital LOS (SMD 0.03, 95% CI: −0.26–0.33, P = 0.84). At meta-regression, there was no effect of age, gender, or type of opioid on the difference between groups. ConclusionsOur data suggest that low-dose opioids, both short acting and long acting, are safe and effective to use in adult cardiac surgery patients, independent of the clinical characteristics of the patients and the type of opioid used. In view of the current opioid epidemic, low-dose opioid anesthesia should be considered for cardiac surgery patients.

A Propensity Score Analysis of Clostridium difficile Infection among Adult Trauma Patients.

Clostridium difficile infection (CDI) is now the most common cause of health-care-associated infection and carries a mortality rate ranging from 5-30%. Previously, trauma patients in whom CDI developed were thought to represent a unique younger at-risk population. This study aimed to establish the incidence of CDI among adult trauma patients. We hypothesized that these patients would have increased risk of death, intensive care unit (ICU) length of stay (LOS), and hospital LOS compared with trauma patients without CDI. A retrospective study of all adult trauma patients admitted for greater than 48 hours to a single Level I trauma center between 2014 and 2016 was conducted. Analysis was performed using 1-to-5 propensity score matching with the aim to analyze the relationship between CDI, death, and other outcome variables. Between 2014 and 2016, of 4893 trauma patients admitted for >48 hours, 27 (0.6%) patients received a diagnosis of CDI. These patients had a mean age of 55.6 years, mean injury severity score (ISS) of 22.4, and mortality rate of 9.1%. Of these patients, 22 were able to find appropriate propensity score matches. After adjusting for important covariables, there was no significant difference in death between CDI and non-CDI patients (odds ratio = 0.39, 95% confidence interval [CI]: 0.06-2.57, adjusted p = 0.66). In addition, there was no significant difference in ICU LOS between the two groups (relative mean [RM]: 1.55, 95% CI: 1.04-2.33, adjusted p = 0.0971). The CDI patients, however, did have a significantly longer hospital LOS, compared with non-CDI patients (RM = 1.39, 95% CI: 1.16-1.66, adjusted p = 0.0017). Among trauma patients admitted >48 hours CDI occurred at a rate of 0.6%, much lower than anticipated. Patients in whom CDI developed had a significantly longer hospital LOS however, had no significant difference in odds of mortality or ICU LOS compared to patients without CDI.

Timing of PROTein INtake and clinical outcomes of adult critically ill patients on prolonged mechanical VENTilation: The PROTINVENT retrospective study

Optimal protein intake during critical illness is unknown. Conflicting results on nutritional support during the first week of ICU stay have been published. We addressed timing of protein intake and outcomes in ICU patients requiring prolonged mechanical ventilation. We retrospectively collected nutritional and clinical data on the first 7 days of ICU admission of adult critically ill patients, who were mechanically ventilated in our ICU for at least 7 days and admitted between January 1st 2011 and December 31st 2015. Based on recent literature, patients were divided into 3 protein intake categories, <0.8g/kg/day, 0.8-1.2g/kg/day and >1.2g/kg/day. Our primary aim was to identify the optimum protein dose and timing related to the lowest 6 month mortality. Secondary endpoints were ventilation duration, need for renal replacement therapy (RRT), ICU length of stay (LOS) and mortality and hospital LOS and mortality. In total 455 patients met the inclusion criteria. We found a time-dependent association of protein intake and mortality; low protein intake (<0.8g/kg/day) before day 3 and high protein intake (>0.8g/kg/day) after day 3 was associated with lower 6-month mortality, adjusted HR 0.609; 95% CI 0.480-0.772, p<0.001) compared to patients with overall high protein intake. Lowest 6-month mortality was found when increasing protein intake from <0.8g/kg/day on day 1-2 to 0.8-1.2g/kg/day on day 3-5 and >1.2g/kg/day after day 5. Moreover, overall low protein intake was associated with the highest ICU, in-hospital and 6-month mortality. No differences in ICU LOS, need for RRT or ventilation duration were found. Our data suggest that although overall low protein intake is associated with the highest mortality risk, high protein intake during the first 3-5 days of ICU stay is also associated with increased long-term mortality. Therefore, timing of high protein intake may be relevant for optimizing ICU, in-hospital and long-term mortality outcomes.

High Ionized Calcium Concentration Is Associated With Prolonged Length of Stay in the Intensive Care Unit for Postoperative Pediatric Cardiac Patients

There has been controversy regarding the beneficial effects of calcium on myocardial contractility and the harmful effects on myocardial cells, especially in children. The aim of this study was to investigate an association between ionized calcium concentration (iCa) and outcomes for pediatric patients after cardiac surgery. A retrospective, single-center study from May 2013 to December 2014. Referral high-volume pediatric cardiac center in a tertiary teaching hospital. Patients <72 months old with congenital heart disease who underwent palliative or definitive surgery. None. The association between pH-corrected iCa within 24 hours after surgery and intensive care unit (ICU) length of stay (ILOS) was defined as the primary outcome. The highest iCa (iCamax), lowest iCa (iCamin), and time-weighted average iCa (iCaave) were stratified and compared with the outcomes. The authors reviewed 5,468 ionized calcium measurements from 357 consecutive pediatric patients during the study period. One patient died at postoperative day 34 in the ICU. Significant differences in ILOS were observed among patients after cardiopulmonary bypass (CPB) according to iCaave, iCamax, and iCamin but not among patients without CPB. Patients with CPB and an iCaave value of 1.31-to-1.40 mmol/L, 1.41-to-1.50 mmol/L, 1.51-to-1.60 mmol/L, and >1.60 mmol/L stayed in the ICU for 7 (interquartile range [IQR] 4-10) days, 8 (IQR 6-16) days, 10 (IQR 8-14) days, and 19 (IQR 12-38) days, respectively, which was significantly longer than the ILOS of 5 (4-8) days for patients with an iCaave of 1.21-to-1.30 mmol/L. Even after adjustment for other predictors of ILOS using multivariable analyses, there were significant relationships of ILOS with iCaave and iCamin values of >1.50 mmol/L among patients with CPB. Higher iCa within 24 hours after congenital cardiac surgery using CPB was independently associated with longer LOS in the ICU.