Duration Of Intensive Care Unit Admission Research Articles

Clinical investigation into risk factors for delirium post-cardiac surgery and its implications for nursing intervention guided by behavior change theory

BackgroundThis study explores the factors contributing to the occurrence of delirium following cardiac surgery and devises nursing strategies rooted in behavior change theory.MethodsA cohort of 320 cardiac surgery patients was selected, categorized into two groups: 93 cases where postoperative delirium (POD) was anticipated, and 227 cases where it was not. Preoperative, intraoperative, and postoperative factors of POD were scrutinized using single-factor analysis, while binary logistic regression analysis was employed to pinpoint risk factors.ResultsAmong the 320 patients, 93 displayed POD symptoms post-surgery, yielding an incidence of 29.06%. Preoperative univariate analysis disclosed significant differences in gender, age, smoking, hypertension, and diabetes (P < 0.05). Intraoperatively, significant differences were noted in the American Society of Anesthesiologists (ASA) anesthesia grade (II, III, and IV), surgery time, cardiopulmonary bypass duration, and aortic occlusion duration (P < 0.05). Post-surgery, significant differences were observed in the duration of Intensive Care Unit (ICU) stay, mechanical ventilation time, and visual analogue scale (VAS) scores (P < 0.05). Multivariate Logistic regression identified surgery time (OR = 2.334, P < 0.001), ICU admission duration (OR = 1.457, P < 0.001), mechanical ventilation time (OR = 1.235, P = 0.004), and VAS scores (OR = 2.986, P < 0.001) as independent risk factors for POD. ROC curve analysis indicated higher sensitivity and specificity in predicting POD with surgery time, ICU stay duration, mechanical ventilation time, and VAS scores.ConclusionIrrespective of the surgical intervention type, surgery time, ICU stay duration, mechanical ventilation time, and VAS scores are recognized as risk factors for POD in cardiac surgery patients. Hence, continuous patient monitoring and early intervention tailored to specific risk factors are essential in clinical practice to mitigate POD incidence.

Safety and Efficacy of N-Acetylcysteine as an Adjuvant Therapy in Critically Ill COVID-19 Patients

Abstract Background COVID-19 may cause pneumonia, acute respiratory distress syndrome, cardiovascular alterations, and multiple organ failure, which have been ascribed to a cytokinestorm, a systemic inflammatory response, and an attack by the immune system. Moreover, an oxidative stress imbalance has been demonstrated to occur in COVID- 19 patients. N- Acetyl-L-cysteine (NAC) is a precursor of reduced glutathione (GSH). Aim of the Work we retrospectively will investigate safety and efficacy of NAC dose given in paracetamol toxicity as an adjuvant therapy in critically ill COVID-19 patients with acute respiratory distress and determine whether NAC in high doses can avoid respiratory failure in patients with COVID-19. Patients and Methods This was a retrospective observational study in which all cases were collected from ICU of Ain shams university hospitals during COVID-19 outbreak. All data were extracted from clinical records. All patients initially admitted to ICU with SPO2 less than 94 % were included between December 2020 to February 2022. Exclusion Criteria included Need for immediate mechanical ventilation on admission, known allergy or hypersensitivity to NAC, end stage renal and liver diseases, heart failure and pregnancy. All patients with severe COVID-19 (confirmed or suspected received standard care, according to the institutional protocol. Results Patients were randomized into two equal groups (number (n)=40 each) as the N1(NAC) group who was given intravenously, initially 150 mg/kg in 200 mL of 0.9% NaCL for 60 minutes (first bag), followed by 50 mg/kg in 500 mL of 0.9% NaCL for 4 hours (second bag), and then 100 mg/kg in 1000 mL of 0.9%NaCL for 16 hours (third bag) and N2(Non NAC) group who received intravenously N-acetylcysteine (NAC) 600mg /12hr and The primary endpoint was the need for mechanical ventilation. Secondary endpoints were time of mechanical ventilation, admission to the intensive care unit (ICU), time in ICU, and mortality. There were no statistically significant differences between the two groups (p &amp;gt; 0.05) The effect of NAC on mechanical ventilations, mortality, ICU stays, and hospital stays is a matter of controverse in ARDS patients. We found that intravenous high dose of NAC did not improve oxygenation, mortality rate and did not reduce the requirement for mechanical ventilation when administered for COVID 19 patients with ARDS. Also, the duration of ICU and hospital stays were relatively prolonged in the NAC-treated patients. These might be due to prolonged survival time with NAC-treated patients, but not to be detected with the small single centered trial.. Conclusion Use of high doses of NAC administration can not affect the need of mechanical ventilation, rate of mortality, the need, duration of ICU admission and hospital stays for patients with severe COVID-19.

Acute Neuropsychiatric Symptoms During COVID-19: Results From Two Independent Cohort Studies.

Converging evidence suggests that COVID-19 infects not only the respiratory system, but also has a large impact on the central nervous system (CNS), leading to acute neuropsychiatric symptoms (NPSs) such as anxiety and delirium. It is thus far unclear which acute NPSs are most common in COVID-19 and if NPSs are associated with an altered COVID-19 disease course. We used data from two independent retrospective cohort studies performed in an academic hospital. A total of 93 patients with NPS and 125 patients without NPS were included. Main outcome measures consisted of type of acute NPS, COVID-19 severity (based on CT severity score), admission to the intensive care unit (ICU), and mortality. Most common acute NPSs were delirium, anxiety, and mood symptoms. NPS patients were more often admitted to the ICU than patients without NPS. However, there was no difference in duration of ICU admission, CT severity score, and mortality. Somatic comorbidity was similar between the two groups. These data suggest that delirium, anxiety, and mood symptoms were the most common NPS. Independent of other clinical characteristics, ICU admission in COVID-19 patients was associated with NPS. We recommend that all COVID-19 patients should be actively screened for acute NPS such as delirium, anxiety, and mood symptoms, especially when admitted to an ICU.

The application of enhanced recovery after surgery (ERAS) protocol in radical cystectomy and urinary diversion using bowel segment reduces the length of stay: A multicenter comparative study in Indonesia

Link of Video Abstract: https://youtu.be/GvdRCXyJmuk Introduction: Radical cystectomy is one of the most invasive urological procedures, with high difficulty and various complications. The Enhanced Recovery After Surgery (ERAS) protocol was created to improve patient outcomes after such surgery, including radical cystectomy. This study aims to evaluate the application of ERAS on radical cystectomy in Indonesia. Methods: This was a multicenter study (Jakarta, Yogyakarta, Bandung, and Medan) from July 2016 to April 2021. This study compared the postoperative length of stay, diet intake, bowel movement, and mobilization pattern of the subject receiving ERAS protocol with the non-ERAS subject. Curtailed, fast preoperative carbohydrate loading was administered to patients. There was no mechanical bowel preparation except one day before in selected cases. Postoperative patterns after surgery and the length of stay were analyzed. Results: We collected 128 subjects in this study, with 74 (60 %) subjects enrolled with ERAS protocol and 54 (40 %) with non-ERAS. There were statistically significant differences in length of stay with a median of 11 days vs. 16 (p: 0.001), intensive care unit admission duration with a median of 2 days vs. 3 (p: 0.004) and time to sit after radical cystectomy with a mean of 2.14 days vs 2.89 (p-: 0.004) in subject with ERAS protocol compared to non-ERAS protocol. Conclusion: This multicenter study found that ERAS was demonstrated to be efficacious in decreasing the duration of hospital stay, the duration of intensive care unit admission, and the time for the subject to sit after the radical cystectomy.

#4641 RISK FACTORS FOR RRT RESTART AFTER CESSATION OF CRRT: A MULTICENTER STUDY

Abstract Background and Aims Acute Kidney Injury occurs frequently in patients admitted to the Intensive Care Unit (ICU) and continuous renal replacement therapy (CRRT) is a commonly used treatment modality in these patients. Restart of renal replacement therapy (RRT) after initial discontinuation of CRRT is also frequently needed. The purpose of this study is to identify clinical characteristics and biomarkers influencing the restart of RRT after the cessation of CRRT, and to build a predictive model using these parameters. Method This multicenter retrospective study includes 891 patients who were treated using CRRT from July 2012 to December 2020 in the ICU of 3 academic hospitals. The primary end point observed was the restart of RRT during hospitalization. Baseline characteristics were compared between the no restart and restart RRT groups. Using univariate analysis and logistic regression, a prospective index was developed, and receiver operator characteristic (ROC) curve analysis was performed to confirm the predictivity of the prognostic index. Results Restart of RRT was needed in 632 (71.2%) patients. Compared to patients that did not restarting, patients in the restart RRT group demonstrated higher age, higher BMI, higher baseline serum creatinine (Cr), lower urine output, longer ICU admission, and more comorbid conditions (HTN, DM, HF, ischemic heart disease). In the multivariate analysis, five parameters demonstrated independent influence on restart of RRT: HTN, Cr, ICU admission duration, BMI, and mean blood pressure. The prognostic index, which was calculated from these variables, showed a satisfactory potential to predict the restart of RRT after discontinuation of CRRT. ROC analysis revealed an area under the curve of 0.738 (95% CI, 0.703-0.773, p&amp;lt;0.001). Conclusion We found that 5 of the 40 parameters observed in our study were independent risk factors for the restart of RRT during admission and we successfully developed a prognostic index based on these variables to predict the restart of RRT after discontinuation of CRRT.

Arterial thromboembolism (ATE) and mortality among COVID-19 patients in the intensive care unit (ICU): prevalence and risk factors

Abstract Funding Acknowledgements Type of funding sources: None. Objective To investigate the prevalence of arterial thromboembolic (TE) complications including stroke, peripheral arterial disease (PAD) and myocardial infarction (MI) and mortality among COVID-19 patients admitted to an ICU at a single centre hospital in the area of Klang Valley, Malaysia. The proportions of patients with ATE complication who died, and factors associated with the occurrence of ATE were explored. Methods Patients admitted to a single centre ICU with PCR confirmed of SARS-CoV-2 virus and received adequate thromboprophylaxis within February 2020-2021 were included in this retrospective Malaysian cohort study. ATE event is a combination of ≥1 stroke, PAD and MI. Results Mean (SD) age 56.6 (13.7), 63.5% were male, 61.6% Malays, median (IQR) 7 (3-14) days of ICU admission, 64.2%, 53.2 % and 20.9% had underlying hypertension, diabetes and obesity respectively. Of 534 patients, 21 (3.9%) developed stroke, 39 (7.3%) MI, 1(0.2%) PAD and 22.8% died despite adequate thromboprophylaxis. In total, only 58 (10.9%) developed ATE event during their ICU admission. Significantly higher proportions of COVID-19 patients admitted to ICU who developed complications of stroke (12.3% vs. 1.5; p&amp;lt;0.001) and MI (16.4% vs. 4.6%; p&amp;lt;0.001) died. Age, duration of ICU admission, proportion of underlying hypertension, stroke, IHD, diabetes, kidney disease, troponin, D-Dimer were significantly greater among those with ATE events. Predictors of ATE event on multivariate logistic regression analysis were duration of ICU admission [OR 1.0 (95% CI 1.00-1.04)] and troponin [OR 1.3 (95% CI 1.1-1.4)] level. Conclusion The overall prevalence of ATE complication among the severely ill COVID-19 patients was low (10.9%) with the overall mortality of 22.8% despite adequate thromboprophylaxis. Key predictors of ATE events included increased troponin level and duration of ICU admission. Perhaps a more aggressive preventive strategies can be undertaken to prevent further increase in the prevalence of arterial thromboembolism and death.

Thromboembolic complication among COVID-19 patients in the intensive care unit (ICU): a single-centre study from a Malaysian perspective

Funding AcknowledgementsType of funding sources: None.IntroductionThe emerging complications of thromboembolism (TE) in COVID-19 patients have led to severe consequence such as death. Nonetheless, the prevalence of TE complications among COVID-19 patients in the Intensive Care Unit (ICU) in Malaysia is unknown.ObjectiveTo investigate the prevalence of thromboembolic (TE) complications including venous [deep vein thrombosis (DVT), pulmonary embolism (PE), and line related thrombosis] and arterial [stroke, peripheral arterial disease and myocardial infarction (MI)] thrombosis and mortality among COVID-19 patients admitted to an ICU at a single centre hospital. The proportions of patients with TE complication who died, and factors associated with the occurrence of thrombotic complications were explored.MethodsIn this retrospective Malaysian cohort study, patients admitted to a single centre ICU with PCR confirmed of SARS-CoV-2 virus and received adequate thromboprophylaxis within February 2020-2021 were included. Thromboembolic (TE) event is a combination of venous and arterial thrombosis.ResultsMean (SD) age 56.6 (13.7), 63.5% were male, 61.6% Malays, median (IQR) 7 (3-14) days of ICU admission, 64.2%, 53.2% and 20.9% had underlying hypertension, diabetes and obesity respectively. Of 534 patients, 4 (0.7%) developed DVT, 198 (37.1%) PE and 2 (0.4%) line related thrombosis. Meanwhile, 21 (3.9%) developed stroke, 39 (7.3%) MI, 1(0.2%) PAD and 22.8% died despite adequate thromboprophylaxis. In total, 240 (44.9%) developed TE event during their ICU admission. Significantly higher proportions of COVID-19 patients who developed complications of DVT (2.5% vs. 0.2%; p = 0.013), PE (47.5% vs 34.0%; p = 0.006), stroke (12.3% vs. 1.5; p < 0.001) and MI (16.4% vs. 4.6%; p < 0.001) died. Age, duration of ICU admission, obesity, white cell count (WCC), troponin, D-Dimer and corticosteroid use were significantly greater among those with TE events. Demographics, co-morbidities, other laboratory parameters and inflammatory markers were similar in COVID-19 patients with and without TE events. Predictors of TE events on multivariate logistic regression analysis were age [OR 1.02 (95% CI 1.00-1.03)], obesity [OR 2.84 (95% CI 1.93-4.18)], WCC [OR 1.04 (95% CI 1.00-1.07)], and duration of ICU admission [OR 1.04 (95% CI 1.02-1.06)].ConclusionIn this cohort of severely ill COVID-19 patients, the overall prevalence of TE complication was high (44.9%) with the overall mortality of 22.8% despite adequate thromboprophylaxis. Key predictors of TE events included age, obesity, white cell count, and duration of ICU admission. Perhaps a more aggressive treatment (combination of thromboprophylaxis and enhanced anti-inflammatory treatment) may be needed among COVID-19 patients admitted to ICU with high risk factors to prevent further increase in the incidence of thromboembolism and death.

The Effect of High Glucose Intake on Weight Gain in Very Low Birth Weight Neonates: A Randomized Controlled Trial.

This study aims at evaluating the effect of high glucose intake as a component of total parenteral nutrition on birth weight (BW) regain in very low birth weight neonates. Ninety newborns with BW <1500 g were randomized to control or experimental groups. Both groups received the same total parenteral nutrition regimens except glucose intake provided by dextrose water (DW) serum: 7 to 15 g/kg/d (10% DW) in the former versus 8.75 to 18.75 g/kg/d (12.5% DW) in the latter. Body weight as the primary outcome was monitored until the BW was regained. Results revealed that neonates who received 12.5% DW regained BW significantly faster (10.98 ± 2.46 vs 13.24 ± 4.03 days, P = .024) and needed lesser duration of respiratory support (5.34 ± 2.11 vs 7.17 ± 3.19 days, P = .003). As the proposed intervention can reduce neonatal intensive care unit admission duration, it mitigates risks of health care-associated infections, while favorably affecting the health economy.

Single Stage Cleft Lip and Palate Repair In Toddlers: Retrospective Review of Feasibility and Operative Experience

In children with cleft lip and palate (CLP), we aimed to compare a single-stage surgery group or all in one (AIO) approach with a 2-stage surgery group (2-SSG) of 18 and 12 toddlers, respectively. A retrospective review of 30 patients with CLP was conducted between 2007 and 2019. All in one procedure was performed at 12 to 24 months and 2-SSG patients had lip and primary nasal correction at 3 to 9 months, followed by palatoplasty and myringotomies at 12 to 16 months. In the AIO group, 13 (72.2%) patients had unilateral CLP, while 5 (27.8%) had bilateral CLP, which is comparable to the 2-SSG who had 8 (66.7%) unilateral CLP, 3 (25%) bilateral CLP, and 1 (8.3%) incomplete CL with submucous CP. The 2-SSG had a 30 minutes longer cumulative operative time and increased blood loss that was not statistically significant (P = 0.149 and 0.219, respectively). The AIO group had a slightly longer intubation (0.67 versus 0.33 day) and pediatric intensive care unit admission duration of 1.72 versus 1.67 days, (P = 0.427, 0.927), respectively. Total hospitalization time was significantly shorter with the AIO (8 versus 10.67 days, P = 0.016). The duration of postoperative pediatric intensive care unit and need for supplemental oxygen were higher in the AIO (38.9% versus 8.3%, P = 0.064). The “AIO” approach of lip, nasal, and palate surgery from 12 to 24 months completes early surgical care in a single operation. However, based on our review, this protocol must be selective; children with comorbidities or syndromes are advised to be exempted and operated in stages.

Association of External Ventricular Drain Wean Strategy with Shunt Placement and Length of Stay in Subarachnoid Hemorrhage: A Prospective Multicenter Study.

Survivors of aneurysmal subarachnoid hemorrhage (SAH) face a protracted intensive care unit (ICU) course and are at risk for developing refractory hydrocephalus with the need for a permanent ventriculoperitoneal shunt (VPS). Management of the external ventricular drain (EVD) used to provide temporary cerebrospinal fluid diversion may influence the need for a VPS, ICU length of stay (LOS), and drain complications, but the optimal EVD management approach is unknown. Therefore, we sought to determine the effect of EVD discontinuation strategy on VPS rate. This was a prospective multicenter observational study at six neurocritical care units in the United States. The target population included adults with suspected aneurysmal SAH who required an EVD. Patients were preassigned to rapid or gradual EVD weans based on their treating center. The primary outcome was the rate of VPS placement. Secondary outcomes were EVD duration, ICU LOS, hospital LOS, and drain complications. A rapid EVD wean protocol was associated with a lower rate of VPS placement, including a delayed posthospitalization shunt, in an adjusted Cox proportional analysis (hazard ratio 0.52 [p = 0.041]) and adjusted logistic regression model (odds ratio 0.43 [95% confidence interval 0.18-1.03], p = 0.057). A rapid wean was also associated with 2.1 fewer EVD days (p = 0.007) and saved an estimated 2.5 ICU days (p = 0.049), as compared with a gradual wean protocol. There were fewer nonfunctioning EVDs in the rapid group (odds ratio 0.32 [95% confidence interval 0.11-0.92]). Furthermore, we found that the time to first wean and the number of weaning attempts were important independent covariates that affected the likelihood of receiving a VPS and the duration of ICU admission. A rapid EVD wean was associated with decreased rates of VPS placement, decreased ICU LOS, and decreased drain complications in survivors of aneurysmal SAH. These findings suggest that a randomized multicentered controlled study comparingrapid vs. gradual EVDweaning protocols is justified.

Comparison of Goal-Directed Fluid Therapy using LiDCOrapid System with Regular Fluid Therapy in Patients Undergoing Spine Surgery as a Randomised Clinical Trial.

Goal-directed fluid therapy (GDFT) is a new concept to describe the cardiac output (CO) and stroke volume variation to guide intravenous fluid administration during surgery. LiDCOrapid (LiDCO, Cardiac Sensor System, UK Company Regd 2736561, VAT Regd 672475708) is a minimally invasive monitor that estimates the responsiveness of CO versus fluid infusion. We intend to find whether GDFT using the LiDCOrapid system can decrease the volume of intraoperative fluid therapy and facilitate recovery in patients undergoing posterior fusion spine surgeries in comparison to regular fluid therapy. This study is a randomised clinical trial, and the design was parallel. Inclusion criteria for participants in this study were patients with comorbidities such as diabetes mellitus, hypertension, and ischemic heart disease undergoing spine surgery; exclusion criteria were patients with irregular heart rhythm or severe valvular heart disease. Forty patients with a previous history of medical comorbidities undergoing spine surgery were randomly and evenly assigned to receive either LiDCOrapid guided fluid therapy or regular fluid therapy. The volume of infused fluid was the primary outcome. The amount of bleeding, number of patients who needed packed red blood cell transfusion, base deficit, urine output, days of hospital length of stay and intensive care unit (ICU) admission, and time needed to start eating solids were monitored as secondary outcomes. The volume of infused crystalloid and urinary output in the LiDCO group was significantly lower than that of the control group (p = .001). Base deficit at the end of surgery was significantly better in the LiDCO group (p < .001). The duration of hospital length of stay in the LiDCO group was significantly shorter (p = .027), but the duration of ICU admission was not significantly different between the two groups. Goal-directed fluid therapy using the LiDCOrapid system reduced the volume of intraoperative fluid therapy.

Effectiveness of Prone Positioning in Nonintubated Intensive Care Unit Patients With Moderate to Severe Acute Respiratory Distress Syndrome by Coronavirus Disease 2019.

In the treatment for severe acute respiratory distress syndrome (ARDS) from coronavirus disease 2019 (COVID-19), the World Health Organization (WHO) recommends prone positioning (PP) during mechanical ventilation for periods of 12-16 h/d to potentially improve oxygenation and survival. In this prospective observational study, we evaluated the ability of long PP sessions to improve oxygenation in awake intensive care unit (ICU) patients with moderate or severe ARDS due to COVID-19. The study was approved by the ethics committee of Galicia (code No. 2020-188), and all patients provided informed consent. In this case series, awake patients with moderate or severe ARDS by COVID-19 admitted to the ICU at University Hospital of Santiago from March 21 to April 5, 2020 were prospectively analyzed. Patients were instructed to remain in PP as long as possible until the patient felt too tired to maintain that position. Light sedation was administered with dexmedetomidine. The following information was collected: number and duration of PP sessions; tissue O2 saturation (StO2) and blood gases before, during, and following a PP session; need of mechanical ventilation; duration of ICU admission; and ICU outcome. Linear mixed-effects models (LMM) were fit to estimate changes from baseline with a random effect for patient. Seven patients with moderate or severe ARDS by COVID-19 were included. All patients received at least 1 PP session. A total of 16 PP sessions were performed in the 7 patients during the period study. The median duration of PP sessions was 10 hours. Dexmedetomidine was used in all PP sessions. Oxygenation increased in all 16 sessions performed in the 7 patients. The ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FIO2) significantly increased during PP (change from baseline 110 with 97.5% confidence interval [CI], 19-202) and, after PP, albeit not significantly (change from baseline 38 with 97.5% CI, -9.2 to 85) compared with previous supine position. Similarly, tissue oxygenation underwent a small improvement during PP (change from baseline 2.6% with 97.5% CI, 0.69-4.6) without significant changes after PP. Two patients required intubation. All patients were discharged from the ICU. We found that PP improved oxygenation in ICU patients with COVID-19 and moderate or severe ARDS. PP was relatively well tolerated in our patients and may be a simple strategy to improve oxygenation trying to reduce the number of patients in mechanical ventilation and the length of stay in the ICU, especially in COVID-19 pandemic.

Ventilator-associated Pneumonia: Multidrug Resistant Acinetobacter vs. Extended Spectrum Beta Lactamase-producing Klebsiella.

Ventilator-associated pneumonia (VAP) has been considered as a healthcare-associated infection with high mortality. Acinetobacter baumannii and Klebsiella pneumoniae are the common causes of VAPs around the world. This research was a retrospective observational study in the intensive care unit (ICU) in a tertiary referral collegiate hospital in Tehran between March 2016 and May 2018. Patients who fulfilled VAP due to documented Multidrug Resistant Acinetobacter baumannii (MDR-AB) or Extended Spectrum Beta Lactamase-producing Klebsiella pneumoniae (ESBL-KP) criteria were enrolled. General demographic features, duration of hospital stay, antimicrobial treatment regimens, duration of ICU admission, the period of mechanical ventilation (MV) and 30-day mortality were documented and compared. 210 patients were found with clinical, microbiological and radiological evidence of VAP. In total, 76 patients with MDR-AB and 76 patients with ESBL-KP infections were matched in the final analysis. Duration of hospitalization in the patients with MDR-AB was significantly more than that of patients infected with ESBL-KP (p-value: 0.045). Patients diagnosed with MDR-AB VAP had a 65.8% mortality rate compared to 42.1% in the ESBL-KP infection group (p = 0.003). Results of the present study demonstrated that VAPs caused by MDR-AB may be more hazardous than ESBL-KP VAPs because they could be accompanied by a longer hospitalization course and even a higher mortality.

Can glyburide be advocated over subcutaneous insulin for perinatal outcomes of women with gestational diabetes? A systematic review and meta-analysis.

To obtain precise findings from published studies about the efficacy and safety of glyburide versus subcutaneous insulin in patients with gestational diabetes mellitus (GDM). We searched PubMed, Cochrane Library, Web of Science, and Scopus, up to January 2019, for relevant studies that compared glyburide with subcutaneous insulin for patients with GDM. We extracted maternal and neonatal outcomes from included studies, performed meta-analysis, evaluated heterogeneity, assessed the risk of bias of included studies, and conducted subgroup and sensitivity analyses. A total of 24 studies (11 randomized controlled trials (RCTs) and 13 observational cohort studies) with a total of 24,517 women were included in the present study. The pooled estimate showed that glyburide significantly decreased the need for cesarean section (OR = 0.87, 95% CI [0.82, 0.92], p < 0.0001), fasting blood glucose (MD -5.63mg/dL, 95% CI [-10.97, -0.28], p = 0.04), and Apgar score at 5min (MD -0.30, 95% CI [-0.36, -0.23], p < 0.001) than insulin. However, glyburide significantly increased the risk of neonatal hypoglycemia (OR = 1.42, 95% CI [1.03, 1.95], p = 0.03) and neonatal intensive care unit admission duration (NICU) (MD 4.26days, 95% CI [2.65, 5.86], p < 0.01) compared to insulin. The overall results did not favor either group in terms of macrosomia (OR = 1.14, 95% CI [0.92, 1.41], p = 0.25) and large for gestational age (LGA) (OR = 1.38, 95% CI [0.99, 1.92], p = 0.06). While subgroup analysis of RCTs showed that maternal hypoglycemia and LGA rates were significantly higher in glyburide than insulin and cesarean section rates were comparable between both compared groups. Our study suggests that glyburide is an effective and well-tolerated drug compared to insulin in the management of women with GDM, provided neonates are monitored for hypoglycemia and Apgar score. In addition, glyburide was associated with lower cesarean sections, which may add to the potential clinically benefits of glyburide compared to insulin.

An Observational Study of QTc Prolongation in Critically Ill Patients: Identification of Incidence and Predictors.

ABSTRACTAimsDespite the importance of abnormal QTc interval values in intensive care unit (ICU) patients, there is a paucity of information on this topic. The current study was designed to identify the incidence and predictors of QTc prolongation in medical (M), surgical (S), and emergency (E) ICUs.Materials and methodsA prospective observational study was conducted for 6 months. Patients more than 18 years old who admitted to MICU, SICU, and EICU were included in the study. Electrocardiogram (ECG) was taken on day 1, 3, and 5 of ICU admission. The QTc intervals >460 ms in male and >470 ms in female and increased >60 ms above baseline were considered QTc prolongation. Comparative analysis was done between two groups of patients (normal vs prolonged QTc). Logistic regression models were carried out to determine the predictors of QTc prolongation.ResultsIncidence of QTc prolongation was 6.5, 9.8, and 15.7% on day 1, 3, and 5 of ICU admission, respectively. On day 1, the history of alcohol addiction and the reason of ICU admission were associated with a prolonged QTc. A significant association was demonstrated between administration of azithromycin and QTc prolongation on day 3. High serum creatinine and hospitalization in EICU were predictors of QTc prolongation on day 5 of ICU admission.ConclusionThe QTc prolongation is relatively common among patients admitted to ICUs and its incidence increases with increasing length of hospital stay. Predictors of QTc prolongation may be affected by the duration of ICU admission. Physicians should consider these predictors particularly before prescribing QTc-prolonging drugs.How to cite this articleFarzanegan B, Hosseinpoor Z, Baniasadi S, Seyyedi SR, Rajabi M. An Observational Study of QTc Prolongation in Critically Ill Patients: Identification of Incidence and Predictors. Indian J Crit Care Med 2020;24(4):270–275.

Augmented Renal Clearance in Critically Ill Patients in Malaysian Intensive Care Unit: Assessment of Prevalence, Risk Factors and Outcomes

Introduction: Augmented renal clearance (ARC) is a phenomenon where there is elevated renal clearance and defined by creatinine clearance &gt;130ml/min. ARC results in changes of the pharmacokinetic and pharmacodynamic of antimicrobial therapy being administered resulting in its subtherapeutic dose. We evaluated the prevalence, risk factors and outcome of ARC in critically ill patients in two Intensive Care Units (ICU) in Kuantan. Materials and Methods: This was a two centre, prospective observational study of critically ill patients. Inclusion criteria were patients older than 15 years old with plasma creatinine &lt;130µmol/l, with arterial line and urinary catheter inserted. The creatinine clearance (CrCl) were measured using plasma creatinine, urinary creatinine and urinary flow rate. ARC is defined as CrCl of more 130ml/min. Results: Among 102 patients recruited, 57 (55.9%) had ARC. Those with younger age (39.9±19 years old, p=0.013) and lower SOFA score (2.8±2.6, p=0.012) had increased risk of developing ARC. No significant difference in other risk factors such as male and trauma were found. There was no difference in the ICU and hospital mortality (p=0.652 and p=0.128). There was also no difference in the duration of ICU admission amongst survivors with or without ARC (100.6±142.3). Measured CrCl correlated well with the estimated glomerular filtration rate (eGFR) using all four different eGFR equations (r=0.436 to 0.552, p&lt;0.0001). Conclusion: ARC occurs in almost half of critically ill patients and more common in younger age and lower SOFA score. However, there was no difference in the outcome. eGFR may be used as surrogate in detecting ARC.

Blood Loss Due to Laboratory Testing in Critical Care Patients: A Retrospective Cohort Study

Background: Anemia and red blood cell (RBC) transfusions occur frequently in intensive care unit (ICU) patients and are associated with morbidity and mortality. Observational data suggest that anemia (nadir hemoglobin ≤ 9 g/dL) in ICU patients is associated with an increased risk of death within 30 days (OR 1.54, 95% confidence interval [CI] 1.12-2.12). Although anemia in this population is likely multifactorial, phlebotomy for laboratory testing is substantial (up to 41 mL/day) and may be a modifiable contributor as only 10% of the blood collected is required for analysis. This study aims to (i) characterize the blood volume taken for laboratory testing in ICU patients, and (ii) explore the effect of blood taken for testing on rates of RBC transfusion and anemia in a contemporary cohort of ICU patients.Methods: We conducted a retrospective cohort study of consecutive adult patients, age ≥18 years, admitted to a medical-surgical ICU for ≥48 hours in Hamilton, Ontario between November 1, 2012 to October 1, 2015. We extracted data from previously validated administrative databases. The primary outcome was estimated volume of blood drawn for laboratory testing during index ICU admission calculated using the number of unique blood specimens drawn and known sampling tube volumes. Secondary outcomes included: incidence of severe anemia (hemoglobin ≤9 g/dL), discharge hemoglobin adjusted for RBC transfusion (1.0 g/dL subtracted for each RBC transfusion administered), proportion of patients receiving RBC transfusion, number of RBC units transfused per patient, duration of ICU admission and ICU mortality. Categorical data are reported as counts and proportions. Continuous data are reported as means with standard deviations (SD) or medians with interquartile range (IQR). Predictors of RBC transfusion were examined using Cox regression analysis. P-values <0.05 were considered statistically significant.Results: We included 7,273 ICU patients. The median age was 66 years (IQR 54-76 years) and 40.8% of patients were female. Most responsible diagnosis was circulatory (33.3%), followed by injury/poisoning (15.9%), respiratory (12.8%), and gastrointestinal (9.2%). The ICU mortality rate was 13.8% and the median ICU length of stay was 5 days (IQR 3-10 days). On ICU admission, median hemoglobin value was 9.7 g/dL (IQR 8.2-11.6 g/dL) and 39.6% of patients had hemoglobin ≤ 9.0 g/dL.Median blood loss due to laboratory testing was 25 mL per patient per day (IQR 14-43 mL) and 213 mL per patient for the ICU admission (IQR 133-382 mL). On ICU discharge, median hemoglobin was 8.4 g/dL (IQR 5.8-10.5 g/dL), and 67.0% of patients had hemoglobin ≤ 9.0 g/dL while in ICU. After adjusting for RBC transfusions, the median decrease in hemoglobin from ICU admission to discharge was 1.2 g/dL (IQR 0-2.9 g/dL). RBC transfusions were administered to 47.5% of patients while in the ICU with 37.3% of these patients receiving 5 or more units. The median number of RBC units received in transfused patients was 3 (IQR 2-7). Additional blood drawn for laboratory testing of 150 mL from day 2 to day 7 of ICU admission (hazard ratio [HR] 2.3, 95%CI 2.1-2.5), hematologic diagnosis vs. other (HR 1.5, 95%CI 1.2-2.0), and RBC transfusion prior to ICU admission vs. none (HR 1.5, 95%CI 1.2-1.9) were associated with a higher risk of RBC transfusion in the ICU.Conclusions: Anemia and RBC transfusions are frequent in ICU patients with two-thirds of patients developing severe anemia (hemoglobin <9.0 g/dL) and 47.5% receiving RBC transfusion, respectively. Our results suggest that blood loss for laboratory testing remains substantial in contemporary medical-surgical ICU patients and is associated with the need for RBC transfusion. Strategies to reduce blood loss from laboratory testing represent an area for further prospective investigation. DisclosuresSiegal:BMS-Pfizer: Honoraria; Bayer: Honoraria; Portola Pharmaceuticals: Honoraria.

Comparing effects between music intervention and aromatherapy on anxiety of patients undergoing mechanical ventilation in the intensive care unit: a randomized controlled trial.

Using patient-reported outcomes and physiological indicators to test the effects of music intervention and aromatherapy on reducing anxiety for intensive care unit (ICU) patients undergoing mechanical ventilation. Patients with ICU admission duration >24h were randomly assigned to a Music intervention group (n = 41), Aromatherapy group (n = 47), or Control group (rest only; n = 44). Each patient in the Music group listened to music; each patient in the Aromatherapy group received lavender essential oil massage on his/her back for 5min; each patient in the Control group wore noise-canceling headphones. Anxiety was measured using the Chinese version of the Stage-Trait Anxiety Inventory (C-STAI) and the Visual Analogue Scale for Anxiety (VAS-A) at baseline, post-test, and 30-min follow-up. Heart rate, breathing rate, and blood pressure were measured every 10min from baseline to the 30-min follow-up. The Music group had significantly better post-test VAS-A and C-STAI scores, and had lower heart rate and blood pressure than the Control group. The Aromatherapy group had significantly better VAS-A score and lower heart rate than the Control group. The 30-min follow-up showed that both Music and Aromatherapy groups had lower heart rate and blood pressure than the Control group. Music and aromatherapy interventions were both effective for ICU patients. The effects of music intervention were greater than that of aromatherapy; both interventions maintained the effects for at least 30min.

Mortality rates increase dramatically below a systolic blood pressure of 105-mm Hg in septic surgical patients

BackgroundThis study used a prospective surgical database, to investigate the level of systolic blood pressure (SBP) at which the mortality rates begin to increase in septic surgical patients. MethodsAll acute, septic general surgical patients older than 15 years of age admitted between January 2012 and January 2015 were included in these analyses. ResultsOf a total of 6,020 adult surgical patients on the database, 3,053 elective patients, 1,664 nonseptic, 52 duplicates, and 11 patients with missing SBP were excluded to leave a cohort of 1,232 acute, septic surgical patients. The median age (intraquartile range [IQR]): 48 (32 to 62) and roughly 50:50 sex ratio (620 female: 609 male). Most of the patients were African: 988 (80.2%) followed by Asians (128 or 10.4%). More than two-thirds (852 or 69.2%) of the patient cohort underwent some form of surgery, and 152 or 12.3% required intensive care unit (ICU) admission. The median length of ICU stay (IQR) was 2 (1 to 4.5) days. The median length of total hospital stay (IQR) was 4 (2 to 9) days. The median SBP (IQR) on admission was 122 (107 to 138). A total of 167 patients died (13.6%). Those that died did have a significantly lower mean SBP compared with the survivors (116 vs 125, P <. 001). Six of 10 patients (60%) with a SBP less than 70 died. The receiver operating characteristic analysis suggests an optimal SBP cut-off of 111 when predicting mortality (area under the receiver operating characteristic curve: .6 [.551, .65]). This cut-off yields a moderate sensitivity (70%), high positive predictive value (90%) but low specificity, and negative predictive value when predicting mortality. Based on this optimal cut-off, 388 or 31.5% of the patients would be classified as shocked. The inflection curve below with fitted nonlinear curve (95% confidence intervals) clearly shows the upward change in observed mortality frequency at lower systolic and base excess (ie base deficit) values. Shocked patients had a significantly higher frequency of mortality (20% vs 11%, P < .001), a significantly higher median lactate (1.9 vs 1.5, P < .001), and mean base deficit (−2.8 vs −1.0, P = .001). No significant difference in mean age, ICU admission, duration of ICU admission, and total length of hospital stay was observed by shocked status. ConclusionsOur data suggest that patients who die have a significantly lower SBP and clinically significant hypotension in sepsis with regard to increased mortality risk begins at a level of ∼111-mm Hg. This finding needs to be incorporated into bundles of care for surgical sepsis.

The predictive value of systemic inflammatory response syndrome on the outcome of perforated viscus in adult

Purpose: Perforated viscus is one of the most series conditions that need to be evaluated and studied, especially if it associated with systemic inflammatory response syndrome (SIRS). There are some studies carried out in the same subject that do not exactly clarify the predictive role of SIRS in the evaluating patients with perforated viscus, and they lack of a strong result foundation of the subject. Objective: The main purpose of this study is to evaluate the role of SIRS criteria in patients with perforated viscus and to see if SIRS have important value in predicting the surgical intervention, complications, Intensive Care Unit (ICU) admission, mortality, the outcome, and its effect on them later on. Methods: A retrospective study was carried out which included sixty patients with perforated viscus presented to Al-Noor Hospital Emergency Department in Makkah during 1435H. Certain variables including SIRS criteria were collected using a data collecting sheet. These variables are comorbidities, vital sign on presentation, the result of certain investigation), intervention which had done, presence of postoperative complication, ICU length stay, and outcome. Results: The role of SIRS criteria in patients with perforated viscus was found to be statistically significant as regards the patient's gender, the type of surgical intervention (either laparoscopic or open), and the duration of ICU admission, with P P > 0.05. Conclusion: SIRS criteria in patients with Perforated visus (PV) can be used clinically to predict the need for surgical intervention and ICU admission.