General Surgical Intensive Care Unit Research Articles

Effectiveness of Sublingual Buprenorphine for Pain Control in the ICU.

The objective of this study was to compare pain control and opioid consumption in critically ill patients who were treated with buprenorphine sublingual or oxycodone oral/enteral during ICU admission. This was a retrospective, parallel, cohort study. General medical or surgical ICUs of a quaternary, urban hospital in Sydney, NSW, Australia. Data were obtained for all patients admitted to two general medical or surgical ICU from January 2019 to January 2023. Patients were grouped as those who received buprenorphine sublingual versus oxycodone oral/enteral. None. Pain control was compared between a propensity score matched cohort of patients who received buprenorphine versus oxycodone. The primary outcome was the probability of significant pain. A significant pain score was defined as greater than or equal to 4 on the 0-10 Numeric Rating Scale or greater than or equal to 6 on the Behavioral Pain Scale. The study cohort included 1,070 patients (288 buprenorphine and 782 oxycodone). After propensity score matching, there were 288 patients in each group. The mean age of the matched cohort was 64 ± 16 years, 295 (51%) were male, and 359 (62%) had a surgical admission. The median probability of significant pain was 0.16 with buprenorphine and 0.17 with oxycodone (median difference, 0.01; 95% CI, -0.02 to 0.04; p = 0.50). Median opioid consumption in oral morphine milligram equivalents (MMEs) was 65 with buprenorphine and 70 with oxycodone (median difference, -1 mg; 95% CI, -10 to 10 mg; p = 0.73). Median MME per ICU day was 22 with buprenorphine and 22 with oxycodone (median difference, 1 mg; 95% CI, -2 to 5 mg; p = 0.38). Buprenorphine sublingual is as effective as oxycodone oral/enteral with regard to pain control and opioid consumption in the ICU. Buprenorphine sublingual is an appropriate option for patients in the ICU who are unable to take oral/enteral medications.

Clinical characteristics and outcomes of extracorporeal membrane oxygenation used in a non-cardiac surgical intensive care unit: Siriraj experiences and literature review

Background: Extracorporeal membrane oxygenation (ECMO) has substantially increased in frequency of use over the past decades. Occasionally, patients who require ECMO support are admitted to an ICU rather than medical or cardiac ICU, where physicians may be not familiar with the process of how to care for ECMO patients. The aims of this case series were to explore the utilization of ECMO support in a non-cardiac general surgical ICU (SICU) in terms of indications, ECMO-related complications and clinical outcomes. Methods: Adult patients admitted to the SICU from January 2014 to June 2021 who received ECMO support were included. Demographic data, data regarding ECMO utilization and clinical outcomes were described. Current evidence and updated literature were also researched and reviewed. Results: A total of 18 patients were admitted to the SICU and received ECMO support, but four died within four hours of SICU admission. The most common reason for ECMO support was extracorporeal cardiopulmonary resuscitation (ECPR) (9 cases, 50.0%), followed by cardiac and/or respiratory support. The majority of patients received venoarterial ECMO support (15 cases, 83.3%). Unfractionated heparin was used in 10 cases (71.4%) and the anticoagulant effect was monitored with aPTT, which was maintained at a lower range (30–50 seconds). There was no thromboembolic event, and four patients (28.6%) developed major bleeding. The overall hospital mortality was as high as 77.8%. Conclusion: There was a small volume of cases receiving ECMO support in the SICU. ECPR was the most common reason for ECMO support in these patients. Overall, the hospital mortality was 77.8%. To improve outcomes in these patients, appropriate patient selection, well-organized protocols, and a multidisciplinary approach are mandatory.

An innovative idea and design scheme of continuous arterial blood glucose monitoring equipment

Hyperglycemia is a common complication of critical patients. Currently, clinical assessment of the changes in the blood glucose of critical patients is mainly based on the intermittent monitoring of peripheral blood glucose at a certain time point. This method cannot get the true blood glucose fluctuation, and it is more difficult to find asymptomatic hyperglycemia and hypoglycemia, so the guiding value of blood glucose control is limited. Arterial blood is the most accurate sample of blood glucose monitoring, so it is urgent to ensure the accuracy of arterial blood sample. A continuous arterial blood glucose monitoring equipment was independently developed by general surgical intensive care unit (ICU) of the First Affiliated Hospital of Nanjing Medical University, and National Utility Model Patent of China was obtained. It could greatly improve the efficiency of medical staff, and provide accurate and dynamic statistic data that would be an important basis for doctors' clinical decision-making. The continuous arterial blood glucose monitoring equipment was mainly composed of arterial pressure measuring monitor, program-controlled dynamic blood glucose meter, wire, electric switch, integrated collecting syringe, electric clip, rotary electric bracket, and blood glucose test strips, etc., which could be continuously and dynamically monitor patient blood glucose levels and perform various additional value-added functions such as automatic recording and alarming.

FRESH FROZEN PLASMA

Introduction: As the use of Fresh Frozen Plasma (FFP) is having establishedcomplications including Allergic reactions, infectious complications, hemolysis, fluid overload, transfusion related acute lung injury (TRALI) and immune suppression, therefore it mustbe used cautiously. Objectives: To evaluate the inappropriate use of FFPs, to carry out anaudit of appropriateness of FFP transfusion with reference to international guidelines and setfoundations for blood bank and transfusion protocols. Study Design: Cross sectional study.Setting: Khyber Teaching Hospital Peshawar. Period: 6 months, 1st January 2016 to 30th June2016. Methods: During which FFP transfusion requests made to the blood bank by various unitsof the hospital were studied including general surgery, surgical ICU, general medicine, medicalICU, gynecology and obstetrics. Seventy Six requests were received that were judged using6 variables: indication for FFP use, sampling errors, laboratory analysis errors, interpretationerrors, dosage of FFP (number of units being transfused) and timing of FFP transfusion. Scoreof “1” was given for each correct variable. After matching data to the international protocols, ascore of 4-5 was taken as appropriate and <3 was classified as inappropriate. Results: TwentySeven (35.5%) FFP transfusions were done with a score of 4-5 and were considered appropriatewhile 49(64.5%) FFP transfusions were given a score of 3 or less and were consideredinappropriate. Conclusions: Almost two third of FFP were used inappropriately in our hospital,the commonest indication being acute Disseminated Intravascular Coagulation (DIC) andmostly requested from surgical units. Maximum cases of inappropriate transfusions were dueto wrong sampling techniques and wrong dosage calculations. Most inappropriate transfusionswere done in MICU. It is recommended that annual clinical audit of all blood products usageshould be conducted. Local guidelines for physicians and training programs for nurses andparamedics regarding proper use of blood products should be established.

INAPPROPRIATE USE OF FRESH FROZEN PLASMA AN AUDIT OF A TERTIARY CARE HOSPITAL.

Introduction: As the use of Fresh Frozen Plasma (FFP) is having establishedcomplications including Allergic reactions, infectious complications, hemolysis, fluid overload, transfusion related acute lung injury (TRALI) and immune suppression, therefore it mustbe used cautiously. Objectives: To evaluate the inappropriate use of FFPs, to carry out anaudit of appropriateness of FFP transfusion with reference to international guidelines and setfoundations for blood bank and transfusion protocols. Study Design: Cross sectional study.Setting: Khyber Teaching Hospital Peshawar. Period: 6 months, 1st January 2016 to 30th June2016. Methods: During which FFP transfusion requests made to the blood bank by various unitsof the hospital were studied including general surgery, surgical ICU, general medicine, medicalICU, gynecology and obstetrics. Seventy Six requests were received that were judged using6 variables: indication for FFP use, sampling errors, laboratory analysis errors, interpretationerrors, dosage of FFP (number of units being transfused) and timing of FFP transfusion. Scoreof “1” was given for each correct variable. After matching data to the international protocols, ascore of 4-5 was taken as appropriate and <3 was classified as inappropriate. Results: TwentySeven (35.5%) FFP transfusions were done with a score of 4-5 and were considered appropriatewhile 49(64.5%) FFP transfusions were given a score of 3 or less and were consideredinappropriate. Conclusions: Almost two third of FFP were used inappropriately in our hospital,the commonest indication being acute Disseminated Intravascular Coagulation (DIC) andmostly requested from surgical units. Maximum cases of inappropriate transfusions were dueto wrong sampling techniques and wrong dosage calculations. Most inappropriate transfusionswere done in MICU. It is recommended that annual clinical audit of all blood products usageshould be conducted. Local guidelines for physicians and training programs for nurses andparamedics regarding proper use of blood products should be established.

LOW LEVEL OF ANTITHROMBIN III AS A WARNING SIGN FOR DEVELOPING THROMBOTIC COMPLICATIONS IN SURGICAL PATIENTS

Introduction.Pulmonary embolism (PE), being the most severe embolic complication, is characterised by low predictability, high mortality and incapacitation rates as well as a correspondingly high economic cost of therapy and aftercare. In this connection, the main purpose of our work is to find a warning for PE development in non-cardiosurgical patients that have undergone intensive therapy under conditions of general surgical ICU, among the indicators of the haemostasis system.Materials and methods. Based at the anaesthesiology and emergency surgical department № 1 of the Kuvatov Republic Clinical Hospital (Russia), the researchers carried out an analysis of the haemostasis system in 430 patients hospitalised between 2010 and 2014. The functional activity of platelets was studied using a Biola 230LA laser platelet aggregation analyser (Russia). The determination of circulating aggregates was conducted using the Wu — Hoak method. Thromboelastography was carried out using a TEG 5000 Thromboelastograph (USA). A Stago STA Compact automated selective haemostasis analyser (France) was used to register indicators that characterise the state of endothelium, the haemostatic coagulation element and thrombosis and fibrinolysis markers.Results. Univariate analysis demonstrated a connection between nosocomial episodes of thrombosis and the following factors: emergency surgery (OR 9.1, p&lt;0.01), peripheral vessel disease (OR 13.5, p=0.01), collapse development in pre-operation period (OR 30, p&lt;0.01), high content of D-dimers (OR 30, p&lt;0.01) and low content of AT III (OR 13.5, p=0.01). The results of multifactor analysis show that the significant diagnostic criteria are high D-dimer content and low AT III venous blood activity.Conclusion. A determination of high risks will enable the incidence of pulmonary embolism to be to minimised as well as provide a timely assessment of the efficiency of preventive measures carried out.

Health-related quality of life after general surgical intensive care.

Impaired mental and physical health are common complications after intensive care that could influence the patient's health-related quality of life (HRQoL). Earlier research has mainly focused on HRQoL in mixed surgical and medical ICU populations. This study aimed to describe and analyze factors associated with HROoL after discharge from a general surgical ICU. A prospective cohort study was conducted in a general surgical ICU in Sweden between 2005 and 2012. Adult patients (≥18years) with an ICU length of stay ≥96hours were included. HRQoL was measured at 3, 6, and 12months after discharge from the ICU using a questionnaire (SF-36). A linear mixed model was used to analyze changes over time and Wilcoxon Signed Rank Tests were used to compare the 12-months results to an age and gender matched reference population in Sweden. Linear regression analyses were performed to explore the impact on HRQoL from background variables. Of 447 patients eligible for the study, 276 patients (62%) answered SF-36 at least once at 3, 6 or 12months after ICU care and were included in the study. HRQoL improved over time but was still significantly lower at 12months compared to the reference population. Female gender, age <75years, living single, and ICU-stay of more than 14days were associated with lower HRQoL. General surgical ICU patients reports low HRQoL 1year after ICU stay. The impaired HRQoL could be a long-lasting problem with major consequences for the individual, family, and society.

Elevated admission N-terminal pro-brain natriuretic peptide level predicts the development of atrial fibrillation in general surgical intensive care unit patients.

New onset atrial fibrillation (AF) in critically ill surgical patients is associated with significant morbidity and increased mortality. N-terminal pro-B type natriuretic peptide (NT-proBNP) is released by cardiomyocytes in response to stress and may predict AF development after surgery. We hypothesized that elevated NT-proBNP level at surgical intensive care unit (ICU) admission predicts AF development in a general surgical and trauma population. From July to October 2015, NT-proBNP concentrations were measured at ICU admission. Abnormal NT-proBNP concentrations were defined by age-adjusted cut-offs. We examined the relationship between the development of AF and demographics, clinical variables, and NT-proBNP level using univariate analysis and a multivariable logistic regression model. Three hundred eighty-seven subjects were included in the cohort, none of whom were in AF at ICU admission. The median age was 63 years (52-73 years), and 40.3% were women. The risk of developing AF was higher for abnormal versus normal NT-proBNP (22% vs. 4%; p < 0.0001). Using optimal derived cutoffs (regardless of age), the risk of developing AF was 2% for NT-proBNP less than 600 ng/L, 15% for NT-proBNP of 600 ng/L to 1,999 ng/L, and 27% for NT-proBNP of 2,000 ng/L or greater. Multiple logistic regression analysis identified three independent predictors for new-onset AF: age, older than 70 years (odds ratio [OR], 3.7, 95% confidence interval [CI], 1.5-9.3), history of AF (OR, 25.3; 95% CI, 9.6-67.0), and NT-proBNP of 600 or greater (OR, 4.3; 95% CI, 1.3-14.2). When none or only one predictor was present, AF incidence was less than 1%. When all three predictors were present, AF incidence was 66%. For subjects 70 years or older but no history of AF, AF incidence was 12.8% when NT-proBNP was 600 or greater compared with 0% when NT-proBNP was less than 600. For subjects younger than 70 years with a history of AF, AF incidence was 44.4% when NT-proBNP was 600 or higher compared to 0% when NT-proBNP was less than 600. Elevated NT-proBNP at ICU admission in general surgical and trauma patients is predictive of AF development in the first 3 ICU days. Addition of NT-proBNP measurement to known risk factors can improve predictive power and identify patients who might potentially benefit from evidence-based prophylactic treatment for AF.

Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients.

To track compliance by an interprofessional team with the Awakening and Breathing Coordination, Choice of drugs, Delirium monitoring and management, Early mobility, and Family engagement (ABCDEF) bundle in implementing the Pain, Agitation, and Delirium guidelines. The aim was to study the association between ABCDEF bundle compliance and outcomes including hospital survival and delirium-free and coma-free days in community hospitals. A prospective cohort quality improvement initiative involving ICU patients. Seven community hospitals within California's Sutter Health System. Ventilated and nonventilated general medical and surgical ICU patients enrolled between January 1, 2014, and December 31, 2014. Total and partial bundle compliance were measured daily. Random effects regression was used to determine the association between ABCDEF bundle compliance accounting for total compliance (all or none) or for partial compliance ("dose" or number of bundle elements used) and outcomes of hospital survival and delirium-free and coma-free days, after adjusting for age, severity of illness, and presence of mechanical ventilation. Of 6,064 patients, a total of 586 (9.7%) died before hospital discharge. For every 10% increase in total bundle compliance, patients had a 7% higher odds of hospital survival (odds ratio, 1.07; 95% CI, 1.04-1.11; p < 0.001). Likewise, for every 10% increase in partial bundle compliance, patients had a 15% higher hospital survival (odds ratio, 1.15; 95% CI, 1.09-1.22; p < 0.001). These results were even more striking (12% and 23% higher odds of survival per 10% increase in bundle compliance, respectively, p < 0.001) in a sensitivity analysis removing ICU patients identified as receiving palliative care. Patients experienced more days alive and free of delirium and coma with both total bundle compliance (incident rate ratio, 1.02; 95% CI, 1.01-1.04; p = 0.004) and partial bundle compliance (incident rate ratio, 1.15; 95% CI, 1.09-1.22; p < 0.001). The evidence-based ABCDEF bundle was successfully implemented in seven community hospital ICUs using an interprofessional team model to operationalize the Pain, Agitation, and Delirium guidelines. Higher bundle compliance was independently associated with improved survival and more days free of delirium and coma after adjusting for age, severity of illness, and presence of mechanical ventilation.

Incidence and outcomes of acute lung injury in the surgical intensive care unit of a tertiary care hospital in Bangkok, Thailand

Abstract Background Although the pathophysiology and treatment of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are well established, the incidence and outcomes of ALI have not been extensively reported. Variations in healthcare systems, demographics, socioeconomics, and levels of intensive care units (ICU) may explain remarkable differences in outcomes reported. Objectives To evaluate the incidence and outcomes of ALI/ARDS at the surgical ICU (SICU) at Siriraj Hospital of Mahidol University, Bangkok. Methods We included patients aged ≥18 years admitted to the general SICU between June 1, 2010 and May 31, 2013 in this prospective, cohort observational study. All patients required ≥24 h of ventilatory support. The study outcomes were the incidence of ALI/ARDS, SICU length of stay, and mortality rate. Results Of 2523 patients admitted to the SICU, 495 (20%) required ≥24 h ventilatory support, and 15 (3%) developed ALI/ARDS. ALI/ARDS occurred on day 2 of ventilatory support. ARDS was caused by sepsis and pneumonia. The patients who developed ALI/ARDS had a higher APACHE II score (P = 0.001) and end-stage renal disease (P = 0.01). Pneumonia and acute kidney injury were more severe in patients with ALI and ARDS (40% vs 9%, P = 0.002; 33% vs 10%, P = 0.02, respectively). Ventilatory support duration, SICU lengths of stay and hospital mortality were higher in the ALI/ARDS group. Conclusions The incidence of ALI/ARDS in the SICU was low, but the mortality rate was high. A larger sample size is necessary to identify independent risk factors for ALI/ARDS.

Current practice of hemodynamic monitoring with PiCCO in a single general surgical ICU in a university hospital - a short report

Background: In recent years, there has been an overall trend toward using less in-vasive hemodynamic monitoring in surgi-cal intensive care units. The pulse contour cardiac output monitor (PiCCO) is one of them. Objectives: The aim of this study was to evaluate our practice of hemodynamic monitoring with PiCCO in the periopera-tive period. Methods: A retrospective descriptive analysis was performed in a single general surgical intensive care unit (ICU) run by anesthesiologists for the years 2013-2016. We collected information about patients, ICU quality parameters and monitoring equipment available in the ICU. The pri-mary endpoint was the incidence of PiC-CO use. Results: Out of 2972 patients admitted to the general surgical ICU in a 4-year pe-riod, besides basic monitoring with elec-trocardiography (ECG), pulse oximetry and blood pressure monitoring, more than half of the patients received central venous catheterization (55.1%), less than the half invasive arterial catheterization (44.1 %) and only a small proportion PiCCO (0.91%). No patient received a pulmonary arterial catheter. Mortality rate was 7.47 %. Conclusion: The use of PiCCO in our ICU is far below reported in literature. In the majority of cases, our anesthesiologists make clinical decisions based on measure-ment of central venous and invasive arte-rial pressure.

The value of blood lactate kinetics in critically ill patients: a systematic review.

BackgroundThe time course of blood lactate levels could be helpful to assess a patient’s response to therapy. Although the focus of published studies has been largely on septic patients, many other studies have reported serial blood lactate levels in different groups of acutely ill patients.MethodsWe performed a systematic search of PubMed, Science Direct, and Embase until the end of February 2016 plus reference lists of relevant publications. We selected all observational and interventional studies that evaluated the capacity of serial blood lactate concentrations to predict outcome. There was no restriction based on language. We excluded studies in pediatric populations, experimental studies, and studies that did not report changes in lactate values or all-cause mortality rates. We separated studies according to the type of patients included. We collected data on the number of patients, timing of lactate measurements, minimum lactate level needed for inclusion if present, and suggested time interval for predictive use.ResultsA total of 96 studies met our criteria: 14 in general ICU populations, five in general surgical ICU populations, five in patients post cardiac surgery, 14 in trauma patients, 39 in patients with sepsis, four in patients with cardiogenic shock, eight in patients after cardiac arrest, three in patients with respiratory failure, and four in other conditions. A decrease in lactate levels over time was consistently associated with lower mortality rates in all subgroups of patients. Most studies reported changes over 6, 12 or 24 hrs, fewer used shorter time intervals. Lactate kinetics did not appear very different in patients with sepsis and other types of patients. A few studies suggested that therapy could be guided by these measurements.ConclusionsThe observation of a better outcome associated with decreasing blood lactate concentrations was consistent throughout the clinical studies, and was not limited to septic patients. In all groups, the changes are relatively slow, so that lactate measurements every 1–2 hrs are probably sufficient in most acute conditions. The value of lactate kinetics appears to be valid regardless of the initial value.

Incidence of surgical site infection in postoperative patients at a tertiary care centre in India.

A prospective observational was carried out to calculate the incidence of surgical site infections (SSI) along with the main risk factors and causative organisms in postoperative patients at a tertiary care setting in Mumbai. A total number of 1196 patients between June 2011 to March 2013 admitted to the general surgical ward or surgical ICU of our hospital were included in the study. Post laproscopy patients and organ space SSIs were excluded. Patient data were collected using a preformed pro forma and a wound Southampton score tabulated and checked repeatedly until suture removal of patient. Regular follow-up was maintained until at least 30 days postoperatively. The study showed a SSI rate of 11%. Risk factors associated with a higher incidence of SSI were found to be age (>55 years), diabetes mellitus (especially uncontrolled sugar in the perioperative period), immunocompromised patients (mainly HIV and immunosuppressive therapy patients), surgeon skill (higher in senior professors compared with junior residents), nature of the cases, (emergency surgeries), placement of drains, wound class (highest in dirty wounds), type of closure (multilayer closure), prolonged duration of hospital stay, longer duration of surgery (>2 hours), type of surgery (highest in cholecystectomy). The highest rates of causative organisms for SSIs found were Staphylococcus aureus, Escherichia coli and Klebsiella ssp. Prevention of SSIs requires a multipronged approach with particular emphasis on optimising preoperative issues, adhering religiously to strict protocols during the intraoperative period and addressing and optimising metabolic and nutritional status in postoperative period.

Acquired hypernatremia in a general surgical Intensive Care Unit: Incidence and prognosis.

Purpose:Intensive Care Unit (ICU)-acquired hypernatremia (IAH) is a serious electrolyte disturbance that recently was shown to present an independent risk factor for mortality in critically ill patients. IAH has not been widely investigated in Surgical ICU (SICU) patients. No study has specifically investigated IAH epidemiology in the Kingdome of Saudi Arabia (KSA) in general SICU. The objectives of this study are to assess the epidemiological characteristics and prognostic impact of IAH on SICU mortality and outcome in KSA and compare it with international figures.Materials and Methods:A retrospective observational study on a prospectively collected data of patients (14 years of age or older) admitted to SICU over 2 years, with normal serum sodium on admission and who developed IAH (serum sodium above 145 mmol/L) from day two of admission. Traumatic brain injury patients with therapeutic target sodium level above 145 mmol/L were excluded.Results:Over 2 years study period, 864 patients were admitted to SICU. A total of 50 (5.8%) developed IAH and were included in the study. Twenty-eight (56%) patients were male. The median age was 47 (14-84) years. The mean (± standard deviation) Acute Physiology and Chronic Health Evaluation II score was 17 ± 6.5. The incident density (the rate of occurrence of IAH per 100 days care for SICU admission for the first episode) was 0.71. Risk factors include mechanical ventilation, male sex, age ≥50 years, postgastrointestinal surgeries, weekend and night admission. SICU mortality was 40%. The SICU and hospital median (range) length of stay was 8.3 (2-53) and 28.8 (3-95), respectively.Conclusions:IAH is not uncommon in SICU patients and is associated with increased risk of SICU as well as hospital mortality.

Tissue Doppler indices of diastolic function in critically ill patients and association with mortality - a systematic review.

Systolic impairment is well reported in critically ill patients but diastolic function has been relatively understudied. The objective of this review was to assess tissue Doppler indices of diastolic function in critically ill patients along with any association with mortality. A systematic review of articles in English using Medline, EMBASE, CINAHL and the Cochrane database of systematic reviews. Search terms included diastolic function, diastolic dysfunction, diastolic abnormal*, diastolic heart failure, diastolic filling, ventricular relaxation, pulmonary artery occlusion pressure, left ventricular filling pressure, cardiac dysfunction, intensive care, critical care, critically ill, critical illness, sepsis and septic shock. Only studies of critically ill adult patients (excluding post-cardiac surgical patients) whose diastolic function was assessed using tissue Doppler imaging were included. Study quality was assessed using a modified version of the Newcastle-Ottawa Scale (NOS). Nineteen studies were included, with a total of 1365 patients. All trials were observational. There was a large heterogeneity in patient populations and the methodology of tissue Doppler assessment of diastology resulting in a descriptive analysis. Patient groups included severe sepsis or septic shock (5 studies), septic shock (5 studies), systemic inflammatory response syndrome and shock (1 study), septic shock and acute lung injury (1 study), cancer and septic shock (2 studies), general ICU patients (1 study), combined medical and surgical ICU (2 studies) and sub-arachnoid haemorrhage patients (2 studies). Seventeen studies scored 5/6 on the NOS with the remaining two scoring 4/6. Fourteen studies reported on numbers of patients diagnosed with diastolic dysfunction (500/999, mean 50%, range 20-92%). Three studies found that diastolic dysfunction was an independent predictor of mortality. Current data shows a large range in the incidence of diastolic dysfunction in this patient population and a variable link with mortality. Future research should focus on the definition of normal values for diastolic function in critically ill patients along with the effects of ICU therapies and consensus criteria for its assessment in this patient population.

Fluid accumulation threshold measured by acute body weight change after admission in general surgical intensive care units: how much should be concerning?

BackgroundThe objective of this study (ClinicalTrials.gov: NCT01351506) was to identify the threshold level of fluid accumulation measured by acute body weight (BW) change during the first week in a general surgical intensive care unit (ICU), which is associated with ICU mortality and other adverse outcomes.MethodsFour hundred sixty-five patients were prospectively followed for a 28-day period. The maximum BW change threshold during the first week was evaluated by the maximum percentage change in BW from the ICU admission weight (Max%ΔBW). Daily screening of adverse events in the ICU were recorded. The cutoff point of Max%ΔBW on ICU mortality was defined by considering the area under the receiver operating characteristic (ROC) curve, intersection of the sensitivity and specificity, and the Youden Index. Univariable and multivariable regression analyses were used to demonstrate the associations. Statistical significance was defined as P<0.05.ResultsThe appropriate cutoff value of Max%ΔBW threshold was 5%. Regarding the multivariable regression model, in overall patients, the occurrence of the following adverse events (expressed as adjusted odds ratio [95% confidence interval]) were significantly associated with a Max%ΔBW of >5%: ICU mortality (2.38 [1.25–4.54]) (P=0.008), ICU mortality in patients without renal replacement therapy (RRT) (2.47 [1.21–5.06]) (P=0.013), reintubation within 72 hours (2.51 [1.04–6.00]) (P=0.039), RRT requirement (2.67 [1.13–6.33]) (P=0.026), and delirium (1.97 [1.08–3.57]) (P=0.025). Regarding the postoperative subgroup, a Max%ΔBW value of more than 5% was significantly associated with: ICU mortality (3.87 [1.38–10.85]) (P=0.010), ICU mortality in patients without RRT (6.32 [1.85–21.64]) (P=0.003), reintubation within 72 hours (4.44 [1.30–15.16]) (P=0.017), and vasopressor requirement (2.04 [1.04–4.01]) (P=0.037).ConclusionFluid accumulation, measured as acute BW change of more than the threshold of 5% during the first week of ICU admission, is associated with adverse outcomes of higher ICU mortality, especially in the patients without RRT, with reintubation within 72 hours, with RRT requirement, with vasopressor requirement, and with delirium. Some of these effects were higher in postoperative patients. This threshold value might be an indicator for caution during fluid management in surgical ICU.

Early versus delayed administration of norepinephrine in patients with septic shock.

IntroductionThis study investigated the incidence of delayed norepinephrine administration following the onset of septic shock and its effect on hospital mortality.MethodsWe conducted a retrospective cohort study using data from 213 adult septic shock patients treated at two general surgical intensive care units of a tertiary care hospital over a two year period. The primary outcome was 28-day mortality.ResultsThe 28-day mortality was 37.6% overall. Among the 213 patients, a strong relationship between delayed initial norepinephrine administration and 28-day mortality was noted. The average time to initial norepinephrine administration was 3.1 ± 2.5 hours. Every 1-hour delay in norepinephrine initiation during the first 6 hours after septic shock onset was associated with a 5.3% increase in mortality. Twenty-eight day mortality rates were significantly higher when norepinephrine administration was started more than or equal to 2 hours after septic shock onset (Late-NE) compared to less than 2 hours (Early-NE). Mean arterial pressures at 1, 2, 4, and 6 hours after septic shock onset were significantly higher and serum lactate levels at 2, 4, 6, and 8 hours were significantly lower in the Early-NE than the Late-NE group. The duration of hypotension and norepinephrine administration was significantly shorter and the quantity of norepinephrine administered in a 24-hour period was significantly less for the Early-NE group compared to the Late-NE group. The time to initial antimicrobial treatment was not significantly different between the Early-NE and Late-NE groups.ConclusionOur results show that early administration of norepinephrine in septic shock patients is associated with an increased survival rate.

Hand-hygiene compliance does not predict rates of resistant infections in critically ill surgical patients.

Our institution had a major outbreak of multi-drug-resistant Acinetobacter (MDRA) in its general surgical and trauma intensive care units (ICUs) in 2011, requiring implementation of an aggressive infection-control response. We hypothesized that poor hand-hygiene compliance (HHC) may have contributed to the outbreak of MDRA. A response to the outbreak including aggressive environmental cleaning, cohorting, and increased hand hygiene compliance monitoring may have led to an increase in HHC after the outbreak and to a consequent decrease in the rates of infection by the nosocomial pathogens methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridium difficile. Hand-hygiene compliance, tracked in monthly audits by trained and anonymous observers, was abstracted from an infection control database. The incidences of nosocomial MRSA, VRE, and C. difficile were calculated from a separate prospectively collected data base for 6 mo before and 12 mo after the 2011 outbreak of MDRA in the institution's general surgical and trauma ICUs, and data collected prospectively from two unaffected ICUs (the thoracic surgical ICU and medical intensive care unit [MICU]). We created a composite endpoint of "any resistant pathogen," defined as MRSA, VRE, or C. difficile, and compared incidence rates over time, using the Wilcoxon signed rank test and Pearson product-moment correlation coefficient to measure the correlations among these rates. Rates of HHC before and after the outbreak of MDRA were consistently high in both the general surgical (median rates: 100% before and 97.6% after the outbreak, p=0.93) and trauma ICUs (median rates: 90% before and 96.75% after the outbreak, p=0.14). In none of the ICUs included in the study did the rates of HHC increase in response to the outbreak of MDRA. The incidence of "any resistant pathogen" decreased in the general surgical ICU after the outbreak (from 6.7/1,000 patient-days before the outbreak to 2.7/1,000 patient-days after the outbreak, p=0.04), but this decrease did not correlate with HHC (trauma ICU: Pearson correlation [ρ]=-0.34, p=0.28; general surgical ICU: ρ=0.52, p=0.08). The 2011 outbreak of MDRA at our institution occurred despite high rates of HHC. Notwithstanding stable rates of HHC, the rates of infection with MRSA, VRE and C. difficile decreased in the general surgical ICU after the outbreak. This suggests that infection control tactics other than HHC play a crucial role in preventing the transmission of nosocomial pathogens, especially when rates of HHC have been maximized.

Epidemiology and outcomes of acute kidney injury in critically ill surgical patients

PurposeAcute kidney injury (AKI) is common in critically ill patients but is poorly defined in surgical patients. We studied AKI in a representative cohort of critically ill surgical patients. MethodsThis was a retrospective 1-year cohort study of general surgical intensive care unit patients. Patients were identified from a prospective database, and clinical data were reviewed. Acute kidney injury events were defined by risk, injury, failure, loss, and end-stage renal classification criteria. Outcomes were inpatient and 1-year mortality, inpatient lengths of stay, and discharge renal function. Risk factors for AKI and outcomes were compared by univariate and multivariate analyses. ResultsOf 624 patients, 296 (47%) developed AKI. Forty-two percent of events were present upon admission, whereas 36% occurred postoperatively. Risk, injury, failure, loss, and end-stage renal classification distributions by grade were as follows: risk, 152 (51%); injury, 69 (23%); and failure, 75 (25%). Comorbid diabetes, emergency admission, major surgery, sepsis, and illness severity were independently associated with renal dysfunction. Patients with AKI had significantly worse outcomes, including increased inpatient and 1-year mortality. Acute kidney injury starting before admission was associated with worse renal dysfunction and greater renal morbidity than de novo inpatient events. ConclusionsAcute kidney injury is common in critically ill surgical patients and is associated with increased mortality, persisting renal impairment and greater resource use.

Microbiology, resistance patterns, and risk factors of mortality in ventilator-associated bacterial pneumonia in a Northern Thai tertiary-care university based general surgical intensive care unit.

BackgroundVentilator-associated pneumonia (VAP) occurrence, causative pathogens, and resistance patterns in surgical intensive care units (SICU) are different between Western and developing Asian countries. In Thailand, resistant organisms have progressively increased in the last decade. However, the evidence describing causes of VAP and its outcomes, especially secondary to resistant pathogens, in Asian developing countries’ SICUs is very limited. Therefore, the objective of this study was to describe the incidence, pathogen characteristics, and risk factors that impact mortality and patient survival following VAP in a tertiary Northern Thai SICU.MethodsBetween 2008 and 2012, VAP occurred in a total of 150 patients in Chiang Mai University’s general SICUs (6.3±2.8 cases per 1,000 mechanical ventilator days). The following clinical data were collected from 46 patients who died and 104 patients who survived: microbiologic results, susceptible patterns, and survival status at hospital discharge. Antimicrobial susceptibility patterns were classified as susceptible, multidrug resistant (MDR), extensively drug resistant (XDR), and pan-drug resistant (PDR). The hazard ratio (HR) was calculated for risk factor analysis.ResultsRegarding the microbiology, gram negative organisms were the major pathogens (n=142, 94.7%). The first three most common organisms were Acinetobacter baumannii (38.7% of all organisms, mortality 41.4%), Klebsiella pneumoniae (17.3%, mortality 30.8%), and Pseudomonas aeruginosa (16.7%, mortality 16%) respectively. The most common gram positive organism was Staphylococcus aureus (4.0%, mortality 50%). The median day of VAP occurrence were significantly different between the three groups (P<0.01): susceptible (day 4), MDR (day 5), and XDR (day 6.5). Only half of all VAP cases were caused by susceptible organisms. Antibiotic resistance was demonstrated by 49.3% of the gram negative organisms and 62.5% of the gram positive organisms. Extensive drug resistance was evident only in Acinetobacter baumannii (30.6%) and Pseudomonas aeruginosa (1.3%). No pan-drug resistance was found during surveillance. The significant HR risk factors were age (P=0.03), resistant organisms (P=0.04), XDR (P=0.02), and acute physiology and chronic health evaluation II score (<0.01). Acinetobacter baumannii (P=0.06) and intubation due to severe sepsis (P=0.08) demonstrated a trend toward a significant increase in the HR. On the other hand, there were significantly decreased HRs in trauma patients (P=0.01). Initial administration of appropriate antibiotic therapy had a tendency toward a significant decrease in the HR (P=0.08).ConclusionGram negative organisms were the primary cause of bacterial VAP in Chiang Mai University’s general SICU. Resistant strains were present in half of all VAP cases and were associated with the day of VAP onset. Regarding risk factors, age, acute physiology, chronic health evaluation II score, resistant organisms (especially XDR), and being a non-trauma patient increased the risk of mortality.