Included Intensive Care Unit Length Of Stay Research Articles

Assessment of Outcomes in Patients with Heart Failure and End-Stage Kidney Disease after Fluid Resuscitation for Sepsis and Septic Shock

BackgroundSepsis fluid resuscitation is controversial, especially for patients with volume overload risk. The Surviving Sepsis Campaign recommends a 30-mL/kg crystalloid fluid bolus for patients with sepsis-induced hypoperfusion. Criticism of this approach includes excessive fluid resuscitation in certain patients. ObjectiveThe aim of this study was to assess the efficacy and safety of guideline-concordant fluid resuscitation in patients with sepsis and heart failure (HF) or end-stage kidney disease (ESKD). MethodsA retrospective cohort study was conducted in patients with sepsis who qualified for guideline-directed fluid resuscitation and concomitant HF or ESKD. Those receiving crystalloid fluid boluses of at least 30 mL/kg within 3 h of sepsis diagnosis were placed in the concordant group and all others in the nonconcordant group. The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS); vasoactive medications and net volume over 24 h; new mechanical ventilation, new or increased volume removal, and acute kidney injury within 48 h; and shock-free survival at 7 days. ResultsOne hundred twenty-five patients were included in each group. In-hospital mortality was 34.4% in the concordant group and 44.8% in the nonconcordant group (p = 0.1205). The concordant group had a shorter ICU LOS (7.6 vs. 10.5 days; p = 0.0214) and hospital LOS (12.9 vs. 18.3 days; p = 0.0163), but increased new mechanical ventilation (37.6 vs. 20.8%; p = 0.0052). No differences in other outcomes were observed. ConclusionsReceipt of a 30-mL/kg fluid bolus did not affect outcomes in a cohort of patients with mixed types of HF and sepsis-induced hypoperfusion.

Appraisal of Postoperative Outcomes of Volatile and Intravenous Anesthetics: A Network Meta-Analysis of Patients Undergoing Cardiac Surgery

To determine the relative efficacy of specific regimens used as primary anesthetics, as well as the potential combination of volatile and intravenous anesthetics among patients undergoing cardiac, thoracic, and vascular surgery. This frequentist, random-effects network meta-analysis was registered prospectively (CRD42022316328) and conducted according to the PRISMA-NMA framework. Literature searches were conducted up to April 1, 2022 across relevant databases. Risk of bias (RoB) and confidence of evidence were assessed by RoB-2 and CINeMA, respectively. Pooled treatment effects were compared with propofol monotherapy. Fifty-three randomized controlled trials (N=8,085) were included, of which 46 trials (N=6,604) enrolled patients undergoing cardiac surgery. Trials enrolling adults (≥18) undergoing cardiac, thoracic, and vascular surgery, using the same induction regimens, and comparing volatile and/or total intravenous anesthesia for the maintenance of anesthesia. Given that the majority of trials focused on those undergoing cardiac surgery and the heterogeneity, analyses were restricted to this population. Outcomes of interest included intensive care unit (ICU) length of stay (LOS), myocardial infarction, in-hospital and 30-day mortality, stroke, and delirium. Across 19 trials (N=1,821; 9 arms; I2=64.5%), sevoflurane combined with propofol decreased ICU LOS (mean difference [MD] -18.26 hours; 95% CI -34.78 to -1.73 hours), whereas midazolam with propofol (MD 17.51 hours; 95% CI 2.78-32.25 hours) was associated with a significant increase in ICU LOS, when compared with propofol monotherapy. Among 27 trials (N=4,080; 10 arms; I2=0%), midazolam was associated with significantly greater risk of myocardial infarction versus propofol (risk ratio 1.94; 95% CI 1.01-3.71). There were no significant differences across other outcomes. In patients undergoing cardiac surgery, sevoflurane with propofol was associated with decreased ICU LOS compared with propofol monotherapy. Midazolam with propofol increased ICU LOS compared with propofol alone. The combined use of intravenous and volatile anesthetics should be explored further. Future trials in thoracic and vascular surgery are warranted.

The impact of holiday season and weekend effect on traumatic injury mortality: Evidence from a 10-year analysis.

Trauma is one of the leading causes of death and its incidence increases annually. The "weekend effect" and "holiday season effect" on traumatic injury mortality remain controversial, whereby traumatic injury patients admitted during weekends and/or holiday season have a higher risk of in-hospital death. The present study is aimed to explore the association between "weekend effect" and "holiday season effect" and mortality in traumatic injury population. This retrospective descriptive study included patients from the Taipei Tzu Chi Hospital Trauma Database between January 2009 and June 2019. The exclusion criterion was age of < 20 years. The primary outcome was the in-hospital mortality rate. The secondary outcomes included intensive care unit (ICU) admission, ICU re-admission, length of stay (LOS) in the ICU, ICU admission duration ≥ 14 days, total hospital LOS, total hospital LOS ≥ 14 days, need for surgery, and re-operation rate. In this study, 11,946 patients were included in the analysis, and 8143 (68.2%) patients were admitted on weekdays, 3050 (25.5%) on weekends, and 753 (6.3%) on holidays. Multivariable logistic regression revealed that the admission day was not associated with an increased risk of in-hospital mortality. In other clinical outcome analyses, we found no significant increase in the risk of in-hospital mortality, ICU admission, ICU LOS ≥ 14 days, or total LOS ≥ 14 days in the weekend and holiday season groups. The subgroup analysis showed that the association between holiday season admission and in-hospital mortality was noted only in the elderly and shock condition populations. The holiday season duration did not differ in terms of in-hospital mortality. Longer holiday season duration was also not associated with an increased risk of in-hospital mortality, ICU LOS ≥14 days, and total LOS ≥14 days. In this study, we did not find any evidence that weekend and holiday season admissions in the traumatic injury population were associated with an increased risk of mortality. In other clinical outcome analyses, there was no significant increase in the risk of in-hospital mortality, ICU admission, ICU LOS ≥ 14 days, or total LOS ≥ 14 days in the weekend and holiday season groups.

1217: ABRUPT DISCONTINUATION VERSUS WEANING OF HYDROCORTISONE IN THE TREATMENT OF REFRACTORY SEPTIC SHOCK

Introduction: Current guidelines lack guidance on discontinuation of hydrocortisone (HCT) used in the treatment of refractory septic shock, thus discontinuation strategies vary widely in practice. The purpose of this study was to identify the incidence of recurrent shock and the associated safety outcomes when comparing HCT discontinuation strategies used for septic shock. Methods: A retrospective, cohort study was conducted with medical critical care patients grouped based on HCT discontinuation strategy: abrupt discontinuation (discontinuation while dose ≥200 mg/day) and weaning (use of any dose < 200 mg/day). Adult patients with septic shock who received IV HCT at a dose of ≥200 mg/day for ≥48 hours prior to discontinuation or wean were included. The primary outcome was the recurrent shock within 24 hours from HCT discontinuation, defined as restarting vasopressors for at least 2 hours, or, if patients still had vasopressors active at HCT discontinuation, an increase in vasopressors to ≥0.2 mcg/kg/min in norepinephrine equivalents or the addition of another vasopressor. Secondary outcomes included intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation, and duration of HCT therapy. Safety outcomes included rates of gastrointestinal bleed, hyperglycemia, and hypertension. Results: A total of 149 patients were included in the analysis: 89 in the abrupt group and 60 in the wean group. All patients received 200-300 mg/day of HCT initially. Both groups had similar durations of HCT therapy prior to their discontinuation/wean. Recurrent septic shock occurred in 6/89 patients (6.7%) in the abrupt discontinuation group and 6/60 patients (10%) in the weaning group (p=0.473). No differences were observed for ICU LOS or duration of mechanical ventilation, but patients in the abrupt group spent fewer total days on any dose of HCT (difference, 3 days, p< 0.001). For safety outcomes, patients in the wean group experienced higher rates of hyperglycemia during their wean compared to patients who had HCT abruptly discontinued (33.3% vs 19.1%, p=0.049); there were no differences in other safety outcomes. Conclusions: Among adults treated with HCT for septic shock, there was no difference in rates of recurrent shock when comparing a weaning strategy to an abrupt discontinuation strategy.

791: IMPACT OF SEDATION WITH KETAMINE COMPARED TO BENZODIAZEPINES ON DELIRIUM IN THE INTENSIVE CARE UNIT

Introduction: The use of high-dose ketamine infusions for sedation has grown in popularity as an alternative to benzodiazepines in intensive care unit (ICU) patients. Currently, there is a paucity of literature describing the use of high-dose ketamine for sedation. The objectives of this study are to describe high-dose ketamine use in the ICU and its impacts on delirium compared to benzodiazepines. Methods: This is a single-center, retrospective cohort study of patients admitted to an ICU between 5/5/2018 and 12/1/2021. Neurocritical care and cardiovascular surgery patients were excluded. Patients included were mechanically ventilated for ≥ 48 hours and received either ketamine ≥ 1 mg/kg/hr or a benzodiazepine infusion (midazolam or lorazepam) for ≥ 24 hours during their index ICU stay. and baseline demographics, sedative drip information, CAM-ICU scores, hospital and ICU length of stay (LOS), duration of mechanical ventilation, and chloride disturbances were collected The primary outcome was the percentage of eligible ICU days CAM-ICU positive, and secondary outcomes included ICU LOS and duration of mechanical ventilation. Eligible ICU days were defined as days with a Richmond Agitation Sedation Scale score ≥ - 3, and a CAM-ICU positive day was defined as having one positive CAM-ICU score positive. Results: A total of 187 patients were included, with 70 and 117 patients in the ketamine and benzodiazepine groups, respectively. The mean age was 56.9 (14.7), and 64.2% were male. The percentage CAM-ICU positive days in the ICU was 68.1% for ketamine and 51.5% for benzodiazepines (p=0.15). The median ICU LOS in days was 20.1 (11.6, 38.9) for the ketamine arm compared to 15.9 (8.7, 26.0) for the benzodiazepine arm (p=0.069). The median duration of mechanical ventilation in days was 19.5 (7.4, 37.4) compared to 11 (6.1, 22.0) for ketamine and benzodiazepines respectively (p=0.053). Overall, 57.5% of ketamine arm patients and 44.1% of benzodiazepine arm patients died during hospitalization (p=0.17). Conclusions: Compared to benzodiazepine infusions, high-dose ketamine infusions did not result in a significantly different number of CAM-ICU positive ICU days, ICU LOS, or duration of mechanical ventilation.

Dysphagia is associated with worse clinical outcomes in geriatric trauma patients

IntroductionDysphagia is associated with increased morbidity, mortality, and resource utilization in hospitalized patients, but studies on outcomes in geriatric trauma patients with dysphagia are limited. We hypothesized that geriatric trauma...

The Impact of Malnutrition and Body Mass Index on Heart Transplant Outcomes

<h3>Purpose</h3> Up to 70% of heart failure patients are malnourished which may affect post heart transplant (HT) outcomes. Studies assessing malnutrition pre-HT using validated tools are limited. This study aimed to assess if nutritional status using a validated tool and body mass index (BMI) impacted post-HT outcomes. <h3>Methods</h3> Single centre retrospective study of consecutive patients undergoing HT July 2015 to June 2021. Pre-HT nutritional status was assessed using the Subjective Global Assessment (SGA) tool and anthropometric data. Outcome measures included Intensive Care Unit (ICU) and total length of stay (LOS) at time of HT; post-HT infection and mortality (to 12-months). Results reported as mean±SD. <h3>Results</h3> 103 patients underwent HT during the study (mean age 50.3±12.2 years, 74% male). SGA at HT completed for 85.4% (n=88) of patients, 28.4% (n=25) were mild or moderately malnourished (SGA B), of these 24% (n=6) were overweight (BMI ≥25kg/m²). Malnourished patients had a longer but not statistically significant ICU LOS (18.5±26.8 days) compared to well-nourished patients (12.3±15.7 days, <i>p</i>=0.22). Total LOS between groups was not significant (malnourished 31.3±22.5 vs well-nourished 41.6±52.0 days; <i>p=0.37).</i> Malnourished patients experienced more post-HT infections compared to well-nourished patients (28% vs 22%, <i>p</i>=0.58). 16 patients died within 12 months post-HT and were more likely to be malnourished (n=7 of 12 SGAs completed, 58%, <i>p</i>=0.03). Obesity (BMI≥30kg/m²) was associated with significantly longer LOS (60.9±69.1 vs 28.8±28.5 days, <i>p</i>=0.002), but not ICU LOS (<i>p</i>=0.22). Overweight (BMI 25-29.9kg/m²) patients had higher rates of infections than healthy weight and obese patients (47.6% vs 23.8% and 28.6%, <i>p</i>=0.68). BMI had no impact on 12-month mortality post-HT (<i>p</i>=0.55). <h3>Conclusion</h3> Malnourished patients had a significant increased risk of 12-month mortality and experienced increased ICU LOS and infection rates post-HT. Obesity (BMI ≥30 kg/m²) was significantly associated with increased total LOS. Findings highlight the presence of potentially modifiable nutrition risk factors in HT patients. Nutrition assessments pre-and post-HT provide an opportunity to identify at risk patients, optimise nutritional status and may improve post-HT outcomes. This study was limited by small sample size. Future larger studies to investigate the impact of malnutrition and BMI on HT outcomes are warranted.

The effect of supplementation of vitamin D in neurocritical care patients: RandomizEd Clinical TrIal oF hYpovitaminosis D (RECTIFY).

Hypovitaminosis D is prevalent in neurocritical care patients, but the potential to improve patient outcome by replenishing vitamin D has not been investigated. This single-center, double-blinded, placebo-controlled, randomized (1:1) clinical trial was designed to assess the effect on patient outcome of vitamin D supplementation in neurocritical care patients with hypovitaminosis D. From October 2016 until April 2018, emergently admitted neurocritical care patients with vitamin D deficiency (≤ 20 ng/ml) were randomized to receive vitamin D3 (cholecalciferol, 540,000 IU) (n = 134) or placebo (n = 133). Hospital length of stay (LOS) was the primary outcome; secondary outcomes included intensive care unit (ICU) LOS, repeat vitamin D levels, patient complications, and patient disposition. Exploratory analysis evaluated specific subgroups of patients by LOS, Glasgow Coma Scale (GCS) score, and Simplified Acute Physiology Score (SAPS II). Two-hundred seventy-four patients were randomized (intent-to-treat) and 267 were administered treatment within 48 hours of admission (as-treated; 61.2% of planned recruitment) and monitored. The mean age of as-treated patients was 54.0 ± 17.2 years (56.9% male, 77.2% white). After interim analysis suggested a low conditional power for outcome difference (predictive power 0.12), the trial was halted. For as-treated patients, no significant difference in hospital LOS (10.4 ± 14.5 days vs 9.1 ± 7.9 days, p = 0.4; mean difference 1.3, 95% CI -1.5 to 4.1) or ICU LOS (5.8 ± 7.5 days vs 5.4 ± 6.4 days, p = 0.4; mean difference 0.4, 95% CI -1.3 to 2.1) was seen between vitamin D3 and placebo groups, respectively. Vitamin D3 supplementation significantly improved repeat serum levels compared with placebo (20.8 ± 9.3 ng/ml vs 12.8 ± 4.8 ng/ml, p < 0.001) without adverse side effects. No subgroups were identified by exclusion of LOS outliers or segregation by GCS score, SAPS II, or severe vitamin D deficiency (≤ 10 ng/ml). Despite studies showing that vitamin D can predict prognosis, supplementation in vitamin D-deficient neurocritical care patients did not result in appreciable improvement in outcomes and likely does not play a role in acute clinical recovery.Clinical trial registration no.: NCT02881957 (clinicaltrials.gov).

Isolated hip fracture in the elderly and time to surgery: is there an outcome difference?

BackgroundEarly operative intervention for hip fractures in the elderly is advised to reduce mortality and morbidity. Postoperative complications impose a significant burden on patient outcomes and cost of medical care....

Effect of postoperative anemia and baseline cardiac risk on serious adverse outcomes after major vascular interventions

ObjectivePublished data suggest that permissive anemia strategies that allow nadir hemoglobin (nHb) values of 7 g/dL or lower are safe in a variety of clinical settings. The appropriateness of these strategies in patients at high risk for adverse postoperative cardiac events remains unclear. We sought to determine the combined effect of postoperative nHb and cardiac risk status on major complications after vascular surgical interventions. MethodsThis was a single-institution retrospective analysis of consecutive patients who underwent elective open procedures for occlusive vascular disease and aneurysm repair, either open or endovascular. The Revised Cardiac Risk Index (RCRI) was used to assess baseline cardiac risk. Primary outcome was a composite end point of mortality or major ischemic events (myocardial infarction, stroke, acute kidney injury, or coronary revascularization) within 90 days from the index operation. Secondary outcomes included intensive care unit (ICU) length of stay (LOS) and 90-day respiratory complications (pneumonia, ventilator dependence for >48 hours postoperatively, or reintubation). Hierarchical multivariable regression was used to model each outcome with adjustment for age, type of operation, baseline comorbidities, and intraoperative covariates. ResultsWe analyzed 2508 operations performed during 8 years in 2106 patients with a mean age of 67 years (range, 45-90 years). In the fully adjusted multivariable model, lower values of nHb increased the risk of the primary composite end point (odds ratio [OR], 1.24; P < .001, representing a 24% increase in the odds of the composite end point for each 1-g/dL increase in nHb). In the same model, RCRI class II (OR, 1.8; P < .001), class III (OR, 2.06; P < .0001), and class IV (OR, 2.35; P < .0001) were associated with progressively increasing odds of the composite end point compared with RCRI class I. An interaction term between transfusion and nHb was not significant statistically, indicating that the harmful effect of anemia was independent of blood transfusion. Lower values of nHb also increased the risk of respiratory complications (OR, 1.41; P = .002) and ICU LOS (average 2.6-day increase per 1-g/dL increase of nHb; P < .0001). ConclusionsPostoperative anemia increases the rate of early postoperative mortality and major ischemic events, particularly in patients at higher baseline cardiac risk. It also adversely affects respiratory complications and ICU LOS. Until a randomized trial definitively settles the issue, restrictive transfusion strategies should be practiced with caution in patients undergoing major vascular interventions.

Implementation of an Early Mobility Pathway in Neurointensive Care Unit Patients With External Ventricular Devices.

Patients with an external ventricular drain (EVD) may not be readily mobilized because of concerns of catheter dislodgment and/or inappropriate cerebrospinal fluid drainage. Delayed mobilization may result in longer hospital stays and an increased risk for complications related to immobility. We aimed to determine the safety, feasibility, and outcome of an EVD mobilization protocol in patients with subarachnoid hemorrhage (SAH). A multidisciplinary group developed a formal algorithm for the mobilization of patients with SAH with EVDs. Outcome measures included intensive care unit (ICU) length of stay (LOS), day to first mobilization, and discharge disposition. Patients were prospectively enrolled during a 12-month period and compared with a historical control group of patients with SAH for the preceding 12-month period. Thirty-nine of 45 (86.7%) patients were women. Mean age did not differ significantly between the preintervention (n = 19) and postintervention (n = 26) groups (59.6 vs 55.7). Number of EVD device days did not differ significantly between groups (16.3 vs 15, P = .422]. Of 101 attempted postintervention mobilization sessions, six were aborted for increased lethargy (1), pain (1), elevated intracranial pressure (1), drain malfunction (1), and hypotension (2). Twenty-four sessions were attempted but never initiated because of worsening neurologic examination (10), pulmonary instability (2), hemodynamic instability (2), medical instability (3), and provider request (1). No patient experienced catheter dislodgment. Mean ICU LOS was not different between groups (20.7 vs 18.2, P = .262). The day of first mobilization was significantly earlier in the postintervention group (18.7 vs 6.5, P < .0001). The percentage of patients discharged home or to acute rehabilitation was higher in the postintervention group (63.2% vs 88.5%, P = .018], when accounting for Hunt and Hess grade. The mobilization of patients with EVDs is safe and feasible; it may be associated with earlier mobilization, reduced ICU LOS, and better discharge disposition. No major complications were attributable to early mobilization.

Implementation of a Trauma Service Activation and Admission Policy for Very Elderly Trauma Patients: Impact on Hospital Efficiency and Patient Outcomes

Very elderly trauma patients (VETs) were routinely admitted to nonsurgical services at our institution; therefore, a trauma service activation and admission policy was implemented. Our goal was to determine policy success and impact on efficiency and outcomes. VETs, defined as trauma patients aged >89 years, admitted before and after policy implementation were reviewed. Demographics included age, gender, Injury Severity Score, Glasgow Coma Score, admission diagnosis, mechanism of injury, admission service, and comorbidities. Efficiency included intensive care unit length of stay (ICU-LOS) and hospital length of stay (H-LOS). Outcomes included complications, discharge disposition, and mortality. Statistical analysis included Chi square, Fisher's exact test, and regression analyses, significance denoted by P < 0.05. 375 VETs were investigated. Demographic analysis revealed differences in Injury Severity Score (9.4 + 5.4 vs 7.2 + 4.0, P < 0.001), coronary artery disease (2.1% vs 38.2%, P < 0.001), neurologic disease (7.4% vs 28.24%, P < 0.001), and intracranial hemorrhage (15.6% vs 6.1%, P = 0.01). The most common mechanism of injury and admission diagnosis was fall and femur fracture. VETs admitted to the trauma service increased from 28.3 per cent to 40.5 per cent, P = 0.02. Efficiency analysis revealed differences in ICU-LOS (4.0 + 4.2 days vs 0.7 + 1.3 days, P < 0.001) and H-LOS (7.3 + 4.9 days vs 6.3 + 5.5 days, P = 0.005). Outcomes analysis revealed differences in pneumonia (0.8% vs 5.3%, P = 0.01), acute respiratory distress syndrome (0% vs 2.3%, P = 0.04), discharge to skilled nursing facility (75.8% vs 57.3%, P < 0.001), but no difference in mortality. Regression analyses revealed that trauma service admission was associated with decreased ICU-LOS and H-LOS. The trauma service activation and admission policy for VETs led to improved hospital efficiency.

The impact of "early" versus "late" initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis.

BackgroundThe optimal timing of initiating renal replacement therapy (RRT) in critical illness complicated by acute kidney injury (AKI) is not clearly established. Trials completed on this topic have been marked by contradictory findings as well as quality and heterogeneity issues. Our goal was to perform a synthesis of the evidence regarding the impact of “early” versus “late” RRT in critically ill patients with AKI, focusing on the highest-quality research on this topic.MethodsA literature search using the PubMed and Embase databases was completed to identify studies involving critically ill adult patients with AKI who received hemodialysis according to “early” versus “late”/“standard” criteria. The highest-quality studies were selected for meta-analysis. The primary outcome of interest was mortality at 1 month (composite of 28- and 30-day mortality). Secondary outcomes evaluated included intensive care unit (ICU) and hospital length of stay (LOS).ResultsThirty-six studies (seven randomized controlled trials, ten prospective cohorts, and nineteen retrospective cohorts) were identified for detailed evaluation. Nine studies involving 1042 patients were considered to be of high quality and were included for quantitative analysis. No survival advantage was found with “early” RRT among high-quality studies with an OR of 0.665 (95 % CI 0.384–1.153, p = 0.146). Subgroup analysis by reason for ICU admission (surgical/medical) or definition of “early” (time/biochemical) showed no evidence of survival advantage. No significant differences were observed in ICU or hospital LOS among high-quality studies.ConclusionsOur conclusion based on this evidence synthesis is that “early” initiation of RRT in critical illness complicated by AKI does not improve patient survival or confer reductions in ICU or hospital LOS.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1291-8) contains supplementary material, which is available to authorized users.

Goal-directed diuresis: A case - control study of continuous furosemide infusion in critically ill trauma patients.

Background:Excessive crystalloid administration is common and associated with negative outcomes in critically ill trauma patients. Continuous furosemide infusion (CFI) to remove excessive fluid has not been previously described in this population. We hypothesized that a goal-directed CFI is more effective for fluid removal than intermittent bolus injection (IBI) diuresis without excess incidence of hypokalemia or renal failure.Materials and Methods:CFI cases were prospectively enrolled between November 2011 and August 2012, and matched to historic IBI controls by age, gender, Injury Severity Score (ISS), and net fluid balance (NFB) at diuresis initiation. Paired and unpaired analyses were performed to compare groups. The primary endpoints were net fluid balance, potassium and creatinine levels. Secondary endpoints included intensive care unit (ICU) and hospital length of stay (LOS), ventilator-free days (VFD), and mortality.Results:55 patients were included, with 19 cases and 36 matched controls. Mean age was 54 years, mean ISS was 32.7, and mean initial NFB was +7.7 L. After one day of diuresis with CFI vs. IBI, net 24 h fluid balance was negative (−0.55 L vs. +0.43 L, P = 0.026) only for the CFI group, and there was no difference in potassium and creatinine levels. Cumulative furosemide dose (59.4mg vs. 25.4mg, P < 0.001) and urine output (4.2 L vs. 2.8 L, P < 0.001) were also significantly increased with CFI vs. IBI. There were no statistically significant differences in ICU LOS, hospital LOS, VFD, or mortality.Conclusions:Compared to IBI, goal-directed diuresis by CFI is more successful in achieving net negative fluid balance in patients with fluid overload with no detrimental side effects on renal function or patient outcome.

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Introduction: Patient characteristics are an important contributor to intensive care unit (ICU) cost. Few studies, however, have focused on the influence of patient factors on cost. Hypothesis: After adjusting for ICU length of stay (LOS) and specific hospital, patient characteristics such as severity of illness, age, and diagnosis will be major contributors to overall ICU cost. Methods: Retrospectively, ICU cost data were obtained for all admissions to 13 ICUs at four U.S. hospitals during 2006 - 2010. Cost data for each admission were matched with that patient’s respective clinical and demographic data in the APACHE® database. We excluded readmissions, lengths of stay (LOS) < 1 day, and CABG patients. ICU cost was adjusted for the annual in-patient inflation rate through information provided by the Bureau of Labor Statistics, and the natural log of inflation-adjusted cost was calculated. We then developed a multivariable linear model to determine the largest contributors to variation in costs across patients. Predictor variables included ICU LOS, each hospital (n=4) as a fixed effect, the acute physiology score component of the APACHE III score, diagnosis (n=57), day 1 mechanical ventilation (MV), other day 1 life supporting therapy, patient location as well as length of stay before ICU admission, age, gender,? 1 APACHE chronic health item, and mortality before unit discharge. Results: Among 15,002 admissions meeting inclusion criteria, 12,554 (84%) had financial data that could be matched with their respective APACHE data. The mean cost of an ICU stay was $19,272 (median = $9,476, IQR = $4,812 - $20,075). There was substantial variation in costs among hospitals. After adjusting for ICU LOS and specific hospital, the following variables contributed the most to variation in costs (in descending order): day 1 MV, acute physiology score, day 1 life support other than/in addition to MV, and length of hospital stay before ICU admission. All were significant at p <.001. Conclusions: Life supporting therapy and physiologic derangement greatly impact total ICU cost. Benchmarks based on age and diagnosis may prove insufficient for comparing ICU costs.