Medicine Intensive Care Unit Research Articles

Osmotic Demyelination Syndrome: A Rare Clinical Image.

The term "Osmotic Demyelination Syndrome" (ODS) is synonymous with central pontine myelinolysis (CPM), denoting a condition characterised by brain damage, particularly affecting the white matter tracts of the pontine region. This damage arises due to the rapid correction of metabolic imbalances, primarily cases of hyponatremia. Noteworthy triggers encompass severe burns, liver transplantations, anorexia nervosa, hyperemesis gravidarum, and hyperglycaemia, all linked to the development of CPM. Clinical manifestations encompass a spectrum of signs and symptoms, including dysphagia, dysarthria, spastic quadriparesis, pseudobulbar paralysis, ataxia, lethargy, tremors, disorientation, catatonia, and, in severe instances, locked-in syndrome and coma. A recent case involving a 45-year-old woman illustrates these complexities. Upon admission to the Medicine Intensive Care Unit, she presented with symptoms indicative of diminished responsiveness and bilateral weakness in the upper and lower limbs. Of significance, the patient had a pre-existing medical history of hyperthyroidism. Extensive diagnostic investigations were undertaken, revealing compelling evidence of profound hyponatremia through blood analyses. Furthermore, magnetic resonance imaging (MRI) was performed, unveiling conspicuous areas of abnormal hyperintensity located in the central pons, intriguingly accompanied by spared peripheral regions. These radiological findings align with the characteristic pattern associated with osmotic demyelination syndrome, illuminating the underlying pathology.

Non-variceal causes and outcome of acute upper gastro-intestinal bleeding among cirrhotic patients in tropical medicine intensive care unit

Non-variceal causes and outcome of acute upper gastro-intestinal bleeding among cirrhotic patients in tropical medicine intensive care unit

The Frequency of Musculoskeletal Pain in Nurses Working in Internal Medicine Intensive Care Unit and Related Factors

Background: The primary purpose of this study was to determine the frequency of musculoskeletal pain in nurses working in the internal medicine intensive care unit and to determine whether there were differences between nurses working in the internal medicine clinic. In addition, it was aimed to determine the individual and professional risk factors that will cause musculoskeletal pain in nurses working in the internal medicine intensive care unit.
 Material and Methods: After evaluating eligibility, 82 volunteer nurses, 36 working in the internal medicine intensive care unit and 46 working in the internal medicine clinic, were included in this single-centre, cross-sectional and descriptive study. The demographic characteristics of the participants, their regular exercise status and the factors related to their working conditions were determined by the questionnaire form created by the researchers.
 Results: Musculoskeletal pain was detected in 61.11% of internal medicine intensive care nurses. There was no statistical difference between the internal medicine intensive care and clinical nurses regarding musculoskeletal pain (p>0.05). A statistically significant relationship was found between the situation of changing the patient's clothes and positioning the patient and the occurrence of musculoskeletal pain (p

The effect of audiobooks on sleep quality and vital signs in intensive care patients

ObjectiveImproving sleep quality in the intensive care unit is significant for the recovery process. This study investigated the effect of listening to audiobooks on sleep quality and vital signs in intensive care patients. MethodsThis quasi-experimental study utilized the pre-posttest design, involving control and intervention groups. The study was conducted in the internal medicine intensive care unit of a hospital in Turkey between January–June 2022. Standard nursing care was given to both groups on the first night, and the Sleep Evaluation Form and Richard Campbell Sleep Scale were used to measure sleep quality in the morning. On the second day, the intervention group listened to a recorded story, and the control group had standard care. Sleep quality and vital signs were measured again. ResultsData from 56 participants were analyzed. Noise (96.4%), light (69.6%), unfamiliar environment (64.8%), concerns about illness (33.9%), and care and treatments (58.9%) are the main causes of sleep disruption. The effect of these factors decreased in the intervention group after the Audiobook Listening Practice, which significantly improved the sleep quality of the ICU patients (p < 0.001). Among the vital signs, a significant difference was found in pulse and blood pressure (p < 0.001), while no changes were observed in temperature and respiratory rate in time group interaction (p > 0.05). ConclusionsThe Audiobook Listening Practice improved sleep quality and life parameters in the ICU. Nurses can use the practice to improve sleep quality in intensive care units. Implications for clinical practiceEvidence-based studies are needed to improve the sleep quality of patients in intensive care units, to ensure clinical improvement, and to reduce the length of stay at hospital. The practice is effective in manipulating environmental stressors. This low-cost method significantly improves patient care activities. It is recommended to integrate such complementary activities into intensive care units, to train nurses about the practice, and to support the practice with new studies.

Tekrarlayan başarısız weaning ve uzamış apne ile tanı konulan yaşlı myastenia gravis hastası

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disorder caused by the development of antibodies to nicotinic acetylcholine receptors. The disease characterized by variable muscle weakness worsening with exercise. Although most patients have neurological signs and symptoms, respiratory symptoms occur in the late stages of the disease. However, rarely, respiratory failure may be the first symptom in some undiagnosed patients. We report the case of an elderly patient who was admitted with respiratory failure and intubated and transferred to the internal medicine intensive care unit. Two days after intubation, when she was awake and met the extubation criteria, endotracheal tube was successfully removed. At this time, her vital signs were normal. However, next day, her arterial blood gas CO2 rose and he became drowsy, requiring re-intubation. This situation repeated on the fifth and 16th days of her hospitalization and prolonged apnea was observed after intubation with rocuronium. All other causes of failed extubation, such as sepsis and pneumonia, were ruled out. During follow-up, ptosis was detected in the right eye and acetylcholine receptor antibody was positive. On the 30th day of the follow-up, methylprednisolone 1mg/kg and pyridostigmine 240 mg/day was initiated. The patient, whose spontaneous respiration was sufficient, was extubated and taken to the neurology clinic for further examination and treatment.

Paving the way to Precision Medicine in ICU: Biobank integration with OMOP-CDM. Challenges, opportunities, and insights from Hospital Israelita Albert Einstein, Brazil

Paving the way to Precision Medicine in ICU: Biobank integration with OMOP-CDM. Challenges, opportunities, and insights from Hospital Israelita Albert Einstein, Brazil

Examining the Nutrition, Oral Mucositis, and Gastrointestinal System Symptoms of Intensive Care Units Patients Receiving Enteral and Parenteral Nutrition.

This descriptive study aims to examine the complications that might develop in patients who receive enteral or parenteral nutrition treatment in intensive care unit in this process and to examine the nutritional status, oral mucositis, and gastrointestinal system symptoms among patients who receive enteral or parenteral nutrition treatment in intensive care unit. A sample of this study consists of 104 patients who received enteral or parenteral nutrition treatment in intensive care units between January and June 2019. The data were collected face to face by using Sociodemographic Form, constipation severity scale, Mini Nutritional Assessment Scale, Mucositis Assessment Scale, visual analog scale, and gastrointestinal system Symptoms Scale. The results were calculated as numbers, percentage, SD, and mean values. Among the participating patients, 67.4% were older than 65 years, 55.8% were female, 42.3% were receiving treatment in internal medicine intensive care units, and 43.4% had severe mucositis. It was determined that 31.7% of the patients receiving treatment in intensive care units required nutrition treatment. It was determined that patients receiving parenteral nutrition had more symptoms such as gastrointestinal system symptoms, mucositis, constipation, and colonic inertia. It was determined that when compared to the patients receiving enteral nutrition, the patients receiving parenteral nutrition had higher scores in mucositis, visual analog scale pain, Mini Nutritional Assessment Test, constipation, obstructive defecation, colonic inertia, and gastrointestinal symptom total scores.

Urinary Neutrophil Gelatinase-associated Lipocalin as a Diagnostic and Prognostic Marker for Acute Kidney Injury in Hospitalized Cirrhotic Patients: A Study from North Indian Population.

A serious problem in cirrhosis is acute renal injury. The study aimed to examine the urinary neutrophil gelatinase-associated lipocalin (uNGAL) as a diagnostic and prognostic marker of acute kidney injury (AKI) in cirrhotic patients. A prospective study was carried out over a period of 1 year. A total of 490 patients suffering from cirrhosis who visited an indoor hospital were screened, and after the exclusion, a total of 90 subjects admitted to the medicine intensive care unit (MICU) fulfilling inclusion criteria were enrolled. Those having a history of renal diseases, on nephrotoxic drugs, in septic shock, peritonitis, UTI, and no urine output were excluded. On admission, for the estimation of uNGAL, urinary levels of sodium, creatinine, fresh urine samples were obtained, and blood samples were taken for serum creatinine estimation. Out of 90 patients, 33.3% did not develop AKI, and 66.7% developed AKI. Urinary neutrophil gelatinase-associated lipocalin levels were six times higher in patients with acute tubular necrosis (259.08 ± 118.41 ng/mL) and three times higher in Hepatorenal syndrome (HRS)-AKI (124.97 ± 16.38) as compared with patients with normal kidney function (39.76 + 5.7). Those who died had a higher uNGAL (171.6 ng/mL) in comparison to those who survived (133.7 ng/mL). At a cutoff value of ≥114.9 (ng/mL), urinary NGAL represents a sensitivity of 86.92% and specificity of 100% to diagnose AKI and AUC 0.966 (95% CI: 0.919-0.990) in cirrhotic patients. Urinary NGAL is good for diagnosing AKI and is a marker to distinguish the types of AKI in liver cirrhosis. Patel ML, Shyam R, Chaudhary A, Sachan R, Ali W. Urinary Neutrophil Gelatinase-associated Lipocalin as a Diagnostic and Prognostic Marker for Acute Kidney Injury in Hospitalized Cirrhotic Patients: A Study from North Indian Population. Indian J Crit Care Med 2023;27(8):545-551.

DETERMINANTS OF MORTALITY IN PATIENTS OF COVID-19 BRONCHOPNEUMONIA: A PROSPECTIVE OBSERVATIONAL STUDY

Background &amp; objectives:COVID-19, an emerging viral disease affected more than 200 countries worldwide andnovel coronavirus pandemic has caused significant mortality throughout the world.The present study was undertaken to identify the determinants of mortality in COVID-19 bronchopneumonia patients. Methods:A total of160 COVID RT-PCR and RAT positive patients with evidence of bronchopneumonia were admitted in medicine covid ward and ICU above the age of 12 years were included in the study during a period of 2.5 years from July 2020- August 2022.Patients were divided into two groups- Survivors (119 patients) and non-Survivors (41 patients). Various sociodemographic factors, clinical symptoms, NEWS-2 scores inflammatory markers,imaging modalities,oxygen levels,type and duration of oxygenation support given were compared between two groups. Results:The sociodemographic data included age, gender and place of residence was not statistically significant with the outcome(mortality) whereas greater number of preexisting medical conditions, requirement of higher quantity of oxygen, various lab parameters (higher values of CRP, Ferritin, LDH, D-Dimer, N-L ratio) and a higher score in NEWS-2, HRCT and chest x-ray was statistically significant factor associated with mortality in our patients suffering from COVID-19 bronchopneumonia. Interpretation &amp; Conclusions:We thereby conclude that, patients in the mortality group had greater number of preexisting medical conditions higher requirement of oxygen at the time of admission, higher NEWS-2 score, N-L ratio, CRP, Ferritin, LDH, D-dimer, Chest x-ray score &amp; HRCT severity score and hence these parameters may be used to predict disease severity, especially in resource-limited settings.

Clinicians’ perceptions on implementation strategies used to facilitate ABCDEF bundle adoption: A multicenter survey

BackgroundIntensive care unit (ICU) clinicians struggle to routinely implement the ICU Liberation bundle (ABCDEF bundle). As a result, critically ill patients experience increased risk of morbidity and mortality. Despite extensive research related to the barriers and facilitators of bundle use, little is known regarding which implementation strategies are used to facilitate its adoption and sustainability. ObjectivesTo identify implementation strategies used to increase adoption of the ABCDEF bundle and how those strategies are perceived by end-users (i.e., ICU clinicians) related to their helpfulness, acceptability, feasibility, and cost. MethodsWe conducted a national, cross-sectional survey of ICU clinicians from the 68 ICU sites that previously participated in the Society of Critical Care Medicine's ICU Liberation Collaborative. The survey was structured using the 73 Expert Recommendations for Implementing Change (ERIC) implementation strategies. Surveys were delivered electronically to site contacts. ResultsNineteen ICUs (28%) returned completed surveys. Sites used 63 of the 73 ERIC implementation strategies, with frequent use of strategies that may be readily available to clinicians (e.g., providing educational meetings or ongoing training), but less use of strategies that require changes to well-established organizational systems (e.g., alter incentive allowance structure). Overall, sites described the ERIC strategies used in their implementation process to be moderately helpful (mean score >3<4 on a 5-point Likert scale), somewhat acceptable and feasible (mean score >2<3), and either not-at-all or somewhat costly (mean scores >1<3). ConclusionsOur results show a potential over-reliance on accessible strategies and the possible benefit of unused ERIC strategies related to changing infrastructure and utilizing financial strategies.

Fungal Spectrum and Susceptibility Against Nine Antifungal Agents in 525 Deep Fungal Infected Cases.

Deep fungal infection has become an important cause of infection and death in hospitalized patients, and this has worsened with increasing antifungal drug resistance. A 3-year retrospective study was conducted to investigate the clinical characteristics, pathogen spectrum, and drug resistance of deep fungal infection in a regional hospital of Guangzhou, China. Non-duplicate fungi isolates recovered from blood and other sterile body fluids of in-patients of the clinical department were identified using biochemical tests of pure culture with the API20C AUX and CHROMagar medium. Antifungal susceptibilities were determined by Sensititre YeastOne® panel trays. In this study, 525 patients (283 female, 242 male) with deep fungal infection were included, half of them were elderly patients (≥60 years) (54.67%, n=286). A total of 605 non-repetitive fungi were finally isolated from sterile samples, of which urine specimens accounted for 66.12% (n=400). Surgery, ICU, and internal medicine were the top three departments that fungi were frequently detected. The mainly isolated fungal species were Candida albicans (43.97%, n=266), Candida glabrata (20.00%, n=121), and Candida tropicalis (17.02%, n=103), which contributed to over 80% of fungal infection. The susceptibility of the Candida spp. to echinocandins, 5-fluorocytosine, and amphotericin B remained above 95%, while C. glabrata and C. tropicalis to itraconazole were about 95%, and the dose-dependent susceptibility of C. glabrata to fluconazole was more than 90%. The echinocandins had no antifungal activity against Trichosporon asahi in vitro (MIC90>8 μg/mL), but azole drugs were good, especially voriconazole and itraconazole (MIC90 = 0.25 μg/mL). The main causative agents of fungal infection were still the genus of Candida. Echinocandins were the first choice for clinical therapy of Candida infection, followed with 5-fluorocytosine and amphotericin B. Azole antifungal agents should be used with caution in Candida glabrata and Candida tropicalis infections.

Heart rate variability as a prognostic marker in critically ill patients

Background: Heart rate variability (HRV) can be used to assess cardiac autonomic activity in critically ill patients. Heart rate variability is termed as fluctuation in the time interval between adjacent heartbeats. The equilibrium among the sympathetic and parasympathetic subgroups of the autonomic nervous system (ANS) is essential for the maintenance of systemic homeostasis and effective response to external stressors. Hence we aimed this study to determine whether heart rate variability can be used as a prognostic marker in critically ill patients. Methods: A cross-sectional study was conducted among 225 consecutive critically ill patients admitted to the medicine Intensive care unit (ICU) of AVBRH, Sawangi (Meghe) based on the inclusion and exclusion criteria. The selected participants were evaluated for 24 hours Heart Rate Variability (HRV) and APACHE 4 score. Outcomes like mortality and survival were corelated with 24 hours Heart Rate Variability and APACHE 4 score. Results: The variables were significantly associated (p&lt;0.05) with Standard deviation of the average Normal-to normal HRV intervals (SDANN) and Standard deviation of the NN intervals (SDNN). The variables were also significantly associated (p&lt;0.05) with the variable High frequency (HF), High frequency/Low frequency (LF/HF) ratio. LF/HF parameter was abnormal in 86% of patients who died as compared to 54% of the patients who survived (p-value &lt;0.001). Conclusions: Out of the 225 participants, 20% died during the study period. APACHE 4, Glasgow coma scale (GCS) score, and LF were significantly and independently associated with mortality. Decrease in Low frequency parameter of 24 hours Heart Rate Variability identified mortality with accuracy of 74% with 81.2% specificity, and 46.7 % sensitivity

#3242 OUTCOMES OF THERAPEUTIC PLASMA EXCHANGE: A ONE-YEAR EXPERIENCE IN AN INTERNAL MEDICINE INTENSIVE CARE UNIT

Abstract Background and Aims There is uncertainty regarding the best indication, device type, frequency, length of time, kind of replacement fluid, and criteria for ceasing therapeutic plasma exchange (TPE) for various disorders. TPE is an intrusive technique that has the potential to save lives, but it also has a risk of unfavorable outcomes and complications, necessitating close supervision by professional teams. In the intensive care unit (ICU), there are three categories of indications for TPE: (1) absolute, well-established, and evidence-based, for which TPE is recognized as first-line therapy; (2) relative; for which TPE is a recognized second-line treatment (alone or in combination) and (3) rescue therapy; for which TPE is used with a limited or theoretical evidence base. The purpose of this study is to continue our evaluation of the outcome of nephrology care in internal medicine ICU regarding bedside membrane therapeutic plasma exchange. Method In the continuity of our previous work in the analysis of the outcome of TPE. From August 2021 to August 2022, 425 membrane plasma exchange sessions were performed on 69 patients in the internal medicine department's ICU-Cairo University Hospitals-Egypt. Results Closely similar to what we found before; the most frequent diagnosis was thrombotic microangiopathies (24 (34.8%) patients) with complete recovery seen in 18/24 patients (75%); followed by systemic vasculitis with pulmonary renal involvement (14 (20.3%) patients) with partial remission was seen in 9/14 patients (64.3%); Guillain-Barré syndrome (13 (18.8%) patients) with complete recovery was seen in 8/13 patients (61.5%); Proliferative Lupus Nephritis with crescents [10 (14.5%) patients] with partial remission in 8/10 patients (80%), and myasthenia gravis [8 (11.6%) patients] with complete recovery in 6/8 patients (75%). Hypotension occurred during 69/425 (16.2%) sessions and hypocalcemia in 8/69 (11.5%) patients during treatment. Infection of vascular access occurred in 4/69 (5.8%) patients. 6/69 (8.7%) patients died during their stay in ICU none during treatment with TPE, all of them were diagnosed to have severe sepsis as a cause of death. Conclusion According to our experience, membrane therapeutic plasma exchange is a successful and secure treatment for a variety of illnesses including thrombotic microangiopathies, systemic vasculitis, myasthenia gravis, proliferative lupus nephritis, and Guillain-Barré syndrome. The main reason for death was sepsis.

Randomized Controlled Trials in ICU in the Four Highest-Impact General Medicine Journals.

To study ICU trials published in the four highest-impact general medicine journals by comparing them with concurrently published non-ICU trials in the same journals. PubMed was searched for randomized controlled trials (RCTs) published between January 2014 and October 2021 in the New England Journal of Medicine , The Lancet , the Journal of the American Medical Association , and the British Medical Journal. Original RCT publications investigating any type of intervention in any patient population. ICU RCTs were defined as RCTs exclusively including patients admitted to the ICU. Year and journal of publication, sample size, study design, funding source, study outcome, type of intervention, Fragility Index (FI), and Fragility Quotient were collected. A total of 2,770 publications were screened. Of 2,431 original RCTs, 132 (5.4%) were ICU RCTs, gradually rising from 4% in 2014 to 7.5% in 2021. ICU RCTs and non-ICU RCTs included a comparable number of patients (634 vs 584, p = 0.528). Notable differences for ICU RCTs were the low occurrence of commercial funding (5% vs 36%, p < 0.001), the low number of RCTs that reached statistical significance (29% vs 65%, p < 0.001), and the low FI when they did reach significance (3 vs 12, p = 0.008). In the last 8 years, RCTs in ICU medicine made up a meaningful, and growing, portion of RCTs published in high-impact general medicine journals. In comparison with concurrently published RCTs in non-ICU disciplines, statistical significance was rare and often hinged on the outcome events of just a few patients. Increased attention should be paid to realistic expectations of treatment effects when designing ICU RCTs to detect differences in treatment effects that are reliable and clinically relevant.

Editorial introductions.

Editorial introductions.

Predictability performance of urinary C–C motif chemokine ligand 14 and renal resistive index for persistent sepsis-associated acute kidney injury in ICU patients

ObjectivesThe performance of renal resistance index (RRI) in predicting persistent sepsis-associated acute kidney injury (S-AKI) remains debatable, and the value of urinary C–C motif chemokine ligand 14 (CCL14) in predicting persistent S-AKI has not been validated yet. Therefore, we aimed to determine the applicability of a urinary biomarker CCL14 for the early detection of persistent S-AKI. Furthermore, the use of RRI obtained from renal Doppler ultrasonography was applied to differentiate transient from persistent S-AKI. Finally, we aimed to evaluate the use of these techniques in predicting different subtypes of S-AKI.MethodsThis prospective observational study was conducted at the internal medicine intensive care unit (ICU) of a university hospital. The RRI was determined within 12 h of ICU admission and the urinary CCL14 was evaluated at T0, T6, T12, and T24. The reversibility of renal dysfunction was assessed within 48 h. The receiver operating characteristic curves were then plotted to assess the diagnostic efficacy of the RRI and urinary CCL14 in predicting persistent S-AKI.ResultsOut of 48 patients, 23 developed persistent S-AKI upon admission. The RRI was higher in the persistent S-AKI group (P = 0.02) and the RRI ≥ 0.679 could predict persistent S-AKI with an area under the receiver operating characteristic curve of 0.79 (95% CI 0.65–0.93), a sensitivity of 91.30% (95% CI 70–98%), and a specificity of 65.20% (95% CI 43–83%). Urinary CCL14 was not significantly different between the two groups at the tested period, showing poor diagnostic performance at T0, T6, T12, and T24, with areas under the receiver operating characteristic curves of 0.56 (95% CI 0.38–0.73), 0.62 (95% CI 0.46–0.79), 0.52 (95% CI 0.35–0.68), and 0.60 (95% CI 0.43–0.77), respectively.ConclusionsThe RRI obtained from renal Doppler ultrasound is extremely effective in predicting persistent S-AKI in critically ill patients, and urinary CCL14 could not distinguish between transient and persistent S-AKIs.

Standard workload-based estimation of nursing manpower requirement in the ICU of a tertiary care teaching hospital: A time and motion study.

The safety of patients remain at risk due to a higher workload and lower nurse-to-patient ratio. However, in India, most hospitals still adhere to long-known nurse staffing norms set by their statutory or accreditation bodies. Therefore, the present study was undertaken to recommend a standard workload-based estimation of nursing manpower requirement in the ICU of a tertiary care teaching hospital. It was a descriptive, observational, time and motion study was conducted in the medicine ICU of a tertiary care teaching hospital. Data collection was done by using demographic and clinical profile sheet of patients, NPDS-H dependency assessment scale, time and activities record sheet, and WHO WISN tool. The nurses' activities were observed by nonparticipatory and non-concealment technique. Data analysis was done using descriptive statistics and the WHO WISN tool. The bed occupancy rate and the average length of stay in the medicine ICU were 93.23% and 7.18 days respectively. Distribution of dependency level of the medical ICU patients was very high (41.67%), low-high (33.33%), and medium-high (25.0%) dependency level. Considering available resources and workload in tertiary care hospitals in India, the study recommended a nurse-to-patient ratio of 1:1.2 in each shift for the medicine ICU of a tertiary care hospital. The study suggested minimum nurse-to-patient ratio in medical ICU should be 1:1.2 with provision of power to ICU incharge nurse to allocate nurses according to the workload in different shifts. Also, nurse staffing norms in hospitals need to be estimated or selected with serious consideration of health care demands when employing nurse staffing norms.

Comparative Analysis of Different Prognostic Markers in Predicting Outcome in Advanced Heart Failure

Introduction: Heart failure (HF) is a debilitating condition with an adverse outcome, especially during the advanced stage having higher morbidity and mortality rates. Various parameters have been used as prognostic markers in advanced HF. This study highlights about the comparative analysis of different prognostic markers in predicting mortality in advanced HF. Methods: This prospective observational study was conducted in patients of advanced HF admitted to the department of medicine intensive care unit in a rural tertiary care hospital from 2018 to 2020. Advanced HF was diagnosed using the updated HF Association-European Society of Cardiology criteria. The serum N-terminal pro-B-type natriuretic peptide (NT-proBNP), six-minute walk test (6MWT), left ventricular ejection fraction (LVEF), estimated glomerular filtration rate, and glycosylated hemoglobin type A1c levels were measured on admission. Receiver operating characteristic (ROC) curve was also studied for the above-mentioned variables, and the area under ROC curve (AUROC) was also determined. Results: Seventy-five patients with an average age of 60.55 ± 14.04 years were evaluated. Out of 75, 48 (64%) were male and 27 (36%) were female. There was inhospital mortality in 20 (26.67%) patients. The mean NT-proBNP levels among the mortality group was 9826.95 ± 3485.10 pg/mL, while in nonmortality group, it was 6135.40 ± 2342.77 pg/mL (P = 0.001). The cutoff range in this study for on-admission serum NT-proBNP levels was 8990 pg/mL, with AUROC of 0.81, the sensitivity of 70.0%, and specificity of 90.9%. In multiple regression analysis keeping mortality as the dependent variable, it was seen that variables NT-proBNP, 6MWT (&lt;300 m), and LVEF were significantly associated with mortality. Conclusion: Serum NT-proBNP and 6MWT (&lt;300 m) were important predictors of mortality in advanced HF.

122: APPROPRIATE USE OF QUETIAPINE IN ICU AND GENERAL MEDICINE PATIENTS

Introduction: In recent years, atypical antipsychotics, like, quetiapine, have gained traction for its off-label indications and sedative properties. The goal of this study is to describe the typical indication for quetiapine in the ICU and general medicine services to evaluate if quetiapine is being used according to evidence-based practice and guidelines. Methods: A retrospective analysis of an electronic medical record report was performed. Admitted patients who received a dose of quetiapine were included. General demographics collected include age, gender, and hospital length of stay. Additional data collected include quetiapine indication, CAM-ICU score at quetiapine initiation, duration of therapy, psych consult, home regimen, discharged on quetiapine, discharged from the ICU to the floor with a new quetiapine indication. Results: Over two months, 115 patients were identified and included. The cohort was ~63 years old, mostly male (60%), with an average hospital length of stay of 19 days. Delirium/agitation was the most frequent off-label indication (70%) with (30%) patients receiving quetiapine for a psychiatric or insomnia indication. At the initiation of quetiapine (38%) of patients were CAM positive. On average quetiapine was not initiated until six days into the hospital admission with (27%) of patients resuming a home regimen. During the admission (15%) of patients had a psychiatric consult placed. The cohort had (25%) of patients discharged from the ICU to the floor with quetiapine continued, and (44%) of patients discharged home with quetiapine that was a continuation of home therapy or a new start. The mortality rate for the entire population evaluated was 22%, additional comorbidities were not evaluated at the time of analysis. For delirium/agitation the common dosages were a combination of 25mg/25mg/50mg. For psychiatric indications the average dose was 100-300mg at bedtime. Conclusions: Psychoactive medications are frequently continued during transitions of care without a clear indication, especially in ICU patients discharging. To aid in discontinuation of potentially inappropriate use of atypical antipsychotics more effort should be made to prescribe according to true indication with a plan to discontinue when appropriate.

791. ICU Provider Overestimation of Ventilator-Associated Pneumonia Diagnostic Probability: An Opportunity for Diagnostic Stewardship

Abstract Background Overdiagnosis of ventilator-associated pneumonia (VAP) is common in intensive care units (ICUs). Because VAP is a clinical diagnosis without an easily accessible confirmatory diagnostic test, understanding how ICU physicians practice diagnostic reasoning in suspected VAP is vital to informing diagnostic stewardship efforts. We aimed to assess the accuracy of ICU practitioner estimates of VAP diagnostic probability. Methods We conducted a survey of physicians at Michigan Medicine ICUs. Providers were presented with clinical vignettes (Figure 1) in which mechanically ventilated patients developed clinical signs suggestive of VAP and then had radiographic/microbiologic tests performed. Providers were asked to estimate the probability of VAP before and after each presented clinical sign or test result, which were then used to impute provider-estimated likelihood ratios (pLRs) for each clinical sign and diagnostic test. Provider-estimated probabilities and LRs were compared to evidence-based VAP probabilities and LRs (eLRs) derived from systematic reviews and meta-analyses. Survey Case Example. Results Of 102 survey respondents, 54% felt moderately to extremely confident in their ability to accurately diagnose VAP. Providers significantly overestimated the pre and post-test probability of VAP in all clinical scenarios (provider-estimated VAP diagnostic probabilities are visualized using density plots relative to evidence-based diagnostic probability in Figure 2). Median pLRs for nearly all VAP clinical signs and diagnostic tests were also significantly higher than eLRs (Figure 3), most notably for isolated purulent endotracheal secretions (pLR 1.54 vs eLR 0.76, p&amp;lt; 0.01), positive chest radiograph (pLR 6.0 vs eLR 3.55, p&amp;lt; 0.01), and positive bronchoalveolar lavage culture (pLR 5.7 vs eLR 1.37, p&amp;lt; 0.01). Density Plots of Provider-Estimated vs Evidence-Based Diagnostic Probability of Ventilator-Associated Pneumonia. Provider-Estimated vs Evidence-Based Diagnostic Likelihood Ratios for Clinical Signs and Test Results Related to Ventilator-Associated Pneumonia. Conclusion Physicians routinely overestimated the diagnostic probability of VAP and the positive LRs of possible VAP clinical signs, as well as VAP diagnostic radiographic and microbiologic tests. Educational initiatives addressing and calibrating ICU providers’ perceptions of VAP diagnostic probability warrant investigation as an antimicrobial stewardship tool. Disclosures Owen Albin, MD, Charles River Laboratory: Advisor/Consultant|Cipla Pharmaceuticals: Advisor/Consultant|Shionogi Inc: Advisor/Consultant.