Intensive Care Unit Length Of Stay Research Articles

Improving Outcomes for Patients With Tracheostomy Through Implementation of AARC Clinical Practice Guidelines.

The COVID-19 global pandemic dramatically increased our institution's tracheostomy census. Comparing our existing protocols with American Association for Respiratory Care (AARC) January 2021 clinical practice guideline (CPG) relevant to caring for adult patients with tracheostomy in the acute care setting revealed numerous opportunities for improving our care of those patients. We assembled an interdisciplinary tracheostomy team to implement AARC CPG recommendations and manage all patients with tracheostomy in our hospital. We examined the effect our interdisciplinary team approach and implementation of AARC CPG recommendations had on the following metrics: average patient length of stay (LOS); ICU LOS; percentage of ventilator days; percentage of tracheostomy mask days; tracheostomy tube changes; decannulations; average time to decannulation; mortality; 30-d readmissions; and consultations for speech-language pathology (SLP), one-way speaking valves, physical therapy, and occupational therapy. A total of 203 subjects with tracheostomy were followed in a quality improvement study from June 2019-June 2023 (94 in the pre-intervention group, 109 in the post group). There were significant increases between before and after intervention groups in percentage of decannulations in acutely patients with tracheostomy/not present on admission, non-COVID subjects who survived hospitalization (11.8% vs 33.3%, P = .043), percentage of SLP consults (53.2% vs 89.0%, P < .001), and percentage of one-way speaking valve consults (17.0% vs 32.1%, P = .02). Establishment of an interdisciplinary tracheostomy team and implementation of AARC CPG recommendations for care of adult patients with tracheostomy in the acute care setting resulted in positive, statistically significant outcomes.

The Impact of Non-trauma Factors on Trauma Patient Mortality and Hospital Resource Utilization: Population-Based Retrospective Review.

The death of trauma patients with low injury severity scores (ISS) may not be fully explained by the severity of their injuries. Our objective was to evaluate preexisting conditions (PECs) that may contribute to the mortality rate of and hospital resources consumed by patients with low ISS. Trauma patients with ISS <9 were selected from the National Trauma Database Bank [NTDB] [2019-21]. Bivariate and multivariate analysis identified the risk factors associated with mortality, adjusting for secondary PECs, mechanism of injury, AIS body region, vital signs, and blood transfusion. A t test was used to compare PEC status with intensive care unit (ICU) and hospital length of stay (LOS) for significant differences (P < .05). 1,689,392 patients suffered mild injuries [59.1% male, mean age 45.2, 8579 expired (0.5%)]. Mortality was associated with the presence of several risk factors, especially advanced directive [OR = 9.13, P < .001], cirrhosis [OR = 8.55, P < .001], disseminated cancer [OR = 8.53, P < .001], congestive heart failure (CHF) [OR = 6.62, P < .001], chronic renal failure (CRF) [OR = 6.16, P < .001], chemotherapy for cancer [OR = 5.64, P < .001], peripheral arterial disease (PAD) [OR = 5.32, P < .001], myocardial infarction (MI) [OR = 4.96, P < .001], dementia [OR = 4.62, P < .001], and functionally dependent health [OR = 4.57, P < .001]. In addition, there was a relationship between the presence of several PECs and increased ICU and hospital LOS, especially cirrhosis, CRF, CHF, and PAD. Nontraumatic factors and preexisting conditions are associated with increased mortality and hospital resource consumption in trauma patients with a low ISS. They should be considered during clinical decision-making for these patients, who may otherwise masquerade as part of a low-risk population.

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

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

The Optimized Use of a Contact-Free Continuous Monitoring System on Clinical Outcomes During COVID-19.

The purpose of this study was to examine the impact of a contact-free continuous monitoring system on clinical outcomes including unplanned intensive care unit (ICU) transfer (primary), length of stay (LOS), code blue, and mortality. A secondary aim was to evaluate the return on investment associated with implementing the contact-free continuous monitoring program during the COVID public health emergency. An interrupted time series evaluation was conducted to examine the association between the use of contact-free continuous monitoring and clinical outcomes. A cost-benefit analysis was planned to evaluate the return on investment. Use of contact-free continuous monitoring was not significantly associated with unplanned ICU transfers, deaths, ICU LOS, and or rapid response team calls. However, there were significant increases in code blue events (P = 0.02) and mean hospital LOS (P = 0.01) in the postimplementation period when compared with the preimplementation period. Due to the lack of improvement, costs were calculated but a cost-benefit analysis was not conducted. Contact-free continuous monitoring bed use during the COVID-19 public health emergency was not associated with improvements in clinical outcomes, although there was substantial confounding. Future studies should include large randomized controlled trials to control for factors not under direct experimental control including unit staffing, staff turnover, and differences in the patient population related to surges in the COVID-19 pandemic.

The incidence of atrial fibrillation and its impact on the length of stay following valvular heart surgery.

There is minimal evidence regarding predictors, preventative measures and treatments of new onset of post-operative atrial fibrillation (POAF) in patients undergoing valvular heart surgery. This study aimed to determine the incidence of new onset atrial fibrillation (AF) and its impact on outcomes and length of stay (LOS) for patients following valvular heart surgery. A single-centre, retrospective study was conducted. New onset AF was observed in 51/120 (42.5%) patients. Baseline and surgical characteristics were similar between patients who did and did not develop AF, although suggestive older age may increase the risk of developing POAF (p=0.06). New onset AF was significantly associated with longer intensive care unit (ICU) LOS-median increase of 2 days (p=0.002)-and overall hospital LOS-median increase of 1.5 days (p=0.006). Patients who received double valve surgery spent 2.5 times longer in the ICU compared to patients who had an aortic valve replacement (AVR) (p=0.033). The incidence of new onset AF following valvular heart surgery was high, with associated prolonged ICU and hospital LOS. Patients undergoing double valve surgery were more likely to have a longer ICU LOS compared with those who received an AVR.

Preoperative anemia is associated with increased length of stay in adult spinal deformity surgery: evaluation of a large single-center patient cohort and future suggestions for patient optimization.

This study aimed to investigate the relationship of preoperative hemoglobin levels as an independent prognostic factor for hospital and intensive care unit (ICU) length of stay (LOS) in patients undergoing surgery for adult spinal deformity (ASD), with the intent of determining whether there exists a correlation and enhancing patient preoperative optimization protocols. The authors reviewed consecutive patients who underwent elective thoracolumbosacral posterior spinal fusion (PSF) involving six or more vertebrae for ASD from January 1, 2013, to December 13, 2021, with a minimum follow-up period of two years. This study primarily investigated the association of preoperative hemoglobin levels with hospital and ICU LOS. To analyze the data, both unadjusted and adjusted generalized linear models (GLM), incorporating cubic splines for non-linear variables, were applied. A total of 598 patients were included. GLMs for hospital and ICU LOS demonstrated nonlinear relationships with preoperative hemoglobin levels. Specifically, hospital LOS decreased with increasing preoperative hemoglobin until a significance threshold of 13.5g/dl. Similarly, ICU LOS significantly decreased with increasing preoperative hemoglobin until 13.0g/dl. Lower preoperative hemoglobin was associated with more perioperative transfusions, less likely discharge to home, and greater risk of reoperation. Preoperative anemia is an independent non-linear risk factor that significantly affects LOS, disposition, and outcomes after surgery for ASD. These findings advocate for a systemic preoperative approach and highlight the need for future research to improve postoperative outcomes and reduce hospital resource utilization. IV.

The cardio-protective effect of cardiomyopeptidin in critically ill patients with myocardial injury: a retrospective cohort study

In order to investigate the association between the use of cardiomyopeptidin (CMP) and outcomes in critically ill patients with myocardial injury, we conducted a retrospective cohort study in Nanfang hospital, Southern Medical University. Clinical data of patients with myocardial injury were collected retrospectively and adjusted for possible confounders by propensity score weighting. The main outcome was the in-hospital mortality. Secondary outcomes included the major adverse cardiovascular events (MACE) occurring during the hospital, the individual components of MACEs, changes in high sensitive troponin T (hsTnT) levels, length of stay (LOS) in ICU and hospital. A Cox proportional hazards model was constructed to examine the association between the application of CMP and in-hospital mortality. Logistic regression and linear regression are used to analyze secondary outcomes. In total, 339 critically ill patients with myocardial injury were included in the analysis. After inverse probability of treatment weighting (IPTW), the use of CMP was associated with reduced in-hospital mortality (HR: 0.64, 95%CI: 0.43–0.96, P = 0.03). No significant differences were found in change of hsTnT, the occurrence of MACE and LOS in ICU as well as hospital after IPTW. The association was more significant in the subgroup with hsTnT > 3URL (HR: 0.41, 95%CI: 0.23–0.71, P < 0.001) and APACHE II score < 25 (HR: 0.13, 95%CI: 0.17–0.59, P < 0.001). Cardiomyopeptidin was associated with reduced in-hospital mortality in critically ill patients with myocardial injury. Our study provides initial clinical basis for the application of CMP with cardio-protective effect in critically ill patients. These results need to be confirmed in future randomized controlled trails.

Host Response in Critically Ill Patients Aged 65 Years or Older: A Prospective Study.

The host response plays a critical role in the progression of all critical illnesses, especially in the aging population. With aging becoming a global phenomenon, understanding changes in the host response among elderly patients can provide valuable insights for diagnosis and treatment in the ICU. This study included all patients aged 65 and older admitted to our geriatric intensive care unit (GICU). Demographic, clinical, and medication data were extracted from electronic medical records. The primary outcome was in-hospital mortality, while secondary outcomes included hospital length of stay (LOS) and ICU stay duration. We employed the generalized additive mixed model for analysis and utilized nomogram analysis to build a predictive mortality model. A total of 1204 patients, with a median age of 75 years and a maximum age of 110 years, were admitted to the GICU. Host response biomarkers were notably lower in patients over 85 years. White blood cell (WBC) count, lactate dehydrogenase (LDH), interleukin-10 (IL-10), and tumor necrosis factor-α (TNF-α) were positively associated with mortality, while a higher platelet-to-lymphocyte ratio (PLR) was inversely related to mortality. Lymphocyte count was identified as a significant risk factor for mortality (RR = 1.2181). Elevated host response biomarkers were inversely associated with both hospital and ICU LOS. The predictive model integrating these biomarkers exhibited strong predictive performance for mortality. Our findings underscore the significant impact of aging on host response in critically ill patients. Older patients, particularly those over 85, exhibited lower biomarker levels and higher mortality rates. The predictive model developed from inflammatory, immune, and coagulation markers demonstrated robust prognostic utility, aiding in the evaluation of critically ill elderly patients.

Angioembolization for hemostasis in craniofacial fractures had a higher probability of delayed traumatic intracerebral hemorrhage

IntroductionWhile angioembolization is occasionally required for craniofacial fracture patients who experience massive maxillofacial hemorrhage, complications such as headache, temporal-facial pain, soft tissue necrosis, and embolic material migration leading to stroke or blindness can arise. Few studies have explored delayed or progressive intracerebral hemorrhage (ICH) following angioembolization for craniofacial fractures. MethodsA retrospective review of craniofacial fracture patients from January 1, 2015, to December 31, 2022 at our institution was conducted. We applied univariate and multivariable logistic regression (MLR) analyses to assess whether angioembolization served as an independent factor for delayed or progressive ICH. Propensity score matching (PSM) was used to balance the groups of patients who underwent angioembolization with those who did not. Outcome measurements included delayed or progressive ICH occurring within 72 hours, the need for additional neurosurgical interventions, and the length of stay (LOS) in the intensive care unit (ICU) and hospital. ResultsOf the 2,519 craniofacial fracture patients studied over an 8-year period, 21 (0.8%) underwent angioembolization for maxillofacial hemorrhage. MLR analysis revealed that angioembolization was an independent factor for delayed or progressive ICH (odds ratio=5.71, p = 0.028). After 1:2 PSM, patients who underwent angioembolization had greater rates of delayed or progressive ICH (28.6% vs. 7.1%, p = 0.023), an extended hospital LOS (17.0 vs. 15.0 days, p = 0.009) and a longer ICU LOS (10.0 vs. 4.0 days, p = 0.004). ConclusionsA greater probability of delayed or progressive ICH was observed in craniofacial fracture patients who underwent angioembolization for maxillofacial hemostasis.

Pediatric Burn Care for Burn Injury: Outcomes by Timing of Referral Using a U.S. Single-Center Retrospective Cohort, 2005-2019.

Burn centers offer specialized care to pediatric patients with burn injuries. However, data about outcome in relation to timing of transfer are limited. We examined these timings and outcomes among burn-injured pediatric patients. Single-center, retrospective cohort study of U.S. national and international practice. Shriners ESO Trauma Burn Registry, 2005-2019. Patients 0-17 years old admitted to a pediatric burn center with 10-80% total body surface area (TBSA) burn between 2005 and 2019. None. The cohort of 761 patients was subcategorized according to timing of referral: early presentation (EP) (0-7 d), delayed presentation (DP) (8-60 d), and very delayed presentation (VDP) (> 60 d). Primary outcomes included hospital length of stay (LOS), ICU LOS, percent TBSA (%TBSA)/LOS ratio, mortality, and disposition. Dichotomous outcomes were analyzed using logistic regression and continuous outcomes were compared using median regression, both utilizing multivariable analysis adjusting for a priori confounders and presented as adjusted coefficients (ACs) with 95% CI. Delayed referral (DP and VDP) was associated with higher %TBSA burn and with fewer referrals from high-income countries. Compared with EP, VDP was associated with higher LOS/%TBSA (AC, 0.2 [0.01-0.4]). On univariate analysis, in comparison with EP, DP and VDP were associated with higher ICU (DP 16 [6-29]; VDP 8 [0-18]) and hospital LOS (DP 34 [21-55]; VDP 32 [18-58]). Overall, ten of 761 patients died (1.3%), and we found no association between timing of referral and mortality. Also, in 751 survivors, 635 patients (84.6%) were discharged home without home health, and we found no association with timing of referral on multivariable analysis. In this report, we have reviewed our single-center, international burn-injured pediatric cohort, operating in the United States (2005-2019). We find that referral with VDP as opposed to EP was associated with increased LOS/%TBSA.

Implementing a Bedside Percutaneous Tracheostomy and Ultrasound Gastrostomy Team Reduces Length of Stay and Hospital Costs Across Multiple Critical Care Units in a 1500 Bed Tertiary Care Center.

Thousands of critically ill patients every year in the United States receive tracheostomy and gastrostomy procedures. Recent research has investigated the benefits of a combined team approach to these procedures, with associated decreases in length of stay (LOS) and hospital costs. This study's objective was to determine if implementing a bedside percutaneous tracheostomy and percutaneous ultrasound gastrostomy (PUG) team would reduce LOS and hospital costs. Design and Methods: This retrospective chart review compares the impact of implementing an ICU bedside percutaneous tracheostomy and PUG service team to the hospital's previous workflow (ie, pre-implementation). Inclusion criteria were adult patients with Ventilator Dependent Respiratory Failure (VDRF), a clinical indication for both procedures while admitted to the ICU and received both tracheostomy and gastrostomy procedures while admitted to the hospital. Pre- and post-implementation groups were compared across patients' demographics, clinical characteristics, and outcomes. ICU LOS, hospital LOS and total hospital costs were the primary outcome measures. Results: A total of 101 adult critically ill patients were included in the analysis; 49 patients were in the pre-implementation group and 52 patients in the post-implementation group (ie, PUG group). Patients in the PUG group had a significantly shorter mean ICU LOS and hospital LOS, 10.9- and 14.7-day reductions respectively (p = 0.010, p = 0.006). PUG group patients also had a significant reduction in total hospital costs, a per patient cost savings of $34 778 (p = 0.043). Conclusions: This study supports implementing a bedside percutaneous tracheostomy and PUG team to reduce LOS and total hospital costs in patients with VDRF.

Incidence, predictability, and outcomes of systemic venous congestion following a fluid challenge in initially fluid-tolerant preload-responders after cardiac surgery: a pilot trial

BackgroundFluid administration has traditionally focused on preload responsiveness (PR). However, preventing fluid intolerance, particularly due to systemic venous congestion (VC), is equally important. This study evaluated the incidence and predictability of VC following a 7 ml/kg crystalloid infusion in fluid-tolerant preload-responders and its association with adverse outcomes.MethodsThis single-center, prospective, observational study (May 2023–July 2024) included 40 consecutive patients who were mechanically ventilated within 6 h of intensive care unit (ICU) admission after elective open-heart surgery and had acute circulatory failure. Patients were eligible if they were both fluid-tolerant and preload-responsive. PR was defined as a ≥ 12% increase in left-ventricular outflow tract velocity time integral (LVOT-VTI) 1 min after a passive leg raising (PLR) test. VC was defined by a portal vein pulsatility index (PVPI) ≥ 50%. Patients received a 7 ml/kg Ringer’s Lactate infusion over 10 min. The primary outcome was the incidence of VC 2 min post-infusion (early-VC). Secondary outcomes included VC at 20 min, the incidence of acute kidney injury (AKI) and severe AKI at 7 days, and ICU length of stay (LOS).Results45% of patients developed early-VC, with VC persisting in only 5% at 20 min. One-third of patients developed AKI, with 17.5% progressing to severe AKI. The median ICU LOS was 4 days. Patients with early-VC had significantly higher central venous pressure, lower mean perfusion pressure, worse baseline right ventricular function, and a higher incidence of severe AKI. While LVOT-VTI returned to baseline by 20 min in both groups, PVPI remained elevated in early-VC patients (p < 0.001). The LVOT-VTI versus PVPI regression line showed similar slopes (p = 0.755) but different intercepts (p < 0.001), indicating that, despite fluid tolerance and PR at baseline, early-VC patients had reduced right ventricular diastolic reserve (RVDR). Post-PLR PVPI predicted early-VC with an area under the curve of 0.998, using a threshold of 44.3% (p < 0.001).ConclusionPost-PLR PVPI effectively predicts fluid-induced early-VC in fluid-tolerant preload-responders, identifying those with poor RVDR. Its use can guide fluid management in cardiac surgery patients, helping to prevent unnecessary fluid administration and associated complications.Trial Registration: NCT06440772. Registered 30 May 2024. Retrospectively registered.

A prospective cohort study comparing monitored anesthesia care and intubated general anesthesia in cardiac surgery involving cardiopulmonary bypass

BackgroundThe aim of this study is to assess the feasibility and safety of monitored anesthesia care (MAC) versus intubated general anesthesia (IGA) for patients undergoing elective cardiac surgery with cardiopulmonary bypass (CPB).MethodsThis prospective observational study included patients scheduled for cardiac surgery involving CPB at our institution between April 2012 and February 2017. The enrolled patients were categorized into MAC and IGA groups. MAC involved local anesthesia at the sternotomy site, sedation with dexmedetomidine, analgesia with remifentanil/sufentanil, and electroacupuncture (EA). Eleven patients underwent MAC, and 13 patients received IGA. There were no instances of conversion from MAC to IGA, and both groups exhibited no major complications. The demographic characteristics, baseline parameters, and operative variables were comparable between the two groups.ResultsIntraoperative opioid consumption was significantly lower in the MAC group compared to the IGA group (P < 0.001). The time to oral intake of liquids was significantly shorter in the MAC group (2.14 ± 0.90 h) compared to the IGA group (22.31 ± 3.33 h) (P < 0.001). Furthermore, the intensive care unit length of stay (ICU-LOS) and perioperative vasoactive-inotropic score (VIS) were significantly reduced in the MAC group compared to the IGA group (P < 0.001).ConclusionsMAC emerges as a safe and viable alternative to general anesthesia for specific patient groups undergoing cardiac surgery with CPB. Furthermore, it may enhance postoperative recovery and minimize postoperative complications compared to IGA.

Erector spinae plane block versus intravenous opioid for analgesia in pediatric cardiac surgery: A systematic review and meta-analysis.

The erector spinae plane block (ESPB) has recently emerged as a regional anesthesia technique for perioperative pain management in pediatric cardiac surgery. However, evidence comparing its effectiveness with intravenous (IV) opioid-based analgesia is limited. We aimed to evaluate and compare the analgesic efficacy of ESPB versus IV opioids in this setting. We systematically reviewed and meta-analyzed studies comparing ESPB with IV opioid analgesia in pediatric cardiac surgeries with midline sternotomy. Primary outcomes were intraoperative fentanyl consumption and intensive care unit (ICU) length of stay (LOS). Secondary outcomes included postoperative opioid consumption, time to first rescue analgesia, pain scores, postoperative vomiting and other complications, extubation time, and hospital LOS. Statistical analyses were performed using RStudio version 4.2.3. Five studies with 384 patients were included, with 178 receiving ESPB. ESPB significantly reduced intraoperative fentanyl use (MD -1.90 μg.kg-1; 95% CI -3.15 to -0.66 μg.kg-1; p = .003; I2 = 58%) and ICU LOS (MD -3.50 h; 95% CI -4.32 to -2.69 h; p < .0001; I2 = 0%). No significant differences were found in the remaining outcomes. Our findings suggest the ESPB might be an important adjunct to enhancing analgesia for midline sternotomies in pediatric cardiac surgery, potentially reducing intraoperative opioid requirements and ICU LOS. CRD 42024526961.

Effect of Tele-ICU on Clinical Outcomes of Critically Ill Patients

Despite its implementation in several countries, there has not been a randomized clinical trial to assess whether telemedicine in intensive care units (ICUs) could improve clinical outcomes of critically ill patients. To determine whether an intervention comprising daily multidisciplinary rounds and monthly audit and feedback meetings performed by a remote board-certified intensivist reduces ICU length of stay (LOS) compared with usual care. A parallel cluster randomized clinical trial with a baseline period in 30 general ICUs in Brazil in which daily multidisciplinary rounds performed by board-certified intensivists were not routinely available. All consecutive adult patients (aged ≥18 years) admitted to the participating ICUs, excluding those admitted due to justice-related issues, were enrolled between June 1, 2019, and April 7, 2021, with last follow-up on July 6, 2021. Remote daily multidisciplinary rounds led by a board-certified intensivist through telemedicine, monthly audit and feedback meetings for discussion of ICU performance indicators, and provision of evidence-based clinical protocols. The primary outcome was ICU LOS at the patient level. Secondary outcomes included ICU efficiency, in-hospital mortality, incidence of central line-associated bloodstream infections, ventilator-associated events, catheter-associated urinary tract infections, ventilator-free days at 28 days, patient-days receiving oral or enteral feeding, patient-days under light sedation, and rate of patients with oxygen saturation values under that of normoxemia, assessed using generalized linear mixed models. Among 17 024 patients (1794 in the baseline period and 15 230 in the intervention period), the mean (SD) age was 61 (18) years, 44.7% were female, the median (IQR) Sequential Organ Failure Assessment score was 6 (2-9), and 45.5% were invasively mechanically ventilated at admission. The median (IQR) time under intervention was 20 (16-21) months. Mean (SD) ICU LOS, adjusted for baseline assessment, did not differ significantly between the tele-critical care and usual care groups (8.1 [10.0] and 7.1 [9.0] days; percentage change, 8.2% [95% CI, -5.4% to 23.8%]; P = .24). Results were similar in sensitivity analyses and prespecified subgroups. There were no statistically significant differences in any other secondary or exploratory outcomes. Daily multidisciplinary rounds conducted by a board-certified intensivist through telemedicine did not reduce ICU LOS in critically ill adult patients. ClinicalTrials.gov Identifier: NCT03920501.

6431 Comparison of Diagnostic Scoring Systems for Myxedema Coma

Abstract Disclosure: K.S. Wei: None. A. Joyo: None. A.N. Lim: None. T.E. Angell: None. Introduction: Myxedema coma (MC) is a rare condition of severe hypothyroidism with high mortality. Diagnostic scoring systems exist, such as criteria by Popoveniuc et al. (2014) and Chiong et al. (2015), which both include categories of: “highly likely MC” (hlMC), “suggestive of MC” (sMC), and “unlikely MC” (uMC). Because few data support their clinical utility, we performed an analysis comparing these diagnostic criteria and associations with mortality and hospital measures. Methods: Patients with MC were included from a retrospective cohort of hospitalized adult patients with TSH greater than or equal to 10 mIU/L and free thyroxine (fT4) below the lower reference limit. Initial clinical diagnosis of MC was generally based on: hypothyroidism, precipitating illness, hypothermia, and altered mentation. Data collection included patient characteristics, mortality, ICU admission, and hospital length of stay (LOS). Patients were post-hoc categorized based on criteria of Popoveniuc and Chiong. Results: Of 386 initial patients, 25 patients had a clinical diagnosis of MC (median age = 60.1 years [IQR: 53.6-70.0]; 10/25 [40%] female). Median TSH was 58 mIU/L (IQR: 33.8-93.3) and median fT4 was 0.48 ng/dL (IQR: 0.16-0.68). All patients received IV levothyroxine and supportive care. Using Popoveniuc, 20/25 (80%) patients were hlMC and 5/25 (20%) were sMC. In contrast, using Chiong, 11/25 (44%) were hlMC, while 14/25 (56%) were sMC. No patient was considered uMC by either system. 10/25 (40%) patients were hlMC in both systems. 10/25 (40%) were hlMC in Popoveniuc but not Chiong, while only 1/25 (4%) was hlMC in Chiong but not Popoveniuc. Finally, 4/25 (16%) were not hlMC in either system. Mortality occurred in 3/25 (12%) patients, 2 of which were hlMC in Popoveniuc but not Chiong. There was a trend toward longer median hospital LOS in patients identified as hlMC vs not hlMC using Popoveniuc (11 days [IQR: 5.3-37.0] vs. 3.0 days [IQR: 2.0-17.5], p=0.07) but no statistically significant differences in hospital LOS were noted. There were no significant differences in ICU admission or LOS. Conclusion: Existing diagnostic scoring criteria of MC identified most patients but differed in their categorizations. Some cases of clinically diagnosed MC were not identified as hlMC by either scoring criteria. Criteria by Popoveniuc et al. appears to better capture patients most at risk for mortality and prolonged hospitalization. Presentation: 6/2/2024

A-315 Cardiac Troponin Concentrations in Pediatric Patients Infected with Respiratory Syncytial Virus

Abstract Background Respiratory syncytial virus (RSV) is associated with considerable morbidity and mortality in pediatric patients. Cardiac troponin I (TnI) has been shown to increase in patients with acute respiratory illness, including COVID-19. The impact of RSV infection on circulating TnI has been formally demonstrated in the literature. The goal of this study was to assess the relationship between TnI and respiratory syncytial virus (RSV) in pediatric patients. Methods A prospective study was conducted at St. Louis Children’s Hospital from October 2023 to February 2024. Patients older than 6 months who presented to the ED and had a CBC ordered within 6 hours of testing positive for RSV on the Biofire® FilmArray® Respiratory Panel were enrolled. Patients with Rhinovirus, Enterovirus, Streptococcus pneumoniae, or Adenovirus infections were included as controls. Remnant EDTA specimens were tested on an Abbott ARCHITECT i2000 for high sensitivity TnI (hs-TnI) with a limit of detection of 1.4 ng/L and a limit of quantitation of 3.5 ng/L. 99% upper reference limits from the CALIPER database on the Abbott of &amp;lt;7 ng/L were used as a threshold for positive results. The electronic medical record (EPIC) was assessed for demographic information and outcomes including length of stay (LOS), intensive care unit (ICU) length of stay, requirement of supplemental oxygen, white blood cell count (WBC), and creatinine. Results A total of 103 patients had RSV and 35 had other respiratory infections (ORI). The average age for the RSV positive group was 2.3 and for the ORI group was 2.4. Males made up 61% of the RSV+ group and 51% of the ORIs. 93 patients in the RSV group were admitted. The median TnI for RSV patients was 1.4 (IQR, 1.2-2.9) and for ORIs was 1.4 (IQR, 1.4-6.8). TnI was measurable in 58% of those with RSV and 54% in ORIs. We next assessed the correlation between hospital LOS and TnI in RSV+ patients, with a Pearson r of 0.42 (95% CI= 0.23-0.58). There was no correlation between WBC and LOS (r=-0.04, 95% CI=-0.25-0.17). There was also no correlation between TnI and WBCs or creatinine. Of admitted patients, 44 (47%) in the RSV group were in the ICU compared to 18 (51.4%) in those with ORIs. RSV+ patients that required ICU treatment had comparable TnI (1.4, IQR, 0.9-3.5) to those that didn’t require ICU stay (1.4, IQR, 0.75-1.5). There was no correlation between ICU LOS and TnI in RSV+ patients (r=-0.08, 95% CI=-0.39-0.24). There was a significant difference in mean TnI concentrations in RSV+ patients that required supplemental oxygen (8.7, 95% CI: 0-19) versus those that did not (1.7, 95% CI: 1.1-2.4). Conclusions There was no difference in TnI in patients hospitalized for RSV relative to ORIs. While TnI concentration was associated with LOS, there were minimally other associations between TnI and outcomes in patients hospitalized with RSV. While TnI elevations are associated with acute respiratory infections in adults, the impact on pediatric patients is not as clear. Future investigation is needed to understand how severe respiratory infections impact pediatric cardiac function.

Role of Prophylactic N-Acetylcysteine Supplementation on Postoperative Outcomes in Patients Undergoing Elective Double-Valve Replacement (Aortic and Mitral Valve).

The incidence of postoperative liver dysfunction is high in patients undergoing double-valve replacement - mitral and aortic valve replacement (DVR). This study aims to evaluate N-acetylcysteine's free radical scavenging property (NAC) to prevent postoperative liver dysfunction in these patients, thus affecting overall clinical outcomes. A single-center, prospective, randomized, double-blinded interventional study of 60 patients divided into two groups of 30 each. Group N received prophylactic intravenous NAC, and Group C received volume-matched 5% dextrose. Data comprised demographics, liver function tests (LFT), renal function tests (RFT), vasoactive-inotropic scores (VIS) score, and C-reactive protein (CRP) at various time intervals. Postoperative parameters such as ventilation duration, length of stay in ICU (LOS-ICU), length of hospital stay (LOHS), atrial fibrillation (AF), acute kidney injury (AKI) requiring hemodialysis, and mortality were noted. Statistical analysis was performed with the Student's t-test and Chi-square test (SPSS 22 software). All postoperative LFT parameters (total bilirubin, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), and alkaline phosphatase (ALP)) were significantly lower (P < 0.05) at 24, 48, and 72 hours in Group N compared to Group C. RFT and VIS scores were lower in Group N; however, were not statistically significant except for Serum Creatinine at 48 hours (P = 0.0478). Ventilation duration (P = 0.0465) and LOS-ICU (P = 0.0431) were significantly lower in Group N. Other outcomes like AF, LOHS, and mortality were lower in Group N but were not statistically significant. Our study showed that prophylactic administration of NAC in patients undergoing DVR is associated with a reduction in the incidence of postoperative liver dysfunction with a positive impact on postoperative outcomes.

Clinical effect on major trauma patients during simultaneous or overlapping presentations at an urban level I trauma center in Korea

Objective: Overcrowding in an emergency department (ED) or intensive care unit (ICU) of the trauma center (TC) is an important issue for timely acute health care of a critically injured patient. Accumulated scientific evidence has indicated the negative influence of overcrowding to the process and clinical outcome of trauma care. Method: The institutional trauma registry at an urban level I TC was retrospectively evaluated for 5 years (2018–2022). Major trauma was defined as an injury severity score (ISS) of >15. We determined simultaneous or overlapping presentations of major trauma (SOMT) in two or more patients with ISS of >15 who presented within a 4-h time window. When only two patients were included within a single time window, they were classified as SOMT-2, whereas when three or more patient clusters were identified in a single time window, they were classified as SOMT-3. The outcome measurement included process and clinical variables, such as trauma team activation (TTA) ratio, ED length of stay (LOS), time to blood product transfusion (TF), time to emergency surgery or intervention (ESI), ICU LOS, and mortality. Result: A total of 2,815 patients were included, of which 39.6% (N = 1,116) classified as SOMT.The SOMT group had lower TTA ratio than the non-SOMT group (69.4% vs. 73.4%, P = 0.022). The TTA ratio exhibited a decreasing trend in non-SOMT, SOMT-2, and SOMT-3 groups (P = 0.006). The time to TF was significantly delayed in the SOMT group (129 vs. 91 min, P < 0.001). Conclusion: SOMT regularly occurs and results in fewer trauma team activation and a delayed time to blood transfusion. The current intensive trauma care system should be strategically modified to improve critical trauma care and enhance disaster preparedness.

Early Tracheostomy in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation

BackgroundEarly tracheostomy (ET) can decrease length of stay and mortality. The benefits of ET in patients requiring venovenous (VV) extracorporeal membrane oxygenation (ECMO) remain contentious. We assessed the influence of ET on outcomes in patients requiring VV ECMO. MethodsWe queried a multiinstitutional ECMO registry to evaluate patients requiring VV ECMO for severe acute respiratory distress syndrome and compared outcomes between ET and late tracheostomy (LT) groups. Outcomes of interest included time to decannulation, extubation, discharge, survival, hospital, and intensive care unit length of stay (LOS). Univariate analyses of continuous and categorical variables were performed using t tests and χ2 tests where appropriate. Multistate Cox proportional hazards models and generalized linear models were used for multivariable analysis. ResultsOur sample comprised 133 patients, 88 who underwent ET and 45 who underwent LT. Patients who underwent ET were younger (P = .046), had a higher body mass index (P = .046), and had higher respiratory ECMO survival prediction (RESP) scores (P < .001). The number of days from ECMO to tracheostomy was 1.65 ± 1.26 days in the ET group and 13.6 ± 10 days in the LT group. There were no statistically significant differences in time to decannulation between the 2 groups. Univariate analysis demonstrated that patients with ET had a shorter interval and higher survival to extubation. Multivariable analysis demonstrated that patients with ET had a shorter duration to extubation (P = .03), time to discharge (P = .013), intensive care unit LOS (P = .012), and hospital LOS (P = .044). There was no significant difference in survival (P = .83) or time to decannulation (P = .12) between the 2 cohorts. ConclusionsExtracorporeal support involves high-intensity resource use. ET in patients requiring VV ECMO may improve outcomes and decrease resource consumption.