Longer Intensive Care Unit Length Of Stay Research Articles

Anticoagulation dosage strategy therapy, length of stay, and all-cause mortality in critically ill COVID-19 patients admitted to the intensive care unit.

Few studies examined several anticoagulation (AC) dosage strategy therapies for various outcomes among coronavirus disease-2019 (COVID-19) patients. However, this AC dosage strategy therapy has not been investigated to assess the length of stay (LOS) and all-cause mortality among critically ill COVID-19 patients admitted to the intensive care unit (ICU), especially in the eastern province of Saudi Arabia. Thus, this study aimed to examine the association of AC dosage strategy therapy with the LOS and all-cause mortality among critically ill COVID-19 patients admitted to the ICU. We enrolled 170 patients aged 18 years or older, had a confirmed COVID-19, and were hospitalized in a tertiary care facility in the eastern province of Saudi Arabia between March 1, 2020, and January 31, 2021. Patients (n = 56) who received Enoxaparin at a dose of less than or equal to 5000 units of unfractionated heparin thrice daily were categorized as receiving a "prophylaxis" dose. Patients (n = 114) who received a therapeutic dose but not a prophylaxis dose were categorized as receiving a "therapeutic dose." The 30-day ICU LOS was the main outcome, while all-cause mortality was the secondary outcome. The covariate-adjusted logistic regression analysis revealed that the therapeutic dose was significantly associated with a 1.74-fold longer ICU LOS and 6.60-fold greater mortality risk than the prophylaxis dose. Critically ill COVID-19 patients who received the therapeutic dose had a longer ICU LOS and higher mortality than those who received the prophylaxis dose.

Comparative Effectiveness of Early Neurosurgical Intervention in Civilian Penetrating Brain Injury Management.

To compare the outcomes of early vs no-neurosurgical intervention in civilians with penetrating brain injury (PBI). We collected data from the National Trauma Data Bank for PBI between 2017 and 2019. A total of 10 607 cases were identified; 1276 cases met the following criteria: age 16-60 years, an intensive care unit (ICU) length of stay (LOS) of >2 days, a Glasgow Coma Scale of 3-12, and at least one reactive pupil on presentation. Patients with withdrawal of life-sustaining treatments within 72 hours were excluded, leaving 1231 patients for analysis. Neurosurgical intervention was defined as an open-approach cranial procedure involving release, drainage, or extirpation of brain matter performed within 24 hours. Outcomes of interest were mortality, withdrawal of life-sustaining treatments, ICU LOS, and dispositional outcome. The target population was 1231 patients (84.4% male; median [IQR] age, 29 [18] years); 267 (21.7%) died, and 364 (29.6%) had a neurosurgical intervention within the first 24 hours. 1:1 matching yielded 704 patients (352 in each arm). In the matched cohort (mortality 22.6%), 64 patients who received surgery (18.2%) died compared with 95 (27%) in the nonsurgical group. Survival was more likely in the surgical group (odds ratio [OR] 1.66, CI 1.16-2.38, P < .01; number needed to treat 11). Dispositional outcome was not different. Overlap propensity score-weighted analysis (1231 patients) resulted in higher odds of survival in the surgical group (OR 1.8, CI 1.16-2.80, P < .01). The E-value for the OR calculated from the matched data set was 2.83. Early neurosurgical intervention was associated with longer ICU LOS (median 12 days [7.0, 19.0 IQR] vs 8 days [4.0, 15.0 IQR], P < .05). Management including early neurosurgical intervention is associated with decreased mortality and increased ICU LOS in matched cohorts of PBI.

Factors associated with prolonged intensive care unit treatment and organ failure in pediatric patients with diabetic ketoacidosis

Context: Patients with diabetic ketoacidosis (DKA) have potential complications, such as respiratory failure, cerebral edema, or acute renal injury, all of which can lead to a prolonged hospital course. Aims: This study identified risk factors for prolonged intensive care unit (ICU) stay and organ failure in pediatric patients with DKA. Materials and Methods: Patients with DKA aged <19 years admitted to the pediatric ICU of our hospital between June 2011 and May 2021 were enrolled. Demographic characteristics, initial Glasgow Coma Scale score, source of admission, biochemical values, ICU length of stay (LOS), and hospital LOS were collected. The primary outcome was to identify factors associated with prolonged (≥48 h) ICU treatment. The secondary outcomes were to identify factors associated with respiratory failure, cerebral injury, or acute renal failure. Results: This study enrolled 137 patients. Nonemergency room admission was associated with longer ICU LOS [adjusted odds ratio (aOR), 3.14; 95% confidence interval (CI) 1.01–9.82] compared with admission from the emergency room. Older age (aOR, 0.89; 95% CI, 0.80–0.99) and underweight (aOR, 0.33; 95% CI, 0.12–0.95) were associated with shorter ICU LOS. Conclusions: Recognizing the risk factors associated with prolonged ICU LOS in pediatric patients with DKA may help clinicians with the early identification of critical DKA cases.

If at First You Do Not Succeed: Consideration of Attempts in Patients With Trauma

IntroductionFailed extubation in critically ill patients is associated with poor outcomes. In critically ill trauma patients who have failed extubation, providers must decide whether to proceed with tracheostomy or attempt extubation again. The aim of this study was to describe the natural history of failed extubation in trauma patients and determine whether tracheostomy or a second attempt at extubation is more appropriate. MethodsTrauma patients admitted to our level I trauma center from 2013 to 2019 were identified. Patients who failed extubation, defined as an unplanned reintubation within 48 h of extubation, were included. Patients who immediately underwent tracheostomy were compared with those who had subsequent attempts at extubation. The primary outcome was mortality, and the secondary outcomes were intensive care unit (ICU) length of stay (LOS), ventilator days, and hospital LOS. ResultsThe population included 93 patients who failed extubation and met inclusion criteria. A total of 53 patients were ultimately successfully extubated, whereas 40 patients underwent a tracheostomy. There was no statistically significant difference in demographics or injury patterns. Patients who underwent tracheostomy had a longer ICU LOS and more ventilator days. There was no difference in mortality or hospital LOS between the two groups. ConclusionsIn trauma patients, those who underwent subsequent attempts at extubation did not experience higher rates of mortality than those who received a tracheostomy. Tracheostomy was associated with longer ICU LOS and ventilator days. In certain situations, it is appropriate to consider subsequent attempts at extubation in trauma patients who fail extubation rather than proceeding directly to tracheostomy.

Predictors of Intensive Care Unit Stay in Patients with Acute Traumatic Spinal Cord Injury Above T6

The objective of this study was to identify factors associated with the intensive care unit (ICU) length of stay (LOS) of patients with an acute traumatic spinal cord injury above T6. We performed a retrospective, observational study of patients admitted to an ICU between 1998 and 2017 (n= 241). The LOS was calculated using a cumulative incidence function, with events of death being considered a competing event. Factors associated with the LOS were analyzed using both a cause-specific Cox proportional hazards regression model and a competing risk model. A multistate approach was also used to analyze the impact of nosocomial infections on the LOS. A total of 211 patients (87.5%) were dischargedalive from the ICU (median LOS=23days), and 30 (12.4%) died (median LOS=11days). In the multivariate analysis after adjusting for variables collected 4days after the ICU admission, a higher American Spinal Injury Association motor score (subdistribution hazards ratio [sHR]=1.01), neurological level C5-C8 (HR=0,64), and lower Sequential Organ Failure Assessment score (sHR=0.82) and fluid balance (sHR=0.95) on day 4 were linked to a lower LOS in this unit. In the multivariate analysis, the onset of an infection was significantly associated with a longer LOS when adjusting for variables collected both at ICU admission (adjusted sHR=0.62; 95% confidence interval=0.50-0.77) and on day 4 (adjusted hazards ratio=0.65; 95% confidence interval=0.52-0.80). After adjusting the data for conventional variables, we identified a lower American Spinal Injury Association motor score, injury level C5-C8, a higher Sequential Organ Failure Assessment score on day 4, a more positive fluid balance on day 4, and the onset of an infection as factors independently associated with a longer ICU LOS.

Abstract TP124: Early Neurological Improvement Can Reduce Intensive Care Unit Length Of Stay In Aneurysmal Subarachnoid Hemorrhage

Introduction: Aneurysmal Subarachnoid Hemorrhage (aSAH) is often accompanied by an extended length of stay (LOS) in the intensive care unit (ICU), at tremendous cost to both the hospital system and the patient. We sought to determine predictors for ICU LOS in these patients. Methods: We performed a retrospective study of a cohort of consecutive patients with aSAH admitted to an academic referral center from 2016 to 2021. Multiple linear regression was performed in survivors to identify predictors for ICU LOS among factors present on admission and those related to hospital course. Results: In a cohort of 306 patients with confirmed aSAH, mean age was 57 years (SD 13.7), 61% were female and 70% were white. ICU LOS was longer for survivors (median 19 days, IQR 14-25) than for non-survivors (median 5 days, IQR 2-8; p&lt;0.001). For survivors (n=210), admission-related factors including Hunt and Hess grades 4 or 5 (4 additional days, 95% CI 0.5-7.5; p=0.027), hydrocephalus with external ventricular drain (EVD) requirement (9.2 additional days, 95% CI 5.7-12.8; p&lt;0.001), and coagulopathy (3.2 additional days, 95% CI 0.9-6.2; p=0.03) were associated with longer ICU LOS; however, early neurological improvement (defined as decrease in Hunt and Hess grades within first 3 days of admission) was associated with shorter ICU LOS (5.4 fewer days, 95% CI 2.7-8.5; p=0.001). Among hospital-related factors, symptomatic vasospasm (3.2 additional days, 95% CI 1.9-6.5; p=0.016), pneumonia (5.7 additional days, 95% CI 3.5-9.4; p= 0.001), and laryngeal edema requiring intubation or reintubation (4.3 additional days, 95% CI 0.7-7.8; p&lt;0.001) were associated with prolonged ICU LOS. Laboratory values from the emergency department and past medical history were not predictive for ICU LOS. Conclusion: Admission-related factors and in-hospital complications were more predictive for prolonged ICU LOS than past medical history or any laboratory values on admission. Early neurological improvement was associated with shorter ICU LOS which underscores the importance of early aggressive treatment measures in patients with aSAH.

Spring-mediated cranioplasty versus endoscopic strip craniectomy for sagittal craniosynostosis.

Endoscopic strip craniectomy (ESC) and spring-mediated cranioplasty (SMC) are two minimally invasive techniques for treating sagittal craniosynostosis in early infancy. Data comparing the perioperative outcomes of these two techniques are sparse. Here, the authors hypothesized that outcomes would be similar between patients undergoing SMC and those undergoing ESC and conducted a study using the multicenter Pediatric Craniofacial Surgery Perioperative Registry (PCSPR). The PCSPR was queried for infants under the age of 6 months who had undergone SMC or ESC for sagittal synostosis. SMC patients were propensity score matched 1:2 with ESC patients on age and weight. Primary outcomes were transfusion-free hospital course, intensive care unit (ICU) admission, ICU length of stay (LOS), and hospital length of stay (HLOS). The authors also obtained data points regarding spring removal. Comparisons of outcomes between matched groups were performed with multivariable regression models. The query returned data from 676 infants who had undergone procedures from June 2012 through September 2019, comprising 580 ESC infants from 32 centers and 96 SMC infants from 5 centers. Ninety-six SMC patients were matched to 192 ESC patients. There was no difference in transfusion-free hospital course between the two groups (adjusted odds ratio [aOR] 0.78, 95% CI 0.45-1.35). SMC patients were more likely to be admitted to the ICU (aOR 7.50, 95% CI 3.75-14.99) and had longer ICU LOSs (incident rate ratio [IRR] 1.42, 95% CI 1.37-1.48) and HLOSs (IRR 1.28, 95% CI 1.17-1.39). In this multicenter study of ESC and SMC, the authors found similar transfusion-free hospital courses; however, SMC infants had longer ICU LOSs and HLOSs. A trial comparing longer-term outcomes in SMC versus ESC would further define the roles of these two approaches in the management of sagittal craniosynostosis.

Association of Timing of Biliary Drainage with Clinical Outcomes in Severe Acute Cholangitis: A Retrospective Cohort Study.

PurposeThe guidelines recommend urgent biliary drainage (BD) for severe acute cholangitis, without a clear definition of “urgent”. To explore the optimal time, we identified the impact of timing of BD on clinical outcomes in severe acute cholangitis.Patients and MethodsA retrospective study of patients with severe acute cholangitis was conducted based on the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) database. Multivariable regressions were used to identified the effect of timing of BD on in-hospital mortality, 30-day mortality, and the length of stay (LOS) in hospital and the intensive care unit (ICU) with adjustment for confounding factors.ResultsA total of 106 severe acute cholangitis patients underwent BD with a median time of 14.14 hours (IQR: 7.60–32.59). Among them, 67.9% were performed within 24 hours and 80.2% within 48 hours. Median length of stay was 2.65 days (IQR: 1.70–5.12) in the ICU and 7.54 days (IQR: 4.49–17.17) in hospital. The in-hospital and 30-day mortality rates were 13.2% and 14.2%, respectively. On multivariate analysis, every 1-day delay of BD increased 1.49 days of stay in hospital (P<0.0001). Delayed BD (>48 hours) was linked with 5.56 days longer ICU LOS (P = 0.0096), while urgent BD (<24 hours) did not significantly shorten the ICU stay (P = 0.0997). No significant increase was observed on in-hospital mortality (OR = 1.03; 95% CI 0.93–1.13) nor 30-day mortality (OR=1.01; 95% CI 0.87–1.14) with BD delay in this population.ConclusionIn severe acute cholangitis patients, delay in BD increased in-hospital LOS. BD after 48 hours was associated with longer ICU LOS. Yet, BD within 24 hours did not significantly reduce the mortality nor shortened the ICU LOS.

Predictors of Length of Stay in Intensive Care Unit after Coronary Artery Bypass Grafting: Development a Risk Scoring System.

IntroductionTo determine predictors of length of stay (LOS) in the intensive care unit (ICU) after coronary artery bypass grafting (CABG) and to develop a risk scoring system were the objectives of this study.MethodsIn this retrospective study, 1202 patients' medical records after CABG were evaluated by a research-made checklist. Tarone-Ware test was used to determine the predictors of patients' LOS in the ICU. Cox regression model was used to determine the risk factors and risk ratios associated with ICU LOS.ResultsThe mean ICU LOS after CABG was 55.27±17.33 hours. Cox regression model showed that having more than two chest tubes (95% confidence interval [CI] 1.005-1.287, Relative Risk [RR]=1.138), occurrence of atelectasis (95% CI 1.000-3.007, RR=1.734), and occurrence of atrial fibrillation after CABG (95% CI 1.428-2.424, RR=1.861) were risk factors associated with longer ICU LOS. The discrimination power of this set of predictors was demonstrated with an area under the receiver operating characteristic curve and it was 0.69. A simple risk scoring system was developed based on three identified predictors that can raise ICU LOS.ConclusionThe simple risk scoring system developed based on three identified predictors can help to plan more accurately a patient's LOS in hospital for CABG and can be useful in managing human and financial resources.

Risk factors for determining length of intensive care unit and hospital stays following correction of cervical deformity: evaluation of early severe adverse events.

Correction of rigid cervical deformities can be associated with high complication rates and result in prolonged intensive care unit (ICU) and hospital stays. In this study, the authors aimed to examine the risk factors contributing to length of stay (LOS) in both the hospital and ICU following adult cervical deformity (ACD) surgery and to identify severe adverse events that occurred in this setting. A retrospective review of ACD patients who underwent posterior-based osteotomies for deformity correction from 2010 to 2019 was performed. Inclusion criteria were cervical kyphosis > 20° and/or cervical sagittal vertical axis (cSVA) > 4 cm. Multivariate analysis was used to identify risk factors independently associated with ICU and hospital LOS. A total of 107 patients were included. The mean age was 63.5 years, and 61.7% were female. Over half (52.3%) underwent 3-column osteotomies, while 47.7% underwent posterior column osteotomies. There was significant correction of all cervical parameters: cSVA (6.0 vs 3.6 cm, p < 0.001), cervical lordosis (8.2° vs -5.3°, p < 0.001), cervical scoliosis (6.5° vs 2.2°, p < 0.001), and T1-slope (40.2° vs 34.5°, p < 0.001). There were also reciprocal changes to the distal spine: thoracic kyphosis (54.4° vs 46.4°, p < 0.001), lumbar lordosis (49.9° vs 45.8°, p = 0.003), and thoracolumbar scoliosis (13.9° vs 11.1°, p = 0.009). Overall, 4 patients (3.7%) suffered aspiration-related complications, 3 patients (2.8%) experienced dysphagia requiring a feeding tube, and 4 patients (3.7%) had compromised airways, with 1 resulting in death. The mean ICU and hospital LOS were 2.8 days and 7.9 days, respectively. Multivariate analysis identified three factors independently associated with longer ICU LOS: female sex (3.0 vs 2.4 days, p = 0.004), ≥ 12 segments fused (3.5 vs 1.9 days, p = 0.002), and postoperative complication (4.0 vs 1.9 days, p = 0.017). These same factors were independently associated with longer hospital LOS as well: female sex (8.3 vs 7.3 days, p = 0.013), ≥ 12 segments fused (9.4 vs 6.2 days, p = 0.001), and complication (9.7 vs 6.7 days, p = 0.026). Posterior-based osteotomies are very effective for the correction of ACD, but postoperative hospital stays are relatively longer than those following surgery for degenerative disease. Risk factors for prolonged ICU and hospital LOS consist of both nonmodifiable (female sex) and modifiable (≥ 12 segments fused and presence of complication) risk factors. Additional multicenter prospective studies will be needed to validate these findings.

Outcomes of Hospitalized COVID-19 Patients by Risk Factors: Results from a United States Hospital Claims Database.

Background/ObjectiveThe primary objective was to quantify the role of the number of Centers of Disease Control and Prevention (CDC) risk factors on in-hospital mortality. The secondary objective was to assess the associated hospital length of stay (LOS), intensive care unit (ICU) bed utilization, and ICU LOS with the number of CDC risk factors.MethodsA retrospective cohort study consisting of all hospitalizations with a confirmed COVID-19 diagnosis discharged between March 15, 2020 and April 30, 2020 was conducted. Data was obtained from 276 acute care hospitals across the United States. Cohorts were identified based upon the number of the CDC COVID-19 risk factors. Multivariable regression modeling was performed to assess outcomes and utilization. The odds ratio (OR) and incidence rate ratio (IRR) were reported.ResultsCompared with patients with no CDC risk factors, patients with risk factors were significantly more likely to die during the hospitalization: One risk factor (OR 2.08, 95% CI, 1.60–2.70; P < 0.001), two risk factors (OR 2.63, 95% CI, 2.00–3.47; P < 0.001), and three or more risk factors (OR 3.49, 95% CI, 2.53–4.80; P < 0.001). The presence of CDC risk factors was associated with increased ICU utilization, longer ICU LOS, and longer hospital LOS compared to those with no risk factors. Patients with hypertension (OR 0.77, 95% CI, 0.70–0.86; P < 0.001) and those administered statins were less likely to die (OR 0.54, 95% CI, 0.49–0.60; P < 0.001).ConclusionsQuantifying the role of CDC risk factors upon admission may improve risk stratification and identification of patients who may require closer monitoring and more intensive treatment.

Evaluation of Amiodarone Use for New-Onset Atrial Fibrillation in Critically Ill Patients With Septic Shock.

Objective: To describe the use of amiodarone in critically ill, septic shock patients experiencing new-onset atrial fibrillation (NOAF) during the acute resuscitative phase of septic shock. Methods: Single-center, retrospective review of adult medical or surgical intensive care unit (ICU) patients with septic shock and NOAF. All patients received amiodarone for NOAF during the acute resuscitative phase of septic shock. The cohort was analyzed via descriptive statistics. Associations between amiodarone exposure and clinical outcomes were analyzed via a Cox proportional-hazards model. An a priori defined sensitivity analysis of hospital survivors was also employed. Main Results: A total of 239 patients were included in the analysis. Patients had a median baseline Charlson Comorbidity Index of 4 (interquartile range [IQR]: 2-6) and were acutely ill with a median Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 18 (IQR: 13-22) and an incidence of mechanical ventilation of 85%. In-hospital mortality was 56% with median ICU and hospital length of stay (LOS) of 9 and 15 days, respectively. Included patients received a median of 2760 (IQR: 1110-6415) mg of intravenous (IV) amiodarone during their ICU stay. Receipt of more than or equal to 2700 mg of amiodarone was identified as an independent factor associated with longer ICU LOS (hazard ratio [HR]: 1.30; 95% confidence interval [CI], 1.10-2.28). In a sensitivity analysis of hospital survivors (n = 105), receipt of more than or equal to 2700 mg of amiodarone remained independently associated with longer ICU LOS (HR: 1.64; 95% CI, 1.05-2.58). Conclusions: Exposure to more than or equal to 2700 mg of amiodarone in the setting of NOAF and septic shock is positively correlated with longer ICU LOS. Identifying opportunities to limit amiodarone exposure and address/resolve potential precipitating causes of NOAF in this clinical scenario may reduce the morbidity associated with septic shock.

Effect of Donor Age on Outcome of Lung Transplantation Stratified by Recipient Diagnosis: A Nordic Multicenter Study.

Organs from older donors are increasingly used in lung transplantation, and studies have demonstrated that this could be safe in selected recipients. However, which recipient groups that have the largest benefit of older organs are unclear. This multicenter study reviews all bilateral lung transplantations (BLTx) from donors 55 years or older stratified by recipient diagnosis and compares outcomes with transplantations from younger donors. All BLTx recipients (excluding retransplantation) at 5 Scandiatransplant centers between 2000 and 2013 were included (n = 913). Recipients were stratified to diagnosis groups including cystic fibrosis (CF), chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), and "other." Intensive care unit (ICU) length of stay (LOS) and survival were assessed. Overall, there was no difference in survival among patients transplanted from donors 55 years or older compared with younger donors. However, in CF recipients, donor age 55 years or older was associated with inferior survival (P = 0.014), and this remained significant in a multivariate model (hazard ratio, 5.0; 95% confidence interval, 1.8-14.1; P = 0.002). There was no significant effect of donor age on survival in recipients with COPD, ILD, or in the "other" group in multivariate models. Utilization of older donors was associated with increased ICU LOS for recipients with CF and ILD, but not in the COPD or "other" group. The BLTx recipients with CF had inferior survival and longer ICU LOS when receiving organs from donors 55 years or older. Recipients with COPD, ILD, or in the "other" group did not have inferior survival in multivariate models.

The novel oral anticoagulants (NOACs) have worse outcomes compared with warfarin in patients with intracranial hemorrhage after TBI.

Novel oral anticoagulant (NOAC) use is increasing in trauma patients. The reversal of these agents after hemorrhage is still evolving. The aim of our study was to evaluate outcomes after traumatic brain injury in patients on NOACs. 3-year (2014-2016) analysis of our prospectively maintained traumatic brain injury (TBI) database. We included all TBI patients with intracranial hemorrhage (ICH) on anticoagulants. Patients were stratified into two groups, those on NOACs and on warfarin, and were matched in a 1:2 ratio using propensity score matching for demographics, injury and vital parameters, type, and size of ICH. Outcome measures were progression of ICH, mortality, skilled nursing facility (SNF) disposition, and hospital and intensive care unit (ICU) length of stay (LOS). We analyzed 1,459 TBI patients, of which 210 patients were matched (NAOCs, 70; warfarin, 140). Matched groups were similar in age (p = 0.21), mechanism of injury (p = 0.61), Glasgow Coma Scale (GCS) score (p = 0.54), Injury Severity Score (p = 0.62), and type and size of ICH (p = 0.09). Patients on preinjury NOACs had higher rate of progression (p = 0.03), neurosurgical intervention (p = 0.04), mortality (p = 0.04), and longer ICU LOS (p = 0.04) compared with patients on warfarin. However, there was no difference in hospital LOS (p = 0.22) and SNF disposition (p = 0.14). On sub-analysis of severe TBI patients (GCS ≤ 8), rate of progression (p = 0.59), neurosurgical intervention (p = 0.62), or mortality (p = 0.81) was similar in both groups. The use of NOACs generally carries a high risk of bleeding and can be detrimental in head injuries with ICH. NOAC use is associated with increased risk of progression of ICH, neurosurgical intervention, and mortality after a mild and moderate TBI. Primary care physicians and cardiologists need to reconsider the data on the need for anticoagulation and the type of agent used and weigh it against the risk of bleeding. In addition, development of reversal agents for the NOACs and implementation of a strict protocol for the reversal of these agents may lead to improved outcomes. Therapeutic studies, level III.

Malnutrition Risk in Hospitalized Children: A Descriptive Study of Malnutrition-Related Characteristics and Development of a Pilot Pediatric Risk-Assessment Tool.

Underrecognition of pediatric malnutrition may affect nutrition interventions and outcomes. Pediatric malnutrition uses more specific etiology-based criteria but lacks clarity in implementation guidelines. Study goals were to identify malnutrition and risk among hospitalized patients, characterize malnutrition risk factors, and assess reliability of criteria against outcome measures. All children 44 weeks postmenstrual age-18 years, admitted for 48 hours during a 16-day period, were included (n=528). Trained dietitians assessed patients in physical assessments (PA), growth, energy intake, increased nutrient losses (IL), altered absorption of nutrients (AA), hypermetabolism and inflammation, laboratory information, micronutrient deficiency, and functional status. Outcome data assessed were length of stay (LOS), intensive care unit (ICU) LOS, ventilation days, nutrition support, and dietitian intervention. Malnutrition prevalence upon admission was 19.7%. Weight/length or BMI/age z-score (ZS) had no effect on LOS. AA and IL upon admission were independently associated with malnutrition (both, P<.01). Wasting and hypermetabolism were independently associated with longer LOS (P<.01). Other factors associated with longer LOS included IL and inflammation (P<.05). Those with hypermetabolism had significant ZS improvements if followed by a dietitian (P < .05). Wasting via PA was the only factor associated with longer ICU LOS (P<.05). Identification of risk factors (wasting, hypermetabolism, AA, IL) beyond anthropometrics to define malnutrition and risk is important in prioritizing care in a tertiary pediatric facility. Of great significance is the ability of dietitian-based PA to predict LOS and need for intervention.

Impact of multidrug-resistant bacteria on outcome in patients with prolonged weaning

BackgroundPneumonia and septic pneumonic shock are the most common indications for long-term mechanical ventilation and prolonged weaning, independent of any comorbidities. Multidrug resistant (MDR) bacteria are emerging as a cause of pneumonia or occur as a consequence of antimicrobial therapy. The influence of MDR bacteria on outcomes in patients with prolonged weaning is unknown.MethodsPatients treated in a specialized weaning unit of a university hospital between April 2013 and April 2016 were analyzed. Demographic data, clinical characteristics, length of stay (LOS) in the intensive care unit (ICU) and weaning unit, ventilator-free days and mortality rates were determined in prolonged weaning patients with versus without MDR bacteria (methicillin-resistant Staphylococcus aureus bacteria, [MRSA]; extended spectrum beta lactamase [ESBL]- and Gyrase-producing gram negative bacteria resistant to three of four antibiotic groups [3 MRGN]; panresistant Pseudomonas aeruginosa and other carbapenemase-producing gram-negative bacteria resistant to all four antibiotic groups [4 MRGN]). Weaning failure was defined as death or discharge with invasive ventilation.ResultsOf 666 patients treated in the weaning unit, 430 fulfilled the inclusion criteria and were included in the analysis. A total of 107 patients had isolates of MDR bacteria suspected as causative pathogens identified during the treatment process. Patients with MDR bacteria had higher SAPS II values at ICU admission and a significantly longer ICU LOS. Four MRGN P. aeruginosa and Acinetobacter baumanii were the most common MDR bacteria identified. Patients with versus without MDR bacteria had significantly higher arterial carbon dioxide levels at the time of weaning admission and a significantly lower rate of successful weaning (23% vs 31%, p < 0.05). Mortality rate on the weaning unit was 12.4% with no difference between the two patient groups. There were no significant differences between patient groups in secondary infections and ventilator-free days.ConclusionsIn patients with pneumonia or septic pneumonic shock undergoing prolonged weaning, infection with MDR bacteria may influence the weaning success rate but does not appear to impact on patient survival.

Malnutrition is Associated with Poor Outcomes after Liver Transplantation

Introduction Malnutrition is prevalent in recipients undergoing liver transplantation. However, the implication of nutritional status on morbidity and mortality remains unclear. This study aims to evaluate the impact of malnutrition on recipient outcomes. Methods A retrospective review of 390 adult recipients who underwent liver transplantation between January 2009 and June 2016 was performed. Recipients with fulminant liver failure or those requiring re-transplantation were excluded. A total of 321 recipients was analysed. Nutritional status was determined by the subjective global assessment (SGA) at wait-listing and at transplantation. Outcome measures comprised the development of infection within the index admission, rejection within 90-days, and biliary anastomotic strictures within 90-days, as well as readmission within 90-days, intensive care unit (ICU) length of stay (LOS), hospital LOS, and overall survival. Results Malnutrition (SGA-B & SGA-C) was identified in 67% of the recipients at wait-listing. Progressive decline in nutritional status was observed at transplantation (wait-list median 4.4-months), where 77% of the recipients were malnourished. Of these, 18% (n=58) were severely malnourished (SGA-C). Severe malnutrition at transplantation was associated with longer ICU LOS (147-hours vs 89-hours, p<0.01), longer hospital LOS (40-days vs 16-days, p<0.01) and increased incidences of infection (55.2% vs 33.8%, p<0.01) when compared to the well-nourished recipients (SGA-A). Other outcome measures were not associated with nutritional status. Conclusion This large study demonstrates the impact of malnutrition on early recipient morbidity. Nutritional interventions prior to transplantation may potentially improve outcomes and reduce the economic burden on our healthcare system.

Long-term survival and resource use in critically ill cardiac surgery patients: a population-based study.

Most cardiac surgery patients recover well; a substantial minority become critically ill after surgery. The epidemiology of critical illness after cardiac surgery is poorly described. We measured the association of prolonged critical illness with long-term survival and resource use after cardiac surgery. This was a historical population-based cohort study in Ontario, Canada (2002-2013), of adult cardiac surgery patients. Validated methods were used to measure postoperative intensive care unit (ICU) length of stay (LOS). We categorized patients into short (0-2 day), moderate (3-9 day), and long (10+ day) ICU LOS groups. The adjusted associations of ICU LOS with one-year survival (primary outcome) and costs, hospital readmissions, and institutional discharge were measured using multilevel, multivariable regression. Pre-specified sensitivity analyses were performed. We included 111,740 patients having their first cardiac surgery during the study period who survived ≥ ten postoperative days. Most patients had a short ICU LOS (75.9%); 20.9% and 3.3% had moderate or long ICU LOS, respectively. The short-stay one-year mortality rate was 2.1%. Longer ICU LOS was independently associated with decreased one-year survival (moderate LOS: hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.6 to 1.94; long LOS: HR, 8.66; 95% CI, 7.93 to 9.44). Sensitivity analyses supported the findings of the primary analysis. Secondary outcomes were independently associated with longer ICU LOS. Long ICU LOS patients occupied 30% of all ICU bed days, and 55% died or were discharged to an institution. Prolonged ICU LOS after cardiac surgery is associated with decreased 1-year survival and increased healthcare resource use.

Seizures and Epileptiform Discharges in Patients With Acute Subdural Hematoma.

Subdural hematomas (SDH) are associated with seizures and epileptiform discharges, but little is known about the prevalence and impact of seizures, status epilepticus (SE), and epileptiform discharges on outcomes in patients with isolated acute SDH (aSDH). Continuous EEG reports from 76 adult patients admitted to Rush University Medical Center with aSDH between January 2009 and March 2012 were reviewed. Clinical and radiographic findings, comorbidities, treatment, and outcome parameters, such as mortality, discharge destination, need for tracheostomy/percutaneous endoscopic gastrostomy placement, and length of stay (LOS), were assessed. Univariate and multivariate analyses were performed to assess the impact of clinical seizures, SE, and epileptiform EEG on outcomes. Of 76 patients with aSDH who underwent EEG monitoring, 74 (97.4%) received antiseizure prophylaxis. Thirty-two (41.1%) patients had seizures, most of which were clinical seizures. Twenty-four (32%) patients had epileptiform EEG findings. Clinical or nonconvulsive SE was diagnosed in 12 (16%) patients. Clinical seizures were not associated with outcome parameters. Epileptiform EEG findings were independently associated with longer hospital LOS (13 vs. 8 days, P = 0.04) and intensive care unit LOS (10 vs. 4 days, P = 0.002). The SE also predicted longer intensive care unit LOS (10 vs. 4 days, P = 0.002). Neither epileptiform EEG nor SE was significantly related to mortality, discharge destination, or need for tracheostomy/percutaneous endoscopic gastrostomy placement. Seizures and epileptiform EEG findings are very common in patients with aSDH despite antiseizure prophylaxis. While clinical seizures did not affect outcomes, the presence of epileptiform EEG findings and SE was independently associated with longer intensive care unit LOS and hospital LOS.

Influence of Left Ventricular Hypertrophy on In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease

ABSTRACTLeft ventricular hypertrophy (LVH) is associated with worse outcomes in chronic obstructive pulmonary disease (COPD); however, its role in an acute exacerbation of COPD (AECOPD) has not been reported. This was a retrospective cohort study during 2008–2012 at an academic medical center. AECOPD patients >18 years with available echocardiographic data were included. LVH was defined as LV mass index (LVMI) >95 g/m2 (women) and >115g/m2 (men). Relative wall thickness was used to classify LVH as concentric (>0.42) or eccentric (<0.42). Outcomes included need for and duration of non-invasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed p < 0.05 was considered statistically significant. Of 802 patients with AECOPD, 615 patients with 264 (42.9%) having LVH were included. The LVH cohort had higher LVMI (141.1 ± 39.4 g/m2 vs. 79.7 ± 19.1 g/m2; p < 0.001) and lower LV ejection fraction (44.5±21.9% vs. 50.0±21.6%; p ≤ 0.001). The LVH cohort had statistically non-significant longer ICU LOS, and higher NIV and MV use and duration. Of the 264 LVH patients, concentric LVH (198; 75.0%) was predictive of greater NIV use [82 (41.4%) vs. 16 (24.2%), p = 0.01] and duration (1.0 ± 1.9 vs. 0.6 ± 1.4 days, p = 0.01) compared to eccentric LVH. Concentric LVH remained independently associated with NIV use and duration. In-hospital outcomes in patients with AECOPD were comparable in patients with and without LVH. Patients with concentric LVH had higher NIV need and duration in comparison to eccentric LVH.