Mean Intensive Care Unit Length Research Articles

Positive Heparin/PF4 Antibodies and High Mortality Rate: a Retrospective Case-Series Analysis.

IntroductionHeparin-induced thrombocytopenia (HIT) is a potentially lethal complication of unfractionated or low-molecular weight heparin therapy. We aimed to determine the incidence and mortality rate of patients with positive heparin/platelet factor 4 (PF4) antibodies, which is a rapid detection test of HIT.MethodsCoronary artery bypass grafting and mitral and aortic valve surgeries were evaluated. Cardiopulmonary bypass was employed in all patients. The diagnosis of HIT was based on immunological assays. Postoperative complications, mortality rates, and the causes of death were specified in patients with positive heparin/PF4 antibodies.ResultsPostoperative thrombocytopenia was detected in 257 patients. Twenty of these patients undergoing open heart surgery were included in the final analysis. Antibodies against heparin/PF4 complex were positive in 20 patients. The mean body mass index was 28.8±2.3 kg/m2, mean value of left ventricular ejection fraction was 48.3±6.7%, cardiopulmonary bypass time was 113.0±35.0 min, aortic cross-clamping time was 88.0±32.7 min, mean intensive care unit length of stay was 10.9±4.9 days, mean preoperative platelet count was 307.250±88528 platelets/microliter, and mean postoperative platelet count was 243.050±89.354 platelets/microliter. The mean duration of heparin exposure was 6.9±2.9 days. The mortality rate was 45% (nine patients) and 1.2% (three patients) in heparin/PF4 complex positive and negative patients, respectively.ConclusionAlthough the incidence of HIT was low in patients undergoing open heart surgery, an increased rate of early mortality was observed in patients with positive heparin/PF4 antibodies.

Tracheostomy ventilation outside the intensive care unit: Experience of a tertiary care hospital

INTRODUCTION: Some patients remain dependent on invasive mechanical ventilation after critical illness. In most centers, these patients require Intensive Care Unit (ICU)-level care for ongoing tracheostomy-based mechanical ventilation. Our center has over 22 years of experience providing care for patients who require ventilation via tracheostomy on a medical ward. OBJECTIVE: The objective was to describe a patient cohort, including demographics, length of stay, complications and discharge disposition, who were ventilated via tracheostomy on medical wards. METHODS: A single center, retrospective study was conducted from 1993 to 2015. RESULTS: There were 144 admissions for 50 patients over the 22-year study period. Mean age at first admission was 55.6 years; 32 patients (64%) were male and 42 (84%) were admitted from home. Patients required ventilation for amyotrophic lateral sclerosis (ALS; 36%), spinal cord injury (16%), Guillain-Barre (12%) or another neuromuscular disorder (12%). Mean ICU length of stay on index admission was 46.6 days (range 2–219), and ward stay was an average of 264 days (range, 5–1402). Complications on index admission included 23 episodes of stoma infection, 48 episodes of pneumonia, and a total of 28 ICU transfers. Of the 50 patients, 19 (38%) were discharged home, 18 (36%) were transferred to long-term care and 12 patients (24%) died in hospital including 1 due to a critical incident involving prolonged disconnection from the ventilator. CONCLUSION: The complex care needs of patients requiring mechanical ventilation can safely be provided on medical wards. This opens ICU beds for other patients requiring critical care.

Indications and outcomes of combined heart-liver transplant: A systematic review and met-analysis.

Combined heart-liver transplantation (CHLT) has become a viable option for treating concomitant heart and liver failure. However, data are lacking with respect to long-term outcomes. An electronic search was performed to identify all studies on CHLT. Following application of inclusion and exclusion criteria, a total of seven studies consisting of 99 CHLT patients were included from the original 1864 articles. CHLT recipient mean age was 53.0 years (95% CI 48.0-58.0), 67.5% of which (95% CI 56.5-76.9) were male. 65.5% (95% CI 39.0-85.0) of patients developed heart failure due to amyloidosis whereas 21.6% (95% CI 12.3-35.2) developed heart failure due to congenital causes. The most common indication for liver transplant was amyloidosis [65.5% (95% CI 39.0-85.0)] followed by liver failure due to hepatitis C [13.8% (95% CI 2.1-54.4)]. The mean intensive care unit length of stay was 8 days (95% CI 5-11) with a mean length of stay of 24 days (95% CI 17-31). Cardiac allograft rejection within the first year was 24.7% (95% CI 9.5-50.7), including antibody mediated [5% (95% CI 1.7-15.2)] and T-cell mediated rejection [22.7% (95% CI 8.8-47.1)]. Overall survival was 87.5% (95% CI 78.6-93.0) at 1 year and 84.3% (95% CI 75.4-90.5) at 5 years. CHLT in select patients with coexisting end-stage heart and liver failure appears to offer high survival and low rejection rates.

Are We Out of the Woods Yet? The Aftermath of Resuscitative Thoracotomy

BackgroundAfter traumatic arrest, resuscitative thoracotomy is lifesaving in appropriately selected patients, yet data are limited regarding hospital course after intensive care unit (ICU) admission. The objective of this study was to describe the natural history of resuscitative thoracotomy survivors admitted to the ICU. Materials and methodsWe conducted a retrospective review (January 1, 2012–June 30, 2017) of all adult trauma patients who underwent resuscitative thoracotomy after traumatic arrest at two adult level 1 trauma centers. Data evaluated include demographics, injury characteristics, hospital course, and outcome. ResultsOver 66 mo, there were 52,624 trauma activations. Two hundred ninety-eight patients underwent resuscitative thoracotomy and 96 (32%) survived to ICU admission. At ICU admission, mean age was 35.8 ± 14.5 y, 79 (82%) were male, 36 (38%) sustained blunt trauma, and the mean injury severity score was 32.3 ± 13.7. Eight blunt and 20 penetrating patients (22% and 34% of ICU admissions, respectively) survived to discharge. 67% of deaths in the ICU occurred within the first 24 h, whereas 90% of those alive at day 21 survived to discharge. For the 28 survivors, mean ICU length of stay was 24.1 ± 17.9 d and mean hospital length of stay was 43.9 ± 32.1 d. Survivors averaged 1.9 ± 1.5 complications. Twenty-four patients (86% of hospital survivors) went home or to a rehabilitation center. ConclusionsAfter resuscitative thoracotomy and subsequent ICU admission, 29% of patients survived to hospital discharge. Complications and a long hospital stay should be expected, but the functional outcome for survivors is not as bleak as previously reported.

Acute and 1-Year Hospitalization Costs for Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention: ResultsFrom the TRANSLATE-ACS Registry.

BackgroundHospitalization for acute myocardial infarction (MI) in the United States is both common and expensive, but those features alone provide little insight into cost‐saving opportunities.Methods and ResultsTo understand the cost drivers during hospitalization for acute MI and in the following year, we prospectively studied 11 969 patients with acute MI undergoing percutaneous coronary intervention at 233 US hospitals (2010–2013) from the TRANSLATE‐ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) registry. Baseline costs were collected in a random subset (n=4619 patients, 54% ST‐segment–elevation MI [STEMI]), while follow‐up costs out to 1 year were collected for all patients. The mean index length of stay was 3.1 days (for both STEMI and non‐STEMI) and mean intensive care unit length of stay was 1.2 days (1.4 days for STEMI and 1.0 days for non‐STEMI). Index hospital costs averaged $18 931 ($19 327 for STEMI, $18 465 for non‐STEMI), with 45% catheterization laboratory–related and 20% attributable to postprocedure hospital stay. Patient factors, including severity of illness and extent of coronary disease, and hospital characteristics, including for profit status and geographic region, identified significant variations in cost. Intensive care was used for 53% of non‐STEMI and increased costs by $3282. Postdischarge 1‐year costs averaged $8037, and 48% of patients were rehospitalized (half within 2 months and 57% with a cardiovascular diagnosis).ConclusionsWhile much of the cost of patients with acute MI treated with percutaneous coronary intervention is probably not modifiable by the care team, cost reductions are still possible through quality‐preserving practice efficiencies, such as need‐based use rather than routine use of intensive care unit for patients with stable non‐STEMI.Clinical Trial RegistrationURL: https://www.clinicaltrials.gov. Unique identifier: NCT00097591.

Utilisation of critical care services for surgical patients in a model three hospital.

The demand for intensive care unit (ICU) beds in the surgical population has increased in recent years. This is due to increased complexity of operative interventions, development of critical care services and improved availability of technologies. The number of beds in ICUs nationwide remains limited. In model three hospitals, this is further impacted by a lack of high dependency unit (HDU) facilities and difficulty with transfer of patients to tertiary centres. To assess utilisation of ICU resources amongst general surgical patients admitted for elective and emergency procedures to Mayo University Hospital. A prospective study was conducted between 31/10/2016 and 01/11/2017 on general surgical patients admitted to the intensive care unit. The ICU register and ICU database were used to collect data regarding patient demographics, admission by specialty, ICU length of stay, interventions performed, level of care, infection status and antimicrobial usage. Eight hundred seventy-three patients were admitted to the ICU. One hundred thirty-four (15.35%) were surgical admissions, of which 55 were elective and 79 were emergency. The most common cause for emergency admission to ICU was emergency laparotomy. Mean ICU length of stay (LOS) for surgical patients was 3.6days. Three (2.2%) surgical patients were transferred to model four hospitals. This study demonstrates the need to protect sufficient numbers of ICU beds for delivery of emergency surgical care. It highlights the potential utility of an HDU in this setting. The introduction of such a facility would impact cost savings and increase access for those requiring definitive ICU level care.

Adequacy of enteral nutritional support in intensive care units does not affect the short- and long-term prognosis of mechanically ventilated patients: a pilot study.

ObjectiveTo correlate short-term (duration of mechanical ventilation and length of intensive care unit stay) and long-term (functional capacity) clinical outcomes of patients who reached nutritional adequacy ≥ 70% of predicted in the first 72 hours of hospitalization in the intensive care unit.MethodsThis was a prospective observational pilot study conducted in an 18-bed intensive care unit. A total of 100 mechanically ventilated patients receiving exclusive enteral nutritional support and receiving intensive care for more than 72 hours were included. Patients who never received enteral nutrition, those with spinal cord trauma, pregnant women, organ donors and cases of family refusal were excluded. The variables studied were nutritional adequacy ≥ 70% of predicted in the first 72 hours of hospitalization, length of intensive care unit stay, duration of mechanical ventilation and the ability to perform activities of daily living after 12 months, assessed via telephone contact using the Lawton Activities of Daily Living Scale.ResultsThe mean duration of mechanical ventilation was 18 ± 9 days, and the mean intensive care unit length of stay was 19 ± 8 days. Only 45% of the patients received more than 70% of the target nutrition in 72 hours. There was no association between nutritional adequacy and short-term (duration of mechanical ventilation, length of stay in the intensive care unit and mortality) or long-term (functional capacity and mortality) clinical outcomes.ConclusionCritically ill patients receiving caloric intake ≥ 70% in the first 72 hours of hospitalization did not present better outcomes in the short term or after 1 year.

Pediatric Major Vascular Injuries: A 16-Year Institutional Experience From a Combined Adult and Pediatric Trauma Center.

Vascular injury in pediatric trauma patients is uncommon but associated with a reported mortality greater than 19% in some series. The purpose of this study was to characterize pediatric major vascular injuries (MVIs) and analyze mortality at a high-volume combined adult and pediatric trauma center. A retrospective review (January 2000 to May 2016) was conducted of all pediatric (<18 years old) trauma patients who presented with a vascular injury. A total of 177 patients were identified, with 60 (34%) having an MVI, defined as injury in the neck, torso, or proximal extremity. Patients were then further analyzed based on location of injury, mechanism, age, and race. P ≤ 0.05 was deemed significant. Of the 60 patients with MVI, the mean age was 14.3 years (range, 4-17 years). Mean intensive care unit length of stay (LOS) was 5.4 days, and mean hospital LOS was 12.5 days. Blunt mechanism was more common in patients 14 years or younger; penetrating trauma was more common amongst patients older than 14 years. Overall, blunt injuries had a longer intensive care unit LOS compared with penetrating trauma (7.8 vs 3.1 days; P = 0.016). A total of 33% (n = 20) of MVIs occurred in the torso, with 50% (n = 10) of these from blunt trauma. Location of injury did correlate with mortality; 45% (n = 9) of torso MVIs resulted in death (penetrating n = 7, blunt n = 2). Overall mortality from an MVI was 15.3% (n = 9); all were torso MVIs. Higher Injury Severity Score and Glasgow Coma Scale score were found to be independently associated with mortality. Our experience demonstrates that MVIs are associated with a significant mortality (15.3%), with a majority of those resulting from gunshot wounds, more than 9-fold greater than the overall mortality of pediatric trauma patients at our institution (1.6%). Further research should be aimed at improving management strategies specific for MVIs in the pediatric trauma patient as gun violence continues to afflict youth in the United States.

Intraoperative initiation of a modified ARDSNet protocol increases survival of septic patients with severe acute respiratory distress syndrome

PurposeTo assess the intraoperative initiation and feasibility of a modified NIH-NHLBI ARDS Network Mechanical Ventilation Protocol (mARDSNet protocol) in septic patients with severe ARDS. Materials and methodsThis prospective observational study included consecutive adult septic patients with severe ARDS who underwent emergency abdominal surgery prior to intensive care unit (ICU) admission. The primary outcome was survival to hospital discharge and at 90 days. Secondary outcomes were intraoperative adverse events and ICU length of stay. ResultsSeven patients were included. A statistically significant difference in lung compliance [ε=0.150, F(1.053, 3.158)=31.098, p=0.010] and driving pressure [ε=0.263, F(1.844, 5.532)=7.042, p=0.031] was observed with time, while plateau pressure did not changed significantly during surgery [ε=0.322, F(2.256, 6.769)=1.920, p=0.219]. Also, PEEP values were constantly increased during surgery [ε=0.252, F(1.766, 5.297)=9.994, p=0.017], with the highest values being observed towards to the end of the procedure. No intraoperative adverse events were observed. Mean (±SD) ICU length of stay was 10.43 (±2.64) days, while all patients survived to hospital discharge and at 90 days. ConclusionsThe intraoperative implementation of our mARDSNet protocol is feasible and may increase the survival of septic patients with severe ARDS if initiated prior to ICU admission.

A Randomized Trial of a Family-Support Intervention in Intensive Care Units

BackgroundSurrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients’ preferences.MethodsWe conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates’ mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates’ mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician–family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient- and family-centered care), as well as the mean length of ICU stay.ResultsA total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates’ mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, −0.34; 95% confidence interval [CI], −1.67 to 0.99; P=0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, −1.66 to 3.47; P=0.49). The surrogates’ mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P=0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, −0.15; 95% CI, −0.26 to −0.04; P=0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P=0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P<0.001).ConclusionsAmong critically ill patients and their surrogates, a family-support intervention delivered by the interprofessional ICU team did not significantly affect the surrogates’ burden of psychological symptoms, but the surrogates’ ratings of the quality of communication and the patient- and family-centeredness of care were better and the length of stay in the ICU was shorter with the intervention than with usual care. (Funded by the UPMC Health System and the Greenwall Foundation; PARTNER ClinicalTrials.gov number, NCT01844492.)

Evaluation of stressors in intensive care units.

Physical and psychological stressors adversely affect the treatment and length of stay of patients in intensive care units. In this study, we aimed to describe environmental and psychological stressors affecting intensive care unit patients and to determine their priorities. In this study, the 40-item Intensive Care Unit Environmental Stressor Scale was administered to patients in the General Surgery Intensive Care Unit and the Anesthesiology and Reanimation Intensive Care Unit. The patients' age, gender, marital status, educational status, cause of hospitalization, and intensive care unit length of stay were questioned and recorded. Acute Physiology And Chronic Health Evaluation II scores were determined for intensive care unit patients. A total of 98 patients, 80 in the General Surgery Intensive Care Unit and 18 in the Anesthesiology and Reanimation Intensive Care Unit, were included in the study between May 1, 2015 and October 31, 2015. Fifty-six of the patients were male (57.1%) and 42 were female (42.9%). The mean age of the patients was 55.1±15.1 years. The mean intensive care unit length of stay was 3.4±1.6 days. The median Acute Physiology And Chronic Health Evaluation II score of the patients was 6 (0 to 17). The patients were most affected by thirst (mean 2.44). The second most stressful stress factor was the presence of tubes in the mouth and nose (mean 2.25). The least stressful factor for the patients was the presence of nurses constantly performing activities around the bed. Although 51% of the patients were postoperative, pain was ranked 5th among stress factors. The environmental and psychological factors affecting intensive care unit patients varied according to age, sex, and educational and surgical status. These factors had adverse effects on the patients. The elimination or modification of these factors would contribute positively to the treatment of intensive care unit patients and shorten their length of stay in the intensive care unit.

Clostridium difficile Infection in Trauma, Surgery, and Medical Patients Admitted to the Intensive Care Unit.

Clostridium difficile infection (CDI) causes significant morbidity and mortality rates, especially for patients in the intensive care unit (ICU). Data comparing trauma and surgery patients with CDI in the ICU with medical patients with CDI in the ICU are limited. In a single-center study, we analyzed retrospective data from 25 trauma patients and 13 surgery patients aged 18 years or older who had CDI and had been admitted to the ICU. A comparison group of 156 medical patients aged 18 years or greater who had CDI and were admitted to the ICU also was identified. The trauma/surgery patients had a significantly higher mean number of ventilator days (13.5 ± 9.3 vs. 7.3 ± 7.2; p < 0.0004), Foley catheter days (11.9 ± 6.8 vs. 8.0 ± 7.9; p = 0.005), mean ICU length of stay (LOS) (12.34 ± 9.7 vs. 5.9 ± 5.9 days; p < 0.0003), and mean total LOS (16 ± 9.3 vs. 10.7 ± 8.4 days; p = 0.0008). However, the medical group had a significantly higher mean number of vasopressor days (2.07 ± 3.51) than the trauma/surgery group (0.58 ± 1.55; p < 0.0001). The overall survival rate was significantly higher in the trauma/surgery group than in the medical group (100% vs. 81%, respectively; p = 0.003). A higher percentage of patients in the trauma/surgery group received piperacillin/tazobactam before the diagnosis of CDI than the medical patients (58% vs. 37%, respectively; p = 0.02). The number of days that antibiotics were given prior to the development of CDI was greater in the trauma/surgery group than in the medical group (10.3 ± 6.7 vs. 7.6 ± 7.3 days; p = 0.04). Multiple logistic regression models determined ICU LOS (adjusted odds ratio [aOR] 1.27 days; 95% confidence interval [CI] 1.13-1.41), the presence of chronic obstructive pulmonary disease (COPD) (aOR 3.44; 95% CI 1.19-9.95), and piperacillin/tazobactam use (aOR 3.27; 95% CI 1.24-8.65) to be positively associated with CDI in the trauma/surgery group compared with the medical patients. Longer ICU stay, receipt of piperacillin/tazobactam, and having COPD were positively associated with CDI in trauma/surgery patients compared with medical patients. These findings suggest further consideration of the possibility of CDI should be given to patients admitted the surgical ICU for an extended period of time, receiving piperacillin/tazobactam, or having COPD. Additional evaluation of these factors in a larger patient sample is warranted.

Predictive factors of in-hospital mortality in ventilated intensive care unit: A prospective cohort study.

Although it is clear that ventilated intensive care unit (ICU) patients have worse outcomes than those who are not, information about the risk factors of in-hospital mortality remains important for medical groups to target interventions for these patients.The purpose of this study was to identify predictive factors of in-hospital mortality in ventilated ICU patients with an admission diagnosis of acute respiratory failure.We conducted a prospective cohort study in 3 medical ICUs in a 3600-bed university hospital. Consecutive patients with acute respiratory failure who received mechanical ventilation (MV) for at least 96 hours without evidence of pre-existing neuromuscular diseases were followed until discharge. Upon inclusion, the following parameters were collected or evaluated: demographics, clinical history (admission body mass index [BMI], etiology of acute respiratory failure, comorbidity, Charlson comorbidity index, laboratory data), Acute Physiology and Chronic Health Evaluation (APACHE) II, and right and left quadriceps femoris muscle force. The days of MV before extubation, ICU length of stay, survival status at discharge, and hospital length of stay were recorded from the hospital discharge summary. The primary endpoint was in-hospital mortality.In all, 113 patients (65.49% males) were recruited with a mean age of 69.78 years and mean APACHE II score of 22.63. The mean ICU length of stay was 14.88 ± 9.79 days. Overall in-hospital mortality was 25.66% (29 out of 113 patients). Multivariate analysis showed that the essential factors associated with increased in-hospital mortality were lower BMI (P = .013), and lower scores on the right or left quadriceps femoris muscle force (P = .002 and .010, respectively).Our study suggests that lower BMI and lower scores on lower limb muscle force may be associated with increased in-hospital mortality in ventilated ICU patients.

Novel Automated Suturing Technology for Minimally Invasive Aortic Valve Replacements

Annular suture placement during minimally invasive right anterior thoracotomy aortic valve replacements (MI-AVR) can be challenging. We present the early clinical experience with novel automated suturing technology that may reduce the technical difficulty of this operation. The technology presented involves an automated articulating suturing device that simultaneously drives dual-curved needles through the aortic annulus to place a pledgeted horizontal mattress suture remotely; a second device with 2 straight needles places suture through the sewing cuff of a prosthetic heart valve. Automated annular suturing was used in five MI-AVR procedures, which were successfully completed, with no paravalvular leaks detected and a mean aortic valve gradient of 6.4 mm Hg postprocedure. Mean aortic cross-clamp and cardiopulmonary bypass times were 100 and 134 minutes, respectively. All 5 patients were successfully discharged home, with a mean intensive care unit and total length of stay of 2 and 7 days, respectively. Automated suturing during MI-AVRs is feasible and may reduce the technical challenge of this operation. Further research is necessary to determine its effect on patient outcomes.

Spectrum of microbial growth and antimicrobial usage in an intensive-care unit of a tertiary-care hospital in Trinidad, West Indies

Background. Intensive-care units (ICUs) are a source of multidrug-resistant organisms, owing to the indiscriminate usage of broad-spectrum antimicrobial drugs. In such settings, one must be aware of the spectrum of microbes and pattern of antibiotic usage. Objectives . To evaluate the spectrum, susceptibility and resistance patterns of microbes found in ICU patients in a tertiary-care teaching hospital in Trinidad, and to quantify antimicrobial usage. Methods . All adult patients (≥15 years of age) admitted to the ICU for ≥48 h who developed nosocomial infections conforming to the Centers for Disease Control and Prevention criteria were included. Demographic data and clinical data, including specimens sent, isolates grown, antimicrobial sensitivity and resistance patterns, the usage of antimicrobials and patient outcomes, were recorded. Variables such as age, admission white blood cell count, duration of first antibiotic used, length of ICU stay, length of hospital stay, organ support and total comorbidities were analysed. Antimicrobial usage was quantified as the defined daily dosage per 1 000 patient-days. Results . A total of 153 patients with 287 microbiological specimens were studied. The mean patient age was 48.4 years, and the mean ICU length of stay was 7.9 days. The most common admitting diagnoses were sepsis and multiple trauma. Staphylococcus aureus was the most common isolate from blood and central venous lines, and Pseudomonas aeruginosa from tracheal aspirates and wound swabs. Non-survivors had significantly higher age, leucocyte count and organ support requirements, and shorter lengths of stay. Cefuroxime was the most-used antimicrobial in the unit. Conclusion. The usage pattern of antimicrobials did not correlate with susceptibility in most instances. There is a need to improve antimicrobial usage by implementing antimicrobial-stewardship programmes to establish an antimicrobial protocol and guidelines for usage in the ICU.

A Guideline-Based Policy to Decrease Intensive Care Unit Admission Rates for Accidental Hypothermia.

Despite guidelines advising passive rewarming for mild accidental hypothermia (AH), patients are frequently admitted to intensive care unit (ICU) for active rewarming using a forced-air warming device. We implemented a new policy at our institution aimed at safely reducing ICU admissions for AH. We analyzed our practice pre- and post-policy intervention and compared our experiences with acute care hospitals in Connecticut. A retrospective chart review was performed on 203 participants with AH identified by primary and secondary discharge codes. Our new policy recommended passive rewarming on the medical floors for mild hypothermia (>32°C) and ICU admission for moderate hypothermia (<32°C). Practices of other Connecticut hospitals were obtained by surveying ICU nurse managers and medical directors. Over a 3-year period, prior to rewarming policy change, 64% (n = 92) of patients with AH were admitted to ICU, with a mean ICU length of stay (LOS [SD]) of 2.75 (2.2) days. After the policy change, over a 3-year period, 15% (n = 9) were admitted to ICU (P < .001), with an ICU LOS of 2.11 (0.9) days (P = 0.005). In both groups with AH, altered mental status, infection, and acute alcohol intoxication were the most common diagnoses at presentation. Alcohol intoxication was more prevalent in the post-policy intervention group, pre 17% versus post 46% (P < .001). No complications such as dermal burns or cardiac arrhythmias were noted with forced-air warming device use during either time period. Among the 29 hospitals surveyed, 20 used active rewarming in ICU or intermediate care units and 9 cared for patients on telemetry units. Most hospitals used active external rewarming for core body temperature of <35°C; however, 37% of hospitals performed active rewarming at temperatures >35°Cor lacked a policy. Reserving forced-air warming devices for the treatment of moderate-to-severe hypothermia (<32°C) significantly reduced ICU admissions for AH.

Epidemiology and long-term outcome after severe symmetric peripheral gangrene

Symmetric peripheral gangrene (SPG) is a rare but severe complication of septic shock often leading to multiple amputations. Epidemiology of SPG and long-term outcome remain poorly known. Amputations are serious offense to body but can benefit from rehabilitation and prosthesis. Our objectives were to describe epidemiology of SPG and to assess health-related quality of life (HRQOL) once rehabilitation was achieved. A prospective and retrospective, multicentric study was performed. Adult patients hospitalised between 2005 and 2015 were included. They must have undergone at least two amputations (whatever the level) and have been discharged in a specialized rehabilitation Department. HRQOL was assessed with generic scale EQ-5D-3L by phone call. Epidemiologic data were extracted from medical letters. Nine centres on 13 participated, 32 patients were recruited and medical letters were available for 27 of them. SPG was observed in a majority of female (59%), aged around 53 yo. Mean intensive care unit (ICU) length of stay was 39 (±22) days. Infectious agents were in majority Gram positive or negative cocci (68%), but Escherichia Coli took an important part (17%). All patients were amputated of the two lower limbs and 84% were quadruple amputees. HRQOL estimated with EQ index was inferior to the French reference. However, patients rated themselves their health state as similar to the reference and superior to the reference before SPG. Intense pain due to phantom pain was the main factor of impaired EQ index. Painkillers use was statistically dependant of antidepressants use. All patient, except one, said they would be willing to be treated again for SPG. SPG is mainly due to Gram positive or negative cocci but also Escherichia Coli and leads to severe amputations with impaired HRQOL. This is in line with the literature. However, patients report being in good health, but in excellent health before SPG. Such important decrease after sudden critical illness was observed in major trauma. A better analgesic strategy may improve HRQOL. Nevertheless, patients would be willing to be treated again. This should be taken into account before withdrawing life-sustaining therapies.

294 - Evaluating Hemodynamic Effects of Clevidipine in Cardiothoracic Surgery Patients with Reduced Ejection Fraction

Background: Clevidipine is an ultra-rapid acting intravenous dihydropyridine calcium channel blocker indicated for the reduction of blood pressure. It is particularly beneficial in the post-operative surgical setting due to its ability for rapid titration. However, there is limited data regarding the efficacy and hemodynamic effects of clevidipine in patients with heart failure with reduced ejection fraction (HFrEF). The primary objective of this study is to evaluate the hemodynamic effects of clevidipine in post-cardiothoracic surgery patients. Secondary objectives include evaluating the percentage of mean arterial pressure readings at goal, intensive care unit (ICU) and hospital length of stay, presence of arrhythmias, and rehospitalization and mortality within 1 year of follow up. Methods: This study was a single center, retrospective chart review of cardiothoracic surgery patients who received clevidipine between December 1, 2012 and November 30, 2016. Patients were included if they underwent cardiothoracic surgery excluding heart transplantation, had invasive hemodynamic monitoring, left ventricular ejection fraction of 40% or less, and were 18 years or older. Patients on extracorporeal membrane oxygenation or concomitant vasopressor or inotropic therapy, with the exception of milrinone and dobutamine, were excluded. Results: A total of 633 patients received clevidipine during the study period. Only 11 patients met all inclusion criteria. The mean clevidipine rate was 5.07 mg/hr with a mean length of infusion of 30.9 hours. The cardiac index increased from baseline to time of clevidipine discontinuation in 7 patients, but the mean change in cardiac index from baseline to time of clevidipine discontinuation was −0.036 L/min/m2. The mean pulmonary artery pressure trended down in most patients (72.7%) when compared at clevidipine initiation and discontinuation. All patients saw a reduction in their mean arterial pressure to a value of 90 mmHg or less within the first 6 hours of clevidipine administration. The mean ICU and hospital length of stay was 15.1 days and 22.3 days. There were 4 patients that developed an arrhythmia during the clevidipine infusion. Serum creatinine remained stable between 0.5 and 1.5 mg/dL in 8 of 11 patients. All patients survived to hospital discharge, with 63.6% of patients discharged to home and the remaining discharged to a rehab facility. No patients died within 1 year of discharge. Conclusions: The results of this study showed that the use of clevidipine in cardiothoracic surgery patients was associated with quick and effective blood pressure management. Patients did not have any sustained adverse effects thought to be contributed to the administration of clevidipine. The main limitation of this study was that concomitant medications may have impacted patient hemodynamic profile and outcomes. Future prospective studies are needed to assess the safety and efficacy of clevidipine in this population.

Surgery for Cardiac Papillary Fibroelastoma: A 12-Year Single Institution Experience.

BackgroundWe reviewed our clinical experience with cardiac papillary fibroelastoma from 2005 to 2017. The objective of this study was to investigate the clinical and operative data, as well as the early survival rate and immediate postoperative complications.Material/MethodsWe performed a retrospective analysis of 11 patients (eight males and three females) who underwent resection of cardiac papillary fibroelastoma in our institution.ResultsMean age at tumor diagnosis was 60±14 years. The mean dimension of the tumor was 14±11 mm. The most common symptoms were dyspnea, palpitation, and angina pectoris, while one patient had recurrent fever attacks and another patient had a transient ischemic attack. Two patients had concomitant malignant tumors (cervical and colon carcinoma) and another two had concomitant benign neoplasms (liver cyst and thyroid adenoma). Bypass and cross clamp times were 77±32 minutes and 54±18 minutes, respectively. The tumors were found predominantly on cardiac valves (n=7). In eight cases, only tumor extirpation was performed, whereas in the other three cases, the valves had to be replaced. The mean intensive care unit length of stay was 1.1±0.3 days and there was no in-hospital mortality. All patients were alive at one-year follow-up and the survival rate was 91% in the mean follow-up period of 4.15 years.ConclusionsThe surgical treatment of cardiac papillary fibroelastoma was curative and safe. Thus, potential complications such as embolization or mechanical irritation of the valves can be avoided without high surgical risk.

Renal recovery after severe acute kidney injury in critically ill myeloma patients: a retrospective study.

BackgroundDespite substantial improvements in the management of multiple myeloma, renal failure remains an important burden that tremendously impairs prognosis. The purpose of this study was to describe the characteristics and to establish prognostic factors of renal recovery in myeloma patients admitted to the intensive care unit (ICU) for acute kidney injury (AKI) Stage 3 treated with renal replacement therapy (RRT). MethodsA retrospective single-centre cohort study was performed, including consecutive myeloma patients admitted to one medical ICU between 1 January 2007 and 1 September 2015 and treated with RRT. Patients were evaluated 60 days after initiation of RRT and divided into three groups: alive without dialysis, alive and dialysis-dependent or deceased. A univariate analysis was performed to identify factors associated with renal recovery (alive without dialysis 60 days after initiation of RRT).ResultsFifty patients were included in the study. Mean age was 63 (interquartile range: 58–70) years and 32 (64%) were male. Patients were admitted to the ICU 4 (1–7) years after the diagnosis of myeloma. Twenty-one (42%) had already been treated with high-dose therapy combined with autologous stem cell transplantation. Baseline renal function evaluated by estimated glomerular filtration rate (GFR) before ICU admission was 63 (44–90) mL/min/1.73 m2. The mean SOFA score at Day 1 was 7 (4–8). The three main reasons for ICU admission were AKI (n = 31, 62%), acute pulmonary oedema (n = 17, 32%) and sepsis (n = 10, 20%). During ICU stay, RRT was implemented in all patients, 16 (32%) patients required invasive mechanical ventilation and 12 (24%) received vasopressors. The mean ICU and hospital length of stay were 6 (1–7) and 28 (13–34) days, respectively. At Day 60, 23 (46%) patients were alive without dialysis, 17 (32%) had died and 10 (20%) were still undergoing dialysis. Among the 23 patients who recovered, the mean duration of dialysis was 6 (2–18) days and renal function was not significantly different from baseline [estimated GFR at baseline = 65 (25–74) mL/min/1.73 m2 versus 63 (56–70) mL/min/1.73 m2 at Day 60, P = 0.70]. By univariate analysis, two factors were associated with nonrecovery of renal function at Day 60: a history of high-dose therapy combined with autologous stem cell transplantation [odds ratio (OR) = 6.1, 95% confidence interval (CI) 1.7–21.6; P = 0.008] and a proteinuria at ICU admission >370 mg/mmol creatinine (OR = 4.2, 95% CI 1.1–17; P = 0.02). None of the other variables related to the haematological malignancy or to the ICU stay was associated with renal recovery at Day 60.ConclusionsAKI Stage 3 in critically ill myeloma patients was associated with a lower than expected hospital mortality. Patients with a high level of proteinuria and a history of high-dose therapy combined with autologous stem cell transplantation were less likely to recover their renal function at Day 60.Key wordsdialysis, intensive care, multiple myeloma, prognosis, proteinuria