Medical Intensive Care Unit Patients Research Articles

Use of actigraphy to characterize inactivity and activity in patients in a medical ICU

BackgroundIn the intensive care unit (ICU), inactivity is common, contributing to ICU-acquired weakness and poor outcomes. Actigraphy may be useful for measuring activity in the ICU. ObjectivesTo use actigraphy to characterize inactivity and activity in critically ill patients. MethodsThis prospective observational study involved 48-h wrist actigraphy in medical ICU (MICU) patients, with activity data captured across 30-s epochs. Inactivity (zero-activity epochs) and activity (levels of non-zero activity) were summarized across key patient (e.g., age) and clinical (e.g., mechanical ventilation status) variables, and compared using multivariable regression. ResultsOverall, 189,595 30-s epochs were collected in 34 MICU patients. Zero-activity (inactivity) comprised 122,865 (65%) of epochs; these epochs were 24% and 13% more prevalent, respectively, in patients receiving mechanical ventilation (versus none, p < 0.001) and in the highest (versus lowest) organ failure score tertile (p = 0.03). Ambulatory (versus non-ambulatory) patients exhibited more non-zero activity (35 more movements per epoch, p < 0.001), while those in the highest (versus lowest) organ failure score tertile exhibited less activity (22 fewer movements per epoch, p = 0.03). Significant inactivity/activity differences were not observed when evaluated based on age, sedation, or restraint status. ConclusionsActigraphy demonstrated that MICU patients are profoundly inactive, including those who are young, non-sedated and non-restrained. Hence, ICU-specific, non-patient-related factors may contribute to inactivity, an issue requiring further investigation.

Abdominal compartment syndrome: Often overlooked conditions in medical intensive care units.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome are well recognized entities among surgical patients. Nevertheless, a number of prospective and retrospective observational studies have shown that IAH is prevalent in about half of the critically ill patients in the medical intensive care units (ICU) and has been widely recognized as an independent risk factor for mortality. It is alarming to note that many members of the critical care team in medical ICU are not aware of the consequences of untreated IAH and the delay in making the diagnosis leads to increased morbidity and mortality. Frequently it is underdiagnosed and undertreated in this patient population. Elevated intra-abdominal pressure decreases the blood flow to the kidneys and other abdominal viscera and also results in reduced cardiac output and difficulties in ventilating the patient because of increased intrathoracic pressure. When intraabdominal hypertension is not promptly recognized and treated, it leads to abdominal compartment syndrome, multiorgan dysfunction syndrome and death. Large volume fluid resuscitation is very common in medical ICU patients presenting with sepsis, shock and other inflammatory conditions like pancreatitis and it is one of the major risk factors for the development of intra-abdominal hypertension. This article presents an overview of the epidemiology, definitions, risk factors, pathophysiology and management of IAH and abdominal compartment syndrome in critically ill medical ICU patients.

Mortality of Patients Requiring Escalation to Intensive Care within 24 Hours of Admission in a Mixed Medical-Surgical Population.

Delayed intensive care unit (ICU) admissions are associated with increased mortality. We present a retrospective study looking at whether indirect admissions to the ICU within 24 hours of hospital admission were associated with increased mortality. Retrospective cohort study SETTING: Mixed medical-surgical ICU at a large tertiary United States Veterans Affairs (VA) Hospital System POPULATION: The patients were a mix of medical and surgical patients. Patients included both those directly admitted from the operating room as well as those escalated to the ICU after initial admission to the ward (indirect admission). All admissions to a medical-surgical ICU from 2008 to 2013 were included in the study. The database was queried for time and location where the admission originated. Separate lists were created for patients with severe sepsis, patients who transferred to the ICU within the first 24 hours, and patients who had rapid response or code team activations. Analysis was applied to the whole group and to medical and surgical subpopulations. A total of 3,862 ICU admissions were studied. Univariate analysis indicated an impact of delayed admission on whole group and surgical patients; however, multivariate analysis indicated a significant effect of delayed admission on 1-year surgical mortality. Multivariate analysis also showed a consistent effect of age, ICU length of stay, and cardiac arrest on mortality of both medical and surgical ICU patients. In a large retrospective study, surgical patients had increased 1-year mortality if they required escalation to the ICU within 24 hours of hospital admission. This result was not replicated in medical patients, possibly related to a burden of illness that could not be altered by earlier care.

Clinical Profile and Prognostication in Patients Admitted at Medical Intensive Care Unit at B. P. Koirala Institute of Health Sciences

Introduction: Critical Care management is an important issue in developing countries where Medical Intensive Care Units (MICU) patients have comorbidity or complications of multisystem involvement.&#x0D; Objectives: The objective of study was to analyze clinical profiles of patients in Medical Intensive Care Unit and identify applicable factors that prognosticate outcomes.&#x0D; Methodology: Study conducted at Medical Intensive Care Unit of B. P. Koirala Institute of Health Sciences, Dharan, Nepal. Records from July 31, 2013 to August 1, 2014 were retrospectively studied. Clinical profiles were analyzed, outcomes defined as improved, referred, Leave Against Medical Advice (LAMA) or death. An online calculator (MD+Calc) was used to calculate Sequential Organ Failure Assessment Score (SOFA). Descriptive statistics were used, values &lt;0.05 were statistically significant.&#x0D; Results: Of 70 patients 36 (51.4%) were female, 30 (42.9%) had sepsis of which 12 (40%) had Community-Acquired Pneumonia. 8 (11.43%) had Acute Respiratory Distress Syndrome, 7 (10%) had congestive cardiac failure. 43 (61.43%) improved, 17 (24.3%) expired, 9 (12.86%) LAMA, one patient was referred. Sequential Organ Failure Assessment Score was &gt;9 in 23 (41.07%) cases. Of 17 expired cases, 14 (82.35%) had SOFA score &gt;9.&#x0D; Conclusion: Sepsis with pulmonary involvement is primary diagnosis in patients requiring Medical Intensive Unit Care. Sequential Organ Failure Assessment Score was useful for prognostication and can be used for better clinical decision-making.

Differences in Vancomycin Clearance between Trauma and Medical Intensive Care Unit Patients.

BackgroundTo identify the differences in the vancomycin pharmacokinetics between multiple trauma patients and medically ill patients in the intensive care unit (ICU) stratified by the use of continuous renal replacement therapy (CRRT), and the factors affecting vancomycin clearance (CLvan).Materials and MethodsAll the included patients received at least three consecutive doses of vancomycin, then, therapeutic drug monitoring was conducted. Patients' serum vancomycin trough levels and other clinical variables were identified retrospectively. The vancomycin pharmacokinetics and associated factors were compared and analyzed between trauma ICU (TICU) and medical ICU (MICU) patients.ResultsIn the non-dialyzed group, the CLvan was higher among the TICU patients than the MICU patients. However, in the continuous renal replacement therapy group, there was no significant difference in the CLvan between the multiple trauma and medically ill patients. The only factor associated with CLvan in the non-dialyzed group was creatinine clearance; none of the factors was associated with CLvan in the CRRT group.ConclusionIn the case of non-dialyzed patients in the TICU, vancomycin dosages must be adjusted, depending on the patient's actual body weight changes. In the case of patients undergoing CRRT in both ICUs, vancomycin can be infused with fixed doses regardless of the patients' characteristics.

Effect of calorie on cognitive function among traumatic brain injury (tbi) patients: a pilot study

Cognitive recovery is a major concern to traumatic brain injury (TBI) patients and their caregivers as patients need to resume normal life after hospital discharge. A recent discovery showed that low calorie was beneficial for cognitive function with lower mortality rate and produced better clinical outcomes in critically-ill and medical intensive care unit patients. However, the effect of low calorie on cognitive function among TBI patients has not been determined yet. Hence this study was conducted to provide preliminary evidence of the relation between calorie and cognitive function and to determine calorie adequacy for optimal cognitive recovery among them. This pilot study involved ten patients recruited from Hospital Sultanah Nur Zahirah, Kuala Terengganu. The patients underwent a series of nutritional assessments including 24-hours diet recall combined with food diary; neuropsychology test [Montreal Cognitive Assessment (MoCA)], and eye-open-eye-close paradigm of electroencephalography (EEG) for two to six days. Socio-demography, nutritional and neuropsychology data were analyzed using SPSS version 22 with the percentage of calorie intake (%CI) was set as the independent variable; whilst duration to finish trail-making subtest (FT), and the total score (TS) of MoCA were the dependent variables. EEG data were analyzed using Fast-Fourier Transform (FFT) and power ratio (PR) which is the ratio of slow to fast frequency brain band was calculated. Then the comparison of %CI, FT, TS, and PR were done between day-1 and discharge-day (early or follow-up visit in EEG). Six male and four female patients with mild TBI, median age 24.0 years (IQR = 9.5) were included in the study. Scatter dot plot between %CI to FT and TS showed that the graph increased at the beginning before it became a plateau at 70%. The %CI had significant negative correlation with FT (r = -0.717; p = 0.000) but positive correlation with TS (r = 0.789; p = 0.000). Results revealed that cognitive function was improved at low %CI, approximately below CI of 70%. Improvement in neuropsychology test results was strengthened by the significant differences of median EEG power ratio between follow-up and first visit (p = 0.000). In this pilot study, it appears that cognitive function showed improvement with low calorie intake among TBI patients.

Effect of post-extubation high-flow nasal cannula on reintubation in elderly patients: a retrospective propensity score-matched cohort study.

Background:Studies of mechanically ventilated patients with a low risk of reintubation have suggested that the use of high-flow nasal cannula (HFNC) oxygen therapy reduces the risk of reintubation compared with conventional oxygen therapy (COT). However, the effect of HFNC following extubation in elderly patients with a high risk of reintubation remains unclear.Methods:All consecutive medical intensive care unit (ICU) patients aged >65 years who were mechanically ventilated for >24 h were prospectively registered between July 2017 and June 2018. Control was obtained from a historical database of patients attending the same ICU from January 2012 to December 2013. A total of 152 patients who underwent HFNC after planned extubation according to institutional protocols (HFNC group) were compared with a propensity-matched historical control group who underwent COT (n = 175, COT group). The primary outcome was the proportion of reintubated patients within 48 h after planned extubation.Results:One hundred patients from the HFNC group and 129 patients from the COT group were matched by a propensity score that reflected the probability of receiving HFNC, and all variables were well matched. Post-extubation respiratory failure (41.0% versus 33.3%, p = 0.291) and reintubation rate within 48 h (16.0% versus 11.6%, p = 0.436) did not differ between the HFNC and COT groups. However, decreased levels of consciousness as a sign of post-extubation respiratory failure (27.0% versus 11.7%, p = 0.007) were significantly increased in the HFNC group compared with the COT group.Conclusion:Among elderly patients who underwent planned extubation, HFNC was not associated with a decrease in the risk of reintubation. Further prospective study evaluating the clinical benefits of post-extubation HFNC in elderly patients is needed. The reviews of this paper are available via the supplemental material section.

Pilot Study to Assess the Feasibility and Safety of Intermittent Enteral Feeding in Mechanically Ventilated Medical Intensive Care Unit Patients

Pilot Study to Assess the Feasibility and Safety of Intermittent Enteral Feeding in Mechanically Ventilated Medical Intensive Care Unit Patients

Improving end-of-rotation transitions of care among ICU patients

BackgroundHospitalised patients whose inpatient teams rotate off service experience increased mortality related to end-of-rotation care transitions, yet standardised handoff practices are lacking.ObjectiveDevelop and implement a multidisciplinary patient-centred handoff intervention to...

Factors Associated With Discharge Home Among Medical ICU Patients in an Early Mobilization Program.

One goal of early mobilization programs is to facilitate discharge home after an ICU hospitalization, but little is known about which factors are associated with this outcome. Our objective was to evaluate factors associated with discharge home among medical ICU patients in an early mobilization program who were admitted to the hospital from home. Retrospective cohort study of medical ICU patients in an early mobilization program. Tertiary care center medical ICU. Medical ICU patients receiving early mobilization who were community-dwelling prior to admission. None. A comprehensive set of baseline, ICU-related, and mobilization-related factors were tested for their association with discharge home using multivariable logistic regression. Among the analytic cohort (n = 183), the mean age was 61.9 years (sd 16.67 yr) and the mean Acute Physiology and Chronic Health Evaluation II score was 23.5 (sd 7.11). Overall, 65.0% of patients were discharged home after their critical illness. In multivariable analysis, each incremental increase in the maximum level of mobility achieved (range, 1-6) during the medical ICU stay was associated with nearly a 50% greater odds of discharge home (odds ratio, 1.46; 95% CI, 1.13-1.88), whereas increased age (odds ratio, 0.95; 95% CI, 0.93-0.98) and greater hospital length of stay (odds ratio, 0.94; 95% CI, 0.90-0.99) were associated with decreased odds of discharge home. Prehospital ambulatory status was not associated with discharge home. Among medical ICU patients who resided at home prior to their ICU admission, the maximum level of mobility achieved in the medical ICU was the factor most strongly associated with discharge back home. Identification of this factor upon ICU-to-ward transfer may help target mobilization plans on the ward to facilitate a goal of discharge home.

1017. Scratching the Surface with NHSN Data: Defining High Impact Stewardship Targets in Critical Care

BackgroundThe National Healthcare Safety Network (NHSN) provides risk-adjusted Standardized Antimicrobial Administration Ratios (SAAR) as a benchmark for medical and surgical intensive care units (ICU). Antibiotic use (AU) data does not provide patient-level information (e.g., antibiotic appropriateness, indications, durations, etc.). However, we hypothesize that AU data can help define high impact stewardship targets, particularly in the context of critical care Clostridioides difficile rates.MethodsUnits with high rates of AU and hospital-onset (HO) C. difficile were selected for review. A monthly AU and C. difficile dashboard was created for ICU providers, inclusive of data from May 2018 onwards. We also performed chart audits for indication, duration, and location of initiation for all medical intensive care unit (MICU) patients receiving piperacillin/tazobactam (P/T) or vancomycin (Van) during February 2019 per request of ICU stakeholders. Data were used to obtain stewardship buy-in from local MICU champions.ResultsAU data indicated that (1) all 3 MICUs consistently had SAARs >1 for broad-spectrum categories and (2) Van and P/T were the highest volume agents on these units (Figure 1). Chart audit of 135 MICU patients showed that 17 patients received P/T, 34 Van, and 84 (62%) both agents; median duration was 2 days for Van and 3 days for P/T (Figure 2). Approximately half of initiations occurred in the emergency department (ED) (50% Van, 47% P/T); most common indications were “respiratory tract infection” and “severe sepsis/septic shock” for both P/T (77%) and Van (74%) (Figure 2). HO C. difficile in MICUs accounted for 6%, 13%, and 16% of total HO C. difficile cases in campuses A, B, and C, respectively during the time frame (Figure 1).ConclusionWe feel that NHSN data scratches the surface of the deep-rooted challenges of ICU stewardship. However, it can identify AU trends and most frequently prescribed antibiotics in the context of unit-specific C. difficile rates. Intensive stewardship audit can further uncover areas for intervention, such as ED Van and P/T overprescribing. We suggest presenting clinical stakeholders with a quarterly “stewardship dashboard” combining AU rates, patient-level data, and C. difficile rates to maximize the impact of stewardship endeavors. Disclosures All authors: No reported disclosures.

572. Relationship Between Chlorhexidine Gluconate (CHG) Skin Concentrations and Microbial Skin Colonization among Medical Intensive Care Unit (MICU) Patients

BackgroundCHG bathing is used to suppress patients’ microbial skin colonization, in order to prevent infections and transmission of multidrug-resistant organisms. Prior work has suggested that microbial growth is inhibited when CHG skin concentrations exceed threshold levels.MethodsWe conducted 6 single-day surveys from January 2018 to February 2019 in 7 academic hospital MICUs with established CHG patient bathing. Adult patients were eligible to have skin swabbed from adjacent 25 cm2 areas on the neck, axilla, and inguinal region for culture and CHG concentration determination. CHG skin concentrations were measured by a semi-quantitative colorimetric assay. Selective media were used to isolate targeted microorganisms (Table 1). Species were confirmed by matrix-assisted laser desorption ionization time-of-flight mass spectrometry; antibiotic susceptibility was determined by MicroScan (Beckman Coulter). We modeled the relationship between CHG skin concentrations (log2-transformed) and microorganism recovery (yes/no as primary outcome) using multilevel models controlling for clustering of body sites within patients and within ICUs, assessing slope and threshold effects.ResultsWe enrolled 736/759 (97%) patients and sampled 2176 skin sites. Gram-positive bacteria were detected most frequently (Table 1). The adjusted odds of identifying gram-positive organisms decreased linearly as CHG skin levels increased (Figure 1a), without evidence of a threshold effect. We also found significant negative linear slopes without evidence of threshold effects for other pathogens tested (Table 2; Figure 1), with the exception of gram-negative bacteria and vancomycin-resistant enterococci. When modeling quantitative culture results (colony-forming units) for gram-positive organisms as a continuous outcome variable, a similar relationship was found.ConclusionHigher concentrations of CHG were associated with less frequent recovery of gram-positive bacteria and Candida species on the skin of MICU patients who were bathed routinely with CHG. For microbial inhibition, we did not identify a threshold concentration of CHG on the skin; rather, increasing CHG skin concentrations led to additional gains in inhibition. For infection prevention, aiming for high CHG skin levels may be beneficial. Disclosures All authors: No reported disclosures.

895. Impact of Measurement and Results Feedback of Chlorhexidine Gluconate (CHG) Skin Concentrations in Medical Intensive Care Unit (MICU) Patients Receiving CHG Bathing

BackgroundHigher CHG skin levels may be needed to adequately control infection and transmission of pathogens in the ICU. We assessed whether measurement and feedback of patient CHG skin concentrations could improve CHG bathing quality and identified factors associated with higher CHG skin concentrations.MethodsWe conducted 6 one-day surveys from January 2018 to February 2019 in 7 academic hospital MICUs with established daily CHG bathing. Adults admitted >1 day were assessed for CHG skin levels with a semi-quantitative colorimetric assay using swabbed 25 cm2 areas of anterior neck, axilla, and inguinal skin. Prior to survey 4, results from the first 3 surveys (baseline) were reported to ICU leadership and front-line staff to retrain and reeducate on bathing technique. Feedback of results from prior surveys also occurred before surveys 5 and 6. For statistical analysis, mixed-effects models accounted for clustering of CHG measurements within patients and ICUs. We categorized CHG product type as “cloth” for no-rinse 2% CHG-impregnated cloth and “liquid” for 4% CHG liquid or foam.ResultsIn total, 681 of 704 (97%) patients were enrolled. Three ICUs used CHG cloth, 3 ICUs used CHG liquid, and 1 ICU switched from liquid to cloth after the second survey. Median CHG skin concentrations were higher in both the baseline and feedback period for institutions using CHG cloth, as compared with liquid (table). Across all time points, axillary and inguinal regions had higher skin CHG concentrations than the neck (median 39.1, 78.1, 19.5 µg/mL, respectively, P < 0.001). After controlling for age, mechanical ventilation, presence of a central venous catheter, body site, and hours since last CHG bath, institutions that used CHG cloth had a 3-fold increase in adjusted CHG skin concentrations in the feedback period compared with the baseline period (P = 0.001, Figure). There was no significant change in CHG skin concentrations from baseline to feedback period for institutions that used liquid CHG.ConclusionCHG skin concentrations on MICU patients receiving daily CHG bathing varied by body site and CHG product type. The use of CHG cloth was associated with higher CHG skin levels, compared with CHG liquid. For ICUs using CHG cloth, feedback of CHG skin concentration results to ICU staff improved CHG bathing quality. Disclosures All Authors: No reported Disclosures.

2424. Shedding of Viable Clostridiodes difficile in Patients Admitted to a Medical Intensive Care Unit

BackgroundHospitalized patients are at risk of colonization with a range of healthcare-associated bacterial pathogens, including C. difficile. In patients admitted to intensive care units (ICUs), in whom C. difficile infection (CDI) is associated with increased morbidity and mortality. To understand the risk for acquisition of C. difficile and development of CDI, we monitored ICU patients daily for shedding of C. difficile by culture.MethodsWe conducted a secondary analysis of daily rectal/fecal swab samples collected from medical ICU patients of a 720-bed academic medical center in Chicago, IL. Selective culture for C. difficile was performed on swab samples from patients who had 2 or more samples obtained using selective media. Confirmation of putative C. difficile isolates was done by specific PCR assays for the 16S rRNA-encoding gene and the toxin genes tcdA, tcdB, cdtA and cdtB. Clinical testing for CDI was performed using the Xpert® C. difficile PCR assay (Cepheid). Clinical and demographic metadata were collected at bedside and by electronic medical record review.ResultsCulture was attempted on 2106 swab samples from 451 patients (486 ICU admissions) (Figure 1). A mean of 4.33 samples was obtained from each patient. C. difficile was isolated from 211 (10%) samples from 79 patients (Table 1). The first sample was positive by culture for 48 (9.9%) of patient admissions to the ICU. 31 (6.4%) patients who were initially negative by culture had a subsequent sample from which C. difficile was isolated. Persistence of culture-positivity varied from patient to patient (Figure 2). Of 80 patients who were tested for CDI based on physician suspicion, 12 patients had a positive Cepheid PCR test; 9 had diarrhea and were treated for CDI.ConclusionSurveillance for shedding of C. difficile by daily culture reveals that patients admitted to the ICU can shed the pathogen intermittently without attributable disease. This can be in the form patients who are admitted carrying the organism as well as those who appear to acquire the organism during their stay. It is unclear whether patient or microbiome factors underlie the differences seen in patterns of shedding. Furthermore, intermittent shedding may reflect multiple episodes of exposure to C. difficile spores and asymptomatic shedding without stable colonization. Disclosures All authors: No reported disclosures.

DIAGNOSTIC ACCURACY OF 4TS SCORE COMPARED TO HEPARIN-INDUCED THROMBOCYTOPENIA EXPERT PROBABILITY SCORE FOR IDENTIFYING HEPARIN-INDUCED THROMBOCYTOPENIA IN A MEDICAL ICU

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Heparin-induced thrombocytopenia (HIT) is challenging to diagnose in critically ill patients due to a higher incidence of acute thrombocytopenia. Underdiagnosis of HIT is potentially fatal, but overdiagnosis leads to unnecessary exposure to non-heparin anticoagulation. The 4Ts score was developed to aid in diagnosis but has limitations in the intensive care unit (ICU). The HIT expert probability (HEP) score is an alternative scoring system shown to have increased diagnostic accuracy in ICU patients in a subgroup analysis. We aim to validate these findings in a purely medical ICU. METHODS: 4Ts and HEP scores were retrospectively calculated for 91 patients with suspected HIT seen in an academic, tertiary care center medical ICU between January 2017 and April 2018. All patients had serotonin release assays (SRA) ordered. SRA positivity was used as the gold standard for HIT diagnosis. Scorers were blinded to both SRA and calculated results of the alternate scoring system. 4Ts scores equal to or greater than four and HEP scores equal to or greater than three represented positive scores. Sensitivity, specificity and likelihood ratios were calculated. McNemar’s test was used to evaluate differences in score results, sensitives and specificities. For significant differences, 95% confidence intervals were calculated using the Wald method. All statistical analyses used a significance level of 0.05. RESULTS: Three of our 91 patients had positive SRAs. The 4Ts score had a sensitivity of 0.67 (0.09-0.99), specificity of 0.45 (0.35-0.56) and a positive likelihood ratio (LR+) of 1.22 (0.54-2.78). The HEP score had a sensitivity of 1.00 (0.29-1.00), specificity of 0.69 (0.59-0.79) and a LR+ of 3.26 (2.83-4.46). Receiver operative characteristic (ROC) curve could not be created due to the low number of positive HIT cases. CONCLUSIONS: The accuracy measures of the HEP score were superior to the 4Ts score among medical ICU patients. The study was limited by single center status, small sample size of true positive HIT, retrospective design and having less experienced physicians conducting scoring, which has been suggested to favor HEP scoring in a previous study. Future studies continuing to look at this population are needed. CLINICAL IMPLICATIONS: The HEP score may have better diagnostic accuracy for HIT than the 4Ts score in the medical ICU population. DISCLOSURES: No relevant relationships by Thomas Iden, source=Web Response No relevant relationships by Audrey Jernigan, source=Web Response No relevant relationships by Markos Kashiouris, source=Web Response No relevant relationships by Victoria Okhomina, source=Web Response No relevant relationships by Xian Qiao, source=Web Response No relevant relationships by Kathleen Waybill, source=Web Response

RADIATION DOSE TRENDS AND CANCER RISK ACCRUED FROM RADIATION EXPOSURE IN THE MEDICAL ICU: A 5-YEAR PERSPECTIVE

SESSION TITLE: Tuesday Electronic Posters 2 SESSION TYPE: Original Inv Poster Discussion PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Patients admitted to Medical Intensive care unit (MICU) are subjected to multiple radiological studies.Some endure radiation dose exposure [Cumulative Effective dose (CED) ] in excess of annual federal occupational health standard limits (CED≥50 mSv) and those statistically linked with cancer induction (CED≥100 mSv). We evaluated the cancer risk( life time attributable risk) from the CED accrued during a single admission and radiation dose trends over a 5 year period METHODS: This is a retrospective observational study conducted in an academic medical center involving all adult admissions (N=21,108) admitted to the MICU between January 2013 and December 2017. Clinical and radiologic data were obtained from the electronic medical records and the picture archiving & communication system. Radiation doses from ionizing radiological studies were calculated from reference values to determine CED. RESULTS: Four percent of the patients (n=562) accrued CED ≥50%, 1 % (n=195) accrued CED ≥100 mSv. The median CED was 0.72 mSv (IQR, 0.02-4.08 mSv)over a five year period with a range of 0.00 mSv to 1607 mSv . The mean MICU length of stay(LOS ) was 4.7(+/-6.7 )days and APACHE score was 65.8(+/-29.6) over a 5 year period . Higher APACHE 3 scores (p< 0.001), hepatic failure (p=0.03 ), and gastrointestinal disorders (0.0001) predicted higher CED in a multivariable linear regression model. Odds ratio of accruing CED≥ 50mSv was noted at 8.9 (CI 6.84-11.59, P< 0.0001) in gastrointestinal bleeding, 2.6 (CI 2.17-4.04, p < 0.0001) in gastrointestinal disorders ,3.58 (CI 2.69-4.78 P<0.001) in hematological disorders and 1.38 (CI 0.99-1.92 p<0.001) in Cirrhosis. CT scan and interventional radiology accounted for 59% and 29% of the total CED, respectively. The median increase in cancer risk from CED accrued was 0.36(IQR, 0.23-0.58).The Median CED remained constant across 5 years without an uptrend. CONCLUSIONS: MICU patients are exposed to radiation doses that can be substantial, exceeding federal annual occupational limits and in a select subset, exceeds >100 mSv resulting in an increased cancer risk from baseline among ICU survivors. Median CED remained constant across the study period without an uptrend. Efforts to justify, restrict & optimize the use of radiological resources when feasible, are warranted. CLINICAL IMPLICATIONS: Younger MICU survivors could be at substantial cancer risk from CED accrued in the MICU within a relatively short span of time. Those discharged could be subjected to even more medical radiation as a part of ongoing medical care, adding to the annual CED and increasing the radiogenic risk further. Attempts to mitigate radiation burden by optimizing the utilization of fluoroscopically guided interventional procedures and computerized tomography merits further discussion and research. DISCLOSURES: No relevant relationships by Sinan Abdul-Wahab, source=Web Response No relevant relationships by Anirban Bhattacharyya, source=Web Response No relevant relationships by Abhijit Duggal, source=Web Response No relevant relationships by Sravanthi Ennala, source=Web Response No relevant relationships by Nagamani Guduguntla, source=Web Response no disclosure on file for Jorge Guzman; No relevant relationships by Xiaozhen Han, source=Web Response No relevant relationships by Tarik Hanane, source=Web Response no disclosure on file for Ali Khwaja; No relevant relationships by Sudhir Krishnan, source=Web Response Advisory Committee Member relationship with Boston Scientific Corp. Please note: $1001 - $5000 Added 03/14/2019 by CHARLES MARTIN, source=Web Response, value=Consulting fee Consultant relationship with Terumo Interventional Corp. Please note: $1001 - $5000 Added 03/14/2019 by CHARLES MARTIN, source=Web Response, value=Consulting fee Advisory Committee Member relationship with BTG Inc. Please note: $1001 - $5000 Added 03/14/2019 by CHARLES MARTIN, source=Web Response, value=Consulting fee No relevant relationships by Xiaofeng Wang, source=Web Response

AN INSTITUTIONAL EXPERIENCE WITH KETAMINE INFUSION FOR ANALGOSEDATION IN THE MEDICAL ICU

SESSION TITLE: Monday Electronic Posters 2 SESSION TYPE: Original Inv Poster Discussion PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: The use of ketamine infusion for analgosedation in the medical intensive care unit (MICU) has historically been an uncommon practice. However, interest in its use has increased in recent years due to its unique pharmacologic properties that appear to make the drug ideally suited to this purpose. However, sparse data on the safety and efficacy of this practice continues to limit its widespread adoption. This study assessed the impact of continuous ketamine infusion on requirements for other concomitant analgosedative and vasopressor agents. METHODS: This was a single-center retrospective study of patients who received continuous infusion of ketamine to facilitate mechanical ventilation in the MICU between May 1, 2015 and September 1, 2018. Infusion rates of other analgosedative and vasopressor agents, as well as Richmond Agitation and Sedation Scores (RASS), were collected at the time of ketamine initiation and at 12, 24, and 48-hour intervals thereafter. RESULTS: Of the 81 ketamine infusion patients screened, 60 met inclusion criteria for the analysis of vasopressor infusion rates, and 41 were included in the analysis of RASS and concomitant analgosedative infusion rates after excluding 19 patients who were receiving neuromuscular blockade. There was a prominent trend towards decreased requirements for other analgosedative agents following the introduction of ketamine infusion. This reached statistical significance for total number of analgosedative infusions running (n=41) at 24 hours (-22%; p=0.03) and 48 hours (-32.6%; p=0.003), propofol infusion rate (n=14) at 12 (-53.3%; p=0.006), 24 (-56.3%; p=0.005), and 48 hours (-75.2%; p=0.001), and fentanyl infusion rate (n=14) at 12 (-20.9%; p=0.05), 24 (-35.4%; p=0.009), and 48 hours (-58.2%; p=0.0005). These dose reductions were accomplished without a significant change in the percentage of RASS scores within goal range (-1 to +1) at each time point. In addition, ketamine initiation was followed by a trend towards reduced vasopressor requirements which reached statistical significance for norepinephrine infusion rate (n=23) at 48 hours (-76%; p=0.006). CONCLUSIONS: Despite small sample size, the initiation of ketamine infusion for analgosedation in MICU patients was associated with significantly decreased requirements for other concomitant analgosedative and vasopressor agents without impacting time within RASS goal. However, retrospective design and lack of a comparison group were major limitations to our study. Future studies are needed to assess these findings in a prospective randomized fashion. CLINICAL IMPLICATIONS: This study supports the use of ketamine infusion for analgosedation in mechanically ventilated MICU patients. Its use is linked with decreased requirements for other concomitant analgosedative and vasopressor agents. These findings may lead to the more frequent use of ketamine infusion for analgosedation in the MICU. DISCLOSURES: No relevant relationships by Michael Cardone, source=Web Response No relevant relationships by Bruce Doepker, source=Web Response No relevant relationships by Gregory Eisinger, source=Web Response No relevant relationships by Jessica Elefritz, source=Web Response No relevant relationships by Matthew Exline, source=Web Response No relevant relationships by Matthew Huang, source=Web Response No relevant relationships by Jennifer McCallister, source=Web Response

Evaluation of Drug-Related Problems among Medical Intensive Care Unit Patients; the Role of Clinical Pharmacist

Evaluation of Drug-Related Problems among Medical Intensive Care Unit Patients; the Role of Clinical Pharmacist

Factors Associated with Morbidity in ICU

Factors Associated with Morbidity in ICU

The Pros and Cons of the Prediction Game: The Never-ending Debate of Mortality in the Intensive Care Unit.

Background: The Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II, and Sequential Organ Failure Assessment (SOFA) scales are scoring systems used in intensive care units (ICUs) worldwide. We aimed to investigate their usefulness in predicting short- and long-term prognosis in the local ICU. Methods: This single-center observational study covered 905 patients admitted from 1 January 2015 to 31 December 2017 to a tertiary mixed ICU. SAPS II, APACHE II, and SOFA scores were calculated based on the worst values from the first 24 h post-admission. Patients were divided into surgical (SP) and nonsurgical (NSP) subjects. Unadjusted ICU and post-ICU discharge mortality rates were considered the outcomes. Results: Baseline SAPS II, APACHE II, and SOFA scores were 41.1 ± 20.34, 14.07 ± 8.73, and 6.33 ± 4.12 points, respectively. All scores were significantly lower among SP compared to NSP (p < 0.05). ICU mortality reached 35.4% and was significantly lower for SP (25.3%) than NSP (57.9%) (p < 0.001). The areas under the receiver-operating characteristic (ROC) curves were 0.826, 0.836, and 0.788 for SAPS II, APACHE II, and SOFA scales, respectively, for predicting ICU prognosis, and 0.708, 0.709, and 0.661 for SAPS II, APACHE II, and SOFA, respectively, for post-ICU prognosis. Conclusions: Although APACHE II and SAPS II are good predictors of ICU mortality, they failed to predict survival after discharge. Surgical patients had a better prognosis than medical ICU patients.