Medical Intensive Care Unit Admission Research Articles

Outcomes and prognostic factors of patients with lung cancer and pneumonia-induced respiratory failure in a medical intensive care unit: A single-center study

PurposeTo evaluate the outcomes and prognostic factors of 28-day mortality following medical intensive care unit (MICU) admission of patients with lung cancer and pneumonia-induced respiratory failure. Materials and methodsPatients admitted to the MICU of a tertiary referral hospital between 2000 and 2009 were retrospectively studied. ResultsIn total, 143 patients were included. Their mean age was 65 ± 8 years and 94% were male. The 28-day mortality rate was 57%. Multivariate analysis was performed to identify variables associated with 28-day mortality. At 72 hours after admission, a history of radiotherapy (OR = 2.80, 95% CI: 1.15-6.78), Pao2/Fio2 (P/F) ratio at admission of <100 mmHg (OR = 5.62, 95% CI: 2.10-15.07), P/F ratio after 72 hours of <100 mmHg (OR = 4.61, 95% CI: 1.24-17.15), and arterial pH after 72 hours of <7.30 (OR = 5.78, 95% CI: 1.15-28.89) were associated with increased mortality. ConclusionsThe prognosis of patients with lung cancer and severe pneumonia after 72 hours of MICU management mainly depends on the severity of the underlying lung injury, which is reflected by a history of radiotherapy and a low P/F ratio, rather than on cancer stage or disease status.

Successful Implementation of a Rapid Response System in the Department of Internal Medicine

Background: A rapid response system (RRS) aims to prevent unexpected patient death due to clinical errors and is becoming an essential part of intensive care. We examined the activity and outcomes of RRS for patients admitted to our institution’s department of internal medicine. Methods: We retrospectively reviewed patients detected by the RRS and admitted to the medical intensive care unit (MICU) from October 2012 through August 2013. We studied the overall activity of the RRS and compared patient outcomes between those admitted via the RRS and those admitted conventionally. Results: A total of 4,849 alert lists were generated from 2,505 medical service patients. The RRS was activated in 58 patients: A (Admit to ICU), B (Borderline intervention), C (Consultation), and D (Do not resuscitate) in 26 (44.8%), 21 (36.2%), 4 (6.9%), and 7 (12.1%) patients, respectively. Low oxygen saturation was the most common criterion for RRS activation. MICU admission via the RRS resulted in a shorter ICU stay than that via conventional admission (6.2 vs. 9.9 days, p = 0.018). Conclusions: An RRS can be successfully implemented in medical services. ICU admission via the RRS resulted in a shorter ICU stay than that via conventional admission. Further study is required to determine long-term outcomes.

The prognosis of patients with lung cancer admitted to the medical intensive care unit

Lung cancer remains the leading cause of cancer mortality worldwide. Despite their poor prognosis, patients with lung cancer are increasingly being admitted to the medical intensive care unit (MICU) for treatment of critical illnesses. The aim of this study was to assess the outcome of patients with lung cancer who are admitted to an MICU and to identify the measurable predictors of their MICU outcome. We conducted retrospective analysis on 97 patients with lung cancer admitted to the MICU between 2007 and 2011. The mean age ± standard deviation was 71.8 ± 6.8 years. Of the 97 patients (82 male), 73 patients (75%) had non-small cell lung cancer stage IIIB, IV and 24 patients (25%) had small cell lung cancer. The intensive care unit mortality and in-hospital mortality rates were 53.6 and 61.8%. The main reasons for MICU admission were pneumonia (n = 51) and complication of cancer management (n = 45). The predictors of poor MICU outcome were history of diabetes mellitus (P = 0.028), Acute Physiology and Chronic Health Evaluation II score (P = 0.018), need for mechanical ventilation (P = 0.014), use of vasoactive agents (P < 0.0001), the presence of acute renal failure (P < 0.0001) and presence of multiorgan failure (P < 0.0001). We found that in-hospital mortality was not influenced by age, sex or performance status score of patients with lung cancer but increased with the severity of organ failure at MICU admission.

NIH: Developing And Funding Research In Emergency Care And Training The Next Generation Of Emergency Care Researchers

For the best health care to be provided in emergency settings, it must be based on the best available science. There are about 136million visits to emergency departments (EDs) in the United States annually. Many of the nation's most critically ill patients are first stabilized and treated in EDs-the point of origin for nearly half of all medical intensive care unit admissions and a fourth of all surgical intensive care unit admissions. This article explores the role of the National Institutes of Health (NIH) in developing and funding research in emergency care and in training the next generation of emergency care researchers. Recognizing that effective emergency care research spans multiple organ systems and disciplines, the NIH established the Office of Emergency Care Research in December2011 to facilitate and coordinate funding opportunities relevant to research and research training in emergency settings. Because the NIH funds education, basic research, and large clinical trials, it plays a key role in improving emergency care.

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Introduction: The Modified Early Warning Score (MEWS) is a tool for bedside evaluation based on five physiological parameters: systolic blood pressure, pulse rate, respiratory rate, temperature and mental status. It is a simple physiological scoring system that identifies patients at high risk of deterioration and helps in triaging patients to appropriate level of medical care. Raised MEWS is associated with increased morbidity and mortality [1]. Whether MEWS can be utilized as an adjunct tool along with clinical judgment, to identify patients who will benefit from early intensive care unit (ICU) admission (step down vs. step up) from the emergency room has not been looked at before. Methods: A retrospective, single-center study was conducted at a large tertiary care hospital. Patients admitted to a 12-bed medical step down unit (SDU) in a 1-year period were identified. 102 patients admitted to the SDU, needing transfer to the Medical ICU (MICU), within the first 24 hours were selected as CASES. 93 patients who were admitted to the SDU but did not need transfer to the MICU in the first 24 hours were randomly selected by an independent researcher. These served as CONTROLS. The data regarding demographics and comorbidities were collected based on documentation in the chart on admission. The MEWS at the time of admission to the unit was calculated retrospectively for both groups based on chart documentation. Using the Chi-square test, we compared whether having a higher MEWS (more than or equal to 5) correlated with transfer from SDU to MICU in the first 24 hours of admission. Results: There was no significant difference between the cases and controls with respect to their demographics and comorbidities, prior to the admission to the SDU. 40/102 (39.2%) of patients in the "CASE" group, and 13/93 (14.0%) in the "CONTROL" group, had a MEWS ≥ 5 (χ2 p<0.001). 40/53 (75.4%) of patients with a MEWS ≥ 5 and 62/142 (43.6%) of patients with MEWS < 5 were transferred to the unit. The odds ratio with 95% confidence interval (OR, 95% CI) that MEWS ≥ 5 was associated with going to ICU was 3.90 (1.95-8.0) p<0.001. A ROC curve was constructed with the above data, with the null hypothesis being "using MEWS ≥ 5 is equivalent to guessing," resulted in an area under the curve (AUC) of AUC = 0.659 ± 0.053, p=0.001. Conclusions: 1. Patients with MEWS ≥ 5 demonstrated a 3.9 times increased risk of transfer to the MICU within the first 24 hours of admission (p < 0.001). 2. A prospective randomized controlled trial is required to validate MEWS as a prediction tool for patients who may benefit from early MICU admissions, thus favoring a "STEP-DOWN" model. 3. The impact of MEWS ≥ 5 on length of stay and total cost of hospitalization will be studied in phase 2 of this project.

High Burden of Palliative Needs among Older Intensive Care Unit Survivors Transferred to Post–Acute Care Facilities. A Single-Center Study

Adults with chronic critical illness (tracheostomy after ≥ 10 d of mechanical ventilation) have a high burden of palliative needs, but little is known about the actual use and potential need of palliative care services for the larger population of older intensive care unit (ICU) survivors discharged to post-acute care facilities. To determine whether older ICU survivors discharged to post-acute care facilities have potentially unmet palliative care needs. We examined electronic records from a 1-year cohort of 228 consecutive adults ≥ 65 years of age who had their first medical-ICU admission in 2009 at a single tertiary-care medical center and survived to discharge to a post-acute care facility (excluding hospice). Use of palliative care services was defined as having received a palliative care consultation. Potential palliative care needs were defined as patient characteristics suggestive of physical or psychological symptom distress or anticipated poor prognosis. We examined the prevalence of potential palliative needs and 6-month mortality. The median age was 78 years (interquartile range, 71-84 yr), and 54% received mechanical ventilation for a median of 7 days (interquartile range, 3-16 d). Six subjects (2.6%) received a palliative care consultation during the hospitalization. However, 88% had at least one potential palliative care need; 22% had chronic wounds, 37% were discharged on supplemental oxygen, 17% received chaplaincy services, 23% preferred to not be resuscitated, and 8% were designated "comfort care." The 6-month mortality was 40%. Older ICU survivors from a single center who required postacute facility care had a high burden of palliative care needs and a high 6-month mortality. The in-hospital postcritical acute care period should be targeted for palliative care assessment and intervention.

Changes in the Calcium-Parathyroid Hormone-Vitamin D Axis and Prognosis for Critically Ill Patients: A Prospective Observational Study

ObjectiveVitamin D deficiency is prevalent in critically ill patients and may contribute to suboptimal clinical outcomes, but little is known about alterations of the calcium-parathyroid hormone (PTH)-vitamin D axis and prognosis in these individuals.MethodsA prospective observational study was conducted on 216 patients admitted to a university-affiliated, tertiary-care medical intensive care unit(MICU) between June 2011 and December 2012. Serum levels of 25-hydroxyvitamin D, ionised calcium and intact PTH were determined within 24 h of MICU admission. The primary end point was all-cause hospital mortality within 90-days of admission.Results95 patients (44%) showed 25-hydroxyvitamin D deficiency. Patients deficient in vitamin D showed significantly higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score, rate of positive blood culture, incidence of multiple organ dysfunction syndrome, and 90-day mortality rate than did patients with vitamin D insufficiency or sufficiency (P<0.05), as well as lower levels of serum IgG. 25-Hydroxyvitamin D deficiency was identified as an independent risk factor for mortality (OR = 3.018, 95%CI 1.329–6.854, P = 0.008). Hypovitaminosis D in PTH-responders was associated with higher mortality than was the same condition in non-responders (P<0.05).ConclusionsThese results suggest that vitamin D deficiency is prevalent among MICU patients, suggesting a significant derangement of the calcium-PTH-vitamin D axis in critically ill patients. Vitamin D deficiency is an independent risk factor for 90-day mortality, and hypovitaminosis D in PTH-responders is associated with higher mortality than is the same condition in non-responders.

Medical ICU Admissions During Weekday Rounds Are Not Associated With Mortality

This study investigated whether intensive care unit (ICU) admissions to the research team's tertiary care academic hospital during morning rounds was associated with increased mortality. Discharge data were analyzed on 1912 patients admitted to the ICUs between July 2007 and June 2011. Measures included discharge disposition, time of admission to the ICU, source of admission, and expected mortality score. Descriptive statistics were generated to examine the proportion of subjects who died based on admission time to the ICU, and Pearson's χ(2) test was used to test the null hypothesis that mortality rates for admissions during rounds and those at other times of the day would be similar. No difference in mortality was detected between admissions during rounds and all other times, whether analyzed using a bivariate (P = .55) or multivariable (P = .78) analysis. In this study, mortality was associated with severity of illness and not associated with admission during morning rounds.

A Prognostic Model for 6-Month Mortality in Elderly Survivors of Critical Illness

Although 1.4 million elderly Americans survive hospitalization involving intensive care annually, many are at risk for early mortality following discharge. No models that predict the likelihood of death after discharge exist explicitly for this population. Therefore, we derived and externally validated a 6-month postdischarge mortality prediction model for elderly ICU survivors. We derived the model from medical record and claims data for 1,526 consecutive patients aged ≥ 65 years who had their first medical ICU admission in 2006 to 2009 at a tertiary-care hospital and survived to discharge (excluding those patients discharged to hospice). We then validated the model in 1,010 patients from a different tertiary-care hospital. Six-month mortality was 27.3% and 30.2% in the derivation and validation cohorts, respectively. Independent predictors of mortality (in descending order of contribution to the model's predictive power) were a do-not-resuscitate order, older age, burden of comorbidity, admission from or discharge to a skilled-care facility, hospital length of stay, principal diagnoses of sepsis and hematologic malignancy, and male sex. For the derivation and external validation cohorts, the area under the receiver operating characteristic curve was 0.80 (SE, 0.01) and 0.71 (SE, 0.02), respectively, with good calibration for both (P = 0.31 and 0.43). Clinical variables available at hospital discharge can help predict 6-month mortality for elderly ICU survivors. Variables that capture elements of frailty, disability, the burden of comorbidity, and patient preferences regarding resuscitation during the hospitalization contribute most to this model's predictive power. The model could aid providers in counseling elderly ICU survivors at high risk of death and their families.

Medical ICU Admission Diagnoses and Outcomes in Human Immunodeficiency Virus–Infected and Virus–Uninfected Veterans in the Combination Antiretroviral Era*

Human immunodeficiency virus (HIV)-infected (HIV+) patients on combination antiretroviral therapy are living longer but have increased risk for aging-associated disease which may lead to increasing critical care requirements. We compare medical ICU admission characteristics and outcomes among HIV infected and demographically similar uninfected patients (uninfected) and considered whether an index which combines routine clinical biomarkers (the Veterans Aging Cohort Study Index) predicts 30-day medical ICU mortality. Observational data analyses (Veterans Aging Cohort Study). Eight Veterans Affairs medical centers nationwide. HIV infected and uninfected with a medical ICU admission between 2002 and 2010. None. Medical ICU admission was determined using bedsection (Veterans Affairs) and revenue center codes (Medicare). For Veterans Affairs admissions, we used clinical data to calculate Veterans Aging Cohort Study Index scores and multivariable logistic regression to determine factors associated with 30-day mortality. Overall, 539 of 3,620 (15%) HIV infected and 375 of 3,639 (10%) uninfected had a medical ICU admission; 72% and 78%, respectively, were Veterans Affairs based. HIV+ patients were younger at admission (p < 0.0001). Although most HIV+ patients were on antiretroviral therapy (71%) with undetectable HIV-1 RNA (54%), compared with uninfected they were more commonly admitted with respiratory diagnoses or infections (21% vs. 12%), were more likely to require mechanical ventilation (17% vs. 9%; p = 0.001), and had a higher mortality rate (18.6% vs. 11.2%, p = 0.003). Cardiovascular diagnoses were less common among HIV infected (18% vs. 29%; p < 0.0001). In logistic regression (c-statistic 0.87), a 5-point increment in Veterans Aging Cohort Study Index was associated with an odds ratio of death of 1.22 (95% confidence interval 1.14-1.30) among HIV infected and of 1.50 (95% confidence interval 1.29-1.76) among uninfected; infection/sepsis and respiratory diagnoses were also associated with mortality. Medical ICU admission was frequent, 30-day mortality higher, and mechanical ventilation more common in HIV infected compared with uninfected. The Veterans Aging Cohort Study Index calculated at medical ICU admission predicted 30-day mortality for HIV infected and uninfected. As more individuals age with HIV, their requirements for medical ICU care may be greater than demographically similar uninfected individuals.

Association between Endothelial Dysfunction and Acute Brain Dysfunction during Critical Illness

Acute brain dysfunction (delirium and coma) during critical illness is prevalent and costly, but the pathophysiology remains unclear. The relationship of acute brain dysfunction with endothelial function, which is impaired in critical illness and may contribute to alterations in cerebral blood flow and blood-brain barrier permeability, has not been studied. This study sought to determine whether systemic endothelial dysfunction is associated with acute brain dysfunction during critical illness. In this prospective cohort study, adult medical/surgical intensive care unit patients in shock and/or respiratory failure were enrolled. Endothelial function was assessed at enrollment using peripheral artery tonometry to calculate the reactive hyperemia index, with lower reactive hyperemia index indicative of worse endothelial function. Patients were assessed for coma and delirium with the Richmond Agitation-Sedation Scale and Confusion Assessment Method for the Intensive Care Unit. Multivariable linear regression was used to analyze the association between reactive hyperemia index and (1) delirium/coma-free days among all patients and (2) delirium duration among survivors, both over a 14-day period. One hundred forty-seven patients with median age of 57 yr and median Acute Physiology and Chronic Health Evaluation II score of 26 were enrolled. After adjusting for age, severity of illness, severe sepsis, preexisting cognitive function, medical versus surgical intensive care unit admission, and prehospital statin use, lower reactive hyperemia index (worse systemic endothelial function) was associated with fewer delirium/coma-free days (P = 0.02) and more delirium days (P = 0.05). In this study, critically ill patients with lower vascular reactivity indicative of worse systemic endothelial function had increased duration of acute brain dysfunction.

Common laboratory tests predict imminent medical emergency team calls, intensive care unit admission or death in emergency department patients

To estimate the ability of commonly measured laboratory variables to predict imminent (within the same or next calendar day) medical emergency team (MET) calls, ICU admission or death. We performed a retrospective observational study of ED patients. We estimated the ability of each laboratory variable or combination of variables together with patient age to predict imminent MET calls, ICU admission or death. We externally validated our findings in patients from a different hospital. We studied 160 341 batches in 71 453 ED patients (average age: 59.9 ± 22.1 years) for a total of 1 million individual measurements. There were 341 MET calls, 160 ICU admissions from the wards and 858 deaths. Multivariable modelling achieved a receiver operating characteristic area under the curve (ROC-AUC) of 0.69 (95% CI 0.63-0.74) for imminent MET call with prediction occurring a mean of 11.9 h before the call. Additionally, it achieved a ROC-AUC of 0.82 (95% CI 0.73-0.87) for imminent ICU admission. Finally, it achieved a ROC-AUC of 0.90 (95% CI 0.87-0.91) for imminent death. When tested using an additional 37 367 batches from a cohort of 21 430 ED patients from a second teaching hospital, the multivariate model achieved a ROC-AUC of 0.70 (95% CI 0.66-0.73) for imminent MET call, a ROC-AUC of 0.84 (95% CI 0.78-0.90) for imminent ICU admission. Finally, it achieved a ROC-AUC of 0.89 (95% CI 0.86-0.91) for imminent death. Commonly performed laboratory tests can help predict imminent MET calls, ICU admission or death in ED patients. Prospective investigations of the clinical utility of such predictions appear desirable.

Risk Factors for Hospitalization and Medical Intensive Care Unit (MICU) Admission Among HIV-Infected Veterans

With improved survival of HIV-infected persons on antiretroviral therapy and growing prevalence of non-AIDS diseases, we asked whether the VACS Index, a composite measure of HIV-associated and general organ dysfunction predictive of all-cause mortality, predicts hospitalization and medical intensive care unit (MICU) admission. We also asked whether AIDS and non-AIDS conditions increased risk after accounting for VACS Index score. We analyzed data from the Veterans Aging Cohort Study (VACS), a prospective study of HIV-infected Veterans receiving care between 2002 and 2008. Data were obtained from the electronic medical record, VA administrative databases, and patient questionnaires and were used to identify comorbidities and calculate baseline VACS Index scores. The primary outcome was first hospitalization within 2 years of VACS enrollment. We used multivariable Cox regression to determine risk factors associated with hospitalization and logistic regression to determine risk factors for MICU admission, given hospitalization. Of 3410 patients, 1141 were hospitalized within 2 years; 203 (17.8%)/1141 patients included an MICU admission. Median VACS Index scores were 25 (no hospitalization), 34 (hospitalization only), and 51 (MICU). In adjusted analyses, a 5-point increment in VACS Index score was associated with 10% higher risk of hospitalization and MICU admission. In addition to VACS Index score, Hispanic ethnicity, current smoking, hazardous alcohol use, chronic obstructive pulmonary disease, hypertension, diabetes, and prior AIDS-defining event predicted hospitalization. Among those hospitalized, VACS Index score, cardiac disease, and prior cancer predicted MICU admission. The VACS Index predicted hospitalization and MICU admission as did current smoking, hazardous alcohol use, and AIDS and certain non-AIDS diagnoses.

Evaluation of recombinant activated protein C for severe sepsis at a tertiary academic medical center

PurposeEarly clinical trials of recombinant human activated protein C (rhAPC) for severe sepsis excluded patients at high risk of bleeding. Recent literature suggests bleeding rates are higher in clinical practice and may be associated with worsened outcomes. Our objective was to evaluate baseline demographics; incidence, and risk factors for major bleeding; and mortality of patients receiving rhAPC for severe sepsis at our institution.MethodsA retrospective study was performed for all patients receiving rhAPC for treatment of severe sepsis at a tertiary academic medical center from January 2002 to June 2009. Demographic information, clinical variables, intensive care unit, and hospital outcomes were recorded.ResultsOf the 156 patients that received rhAPC, 54 (34.6%) did not meet institutional criteria for safe use at baseline due to bleeding precaution or contraindication. Twenty-three (14.7%) patients experienced a major bleeding event. Multivariate analysis demonstrated baseline International Normalized Ratio ≥2.5 (odds ratio [OR] 3.68, 95% confidence interval [CI]: 1.28–10.56; P = 0.03) and platelet count ≤100 × 103/mm3 (OR 2.86, 95% CI: 1.07–7.67; P = 0.01) as significant predictors of a major bleed. Overall hospital mortality was 57.7%. Multivariate analysis demonstrated the presence of ≥3 organ dysfunctions (OR 2.46, 95% CI: 1.19–5.09; P < 0.05) and medical intensive care unit admission (OR 1.99, 95% CI: 1.00–3.98; P = 0.05) were independent variables associated with hospital mortality.ConclusionPatients receiving rhAPC at our institution had higher APACHE II scores, mortality, and major bleeding events than published postmarketing studies. Risk factors for major bleeding other than package-labeling contraindications and bleeding precautions were identified in our patient population.

Disulfiram ethanol reaction mimicking anaphylactic, cardiogenic, and septic shock

Shock is a common reason for medical intensive care unit admission, with septic and cardiogenic accounting for most of the etiologies. However, the potential severity of adverse side effects of drugs indicates that any medication should be carefully scrutinized for potential pharmacokinetic and pharmacodynamic interactions that may result. We herein report the case of a life-threatening shock mimicking successively anaphylactic, cardiogenic, and septic shock, which was finally related to disulfiram ethanol reaction. Indeed, disulfiram ethanol reaction is known to provoke unpleasant symptoms through vasodilatation in various organs. However, extreme manifestations of vasodilatory shock may lead to circulatory failure and lactic acidosis. Because of large prevalence of alcoholism and disulfiram medication, emergency physicians and medical specialists should be aware of this life-threatening condition, with its misleading presentation.

Empiric antibiotic, mechanical ventilation, and central venous catheter duration as potential factors mediating the effect of a checklist prompting intervention on mortality: an exploratory analysis

BackgroundChecklists are clinical decision support tools that improve process of care and patient outcomes. We previously demonstrated that prompting critical care physicians to address issues on a daily rounding checklist that were being overlooked reduced utilization of empiric antibiotics and mechanical ventilation, and reduced risk-adjusted mortality and length of stay. We sought to examine the degree to which these process of care improvements explained the observed difference in hospital mortality between the group that received prompting and an unprompted control group.MethodsIn the medical intensive care unit (MICU) of a tertiary care hospital, we conducted face-to-face prompting of critical care physicians if processes of care on a checklist were being overlooked. A control MICU team used the checklist without prompting. We performed exploratory analyses of the mediating effect of empiric antibiotic, mechanical ventilation, and central venous catheter (CVC)duration on risk-adjusted mortality.ResultsOne hundred forty prompted group and 125 control group patients were included. One hundred eighty-three patients were exposed to at least one day of empiric antibiotics during MICU admission. Hospital mortality increased as empiric antibiotic duration increased (P<0.001). Prompting was associated with shorter empiric antibiotic duration and lower risk-adjusted mortality in patients receiving empiric antibiotics (OR 0.41, 95% CI 0.18-0.92, P=0.032). When empiric antibiotic duration was added to mortality models, the adjusted OR for the intervention was attenuated from 0.41 to 0.50, suggesting that shorter duration of empiric antibiotics explained 15.2% of the overall benefit of prompting. Evaluation of mechanical ventilation was limited by study size. Accounting for CVC duration changed the intervention effect slightly.ConclusionsIn this analysis, some improvement in mortality associated with prompting was explained by shorter empiric antibiotic duration. However, most of the mortality benefit of prompting was unexplained.

Ambient light levels and critical care outcomes

PurposeGuidelines for the construction of critical care units require windows in room design to ensure a contribution of natural sunlight to ambient lighting. However, few studies have been published with evidence assessing this recommendation. We investigated the association of ambient light levels with clinical outcomes and sedative/analgesic/neuroleptic use in a medical intensive care unit (MICU). MethodsThis is a retrospective, observational study at a tertiary care facility with a 29-bed MICU. First/single MICU admissions between April 19, 2006, and June 30, 2009 (N = 3577), were analyzed with respect to clinical outcomes and sedation use according to MICU room orientation and corresponding light levels. ResultsLight levels were low but varied among the 4 room orientations. There were no significant differences in MICU mortality (north, 14.0%; east, 13.5%; west, 16.2%; south, 15.6%; P = .451), hospital mortality (20.8%, 20.9%, 22.2%, 22.3%; P = .796), 28-day intensive care unit–free days (17.6 ± 10.2, 18.0 ± 10.1, 17.7 ± 10.5, 17.2 ± 10.4; P = .555), 28-day ventilator-free days (16.3 ± 11.1, 16.5 ± 11.1, 15.5 ±11.5, 15.4 ± 11.4; P = .273). No clinically significant differences in intravenous sedative/analgesic use occurred across room orientations. ConclusionsDespite differing ambient light, room orientation was not associated with critical care outcomes or differences in sedative/analgesic/neuroleptic use. Current guidelines positing that windows alone are necessary or sufficient for MICU room light management may require further investigation and consideration.

The association between initial anion gap and outcomes in medical intensive care unit patients

PurposeAnion gap (AG) metabolic acidosis is common in critically ill patients. The relationship between initial AG at the time of admission to the medical intensive care unit (MICU) and mortality or length of stay (LOS) is unclear. This study was undertaken to evaluate this relationship. Materials and MethodWe prospectively examined the acid-base status of 100 consecutive patients at the time of MICU admission and recorded their mortality and LOS. The etiology of each AG was also recorded. Anion gap was corrected for albumin levels. The patients were divided into 4 stages based on severity of AG. Outcomes based on severity of AG were measured, and comparisons that adjusted for baseline characteristics were performed. ResultsThis study showed that increased AG was associated with the higher mortality and that an AG more than 30 had the highest mortality. Mortality was significantly (P = .013) increased, even after accounting for AG etiology. Patients with highest AG also had the longest LOS in the MICU, and patients with normal acid-base status had the shortest MICU LOS (P < .01). ConclusionA high AG at the time of admission to the MICU was associated with higher mortality and LOS. Initial risk stratification based on AG and metabolic acidosis may help guide appropriate patient disposition (especially in patients without other definitive criteria for MICU admission) and assist with prognosis. Mixed AG metabolic acidosis with concomitant acid-base disorder was associated with increased MICU LOS.

Association between illness severity and timing of initial enteral feeding in critically ill patients: a retrospective observational study

BackgroundEarly enteral nutrition is recommended in cases of critical illness. It is unclear whether this recommendation is of most benefit to extremely ill patients. We aim to determine the association between illness severity and commencement of enteral feeding.MethodsOne hundred and eight critically ill patients were grouped as “less severe” and “more severe” for this cross-sectional, retrospective observational study. The cut off value was based on Acute Physiology and Chronic Health Evaluation II score 20. Patients who received enteral feeding within 48 h of medical intensive care unit (ICU) admission were considered early feeding cases otherwise they were assessed as late feeding cases. Feeding complications (gastric retention/vomiting/diarrhea/gastrointestinal bleeding), length of ICU stay, length of hospital stay, ventilator-associated pneumonia, hospital mortality, nutritional intake, serum albumin, serum prealbumin, nitrogen balance (NB), and 24-h urinary urea nitrogen data were collected over 21 days.ResultsThere were no differences in measured outcomes between early and late feedings for less severely ill patients. Among more severely ill patients, however, the early feeding group showed improved serum albumin (p = 0.036) and prealbumin (p = 0.014) but worsened NB (p = 0.01), more feeding complications (p = 0.005), and prolonged ICU stays (p = 0.005) compared to their late feeding counterparts.ConclusionsThere is a significant association between severity of illness and timing of enteral feeding initiation. In more severe illness, early feeding was associated with improved nutritional outcomes, while late feeding was associated with reduced feeding complications and length of ICU stay. However, the feeding complications of more severely ill early feeders can be handled without significantly affecting nutritional intake and there is no eventual difference in length of hospital stay or mortality between groups. Consequently, early feeding shows to be a more beneficial nutritional intervention option than late feeding in patients with more severe illness.

Sa1159 Venous Blood Gas Calculated Hematocrit is an Accurate Predictor of Hematocrit in Patients With Acute Upper Gastrointestinal Hemorrhage

Background: Proton pump inhibitors (PPI) are a commonly used medication in the medical intensive care unit (MICU). Overuse of PPIs can lead to increased healthcare costs as well as a possible risk of Clostridium difficile infection and aspiration pneumonia. The aim of our study is to analyze the prescribing patterns of PPIs in the MICU in order to identify opportunities for improvement. Materials and Methods: 507 MICU admissions were retrospectively reviewed for data concerning PPI use. PPI prescriptions and their indications were analyzed. Results: Of 507 MICU admissions reviewed, 342 (67.5 %) received a PPI. Of the 342 who received a PPI, 40 patients (11.7%) had no documented indication. In addition, 78 admissions out of the 342 (22.8%) received PPI solely for stress ulcer prophylaxis, where an H-2 blocker would have sufficed. Discussion: Our study revealed that PPIs were frequently prescribed in our MICU, but that up to one third (34.5%) of the prescriptions were inappropriate, and represent opportunities for cost savings and possibly reduced clinical complications. Our next step is to improve the rate of appropriate PPI prescription in our ICU through a combination of educational modules and direct interventions to the availability of the drug in current pharmacy order sets.