Mixed Unit Research Articles

Patient readiness for hospital discharge and its relationship to discharge preparation and structural factors: A cross-sectional study

BackgroundNursing discharge preparation is vital to successful hospital-to-home transitions. However, despite a wealth of evidence on its effectiveness, little is known of the structure- and process-related factors that facilitate or impede its use in clinical practice. Specifically, the associations between unit size and type, leadership support, skill mix, staffing, nurse and patient characteristics, discharge teaching and patient readiness for discharge have rarely been studied. ObjectivesThis study aimed to explore the associations between structure-individual characteristics (i.e., unit, nurse and patient characteristics) and process-related (i.e., teaching of self-care and symptom management) factors and patient readiness for hospital discharge. DesignA secondary data analysis of the multicentre observational “Matching Registered Nurse services with changing care demands (MatchRN)” study. Setting and periodData were collected between September 2015 and January 2016 on 123 surgical, medical and mixed units in 23 Swiss acute care hospitals. ParticipantsA total of 1833 registered nurses and 1755 patients were included in the analyses. MethodsStructure-, process- and patient readiness-related hospital discharge variables were assessed using validated items either from existing instruments or self-developed. Multilevel mixed-effects logistic regression was used to test associations. ResultsFewer than half of the patients hospitalized (47.8%) reported readiness for hospital discharge. Fifty-eight percent reported receiving discharge preparation interventions for self-care and 30% for symptom management. Patients’ readiness for hospital discharge was significantly lower in larger units (β = −0.001; 95% confidence interval (CI) = −0.002 to −0.001) and on medical units (β = −0.44; 95% CI = −0.70 to −0.19). Higher nurses’ experience (β = .004; 95% CI = 0.001 to 0.01), better patient self−reported health (β = −0.11; 95% CI = −0.17 to −0.05), higher patient ratings of self-care teaching (β = 1.33; 95% CI = 1.07–1.59) and symptom management teaching (β = 0.79; 95% CI = 0.52–1.06) were significantly associated with greater patient readiness for hospital discharge. ConclusionsPatient readiness for hospital discharge is associated with process- and structure-related factors. Our findings suggest that, for successful uptake in clinical practice, the development and implementation of effective discharge preparation programs should consider the structural context, i.e., patient population, unit size, and experience of nurses within the team. Further research, using a more accurate measure of patient readiness for hospital discharge, is needed to test associations with the nurse work environment and staffing.

Is routine extubation overnight safe in cardiac surgery patients?

ObjectivesExpedient extubation after cardiac surgery has been associated with improved outcomes, leading to postoperative extubation frequently during overnight hours. However, recent evidence in a mixed medical-surgical intensive care unit population demonstrated worse outcomes with overnight extubation. This study investigated the impact of overnight extubation in a statewide, multicenter Society of Thoracic Surgeons database. MethodsRecords from 39,812 patients undergoing coronary artery bypass grafting or valve operations (2008-2016) and extubated within 24 hours were stratified according to extubation time between 06:00 and 18:00 (day) or between 18:00 and 6:00 (overnight). Outcomes including reintubation, mortality, and composite morbidity-mortality were evaluated using hierarchical regression models adjusted for Society of Thoracic Surgeons predictive risk scores. To further analyze extubation during the night, a subanalysis stratified patients into 3 groups: 06:00 to 18:00, 18:00 to 24:00, and 24:00 to 06:00. ResultsA total of 20,758 patients were extubated overnight (52.1%) and were slightly older (median age 66 vs 65 years, P < .001) with a longer duration of ventilation (4 vs 7 hours, P < .001). Day and overnight extubation were associated with equivalent operative mortality (1.7% vs 1.7%, P = .880), reintubation (3.7% vs 3.4%, P = .141), and composite morbidity-mortality (8.2% vs 8.0%, P = .314). After risk adjustment, overnight extubation was not associated with any difference in reintubation, mortality, or composite morbidity-mortality. On subanalysis, those extubated between 24:00 and 06:00 exhibited increased composite morbidity-mortality (odds ratio, 1.18; P = .001) but no difference in reintubation or mortality. ConclusionsExtubation overnight was not associated with increased mortality or reintubation. These results suggest that in the appropriate clinical setting, it is safe to routinely extubate cardiac surgery patients overnight.

U-Pb detrital zircon geochronology, petrography, and synthesis of the middle Neoproterozoic Visingsö Group, Southern Sweden

The middle Neoproterozoic Visingsö Group, Southern Sweden, is a fossiliferous mixed carbonate-siliciclastic unit that provides an environmental and biological record of southeast (present day coordinates) Baltica. Extensive work on microfossil assemblages has allowed correlation with geochronologically constrained middle Neoproterozoic units elsewhere and a proposed depositional age between ∼780 and 730 Ma. The stratigraphic succession comprises three informal formations that record a shift in depositional environment from fluviomarine to a retrograding marine fan delta system. Petrographic and U-Pb LA-ICPMS detrital zircon (DZ) analyses are reported on six sandstone samples spanning the three formations. DZ ages range from 2840 to 919 Ma, with significant populations at 1870, 1800, 1320, and 1020 Ma. Each formation is characterized by a distinct age distribution. In the lower formation, ages are dominated by a peak at 1020 Ma, in the middle formation, however, ages are skewed toward 1800–1870 Ma. DZs from the upper formation display a more bell-curve shaped distribution, with dominant age peaks at 1550 and 1420 Ma. Provenance analysis indicates that the lower formation was likely sourced from the Feda-Sirdal magmatic belt in the distal Telemarkia lithotectonic unit to the west. DZ populations in the middle formation, combined with sedimentology, indicate tectonic activity and sourcing of the older Transscandinavian Igneous Belt east of the Sveconorwegian Front. DZs from the upper member show a predominance of Gothian and Hallandian magmatic rocks sourced from the west and, coupled with sedimentology, indicate tectonic quiescence. The maximum depositional age (919 ± 25 Ma, youngest single grain; 941 ± 12 Ma, average of five youngest grains) is more than 100 m.y. older than the purported age of the strata based on previous paleontological studies, and therefore necessitates that other dating methods be utilized to generate an age model for the Visingsö Group.

A low power fuzzy logic based variable resolution ADC for wireless ECG monitoring systems

Portable low power and high quality monitoring devices play an important role for improving the performance of wireless body sensor networks. Mixed signal processor is required in ECG monitoring unit that comprises of analog front end, analog to digital converter (ADC) and digital signal processor. ADC is a core element in mixed signal processing unit and the proper design of ADC is crucial for data acquisition without losing heart related information and originality. The adaptive sampling has been used in the existing ADCs for choosing the sampling clock adaptively. Adaptive sampling rate ADC performs compression and reduces power consumption to some extent, however low powers ADCs are essential in wireless healthcare monitoring systems. In this paper, fuzzy logic based variable resolution controller is proposed to design the ADC efficiently in terms of circuit complexity and power. To further reduce the power consumption, power gating technique is adopted for static power reduction. Under 90 nm CMOS technology, gate count, core area utilization and power consumption have been determined for existing adaptive sampling ADC and fuzzy logic based adaptive sampling ADC. Cadence design tools have been used for the measurement of power in the designed circuit. The performance has been found to be better in terms of area and power that are very much essential for wireless ECG monitoring systems.

A New Mixed-Valence Mn(II)Mn(III) Compound With Catalase and Superoxide Dismutase Activities.

The synthesis, X-ray molecular structure, physico-chemical characterization and dual antioxidant activity (catalase and superoxide dismutase) of a new polymeric mixed valence Mn(III)Mn(II) complex, containing the ligand H2BPClNOL (N-(2-hydroxybenzyl)-N-(2-pyridylmethyl)[(3-chloro)(2-hydroxy)] propylamine) is described. The monomeric unit is composed of a dinuclear Mn(II)Mn(III) moiety, [Mn(III)(μ-HBPClNOL)(μ-BPClNOL)Mn(II)(Cl)](ClO4)·2H2O, 1, in which the Mn ions are connected by two different bridging groups provided by two molecules of the ligand H2BPClNOL, a phenoxide and an alkoxide group. In the solid state, this mixed valence dinuclear unit is connected to its neighbors through chloro bridges. Magnetic measurements indicated the presence of ferromagnetic [J = +0.076(13) cm−1] and antiferromagnetic [J = −5.224(13) cm−1] interactions. The compound promotes O dismutation in aqueous solution (IC50 = 0.370 μmol dm−3, kcat = 3.6x106 M−1 s−1). EPR studies revealed that a high-valent Mn(III)-O-Mn(IV) species is involved in the superoxide dismutation catalytic cycle. Complex 1 shows catalase activity only in the presence of a base, e.g., piperazine or triethylamine. Kinetic studies were carried out in the presence of piperazine and employing two different methods, resulting in kcat values of 0.58 ± 0.03 s−1 (detection of O2 production employing a Clark electrode) and 2.59 ± 0.12 s−1 (H2O2 consuption recorded via UV-Vis). EPR and ESI-(+)-MS studies indicate that piperazine induces the oxidation of 1, resulting in the formation of the catalytically active Mn(III)-O-Mn(IV) species.

Impact of hyperoxemia on mortality in critically ill patients with ventilator-associated pneumonia.

The objective of this study was to assess the impact of hyperoxemia on mortality in critically ill patients with ventilator-associated pneumonia (VAP). This observational study was performed in a 50-bed mixed intensive care unit (ICU) during a 1-year period. Quantitative microbiological confirmation was required for VAP diagnosis. Hyperoxemia was defined as peripheral capillary oxygen saturation (SpO2) ≥98%. SpO2 was hourly collected in all study patients during the whole period of mechanical ventilation. The primary objective was to assess the influence of hyperoxemia on ICU mortality. Ninety-three patients with VAP were all included in this study. ICU-mortality rate was 32% (30 of 93 patients). The mean percentage of time spent with hyperoxemia in survivors and nonsurvivors at ICU admission, before, after or at the time of VAP diagnosis was not significantly different. Multivariate analysis identified age, and sequential organ dysfunction assessment at the day of VAP occurrence as independent risk factors for ICU mortality [odds ratio (OR) =1.04 (95% CI, 1.01-1.08) per year, P=0.019; 1.19 (95% CI, 1.06-1.34) per point, P=0.003; respectively]. The time spent with hyperoxemia before VAP occurrence was not significantly associated with mechanical ventilation free days, or ICU length of stay. Hyperoxemia at ICU admission, or during ICU stay, had no significant impact on ICU mortality in critically ill patients with VAP.

Prospective evaluation of serum procalcitonin in critically ill patients with suspected sepsis- experience from a tertiary care hospital in Pakistan

BackgroundSepsis is the leading cause of mortality in critically ill patients. Procalcitonin (PCT) is a promising marker for identification of bacterial sepsis. The aim of this study was to determine the diagnostic accuracy of serum PCT concentration in patients with suspected sepsis admitted to mixed medical-surgical Intensive care unit (ICU).Material and methodsA cross-sectional study conducted at section of Chemical Pathology, Department of Pathology and Laboratory Medicine and ICU. Patients with suspected sepsis were included, serum PCT cut off ≥0.5 ng/ml was taken for diagnosing sepsis. Diagnostic accuracy was measured in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) taking blood culture as gold standard. Furthermore, different cut offs were compared by using receiver operating characteristic curves (ROC). Data analysis was done on SPSS version 20.ResultsMedian age of the study group (n = 103) was 48 years (IQR: 22), 60% being males. Out of the 103 patients included 82 patients had PCT levels above the optimal cut off. At a serum PCT cutoff of 0.5 μg/L, the sensitivity and specificity for the diagnosis of sepsis was found to be 93.75% and 43.59% respectively. NPV was higher compared to PPV making PCT a reliable marker to for the screening out of sepsis patients. Furthermore, it was revealed that PCT having an AUC = 0.70 outperformed WBC (AUC = 0.5) and CRP (AUC = 0.6).ConclusionElevated PCT concentration is a promising indicator of sepsis in newly admitted critically ill patients capable of complementing clinical signs and routine laboratory parameters.

Survey of Nutrition Practice in Patients with Severe Sepsis among Canadian Registered Dietitians.

The purpose of this study was to determine the opinions and reported nutrition practices of Canadian Registered Dietitians (RDs) with regard to feeding patients with severe sepsis. In 2017, surveys were sent to 112 eligible Canadian RDs in 10 provinces who were practicing in an intensive care environment. The survey included embedded branching logic questions developed to address major facets of sepsis, critical illness, and nutrition. The survey instrument assimilated all data in an anonymous manner, so respondents could not be linked to their answers. Of the 64 RDs who responded (57% response rate), the majority practiced in adult intensive care (81%), within an academic center (59%), and in a mixed unit (73%). A wide variability of Canadian RDs' opinions and practice was reported in determining energy requirements, enteral nutrition (EN) practice, EN with vasoactive agents, parenteral nutrition (PN), and supplemental micronutrients. Practice variability of Canadian RDs likely reflects gaps in both evidence and guidelines for severe sepsis. Further research efforts are needed to customize nutritional requirements in the patient with evolving sepsis, EN with patients at high risk for gastrointestinal dysfunction, optimizing PN, and the role of micronutrients.

Structures and photocatalytic performance of two d10 metal-based coordination polymers containing mixed building units

The linker 1,4-bis(2-methyl-imidazole-yl)-butane (bib) was used to construct two coordination polymers, specifically [Cd(bib)(ipa)]n (1) and [Zn(bib)(tpa)]n (2), in the presence of isophthalic acid (H2ipa) and terephthalic acid (H2tpa), respectively, under solvothermal conditions. Topological analyses reveal that the crystal of complex 1 consists of a 3D threefold interpenetrating network with Schlafli symbol {65.8}, while complex 2 possesses a 2D wavelike layer structure with Schlafli symbol {66}. The photocatalytic properties of both complexes for the degradation of methyl violet have been explored, revealing that complex 2 is a better photocatalyst than 1. A mechanism for the photocatalytic properties of the complexes is proposed, based on the results of density of states (DOS) and partial DOS calculations.

First Dimethyltin-Functionalized Rare-Earth Incorporated Tellurotungstates Consisting of {B-α-TeW7O28} and {W5O18} Mixed Building Units.

The facile one-step assembly reaction of Na2WO4·2H2O, Sn(CH3)2Cl2, RE(NO3)3·6H2O and K2TeO3 in the presence of dimethylamine hydrochloride as an organic solubilizing agent in acidic aqueous solution resulted in a family of dimethyltin-functionalized rare-earth (RE) incorporated tellurotungstates consisting of {B-α-TeW7O28} and {W5O18} mixed building units [H2N(CH3)2]8Na4H2[RE2(OH)(B-α-TeW7O28)Sn2(CH3)4(W5O18)]2·18H2O [RE = ErIII (1), YbIII (2), HoIII (3), YIII (4)]. The most striking structural characteristic of 1-4 is that they all contain a novel tetrameric S-shaped [RE2(OH)(B-α-TeW7O28)Sn2(CH3)4(W5O18)]214- moiety simultaneously including two pentavacant Keggin [B-α-TeW7O28]12- and two monovacant Lindqvist [W5O18]6- fragments connected by RE and dimethyltin linkers. To the best of our knowledge, such dimethyltin-functionalized RE-containing tellurotungstates have not been reported before. The visible or NIR solid-state emission spectra of 1 and 3 display the characteristic emission bands arising from ErIII and HoIII centers. Moreover, various 1-Er/Yb co-doped samples were prepared by controlling different mass ratio of Er(NO3)3·6H2O/Yb(NO3)·6H2O in the range of 0.96:0.04-0.02:0.98. In the visible region, the emission intensity of the 1-Er0.40/Yb0.60 co-doped sample reaches the maximum at the mass ratio of Er(NO3)3·6H2O/Yb(NO3)·6H2O being 0.40:0.60, and this observation is mainly derived from the fact that the Yb3+ ions can sensitize the Er3+ ions to enhance the emission intensity in the visible region. However, no such phenomenon for the 1-Er/Yb co-doped samples is seen in the NIR region. Besides, the upconversion spectra of the 1-Er/Yb co-doped samples were first observed. In addition, the thermal stabilities of 1-4 were also investigated on the crystalline samples and the thermal decomposition process of 1 has been deeply studied.

Role of physical therapists in the weaning and extubation procedures of pediatric and neonatal intensive care units: a survey

BackgroundWeaning a patient from mechanical ventilation is a complex procedure that involves clinical and contextual aspects. Mechanical ventilation also depends on the characteristics of health professionals who work in intensive care. ObjectiveThis study described the organizational aspects associated with the physical therapist's performance in the weaning procedure from mechanical ventilation and extubation in neonatal, pediatric and mixed (neonatal and pediatric) intensive care units in Brazil. MethodsIn order to identify the existing intensive care units in Brazil, data from the National Health Facilities Census was used to enable the researchers to obtain information about registered units. A cross-sectional survey was carried out by sending an electronic questionnaire to 298 neonatal, pediatric and mixed intensive care units in Brazil. ResultsThis study assessed questionnaires from 146 intensive care units (49.3% neonatal, 35.6% pediatric and 15.1% mixed). A total of 57.5% of these units applied mechanical ventilation weaning protocols, and a physical therapist frequently conducted this procedure (66.7%). However, the clinician responsible for conducting the weaning and deciding when to do extubation varied regardless of ICU patient age profile. Regardless of the type of hospital or the type of units, most of these had a dedicated physical therapist. However, physical therapy care 24h/7 days per week was predominantly in pediatric intensive care units (56.0%), and in public hospitals (45.9%). Moreover, when the physical therapist was available 24h/7 days per week, (s)he was responsible for the mechanical ventilation extubation decision and patients were successfully extubated on the first attempt. ConclusionIn this survey, intensive care units using physical therapy assistance 24h/7 days per week were associated with the use of a mechanical ventilation weaning protocol, an extubation decision and success commonly on the first attempt of extubation.

A Comprehensive Approach for Maximizing Flexibility Benefits of Electric Vehicles

Increasing variability and uncertainty coming from both sides of the power system equilibrium equation, such as wind energy on the generation side and increasing share of new consumers such as electric vehicles on the demand side, entail higher reserve requirements. While traditional approaches of assigning conventional generation units to maintain system stability can increase operational costs, greenhouse gas emissions, or give signals for new investments, utilizing intelligent control of distributed sources might mitigate those negative effects. This can be achieved by controllable charging of domestic electric vehicles. On the other hand, increasing number of public charging stations gives final users the opportunity to fast charge, making their vehicles an additional source of uncertainty rather than a provider of flexibility. This paper brings a full system assessment of combined effect of slow home charging of electric vehicles together with fast charging stations (both with and without integrated energy storage systems), cast as mixed integer linear programming unit commitment model. The contributions of this paper look into optimal periods when fast charging is beneficial for the system operation, as well as assess the benefits of integrating battery storage into fast charging stations to mitigate the negative effects to power system operation.

Relationship between digestive tract colonization and subsequent ventilator-associated pneumonia related to ESBL-producing Enterobacteriaceae

BackgroundVentilator-associated pneumonia (VAP) is the most common ICU-acquired infection. Recently, the incidence of extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBLE) has substantially increased in critically ill patients. Identifying patients at risk for VAP related to ESBLE could be helpful to improve the rate of appropriate initial antibiotic treatment, and to reduce unnecessary exposure to carbapenems. The primary objective was to identify risk factors for VAP related to ESBLE. Secondary objective was to determine the impact of ESBLE on outcome in VAP patients.MethodsThis retrospective study was conducted in a single mixed intensive care unit (ICU), during a 4-year period. All patients with confirmed VAP were included. VAP was defined using clinical, radiologic and quantitative microbiological data. VAP first episodes were prospectively identified using the continuous surveillance data. Exposure to different risk factors was taken into account until the diagnosis of ESBLE VAP or until ICU discharge, in patients with ESBLE VAP and VAP related to other bacteria, respectively. In all patients, routine screening for ESBLE (rectal swab) was performed at ICU admission and once a week. Patients with ESBLE VAP were compared with those with VAP related to other bacteria using univariate analysis. All significant factors were included in the multivariate logistic regression model.ResultsAmong the 410 patients with VAP, 43 (10.5%) had ESBLE VAP, 76 (19%) patients had polymicrobial VAP and 189 (46%) had VAP related to multidrug resistant bacteria. Multivariate analysis identified prior ESBLE colonization of the digestive tract as the only independent risk factor for ESBLE VAP (OR [95% CI] = 23 [10–55], p < 0.001). Whilst the positive predictive value of ESBLE digestive colonization was low (43.6%), its negative predictive value was excellent (97.3%) in predicting ESBLE VAP. Duration of mechanical ventilation (median [IQR], 28 [18,42] vs 23 [15,42] d, p = 0.4), length of ICU stay (31 [19,53] vs 29 [18,46] d, p = 0.6), and mortality rates (55.8% vs 50%, p = 0.48) were similar in ESBLE VAP, compared with VAP related to other bacteria.ConclusionDigestive tract colonization related to ESBLE is independently associated with ESBLE VAP. Its excellent negative predictive value suggests that patients without ESBLE colonization should not receive carbapenems as part of their initial empirical treatment to cover ESBLE.

A Microporous Heterovalent Copper–Organic Framework Based on [Cu2I]n and Cu2(CO2)4 Secondary Building Units: High Performance for CO2 Adsorption and Separation and Iodine Sorption and Release

A microporous heterovalent Cu-based MOF, [(Cu2I)Cu2L2(H2O)2]22+·2NO3–·5DMF (1) (H2L = 5-(4H-1,2,4-triazol-4-yl)benzene-1,3-dicarboxylic acid, DMF = N,N-dimethylformamide), has been successfully synthesized using the mixed secondary building unit (SBU) strategy. Compound 1 was constructed from [Cu2I]n chain and Cu2(CO2)4 paddlewheel SBUs and exhibited a new (3,4,4)-connected topology. Although compound 1 possesses moderate surface area, it exhibits better CO2 capture (91.9 cm3 g–1 at 273 K) and separation ability (selectivity for CO2 over CH4 = 8.2 under 1 bar at 298 K) than most of the reported CuxIy-based MOFs. Moreover, compound 1 is also a good candidate for the capture and release of iodine.

Frequency and outcome of post-extubation dysphagia using nurse-performed swallowing screening protocol.

Post-extubation dysphagia reportedly occurs in 3%-60% of patients and is independently associated with poor patient outcomes. The aim of this study was to investigate the frequency of post-extubation dysphagia, as diagnosed using our novel nurse-performed swallowing screening protocol, and to evaluate patient outcomes, including the frequency of discharge home, the length of the intensive care unit and hospital stays, the frequency of hospital-acquired pneumonia and death in the intensive care unit and hospital. This was a prospective cohort study. This study was conducted in a mixed intensive care unit in a critical care hospital in Japan. Between October 2016 and September 2017, the swallowing functions of 216 patients were assessed using our novel screening protocol. To investigate the correlation between dysphagia and patient outcomes, we compared a dysphagia group with a no dysphagia group. Twenty-five patients (11·6%) were diagnosed with dysphagia. The frequency of discharge home, which was the primary outcome, was significantly lower in the patients with dysphagia (60% versus 87·4%, P = 0·002). Dysphagia was also correlated with longer hospital stay and higher mortality. A binomial logistic regression analysis, including the variables of dysphagia, Acute Physiology and Chronic Health Evaluation II score and duration of ventilator use, showed that dysphagia was an independent risk factor for a lower incidence of discharge home. Among patients admitted to a mixed intensive care unit, post-extubation dysphagia was correlated with a poor prognosis. The current study emphasizes the poor prognosis of patients with dysphagia after extubation. Dysphagia developed in more than 1 in 10 patients post-extubation; therefore, monitoring for a swallowing disorder is crucial in daily nursing in the intensive care unit.

A retrospective evaluation of nutrition support in relation to clinical outcomes in critically ill patients with an open abdomen

BackgroundOptimising nutrition support in critically ill patients with an open abdomen is challenging. ObjectivesThe aims of this study were to (i) quantify the amount and adequacy of nutrition support administered and (ii) determine any relationships that exist between mode of nutrition support delivery and clinical outcomes in critically ill patients with an open abdomen. MethodsA retrospective review of critically ill patients mechanically ventilated for at least 48 h with an open abdomen in a mixed quaternary referral intensive care unit. Enteral and parenteral nutrition (ml) administered daily to patients was recorded for up to 21 days. Length of stay in the intensive care unit and hospital and duration of mechanical ventilation (days) were reported. ResultsThirty patients were studied [14 male, 68 y (15–90 y), body mass index 25 kg/m2 (11–51 kg/m2), Acute Physiology and Chronic Health Evaluation II score 20 (7–41), energy goal 1860 kcal/d (1250–2712 kcal/d)]. Patients received 55% (0–117%) of energy goal and 56% (0–105%) protein goal from either enteral or parenteral nutrition. When enteral nutrition was delivered alone or in combination with parenteral nutrition, patients received 48% (0–146%) of their energy and 59% (19–105%) of their protein goal. Patients fed parenteral nutrition, either alone or as supplementary to enteral nutrition (n = 18), received more energy when compared with those who only received enteral nutrition (n = 9) [65 (27–117) vs 49 (15–89) % energy goal, P = 0.025]. Parenteral nutrition was associated with an increased length of stay in hospital [63 (45–156) vs 45 (17–93) d, P = 0.037]. ConclusionPatients with an open abdomen receive about half of their nutrition requirements when fed exclusively via the enteral route. Providing combination enteral and parenteral nutrition to reach nutritional goals may not result in better clinical outcomes for patients with an open abdomen.

Abstract P-104: INCIDENCES OF BLEEDING AND THROMBOSIS IN CHILDREN RECEIVING EXTRACORPOREAL MEMBRANE OXYGENATION AND THEIR IMPACT ON OUTCOMES - A SINGLE-CENTRE 2-YEAR EXPERIENCE

Aims & Objectives: To determine the incidences of bleeding and thrombotic complications during ECMO support in children and their impact on survival. Methods This was a retrospective study in a single-centre, mixed surgical-medical paediatric intensive care unit (PICU) from 1 January 2016 to 1 December 2017. Patient demographics, anticoagulation practices, severity of illness, ECMO cannulation details, bleeding, thrombotic events, and outcomes were recorded. Results ECMO was used in 10 patients. Major clinical bleeding occurred in 60%. 50% of these were related to unfractionated heparin use and occurred immediately after ECMO initiation, requiring protamine. 1 patient had inadvertent overdose of heparin bolus during ECMO initiation causing major clinical bleed. Half the patients had major bleeding due to pre-morbid disseminated intra-vascular coagulation with sepsis. Patient thrombosis occurred in 4 patients; 1 patient had suspected cerebral thrombosis causing focal seizures, 1 patient had limb ischaemia, and 2 patients had deep vein thromboses related to ECMO cannulation sites. Survival to ECMO decannulation was 80%. Overall survival to hospital discharge was 40%. 2 patients were withdrawn from continuation of therapy while on ECMO due to poor neurological prognosis. Both patients had major clinical bleeding. Conclusions The incidences of bleeding and thrombosis were high during ECMO support in our case series. Major clinical bleeding was associated with overall mortality. After the case of inadvertent heparin overdose, safety measures were instituted to prevent further errors. Streamlining and standardization of anticoagulation practices in ECMO with regular audits would be useful in a centre with relatively limited yearly ECMO runs to improve outcomes.

Abstract P-220: TYPHOID PERFORATION IN CHILDREN – A MAJOR CHALLENGE FOR SOUTHERN MALAWIS ONLY MIXED (P)ICU?

Aims & Objectives: Typhoid perforations still constitutes an important challenge in African children and often needs one of our few PICUs. Blantyre provides 4–5 tertiary care beds in a mixed (P)ICU. We analyse the impact of typhoid perforations on our capacities. Methods We audited prospectively from 2014–2017 and retrospectively from 2007--2014 all children admitted with typhoid perforation in our (P)ICU. Results From January 2007 to June 2017 we saw 31 children suffering from typhoid perforation in our mixed critical care unit. Seventeen girls (54.8%) and 11 boys (35.5%) were treated (sex unknown: 3 (9.7%). From 2007–2011 we only saw 2 children. Three children from 2011–2013, followed by 19 from 2013–2016. Sadly our data sheets from 2/2016 to 11/2016 where lost, but from November 2016 to June 2017 we saw 4 more children. Mean age in our study was 8.3 years. (girls: 8.5 years, boys: 8.25 years). Only 3 children (9.7%) were not between 5 and 13 years (all boys). No neonates and only 1 baby were seen. From our last 12 patients 10 were children (83.3%). Typically several patients suffered from recurrent perforations and posed therefore an additional psychological burden on parents and staff due to the uncertainty of their surgical prognosis. Seven of our patients died (23.3%). Mortality for girls was 18.7% and for boys 36.4%. In one girl outcome remained unclear. Conclusions Even during the obviously ongoing epidemic since 2013 the number of these children is not really a challenge for our (P)ICU – representing around 5% of our paediatric patients.

Tectonic and sedimentary conditions necessary for the deposition of the Messinian evaporite successions in the eastern Mediterranean: A simple 2D model

Abstract The existing literature shows that the only saline water source for the eastern Mediterranean during the Messinian was the Atlantic Ocean and that the Sicily sill created a physical barrier between the eastern and western Mediterranean, higher than the physical barrier at the Gibraltar sill between the western Mediterranean and the Atlantic Ocean. The presence of distinctive Messinian subunits in the eastern Mediterranean similar to those observed in the western Mediterranean, suggests the existence of a similar set of depositional processes across the entire Mediterranean during the Messinian Salinity Crisis. The above statements impose two critical conditions: the eastern Mediterranean massive salt deposits must be older than their counterparts in the western Mediterranean, and the Sicily Gateway must have remained within a “goldilocks” zone during the deposition of the massive eastern Mediterranean evaporites (predominantly halite), while the sea level in the western Mediterranean would remain at the level of the Sicily sill. A simple 2-D model is developed which satisfies these conditions. The model suggests that the eastern and western basin margins experienced a nearly synchronized gypsum deposition associated with the initial drawdown of the Mediterranean level, followed by re-sedimentation in the deep basins of the terrigenous and early evaporite deposits as the drawdown intensified. The synchroneity of evaporite deposition across the eastern and western basins broke down as the Sicily Gateway became largely subaerial during a period when the Calabrian Arc area experienced uplift associated with slab break-off: the Sicily sill must have remained within a “goldilocks” zone to allow the right amount of saline water inflow into the eastern Mediterranean so that evaporites (massive halite) could be deposited. During this time, the sea level in the western Mediterranean was at the breach-level of the Sicily sill, and still open to Atlantic water influx, thus no evaporite deposition took place there. The model suggests that further restriction of the inflow occurred across the Gibraltar region which became largely subaerial associated with the uplift of the Gibraltar Arc caused again by lithospheric slab break-off. Similar to the Sicily Gateway, the Gibraltar Gateway also remained within the “goldilocks” zone to allow the right amount of saline water inflow into the western Mediterranean so that massive halite could be deposited. The re-opening of the Gibraltar Gateway re-flooded the western Mediterranean first, then the eastern Mediterranean allowing the deposition of a mixed evaporite-siliciclastic unit, followed by the transgressive sediments with distinctive brackish water Lago Mare fauna.

Role of Combining Peripheral with Sublingual Perfusion on Evaluating Microcirculation and Predicting Prognosis in Patients with Septic Shock.

Background:Measurement of general microcirculation remains difficult in septic shock patients. The peripheral perfusion index (PI) and sublingual microcirculation monitoring are thought to be possible methods. This study was performed to determine whether assessing microcirculation by PI and a new parameter, proportion of perfusion vessel change rate (ΔPPV) from sublingual microcirculation monitoring, can be associated with patients' outcome.Methods:A prospective observational study was carried out, including 74 patients with septic shock in a mixed intensive care unit. Systemic hemodynamic variables were obtained at T0 and 6 h after (T6). PI and sublingual microcirculation indicators were obtained using a bedside monitor and a sidestream dark-field device, respectively. The t-test, analysis of variance, Mann-Whitney U-test, Kruskal-Wallis test, receiver operating characteristic curve analysis with the Hanley-McNeil test, survival curves using the Kaplan-Meier method, and the log-rank (Mantel-Cox) test were used to statistical analysis.Results:Systemic hemodynamics and microcirculation data were obtained and analyzed. Patients were divided into two groups based on whether the first 6 h lactate clearance (LC) was ≥20%; PI and ΔPPV were lower at T6 in the LC <20% group compared with LC ≥20% (PI: 1.52 [0.89, 1.98] vs. 0.79 [0.44, 1,81], Z = −2.514, P = 0.012; ΔPPV: 5.9 ± 15.2 vs. 17.9 ± 20.0, t = −2.914, P = 0.005). The cutoff values of PI and ΔPPV were 1.41% and 12.1%, respectively. The cutoff value of the combined indicators was 1.379 according to logistic regression. Area under the curve demonstrated 0.709 (P < 0.05), and the sensitivity and specificity of using combined indicators were 0.622 and 0.757, respectively. Based on the PI and ΔPPV cutoff, all the participants were divided into the following groups: (1) high PI and high ΔPPV group, (2) high PI and low ΔPPV group, (3) low PI and high ΔPPV group, and (4) low PI and low ΔPPV group. The highest Sequential Organ Failure Assessment score (14.5 ± 2.9) was in the low PI and low ΔPPV group (F = 13.7, P < 0.001). Post hoc tests showed significant differences in 28-day survival rates among these four groups (log rank [Mantel-Cox], 20.931; P < 0.05).Conclusion:PI and ΔPPV in septic shock patients are related to 6 h LC, and combining these two parameters to assess microcirculation can predict organ dysfunction and 28-day mortality in patients with septic shock.