Surgery ICU Research Articles

Incidence of ventilator associated events among intubated patients in neurosurgery ICU of a tertiary health centre in India

Ventilator associated events (VAE) by Centers for Disease Control and Prevention (CDC) was created to overcome the difficulty in surveillance of ventilator associated pneumonia (VAP). Pathogens causing VAP vary from hospitals to hospitals thus necessitating the need for local surveillance. The objective was to calculate the incidence of VAE in our hospital, to assess various organisms responsible for PVAP and to analyse their sensitivity to different antibiotics. The study retro-prospectively analysed 53 patients by consecutive sampling who were intubated from January 2018 to November 2018 in Neuro surgery ICU of our hospital. We used CDC’s guidelines to report VAE. Patient’s case files were traced using their MRD numbers and data regarding causative organism and their culture and sensitivity reports were obtained. Out of 53 intubated patients, we had eight VAE. All of them were reported as possible ventilator associated pneumonia (PVAP). Prolonged ventilator days (> 5 days) were associated with increased risk of VAE in our study. The incidence and VAE rate per 1000 ventilation days were 15.1 % and was 29.6 respectively. Six patients (75%) had monomicrobial aetiology in which two patients died. Remaining two patients (25%) had polymicrobial aetiology. Klebsiella pneumoniae was seen in majority (n=6) of the patients. Colistin had the highest sensitivity to the isolates while Ampicillin was resistant to all four organisms. All of the organisms isolated were MDR pathogen which was resistant to most of the regular anti-biotics. Therefore, it is important to frame local antibiotic policies and precautions to prevent VAE in the future. Keywords: VAE, E coli, Acinetobacter.

Effect of Thiamine Administration on Lactate Clearance and Mortality in Patients With Septic Shock.

Mounting evidence has shown that critically ill patients are commonly thiamine deficient. We sought to test the hypothesis that critically ill patients with septic shock exposed to thiamine would demonstrate improved lactate clearance and more favorable clinical outcomes compared with those not receiving thiamine. Retrospective, single-center, matched cohort study. Tertiary care academic medical center. Adult patients admitted with an International Classification of Diseases, 9th Edition, or International Classification of Diseases, 10th Edition, diagnosis code of septic shock to either the medicine or surgery ICU. None. Patients who received IV thiamine supplementation within 24 hours of hospital admission were identified and compared with a matched cohort of patients not receiving thiamine. The primary objective was to determine if thiamine administration was associated with a reduced time to lactate clearance in septic shock. Secondary outcomes included 28-day mortality, acute kidney injury, and need for renal replacement therapy, and vasopressor and mechanical ventilation-free days. Two-thousand two-hundred seventy-two patients were screened, of whom 1,049 were eligible. The study consisted of 123 thiamine-treated patients matched with 246 patients who did not receive thiamine. Based on the Fine-Gray survival model, treatment with thiamine was associated with an improved likelihood of lactate clearance (subdistribution hazard ratio, 1.307; 95% CI, 1.002-1.704). Thiamine administration was also associated with a reduction in 28-day mortality (hazard ratio, 0.666; 95% CI, 0.490-0.905). There were no differences in any secondary outcomes. Thiamine administration within 24 hours of admission in patients presenting with septic shock was associated with improved lactate clearance and a reduction in 28-day mortality compared with matched controls.

Impact of intravenous exenatide infusion for perioperative blood glucose control on myocardial ischemia-reperfusion injuries after coronary artery bypass graft surgery: sub study of the phase II/III ExSTRESS randomized trial

BackgroundThe aim of the study was to investigate whether intravenous (iv) infusion of exenatide, a synthetic GLP-1 receptor agonist, could provide a protective effect against myocardial ischemia-reperfusion injury after coronary artery bypass graft (CABG) surgery.MethodsA sub study analysis of patients > 18 years admitted for elective CABG and included in the ExSTRESS trial was conducted. Patients were randomized to receive either iv exenatide (1-h bolus of 0.05 µg min−1 followed by a constant infusion of 0.025 µg min−1) (exenatide group) or iv insulin therapy (control group) for blood glucose control (target range 100–139 mg dl−1) during the first 48 h after surgical incision. All serum levels of troponin I measured during routine care in the Cardiac Surgery ICU were recorded. The primary outcome was the highest value of plasma concentration of troponin I measured between 12 and 24 h after ICU admission. The proportion of patients presenting an echocardiographic left ventricular ejection fraction (LVEF) > 50% at the follow-up consultation was compared between the two groups.ResultsFinally, 43 and 49 patients were analyzed in the control and exenatide groups, respectively {age: 69 [61–76] versus 71 [63–75] years; baseline LVEF < 50%: 6 (14%) versus 16 (32%) patients; on-pump surgery: 29 (67%) versus 33 (67%) patients}. The primary outcome did not significantly differ between the two groups (3.34 [1.06–6.19] µg l−1 versus 2.64 [1.29–3.85] µg l−1 in the control and exenatide groups, respectively; mean difference (MD) [95% confidence interval (95% CI)] 0.16 [− 0.25; 0.57], p = 0.54). The highest troponin value measured during the first 72 h in the ICU was 6.34 [1.36–10.90] versus 5.04 [2.39–7.18] µg l−1, in the control and exenatide groups respectively (MD [95% CI] 0.20 [− 0.22; 0.61], p = 0.39). At the follow-up consultation, 5 (12%) versus 8 (16%) patients presented a LVEF < 50% in the control and in the exenatide groups respectively (relative risk [95% CI] 0.68 [0.16; 2.59], p = 0.56).ConclusionsPostoperative iv exenatide did not provide any additional cardioprotective effect compared to iv insulin in low-risk patients undergoing scheduled CABG surgery.Trial registration ClinicalTrials.gov Identifier NCT01969149, date of registration: January 7th, 2015; EudraCT No. 2009-009254-25 A, date of registration: January 6th, 2009

Prophylactic preoperative levosimendan for off-pump coronary artery bypass grafting in patients with left ventricular dysfunction: Single-centered randomized prospective study.

Background:Off-pump coronary artery bypass surgery (OPCAB) is often complicated by hemodynamic instability, especially in patients with prior left ventricular (LV) dysfunction and appropriate choice of inotrope plays a vital role in perioperative management of these patients.Aim and Objective:To study hemodynamic effects and immediate outcome of prophylactic infusion of levosimendan in patients with the LV dysfunction undergoing OPCAB surgery and whether this strategy helps in successful conduct of OPCAB surgery.Materials and Methods:After Institutional Ethics Committee approval, 60 patients posted for elective OPCAB surgery were randomly divided into two groups (n = 30 each). Patients with the LV ejection fraction <30% were included. Study group was started on injection levosimendan (@ 0.1 μg/kg/min) in the previous night before surgery and continued for 24 h including intraoperative period. Hemodynamic monitoring included heart rate, invasive blood pressure, cardiac index (CI), pulmonary capillary wedge pressure (PCWP), pulse oximetry, and arterial blood gases with serum lactates at as T0 (baseline), T1 (15 min after obtuse marginal and/or PDA anastomoses), T2 (at end of surgery), T3 (6 h after surgery in Intensive Care Unit [ICU]), T4 (12 h after surgery), and T5 (24 h after surgery in ICU). Vasopressor was added to maintain mean arterial pressure >60 mmHg. Chi-square/Fisher's exact/Mid P exact test and Student's t-tests were applied for categorical and continuous data.Results:CI was greater and PCWP reduced significantly in Group L during intraoperative and early postoperative period. Serum lactate concentration was lower in patients pretreated with levosimendan. Incidence of postoperative atrial fibrillation (POAF) (36.6 vs. 6.6%; P = 0.01), low cardiac output syndrome (LCOS) (30% vs. 6%; P = 0.02), and acute kidney injury (23.3% vs. 6.7%; P = 0.04) was less in Group L. Three patients (10%) in control group required conversion to cardiopulmonary bypass (CPB) as compared to none in the study group. There was no difference regarding ICU or hospital stay and mortality in both groups.Conclusion:Preoperative levosimendan helps in successful conduct of OPCAB and reduces the incidence of LCOS, POAF, conversion to CPB, and requirement of intra-aortic balloon pump.

Nebulized Versus IV Amikacin as Adjunctive Antibiotic for Hospital and Ventilator-Acquired Pneumonia Postcardiac Surgeries: A Randomized Controlled Trial*

Nebulized antibiotics offer high efficacy due to significant local concentrations and safety with minimal blood levels. This study evaluates the efficacy and nephrotoxicity of nebulized versus IV amikacin in postcardiothoracic surgical patients with nosocomial pneumonia caused by multidrug-resistant Gram- negative bacilli. Prospective, randomized, controlled study on surgical patients divided into two groups. Postcardiac surgery ICU. The first gtroup was administered IV amikacin 20 mg/kg once daily. The second group was prescribed amikacin nebulizer 400 mg twice daily. Both groups were co-administered IV piperacillin/tazobactam empirically. Recruited patients were diagnosed by either hospital-acquired pneumonia or ventilator-associated pneumonia where 56 (42.1%) patients were diagnosed with hospital-acquired pneumonia, 51 (38.34%) patients were diagnosed with early ventilator-associated pneumonia, and 26 (19.54%) patients with late ventilator-associated pneumonia. Clinical cure in both groups assessed on day 7 of treatment was the primary outcome. Efficacy was additionally evaluated through assessing the length of hospital stay, ICU stay, days on amikacin, days on mechanical ventilator, mechanical ventilator-free days, days to reach clinical cure, and mortality rate. Lower nephrotoxicity in the nebulized group was observed through significant preservation of kidney function (p < 0.001). Although both groups were comparable regarding length of hospital stay, nebulizer group showed shorter ICU stay (p = 0.010), lower number of days to reach complete clinical cure (p = 0.001), fewer days on mechanical ventilator (p = 0.035), and fewer days on amikacin treatment (p = 0.022). Nebulized amikacin showed better clinical cure rates, less ICU stay, and fewer days to reach complete recovery compared to IV amikacin for surgical patients with nosocomial pneumonia. It is also a less nephrotoxic option associated with less deterioration in kidney function.

Effects of dexmedetomidine on heart arrhythmia prevention in off-pump coronary artery bypass surgery: A randomized clinical trial

BackgroundArrhythmia occurring during and after surgery is one of the major complications in open-heart surgery. Dexmedetomidine is an intravenous alpha-2 agonist and very specific short-acting drug to protect the various organs against ischemic injuries and blood reflow. However, the effect of dexmedetomidine for preventing intraoperative heart arrhythmias has not been recognized.ObjectiveThis study aimed to determine the effect of dexmedetomidine on the incidence rate of heart arrhythmias and anesthetic required in off-pump coronary artery bypass surgery.MethodsThis randomized clinical trial was conducted on patients who were candidates for off-pump coronary artery bypass referring to Imam Reza Hospital of Mashhad, Iran, from July 2016 through January 2017. The patients were randomly assigned to two groups of intervention (infusion of 0.5 mcg/kg/h dexmedetomidine together with induction followed by infusion of 0.5 mcg/kg/h by the end of the surgery) or control (saline infusion). Mean arterial pressure (MAP) and heart rate (HR) were measured before induction, during surgery operation and ICU admission. Data were analyzed by SPSS version 18 using Chi Square and independent-samples t-test.ResultsA total of 76 patients with a mean age of 59.8 ± 8.2 years (in two groups of 38) were studied. The two groups had no statistically significant difference in terms of background variables. The MAP and HR values before induction, during surgery and ICU admission were significantly higher in the control group than in the intervention group (p=0.001). Out of the studied arrhythmias, the values of PAC (55.2% vs. 15.7%), PVC (81.5% vs. 21.0%), AF (26.3% vs. 7.8%), VTAC (21.0% vs. 2.6%) were significantly lower in dexmedetomidine group (p=0.001).ConclusionIt seems that dexmedetomidine administration during induction and surgery can cause significant reduction in most of the common arrhythmias in off-pump coronary bypass surgery. The use of dexmedetomidine maintains MAP and HR at significantly lower values, and changes compared to the control group as well as reduces the need for anesthetic compounds.Trial RegistrationThe present study has been registered at the Iranian Registry of Clinical Trials (www.IRCT.IR) with a code of IRCT2016072413159N9 before starting the study.FoundingThis study was fully sponsored by the Research Deputy at Mashhad University of Medical Sciences, Iran (grant number 941413).

Regional anesthesia and analgesia after surgery in ICU.

The aim is to demonstrate that ICU physicians should play a pivotal role in developing regional anesthesia techniques that are underused in critically ill patients despite the proven facts in perioperative and long-term pain, organ dysfunction, and postsurgery patient health-related quality of life improvement. Regional anesthesia and/or analgesia strategies in ICU reduce the surgical and trauma-stress response in surgical patients as well as complications incidence. Recent studies suggested that surgical/trauma ICU patients receive opioid-hypnotics continuous infusions to prevent pain and agitation that could increase the risk of posttraumatic stress disorder and chronic neuropathic pain symptoms, and chronic opioid use. Regional anesthesia use decrease the use of intravenous opioids and the ectopic activity of injured small fibers limiting those phenomena. In Cochrane reviews and prospective randomized trials in major surgery patients, regional anesthesia accelerates the return of the gastrointestinal transit and rehabilitation, decreases postoperative pain and opioids use, reduces ICU/hospital stay, improves pulmonary outcomes, including long period of mechanical ventilation and early extubation, reduces overall adverse cardiac events, and reduces ICU admissions when compared with general anesthesia and intravenous opiates alone. The reduction of long-term mortality has been reported in major vascular or orthopedic surgeries. Promoting regional anesthesia/analgesia in ICU surgical/trauma patients could undoubtedly limit the risk of complications, ICU/hospital stay, and improve patient's outcome. The use of regional anesthesia permits a high doses opioid use limitation which is mandatory and should be considered as feasible and well tolerated in ICU.

Proposal of a score to detect the need for postoperative intensive care unit admission after bariatric surgery

BackgroundWe developed a multi-dimensional score which may help in predicting those patients, undergoing bariatric surgery, who may be in need for postoperative ICU admission and which may also help in avoiding unnecessary admission to the critical care units after bariatric surgery.MethodsWe collected the data of 111patients who underwent either laparoscopic gastric sleeve or bypass and studied the association between some risk factors related to obesity and their postoperative ICU admission. Those factors found to be statistically significant are included in the final score. The cutoff value of our scoring system is determined by running a Receiver Operating Curve (ROC) analysis.ResultsForty patients (36%) were admitted to the ICU postoperatively. Our final score includes 7 independent variables; 6 found to be significantly related to post-bariatric surgery ICU admission; these are age, gender, BMI, ASA, obstructive sleep apnea and spirometry results, and the seventh is the history of venous thrombo-embolism. According to the ROC curve analysis, we set the score value of 10 as our cut-off value for the need of postoperative ICU admission. The score median value is 9. Males’ odds to be admitted to the ICU after bariatric surgery are 11.9 times higher than females. Also, those with BMI above 50 kg m−2 have odds of 29.8 times higher than those below 50 kg m−2.ConclusionsWe propose a scoring system for risk stratification, in which some of the well-known predictor risk factors are included in a simple way to help identify those high-risk patients undergoing bariatric surgery.Trial registry number: NCT02976649.

DEVELOPMENT AND IMPLEMENTATION OF A BEDSIDE ROUNDS CHECKLIST IN A CARDIAC ICU (CICU)

Best practice checklists have been regarded as a cognitive tool to improve quality of care and interprofessional collaboration. This project explores whether implementation of a bedside rounds checklist improves assessment of important aspects of care in the cardiac intensive care unit at St. Michael’s Hospital, with a goal of improving patient outcomes. A multidisciplinary team (physicians, nurses, pharmacists, allied health) adapted a checklist from the cardiovascular surgery ICU. Additional items and standardized definitions were added to reflect the CICU specific needs. After the initial electronic checklist was developed, data was prospectively collected over three days including 19 patients to determine baseline performance. Revisions were made to the tool based on the baseline data and experience from the data collection. The revised tool was then trialed over a 12 week period. Data was collected by the charge nurse on an electronic database after the team’s review of the checklist during daily bedside rounds. After a review of the 12 week data required revisions were identified. Multidisciplinary feedback was collected using a survey to qualitatively describe the perceived value, usability, and integration of the checklist during rounds. The checklist was completed for 556 of 669 patients (83%) admitted to the CICU. Significant improvements were observed in multiple checklist items, in particular documentation of code status (74% to 98%), documentation and assessment of delirium (37% to 94%), and completion of medication reconciliation (79% to 96%). Opportunities for improvement that were identified include the need for a bowel regimen algorithm, reassessment of best practice for NPO status prior to procedures, and need for education on proper use and titration of sedatives. Multidisciplinary feedback is currently being collected using a survey. With multidisciplinary input, a checklist was developed using two PDSA cycles thus far. The use of the checklist demonstrated an increase in several key quality metrics and identified areas for future work.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Structural, Nursing, and Physician Characteristics and 30-Day Mortality for Patients Undergoing Cardiac Surgery in Pennsylvania.

Cardiac surgery ICU characteristics and clinician staffing patterns have not been well characterized. We sought to describe Pennsylvania cardiac ICUs and to determine whether ICU characteristics are associated with mortality in the 30 days after cardiac surgery. From 2012 to 2013, we conducted a survey of cardiac surgery ICUs in Pennsylvania to assess ICU structure, care practices, and clinician staffing patterns. ICU data were linked to an administrative database of cardiac surgery patient discharges. We used logistic regression to measure the association between ICU variables and death in 30 days. Cardiac surgery ICUs in Pennsylvania. Patients having coronary artery bypass grafting and/or cardiac valve repair or replacement from 2009 to 2011. None. Of the 57 cardiac surgical ICUs in Pennsylvania, 43 (75.4%) responded to the facility survey. Rounds included respiratory therapists in 26 of 43 (60.5%) and pharmacists in 23 of 43 (53.5%). Eleven of 41 (26.8%) reported that at least 2/3 of their nurses had a bachelor's degree in nursing. Advanced practice providers were present in most of the ICUs (37/43; 86.0%) but residents (8/42; 18.6%) and fellows (7/43; 16.3%) were not. Daytime intensivists were present in 21 of 43 (48.8%) responding ICUs; eight of 43 (18.6%) had nighttime intensivists. Among 29,449 patients, there was no relationship between mortality and nurse ICU experience, presence of any intensivist, or absence of residents after risk adjustment. To exclude patients who may have undergone transcatheter aortic valve replacement, we conducted a subgroup analysis of patients undergoing only coronary artery bypass grafting, and results were similar. Pennsylvania cardiac surgery ICUs have variable structures, care practices, and clinician staffing, although none of these are statistically significantly associated with mortality in the 30 days following surgery after adjustment.

Thyroid Function as a Predictive Tool for The Prognosis of Traumatic Patients Admitted in Surgery ICUs

Background: APACHE Score is an important criterion for determining the patient prognosis, especially in critically ill patients. According to significantly changes in the serum levels of thyroidal hormones in patients, especially in critically ill patients, the aim of the present study was to evaluate the relationship between thyroid function and APACHE 4 score in the prognosis of the traumatic patients admitted in surgery ICU. Method &amp; Material: In a descriptive-analytical study, 90 patients with multiple trauma were studied. Thyroid hormones and APACHE 4 Score were evaluated on 1st, 5th and10th days of admission for each patient. Their clinical features and duration of hospitalization, either in trauma unit or ICU, elation between thyroidal hormones and APACHE 4 Score, duration of hospitalization, and survival of patients were evaluated. Results: This study included 90 patients. A statistically significant relation was detected between thyroid hormones (TT3) and APACHE 4 Score and duration of hospitalization. Conclusion: TT3 might be utilized as a prognostic factor in the traumatic patients admitted to ICU.

Impact of self-care ability and subjective well-being of based on peer support surgery nursing intervention for ICU surgery patients

Objective To study effect of self-care ability and subjective well-being of Based on peer support surgery nursing intervention for ICU surgery patients. Methods A total of172 cases patients with ICU surgery from July 2014 to June 2015 were divided into observation group and control group, the observation group given based on peer support nursing intervention, the control group routine nursing intervention, and followed up for 6 months, self-care ability, anxiety, depression, and subjective well-being were compared between two groups. Results Followed up for 6 months, the observation group life attitude, life style, diet adjustment, treatment compliance were (79.92±7.23), (82.36±7.15), (83.57±7.25), (85.73±7.45) points, significantly higher than the control group (72.25±7.12), (74.79±6.89), (73.66±7.08), (76.68±7.13) points, (t=7.010-9.069, P<0.01). Anxiety and depression scores were 47.16±4.27, 48.58±5.32, which were significantly lower than the control group 50.48±4.56, 53.37±5.75 (t=4.928, 5.671, P<0.05). Health worry, life satisfaction and interests, energy, sad or happy mood, emotion and behavior control, relaxation and tension, subjective well-being scored 8.12±0.95, 7.68±0.85, 16.45±2.31, 13.02±1.24,13.25±1.33, 17.56±2.45, 78.69±8.02, were significantly higher than the control group 7.52±0.82, 6.31±0.72,13.25±1.22, 12.35±1.22, 12.02±1.21, 14.36±1.42, 67.12±7.02 (t=3.572-11.405, P<0.05 or 0.01). Conclusions Based on peer support surgery nursing intervention help to improve self-care ability of surgery patients, alleviate the negative mood, and improve subjective well-being. Key words: Peer support; ICU surgery patients; Self-care ability; Subjective well-being

Comparing the effect of continuous and intermittent irrigation techniques on complications of arterial catheter and partial thromboplastin time in patients following coronary artery bypass grafting surgery

Background: Different approaches are available to irrigate the arterial catheter, such as continuous and intermittent techniques. However, there is a disagreement regarding the most appropriate method. Aim: this study aimed to compare the effect of two continuous and intermittent irrigation methods on complications of arterial catheter and partial thromboplastin time (PTT) in patients with coronary artery bypass (CABG) surgery. Method: This randomized clinical trial was conducted on 60 participants undergoing coronary artery bypass grafting surgery in open-heart surgery ICU at Imam Reza hospital in Mashhad, Iran, in 2016. In continuous group, the arterial catheter was continuously irrigated with heparin solution at the rate of 2cc/h, and in the intermittent group with a syringe containing 5cc heparin solution every 3 hours. In both groups, catheter was monitored and recorded every 3 hours (until 48 hours and 3 times from enrollment) in terms of complications of partial thromboplastin time. Data were analyzed using SPSS version 16. Results: The findingsof independent t-test showed that the two groups are homogeneous in age (P =0.48). The result of Fisher's exact test revealed no significant difference between the two groups in terms of average incidence of complications during the first 24 hours (P=0.55) and second 24 hours (P=0.55) after catheterization. Also during the 48 hours after surgery, independent t-test results showed no statistically significant difference in partial thromboplastin time (P=0.53) between the two groups. Implications for Practice: According to the results of the research based on the lack of difference between continuous and intermittent irrigation methods up to 48 hours after catheter replacement in terms of arterial catheter complications, further long-term follow-up researches are recommended.

Frequency of Acute Kidney Injury in Patients Treated With Normal Saline after Off-Pump Coronary Artery Bypass Grafting

Introduction: Acute kidney injury (AKI) is a common postoperative complication of cardiac surgery, which is associated with an increased risk of morbidity and mortality. This study investigated the frequency of postoperative AKI in low risk adult patients undergoing off-pump coronary artery bypass grafting (CABG).Materials & Methods: All consecutive adult patients of American Society of Anesthesiologists (ASA) class II and III, who were transferred to the post-operative cardiac surgery ICU after off-pump CABG and were low risk for AKI from October 2013 to September 2014 at Emam Reza Hospital, Mashhad, Iran were enrolled in this prospective cohort study at a teaching hospital. The patients were explored for AKI development, based on risk-injury-failure-loss- end stage kidney disease (RIFLE) and acute kidney injury network (AKIN) criteria, frequency of metabolic acidosis, hypernatremia, hyperchloremia, and length of stay in ICU.Results: According to the results of the present study, 479 patients with the mean age of 60.8±10.75 yrs were included. AKI occurred in 22 (4.4%) and23 (4.8%) patients, based on both the RIFLE and AKIN criteria, respectively with the highest rate of AKI, reported on the third and fourth post-operative days. Additionally, hyperchloremia and hypernatremia were observed in 71 (14.8%) and 76 (15.9%) patients, respectively. Only one case of mortality occurred during the study. Metabolic acidosis was reported in 112 (23.4%) patients with a high anion gap in 60 (12.5%) cases.Conclusion: The current study demonstrated that hypernatremia and metabolic acidosis but not AKI are frequently seen in patients receiving normal saline following off pump CABG with low risk for AKI.

Diagnosis of cardiac surgery-associated acute kidney injury: differential roles of creatinine, chitinase 3-like protein 1 and neutrophil gelatinase-associated lipocalin: a prospective cohort study

BackgroundA common and serious complication of cardiac surgery prompting early detection and intervention is cardiac surgery-associated acute kidney injury (CSA-AKI). Urinary chitinase 3-like protein 1 (UCHI3L1) was found to predict AKI associated with critical illness in adults. Our aims were therefore to evaluate whether UCHI3L1 can also be used to predict AKI associated with elective cardiac surgery in adults, and to compare this predictive ability with that of urinary neutrophil gelatinase-associated lipocalin (UNGAL), more frequently assessed early serum creatinine (SCr) measurements, and various two-biomarker panels.MethodsThis was a single-centre prospective cohort study at the eight-bed cardiac surgery ICU of Ghent University Hospital. AKI was diagnosed and classified according to the Kidney Disease|Improving Global Outcomes definitions for the diagnosis and staging of AKI, which are based on SCr and urine output (UO). Of the 211 enrolled elective cardiac surgery patients, we included 203 patients who had no AKI pre-operatively and at time of post-operative ICU admission (t1) in the primary endpoint analysis (i.e. AKI stage ≥1 within 48 h after t1), while 210 patients without AKI stage ≥2 pre-operatively and at t1 were included in the secondary endpoint analysis (i.e. AKI stage ≥2 within 12 h after t1). Systemic and/or urine concentrations of Cr, CHI3L1 and NGAL were measured more frequently than SCr in routine early post-operative ICU practice. UO was monitored hourly in the ICU.ResultsWithin 48 h after t1, 46.8% of the patients had developed AKI (70.5% stage 1, 20.0% stage 2 and 9.5% stage 3). In the early post-operative period, only SCr was a good predictor of AKI within 48 h after t1 (primary endpoint). SCHI3L1 combined with either UCHI3L1 or UNGAL was a good predictor of AKI stage ≥2 within 12 h after t1 (secondary endpoint). However, SCr and its absolute difference from pre-operative to early measures after surgery outperformed these combinations.ConclusionsWe found that more frequent assessment of the functional biomarker SCr in the early post-operative ICU period (first 4 h) after elective cardiac surgery in adult patients had good to excellent predictive value for CSA-AKI, indicating that routine SCr assessment must become more frequent in order to detect AKI more early. This performance was in contrast with the inadequate predictive value of the urinary renal stress or damage biomarkers UCHI3L1 and UNGAL.

General anesthesia management in carotid endarterectomy surgery: a single center experience

Carotid endarterectomy (CEA) is an effective surgery which is applied in order to reduce the risk of stroke associated with severe stenosis of the carotid artery. Anesthesia management is important in these patients due to high incidence of cardiovascular disease and studies are in progress for ideal anesthesia management. In this study, we aimed to share our experience in carotis endarterectomy and evaluate the clinical outcomes and review retrospectively. Patients informations were obtained from the patients and anesthesia records. Age, ASA physical status, Mallampati score (MP), anesthesia and surgery duration, ICU and discharge time, blood transfusion rate, anesthetic and analgesic drugs, invasive procedures, complications, smoking, stenosis side and ratio, comorbid conditions of patients and drugs were recorded. The mean age of patients was 67.19±1.07 (33-98). It was evaluated that 44 patients (61.2%) were ASA II, 28 patients (38.8%) were ASA III. It was recorded that mean duration of anesthesia was 226.25 ± 37.99 min, duration of surgery was 195.83±38 min, ICU stay was 2.45 ± 2.52 days and hospital stay time was 5.23 ± 2.77 days. 29 of patients (40.3%) were smokers and 7 of patients (9.7%) were identified as secondary smokers. The mortality rate was 6.9% (5 patients). Clinical experience and outcome data from our study are consistent with the literature. In CEA surgery, anesthetic technique that is safe enough to guide the evidence is not there yet. Experience of the anesthesiologist and the surgeon as surgical anesthetic management of CEA is an important point to be noted that the current developments in the patient's characteristics and monitoring.

Effect of Inhalation of Lavender Essential Oil on Vital Signs in Open Heart Surgery ICU.

This study evaluated the effects of inhalation of Lavender essential oil on vital signs in open heart surgery ICU. The main complaint of patients after open-heart surgery is dysrhythmia, tachycardia, and hypertension due to stress and pain. Due to the side effects of chemical drugs, such as opioids, use of non-invasive methods such as aromatherapy for relieving stress and pain parallel to chemical agents could be an important way to decrease the dose and side effects of analgesics. In a multicenter, single-blind trial, 40 patients who had open-heart surgery were recruited. Inclusion criteria were full consciousness, lack of hemorrhage, heart rate >60 beats/min, systolic blood pressure > 100 mmHg, and diastolic blood pressure > 60 mmHg, not using beta blockers in the operating room or ICU, no history of addiction to opioids or use of analgesics in regular, spontaneous breathing ability and not receiving synthetic opioids within 2 h before extubation. Ten minutes after extubation, the patients› vital signs [including BP, HR, Central Venous Pressure (CVP), SPO2, and RR] were measured. Then, a cotton swab, which was impregnated with 2 drops of Lavender essential oil 2%, was placed in patients' oxygen mask and patients breathed for 10 min. Thirty minutes after aromatherapy, the vital signs were measured again. Main objective of this study was the change in vital sign before and after aromatherapy. Statistical significance was accepted for P < 0.05. There was a significant difference in systolic blood pressure (p > 0.001), diastolic blood pressure (p = 0.001), and heart rate (p = 0.03) before and after the intervention using paired t-test. Although, the results did not show any significant difference in respiratory rate (p = 0.1), SpO2 (p = 0.5) and CVP (p = 0.2) before and after inhaling Lavender essential oil. Therefore, the aromatherapy could effectively reduce blood pressure and heart rate in patients admitted to the open heart surgery ICU and can be used as an independent nursing intervention in stabilizing mentioned vital signs. The limitations of our study were sample size and lack of control group. Randomized clinical trials with larger sample size are recommended.

The Problem of Malnutrition in Surgical Intensive Care Unit

At the present stage of critical care medicine development early and optimal nutritional support is the most effective method of prevention and correction of disorders of protein and energy metabolism. In Russian and foreign literature structured data on the impact of new methods of early enteral and parenteral nutrition on the course of the critical illness of heterogeneous groups of patients were published during last 10–15 years. In this connection, it is advisable to conduct more detailed study of the features of violations of disorders of energy and protein metabolism, evaluation of the effectiveness of new methods of correction and prevention of malnutrition in patients general surgery ICU of a single hospital.

Fiber optic bronchoscopy and remifentanil target-controlled infusion in critically ill patients with acute hypoxaemic respiratory failure: A descriptive study

IntroductionSedation optimizes patient comfort and ease of execution during fiber optic bronchoscopy (FOB). Our objective was to describe the safety and efficacy of remifentanil-TCI during FOB in non-intubated, hypoxaemic, thoracic surgery ICU patients. MethodsConsecutive spontaneously breathing adults requiring FOB after thoracic surgery were included if they had hypoxaemia (PaO2/FiO2<300mmHg or need for non-invasive ventilation [NIV]) and prior FOB failure under topical anaesthesia. The remifentanil initial target was chosen at 1ng/mL brain effect-site concentration (Cet), then titrated to 0.5ng/mL Cet increments according to patient comfort and coughing. Outcomes were patient-reported pain and discomfort (Visual Analogue Scale scores), ventilatory support intensification within 24hours after bronchoscopy, and ease of FOB execution. ResultsThirty-nine patients were included; all had a successful FOB. Their median PO2/FiO2 before starting FOB was 187±84mmHg and 24 patients received NIV. Median [interquartile range] pain scores were not different before and after FOB (1.0 [0.0–3.0] and 0.0 [0.0–2.0], respectively). Discomfort was reported as absent or minimal by 27 patients (69%; 95% confidence interval [95% CI], 54–81%) and as bothersome but tolerable by 12 patients (31%; 95% CI, 19–46%). Mean FiO2 returned to baseline within 2hours after FOB in 30 patients; the remaining 9 patients (23%; 95% CI, 13–38%) received ventilatory support intensification. Ease of execution was good or very good in 34 patients (87%; 95% CI, 73–94%), acceptable in 4 patients, and poor in 1 patient (persistent cough). ConclusionSedation with remifentanil-TCI during FOB with prior failure under topical anaesthesia alone was effective and acceptably safe in non-intubated hypoxaemic thoracic surgery patients.

Vascular catheter colonization: surveillance based on culture of needleless connectors.

BackgroundSuperficial culture has a high negative predictive value in the assessment of catheter tip colonization (CC) and catheter-related bloodstream infection (C-RBSI). However, the process of hub culture requires the hubs to be swabbed, and this carries a risk of dislodging the biofilm. At present, most catheter hubs are closed by needleless connectors (NCs) that are periodically replaced. Our objective was to compare the yield of SC (skin + hub culture) with that of skin + NC culture in the assessment of CC and C-RBSI.MethodsDuring 5 months, we included the patients on the Major Heart Surgery ICU when a central venous catheter (CVC) remained in place ≥7 days after insertion. SCs were taken simultaneously when the NC was withdrawn and processed by the semi-quantitative method, even when the catheter was not removed. All catheter tips were cultured. All NCs belonging to a single catheter lumen were individually flushed with 100 μl of brain-heart infusion (BHI) broth. We considered the lumen to be colonized when ≥1 NC culture from the lumen flush was positive. We collected a total of 60 catheters.ResultsThe overall CC rate was 15.0 %, and we confirmed two episodes of C-RBSI. The validity values after the comparison of SCs with skin + NC culture for prediction of CC were the following: sensitivity 66.7 % vs. 77.8 %, and negative predictive value 93.6 % vs. 93.1 %. The sensitivity and negative predictive value for prediction of C-RBSI was 100 % for both SC and skin + NC culture.ConclusionThe combination of skin and flushed NC culture can be an alternative to conventional SC for ruling out CC and C-RBSI.