Adult Surgical Intensive Care Unit Research Articles

Organization and structure of intensive care management of adult congenital heart disease in the United States

BackgroundThe growing number of adults with congenital heart disease has led to the formation of dedicated centers to provide specialized care. There is a paucity of published data on the organization, staffing, and resources available when adult congenital heart disease (ACHD) patients are hospitalized in intensive care settings. This study aims to describe the delivery of intensive care for ACHD patients in the United States and identify key differences between accredited centers or those pending accreditation and non-accredited Adult Congenital Heart Association (ACHA) centers. MethodsA web-based cross-sectional survey targeting centers with specialized ACHD programs was conducted. ResultsData were obtained from 48 of 96 centers (50%). Twenty-seven (56%) were accredited by the ACHA and 8 (17%) were pending accreditation. Surgical ACHD patients were primarily co-managed by cardiologists and intensivists (n = 11, 23%) and treated within an adult cardiac surgical intensive care unit (n = 34, 72%). Compared to non-accredited centers, ACHA accredited centers or those pending accreditation were more likely to offer daily rounds with ACHD providers (30, 86% vs. 6, 46%, p=<0.01), were more likely to support an ACHD fellowship training program (16, 46% vs. 0, 0%, p=<0.01); and were more likely to have durable mechanical support, such as ventricular assist devices (35, 100% vs. 8, 62%, p < 0.01). ConclusionThis survey reports current trends in organization, staffing, and resources available to ACHD patients requiring intensive care. ACHA accredited centers or those pending accreditation were more likely to have dedicated ACHD rounds, fellowship training programs, and access to durable mechanical support.

Nosocomial infections in the surgical intensive care unit: an observational retrospective study from a large tertiary hospital in Palestine

BackgroundNosocomial infections or hospital-acquired infections are a growing public health threat that increases patient morbidity and mortality. Patients at the highest risk are those in intensive care units. Therefore, our objective was to provide a pattern analysis of nosocomial infections that occurred in an adult surgical intensive care unit (ICU).MethodsThis study was a retrospective observational study conducted in a 6-bed surgical intensive care unit (SICU) at An-Najah National University Hospital (NNUH) to detect the incidence of nosocomial infections from January 2020 until December 2021. The study group included 157 patients who received antibiotics during their stay in the SICU.ResultsThe incidence of nosocomial infections, either suspected or confirmed, in the SICU was 26.9% (95 out of 352 admitted patients). Pneumonia (36.8%) followed by skin and soft tissue infections (35.8%) were the most common causes. The most common causative microorganisms were in the following order: Pseudomonas aeruginosa (26.3%), Acinetobacter baumannii (25.3%), extended-spectrum beta lactamase (ESBL)-Escherichia coli (23.2%) and Klebsiella pneumonia (15.8%). The average hospital stay of patients with nosocomial infections in the SICU was 18.5 days.ConclusionsThe incidence of nosocomial infections is progressively increasing despite the current infection control measures, which accounts for an increased mortality rate among critically ill patients. The findings of this study may be beneficial in raising awareness to implement new strategies for the surveillance and prevention of hospital-acquired infections in Palestinian hospitals and health care centers.

Agreement between cardiac output estimation with a wireless, wearable pulse decomposition analysis device and continuous thermodilution in post cardiac surgery intensive care unit patients.

Pulse Decomposition Analysis (PDA) uses integration of the systolic area of a distally transmitted aortic pulse as well as arterial stiffness estimates to compute cardiac output. We sought to assess agreement of cardiac output (CO) estimation between continuous pulmonary artery catheter (PAC) guided thermodilution (CO-CCO) and a wireless, wearable noninvasive device, (Vitalstream, Caretaker Medical, Charlottesville, VA), that utilizes the Pulse Decomposition Analysis (CO-PDA) method in postoperative cardiac surgery patients in the intensive care unit. CO-CCO measurements were compared with post processed CO-PDA measurements in prospectively enrolled adult cardiac surgical intensive care unit patients. Uncalibrated CO-PDA values were compared for accuracy with CO-CCO via a Bland-Altman analysis considering repeated measurements and a concordance analysis with a 10% exclusion zone. 259.7h of monitoring data from 41 patients matching 15,583 data points were analyzed. Mean CO-CCO was 5.55L/min, while mean values for the CO-PDA were 5.73L/min (mean of differences +- SD 0.79 ± 1.11L/min; limits of agreement - 1.43 to 3.01L/min), with a percentage error of 37.5%. CO-CCO correlation with CO-PDA was moderate (0.54) and concordance was 0.83. Compared with the CO-CCO Swan-Ganz, cardiac output measurements obtained using the CO-PDA were not interchangeable when using a 30% threshold. These preliminary results were within the 45% limits for minimally invasive devices, and pending further robust trials, the CO-PDA offers a noninvasive, wireless solution to complement and extend hemodynamic monitoring within and outside the ICU.

Reducing diarrhoea in an adult surgical intensive care unit: A quality improvement study.

Although diarrhoea is a real source of morbidity for critically ill patients, this issue has been little studied, making it difficult to understand its mechanisms and management. We conducted a quality improvement study in an adult surgical intensive care unit before/after the implementation of a specific protocol to firstly improve diarrhoea management for patient benefit and secondly to understand the impact on caregivers. The first part of this before/after study consisted in assessing the proportion of patients receiving an anti-diarrheal treatment before (phase I)/after (phase II) the implementation of the protocol. The second part of the study was to survey the caregivers on this topic. Sixty four adults were included (33 in phase I; 31 in phase II) with 280 diarrheal episodes (129 in phase I; 151 in phase II). The proportion of patients who received at least one anti-diarrheal treatment was similar between the two phases (79% (26/33) vs. 68% (21/31), p = .40). Diarrhoea incidence was also similar (9% (33 patients/368 admissions) vs. 11% (31 patients/275 admissions), p = .35). The delay to initiate at least one treatment was significantly shorter in phase II (2 days [1-7] vs. 0 day [0-2]; p < .001). The patients' rehabilitation was no longer impacted by the occurrence of a diarrheal episode in phase II (39% (13/33) vs. 0% (0/31), p < .001). Eighty team members completed the surveys in phase I and 70 in phase II. Caregivers perceived diarrhoea like a burden and its economic impact remained high. The implementation of a protocol for the management of ICU diarrhoea did not increase the proportion of patients treated, but it did significantly improve the delay to initiate a treatment. The patients' rehabilitation was no longer affected by diarrhoea. The use of specific anti-diarrhoea guidelines may help to reduce the burden of diarrhoea in an ICU.

Implementation of diagnostic stewardship in two surgical ICUs: Time for a blood-culture change

Background: Blood cultures are commonly ordered for patients with low risk of bacteremia. Liberal blood-culture ordering increases the risk of false-positive results, which can lead to increased length of stay, excess antibiotics, and unnecessary diagnostic procedures. We implemented a blood-culture indication algorithm with data feedback and assessed the impact on ordering volume and percent positivity. Methods: We performed a prospective cohort study from February 2022 to November 2022 using historical controls from February 2020 to January 2022. We introduced the blood-culture algorithm (Fig. 1) in 2 adult surgical intensive care units (ICUs). Clinicians reviewed charts of eligible patients with blood cultures weekly to determine whether the blood-culture algorithm was followed. They provided feedback to the unit medical directors weekly. We defined a blood-culture event as ≥1 blood culture within 24 hours. We excluded patients aged &lt;18 years, absolute neutrophil count &lt;500, and heart and lung transplant recipients at the time of blood-culture review. Results: In total, 7,315 blood-culture events in the preintervention group and 2,506 blood-culture events in the postintervention group met eligibility criteria. The average monthly blood-culture rate decreased from 190 blood cultures per 1,000 patient days to 142 blood cultures per 1,000 patient days (P &lt; .01) after the algorithm was implemented. (Fig. 2) The average monthly blood-culture positivity increased from 11.7% to 14.2% (P = .13). Average monthly days of antibiotic therapy (DOT) was lower in the postintervention period than in the preintervention period (2,200 vs 1,940; P &lt; .01). (Fig. 3) The ICU length of stay did not change before the intervention compared to after the intervention: 10 days (IQR, 5–18) versus 10 days (IQR, 5–17; P = .63). The in-hospital mortality rate was lower during the postintervention period, but the difference was not statistically significant: 9.24% versus 8.34% (P = .17). The all-cause 30-day mortality was significantly lower during the intervention period: 11.9% versus 9.7% (P &lt; .01). The unplanned 30-day readmission percentage was significantly lower during the intervention period (10.6% vs 7.6%; P &lt; .01). Over the 9-month intervention, we reviewed 916 blood-culture events in 452 unique patients. Overall, 74.6% of blood cultures followed the algorithm. The most common reasons overall for ordering blood cultures were severe sepsis or septic shock (37%), isolated fever and/or leukocytosis (19%), and documenting clearance of bacteremia (15%) (Table 1). The most common indications for inappropriate blood cultures were isolated fever and/or leukocytosis (53%). Conclusions: We introduced a blood-culture algorithm with data feedback in 2 surgical ICUs and observed decreases in blood-culture volume without a negative impact on ICU LOS or mortality rate.Disclosure: None

Association of clinical prediction scores with hospital mortality in an adult medical and surgical intensive care unit in Kenya.

Mortality prediction among critically ill patients in resource limited settings is difficult. Identifying the best mortality prediction tool is important for counseling patients and families, benchmarking quality improvement efforts, and defining severity of illness for clinical research studies. Compare predictive capacity of the Modified Early Warning Score (MEWS), Universal Vital Assessment (UVA), Tropical Intensive Care Score (TropICS), Rwanda Mortality Probability Model (R-MPM), and quick Sequential Organ Failure Assessment (qSOFA) for hospital mortality among adults admitted to a medical-surgical intensive care unit (ICU) in rural Kenya. We performed a pre-planned subgroup analysis among ICU patients with suspected infection. Prospective single-center cohort study at a tertiary care, academic hospital in Kenya. All adults 18 years and older admitted to the ICU January 2018-June 2019 were included. The primary outcome was association of clinical prediction tool score with hospital mortality, as defined by area under the receiver operating characteristic curve (AUROC). Demographic, physiologic, laboratory, therapeutic, and mortality data were collected. 338 patients were included, none were excluded. Median age was 42 years (IQR 33-62) and 61% (n = 207) were male. Fifty-nine percent (n = 199) required mechanical ventilation and 35% (n = 118) received vasopressors upon ICU admission. Overall hospital mortality was 31% (n = 104). 323 patients had all component variables recorded for R-MPM, 261 for MEWS, and 253 for UVA. The AUROC was highest for MEWS (0.76), followed by R-MPM (0.75), qSOFA (0.70), and UVA (0.69) (p < 0.001). Predictive capacity was similar among patients with suspected infection. All tools had acceptable predictive capacity for hospital mortality, with variable observed availability of the component data. R-MPM and MEWS had high rates of variable availability as well as good AUROC, suggesting these tools may prove useful in low resource ICUs.

Factors Associated With Catheter-Associated Urinary Tract Infection in Patients in the Intensive Care Unit

Catheter-associated urinary tract infection (CAUTI) commonly occurs in intensive care units (ICU) and is associated with longer hospital stays and higher healthcare costs, morbidity, and mortality. The purpose of this study was to examine the factors associated with CAUTI in ICU patients. This study was a secondary analysis of data from a study on the usage of indwelling catheters in adult internal and surgical ICU patients at a teaching hospital in southern Taiwan conducted between January 1 and December 31, 2017. Descriptive analysis, the independent t test, chi-square test, and logistic regression were used to examine the factors associated with CAUTI. Of the 1,120 patients with an indwelling urinary catheter in the ICU, 330 revealed a positive urine culture result, indicating a 29.5% prevalence of CAUTI. The average duration of indwelling urinary catheter usage was 6.55 (SD = 4.89) days. The participants averaged 69.93 years old (SD = 15.19 years), and 627 (56.0%) were men and 493 (44.0%) were women. Being female, having diabetes, having a large indwelling urinary catheter, having a longer duration of indwelling urinary catheter usage, and being unable to remove the indwelling urinary catheter during the ICU stay were found to be associated with a significantly higher risk of CAUTI. Women and patients with diabetes are particularly vulnerable to CAUTI. Thus, urinary catheters should be used with caution. Using smaller-sized urinary catheters and reducing the duration of urinary catheter use are suggested. The results of this study may be used to guide clinical practice to help reduce the incidence of CAUTI and enhance overall healthcare service quality.

Agreement between cardiac output estimation by multi-beat analysis of arterial blood pressure waveforms and continuous thermodilution in post cardiac surgery intensive care unit patients

We sought to assess agreement of cardiac output estimation between continuous pulmonary artery catheter (PAC) guided thermodilution (CO-CTD) and a novel pulse wave analysis (PWA) method that performs an analysis of multiple beats of the arterial blood pressure waveform (CO-MBA) in post-operative cardiac surgery patients. PAC obtained CO-CTD measurements were compared with CO-MBA measurements from the Argos monitor (Retia Medical; Valhalla, NY, USA), in prospectively enrolled adult cardiac surgical intensive care unit patients. Agreement was assessed via Bland-Altman analysis. Subgroup analysis was performed on data segments identified as arrhythmia, or with low CO (less than 5 L/min). 927 hours of monitoring data from 79 patients was analyzed, of which 26 had arrhythmia. Mean CO-CTD was 5.29 ± 1.14 L/min (bias ± precision), whereas mean CO-MBA was 5.36 ± 1.33 L/min, (4.95 ± 0.80 L/min and 5.04 ± 1.07 L/min in the arrhythmia subgroup). Mean of differences was 0.04 ± 1.04 L/min with an error of 38.2%. In the arrhythmia subgroup, mean of differences was 0.14 ± 0.90 L/min with an error of 35.4%. In the low CO subgroup, mean of differences was 0.26 ± 0.89 L/min with an error of 40.4%. In adult patients after cardiac surgery, including those with low cardiac output and arrhythmia CO-MBA is not interchangeable with the continuous thermodilution method via a PAC, when using a 30% error threshold.

Anticoagulation Monitoring with Activated Partial ThromboPlastin Time and Anti-Xa Activity in Intensive Care Unit Patients: Interest of Thrombin Generation Assay.

Current guidelines recommend monitoring the anticoagulant effect of unfractionated heparin (UFH) by measuring anti-Xa activity rather than activated partial thromboplastin time (aPTT) in intensive care unit (ICU) patients. The primary objective of this study was to evaluate the correlation of aPTT, anti-Xa activity, and thrombin generation in UFH-treated ICU patients. A prospective observational pilot study was conducted in adult surgical ICU patients treated with UFH. aPTT and anti-Xa activity were monitored daily. The therapeutic target was aPTT between 50 s and 84 s, and/or anti-Xa between 0.3 and 0.7 U/mL. Correlation among aPTT, anti-Xa activity, and thrombin generation was determined by measuring endogenous thrombin potential (ETP), with the inflammatory response evaluated. C-reactive protein (CRP) was used as a marker of inflammatory response. The plasma of 107 samples from 30 ICU patients was analyzed. The correlation between aPTT and anti-Xa activity was 0.66, CI95% [0.54;0.76] (p < 0.0001). Although thrombin generation, aPTT, and anti-Xa were correlated with inflammatory responses, the correlation was higher with thrombin generation and anti-Xa activity compared to aPTT. When aPTT was in a therapeutic range, a low thrombin generation was observed but was 50% inhibited when anti-Xa was in a therapeutic range. Coagulation testing with aPTT, anti-Xa correlated with thrombin generation. A 50% decrease in thrombin generation was observed when anti-Xa was within a therapeutic range. Further work is needed to evaluate coagulation biomarker responses and clinical outcomes in specific ICU populations.

Family caregivers’ responses to a visitation restriction policy at a Korean surgical intensive care unit before and during the coronavirus disease 2019 pandemic

BackgroundSince the COVID-19 pandemic, restricting family visits in the ICU has increased concerns regarding negative psychosocial consequences to patients and families. ObjectivesTo compare the quality of life, depressive symptoms, and emotions in family caregivers of ICU patients before and during the COVID-19 pandemic, and to explore families’ perceptions and suggestions for the visitation. MethodsA cross-sectional descriptive survey was conducted in 99 family caregivers of adult surgical ICU patients from an urban academic medical center in South Korea (February to July 2021). The WHO's Quality of Life-BREF, Center for Epidemiologic Studies Depression, and Visual Analogue Scale were used to assess quality of life, depressive symptoms, and emotions, respectively. The Family Perception Checklist was used to assess families’ perceptions and suggestions about the visitation restriction. Results were compared with the data from our previous survey (n = 187) in 2017. ResultsFamily caregivers were mostly women (n = 59), adult children (n = 43) or spouse (n = 38) of patients with mean age of 47.34 years. Family caregivers surveyed during the pandemic reported worsening sadness (54.66 ± 28.93, 45.58 ± 29.44, P = 0.005) and anxiety (53.86 ± 30.07, 43.22 ± 29.02, P = 0.001) than those who were surveyed in. While majority of families were satisfied with the visitation restrictions (86.9%), only 50.5% were satisfied with the amount of information provided on the patient's condition. ConclusionsVisitation restriction is necessary during the COVID-19 pandemic despite sadness and anxiety reported in caregivers. Hence, alternative visitation strategies are needed to mitigate psychological distress and provide sufficient information to ICU family caregivers.

Infection-Related Ventilator-Associated Complication and Possible Ventilator-Associated Pneumonia among Mechanically Ventilated Patients of Adult Medical and Surgical Intensive Care Units.

Objective An observational study was conducted to evaluate (1) the incidence rates of infection-related ventilator-associated complication (IVAC) and possible ventilator-associated pneumonia (PVAP) among mechanically ventilated patients of adult medical and surgical intensive care units (ICUs) and (2) the pathogen distribution in patients with PVAP. Materials and Methods The IVAC and PVAP rates of medical and surgical ICUs, between July 1, 2017, and June 30, 2021, per 1,000 mechanical ventilator (MV) days were calculated. The significance of difference in IVAC and PVAP rates between medical and surgical ICUs was calculated. The level of significance was set at less than 0.05. Results MV utilization ratios of adult medical and surgical ICUs were 0.32 and 0.26, respectively ( p < 0.001). About 8 and 7 episodes of IVAC and 14 and 6 episodes of PVAP were reported from adult medical and surgical ICUs, accounting for IVAC rates of 3.17 and 1.8 per 1,000 MV ( p > 0.05) and PVAP rates of 2.46 and 1.59 per 1,000 MV days in medical and surgical ICUs, respectively ( p > 0.05). Acinetobacter baumannii complex either singly or in combination was isolated in 11/20 PVAP cases. Conclusion IVAC and PVAP were more in medical compared with surgical ICUs. The most common pathogen in patients with PVAP was A. baumannii complex. More studies are warranted to monitor the significance of ventilator-associated event on patient outcomes.

Impact of Empiric Linezolid for Necrotizing Soft Tissue Infections on Duration of Methicillin-Resistant Staphylococcus aureus-Active Therapy

Background: Necrotizing soft tissue infections (NSTIs) require prompt surgical debridement and antimicrobial therapy. Indicated antimicrobial therapy involves broad-spectrum coverage against common pathogens and toxin inhibition. Linezolid provides both methicillin-resistant Staphylococcus aureus (MRSA) coverage and toxin inhibition, however, there is limited evidence evaluating its role in empiric treatment. The purpose of this study was to evaluate the impact of empiric linezolid use for NSTIs on the total duration of MRSA-active therapy. Patients and Methods: This retrospective, single-center study included adult surgical intensive care unit (ICU) patients treated with empiric vancomycin and clindamycin or linezolid along with gram-negative and anaerobe coverage for NSTIs. The primary end point of this study was the duration of MRSA-active therapy. Secondary end points included ICU and hospital length of stay (LOS; days), new-onset acute kidney injury (AKI), and Clostridioides difficile infection (CDI). Results: There were 21 patients in the vancomycin/clindamycin cohort and 28 patients in the linezolid cohort. The average duration of vancomycin was 3.9 days versus 2.9 days of linezolid (p = 0.04). The average hospital LOS for the vancomycin/clindamycin cohort was somewhat longer than the linezolid cohort, although the difference was not statistically significant (p = 0.07), and the incidence of new-onset AKI during hospitalization was higher in the vancomycin/clindamycin cohort (38.1% vs. 0%; p < 0.001). No differences were observed for ICU LOS or CDI. Conclusions: Empiric linezolid use for NSTI was associated with one less day of MRSA-active therapy and lower incidence of new-onset AKI during hospitalization. Linezolid was a safe and effective alternative to vancomycin/clindamycin for empiric treatment of NSTIs.

ICU delirium burden predicts functional neurologic outcomes.

BackgroundWe investigated the effect of delirium burden in mechanically ventilated patients, beginning in the ICU and continuing throughout hospitalization, on functional neurologic outcomes up to 2.5 years following critical illness.MethodsProspective cohort study of enrolling 178 consecutive mechanically ventilated adult medical and surgical ICU patients between October 2013 and May 2016. Altogether, patients were assessed daily for delirium 2941days using the Confusion Assessment Method for the ICU (CAM-ICU). Hospitalization delirium burden (DB) was quantified as number of hospital days with delirium divided by total days at risk. Survival status up to 2.5 years and neurologic outcomes using the Glasgow Outcome Scale were recorded at discharge 3, 6, and 12 months post-discharge.ResultsOf 178 patients, 19 (10.7%) were excluded from outcome analyses due to persistent coma. Among the remaining 159, 123 (77.4%) experienced delirium. DB was independently associated with >4-fold increased mortality at 2.5 years following ICU admission (adjusted hazard ratio [aHR], 4.77; 95% CI, 2.10–10.83; P < .001), and worse neurologic outcome at discharge (adjusted odds ratio [aOR], 0.02; 0.01–0.09; P < .001), 3 (aOR, 0.11; 0.04–0.31; P < .001), 6 (aOR, 0.10; 0.04–0.29; P < .001), and 12 months (aOR, 0.19; 0.07–0.52; P = .001). DB in the ICU alone was not associated with mortality (HR, 1.79; 0.93–3.44; P = .082) and predicted neurologic outcome less strongly than entire hospital stay DB. Similarly, the number of delirium days in the ICU and for whole hospitalization were not associated with mortality (HR, 1.00; 0.93–1.08; P = .917 and HR, 0.98; 0.94–1.03, P = .535) nor with neurological outcomes, except for the association between ICU delirium days and neurological outcome at discharge (OR, 0.90; 0.81–0.99, P = .038).ConclusionsDelirium burden throughout hospitalization independently predicts long term neurologic outcomes and death up to 2.5 years after critical illness, and is more predictive than delirium burden in the ICU alone and number of delirium days.

Association between Etomidate Use for Rapid Sequence Intubation and Adrenal Insufficiency in Sepsis.

BackgroundThe risk of adrenal insufficiency (AI) in using single-dose etomidate for intubation among patients with sepsis remains controversial. Our aim was to assess the prevalence of AI and characterize the risk factors in patients who received etomidate for rapid sequence intubation (RSI).MethodsThis is a retrospective study of prospectively-acquired data evaluating surgical intensive care unit (SICU) patients who developed respiratory failure undergoing RSI.ResultsOf the 44 adult SICU patients who developed respiratory failure, 34 patients received etomidate. The average age for the total cohort, for the patients that received etomidate and for those who did not, was 70.91 ± 14.92, 72.82 ± 13.61 years and 64.40 ± 15.93, respectively. Twenty-four patients of the total cohort (54.55%) developed AI; 26 had septic shock (59.09%), and 16 patients had AI and septic shock (36.36%). There was no statistical significance between the incidence of AI in patients who received etomidate (47%) and those who did not (80%). However, in the subset of patients who received etomidate for RSI, there was a non-significant trend toward increased incidence of AI in those who were septic compared to those who were not (p = 0.06).ConclusionA single dose of etomidate used for RSI in SICU patients is not associated with the development of AI or mortality. However, a trend was shown, although not statistically significant, towards the development of AI in septic patients. High-quality and adequately powered randomized control trials (RCTs) are warranted.

Optimal Antibiotic Duration for Bloodstream Infections Secondary to Intraabdominal Infection

BackgroundBloodstream infections (BSIs) secondary to intraabdominal infections (IAIs) are common in the intensive care unit (ICU). The Surgical Infection Society guidelines recommend treatment duration after achieving source control in patients with secondary bacteremia; however, literature supporting this recommendation is limited. The purpose of this study was to compare outcomes in patients who received shorter versus extended duration of antibiotics for bacteremia secondary to IAI. Materials and methodsA retrospective cohort analysis was conducted in adult surgical ICU patients (n = 42) with BSIs and source control procedure(s) for IAI. The primary outcome was recurrent IAI. Secondary outcomes included surgical site infections (SSIs), Clostridium difficile infections (CDIs), secondary fungal infections, and in-hospital mortality. ResultsForty-two patients met inclusion criteria and were divided into groups according to antimicrobial duration; 12 patients received <7 d, and 30 patients received >7 d of antibiotics. There were no differences in baseline characteristics between the two cohorts except for the presence of sepsis [4/12 (33.3%) versus 27/30 (90.0%); P = 0.001]. Thirty-one percent (13/42) of all organisms isolated from blood cultures were gram-negative bacteria, 12/42 (28.6%) were MDROs, and 2/42 (4.8%) patients experienced a culture mismatch in which cultured bacteria were not susceptible to empiric antibiotic therapy. Rates of recurrent IAI were similar between the two cohorts [1/12 (8.3%) versus 4/30 (13.3%), P = 0.554]. ConclusionsAmong surgical ICU patients with BSI secondary to IAI, cessation of antibiotic therapy within 7 d of source control was not associated with an increased incidence of recurrent IAI.

Lessons from a review of physiotherapy and psychological rehabilitation received during ICU stay and beyond to inform the development of an ICU follow clinic.

Critical illness can have a long-term impact. A service evaluation was conducted in a hospital in the south west of Britain with an adult inter-connected general, surgical and neurological intensive care unit (ICU). The aim of the service evaluation was to generate knowledge on experiences of psychological and physical rehabilitation in intensive care, on other hospital wards and at home to inform the development of an Intensive Care follow up clinic. Data was collected from two sources. A week of ICU discharges was randomly selected, and a sample of 30 patients generated. All were sent information sheets and consent forms and offered telephone appointments. 12 participants took part in telephone interviews. The second source of participants was the ICU Expert by Experience group. Informed consent was gained with eight participants taking part. The data was analysed using thematic analysis, employing initial open coding to build a framework of emergent themes. A research group was formed to facilitate cross coding of extracts. The analysis identified three overarching themes: sense making difficulties; rehabilitation context; and sense of self. The theme of sense making difficulties had sub-themes of memory gaps, delirium, lack of information and anxiety. The theme of rehabilitation context had sub-themes of ICU environment, transitions, isolation and abandonment and valued support. the process of sense making can be difficult, is filtered through contextual factors, and may influence sense of self. The results have been used to inform the development of an ICU follow up clinic.

Audiovisual Modules to Enhance Informed Consent in the ICU: A Pilot Study.

Prospective, observational study. Forty-eight-bed adult surgical ICU at a tertiary care center. Critically ill surgical patients and their legally authorized representatives. An audiovisual module describing eight commonly performed ICU procedures. Fifty-nine subjects were enrolled and completed an 11-question pre- and postvideo test of knowledge regarding commonly performed ICU procedures and a brief satisfaction survey. Twenty-nine percent had a healthcare background. High school was the highest level of education for 37% percent of all subjects. Out of 11 questions on the ICU procedure knowledge test, subjects scored an average 8.0 ± 1.9 correct on the pretest and 8.4 ± 2.0 correct on the posttest (p = 0.055). On univariate logistic regression, having a healthcare background was a negative predictor of improved knowledge (odds ratio, 0.185; 95% CI, 0.045-0.765), indicating that those with a health background had a lower probability of improving their score on the posttest. Among subjects who did not have a healthcare background, scores increased from 7.7 ± 1.9 to 8.3 ± 2.1 (p = 0.019). Seventy-five percent of all subjects indicated that the video was easy to understand, and 70% believed that the video improved their understanding of ICU procedures. Audiovisual modules may improve knowledge and comprehension of commonly performed ICU procedures among critically ill patients and caregivers who have no healthcare background.

Clinical Pearls

The death of a loved one in the intensive care unit may cause prolonged grief, social distress, and even symptoms of posttraumatic stress in family members. End-of-life interventions, such as grief education materials, telephone follow-up, and cards, are an important part of bereavement care for families. However, use of these interventions varies across institutions, and research findings on their effectiveness are conflicting.Takaoka and colleagues examined the use of multiauthored, customized handwritten sympathy cards mailed to families 2 to 8 weeks post mortem. They interviewed family members and clinicians and identified 3 themes: The use of personalized, written condolences from staff was experienced as a meaningful and compassionate intervention for bereaved families.See Article, pp 422-428Pressure injuries occur twice as often in intensive care unit (ICU) patients as in other acute care patients, with estimated costs of care exceeding $26.8 billion in the United States. Although there are known risk factors for hospital-acquired pressure injury (HAPI), such as decreased mobility, having surgery, and age greater than 65 years, little research has examined the relationship between skin status and HAPI in ICU patients.Alderden and colleagues examined data from routine nursing skin assessments to identify risk factors for HAPI in adult surgical ICU patients. They found the following: Although further study is warranted to examine intraoperative risk factors, the authors recommend nurses consider the impact of skin changes on the development of HAPIs and remove causes of skin irritation.See Article, pp e128-e134Catheter-associated urinary tract infections continue to occur in both intensive care unit (ICU) patients and non-ICU patients, despite national prevention initiatives. Use of bladder scanning and ultrasound technology has helped to decrease the number of indwelling urinary catheter days, but the technology yields inaccuracies in patients with acute kidney injury, especially those with abdominal fluid/ascites.Schallom et al compared the accuracy of new bladder scanning technology and 2-dimensional ultrasound in measuring bladder volume in ICU patients unable to void 6 hours after catheter removal or patients receiving dialysis. They found Both bladder scanning and ultrasound can be used to measure bladder volumes accurately, but findings suggest that ultrasound should be used to measure bladder volume in patients with ascites.See Article, pp 458-467Many intensive care unit (ICU) patients require feeding tubes for nutritional support and medication delivery. Traditional practice includes every-4-hour assessment to verify tube placement. However, complications from malplaced feeding tubes continue to occur owing to inaccurate verification methods and lack of knowledge about tube migration.Using an electromagnetic placement device (EMPD) for tube placement, Bourgault and colleagues explored the factors associated with tube migration in adult ICU patients. They found See Article, pp 439-447

Development and External Validation of an Online Clinical Prediction Model for Augmented Renal Clearance in Adult Mixed Critically Ill Patients: The Augmented Renal Clearance Predictor.

Augmented renal clearance might lead to subtherapeutic plasma levels of drugs with predominant renal clearance. Early identification of augmented renal clearance remains challenging for the ICU physician. We developed and validated our augmented renal clearance predictor, a clinical prediction model for augmented renal clearance on the next day during ICU stay, and made it available via an online calculator. We compared its predictive performance with that of two existing models for augmented renal clearance. Multicenter retrospective registry-based cohort study. Three Belgian tertiary care academic hospitals. Adult medical, surgical, and cardiac surgery ICU patients. None. Development of the prediction model was based on clinical information available during ICU stay. Out of 33,258 ICU days, we found augmented renal clearance on 19.6% of all ICU days in the development cohort. We retained six clinical variables in our augmented renal clearance predictor: day from ICU admission, age, sex, serum creatinine, trauma, and cardiac surgery. We assessed performance by measuring discrimination, calibration, and net benefit. We externally validated the final model in a single-center population (n = 10,259 ICU days). External validation confirmed good performance with an area under the curve of 0.88 (95% CI 0.87-0.88) and a sensitivity and specificity of 84.1 (95% CI 82.5-85.7) and 76.3 (95% CI 75.4-77.2) at the default threshold probability of 0.2, respectively. Augmented renal clearance on the next day can be predicted with good performance during ICU stay, using routinely collected clinical information that is readily available at bedside. Our augmented renal clearance predictor is available at www.arcpredictor.com.

An antibiotic stewardship program in a surgical ICU of a resource-limited country: financial impact with improved clinical outcomes

BackgroundAntibiotic resistance (ABX-R) is alarming in lower/middle-income countries (LMICs). Nonadherence to antibiotic guidelines and inappropriate prescribing are significant contributing factors to ABX-R. This study determined the clinical and economic impacts of antibiotic stewardship program (ASP) in surgical intensive care units (SICU) of LMIC.MethodWe conducted this pre and post-test analysis in adult SICU of Aga Khan University Hospital, Pakistan, and compared pre-ASP (September–December 2017) and post-ASP data (April–July 2018). January–March 2018 as an implementation/training phase, for designing standard operating procedures and training the team. We enrolled all the patients admitted to adult SICU and prescribed any antibiotic. ASP-team daily reviewed antibiotics prescription for its appropriateness. Through prospective-audit and feedback-mechanism changes were made and recorded. Outcome measures included antibiotic defined daily dose (DDDs)/1000 patient-days, prescription appropriateness, antibiotic duration, readmission, mortality, and cost-effectiveness.Result123 and 125 patients were enrolled in pre-ASP and post-ASP periods. DDDs/1000 patient-days of all the antibiotics reduced in the post-ASP period, ceftriaxone, cefazolin, metronidazole, piperacillin/tazobactam, and vancomycin showed statistically significant (p < 0.01) reduction. The duration of all antibiotics use reduced significantly (p < 0.01). Length of SICU stays, mortality, and readmission reduced in the post-ASP period. ID-pharmacist interventions and source-control-documentation were observed in 62% and 50% cases respectively. Guidelines adherence improved significantly (p < 0.01). Net cost saving is 6360US$ yearly, mainly through reduced antibiotics consumption, around US$ 18,000 (PKR 2.8 million) yearly.ConclusionASP implementation with supplemental efforts can improve the appropriateness of antibiotic prescriptions and the optimum duration of use. The approach is cost-effective mainly due to the reduced cost of antibiotics with rational use. Better source-control-documentation may further minimize the ABX-R in SICU.