Surgical Critical Care Unit Research Articles

Surgical removal of a knotted Swan-Ganz catheter inadvertently placed in the common carotid artery

A Swan-Ganz catheter is an intravenous device used for the invasive measurement of pulmonary capillary wedge pressure and other cardiovascular measurements often utilized in major surgical procedures and critical care units. Several device-related complications were reported in literature - arterial puncture, pneumothorax, inadvertent arterial catheter insertion due to non-ultrasound-guided placement, and formation of knots. This paper presents a case of inadvertent left carotid artery insertion of a Swan-Ganz catheter, complicated by a knot formation requiring surgical intervention to successfully remove the catheter.

Catecholamine concentration as a predictor of mortality in emergency surgical patients

BackgroundTrauma and emergency surgery are major causes of morbidity and mortality. The objective of this study was to determine whether serum levels of epinephrine and norepinephrine are associated with aging and mortality.MethodsThis was a prospective observational cohort study conducted in a surgical critical care unit. We included 90 patients who were admitted for postoperative care, because of major trauma, or both. We collected demographic and clinical variables, as well as serum levels of epinephrine and norepinephrine.ResultsFor patients in the > 60-year age group, the use of vasoactive drugs was found to be associated with an undetectable epinephrine level (OR [95% CI] = 6.36 [1.12, 36.08]), p = 0.05). For the patients with undetectable epinephrine levels, the in-hospital mortality was higher among those with a norepinephrine level ≥ 2006.5 pg/mL (OR [95% CI] = 4.00 [1.27, 12.58]), p = 0.03).ConclusionsThere is an association between age and mortality. Undetectable serum epinephrine, which is more common in older patients, could contribute to poor outcomes. The use of epinephrine might improve the clinical prognosis in older surgical patients with shock.

Assess Nurse's Knowledge toward Venous Thrombosis at Al-sharqat General Hospital

Background and Aims: A blood clot that is stuck in a deep vein is known as deep vein thrombosis, while a blood clot that has broken loose and migrated to the lungs is known as a pulmonary embolus. Thrombotic disorders are the world's most common cause of high mortality and morbidity among preventable diseases was to assess nurse's knowledge toward venous thrombosis at AL-Sharqat General Hospital and relationship between knowledge and their demographic data. Study Design: A descriptive study. Place and Duration of Study: Sample: This study was conducted at Al-Sharqat General Hospital in critical care unit and surgical department, between November 2023 and May 2024. Methodology: A purposive sample (non-probability) consisting of (25) nurses was selected from nurses who work in the critical care units and surgical department. Results: The results showed that over half of the participants were female nurses, making up the majority of the group. These nurses had graduated from nursing institutes and had between one and five years of experience, without having attended any training courses. Results show that nurses knowledge related to venous thrombosis was poor to moderate and there were no significant relationship between nurse's knowledge and their demographic data at P-value >0.05. Conclusion: Nurses working in the surgical department, emergency units, and critical care units had poor knowledge regarding venous thrombosis because their education level was low and they had not attended training courses.

#488 Differences in characteristics and outcomes between Patients suffering AKI in medical vs surgical ICU units

Abstract Background and Aims AKI is a public health problem, affecting one in every five hospitalized adults. It's incidence in the ICU fluctuates between 16-36%, with a mortality rate between 28%-50%. The need for HD in the ICU varies from 3-7%, and these patients have twice the risk of death. But few studies have compared patients in medical (MD-ICU) and surgical (Qx-ICU) critical care units. Method We conducted a single center, retrospective study of individuals admitted to ICU units that underwent nephrology consultation. We examined a 5-y period, in the pre-COVID era, we excluded the pandemic period, because COVID patients were admitted to MD- and Qx-ICU indistinctly. We compared epidemiological and clinical characteristics and hard outcomes between patients in both groups. Results We included 433 patients, 42% in the MD-ICU. We found no statistical differences between sex, HTN, DM, Charlson's-Index, and previous CKD. Qx-ICU patients were older, suffered less Coronary Artery (CAD), and Cerebrovascular Disease (CVD), and their AKI etiology was more frequently obstructive. MD-ICU individuals showed less hospital acquired AKI, and were more frequently classified in KDIGO Stage 3, (Fig. A, Features). We found no differences in time to nephrology consultation, length of hospital-stay and in-hospital mortality. Qx-ICU patients had shorter ICU stay, needed less frequently acute HD, and were less HD dependent at discharge (Fig. B, Results). In-hospital mortality for patients that needed HD in MD-ICU OR 2.2 (1.2-4.1, P = 0.12), Qx-ICU OR 4.4 (2.2-8.6, P < 0.001). Conclusion Individuals don't differ remarkably in their baseline clinical characteristics (Charlson`s, DM, CKD). Nevertheless, Qx-ICU patients are older, suffer less CAD, and CVD, and show significantly more hospital acquired AKI. We found that medical ICU patients suffered worst AKI stage, longer ICU stay, required acute HD and were HD dependent more frequently, but had a lower risk of death when needing acute HD. We found no differences in general mortality rate, and general hospital stay, and time to nephrology consultation between groups. We need multicentric and well-powered studies to explore these differences more profoundly, find clusters of patients and phenotypes of AKI and discover protective factors and new preventive measures against hospital acquired AKI, and need for acute HD.

Retrospective study of occurrence of pressure ulcers among the patients admitted in rural tertiary care hospital and their outcome

This retrospective study addresses the pivotal role of pressure ulcer prevention in evaluating the quality of care within critical care units. The incidence of pressure ulcers serves as a crucial indicator, impacting patient recovery and complicating treatment. In this data based retrospective study we assessed the prevalence of pressure ulcers for a duration of 6 years. In this data we included the patients from surgical, medical, respiratory and cardiac critical care units who were admitted between 01/06/16 to 01/06/22. All male and female patients aged above 18 years were included. Patients who got discharge within 48 hours were excluded. Total of 35 patients were noted to have bedsores in intensive care unit from June 2016-June 2022 admitted under both medical and surgical branches. Out of which 34.3% were in age group above 70yrs where 87.9% were male patients. Most commonly 1-2 bedsores (97.1%) were present involving mostly buttock area (82.9%) of 2-5cm size (45.7%). Most of the patients admitted under medical branch developed bedsores more often than surgical branch and appeared after admission (77.1%) with 15-30 days hospital stay (31.4%). This study has illuminated our path forward in improving patient care and preventing pressure ulcer development among patients admitted to our medical and surgical Intensive Care Units in our Rural Tertiary hospital. The findings have paved the way for targeted interventions, underlining our commitment to raising the standard of care for our critically ill patients.

Estrategias de analgesia, sedación, delirium y confort individualizado en el enfermo crítico: Una revisión narrativa

This group is a product of the collaboration agreement signed by Sociedad de Medicina Intensiva de Madrid (SOMIAMA) and Sociedad de Anestesiología, Reanimación y Terapéutica del Dolor de Madrid (SAR MADRID), under which the organisations agreed to create joint working groups to improve critical patient care.Pain, discomfort, agitation, and delirium cause suffering, delay discharge, and can lead to serious complications in patients admitted to medical and surgical critical care units and post-anaesthesia care units. The main objectives in this type of unit include: Ensuring the comfort of patients suffering or recovering from a critical illness. Avoiding complications associated with the measures, particularly pharmacological, taken to ensure that comfort.

Medication safety climate: managing high-alert medication administration and errors among nurses in intensive and critical care units

Background High-alert medications are drugs that may lead to serious harm when they are wrongly administered to patients. Safe medication administration is the crucial role of nursing staff. Aim This study aims to investigate relationships of medication safety climate and nurses’ knowledge about high-alert medications with managing their administration and errors. Design A cross-sectional correlational study. Sample A convenience sample of 300 nurses. Setting Surgical intensive and critical care units. Tools Self-report questionnaires about medication safety climate, nurses’ knowledge and administration competency of high-alert medications and high-alert medication error experience as well as high-alert medication practice observational tool. Results The nurses’ knowledge, practice, and competencies about administering high-alert medications were below sufficient standards. They described medication safety climate at undesirable levels and reported encountering high-alert medication administration errors of about 25.3%. The medication safety climate and nurses’ knowledge of high-alert medication were associated with and affected nurses’ practice (r =.43; r =.31, respectively) and competencies (r=.32; r=.23, respectively), during administration of high-alert medications. Insufficient levels of medication safety climate and nurses’ knowledge and administration practice of high-medications were the predictive factors of incidence of high-alert medication administration errors among nurses (r =-.18; r =-.32; r = -.21, respectively). Conclusion Sufficient nurses’ knowledge and medication safety climate were deemed to be one of the most important measures to improve managing high-alert medication administration and reduce the occurrence of high-alert medication administration errors. Recommendation The hospital management should implement medication safety in its clinical standards and plan for promoting the safe administration of high-alert medications.

The Pattern and Outcome of Obstetric Patients Getting Admitted in Surgical Critical Care Unit of Rural Tertiary Care Unit

Background: Obstetric patients requiring critical care are a significant and growing concern worldwide, particularly in lowand middle-income countries. While obstetric patients are generally young and healthy, they can experience life-threatening complications during pregnancy, delivery, or postpartum period. Surgical critical care units (SCCUs) are often the first-line of care for critically ill obstetric patients, providing specialized care for complex surgical cases. Aims and objectives: This study was conducted to know the pattern and outcome of obstetric patients getting admitted in surgical critical care unit of our rural tertiary care unit. Methodology: In this retrospective study, and we have collected the data from the records of one year duration, starting from 1st November 2021 to 30th September 2022 and statistically assessed. Results: A total of 54 patients were admitted in the study period and most of the patients were aged between 18-25 years. There was equal number of admissions noted between primi and multi gravida. 91% of the patients got admitted in the ICU post LSCS. 72% of the patients had PIH, 39% of the patients received blood and 44% received blood products during ICU care. Nearly 41% had to get ventilator support during the course of the treatment. Average number of the stay in ICU was 3 days. There were 15% of the patients who couldn’t survive. Conclusion: Despite being a tertiary care rural hospital with limited resources, we were able to effectively manage critical obstetric patients.

The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action.

Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.

ASSESSMENT OF INTRA-ABDOMINAL HYPERTENSION AND ITS CORRELATION TO ORGAN FAILURE IN PATIENTS ADMITTED TO SURGICAL CRITICAL CARE UNIT

Background: Intra-abdominal hypertension (IAH) is the sustained elevation in intra-abdominal pressure (IAP) ≥ 12 mmHg. It has been shown to affect various organs of the body, causing derangement and dysfunction of different organ systems. However the problem remains unappreciated and this study was done to assess the problem of IAH among the ICU patients in our own environment and also to understand the signicance of elevated IAPas a marker of organ dysfunction. Objectives Ÿ To assess prevalence of intra-abdominal hypertension in a surgical critical care unit of a tertiary care hospital Ÿ To correlate intra-abdominal hypertension with organ failure in patients admitted to surgical critical care unit. Methodology: This was an observational prospective study done among 75 patients who were admitted for a minimum period of 3 consecutive days in the surgical critical care unit of JMMC&RI, Thrissur from April 2016 to March 2017. The IAP was measured thrice daily, and SOFAscore daily for 3 consecutive days. The results were analyzed using SPSS software. Results: The prevalence of IAH in patients admitted to surgical critical care unit is 46.7% based on mean IAPand 78.7% based on maximum IAP. The mean IAPand SOFAscore were 11.40 ± 4.37 mmHg and 4.55 ± 2.72 respectively. 34.7 % of patients had organ failure. 51.4% of patients with IAH had organ failure. The mortality was 22.9% in population with IAH. The mean ICU stay and hospital stay in patients with IAH were 6.77 ± 4.98 and 13.37 ± 8.09 days respectively Conclusion:The prevalence of IAH in patients admitted to surgical critical care unit is 46.7%. There is a signicantly higher incidence of organ failure, longer ICU stay and hospital stay in patients with IAH. No signicant association was found between IAH and mortality.

Melatonin intervention to prevent delirium in hospitalized patients: A meta-analysis.

BACKGROUNDEvaluation of the effectiveness of melatonin is necessary to prevent the development of delirium in hospitalized patients. Melatonin (N-acetyl-5-methoxytryptamine) is a hormone produced by the pineal gland of the brain from the amino acid tryptophan. Synthetic melatonin supplements have been used for various medical conditions, especially sleep-related diseases, and have proved to be successful.AIMTo determine the effect of melatonin on the prevention of delirium in hospitalized patients.METHODSA literature search of the CNKI, Wanfang Database, VIP Database, China Biomedical Literature Database, PubMed, Embase, Cochrane Library, Web of Science, and other databases was conducted. The CNKI, Wanfang Database, VIP Database (VIP), and China Biomedical Literature Database were searched for Chinese studies, and PubMed, Embase, Cochrane Library, Web of Science and other databases were searched for international studies. It will be established in June 2021 in a randomized controlled trial (RCT) whether melatonin treatment for 6 mo prevents delirium in hospitalized patients. Literature screening, quality review, and data extraction were carried out using the Cochrane Manual 5.1.0 systematic evaluation method, and Stata 15.0 software and Review Manager 5.3 were used for meta-analysis and processing. RESULTSA total of 18 new RCT articles and 18 experimental subjects were identified. The results of the meta-analysis showed that following the occurrence of delirium, melatonin reduced the incidence of delirium in patients (RR = 0.69, 95%CI: 0.60-0.80), which is of significance, but heterogeneity was significant I2 = 62%. Subgroup analysis was performed to examine the source of heterogeneity, and it was found that different patient types were the source of heterogeneity; the research on subgroup analysis was of high quality and homogeneous. To determine the reliability and robustness of the research results, a sensitivity analysis was carried out. The results showed that after excluding individual studies one by one, the effect size was still within 95%CI, which strengthened the reliability of the original meta-analysis results. Melatonin has a significant preventive effect on delirium in hospitalized medical patients [RR = 0.60, 95%CI: 0.47-0.76), P < 0.001].CONCLUSIONMelatonin can reduce the rate of delirium in medical patients, and the role of melatonin in reducing the incidence of delirium in surgical patients and critical care unit patients requires further study.

An in-depth look at ventilator-associated pneumonia in trauma patients and efforts to increase bundle compliance, education and documentation in a surgical trauma critical care unit

BackgroundVentilator-associated pneumonia (VAP) is considered the most common hospital acquired infection seen in critical care settings and leading cause of death in Intensive Care Units (ICU). The objective of this study was to assess whether specimen collection impacted diagnosis and if implementation of a VAP bundle would decrease rates at our center. MethodsThis single center study design is a retrospective chart review from 2017 to 2020 utilizing the electronic medical record. A pre-/postintervention comparison was performed following implementation of a unit wide VAP bundle and nursing education. Descriptive statistics and continuous variables were analyzed with independent group t -tests, and categorical variables were analyzed with chi-squared tests. ResultsVentilator-associated pneumonia rates decreased in the postimplementation time (20.8%, n = 74 vs 12.2%, n = 15; P = .03). There were no significant differences in the patient profile of those who acquired VAP (ie, males 79.7% vs 86.7%, blunt injuries 63.5% vs 86.7% and severity scores 24.8 vs 25.1, pre vs postimplementation, respectively, all P-values greater than .05). Discussion/ConclusionsReduction in VAP rates were achieved by implementing a standardized, evidence based, prevention protocol. Further research is warranted as studies have noted that patients requiring mechanical ventilation are at greater risk for VAP than other ICU patients due to the nature of their injuries and increased risk of prolonged mechanical ventilation ≥ 21 days.

Pressure Injury Prevention for Complex Cardiovascular Patients in the Operating Room and Intensive Care Unit: A Quality Improvement Project.

PURPOSE:The purpose of our project was to examine the effect of an alternating pressure (AP) overlay on hospital-acquired pressure injury (HAPI) in high-risk cardiovascular surgical patients.PARTICIPANTS AND SETTING:This quality improvement (QI) initiative was conducted in a core group of 8 cardiovascular operating room (OR) suites and 1 cardiovascular surgical critical intensive care unit (ICU) in a large Indiana-based academic hospital. The sample comprised adult patients who underwent complex cardiovascular surgical procedures and those in the cardiovascular surgical ICU with extracorporeal membrane oxygenation (ECMO), ventricular assistive device (VAD), and undergoing heart and/or lung transplant, or open chest procedures.APPROACH:The AP overlay was placed on OR cardiovascular foam surfaces and on selected ICU support surfaces for patients who met inclusion criteria. We used a pre/postcomparative QI design to assess outcomes including OR-related HAPI rates, ICU aggregate unit HAPI data, related costs, and staff satisfaction during the 3-month project period.OUTCOMES:Operating room-related HAPIs were reduced from 8/71 (11%) preintervention to 0/147 (0%) postintervention (P = .008), resulting in a cost avoidance of $323,048 and positive staff satisfaction (mean = 3.85; 1- to 4-point Likert scale). No adverse outcomes occurred. Although not significant, ICU HAPI rates decreased from 10 to 7 pre/postintervention (P = .29), demonstrating a 14% HAPI reduction with a cost avoidance of $121,143. The ICU incidence density decreased from 3.57 to 3.24; however, there was no decrease in ICU monthly unit prevalence. Critical care staff satisfaction was positive (mean = 2.95; 1- to 4-point Likert scale) with most staff members preferring the AP overlay to a fluid immersion surface. A cost savings of 48% (AP overlay vs fluid immersion rental) was identified in the ICU.IMPLICATIONS FOR PRACTICE:We achieved fewer HAPIs and reduced costs and observed positive staff satisfaction, along with no adverse events with the use of the AP overlay. Further research is needed to determine the safety and efficacy of this device for this pressure injury prevention option for immobile patients in both the OR and the ICU.

Pathophysiology, Evaluation, and Management of Metabolic Alkalosis.

Metabolic alkalosis is an increase in blood pH to >7.45 due to a primary increase in serum bicarbonate (HCO3−). Metabolic alkalosis results from alkali accumulation or acid loss, and it is associated with a secondary increase in carbon dioxide arterial pressure (PaCO2). Metabolic alkalosis is a common acid-base disorder, especially in critically ill patients. The pathogenesis of chronic metabolic alkalosis includes two derangements, generation of metabolic alkalosis via gain of alkali or loss of acid and maintenance of metabolic alkalosis by increased tubular HCO3− reabsorption (failure of the kidneys to excrete excess alkali). Metabolic alkalosis is the most common acid-base disorder in hospitalized patients, particularly in the surgical critical care unit. Mortality increases as pH increases.

Prone ventilation as treatment of acute respiratory distress syndrome related to COVID-19.

Prone ventilation refers to the delivery of mechanical ventilation with the patient lying in the prone position. The improvement of oxygenation during prone ventilation is multifactorial, but occurs mainly by reducing lung compression and improving lung perfusion. CT imaging modeling data demonstrated that the asymmetry of lung shape leads to a greater induced pleural pressure gravity gradient when supine as compared to prone positioning. Although proning is indicated in patients with severe ARDS who are not responding to other ventilator modalities, this technique has moved away from a salvage therapy for refractory hypoxemia to an upfront lung-protective strategy intended to improve survival in severe ARDS, especially due to the current COVID-19 pandemic. In view of different roles, we surgeons had to take during the COVID-19 pandemic, it is of importance to learn how to implement this therapeutic measure, especially in a surgical critical care unit setting. As such, this article aims to review the physiological principles and effects of the prone ventilation, positioning, as well as its contraindications and complications.

Measuring Empiric Antibiotic Spectrum Patterns Across Space and Time

Background: Quantitative evaluation of antibiotic spectrum is an important, underutilized metric in measuring antibiotic use (AU) and may assist antimicrobial stewards in identifying targets and strategy for intervention. We evaluated the spectrum of initial antibiotic choices by hospital location, day of the week, and time of day to determine whether these factors may be associated with broad-spectrum antibiotic choices. Methods: We identified all admissions with antibiotic exposure in medical and surgical wards and critical care units in a tertiary academic medical center between July 1, 2014, and July 1, 2019. The antibiotic spectrum index (ASI), proposed by Gerber et al, is a numeric score based on the number of pathogens covered by a particular agent. We defined ASI for initial antibiotic choice as follows: ASI for each unique antibiotic administered within 24 hours of the first antibiotic administration was summed and assigned to the administration time of the first dose. We categorized time into 4 distinct categories: weekday days (Monday–Friday, 7 a.m.–7 p.m.), weekday nights, weekend days, and weekend nights. Weekend time began 7 p.m. Friday and ended 7 a.m. Monday. We constructed heatmaps stratified by hospital location. Mann-Whitney U tests were applied to evaluate differences in the distributions of ASI using weekday days as a reference. Results: Data included 90,455 unique antibiotic admissions with initial antibiotic starts in medical and surgical wards and critical care units. Patterns of ASI for initial antibiotic choice varied between unit locations and time (Figs. 1 and 2). Mean and median ASIs for initial antibiotic choices were higher for medical ward and medical ICUs than for surgical wards and surgical ICUs. Initial antibiotic choices had higher ASIs during overnight hours for all units except the surgical ICU. Notable differences in ASIs were identified between weekday and weekend prescribing for surgical units, whereas medical units demonstrated less extreme differences. Conclusion: We observed a “weekend effect” across hospital units; the most extreme occurred in surgical wards. This observation may be due to differences in patient volume and rounding patterns. For example, hospitalist and critical care units have 7-day schedules, whereas surgical wards are highly influenced by operating room schedules. Antimicrobial stewardship teams may use these data to identify strategies targeting the most opportune time and place to intervene on the spectrum of initial antibiotic choice.Funding: NoneDisclosures: None

The Validity of SOFA Score to Predict Mortality in Adult Patients with Cardiogenic Shock on Venoarterial Extracorporeal Membrane Oxygenation.

Background Venoarterial ECMO is increasingly used in resuscitation of adult patients with cardiogenic shock with variable mortality reports worldwide. Our objectives were to study the variables associated with hospital mortality in adult patients supported with VA-ECMO and to determine the validity of repeated assessments of those patients by the Sequential Organ Failure Assessment (SOFA) score for prediction of hospital mortality. We retrospectively studied adult patients admitted to the cardiac surgical critical care unit with cardiogenic shock supported with VA-ECMO from January 2015 to August 2019 in our tertiary care hospital. Results One hundred and six patients supported with VA-ECMO were included in our study with in-hospital mortality of 56.6%. The mean age of studied patients was 40.2 ± 14.4 years, and the patients were mostly males (69.8%) with a mean BMI of 26.5 ± 7 without statistically significant differences between survivors and nonsurvivors. Presence of CKD, chronic atrial fibrillation, and cardiac surgeries was significantly more frequent in the nonsurvivors group. The nonsurvivors had more frequent AKI (p < 0.001), more haemodialysis use (p < 0.001), more gastrointestinal bleeding (p = 0.039), more ICH (p = 0.006), and fewer ICU days (p = 0.002) compared to the survivors group. The mean peak blood lactate level was 11 ± 3 vs 16.7 ± 3.3, p < 0.001, and the mean lactate level after 24 hours of ECMO initiation was 2.2 ± 0.9 vs 7.9 ± 5.7, p < 0.001, in the survivors and nonsurvivors, respectively. Initial SOFA score ≥13 measured upon ICU admission had a 85% sensitivity and 73.9% specificity for predicting hospital mortality [AUROC = 0.862, 95% CI: 0.791–0.932; p < 0.001] with 81% PPV, 79.1% NPV, and 80.2% accuracy while SOFA score ≥13 at day 3 had 100% sensitivity and 91.3% specificity for predicting mortality with 93.8% PPV, 100% NPV, and 96.2% accuracy [AUROC = 0.995, 95% CI: 0.986–1; p < 0.001]. The ∆1 SOFA (3-1) ≥2 had 95% sensitivity and 93.5% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.913–1; p < 0.001] with 95% PPV, 93.5% NPV, and 94.3% accuracy. SOFA score ≥15 at day 5 had 98% sensitivity and 100% specificity for predicting mortality with 99% accuracy [AUROC = 0.994, 95% CI: 0.982–1; p < 0.001]. The ∆2 SOFA (5-1) ≥2 had 90% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.909–1; p < 0.001] with 97.8% PPV, 90% NPV, and 94.8% accuracy. Multivariable regression analysis revealed that increasing ∆1 SOFA score (OR = 2.506, 95% CI: 1.681–3.735, p < 0.001) and increasing blood lactate level (OR = 1.388, 95% CI: 1.015–1.898, p = 0.04) were significantly associated with hospital mortality after VA-ECMO support for adults with cardiogenic shock. Conclusion The use of VA-ECMO in adult patients with cardiogenic shock is still associated with high mortality. Serial evaluation of those patients with SOFA score during the first few days of ECMO support is a good predictor of hospital mortality. Increase in SOFA score after 48 hours and hyperlactataemia are significantly associated with increased hospital mortality.

Hospital-Acquired Pressure Injury Development Among Surgical Critical Care Patients Admitted With Community-Acquired Pressure Injury: A Retrospective Cohort Study.

Community-acquired pressure injuries (CAPIs) are present among approximately 3% to 8% of patients admitted to acute care hospitals. In the critical care population, little is known about hospital-acquired pressure injury (HAPI) development among patients with CAPIs because most studies exclude patients with CAPIs. The purpose of our study was to determine the incidence of HAPI development and the associated risk factors among surgical critical care patients with CAPIs. Retrospective cohort study. We used electronic health record data from adult critical care patients admitted to the surgical and cardiovascular surgical intensive care units (ICUs) at a level 1 trauma center and academic medical center between 2014 and 2018. Univariate analysis was used to compare patients with CAPIs who developed a HAPI and those who did not, as well as logistic regression analysis to identify independent risk factors for HAPIs among patients with CAPIs. Among 5101 patients admitted to 2 surgical critical care units, 167 (3%) patients were admitted with CAPIs. Hospital-acquired pressure injuries were 4 times more common among patients with CAPIs compared to patients without CAPIs. Among the 167 patients with CAPIs, 47 patients (28%) went on to also develop a HAPI, whereas in the 4934 patients without CAPIs, 352 patients (7%) went on to develop a HAPI. Findings from the multivariate logistic regression analysis (n = 151) showed that decreased serum albumin (odds ratio [OR] = 0.47; 95% confidence interval [CI], 0.25-0.85; P = .02) and excessively dry skin (OR = 2.6; 95% CI, 1.1-6.22; P = .03) were independent predictors of HAPI development among patients admitted with CAPIs. Results from our study show that patients with CAPIs are at high risk for developing a HAPI, particularly among patients with decreased serum albumin or excessively dry skin. Patients with excessively dry skin may benefit from the application of skin moisturizers.

Comparison of the Automated Pediatric Logistic Organ Dysfunction-2 Versus Manual Pediatric Logistic Organ Dysfunction-2 Score for Critically Ill Children.

The Pediatric Logistic Organ Dysfunction-2 is a validated score that quantifies organ dysfunction severity and requires complex data collection that is time-consuming and subject to errors. We hypothesized that a computer algorithm that automatically collects and calculates the Pediatric Logistic Organ Dysfunction-2 (aPELOD-2) score would be valid, fast and at least as accurate as a manual approach (mPELOD-2). Retrospective cohort study. Single center tertiary medical and surgical pediatric critical care unit (Sainte-Justine Hospital, Montreal, Canada). Critically ill children participating in four clinical studies between January 2013 and August 2018, a period during which mPELOD-2 data were manually collected. None. The aPELOD-2 was calculated for all consecutive admissions between 2013 and 2018 (n = 5,279) and had a good survival discrimination with an area under the receiver operating characteristic curve of 0.84 (95% CI, 0.81-0.88). We also collected data from four single-center studies in which mPELOD-2 was calculated (n = 796, 57% medical, 43% surgical) and compared these measurements to those of the aPELOD-2. For those patients, median age was 15 months (interquartile range, 3-73 mo), median ICU stay was 5 days (interquartile range, 3-9 d), mortality was 3.9% (n = 28). The intraclass correlation coefficient between mPELOD-2 and aPELOD-2 was 0.75 (95% CI, 0.73-0.77). The Bland-Altman showed a bias of 1.9 (95% CI, 1.7-2) and limits of agreement of -3.1 (95% CI, -3.4 to -2.8) to 6.8 (95% CI, 6.5-7.2). The highest agreement (Cohen's Kappa) of the Pediatric Logistic Organ Dysfunction-2 components was noted for lactate level (0.88), invasive ventilation (0.86), and creatinine level (0.82) and the lowest for the Glasgow Coma Scale (0.52). The proportion of patients with multiple organ dysfunction syndrome was higher for aPELOD-2 (78%) than mPELOD-2 (72%; p = 0.002). The aPELOD-2 had a better survival discrimination (area under the receiver operating characteristic curve, 0.81; 95% CI, 0.72-0.90) over mPELOD-2 (area under the receiver operating characteristic curve, 0.70; 95% CI, 0.59-0.82; p = 0.01). We successfully created a freely available automatic algorithm to calculate the Pediatric Logistic Organ Dysfunction-2 score that is less labor intensive and has better survival discrimination than the manual calculation. Use of an automated system could greatly facilitate integration of the Pediatric Logistic Organ Dysfunction-2 score at the bedside and within clinical decision support systems.

Validation of acute kidney injury prediction scores in critically ill patients.

Prediction of acute kidney injury (AKI) in critically ill patients allows prompt intervention that improves outcome. We aimed for external validation of two AKI prediction scores that can be bedside calculated. A prospective observational study included patients admitted to medical and surgical critical care units. Performance of two AKI prediction scores, Malhotra score and acute kidney injury prediction score (APS), was assessed for their ability to predict AKI. The best cutoff point for each score was determined by Youden index. Area under the receiving operation characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were used to assess performance of each score. Univariate and multivariate regression analyses were done to detect the predictability of AKI. Goodness-of-fit and kappa Cohen agreement tests were done to show whether the expected score results fit well and agree with the observed results. AKI prevalence was 37.6%. The best cutoff values were 5 and 4 for Malhotra score and APS, respectively. Area under the curve for Malhotra 5 was 0.712 and for APS 4 was 0.652 with nearly similar sensitivity and specificity. Regression analysis demonstrated that Malhotra 5 was the independent predictor of AKI. Goodness-of-fit test showed significant results denoting lack of fit between the scores and the actual results. Kappa test showed moderate agreement for Malhotra 5 and fair agreement for APS 4. Both scores showed moderate performance for AKI prediction. Malhotra 5 showed better performance compared to APS 4. Multicenter international study is warranted to develop a universal model that can predict AKI in critically ill patients.