Surgical Intensive Care Unit Length Of Stay Research Articles

Evaluation of Plasma-Lyte Versus Lactated Ringer's in Surgical Intensive Care Unit Trauma Patients as Fluid Resuscitation.

In critically ill patients, fluid resuscitation with balanced crystalloids close to plasma osmolarity have a lower risk of electrolyte imbalances and demonstrated better clinical outcomes compared to normal saline (NS). While lactated ringer's (LR) has shown benefit over NS, plasma-lyte (PL) with a higher osmolarity and different electrolyte formulation is hypothesized to be superior. We performed a retrospective observational cohort study over 37 months at a tertiary hospital. Inclusion criteria were hospitalization in the surgical intensive care unit (SICU), trauma indication, ≥18 years old, and received either PL or LR. All PL administrations and every fifth patient with LR as resuscitation were included in order to match the sample size in each group. Primary outcomes were SICU length of stay (LOS), hospital LOS, and mortality. Secondary outcomes were biomarker changes from baseline. There were 113 patients in both PL and LR groups. The PL arm had higher APACHE II scores (16 vs 13, P = .033) and were more likely ventilated (39.3% vs 20.4%, P = .002) compared to LR. Median hospital LOS (12.0 vs 8.0, P < .001) and SICU LOS (6.0 vs 3.0, P < .001) are significantly longer in PL group compared to the LR group. However, there was no difference in in-hospital mortality (5.3% vs 3.5% P = .519) and SICU mortality (9.7% vs 5.3%, P > .208) between PL and LR. Overall, PL use was associated with prolonged hospital and SICU LOS. PL use did not demonstrate mortality benefit. However, patients were more critically ill in PL group based on higher APACHE II scores and higher rates of mechanical ventilation, which could be contributing to these unfavorable outcomes.

Outcomes When Using Adjunct Dexmedetomidine with Propofol Sedation in Mechanically Ventilated Surgical Intensive Care Patients

Objective: Compare the duration of mechanical ventilation between patients receiving sedation with continuous infusions of propofol alone or combination with the use of dexmedetomidine and propofol. Design: Retrospective, propensity matched (1:1) cohort study, employing eight variables chosen a priori for matching. Timing of exposure to dexmedetomidine initiation was incorporated into a matching algorithm. Setting: Level 1, university-based, 32-bed, adult, mixed trauma and surgical intensive care unit (SICU). Continuous sedation was delivered according to a protocol methodology with daily sedation vacation and spontaneous breathing trials. Choice of sedation agent was physician directed. Patients: Between 2010 and 2014, 149 SICU patients receiving mechanical ventilation for >24 h received dexmedetomidine with propofol. Propensity matching resulted in 143 pair cohorts. Interventions: Dexmedetomidine with propofol or propofol alone. Measurements and Main Results: There was no statistical difference in SICU length of stay (LOS), with a median absolute difference of 5.3 h for propofol alone group (p = 0.43). The SICU mortality was not statistically different (RR = 1.002, p = 0.88). Examining a 14-day period post-treatment with dexmedetomidine, on any given day (excluding days 1 and 14), dexmedetomidine with propofol-treated patients had a 0.5% to 22.5% greater likelihood of being delirious (CAM-ICU positive). In addition, dexmedetomidine with propofol-treated patients had a 4.5% to 18.8% higher likelihood of being above the target sedation score (more agitated) compared to propofol-alone patients. Conclusions: In this propensity matched cohort study, adjunct use of dexmedetomidine to propofol did not show a statistically significant reduction with respect to mechanical ventilation (MV) duration, SICU LOS, or SICU mortality, despite a trend toward receiving fewer hours of propofol. There was no evidence that dexmedetomidine with propofol improved sedation scores or reduced delirium.

Subjective Global Assessment Can Be Performed in Critically Ill Surgical Patients as a Predictor of Poor Clinical Outcomes.

There is limited evidence on the applicability of subjective global assessment (SGA) in critically ill patients, despite its good performance in diagnosing undernutrition in clinical and surgical patients. Our aim was to evaluate the association between SGA and anthropometric measures and the performance of SGA in predicting clinical outcomes and mortality in critically ill surgical patients. This observational prospective study was carried out with patients admitted to the surgical intensive care unit (SICU) of a Brazilian hospital. Nutrition assessment comprised anthropometric measures (weight and height for body mass index [BMI] calculation, mid-arm circumference [MAC] and calf circumference [CC]), and the SGA. Patients were followed up until hospital discharge for measurement of the following outcomes: length of stay (LOS), SICU LOS, and hospital mortality. This study included 76 surgical patients admitted to an SICU (64.9% males; 87% white ethnicity; mean age, 60.36 ± 16.24 years). According to the SGA, the prevalence of undernutrition was 60.5% (moderate undernutrition = 38.2%; severe undernutrition = 22.4%), and well-nourished 39.0%. Patients with severe undernutrition had lower values of current weight, BMI, MAC, and CC compared with well-nourished patients. The presence of undernutrition increased the risk of LOS >31 days by 2.57 (1.38-4.77) times, but it was not associated with mortality. Patients with severe undernutrition had lower current weight, BMI, MAC, and CC compared with well-nourished patients. Undernutrition did not increase the risk of death; however, it did increase the relative risk for a longer hospital stay by 2.5.

Sooner is better: use of a real-time automated bedside dashboard improves sepsis care

BackgroundMinimizing the interval between diagnosis of sepsis and administration of antibiotics improves patient outcomes. We hypothesized that a commercially available bedside clinical surveillance visualization system (BSV) would hasten antibiotic administration and decrease length of stay (LOS) in surgical intensive care unit (SICU) patients. MethodsA BSV, integrated with the electronic medical record and displayed at bedside, was implemented in our SICU in July 2016. A visual sepsis screen score (SSS) was added in July 2017. All patients admitted to SICU beds with bedside displays equipped with a BSV were analyzed to determine mean SSS, maximum SSS, time from positive SSS to antibiotic administration, SICU LOS, and mortality. ResultsDuring the study period, 232 patients were admitted to beds equipped with the clinical surveillance visualization system. Thirty patients demonstrated positive SSS followed by confirmed sepsis (23 Pre-SSS versus 7 Post-SSS). Mean and maximum SSS were similar. Time from positive SSS to antibiotic administration was decreased in patients with a visual SSS (55.3 ± 15.5 h versus 16.2 ± 9.2 h; P < 0.05). ICU and hospital LOS was also decreased (P < 0.01). ConclusionsImplementation of a visual SSS into a BSV led to a decreased time interval between the positive SSS and administration of antibiotics and was associated with shorter SICU and hospital LOS. Integration of a visual decision support system may help providers adhere to Surviving Sepsis Guidelines.

Effects of Heart Bypass Surgery on Plasma Aβ40 and Aβ42 Levels in Infants and Young Children.

Accumulation of β-amyloid (Aβ) plaques is a pathological hallmark of Alzheimer disease. Aβ levels in animals and adults were reported to be associated with postoperative cognitive dysfunction (POCD). Our goal was to determine the plasma levels of Aβ in infants and young children after cardiac surgery with cardiopulmonary bypass (CPB).Forty-two infants and young children aged from 1 to 35 months undergoing cardiac surgery with general anesthetics were prospectively enrolled from January to June 2014 at a tertiary medical center. Perioperative plasma samples were obtained, and Aβ42 and Aβ40 levels were measured using ELISA. Other clinical characteristics of the patients were also recorded.Plasma levels of Aβ42 and Aβ40 decreased dramatically 2 hours after surgery and remained significantly lower 6 hours after operation. Baseline Aβ42 level correlated significantly with surgical intensive care unit (SICU) length of stay (LOS) and was an independent predictor for SICU LOS on multivariate analysis.Cardiac surgery with CPB decreases plasma Aβ levels. Plasma levels of Aβ42 and Aβ40 might be used as novel biomarkers for predicting outcomes in the patient population.

Delirium prevention program in the surgical intensive care unit improved the outcomes of older adults

BackgroundHospital-acquired delirium is a known risk factor for negative outcomes in patients admitted to the surgical intensive care unit (SICU). Outcomes worsen as the duration of delirium increases. The purpose of this study was to evaluate the efficacy of a delirium prevention program and determine whether it decreased the incidence and duration of hospital-acquired delirium in older adults (age >50 y) admitted to the SICU. MethodsA prospective pre- or post-intervention cohort study was done at an academic level I trauma center. Older adults admitted to the SICU were enrolled in a delirium prevention program. Those with traumatic brain injury, dementia, or 0 d of obtainable delirium status were excluded from analysis. The intervention consisted of multidisciplinary education, a pharmacologic protocol to limit medications associated with delirium, and a nonpharmacologic sleep enhancement protocol. Primary outcomes were incidence of delirium and delirium-free days/30. Secondary outcomes were ventilator-free days/30, SICU length of stay (LOS), daily and cumulative doses of opioids (milligram, morphine equivalents) and benzodiazepines (milligram, lorazepam equivalents), and time spent in severe pain (greater than or equal to 6 on a scale of 1 - 10). Delirium was measured using the Confusion Assessment Method for the ICU. Data were analyzed using Chi-squared and Wilcoxon rank sum analysis. ResultsOf 624 patients admitted to the SICU, 123 met inclusion criteria: 57 preintervention (3/12–6/12) and 66 postintervention (7/12–3/13). Cohorts were similar in age, gender, ratio of trauma patients, and Injury Severity Score. Postintervention, older adults experienced delirium at the same incidence (pre 47% versus 58%, P = 0.26), but for a significantly decreased duration as indicated by an increase in delirium-free days/30 (pre 24 versus 27, P = 0.002). After intervention, older adults with delirium had more vent-free days (pre 21 versus 25, P = 0.03), shorter SICU LOS (pre 13 [median 12] versus 7 [median 6], P = 0.01) and were less likely to be treated with benzodiazepines (pre 85% versus 63%, P = 0.05) with a lower daily dose when prescribed (pre 5.7 versus 3.6 mg, P = 0.04). After intervention, all older adults spent less time in pain (pre 4.7 versus 3.1 h, P = 0.02), received less total opioids (pre 401 versus 260 mg, P = 0.01), and had shorter SICU LOS (pre 9 [median 5] versus 6 [median 4], P = 0.04). ConclusionsAlthough delirium prevention continues to be a challenge, this study successfully decreased the duration of delirium for older adults admitted to the SICU. Our simple, cost-effective program led to improved pain and sedation outcomes. Older adults with delirium spent less time on the ventilator and all patients spent less time in the SICU.

A Nutrition Algorithm Incorporating Early Initiation of Nutrition With Higher Feeding Rates, Percentage of Gastric Residual Volume, Small-Bowel Feedings, and Compensatory Nighttime Feeds Leads to Reduced Energy Deficit in Critically Ill Patients

Background/Objective. A discrepancy often emerges between nutritional goals and actual delivery. This study assesses the relationship between energy balance and length of stay (LOS) in surgical intensive care unit (SICU) patients. SICU patients are frequently catabolic and at risk of underfeeding. We set forth to identify if a nutritional algorithm will improve energy delivery and outcomes. Methods. A prospective observational study conducted in surgical critical care patients was performed. After implementation of a nutrition algorithm; demographic data, initiation of feeding, acquiring caloric goal, caloric deficit, LOS, and mortality were recorded. Cumulative energy balance was calculated as energy delivery minus daily target. Data are presented as mean ± standard deviation. Results. In all, 100 patients aged 66 ± 17 years (45% female and 55% male) admitted to the SICU were evaluated. All were nutritionally compromised, with 72% being NPO (nothing by mouth), 9% orally fed, and 9% enterally fed. SICU LOS was 4.9 ± 10.6 days; 60-day mortality was 3%; and time to goal feeding was 13 ± 10 hours. Mean daily energy delivery was 1459 ± 268 kcal/d. Cumulative energy balance was between −6401 ± 6404 kcal, with 12 patients having a &gt;10 000 kcal deficit, 3 patients a &gt;20 000 kcal deficit, and 1 patient a &gt;30 000 kcal deficit. Conclusions. A nutritional algorithm will improve energy delivery and outcomes in critically ill patients. Accumulation of caloric deficit &gt;5000 kcal is associated with increased SICU LOS and hospital LOS. Clinical implications. Nutritional algorithms and caloric deficit calculations are an underused critical care tool. The nutritional algorithm presented allows faster attainment of caloric goals, shorter LOS, and improvement in outcome.

Global Muscle Strength But Not Grip Strength Predicts Mortality and Length of Stay in a General Population in a Surgical Intensive Care Unit

Paresis acquired in the intensive care unit (ICU) is common in patients who are critically ill and independently predicts mortality and morbidity. Manual muscle testing (MMT) and handgrip dynamometry assessments have been used to evaluate muscle weakness in patients in a medical ICU, but similar data for patients in a surgical ICU (SICU) are limited. The purpose of this study was to evaluate the predictive value of strength measured by MMT and handgrip dynamometry at ICU admission for in-hospital mortality, SICU length of stay (LOS), hospital LOS, and duration of mechanical ventilation. This investigation was a prospective, observational study. One hundred ten patients were screened for eligibility for testing in the SICU of a large, academic medical center. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, diagnoses, and laboratory data were collected. Measurements were obtained by MMT quantified with the sum (total) score on the Medical Research Council Scale and by handgrip dynamometry. Outcome data, including in-hospital mortality, SICU LOS, hospital LOS, and duration of mechanical ventilation, were collected for all participants. One hundred seven participants were eligible for testing; 89% were tested successfully at a median of 3 days (25th-75th percentiles=3-6 days) after admission. Sedation was the most frequent barrier to testing (70.6%). Manual muscle testing was identified as an independent predictor of mortality, SICU LOS, hospital LOS, and duration of mechanical ventilation. Grip strength was not independently associated with these outcomes. This study did not address whether muscle weakness translates to functional outcome impairment. In contrast to handgrip strength, MMT reliably predicted in-hospital mortality, duration of mechanical ventilation, SICU LOS, and hospital LOS.

Geriatric trauma service

Trauma centers nationwide have been experiencing an increase in their elderly trauma patients because of an ever growing elderly population within the United States. Many studies have demonstrated the physiologic differences between an older trauma patient versus a younger trauma patient. Coupling these differences with their coexisting medical comorbidities, makes caring for this population extremely challenging. To meet these challenges, we organized a geriatric trauma unit specifically designed with a multidisciplinary approach to take a more aggressive stance to the care of the geriatric trauma patient. We created a geriatric trauma unit at our Level II trauma facility, called the G-60 unit. This unit opened for admission in August 2009. Inclusion criteria included all trauma patients older than 60 years. Data were abstracted from our G-60 unit from the period of August 2009 to July 2010. We compared these data to a similar patient population (control group) from January 2008 to December 2008. Our Trauma Data Bank yielded 673 patients for the above queried time period. The G-60 group contained 393 patients, while the control group had 280 patients. A decrease was seen among the G-60 group in all categories: average emergency department length of stay (LOS), average emergency department to operating room time, average surgical intensive care unit LOS, and average hospital LOS. A 3.8% mortality rate was found in the G-60 group compared with a 5.7% mortality rate in the control group. Our analysis also showed rate of 0% pneumonia, 1.3% respiratory failure, and 1.5% urinary tract infection in the G-6O group, while the control group had a rate of 1.8% pneumonia, 6.8% respiratory failure, and 3.9% urinary tract infection. Our data from the 1-year experience of our G-60 unit show that addressing the specific needs of elderly trauma patients will lead to better outcomes.

Methicillin-resistant staphylococcus aureus screening and eradication in the surgical intensive care unit: Is it worth it?

Background The problem of intensive care unit methicillin-resistant Staphylococcus aureus (MRSA) infections has led to routine surveillance and eradication strategies. Methods Our surgical intensive care unit (SICU) admissions receive MRSA nares cultures and if positive are isolated followed by eradication treatment. This strategy was retrospectively reviewed. Results Our nares-positive culture rate was 21% (30/145), and the sputum positive (sputum+) rate was 18% (26/145). Positive nares culture (Nares+) was eradicated in 63%. The rate of sputum+ in Nares+ patients was 36% (9/25). The rate of sputum+ in Nares− was 10% (12/115; P = .003). The sputum+ SICU length of stay (LOS) (18 ± 12 days in 23 S+ patients) is longer than in sputum− (10 ± 9 days in 69 S-patients, P = .0002). Conclusions This SICU has high rates of both nares and sputum MRSA cultures. Our data suggest eradicating nares colonization may prevent pneumonia and might decrease SICU LOS.

152: Glucose control in a surgical intensive care unit after orthotopic liver transplantation

Introduction: End-stage liver disease and the process of orthotopic liver transplantation (OLT) is associated with insulin resistance and hyperglycemia. Maintenance of euglycemia has been established as the standard of care in the non-transplant critical care population. The efficacy and safety of euglycemia protocols in OLT patients has not been established. We hypothesized that a computerized euglycemia protocol is safe and effective in the post-OLT population. Methods: All critically ill, ventilated patients were prospectively placed on a euglycemic protocol that uses an automated, computerized tool. Blood glucose (BG) samples and insulin infusion rates were recorded in a protocol database every two hours. After obtaining IRB approval, all patients undergoing OLT were compared to the non-OLT surgical intensive care unit (SICU) patients. Efficacy was defined as number BG values between 80-110 (in mg/dL). Safety was defined as prevention of hypoglycemia (BG<60). Differences between groups were assessed using Fisher’s exact test for categorical variables, and Wilcoxon’s rank-sum test for continuous variables. Statistical significance was defined as p<0.05. Results: Clinical data was available for a total of 560 patients who were divided into two groups: post-OLT (group 1, n=100) and non-OLT SICU patients (group 2, n=460). There were a total of 5899 data points for group 1, 26,644 for group 2. There were no differences between the groups with regard hospital length of stay (LOS), SICU LOS, and APACHE II scores. There were a greater number of males in group 1 (72% vs 58.3%, p<0.05). Mortality was higher in group 2 (4% vs 14.6%, p<0.05). Predicted mortality on the basis of APACHE II scores was 25% for both groups. Group 2 had more BG values in range in the first 24 hours (33.2% vs 22.4%, p<0.05). By 48 and 72 hours, number of BG values in range were similar. Hypoglycemic events (defined by BG<60) and severe hypoglycemic events (BG<40) were similar between the groups. Hyperglycemic events (defined by BG>150 and BG>200) were higher in group 1 over the entire study period (p<0.05). Glucose control is shown in the Table below. Conclusions: Maintenance of euglycemia is as safe following orthotopic liver transplantation as it is in the general SICU patient population, with no increase in the number of hypoglycemic events. Maintenance of euglycemic control was less efficacious for the first 24 hours in post-OLT patients, but was statistically equivocal at 48 and 72 hours. While safe, the benefit of maintaining euglycemia in liver transplant patients requires further study. Tabled 1Glucose control in critically ill surgical population Measurement Group 1 Group 2 p Total% BG 80-110 34.69 39.84 0.0083 % BG 80-110 1st 24 hours 22.40 33.19 <0.0001 % BG 80-110 1st 48 hours 32.86 37.21 0.082 % BG 80-110 1st 72 hours 33.94 38.24 0.0738 % BG <40 0.06 0.15 02144 % BG <60 0.71 1.31 0.4167 % BG >/= 150 21.55 14.91 <0.0001 % BG >= 200 12.38 5.55 <0.0001 BG=Blood Glucose BG values in mg/dL Group 1=OLT Group 2=non-OLT Open table in a new tab

Early tracheostomy versus late tracheostomy in the surgical intensive care unit

Background This study’s purpose was to determine if early tracheostomy (ET) of severely injured patients reduces days of ventilatory support, the frequency of ventilator-associated pneumonia (VAP), and surgical intensive care unit (SICU) length of stay (LOS). Methods This 2-year retrospective review included 185 SICU patients with acute injuries requiring mechanical ventilation and tracheostomy. ET was defined as 7 days or less, and late tracheostomy (LT) as more than 7 days. Results The incidence of VAP was significantly higher in the LT group, relative to the ET group (42.3% vs. 27.2%, respectively; P <.05). Acute Physiology and Chronic Health Evaluation II scores, hospital and SICU LOS, and the number of ventilator days were significantly higher in the LT group. Conclusions In patients who required prolonged mechanical ventilation, there was significant decreased incidence of VAP, less ventilator time, and lower ICU LOS when tracheostomy was performed within 7 days after admission to the SICU.

Survival of critically ill surgical patients discharged to extended care facilities

Background: Rates of discharge of surgical ICU (SICU) patients to extended care facilities (ECF) increase as SICU length of stay (LOS) increases. Increased SICU LOS and APACHE II scores have been related to increased hospital mortality. This study evaluated factors influencing ECF survival after SICU patient discharge. Study Design: We did a longitudinal followup study of patients admitted to our tertiary care SICU during a 2-year period who were eventually discharged to ECF. Demographic data, SICU admission APACHE II score, and LOS data were obtained prospectively. Patient followup was obtained 2 years after discharge by telephone interviews with patients themselves or next of kin to ascertain current status or date of demise. Results: Of 1,799 SICU patients admitted during the study period, 160 patients (9%) were discharged to an ECF. Telephone followup was obtained from 150 patients (94%). Mean length of followup was 21 months after hospital discharge (range 7 to 34 months), mean patient age 64 years (range 16 to 96 years), mean SICU admission APACHE II score 13 (range 2 to 29), and mean SICU LOS 11 days (range 1 to 146 days). At followup, 45% of patients had died, 37% had been discharged home, and 18% still resided in an ECF or hospital. Elderly patients (above age 65) had significantly worse 1-year (p < 0.001) and 2-year (p < 0.001) ECF survival than nonelderly patients. Patients admitted to the SICU after otolaryngologic procedures also had significantly worse 1- and 2-year ECF survival than all other patients. Severity of illness as estimated by admission APACHE II scores or SICU LOS does not seem to influence survival. Conclusions: Outcomes of ECF discharge after SICU admission is poor, with nearly 50% 2-year mortality. ECF mortality seems significantly higher for the elderly, with patients undergoing otolaryngologic procedures being at highest risk. Severity of illness at the time of SICU admission and SICU LOS does not seem to influence ECF outcomes.

An educational intervention in the surgical intensive care unit to improve ethical decisions.

The objective of this study was to determine whether an educational intervention on medical ethics offered during a surgical intensive care unit (SICU) rotation could effect meaningful change in a tertiary SICU. A case-based education program was presented weekly to the surgical residents during their SICU rotation. Cases for study were designed to deal with specific ethical issues common to the SICU. Cases were studied with the residents in a group facilitated by a SICU attending physician and a nursing director. The effect of the course was monitored by case review and by the length of stay (LOS) assessment for patients who died in the SICU during 1990, the base year, through 1993. Discussions of an ethical nature occurred more regularly and earlier during these 4 years as determined by case reviews. For patients who died after being in the SICU a minimum of more than 30 days, a marked decrease occurred in the SICU LOS from 27.8 +/- 3.7 days in 1990 to 15.7 +/- 2.4 days in 1993 (p < 0.05). The number of deaths per year and the average acuity measured by the diagnosis related group score were similar during the 4 years. The LOS in the hospital for dying patients from non-SICU services remained similar during the same time frame. These changes resulted in the dying patients using 1003 SICU days in 1993, down from the 2028 days used in 1990 (p < 0.05). We conclude that through offering a clinical ethics program during the SICU portion of the residency training, residents increased knowledge and skill in addressing and integrating practical ethical issues into their surgical resident practice. In addition, patient care directly improved with an associated reduced SICU LOS and reduced cost.