Surgical Intensive Care Unit Admission Research Articles

The predictive value of systemic inflammatory response syndrome on the outcome of perforated viscus in adult

Purpose: Perforated viscus is one of the most series conditions that need to be evaluated and studied, especially if it associated with systemic inflammatory response syndrome (SIRS). There are some studies carried out in the same subject that do not exactly clarify the predictive role of SIRS in the evaluating patients with perforated viscus, and they lack of a strong result foundation of the subject. Objective: The main purpose of this study is to evaluate the role of SIRS criteria in patients with perforated viscus and to see if SIRS have important value in predicting the surgical intervention, complications, Intensive Care Unit (ICU) admission, mortality, the outcome, and its effect on them later on. Methods: A retrospective study was carried out which included sixty patients with perforated viscus presented to Al-Noor Hospital Emergency Department in Makkah during 1435H. Certain variables including SIRS criteria were collected using a data collecting sheet. These variables are comorbidities, vital sign on presentation, the result of certain investigation), intervention which had done, presence of postoperative complication, ICU length stay, and outcome. Results: The role of SIRS criteria in patients with perforated viscus was found to be statistically significant as regards the patient's gender, the type of surgical intervention (either laparoscopic or open), and the duration of ICU admission, with P P > 0.05. Conclusion: SIRS criteria in patients with Perforated visus (PV) can be used clinically to predict the need for surgical intervention and ICU admission.

Acquired hypernatremia in a general surgical Intensive Care Unit: Incidence and prognosis.

Purpose:Intensive Care Unit (ICU)-acquired hypernatremia (IAH) is a serious electrolyte disturbance that recently was shown to present an independent risk factor for mortality in critically ill patients. IAH has not been widely investigated in Surgical ICU (SICU) patients. No study has specifically investigated IAH epidemiology in the Kingdome of Saudi Arabia (KSA) in general SICU. The objectives of this study are to assess the epidemiological characteristics and prognostic impact of IAH on SICU mortality and outcome in KSA and compare it with international figures.Materials and Methods:A retrospective observational study on a prospectively collected data of patients (14 years of age or older) admitted to SICU over 2 years, with normal serum sodium on admission and who developed IAH (serum sodium above 145 mmol/L) from day two of admission. Traumatic brain injury patients with therapeutic target sodium level above 145 mmol/L were excluded.Results:Over 2 years study period, 864 patients were admitted to SICU. A total of 50 (5.8%) developed IAH and were included in the study. Twenty-eight (56%) patients were male. The median age was 47 (14-84) years. The mean (± standard deviation) Acute Physiology and Chronic Health Evaluation II score was 17 ± 6.5. The incident density (the rate of occurrence of IAH per 100 days care for SICU admission for the first episode) was 0.71. Risk factors include mechanical ventilation, male sex, age ≥50 years, postgastrointestinal surgeries, weekend and night admission. SICU mortality was 40%. The SICU and hospital median (range) length of stay was 8.3 (2-53) and 28.8 (3-95), respectively.Conclusions:IAH is not uncommon in SICU patients and is associated with increased risk of SICU as well as hospital mortality.

421: Patient selection for later delivery timing with suspected previa-accreta

To define a subset of patients with previa and suspected accreta who can be safely managed past the 34 week, ACOG-supported delivery time. We retrospectively identified ongoing 34-week pregnancies between 1997 and 2014 at our medical center, all radiographically diagnosed with placenta previa with signs of accreta. We defined a subgroup felt to be at low risk for major hemorrhage or unscheduled delivery based on the following criteria: singleton gestations with no history of preterm birth; no antepartum bleeding, labor, PPROM or cervical length measurement < 2.5 cm; two or fewer prior cesarean sections; and no radiographic diagnosis of percreta. We evaluated rates of unscheduled or emergent delivery, and compared them to higher-risk patients with regards to surgical morbidity (more than 4u red blood cell (RBC) transfusion, ICU admission, or intraoperative organ injury) and massive RBC transfusion (≥ 10u). 83 patients met our study criteria, of whom 22 (27%) were classified as low-risk and 71 (73%) were high-risk. In the low-risk group, 20 (91%) were scheduled for delivery at ≥36 weeks and two were scheduled at 35-35.9 weeks. Only 1 (4.5%) low-risk patient underwent an unscheduled, non-emergent delivery at 35w due to bleeding. In the high-risk group, 9 (15%) had a scheduled and 7 (11.5%) had an unscheduled delivery at 34 weeks, one of which was emergent. Of the 45 still pregnant at 35w, 3 (7%) had an unscheduled delivery, with one emergent. The low-risk group had a lower rate of composite surgical morbidity (9% vs. 33%, p = .05), and was less likely to receive a pathologic accreta diagnosis (48% vs. 80%, p < .01) than the high-risk group. No patient in the low-risk group underwent massive transfusion during her admission, versus 7 (11.5%) who were high-risk (p = .18). Those patients with a previa and suspected accreta, but without identified risk factors for preterm birth or hemorrhage, were at low risk of complications or emergent delivery. Delivery timing for these low risk accreta patients likely can be delayed until at least 36 weeks.

Cefepime Use and Acute Brain Injury in Critically Ill Patients

• Adjusting for APACHE, cefepime use remained significantly associated with increased risk of ABI, with odds ratio of 8.0,95% confidence interval 6.8-9.6 Results • All adult medical, surgical, cardiac, cardiovascular and trauma ICU admissions between 2006 and 2013 were screened • Neurologic ICU excluded to reduce confounding • Using an ICU data mart, data pertinent to ABI were extracted using a previously described algorithm3

Hyperdynamic left ventricular ejection fraction in the intensive care unit.

IntroductionLimited information exists on the etiology, prevalence, and significance of hyperdynamic left ventricular ejection fraction (HDLVEF) in the intensive care unit (ICU). Our aim in the present study was to compare characteristics and outcomes of patients with HDLVEF with those of patients with normal left ventricular ejection fraction in the ICU using a large, public, deidentified critical care database.MethodsWe conducted a longitudinal, single-center, retrospective cohort study of adult patients who underwent echocardiography during a medical or surgical ICU admission at the Beth Israel Deaconess Medical Center using the Multiparameter Intelligent Monitoring in Intensive Care II database. The final cohort had 2867 patients, of whom 324 had HDLVEF, defined as an ejection fraction >70 %. Patients with an ejection fraction <55 % were excluded.ResultsCompared with critically ill patients with normal left ventricular ejection fraction, the finding of HDLVEF in critically ill patients was associated with female sex, increased age, and the diagnoses of hypertension and cancer. Patients with HDLVEF had increased 28-day mortality compared with those with normal ejection fraction in multivariate logistic regression analysis adjusted for age, sex, Sequential Organ Failure Assessment score, Elixhauser score for comorbidities, vasopressor use, and mechanical ventilation use (odds ratio 1.38, 95 % confidence interval 1.039–1.842, p =0.02).ConclusionsThe presence of HDLVEF portended increased 28-day mortality, and may be helpful as a gravity marker for prognosis in patients admitted to the ICU. Further research is warranted to gain a better understanding of how these patients respond to common interventions in the ICU and to determine if pharmacologic modulation of HDLVEF improves outcomes.

Statistics of causes of death and analysis of risk factors in a surgical intensive care unit

To summarize the causes of death and to analyze the risk factors in a surgical intensive care unit (SICU). The relevant information of patients died in the SICU of Xijing Hospital of Fourth Military Medical University in past 15 years (from December 1999 to February 2015) was retrospectively analyzed. The gender, age, reason and date of hospitalization, date of transfer SICU, past medical history, whether or not admitted directly from emergency department or transferred from other department, operated or not, date of death, the main cause of death, acute physiology and chronic health evaluation II (APACHE II) score, the history of undergoing mechanical ventilation, continuous renal replacement therapy (CRRT), or antifungal therapy, as well as the ratio of the patients with body temperature higher than 39 °C, white blood cell (WBC) count higher than 10 x 10⁹/L, platelet (PLT) count below 100 x 10⁹/L, albumin (Alb) below 35 g/L of two periods, namely from December 1999 to July 2007 (the first period), and from August 2007 to February 2015 (the second period) were compared. The above parameters were compared with those of 201 survivors in SICU, and the risk factors leading to death were analyzed by logistic regression. From December 1999 to February 2015, 4 317 patients were taken care of in the SICU. Among them, the number of death was 186, and the mortality rate was 4.3%. In the first time period (from December 1999 to July 2007), the total number of patients was 1 356, and the number of death were 109 (the mortality rate was 8.0%). In the second period, i.e. from August 2007 to February 2015, the number of SICU patients was 2,961, and 77 died (the mortality rate was 2.6%). The difference of mortality rate between the two periods was statistically significant (χ² = 66.707, P = 0.001 ). The death rate of patients transferred directly from emergency department in the first period was 79.8% (87/109), and it was lower in the second period (51.9%, 40/77, χ² = 16.181, P = 0.001 ). The death rate of the patients with blood A1b below 35 g/L in the second period (59.7%, 46/77) was higher than that of the first period (41.3%, 45/109, χ² = 6.151, P = 0.017). The top three causes of death from December 1999 to February 2015 were sepsis (38.2%), trauma (16.7%), and operation for cancer (14.0%). In the first period, the top three causes of death were sepsis (35.8%), trauma (22.0%), and operation for cancer (13.8%). In the second period, the top three causes of death were sepsis (41.6%), damage of the central nervous system (16.9%), and operation for cancer (14.3%). Top three reasons for SICU admission were trauma (29.03%), abdominal pain (20.97%) and other reasons (18.82%). Top three departments from which the patients were transferred were the emergency department (19.35%), orthopedics department (17.20%), and hepatobiliary department (16.13%). Logistic regression analysis showed that age [odds ratio (OR) = 2.025, 95% confidence interval (95% CI) = 1.500-2.734, P = 0.000], mechanical ventilation (OR = 3.514, 95% CI = 1.701-7.259, P = 0.001), CRR T (OR = 5.604, 95% CI = 3.003-10.459, P = 0.000 ), body temperature higher than 39 °C (OR = 1.992, 95%CI = 1.052-3.771, P = 0.034) were the risk factors of death in SICU patients. Sepsis and severe trauma are the leading causes of death in severe SICU patients, to whom with risk factors of death enough attention should be given.

Should we still use motor vehicle intrusion as a sole triage criterion for the use of trauma center resources?

Motor vehicle intrusion (MVI) is one of the field triage criteria recommended by the American College of Surgeons Committee of Trauma (ACS-COT) and Centers for Disease Control and Prevention (CDC). However, the evidence supporting its validity is scarce. The purpose of this study was to evaluate the validity of this criterion and assess its impact on overtriage or undertriage. This was a retrospective study based on the Los Angeles County Trauma and Emergency Medicine Information System (TEMIS) Trauma database. Included in the analysis were patients with MVI as the sole criterion for trauma center triage. Physiological characteristics, severity of injury, and outcomes of the MVI patients were compared between different age groups. Further, a logistic regression model was used to identify factors significantly associated with the need for trauma center resources. During the period 2002-2012, a total of 10,554 trauma patients involved in motor vehicle crashes had documentation of MVI. A subgroup of 3998 patients (37.9%) did not meet any other criteria that require immediate transportation to a designated trauma center. Only 0.7% of these patients had hypotension and 0.1% had deterioration of the Glasgow Coma Scale on admission to the emergency room. Overall, 18.8% of patients required trauma center resources defined as intubation in the emergency room, certain surgical procedures, in-hospital death, or intensive care unit admission. Age ≥65 years, male gender, prehospital heart rate >100/min, and systolic blood pressure <110 mmHg were significantly associated with the need for trauma center resources. The MVI itself did not appear to be a strong indicator for the use of trauma center resources and is associated with excessive overtriage. However, age >65 years, systolic blood pressure <110 mmHg, and heart rate >100/min were significant predictors for the need of trauma center resources. The MVI criterion should be refined for better utilization of trauma center resources.

Unexpected Deaths of Critically Ill Surgical Patients Following Surgical ICU Discharge: A Six-Year Retrospective Analysis

SESSION TITLE: Quality Improvement to Improve Patient Safety and Reduce Healthcare Costs SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, October 28, 2015 at 07:30 AM - 08:30 AM PURPOSE: To investigate the cause of death in surgical patients who died unexpectedly following discharge from the surgical intensive care unit (SICU) at a tertiary care medical center over a six year period. METHODS: All patients discharged alive to the floor from the SICU between January 1, 2008 and September 30, 2013 were screened for enrollment. Unexpected death was defined as patients who expired on the floor within 28 days from SICU discharge who were not in hospice program, on Palliative Care service or with a DNR/DNI order. A retrospective chart review was conducted and a matched control group selected based on intensive care unit (ICU) diagnosis, age and sex. The APACHE II score on SICU admission, SWIFT (Stability and Workload Index for Transfer) score on SICU discharge, time of ICU discharge, and ICU and hospital length of stay were calculated and analyzed. RESULTS: In this period, 3,213 patients were discharged alive from the SICU and 2,986 patients (93%) survived until hospital discharge, 227 (7%) expired. Of the 227 floor deaths, 130 (4%) died within 28 days of SICU discharge and 96 (3%) expired after 28 days post SICU discharge. Of these, 116 (3.6%) were classified as expected deaths and 14 (0.4%) as unexpected deaths. The most common cause of unexpected death was sepsis (5, 36%) and PE (4, 29%). There was autopsy confirmation of diagnosis in two cases of abdominal sepsis, two cases of PE and one aortic dissection. In the first week following ICU discharge, abdominal sepsis was the most common cause of death, cardiovascular events were the most common from week 2-4 after discharge. In the unexpected death group when compared to matched control, there was no difference in time of discharge or APACHE II score on SICU admission or SWIFT score on SICU discharge. CONCLUSIONS: Of all critically ill surgical patients who were discharged alive, unexpected death within 28 days after SICU discharge was very low 14/3,213 (0.4%). Sepsis was the most common cause in the first week from discharge, while cardiovascular events were most common from day 8 to 28 post discharge. SWIFT score and APACHE II score on admission were poor predictors of post ICU mortality. CLINICAL IMPLICATIONS: While unexpected deaths following SICU discharge is low (0.4%), patients with sepsis remain at high risk of death in the first week of SICU discharge. Predictive indices (APACHE II, SWIFT) have failed to reliably predict unexpected death in surgical patients. It is unclear if post ICU monitoring would have changed outcomes in this population. DISCLOSURE: The following authors have nothing to disclose: Adel Bassily Marcus, Jun Makino, Raja Singh, Ehizode Udevbulu, John Oropello, Anthony Manasia, Roopa Kohli-Seth No Product/Research Disclosure Information

Impact of late fluid balance on clinical outcomes in the critically ill surgical and trauma population

PurposeManagement of fluid status in critically ill patients poses a significant challenge due to limited literature. This study aimed to determine the impact of late fluid balance management after initial adequate fluid resuscitation on in-hospital mortality for critically ill surgical and trauma patients. Materials and MethodsThis single-center retrospective cohort study included 197 patients who underwent surgical procedure within 24 hours of surgical intensive care unit admission. Patients with high fluid balance on postoperative day 7 (>5 L) were compared with those with a low fluid balance (≤5 L) with a primary end point of in-hospital mortality. Subgroup analyses were performed based on diuretic administration, diuretic response, and type of surgery. ResultsHigh fluid balance was associated with significantly higher in-hospital mortality (30.2 vs 3%, P < .001) compared with low fluid balance; this relationship remained after multivariable regression analysis. High fluid balance was associated with increased mortality, independent of diuretic administration, diuretic response, and type of surgery. ConclusionsConsistent with previous literature, high fluid balance on postoperative day 7 was associated with increased in-hospital mortality. Patients who received and responded to diuretic therapy did not demonstrate improved clinical outcomes, which questions their use in the postoperative period.

The prevalence of long QT interval in post-operative intensive care unit patients.

The severity of patient illnesses and medication complexity in post-operative critically ill patients increase the risk for a prolonged QT interval. We determined the prevalence of prolonged QTc in surgical intensive care unit (SICU) patients. We performed a prospective cross-sectional study over a 15-month period at a major academic center. SICU pre-admission and admission EKGs, patient demographics, and laboratory values were analyzed. QTc was evaluated as both a continuous and dichotomous outcome (prolonged QTc>440ms). 281 patients were included in the study: 92% (n=257) post-operative and 8% (n=24) non-operative. On pre-admission EKGs, 32% of the post-operative group and 42% of the non-operative group had prolonged QTc (p=0.25); on post-admission EKGs, 67% of the post-operative group but only 33% of the non-operative group had prolonged QTc (p<0.01). The average change in QTc in the post-operative group was +30.7ms, as compared to +2ms in the non-operative group (p<0.01). On multivariable adjustment for long QTc as a dichotomous outcome, pre-admission prolonged QTc (OR 3.93, CI 1.93-8.00) and having had an operative procedure (OR 4.04, CI 1.67-9.83) were associated with developing prolonged QTc. For QTc as a continuous outcome, intra-operative beta-blocker use was associated with a statistically-significant decrease in QTc duration. None of the patients developed a lethal arrhythmia in the ICU. Prolonged QTc is common among post-operative SICU patients (67%), however lethal arrhythmias are uncommon. The operative experience increases the risk for long QTc.

Adequate Nutrition May Get You Home: Effect of Caloric/Protein Deficits on the Discharge Destination of Critically Ill Surgical Patients.

Macronutrient deficit in the surgical intensive care unit (ICU) is associated with worse in-hospital outcomes. We hypothesized that increased caloric and protein deficit is also associated with a lower likelihood of discharge to home vs transfer to a rehabilitation or skilled nursing facility. Adult surgical ICU patients receiving >72 hours of enteral nutrition (EN) between March 2012 and May 2014 were included. Patients with absolute contraindications to EN, <72-hour ICU stay, moribund state, EN prior to surgical ICU admission, or previous ICU admission within the same hospital stay were excluded. Subjects were dichotomized by cumulative caloric (<6000 vs ≥ 6000 kcal) and protein deficit (<300 vs ≥ 300 g). Baseline characteristics and outcomes were compared using Wilcoxon rank and χ(2) tests. To test the association of macronutrient deficit with discharge destination (home vs other), we performed a logistic regression analysis, controlling for plausible confounders. In total, 213 individuals were included. Nineteen percent in the low-caloric deficit group were discharged home compared with 6% in the high-caloric deficit group (P = .02). Age, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II), and initiation of EN were not significantly different between groups. On logistic regression, adjusting for BMI and APACHE II score, the high-caloric and protein-deficit groups were less likely to be discharged home (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.08-0.96; P = .04 and OR, 0.29; 95% CI, 0.0-0.89, P = .03, respectively). In surgical ICU patients, inadequate macronutrient delivery is associated with lower rates of discharge to home. Improved nutrition delivery may lead to better clinical outcomes after critical illness.

MP9-15 IDENTIFYING RISK FACTORS FOR READMISSION TO THE SURGICAL INTENSIVE CARE UNIT FOLLOWING MAJOR UROLOGICAL SURGERY: A 24-MONTH EXPERIENCE

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes II1 Apr 2015MP9-15 IDENTIFYING RISK FACTORS FOR READMISSION TO THE SURGICAL INTENSIVE CARE UNIT FOLLOWING MAJOR UROLOGICAL SURGERY: A 24-MONTH EXPERIENCE Mark Hockenberry, Zachary Smith, Kavita Gupta, Matthew Robertson, Niels Martin, and Thomas Guzzo Mark HockenberryMark Hockenberry More articles by this author , Zachary SmithZachary Smith More articles by this author , Kavita GuptaKavita Gupta More articles by this author , Matthew RobertsonMatthew Robertson More articles by this author , Niels MartinNiels Martin More articles by this author , and Thomas GuzzoThomas Guzzo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.375AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Readmission to a surgical intensive care unit (SICU) is associated with increased resource utilization and worse patient outcomes. No prior study has examined SICU readmissions in a population of urology patients specifically. We sought to determine factors associated with SICU readmission among patients undergoing major urological surgery. METHODS We retrospectively reviewed all patients admitted to our SICU at an urban, academic medical center following elective major urological surgery over a 2-year period. Patients with a second SICU admission during the same hospital stay (readmitted group) were compared to those with only one SICU admission (non-readmitted group). Preoperative, intraoperative, and postoperative data were examined for each patient. Pearson chi-square and Fisher's exact test were used to compare categorical variables. Odds ratio was calculated to quantify the strength of each statistically significant correlate. RESULTS There were 114 patients admitted to the SICU following elective major urological surgery. 9 patients (7.89%) were readmitted to the SICU with 1 patient (0.88%) readmitted twice. The SICU readmission rate for urology patients was twice that for non-urology patients during this time period (odds ratio 2.38, p=0.015). Clinical scenarios leading to readmission most commonly involved respiratory compromise (60%), hemodynamic instability (40%), and altered mental status (30%). During the initial SICU admission, there was 1 complication (11.11%) in the readmitted group compared with 5 complications (4.76%) and 1 death (0.95%) in the non-readmitted group. Many factors failed to demonstrate a significant association with SICU readmission including ASA classification, surgical Apgar score, APACHE II score at original SICU admission, and occurrence of complications or interventions during the SICU stay. An age-adjusted Charlson comorbidity index (CCI) >5 demonstrated a statistically significant association with SICU readmission (77.78% vs. 35.24%, p=0.026). Odds ratio for CCI >5 vs. ≤5 was 6.43 (p=0.012). CONCLUSIONS Patients undergoing elective major urological surgery were readmitted to the SICU at more than twice the rate of other surgical patients. Respiratory compromise was the most common cause of readmission. A CCI >5 was associated with SICU readmission. Protocols for improved transitions of care with the goal of decreasing SICU readmissions should include enhanced respiratory evaluations and focus on patients with a higher CCI. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e107-e108 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mark Hockenberry More articles by this author Zachary Smith More articles by this author Kavita Gupta More articles by this author Matthew Robertson More articles by this author Niels Martin More articles by this author Thomas Guzzo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

CLINICAL NUTRITION WEEK 2015: Long Beach, CA February 14–17, 2015

CLINICAL NUTRITION WEEK 2015: Long Beach, CA February 14–17, 2015

Lessons Learned from a Palliative Care-Related Communication Intervention in an Adult Surgical Intensive Care Unit

Purpose: Multi-disciplinary, palliative care-related family meetings for intensive care unit(ICU) patients can decrease ICU length-of-stay and family anxiety and distress, but it is unclear how to arrange such meetings in surgical ICUs (SICUs). Materials and Methods: Through meetings with SICU clinician stakeholders, we determined trigger criteria and intervention content. We piloted the intervention over 6 months in a single, 16-bed adult SICU. Results: Clinician stakeholders reached consensus for a 7 day trigger criteria. A social worker arranged the multi-disciplinary meetings. During the six month pilot, 25 patients were identified but only approximately 60% received meetings. The 7 day trigger identified a patient population with high in-hospital mortality (44%) and prolonged ICU and hospital median lengths of stay (34 and 43 days, respectively). The pilot was stopped at 6 months due to high burden of work for social workers and an inability to standardize meeting content. Conclusion: The 7 day criteria for SICU admission identified a subset of high mortality SICU patients likely to benefit from proactive palliative care-related meetings. Meetings were arranged but the format did not ensure meeting content and the intense time commitment of arranging meetings prevented sustainability.

Retrospective observational cohort study of mortality and length of stay for surgical ICU admissions

A significant number require a postoperative ICU stay which may be prolonged [1]. Very limited data exist to characterise mortality and ICU length of stay (LOS) in different surgical specialties [2,3]. We aim to describe this relationship in a large cohort of surgical patients.

Procalcitonin-guided therapy may reduce length of antibiotic treatment in intensive care unit patients with secondary peritonitis: A multicenter retrospective study

PurposeBecause procalcitonin (PCT) might be surrogate for antimicrobial discontinuation in general intensive care units (ICUs), this study explored its use for secondary peritonitis in 4 surgical ICUs (SICUs). MethodsA retrospective study including all consecutive patients with secondary peritonitis, controlled infection source, requiring surgery, and at least 48-hour SICU admission was performed (June 2012–June 2013). Patients were divided following notations in medical records into PCT-guided (notation of PCT-based antibiotic discontinuation) and non–PCT-guided (no notation) groups. ResultsA total of 121 patients (52 PCT-guided, 69 non–PCT-guided) were included. No differences in clinical scores, biomarkers, or septic shock (30 [57.7%] PCT-guided vs 40 [58.0%] non–PCT-guided) were found. Length of intra-SICU (median, 5.0 days; both groups) or in-hospital (median, 20.0 vs 17.5 days) stay, and mortality intra-SICU (9.6% vs 13.0%), 28-day (15.4% vs 20.3%), or in-hospital (19.2% vs 29.0%) were not significantly different (PCT-guided vs non–PCT-guided). In septic shock patients, no mortality differences were found (PCT-guided vs non–PCT-guided): 16.7% vs 22.5% (intra-SICU), 26.7% vs 32.5% (28-day), and 33.3% vs 42.5% (in-hospital). Treatment was shorter in the PCT-guided group (5.1 ±2.1 vs 10.2 ± 3.7 days, P < .001), without differences between patients with and without septic shock. ConclusionProcalcitonin guidance produced 50% reduction in antibiotic duration (P < .001, log-rank test).

Horizontal infection control strategy decreases methicillin-resistant Staphylococcus aureus infection and eliminates bacteremia in a surgical ICU without active surveillance.

Methicillin-resistant Staphylococcus aureus infection is a significant contributor to morbidity and mortality in hospitalized patients worldwide. Numerous healthcare bodies in Europe and the United States have championed active surveillance per the "search and destroy" model. However, this strategy is associated with significant economic, logistical, and patient costs without any impact on other hospital-acquired pathogens. We evaluated whether horizontal infection control strategies could decrease the prevalence of methicillin-resistant S. aureus infection in the ICU, without the need for active surveillance. Retrospective, observational study in the surgical ICU of a tertiary care medical center in Boston, MA, from 2005 to 2012. A total of 6,697 patients in the surgical ICU. Evidence-based infection prevention strategies were implemented in an iterative fashion, including 1) hand hygiene program with refresher education campaign, 2) chlorhexidine oral hygiene program, 3) chlorhexidine bathing, 4) catheter-associated bloodstream infection program, and 5) daily goals sheets. The prevalence of methicillin-resistant S. aureus infection fell from 2.66 to 0.69 per 1,000 patient days from 2005 to 2012, an average decrease of 21% per year. The biggest decline in rate of infection was detected in 2008, which may suggest that the catheter-associated bloodstream infection prevention program was particularly effective. Among 4,478 surgical ICU admissions over the last 5 years, not a single case of methicillin-resistant S. aureus bacteremia was observed. Aggressive multifaceted horizontal infection control is an effective strategy for reducing the prevalence of methicillin-resistant S. aureus infection and eliminating methicillin-resistant S. aureus bacteremia in the ICU without the need for active surveillance and decontamination.

Impact of positive fluid balance on critically ill surgical patients: A prospective observational study

PurposeThe purpose of this study is to determine the effect of postoperative fluid balance (FB) on subsequent outcomes in acute care surgery (ACS) patients admitted to the surgical intensive care unit (ICU). Material and methodsAcute care surgery patients admitted to the surgical ICU from 06/2012 to 01/2013 were followed up prospectively. Patients were stratified by FB into FB-positive (+) and FB-negative (−) groups by surgical ICU day 5 or day of discharge from the surgical ICU. ResultsA total of 144 ACS patients met inclusion criteria. Although there was no statistically significant difference in crude mortality (11% for FB [−] vs 15.5% for FB [+]; P = .422], after adjusting for confounding factors, achieving an FB (−) status by day 5 during the surgical ICU stay was associated with an almost 70% survival benefit (adjusted odds ratio [95% confidence interval], 0.31 [0.13, 0.76]; P = .010). In addition, achieving a fluid negative status by day 1 provided a protective effect for both overall and infectious complications (adjusted odds ratio [95% confidence interval], 0.63 [0.45, 0.88]; P = .006 and 0.64 [0.46, 0.90]; P = .010, respectively). ConclusionsIn a cohort of critically ill ACS patients, achieving FB (−) status early during surgical ICU admission was associated with a nearly 70% reduction in the risk for mortality.

Using the Rothman index to predict early unplanned surgical intensive care unit readmissions.

The Rothman index (RI) is a numerical score calculated hourly from 26 data points in the electronic medical record by a commercial software package. Although it is purported to serve as an indicator of change in a patient's condition, it has not been extensively evaluated in the literature. Our objective was to determine whether the RI can be used to predict early surgical intensive care unit (SICU) readmissions. This is a single-institution, retrospective 12-month period review of all patients transferred from the SICU to the surgical floor. Patients readmitted to the SICU within 48 hours were compared with patients who did not require readmission during this time (control). Demographics and continuous RI scores were collected at admission, 24 hours before SICU transfer, and for the first 48 hours on the surgical floor or until readmission to the SICU. A total of 1,152 SICU patients were transferred to the surgical floor; 27 patients were readmitted within 48 hours of transfer. Demographics were similar in both groups. The SICU length of stay was longer in the readmission group (mean [SD], 4.7 [8.1] vs. 16.5 [15.2]; p < 0.001). The RI immediately before SICU transfer was higher in the control group (70.4 [20.3] vs. 49.1 [20.9], p < 0.001) and was uniformly improved from the RI at the initial SICU admission. In comparison, readmitted patients had more variable RI trends from admission to SICU transfer (mean Δ, 6.51; range, -54.10 to 48.6), and 40.74% of readmitted patients actually had a decreased RI score on transfer. No patient with a RI score greater than 82.90 required readmission within 48 hours. An increased RI score or a score greater than 82.90 correlates with appropriateness for SICU transfer to the surgical floor. A decreased RI score is strongly associated with SICU readmission within 48 hours and should be explored as a potential quality metric. Epidemiologic/prognostic study, level III.

Maternal and Fetal Outcomes in Placenta Accreta After Institution of Team-Managed Care

Placenta accreta significantly contributes to maternal morbidity and mortality. We evaluated whether planned delivery and experienced, team-managed surgical intervention results in improved outcomes. We also examined whether risk factors differed for accreta, increta, and percreta and evaluated whether excess lower segment uterine vascularity correlates with disease severity. We retrospectively analyzed patients before versus after institution of a management protocol. Of the 58 044 deliveries over 10 years, there were 67 women whose pregnancies were histopathologically confirmed as placenta accreta, increta, or percreta (1/866). Clinical outcome measures were estimated blood loss (EBL), packed red blood cells (pRBCs) transfused, maternal and fetal complications, intensive care unit admission, and length of stay. There were no maternal or infant deaths. In the managed cohort, EBL was reduced by 48% (P < .001), intraoperative pRBCs transfused by 40% (P < .01), total transfused pRBCs per case by 50% (P < .01), and surgical intensive care unit admissions by >50% (P < .01). Assessment of maternal risk factors by diagnosis revealed marked differences between accreta versus increta and percreta. Clinically assessed excess vascularity of the lower uterine segment correlated with disease severity. The incidence of neonatal complications was similar in both cohorts. Targeted delivery at 34 weeks and team-managed diagnosis, treatment, and care of patients with placenta accreta were associated with improved maternal, but not neonatal outcomes.