Time Of Intensive Care Unit Discharge Research Articles

Pressure injuries in mechanically ventilated COVID-19 patients utilising different prone positioning techniques – A prospective observational study

ObjectivesTo compare the incidence and distribution of pressure injuries (PIs) with two approaches to prone positioning for mechanically ventilated COVID-19 patients, and to determine the prevalence of these PIs on intensive care unit (ICU) and hospital discharge. DesignA prospective observational study. SettingAdult patients admitted to a quaternary ICU with COVID-19-associated acute lung injury, between September 2021 and February 2022. Main Outcome MeasuresIncidence and anatomical distribution of PIs during ICU stay for “Face Down” and “Swimmers Position” as well as on ICU and hospital discharge. ResultsWe investigated 206 prone episodes in 63 patients. In the Face Down group, 26 of 34 patients (76 %) developed at least one PI, compared to 10 of 22 patients (45 %) in the Swimmers Position group (p = 0.02). Compared to the Swimmers Position group, the Face Down group developed more pressure injuries per patient (median 1 [1, 3] vs 0 [0, 2], p = 0.04) and had more facial PIs (p = 0.002). In a multivariate logistic regression model, patients were more likely to have at least one PI with Face Down position (OR 4.67, 95 % CI 1.28, 17.04, p = 0.02) and greater number of prone episodes (OR 1.75, 95 % CI 1.12, 2.74, p = 0.01). Over 80 % of all PIs were either stage 1 or stage 2. By ICU discharge, 29 % had healed and by hospital discharge, 73 % of all PIs had healed. ConclusionSwimmers Position had a significantly lower incidence of PIs compared to the Face Down approach. One-quarter of PIs had healed by time of ICU discharge and three-quarters by time of hospital discharge. Implications for Clinical PracticeThere are differences in incidence of PIs related to prone positioning approaches. This study validates and helps better inform current prone position guidelines recommending the use of Swimmers Position. The low prevalence of PIs at hospital discharge is reassuring.

Machine learning to predict poor school performance in paediatric survivors of intensive care: a population-based cohort study

PurposeWhilst survival in paediatric critical care has improved, clinicians lack tools capable of predicting long-term outcomes. We developed a machine learning model to predict poor school outcomes in children surviving intensive care unit (ICU).MethodsPopulation-based study of children < 16 years requiring ICU admission in Queensland, Australia, between 1997 and 2019. Failure to meet the National Minimum Standard (NMS) in the National Assessment Program-Literacy and Numeracy (NAPLAN) assessment during primary and secondary school was the primary outcome. Routine ICU information was used to train machine learning classifiers. Models were trained, validated and tested using stratified nested cross-validation.Results13,957 childhood ICU survivors with 37,200 corresponding NAPLAN tests after a median follow-up duration of 6 years were included. 14.7%, 17%, 15.6% and 16.6% failed to meet NMS in school grades 3, 5, 7 and 9. The model demonstrated an Area Under the Receiver Operating Characteristic curve (AUROC) of 0.8 (standard deviation SD, 0.01), with 51% specificity to reach 85% sensitivity [relative Area Under the Precision Recall Curve (rel-AUPRC) 3.42, SD 0.06]. Socio-economic status, illness severity, and neurological, congenital, and genetic disorders contributed most to the predictions. In children with no comorbidities admitted between 2009 and 2019, the model achieved a AUROC of 0.77 (SD 0.03) and a rel-AUPRC of 3.31 (SD 0.42).ConclusionsA machine learning model using data available at time of ICU discharge predicted failure to meet minimum educational requirements at school age. Implementation of this prediction tool could assist in prioritizing patients for follow-up and targeting of rehabilitative measures.

Retrospective Evaluation of Fascial Plane Blocks in Cardiac Surgery With Median Sternotomy in a Tertiary Hospital.

Cardiac surgery typically causes moderate to severe postoperative pain and discomfort. Inadequate pain management in the early postoperative period leads to pulmonary complications. The length of intensive care unit (ICU) stay and the hospital is typically prolonged. As a component of multimodal analgesia regimens, fascial plane blocks have become more popular. In our clinic, serratus anterior plane blocks (SAPB), pectoral nerve blocks (PECS I-II), and pectointercostal nerve fascial plane blocks (PIFB) are performed by ultrasonography. We wished to evaluate the postoperative visual pain scale, initial additional analgesic agent requirement time, extubation time, morbidity and mortality in patients who underwent open heart surgery with fascial plane blocks. Forty-eight patients over 18 yearswho underwent open heart surgery with sternotomy between 01 September 2021 and 15 June 2022 were evaluated retrospectively. Only patients with chest wall blocks placed at the end of surgery were included in the study. In Group 1, the PECS II block was placed on the chest tube side and bilateral PIFBs were placed at the end of surgery in the operating room. In Group 2, SAPB was placed on the chest tube side and bilateral PIFBs were placed at the end of surgery. Data regarding patient demographics, anesthesia method applied, amount of opioid used intraoperatively, cardiopulmonary bypass time, anesthesia and surgery time, postoperative extubation time, mechanical ventilation time, Visual Analogue Scale (VAS) of patients at rest and movement at 6th, 12th, 18th, 24th, 48th hours post-extubation, time to and type of first postoperative analgesic, postoperative complications, length of cardiac intensive care unit (CICU) stay and hospital length of stay were recorded from hospital records. The data of a total of 46 patients (Group 1: PECS II block + PIFB, n=20; Group 2: SAPB+ PIFB, n=26) were analyzed retrospectively. There was no difference in demographic variables between the groups. Intraoperative opioid usage, operation time, Cardiopulmonary bypass time, postoperative mechanical ventilation time, extubation time, ICU discharge time, and length of hospital stay were not statistically different between the groups. The first rescue analgesic requirement time was longer in group 2 than in group 1 but not statistically significant (18.76±15.36 h vs 12.62±10.61 h, p=0.162). The post-extubation VAS scores at rest and movement at the 6th hour were significantly lower in group 2 than in group 1 (1.73±1.28 vs 3.15±2.10, respectively, p=0.02). In our study, the VAS scores at the 6th hour were lower in SAPB + PIFB group than in PECS II + PIFB group. As these blocks can be easy to apply, we thought these combinations could be an alternative for pain relief in cardiac surgery. Prospective randomized studies are needed with a large number of patients.

Effects of ultrasound-guided regional anesthesia in cardiac surgery: a systematic review and network meta-analysis

BackgroundThe objective of this systematic review and network meta-analysis was to compare the effects of single-shot ultrasound-guided regional anesthesia techniques on postoperative opioid consumption in patients undergoing open cardiac surgery.MethodsThis systematic review and network meta-analysis involved cardiac surgical patients (age > 18 y) requiring median sternotomy. We searched PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science. The effects of the single-shot ultrasound-guided regional anesthesia technique were compared with those of placebo and no intervention. We conducted a risk assessment of bias for eligible studies and assessed the overall quality of evidence for each outcome.ResultsThe primary outcome was opioid consumption during the first 24 h after surgery. The secondary outcomes were pain after extubation at 12 and 24 h, postoperative nausea and vomiting, extubation time, intensive care unit discharge time, and length of hospital stay. Fifteen studies with 849 patients were included. The regional anesthesia techniques included pecto-intercostal fascial block, transversus thoracis muscle plane block, erector spinae plane (ESP) block, and pectoralis nerve block I. All the regional anesthesia techniques included significantly reduced postoperative opioid consumption at 24 h, expressed as morphine milligram equivalents (MME). The ESP block was the most effective treatment (-22.93 MME [-34.29;-11.56]).ConclusionsIn this meta-analysis, we concluded that fascial plane blocks were better than placebo when evaluating 24 h MMEs. However, it is still challenging to determine which is better, given the paucity of studies available in the literature. More randomized controlled trials are required to determine which regional anesthesia technique is better.Trial registrationPROSPERO; CRD42022315497.

Impact of early readmission to the cardiac ICUon in-hospital mortality and hospital length of stay in 30,942 cardiac patients

Abstract Background The need for cardiac intensive care unit (ICU) beds remains high in order to monitor and treat emergency patients with severe cardiovascular diseases, particularly during the COVID-19 pandemic. Therefore, timely discharge strategies from the cardiac ICU to peripheral wards are crucial to meet the increasing demand for cardiac ICU beds. Early patient transfer from ICU to the peripheral ward may result in worsening of the patient's clinical condition and outcome with readmission to the ICU, while late transfer may require prolonged expert care and generate unwanted costs. Purpose To investigate whether unplanned readmission of cardiac patients to the cardiac ICU within 72 hours after the index ICU stay is associated with increased mortality risk (primary outcome) and prolonged total hospital length of stay (LOS) (secondary outcome), as well as to identify predictors of ICU readmission in cardiac patients. Methods Adult patients who were admitted to the cardiac ICU due to a primary cardiac admission diagnosis at a tertiary care center between 2003 and 2021 were included. Outcomes were analysed with multivariable regression models adjusted for 26 a priori defined variables on patient demographics, underlying comorbidity levels, ICU procedures and administered ICU drugs. Results 30,942 cardiac patients were included, out of whom 1,499 patients (4.84%) were readmitted to the cardiac ICU within 72 hours. 1,023 (68.2%) of readmitted patients were male. Compared to non-readmitted patients, readmitted patients were older, had more underlying comorbidities (Charlson Index), had more severe disease courses (SOFA score, TISS, APACHE II score and SAPS), as well as required more frequently vasopressor therapy, renal replacement therapy and coronary angiographies (Table 1). Readmission to the cardiac ICU was associated with higher in-hospital mortality risk (Odds Ratio 7.52, 95% Confidence Interval (CI) 4.15–12.27, P&amp;lt;0.001) and prolonged hospital LOS (Incidence Rate Ratio 1.56, 95% CI 1.15–1.58, P&amp;lt;0.001). Patients who were readmitted to the ICU had been discharged 18% earlier during the index ICU stay compared to non-readmitted patients (P&amp;lt;0.001). Of note, readmitted and non-readmitted patients had similar vital parameters at time of ICU discharge after their index ICU stay. During the index ICU stay, non-readmitted patients were prescribed more beta blockers (65.3% vs. 45.8%), ACE inhibitors (37.0% vs. 27.2%) and blood transfusions (10.7% vs. 7.7%). Conclusion Early readmission to the cardiac ICU was associated with increased in-hospital mortality and prolonged hospitalisation. Readmitted patients had been discharged earlier from their index ICU stay and required more comprehensive critical care. ICU discharge strategies should optimally be based on objective patient assessments to facilitate patient safety and shorten hospital length of stay. Artificial intelligence-based algorithms may support clinicians with safe ICU discharge. Funding Acknowledgement Type of funding sources: None.

Impact of customised ICU handover protocol on the quality of ICU discharge reports

BackgroundThe aim of this investigation was to evaluate the impact of implementing a handover protocol, based on a standardised mnemonic tool specific for a cardiovascular intensive care unit (ICU), on...

Effects on physical performance of high protein intake for critically ill adult patients admitted to the intensive care unit: A retrospective propensity-matched analysis

ObjectivesThis study aimed to examine the effects of protein intake on physical performance in critically ill adult patients admitted to the intensive care unit (ICU). MethodsThis was a retrospective cohort study of adult patients mechanically ventilated over 48 h in the ICU who were classified into two groups based on the amount of protein intake: >1.0 g/kg/d (high-protein group) or <1.0 g/kg/d (low-protein group). After adjustment for possible confounding factors with propensity score matching, we compared muscle strength at the time of ICU discharge and the rate of recovery to independent walking between the two groups. ResultsOne-to-one propensity score matching created 20 pairs. The high-protein group had significantly higher muscle strength than the low-protein group at the time of discharge from the ICU. In addition, the rate of recovery to independent walking before hospital discharge was higher in the high-protein group than the low-protein group (16 of 20 patients [80%] vs. 8 of 20 patients [40%]; P = 0.032). ConclusionsOur findings indicate that a sufficient amount of protein intake may lead to a higher rate of recovery to independent walking before discharge from the hospital in critically ill patients admitted to the ICU. This finding is likely related to preserved muscle strength at the time of ICU discharge.

The Perme Mobility Index: A new concept to assess mobility level in patients with coronavirus (COVID-19) infection.

The Coronavirus Disease 2019 (COVID-19) outbreak is evolving rapidly worldwide. Data on the mobility level of patients with COVID-19 in the intensive care unit (ICU) are needed. To describe the mobility level of patients with COVID-19 admitted to the ICU and to address factors associated with mobility level at the time of ICU discharge. Single center, retrospective cohort study. Consecutive patients admitted to the ICU with confirmed COVID-19 infection were analyzed. The mobility status was assessed by the Perme Score at admission and discharge from ICU with higher scores indicating higher mobility level. The Perme Mobility Index (PMI) was calculated [PMI = ΔPerme Score (ICU discharge-ICU admission)/ICU length of stay]. Based on the PMI, patients were divided into two groups: "Improved" (PMI > 0) and "Not improved" (PMI ≤ 0). A total of 136 patients were included in this analysis. The hospital mortality rate was 16.2%. The Perme Score improved significantly when comparing ICU discharge with ICU admission [20.0 (7-28) points versus 7.0 (0-16) points; P < 0.001]. A total of 88 patients (64.7%) improved their mobility level during ICU stay, and the median PMI of these patients was 1.5 (0.6-3.4). Patients in the improved group had a lower duration of mechanical ventilation [10 (5-14) days versus 15 (8-24) days; P = 0.021], lower hospital length of stay [25 (12-37) days versus 30 (11-48) days; P < 0.001], and lower ICU and hospital mortality rate. Independent predictors for mobility level were lower age, lower Charlson Comorbidity Index, and not having received renal replacement therapy. Patients' mobility level was low at ICU admission; however, most patients improved their mobility level during ICU stay. Risk factors associated with the mobility level were age, comorbidities, and use of renal replacement therapy.

Optimal timing of initiating continuous renal replacement therapy in septic shock patients with acute kidney injury

Acute kidney injury (AKI) in patients with septic shock is associated with high mortality, but the appropriate timing for initiating continuous renal replacement therapy (CRRT) is controversial. We retrospectively enrolled 158 septic shock patients with AKI in the medical intensive care unit (ICU) from July 2016 to April 2018. The time from AKI onset to CRRT initiation was compared according to ICU mortality using Cox proportional hazard, receiver operating characteristic, and Kaplan-Meier survival analyses. At the time of ICU discharge, the mortality rate was 50.6% (n = 80). It took longer to initiate CRRT in non-survivors than in survivors (hazard ratio 1.009; 95% confidence interval [CI] 1.003–1.014; P = 0.002). The cut-off time from AKI onset to CRRT initiation for ICU mortality was 16.5 hours (area under the curve 0.786; 95% CI 0.716–0.856; P < 0.001). The cumulative mortality rate was significantly higher in patients in whom CRRT was initiated beyond 16.5 hours after AKI onset than in those in whom CCRT was initiated within 16.5 hours (log-rank test, P < 0.001). Several clinical situations must be considered to determine the optimal timing of CRRT initiation in these patients. Close observation and CRRT initiation within 16.5 hours after AKI onset may help improve survival.

Does the implementation of a novel intensive care discharge risk score and nurse-led inpatient review tool improve outcome? A prospective cohort study in two intensive care units in the UK

ObjectiveTo develop a clinical prediction model for poor outcome after intensive care unit (ICU) discharge in a large observational data set and couple this to an acute post-ICU ward-based review...

Whole body perfusion strategy for aortic arch repair under moderate hypothermia.

Aortic arch reconstruction under moderate hypothermia is commonly performed with antegrade cerebral perfusion (ACP) for brain protection; however, hypothermia alone is often solely relied upon for visceral and lower body protection. We investigated whether the addition of simultaneous lower body perfusion to ACP (whole body perfusion - WBP) may ameliorate the metabolic derangements of moderate hypothermic circulatory arrest (MHCA). Between 2008 and 2014, 106 consecutive patients underwent elective or emergent aortic arch surgery with MHCA, with either ACP only (44 patients, 66±12 years, 30% female) or WBP (62 patients, 61±15 years, 31% female). Primary outcomes included 30-day/in-hospital mortality, intensive care unit (ICU) and hospital lengths of stay (LOS) and specific parameters of metabolic recovery. There were no significant differences between the groups in 30-day/in-hospital mortality (ACP: 3 (6.8%), WBP: 2 (3.2%); p=0.65), stroke (ACP: 1 (2.3%), WBP: 1 (1.6%); p=1.0) or renal failure (ACP: 2 (4.5%), WBP: 1 (1.5%); p=0.57). In the WBP group, we identified a significant reduction in lactate level at ICU admission (ACP 5.5 vs. WBP 3.5 mmol/L; p=0.002), time to lactate normalization (p=0.014) and median ICU length-of-stay (ACP 3 vs. WBP 1 days; p=0.049). There was no difference in post-operative creatinine (ACP: 104, WBP: 107 μmol/L; p=0.66). After multivariable regression adjustment, perfusion strategy no longer remained an independent predictor of ICU discharge time (p=0.09), however, cardiopulmonary bypass time (p=0.02), age (p=0.012) and emergent surgery (p=0.02) were. A WBP strategy during aortic arch reconstruction with MHCA may be associated with more rapid normalization of metabolic parameters and reduced ICU length of stay compared to using ACP alone. Further evaluation with a randomized trial is warranted.

Association between time of discharge from ICU and hospital mortality: a systematic review and meta-analysis.

BackgroundEpidemiological studies have provided inconsistent results on whether intensive care unit (ICU) discharge at night and on weekends is associated with an increased risk of mortality. This systematic review and meta-analysis aimed to determine whether ICU discharge time was associated with hospital mortality.MethodsThe PubMed, Embase, and Scopus databases were searched to identify cohort studies that investigated the effects of discharge from the ICU on weekends and at night on hospital mortality, with adjustments for the disease severity at ICU admission or discharge. The primary meta-analysis focused on the association between nighttime ICU discharge and hospital mortality. The secondary meta-analysis examined the association between weekend ICU discharge and hospital mortality. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model.ResultsWe included 14 studies that assessed outcomes for nighttime versus daytime discharges among 953,312 individuals. Of these 14 studies, 5 evaluated outcomes for weekend versus weekday discharges (n = 70,883). The adjusted OR for hospital mortality was significantly higher among patients discharged during the nighttime, compared to patients discharged during the daytime (OR 1.31, 95% CI 1.25–1.38, P < 0.0001), and the studies exhibited low heterogeneity (I 2 = 33.8%, P = 0.105). There was no significant difference in the adjusted ORs for hospital mortality between patients discharged during the weekend or on weekdays (OR 1.03, 95% CI 0.88–1.21, P = 0.68), although there was significant heterogeneity between the studies in the weekday/weekend analysis (I 2 = 72.5%, P = 0.006).ConclusionsNighttime ICU discharge is associated with an increased risk of hospital mortality, while weekend ICU discharge is not. Given the methodological limitations and heterogeneity among the included studies, these conclusions should be interpreted with caution, and should be tested in further studies.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1569-x) contains supplementary material, which is available to authorized users.

Remifentanil Compared With Sufentanil Does Not Enhance Fast-Track Possibilities in Cardiac Surgery—A Randomized Study

Progressive cost containment has resulted in a growing interest for fast-track cardiac surgery. Ventilation time and length of stay (LOS) in the intensive care unit (ICU) are important factors in patient turnover, a more efficient use of resources, and early patient mobilization. However, LOS in ICU is not an objective measure because, in addition to medical factors, patient discharge may be guided by logistics and policy, and thus more objective measures are warranted. The authors hypothesized that remifentanil compared with sufentanil would reduce ventilation time and LOS in the ICU and that remifentanil would have beneficial effects on the overall quality of recovery. A randomized, prospective study. Sixty patients scheduled for elective coronary artery bypass grafting with or without aortic valve replacement. A university hospital. Patients were assigned randomly to receive either remifentanil or sufentanil combined with propofol. Patients with ejection fraction<0.3, myocardial infarction within the last 4 weeks, diabetes, and severe pulmonary or arterial hypertension were excluded. The primary outcome variables were ventilation time and time to eligibility of discharge from the cardiac recovery unit. Secondary outcomes were actual LOS in the cardiac recovery unit and quality of recovery. The groups were comparable in selected demographics and perioperative parameters. There were no differences in ventilation time or eligible ICU discharge time between the groups. Remifentanil patients received more morphine than did the sufentanil patients during recovery (20 mg v 10 mg; p = 0.040). No difference was found in pharmacologic support or use of a pacemaker. In a fast-track protocol, remifentanil did not seem to be superior to a standard moderate- to high-dose sufentanil regimen.

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

The timing of discharge from the intensive care unit and subsequent mortality. A prospective, multicenter study.

Previous studies suggested an association between after-hours intensive care unit (ICU) discharge and increased hospital mortality. Their retrospective design and lack of correction for patient factors present at the time of discharge make this association problematic. To determine factors independently associated with mortality after ICU discharge. This was a prospective, multicenter, binational observational study involving 40 ICUs in Australia and New Zealand. Participants were consecutive adult patients discharged alive from the ICU between September 2009 and February 2010. We studied 10,211 patients discharged alive from the ICU. Median age was 63 years (interquartile range, 49-74), 6,224 (61%) were male, 5,707 (56%) required mechanical ventilation, and their median Acute Physiology and Chronic Health Evaluation III risk of death was 9% (interquartile range, 3-25%). A total of 8,539 (83.6%) patients were discharged in-hours (06:00-18:00) and 1,672 (16.4%) after-hours (18:00-06:00). Of these, 408 (4.8%) and 124 (7.4%), respectively, subsequently died in hospital (P < 0.001). After risk adjustment for markers of illness severity at time of ICU discharge including limitations of medical therapy (LOMT) orders, the time of discharge was no longer a significant predictor of mortality. The presence of a LOMT order was the strongest predictor of death (odds ratio, 35.4; 95% confidence interval, 27.5-45.6). In this large, prospective, multicenter, binational observational study, we found that patient status at ICU discharge, particularly the presence of LOMT orders, was the chief predictor of hospital survival. In contrast to previous studies, the timing of discharge did not have an independent association with mortality.

Mortality related to after-hours discharge from intensive care in Australia and New Zealand, 2005-2012.

After-hours discharge from the intensive care unit (ICU) is associated with adverse patient outcomes including increased ICU readmissions and mortality. Since Australian and New Zealand data were last published, overall ICU patient mortality has decreased; however it is unknown whether changes in discharge practices have contributed to these improved outcomes. Our aim was to examine trends over time in discharge timing and the contemporary associations with mortality and ICU readmission. Retrospective cohort study using data from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) for patients admitted to Australian and New Zealand ICUs between January 2005 and December 2012. Data collected included patient characteristics, time of ICU discharge, hospital mortality and ICU readmissions. Between 1 January 2005 and 31 December 2012, there were 710,535 patients available for analysis, of whom 109,384 (15.4 %) were discharged after-hours (1800-0600 hours). There were no changes in timing of ICU discharge over the 8 years of the study. Patients discharged after-hours had a higher hospital mortality (6.4 versus 3.6 %; P < 0.001) and more ICU readmissions (5.1 versus 4.5 %; P < 0.001) than patients discharged in-hours. Although post-ICU mortality for all patients declined during the study period, the risk associated with after-hours discharge remained elevated throughout (odds ratio 1.34, 95 % confidence intervals 1.30-1.38). After-hours discharge remains an important independent predictor of hospital mortality and readmission to ICU. Despite widespread dissemination this evidence has not translated into fewer after-hours discharges or reduction in risk in Australian and New Zealand hospitals.

Association between fluid balance and survival in critically ill patients.

Although the consequences of chronic fluid retention are well known, those of iatrogenic fluid retention that occurs during critical illness have not been fully determined. Therefore, we investigated the association between fluid balance and survival in a cohort of almost 16,000 individuals who survived an intensive care unit (ICU) stay in a large, urban, tertiary medical centre. Longitudinal analysis of fluid balance at ICU discharge and 90-day post-ICU survival. Associations between fluid balance during the ICU stay, determined from the electronic bedside record, and survival were tested using Cox proportional hazard models adjusted for severity of critical illness. There were 1827 deaths in the first 90 days after ICU discharge. Compared with the lowest quartile of discharge fluid balance [median (interquartile range) -1.5 (-3.1, -0.7) L], the highest quartile [7.6 (5.7, 10.8) L] was associated with a 35% [95% confidence interval (CI) 1.13-1.61)] higher adjusted risk of death. Fluid balance was not associated with outcome amongst individuals without congestive heart failure or renal dysfunction. Amongst patients with either comorbidity, however, fluid balance was strongly associated with outcome, with the highest quartile having a 55% (95% CI 1.24-1.95) higher adjusted risk of death than the lowest quartile. Isotonic fluid balance, defined as the difference between intravenous isotonic fluid administration and urine output, was similarly associated with 90-day outcomes. Positive fluid balance at the time of ICU discharge is associated with increased risk of death, after adjusting for markers of illness severity and chronic medical conditions, particularly in patients with underlying heart or kidney disease. Restoration of euvolaemia prior to discharge may improve survival after acute illness.

Sedative Efficacy of Propofol in Patients Intubated/Ventilated after Coronary Artery Bypass Graft Surgery

Background:Sedation after open heart surgery is important in preventing stress on the heart. The unique sedative features of propofol prompted us to evaluate its potential clinical role in the sedation of post-CABG patients.Objectives:To compare propofol-based sedation to midazolam-based sedation after coronary artery bypass graft (CABG) surgery in the intensive care unit (ICU).Patients and Methods:Fifty patients who were admitted to the ICU after CABG surgery was randomized into two groups to receive sedation with either midazolam or propofol infusions; and additional analgesia was administered if required. Inclusion criteria were as follows: patients 40-60 years old, hemodynamic stability, ejection fraction (EF) more than 40%; exclusion criteria included patients who required intra-aortic balloon pump or inotropic drugs post-bypass. The same protocol of anesthetic medications was used in both groups. Depth of sedation was monitored using the Ramsay sedation score (RSS). Invasive mean arterial pressure (MAP) and heart rate (HR), arterial blood gas (ABG) and ventilatory parameters were monitored continuously after the start of study drug and until the patients were extubated.Results:The depth of sedation was almost the same in the two groups (RSS=4.5 in midazolam group vs 4.7 in propofol group; P = 0.259) but the total dose of fentanyl in the midazolam group was significantly more than the propofol group (12.5 mg/hr vs 4 mg/hr) (P = 0.0039). No significant differences were found in MAP (P = 0.51) and HR (P = 0.41) between the groups. The mean extubation time in patients sedated with propofol was shorter than those sedated with midazolam (102 ± 27 min vs 245 ± 42 min, respectively; P < 0.05) but the ICU discharge time was not shorter (47.5 hr vs 36.3 hr, respectively; P = 0.24).Conclusions:Propofol provided a safe and acceptable sedation for post-CABG surgical patients, significantly reduced the requirement for analgesics, and allowed for more rapid tracheal extubation than midazolam but did not result in earlier ICU discharge.

Intensive care unit bounce back in trauma patients

Discharging patients from the intensive care unit (ICU) often requires complex decision making to balance patient needs with available resources. Unplanned return to the ICU ("bounce back" [BB]) has been associated with increased resource use and worse outcomes, but few data on trauma patients are available. The goal of this study was to review ICU BB and define ICU discharge variables that may be predictive of BB. Adults admitted to ICU and discharged alive to a ward from November 04, 2012, to September 9, 2012 (interval with no changes in coverage), were selected from our trauma registry. Patients with unplanned return to ICU (BB cases) were matched 1:2 with controls on age, Injury Severity Score (ISS), and duration of post-ICU stay. Data were collected by chart review then analyzed with univariate and conditional multivariate techniques. Of 8,835 hospital admissions, 1,971 (22.3%) were discharged alive from ICU to a ward. Eighty-eight patients (4.5%) met our criteria for BB (male, 75%; mean [SD] age, 52.9 [21.9] years; mean [SD] ISS, 23.1 [10.2]). Most (71.6%) occurred within 72 hours. Mortality for BB cases was high (19.3%). Regression analysis showed that male sex (odds ratio, 2.9; p = 0.01), Glasgow Coma Scale [GCS] score of less than 9 (odds ratio, 22.3; p < 0.01), discharge during day shift (odds ratio, 6.9; p < 0.0001), and presence of one (odds ratio, 3.5; p = 0.03), two (odds ratio, 3.8; p = 0.03), or three or more comorbidities (odds ratio, 8.4; p < 0.001) were predictive of BB. In this study, BB rate was 4.8%, and associated mortality was 19.3%. At the time of ICU discharge, male sex, a GCS score of less than 9, higher FIO2, discharge on day shift, and presence of one or more comorbidities were the strongest predictors of BB. A multi-institutional study is needed to validate and extend these results. Epidemiologic/prognostic study, level IV.

Plasma leukocyte cell‐derived chemotaxin 2 is associated with the severity of systemic inflammation in patients with sepsis

The aim of the present study was to determine the correlations between leukocyte cell-derived chemotaxin 2 (LECT2) and inflammation-related variables in human inflammatory disease. Plasma samples from 23 septic patients who had been admitted to the intensive care unit (ICU) of our institution and 31 volunteers were used. Plasma LECT2 concentrations were examined retrospectively and compared with those of various inflammatory cytokines and routine laboratory data. The LECT2 concentrations of the septic patients at the time of ICU entry (5.3 ± 4.1 ng/mL) were significantly lower than those of the volunteers (19.7 ± 3.4 ng/mL) and these concentrations had significantly increased by the time of ICU discharge. Individual analyses showed that the LECT2 concentrations of all 19 patients had increased by the time of ICU discharge. A combination of LECT2 and C-reactive protein (CRP) concentrations was capable of discriminating the acute and recovery phases of sepsis to a degree similar to those of the combinations of CRP concentration and percentage of neutrophils, CRP concentration and percentage of immature white blood cells, or CRP and interleukin-6 concentrations. Thus, the LECT2 concentration correlates with the severity of systemic inflammation in patients with sepsis. LECT2 may be a reliable diagnostic indicator of human inflammatory diseases.