Transplant Intensive Care Unit Research Articles

Physical function and activity of patients after open abdominal surgery: a prospective cohort study comparing the clinimetric properties of two outcome measures

ObjectivesTo measure and compare the clinimetric properties of the Chelsea Critical Care Physical Assessment (CPAx) and Physical Function in Intensive Care Test-scored (PFIT-s) for assessment of physical function and activity. DesignProspective cohort design using crossover-randomisation of the sequence in which participants were assessed with CPAx and PFIT-s. SettingSurgical and transplant intensive care units (ICU) in an academic hospital. ParticipantsAdults who underwent elective open abdominal surgery. Consecutive sampling was used to enrol 69 participants. InterventionsPhysical function and activity were assessed on ICU days one, three, five and at ICU discharge using the CPAx and PFIT-s in random order. Main outcome measuresResponsiveness to change, minimal clinically important difference (MCID), floor and ceiling effect, and convergent validity. ResultsCPAx demonstrated a large responsiveness (effect size index (ESI)= 0.83) and PFIT-s moderate responsiveness (ESI=0.73) to change in scores. MCID for CPAx was 2.1 (standard error of measurement (SEM) 1.1) and for PFIT-s 0.6 (SEM=0.3). CPAx had no floor effect and a small ceiling effect (9%, n = 6) at ICU discharge compared to 2% (n = 1) floor and 48% (n = 32) ceiling effects of PFIT-s. Moderate convergent validity was found for both tools at ICU admission (n = 67, r = 0.62, p < 0.001) and discharge (n = 67, r = 0.51, p < 0.001). ConclusionCPAx is most responsive to changes in physical function and activity scores, has no floor and limited ceiling effects and moderate convergent validity, and is recommended for similar cohorts. Contribution of the paper•This paper describes clinimetric properties of CPAx compared to PFIT-s for a cohort of middle-aged patients who had elective open abdominal surgery and contributes to the limited existing evidence.•It reports MCID for CPAx and PFIT-s for this elective surgery cohort.

Value of extracorporeal artificial liver support in pediatric acute liver failure: A single-center experience of over 10 years.

Acute liver failure (ALF) is a life-threatening disease characterized by rapid-onset liver dysfunction, coagulopathy, and encephalopathy in patients without chronic liver disease. Today, the combined application of continuous veno-venous hemodiafiltration (CVVHDF) and plasma exchange (PEX), which are forms of supportive extracorporeal therapy (SECT), with conventional liver therapy in ALF is recommended. This study aims to retrospectively analyze the effects of combined SECT in pediatric patients with ALF. We retrospectively analyzed 42 pediatric patients, followed in the liver transplantation intensive care unit. The patients had ALF and received PEX supportive therapy with combined CVVHDF. The biochemical lab values of the results for the patients before the first combined SECT and after the last combined SECT were analyzed comparatively. Of the pediatric patients included in our study, 20 were girls and 22 were boys. Liver transplantation was performed in 22 patients, and 20 patients recovered without transplantation. After the discontinuation of combined SECT, all patients had significantly lower serum liver function test results (total bilirubin, alanine transaminase, aspartate transaminase), ammonia, and prothrombin time/international normalized ratio levels than the previous levels (p < 0.01). Hemodynamic parameters (i.e., mean arterial pressure) also improved significantly. Combined CVVHDF and PEX treatment significantly improved biochemical parameters and clinical findings, including encephalopathy, in pediatric patients with ALF. PEX therapy combined with CVVHDF is a proper supportive therapy for bridging or recovery.

Spontaneous Retroperitoneal Hematoma: A Deadly Complication for Patients Awaiting Liver Transplant.

Patients with end-stage liver disease (ESLD) are at increased risk for hemorrhage and spontaneous retroperitoneal hematoma (sRPH) and also carry a high mortality rate. We sought to review the natural history of sRPH in patients with ESLDat a single center. All patients admitted to a single transplantation intensive care unit (TICU) at Froedtert and the Medical College of Wisconsin Transplant Center between June 2016 and August 2018 were retrospectively reviewed. Six ESLD patients with sRPH were studied. Clinical outcome measures were liver disease severity, sRPH treatment, and patient survival. Six patients were included, four male and two female patients, with a median age of 56.5 years (range 30-67 years). All had alcohol-induced liver cirrhosis. The median Model for End-Stage Liver Disease (MELD) score at the time of sRPH diagnosis was 40 (range 30-43). The most commonly identified source of bleeding was from lumbar arteries. One patient had recurrent bleeding after embolization and underwent repeat embolization. Five patients died. The median time to death from the diagnosis of sRPH was 7.2 days (range 2-12 days). The patient who survived following embolization had the lowest MELD score. Critically ill cirrhotic patients with sRPH have a significant mortality rate. Embolization is successful, albeit seldom. This is the largest retrospective series of sRPH in cirrhotic patients in theliterature.

Assessment of Patient Knowledge of the Role of Advanced Practice Providers in Transplantation Surgical Care: A Single-Center Prospective Study

Advanced practice providers (APPs) are integral to the contemporary transplant surgeon-APP practice model. Patient understanding of APPs' role is vital for optimal patient care and experience. Data on patient knowledge of APPs' roles remain scarce. We sought to assess patient awareness of APPs in their transplantation surgical team. We conducted a prospective study on 100 consecutive transplant candidates and recipients ≥18 years, hospitalized in the transplant surgeon-APP Transplantation Intensive Care Unit (primary service) from September 16, 2019 through June 10, 2021. All patients received a 5-question survey (Table 1). Group 1 (first 50 patients) did not receive any printed introductory materials (Figs 1 and 2) before completing the questionnaire, whereas group 2 (last 50 patients) completed the survey after receiving the materials. Although > 90% of patients were knowledgeable about physician assistants (PAs) and nurse practitioners (NPs), the term "advanced practice providers" was unfamiliar to patients in both groups (Table 1). The level of patient recognition and comfort with APPs in the transplant surgeon-APP care team were comparable for both groups. Our study showed that transplant candidates and recipients were knowledgeable and highly comfortable that PAs and NPs are members of their transplantation surgical team. However, the term advanced practice providers was unfamiliar to the patients. Our study suggested that patient education on provider terms used in current health care delivery is essential and may enhance the patient experience.

Improving Sleep Hygiene to Decrease Delirium Among Critically Ill Patients

A sleep hygiene protocol to reduce risks for delirium among critically ill patients in a transplant intensive care unit was implemented in an urban hospital in the Upper Midwest. The project occurred over a 1-month time frame. The project evaluated the number of hours of uninterrupted sleep, overall participation in therapies and activity, agitation, and confusion scores using standard, validated tools. Staff education was provided pre- and postproject implementation. Pre- and postimplementation surveys were used to assess the knowledge of staff and evaluation of the project. Project results demonstrated effectiveness in reducing sleep disturbance and the risk for delirium.

Abstract 446: Outcome of cancer patients with COVID-19: the VCU experience

Abstract Purpose: COVID-19 has deeply impacted the care and prognosis of those with preexisting acute and chronic conditions including cancer. The purpose of this study is to identify risk factors contributing to death from COVID-19 infection in the cancer population at Virginia Commonwealth University Health System (VCUHS). Materials and Methods: 507 patients were evaluated that had a diagnosis of any solid or hematologic malignancy and admitted to the inpatient service at VCUHS while having a COVID-19 PCR positive test between February 2020 and June 2021. Patient characteristics as well as comorbidities, transplant status, ventilator dependence, intensive care admission, and malignancy type were recorded. Death was recorded as being due to COVID-19 or COVID-19 complications. Logistic regression model was used to determine odds ratio (OR) of death from COVID 19. Results were listed with respective OR both unadjusted and adjusted for age, race, sex, body mass index (BMI), and comorbidities including diabetes, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and chronic kidney disease (CKD). Results: Of the 507 patients, 37 experienced death (7.3%). Only 40 patients required ICU admission (7.9%) and 24 required ventilator support (4.7%). Increased age per 5-year increments was associated with increased risk of death in adjusted and unadjusted analysis (OR 1.30 (1.06,1.63) and 1.26 (1.10,1.46)). There was no significant risk of death in either adjusted or unadjusted analysis between Caucasian, African American, Asian or unspecified races. When not adjusted, COPD (OR 2.56, 1.28-5.11), CAD (OR 2.69, 1.36-5.32), and CKD (OR 2.14, 1.09-4.21) were all shown to have significant risk of death. However, when adjusted, there were no significant difference in odds ratio between patients with diabetes, CAD, COPD, and CKD. When adjusted, malignancies of central nervous system (CNS) (OR 70.30, 2.18-1520.3), hematologic (OR 4.79, 1.05-30.77), and head and neck (OR 11.64, 1.58-100.01) were at increased risk of death; while female associated malignancies, genitourinary (GU), lung, connective tissue, and those with multiple primary malignancies did not have significant risk. Ventilatory dependence did increase mortality risk (OR 50.54, 7.62,459.7), while transplant status and intensive care unit admission did not. Conclusions: Based on the results from this study, there is an increased risk of death from COVID-19 infections in several variables in the cancer population at VCUHS. Age, ventilator dependence, CNS, hematologic, and head and neck malignancies were all associated with increased mortality. Further evaluation will include the 13 other patients in which data was not yet available. Other variables that will be evaluated are COVID treatments, vaccination status, antibody formation, cancer treatment modality used within 30 days of COVID diagnosis, and lab values including cell counts and inflammatory markers. Citation Format: Patrick J. Willard, Temmy Olasehinde, Naji Bou Zeid, Edem Defor, Victor Yazbeck, Dipankar Bandyopadhyay. Outcome of cancer patients with COVID-19: the VCU experience [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 446.

Development of a Comprehensive Extracorporeal Membrane Oxygenation Program in a Cardiac Transplant Intensive Care Unit: A Quality Improvement Initiative.

A major academic medical center in the Midwest has expanded their extracorporeal membrane oxygenation (ECMO) program from 8 ECMO cases in 2014 to 97 ECMO cases in 2017. The Extracorporeal Life Support Organization states that standardized policies, procedures, and standards of care are necessary for an ECMO center to be successful. With the rapid growth of the ECMO program, this medical center has chosen to transition nurses and respiratory therapists into the role of ECMO specialist to bridge the gap in care created by the influx in patients. Currently, no specific set of policies/procedures or standards of care exist for ECMO patients. The primary objective of this study is to improve the self-efficacy of ECMO specialists and bedside nurses through the development of a comprehensive ECMO program that includes standardized policies and procedures, order sets, and evidence-based patient management guidelines. The General Self-Efficacy Survey was used to assess the self-efficacy of both the ECMO specialists and the bedside nurses before implementation of the program. An ECMO manual was created that contained education on veno-arterial and veno-venous ECMO, policies and procedures, and patient management guidelines. An EPIC order set was created to ensure the correct protocols and management guidelines were ordered for all ECMO patients. Postimplementation self-efficacy surveys, direct observations, and chart audits occurred to assess program fidelity. The self-efficacy was assessed of the ECMO specialists and beside nurses 4 months after implementation of policies, procedures, patient management guidelines, and an ECMO order set. The ECMO specialists' self-efficacy survey responses increased by 25% and the bedside nurses' self-efficacy survey responses increased by 27% after 4 months. Direct observation of ECMO specialist handoff to ensure protocol fidelity also occurred. There was a 40% increase in ECMO specialist handoff taking place and a 72% increase in ECMO circuit examination. With the significant growth of ECMO patients, policies, protocols, and management guidelines are essential to provide safe care to these patients. There was a statistically significant improvement in the self-efficacy of both the ECMO specialists and bedside nurses. This was shown to directly correlate to an improvement in professional practice behaviors and ultimately improve the quality of patient care provided to ECMO patients.

Artificial Intelligence May Predict Early Sepsis After Liver Transplantation

Background: Sepsis, post-liver transplantation, is a frequent challenge that impacts patient outcomes. We aimed to develop an artificial intelligence method to predict the onset of post-operative sepsis earlier.Methods: This pilot study aimed to identify “physiomarkers” in continuous minute-by-minute physiologic data streams, such as heart rate, respiratory rate, oxygen saturation (SpO2), and blood pressure, to predict the onset of sepsis. The model was derived from a cohort of 5,748 transplant and non-transplant patients across intensive care units (ICUs) over 36 months, with 92 post-liver transplant patients who developed sepsis.Results: Using an alert timestamp generated with the Third International Consensus Definition of Sepsis (Sepsis-3) definition as a reference point, we studied up to 24 h of continuous physiologic data prior to the event, totaling to 8.35 million data points. One hundred fifty-five features were generated using signal processing and statistical methods. Feature selection identified 52 highly ranked features, many of which included blood pressures. An eXtreme Gradient Boost (XGB) classifier was then trained on the ranked features by 5-fold cross validation on all patients (n = 5,748). We identified that the average sensitivity, specificity, positive predictive value (PPV), and area under the receiver-operator curve (AUC) of the model after 100 iterations was 0.94 ± 0.02, 0.9 ± 0.02, 0.89 ± 0.01, respectively, and 0.97 ± 0.01 for predicting sepsis 12 h before meeting criteria.Conclusion: The data suggest that machine learning/deep learning can be applied to continuous streaming data in the transplant ICU to monitor patients and possibly predict sepsis.

Adjunctive ketamine for sedation in critically ill mechanically ventilated patients: an active-controlled, pilot, feasibility clinical trial

ObjectiveKetamine has been shown to decrease sedative requirements in intensive care unit (ICU). Randomized trials are limited on patient-centered outcomes. We designed this pilot trial to evaluate the feasibility of a large randomized controlled trial (RCT) testing the effect of ketamine as an adjunct analgosedative compared with standard of care alone as a control group (CG) in critically ill patients with mechanical ventilation (MV). We also provided preliminary evidence on clinically relevant outcomes to plan a larger trial.Material and methodsPilot, active-controlled, open-label RCT was conducted at medical, surgical, and transplant ICUs at a large tertiary and quaternary care medical institution (King Faisal Specialist Hospital and Research Center, Saudi Arabia). The study included adult patients who were intubated within 24 h, expected to require MV for the next calendar day, and had institutional pain and sedation protocol initiated. Patients were randomized in a 1:1 ratio to adjunct ketamine infusion 1–2 μg/kg/min for 48 h or CG alone.ResultsOf 437 patients screened from September 2019 through November 2020, 83 (18.9%) patients were included (43 in CG and 40 in ketamine) and 352 (80.5%) were excluded. Average enrollment rate was 3–4 patients/month. Consent and protocol adherence rates were adequate (89.24% and 76%, respectively). Demographics were balanced between groups. Median MV duration was 7 (interquartile range [IQR] 3–9.25 days) in ketamine and 5 (IQR 2–8 days) in CG. Median VFDs was 19 (IQR 0–24.75 days) in ketamine and 19 (IQR 0–24 days) in the CG (p = 0.70). More patients attained goal Richmond Agitation–Sedation Scale at 24 and 48 h in ketamine (67.5% and 73.5%, respectively) compared with CG (52.4% and 66.7%, respectively). Sedatives and vasopressors cumulative use, and hemodynamic changes were similar. ICU length-of-stay was 12.5 (IQR 6–21.2 days) in ketamine, compared with 12 (IQR 5.5–23 days) in CG. No serious adverse events were observed in either group.ConclusionsKetamine as an adjunct analgosedative agent appeared to be feasible and safe with no negative impact on outcomes, including hemodynamics. This pilot RCT identified areas of improvement in study protocol before conducting a large, adequately powered, multicenter RCT which is likely justified to investigate ketamine association with patient-centered outcomes further.Trial registration ClinicalTrials.gov: NCT04075006. Registered on 30 August 2019. Current controlled trials: ISRCTN14730035. Registered on 3 February 2020

Perceived and sources of occupational stress in surgical intensive care nurses

Aim: The study aimed to determine sources of stress and stress levels of nurses working in surgical intensive care units in addition to understanding the stress level in nurses, drawing attention and raising awareness. Material and methods: The study was conducted using a descriptive design with the participation of nurses ( n=132) working in surgical intensive care units of a university hospital. The data were collected through the source of stress identification form and perceived stress scale. The data obtained in the study were transferred to a computer environment, and for statistical analyses, the package for social sciences for Windows 25 software was used. In the analyses of the data, descriptive statistics, independent t-test, one-way analysis of variance and regression analysis, and the Bonferroni test were employed. Results: It was also determined that 28.8% of the surgical nurses were working in an organ transplant intensive care unit and 25% worked in an anaesthesia intensive care unit, that 49.3% had professional experience of between 6 and 11 years and that 92.4% worked on both day and night shifts. In the study, the rate of nurses who perceived a high level of stress was found to be 45.5%, and it was identified that 78.8% needed training in stress management. Conclusion: Imperative funding and human resources should be provided in order to give nurses problem-solving abilities and a stress management course. The financial support of the managers and spiritual support of health professionals and organising regular meetings with nurses can help nurses to experience less stress.

Role of EEG in Predicting Outcome of Hepatic Encephalopathy Patients

ABSTRACT Introduction: A retrospective analysis of 151 patients with hepatic encephalopathy (HE) who were admitted to the liver intensive care unit (LICU) and liver transplant intensive care unit (TICU) and underwent electroencephalographic (EEG) testing was performed. We describe a method of grading the EEGs of patients with HE and predicting their subsequent outcomes. Methods: All liver failure patients with HE who underwent routine EEG testing in the LICU or TICU between October 1, 2018 and March 31, 2019, at the Institute of Liver and Biliary Sciences (ILBS) were enrolled in this analysis. The data was analyzed using Statistical Package for the Social Sciences (SPSS). The patients were divided into four grades of HE based on established EEG criteria (HE-EEG). Results: One hundred fifty-one patients [127 Male (84%), 24 Female (16%)] with HE who underwent EEG testing were enrolled. Ages ranged from 3 to 74 years, with a mean age of 48.34 years and median interquartile range (IQR) of 49 years (38–60 years). Ninety-five patients (62.9%) had grade 1 and 2 hepatic encephalopathy, with a statistically significant, worse outcome seen in grades 3 and 4 HE patients. Seizures were seen in 30 (20.1%) of HE patients. Fifteen of 30 patients with seizures (50%) were in the ethanol and nonalcoholic steatohepatitis (NASH) groups. Forty-four of 59 (74.6%) MRIs and 35 of 60 (58.3%) CTs demonstrated some type of brain abnormality in these patients. Imaging abnormalities and the presence of seizures did not contribute to a statistically worse outcome. Conclusion: EEG has an important role in predicting the outcome and prognosis in HE. Patients with grade 3 or 4 HE-EEG, or with progressive worsening of HE-EEG grading were associated with the highest mortality rates.

Longitudinal Characterization and Transmission Dynamics of Antibiotic-Resistant Organisms in an ICU (LOCATE AROs)

Background: Healthcare-associated infections caused by antibiotic-resistant organisms (AROs) are a major cause of significant morbidity and mortality. To create and optimize infection prevention strategies, it is crucial to delineate the role of the environment and clinical infections. Methods: Over a 14-month period, we collected environmental samples, patient feces, and patient bloodstream infection (BSI) isolates in a newly built bone marrow transplant (BMT) intensive care unit (ICU). Samples were collected from 13 high-touch areas in the patient room and 4 communal areas. Samples were collected from the old BMT ICU, in the new BMT ICU before patients moved in, and for 1 year after patients moved in. Selective microbiologic culture was used to isolate AROs, and whole-genome sequencing (WGS) was used to determine clonality. Antibiotic susceptibility testing was performed using Kirby-Bauer disk diffusion assays. Using linear mixed modeling, we compared ARO recovery across time and sample area. Results: AROs were collected and cultured from environmental samples, patient feces, and BSI isolates (Fig. 1a). AROs were found both before and after a patient entered the ICU (Fig. 1b). Sink drains had significantly more AROs recovered per sample than any other surface area (P &lt; .001) (Fig. 1c). The most common ARO isolates were Pseudomonas aeruginosa and Stenotrophomonas maltophila (Fig. 1d). The new BMT ICU had fewer AROs recovered per sample than the old BMT ICU (P &lt; .001) and no increase in AROs recovered over the first year of opening (P &gt; .05). Furthermore, there was no difference before versus after patients moved into the hospital (P &gt; .05). Antibiotic susceptibility testing reveal that P. aeruginosa isolates recovered from the old ICU were resistant to more antibiotics than isolates recovered from the new ICU (Fig. 2a). ANI and clonal analyses of P. aeruginosa revealed a large cluster of clonal isolates (34 of 76) (Fig. 2b). This clonal group included isolates found before patients moved into the BMT ICU and patient blood isolates. Furthermore, this clonal group was initially found in only 1 room in the BMT ICU, and over 26 weeks, it was found in sink drains in all 6 rooms sampled (Fig. 2b). Conclusions: AROs are present before patients move into a new BMT ICU, and sink drains act as a reservoir for AROs over time. Furthermore, sink-drain P. aeruginosa isolates are clonally related to isolates found in patient BSIs. Overall, these results provide insight into ARO transmission dynamics in the hospital environment.Funding: Research reported in this publication was supported by the Washington University Institute of Clinical and Translational Sciences grant UL1TR002345 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official view of the NIH.Disclosures: None

Percutaneous dilatation tracheostomy at liver transplantation intensive care unit by surgeons

Aim: Tracheostomy has evolved to be a routine procedure for prolonged mechanical ventilation patients in the intensive care unit. We aimed to analyze retrospectively our patients underwent percutaneous dilatation tracheostomy due to prolonged mechanical ventilation following liver transplantation.Material and Methods: Data of 34 patients who underwent percutaneous dilatation tracheostomy by general surgeons due to prolonged mechanical ventilation following liver transplantation were analyzed and evaluated retrospectively.Results: Patients did not experience any complications except minor bleeding following liver transplantation. Besides this technique facilitated patient compliance as well as comfort, which were essential during an accurate weaning process.Conclusion: Percutaneous dilatation tracheostomy is a safe method due to its low complication rate and easy applicability in hands of surgeons who are familiar with the neck anatomy.

Early Cycle Ergometry for Critically-Ill Liver Failure Patients in a Transplant Intensive Care Unit

Early Cycle Ergometry for Critically-Ill Liver Failure Patients in a Transplant Intensive Care Unit

Coagulation abnormalities, bleeding, thrombosis, and management of patients with acute liver failure in Australia and New Zealand.

To study the management of coagulation and hematological derangements among severe acute liver failure (ALF) patients in Australia and New Zealand liver transplant intensive care units (ICUs). Analysis of key baseline characteristics, etiology, coagulation and hematological tests, use of blood products, thrombotic complications, and clinical outcomes during the first ICU week. We studied 62 ALF patients. The first day median peak international normalized ratio was 5.5 (inter-quartile range [IQR] 3.8-8.7), median longest activated partial thromboplastin time was 62s (IQR 44-87), and median lowest fibrinogen was 1.1 (IQR 0.8-1.6) g/L. Fibrinogen was only measured in 85% of patients, which was less than other tests (P<0.0001). Median initial lowest platelet count was 83 (IQR 41-122)×109 /L. Overall, 58% of patients received fresh frozen plasma, 40% cryoprecipitate, 35% platelets, and 15% prothrombin complex concentrate. Patients with bleeding complications (19%) had more severe overall hypofibrinogenemia and thrombocytopenia. Thrombotic complications were less common (10% of patients), were not associated with consistent patterns of abnormal hemostasis, and were not immediately preceded by clotting factor administration and half occurred only after liver transplantation surgery. In ALF patients admitted to dedicated Australia and New Zealand ICUs, fibrinogen was measured less frequently than other coagulation parameters but, together with platelets, appeared more relevant to bleeding risk. Blood products and procoagulant factors were administered to most patients at variable levels of hemostatic derangement, and bleeding complications were more common than thrombotic complications. This epidemiologic information and practice variability provide baseline data for the design and powering of interventional studies.

534. Active Screening for Carbapenemase Producing Enterobacteriaceae: Yield and Cost Considerations

BackgroundDuring 2016, our hospital experienced an outbreak with carbapenemase-producing Enterobacteriaceae (CPE) in our solid-organ transplant (SOT) population. Since this outbreak and until now, our hospital has implemented active CPE screening of patients admitted to SOT units and point prevalence surveillances in any unit with a known CPE patient. The present study evaluates the yield of these screening tests and their cost since implementation.MethodsThis retrospective cohort was performed in a 600-bed hospital in Milwaukee, WI. CPE screening tests were retrieved from the clinical microbiology laboratory dataset from January 2016 to April 2019. CPE tests are performed on rectal swabs or stool samples using the CDC broth enrichment method followed by MIC confirmation using Etest. CPE patients were placed on enhanced precautions (gowns, gloves, booties) and were cohorted geographically and to 1:1 nursing and nurse aid staff.ResultsA total of 6,684 samples belonging to 3,383 patients were processed (1.9 samples/patient). Two hundred thirty (3.44%) had carbapenem-resistant Enterobacteriaceae, although only 33 isolates (0.49%) were confirmed as either KPC (n = 31) or NDM (n = 2) positive. Out of the 3,383 patients tested, 121 were identified as carriers of carbapenem-resistant isolates but only 11 (0.32%) were CPE (KPC = 11; NDM = 2). The incidence of new CPE patients during 2016 was 0.82% but decreased to 0.28% and 0.33% in 2017 and 2018, respectively. The units with the highest number of CPE patients were the transplant intensive care unit (n = 6) and the step-down SOT unit (n = 3). Negative cultures were quoted at $8.49 per sample but culture plates with colonies increased the cost per test to $28.44. The total cost for all the 6,684 screening tests was calculated at $61,335. The cost of CPE screening per positive CPE patient identified comes up to $5,575 (not including RN collection time).ConclusionIn an institution with staff and CPE patient cohorting, active screening of CPE positive patients was relatively expensive given our low -level of transmission. In the near future, we plan to stop staff and patient cohorting due to the high stress that these interventions place on our hospital staff. This might ensue in increase transmission, which will be detected by CPE screening tests.Disclosures All authors: No reported disclosures.

Survival and predictors of outcome among patients with decompensated liver disease in a non-liver transplant intensive care unit. Pessimism is historical and unjustified.

Recent literature emanating from the United Kingdom and United States has reported decreasing mortality rates in patients with decompensated cirrhosis and organ failures presenting to the intensive care unit (ICU). To determine if there were comparable outcomes in a single-centre non-transplant unit in Australia. A retrospective observational study was conducted in a tertiary, non-liver transplant unit in Sydney, Australia. Admission data and mortality outcomes were collected from patients with cirrhosis non-electively admitted to ICU between 2013 and 2017. Liver-specific and general intensive care scoring tools were also assessed for their discriminative ability to predict short-term prognostic outcomes. Sixty-three patients were admitted with decompensated liver disease who fulfilled the inclusion criteria. The overall hospital mortality was 37% (95% CI: 0.26-0.49). There was no difference in survival based on aetiology of liver disease (P = 0.96) but a significant difference was found based on the presenting diagnosis, with greater survival among patients diagnosed with hepatic encephalopathy on ICU admission (P = 0.02). There was 4% mortality in patients with no organ failure and 52% mortality in those with ≥3 organs in failure (P < 0.001). The ICU prognostic Sequential Organ Failure Assessment score was the better discriminative tool in predicting short-term outcomes when compared to liver prognostic scores. The outcomes of this single-centre Australian study align with current overseas literature. These results reinforce and expand on limited local evidence, corroborating the former universal prognostic pessimism towards cirrhotic patients with organ failure as unwarranted.

PTSD in Tx ICU Nurses

Purpose Developments in surgical technique has led to increasing complexity in clinical caseload in transplant intensive care units (ICU) in the UK. The ICU nurse plays a pivotal role in the safe and effective delivery of this complex care. Studies suggested that that ICU nurses experience a greater prevalence of post traumatic stress disorder (PTSD) in comparison with general nurses. There is evidence to suggest that symptoms of PTSD correlate with greater staff burnout and absence rates, which in turn have a financial implication for healthcare providers. This study examined PTSD symptoms in ICU nurses in a cardiothoracic transplant setting in order to establish prevalence. Methods All ICU nurses (N = 180; 153 whole time equivalent) were invited to attend a psychology led support session with the aim of recognizing psychological difficulties in the workforce. All ICU nurses were screened using the Trauma Screening Questionnaire (TSQ, Brewin, 2002). The TSQ is a 10 item self report measure using DSM-IV criteria for PTSD. Demographic data on age, gender and nurse grade was collected. Data was collected on staff sickness and resignation over a 12 month period. Results Using the TSQ (N=136 nurses), indicators for PTSD ranged from 17-48% across the nursing groups. Common themes attributed to experiencing stress were treating adolescent patients and organizational dynamics. Staff sickness hours over the 12 month period ranged from 936.5 (6.24 wte)- 1592.25 hours (10.62 wte). The most common reason for sickness absence were reported as back or knee injury. During this period, 14.4% (N= 26) of the ICU nurses resigned. There was one suicide attempt in the last 18 month period. Conclusion These preliminary findings suggest high levels of PTSD in ICU nurses in a cardiothoracic transplantation centre, in comparison with general nursing. The impact of increasingly complex clinical care places unique demands on ICU nurses. Further studies are needed to explore what psychological support would benefit this cohort, in order to protect them from developing PTSD or other psychological comorbidities. In the short term, all ICU nurses were reminded of how to access occupational health support services. The clinical psychologist also undertook a rolling programme on nurse led team days to provide a reflective practice space for nurses to share their experiences and receive peer support, with a focus on self care and compassion.

Role of Physiotherapy Post Renal Transplantation-A Case Report

Introduction: Physiotherapy is widely used in the renal transplant intensive care unit to minimize postoperative respiratory and musculoskeletal complications. Patients undergoing kidney allotransplants need help in recovery. Improvement of health status after the intervention depends in large measure on cooperation of the therapeutic team. For many physiotherapists, rehabilitation after transplantation becomes a problem with such patients, and there is very sparely available data in the literature about methods for encouraging patients to exercise. Hence this study was taken. Objective: To assess the changes in, pulmonary, physiological and renal outcome in patient with renal transplant. Methodology: A case of chronic kidney disease was reported to SRM General Hospital, Chennai and planned for renal transplant, post operatively patient complaints of pain over lower abdomen and right side while moving around the bed and during sitting. Patient underwent physiotherapy for 2weeks in SRM General Hospital and followed up for three months. Physiotherapy Intervention program including chest physiotherapy, early mobilization and therapeutic exercises was given following which physiological parameters, hemoglobin and renal profile. Results: The improvement in physiological parameters and hemoglobin. There has been a modest improvement in vo2 max. Conclusion: An individualized post renal transplant physiotherapy intervention improved pulmonary and physiological outcomes than renal outcomes in renal transplant

Colistin and polymyxin B for treatment of nosocomial infections in intensive care unit patients: pharmacoeconomic analysis

Background The emergence and rapid spread of multidrug-resistant gram-negative bacteria related to nosocomial infections is a growing worldwide problem, and polymyxins have become important due to the lack of new antibiotics. Objectives To evaluate the outcomes and pharmacoeconomic impact of using colistin and polymyxin B to treat nosocomial infections. Setting Neurosurgical, cardiovascular, or transplantation intensive care unit (ICU) at the Clinical Hospital of the University of Campinas (São Paulo, Brazil). Method A retrospective cohort study was conduct in patients in the ICU. The renal function was determined daily during treatment by measuring the serum creatinine. A cost minimization analysis was performed to compare the relative costs of treatment with colistin and polymyxin B. Main outcomes measure The outcomes were 30-day mortality and frequency and onset of nephrotoxicity after beginning treatment. Results Fifty-one patients treated with colistin and 51 with polymyxin B were included. 30-day mortality was observed in 25.49% and 33.33% of patients treated with colistin and polymyxin B, respectively; Nephrotoxicity was observed in 43.14% and 54.90% of patients in colistin and polymyxin B groups, respectively; and onset time of nephrotoxicity was 9.86 ± 13.22days for colistin and 10.68 ± 9.93days for polymyxin B group. Colistin treatment had a lower cost per patient compared to the cost for polymyxin B treatment (USD $13,389.37 vs. USD $13,639.16, respectively). Conclusion We found no difference between 30-day mortality and nephrotoxicity between groups; however, colistin proved to be the best option from a pharmacoeconomic point of view.