Prolonged Stay in Intensive Care Unit Is a Powerful Predictor of Adverse Outcomes After Cardiac Operations

Data-driven coaching to improve statewide outcomes in CABG: before and after interventional study

BACKGROUND

The impact of quality improvement initiatives program (QIP) on coronary artery bypass grafting surgery (CABG) remains scarce, despite improved outcomes in other surgical areas. This study aims to evaluate the impact of a package of QIP on mortality rates among patients undergoing CABG.

MATERIALS AND METHODS

This prospective cohort study utilized data from the multicenter database Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II), spanning from July 2017 to June 2019. Data from 4018 isolated CABG adult patients were collected and analyzed in three phases: before-implementation, implementation, and after-implementation of the intervention (which comprised QIP training for the hospital team). Propensity Score Matching was used to balance the groups of 2170 patients each for a comparative analysis of the following outcomes: reoperation, deep sternal wound infection/mediastinitis ≤30 days, cerebrovascular accident, acute kidney injury, ventilation time >24 h, length of stay <6 days, length of stay >14 days, morbidity and mortality, and operative mortality. A multiple regression model was constructed to predict mortality outcomes.

RESULTS

Following implementation, there was a significant reduction of operative mortality (61.7%, P =0.046), as well as deep sternal wound infection/mediastinitis ( P <0.001), sepsis ( P =0.002), ventilation time in hours ( P <0.001), prolonged ventilation time ( P =0.009), postoperative peak blood glucose ( P <0.001), total length of hospital stay ( P <0.001). Additionally, there was a greater use of arterial grafts, including internal thoracic ( P <0.001) and radial ( P =0.038), along with a higher rate of skeletonized dissection of the internal thoracic artery.

CONCLUSIONS

QIP was associated with a 61.7% reduction in operative mortality following CABG. Although not all complications exhibited a decline, the reduction in mortality suggests a possible decrease in failure to rescue during the after-implementation period.

Comparison of early mobilization protocols on postoperative cognitive dysfunction, pain, and length of hospital stay in patients undergoing coronary artery bypass graft surgery: A randomized controlled trial

Although coronary artery bypass graft (CABG) surgery improves the life expectancy of patients with coronary artery disease, it is associated with various short and long-term complications. Early mobilization has been shown to reduce the risk of these complications. This study aimed to compare the effectiveness of different early mobilization protocols on postoperative cognitive dysfunction (POCD), pain intensity, and length of hospital stay (LOS) in patients undergoing CABG. This three-arm parallel randomized controlled trial included 120 patients undergoing CABG surgery who were randomly assigned to Intervention A, which received a four-phase early mobilization protocol; Intervention B, which received a three-phase early mobilization protocol; and the Control group, which received routine care. Postoperative cognitive dysfunction and pain were assessed using Mini Mental State Examination (MMSE) and visual analog scale (VAS), respectively. Groups were comparable in demographic and clinical characteristics and postoperative cognitive dysfunction at baseline. After the intervention, Group B had statistically significantly (p < 0.001) less cognitive dysfunction (25.8 ± 1.7) compared to Group A (24.1 ± 2.2) and the Control Group (23.4 ± 2.7). Likewise, hospital stay was statistically (p < 0.01) shorter for Group B (7.7 ± 1.5) than the Control group (8.9 ± 1.9). However, the experience of pain was statistically significantly lower over time in Group A than in the other groups (p < 0.001). This study concludes that an early mobilization protocol based on deep breathing exercises and chest physiotherapy may better improve postoperative cognitive dysfunction and length of hospital stay than an early mobilization protocol based on passive and active range of motion activities or routine care.

The role of immune activation and antigen persistence in acute and long COVID

In late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) triggered the global coronavirus disease 2019 (COVID-19) pandemic. Although most infections cause a self-limited syndrome comparable to other upper respiratory viral pathogens, a portion of individuals develop severe illness leading to substantial morbidity and mortality. Furthermore, an estimated 10%-20% of SARS-CoV-2 infections are followed by post-acute sequelae of COVID-19 (PASC), or long COVID. Long COVID is associated with a wide variety of clinical manifestations including cardiopulmonary complications, persistent fatigue, and neurocognitive dysfunction. Severe acute COVID-19 is associated with hyperactivation and increased inflammation, which may be an underlying cause of long COVID in a subset of individuals. However, the immunologic mechanisms driving long COVID development are still under investigation. Early in the pandemic, our group and others observed immune dysregulation persisted into convalescence after acute COVID-19. We subsequently observed persistent immune dysregulation in a cohort of individuals experiencing long COVID. We demonstrated increased SARS-CoV-2-specific CD4+ and CD8+ T-cell responses and antibody affinity in patients experiencing long COVID symptoms. These data suggest a portion of long COVID symptoms may be due to chronic immune activation and the presence of persistent SARS-CoV-2 antigen. This review summarizes the COVID-19 literature to date detailing acute COVID-19 and convalescence and how these observations relate to the development of long COVID. In addition, we discuss recent findings in support of persistent antigen and the evidence that this phenomenon contributes to local and systemic inflammation and the heterogeneous nature of clinical manifestations seen in long COVID.

Assessing Risk Factors for Prolonged Intensive Care Unit Stay After Surgery for Adult Congenital Heart Disease: A Study From a Lower-Middle-Income Country

Background Prolonged post-surgery intensive care unit (ICU) stay for congenital heart disease (CHD) has been explored in the pediatric population. However, there is limited data for adult CHD (ACHD), also called grown-up congenital heart (GUCH) disease, especially in low-resource countries where intensive care beds are scarce. This study identifies factors associated with prolonged ICU stay following surgery for ACHD in Pakistan, a lower-middle-income country (LMIC). Methods This retrospective study included all adult patients (⩾18 years) who underwent cardiac surgery with cardiopulmonary bypass for their CHD from 2011-2016 at a tertiary-care private hospital in Pakistan. Prolonged ICU stay was defined as stay >6 days (75^th percentile). Regression analysis was used to explore risk factors of prolonged ICU stay. Results A total of 166 patients (53.6% males) with a mean age of 32.05 ± 12.11 years were included. Atrial septal defect repair was the most common surgery (42.2%). Most patients were categorized as Risk Adjustment for Congenital Heart Surgery 1 (RACHS-1) Category 1 (51.8%) and Category 2 (30.1%). Forty-three of 166 patients (25.9%) experienced prolonged ICU stay. Complications occurred in 38.6% of patients postoperatively, with the most common being acute kidney injury (29.5%). On multivariable logistic regression adjusted for age, gender, and RACHS-1 categories, intraoperative inotrope score, cardiopulmonary bypass time, aortic cross-clamp time duration of mechanical ventilation, and postoperative acute kidney injury (AKI) were associated with prolonged ICU stay. Conclusion Surgeons managing ACHD in LMICs must strive for shorter operative durations and the judicious use of intraoperative inotropes in addition to anticipating and promptly managing postoperative complications such as AKI, to minimize ICU stay in countries where intensive care beds are a scarce resource.

Postoperative Outcomes in Elderly Patients Undergoing Cardiac Surgery With Preoperative Cognitive Impairment: A Systematic Review and Meta-Analysis

BACKGROUND

Older patients with preoperative cognitive impairment are at risk for increased postoperative complications after noncardiac surgery. This systematic review and meta-analysis aimed to determine the association between preoperative cognitive impairment and dementia and postoperative outcomes in older surgical patients after cardiac surgery.

METHODS

Eight electronic databases were searched from inception to January 4, 2022. Inclusion criteria were cardiac surgery patients ≥60 years of age; preoperative cognitive impairment; ≥1 postoperative complication reported; comparator group with no preoperative cognitive impairment; and written in English. Using a random-effects model, we calculated effect sizes as odds ratio (OR) and standardized mean differences (SMDs). Risk of random error was assessed by applying trial sequential analysis.

RESULTS

Sixteen studies (62,179 patients) were included. Preoperative cognitive impairment was associated with increased risk of delirium in older patients after cardiac surgery (70.0% vs 20.5%; OR, 8.35; 95% confidence interval [CI], 4.25-16.38; I2, 0%; P < .00001). Cognitive impairment was associated with increased hospital length of stay (LOS; SMD, 0.36; 95% CI, 0.20-0.51; I2, 22%; P < .00001) and intensive care unit (ICU) LOS (SMD, 0.39; 95% CI, 0.09-0.68; I2, 70%; P = .01). No significant association was seen for 30-day mortality (1.7% vs 1.1%; OR, 2.58; 95% CI, 0.64-10.44; I2, 55%; P = .18).

CONCLUSIONS

In older patients undergoing cardiac surgery, cognitive impairment was associated with an 8-fold increased risk of delirium, a 5% increase in absolute risk of major postoperative bleeding, and an increase in hospital and ICU LOS by approximately 0.4 days. Further research on the feasibility of implementing routine neurocognitive testing is warranted.

Outcomes of Prolonged ICU Stay for Patients Undergoing Cardiac Surgery in Australia and New Zealand

OBJECTIVE

To determine the effect of intensive care unit (ICU) length of stay (LOS) on hospital mortality and non-home discharge for patients undergoing cardiac surgery over a 16-year period in Australia and New Zealand.

DESIGN

A retrospective, multicenter cohort study covering the period January 1, 2004 to December 31, 2019.

SETTING

One hundred one hospitals in Australia and New Zealand that submitted data to the Australia New Zealand Intensive Care Society Adult Patient Database.

PARTICIPANTS

Adult patients (aged >18) who underwent coronary artery bypass grafting, valve surgery, or combined valve + coronary artery surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The authors analyzed 252,948 cardiac surgical patients from 101 hospitals, with a median age of 68.3 years (IQR 60-75.5), of whom 74.2% (187,632 of 252,948) were male patients. A U-shaped relationship was observed between ICU LOS and hospital mortality, with significantly elevated mortality at short (<20 hours) and long (>5 days) ICU LOS, which persisted after adjustment for illness severity and across clinically important subgroups (odds ratio for mortality with ICU LOS >5 days = 3.21, 95% CI 2.88-3.58, p < 0.001).

CONCLUSIONS

Prolonged duration of ICU LOS after cardiac surgery is associated with increased hospital mortality in a U-shaped relationship. An ICU LOS >5 days should be considered a meaningful definition for prolonged ICU stay after cardiac surgery.

Machine-learning prediction for hospital length of stay using a French medico-administrative database

INTRODUCTION

Prolonged Hospital Length of Stay (PLOS) is an indicator of deteriorated efficiency in Quality of Care. One goal of public health management is to reduce PLOS by identifying its most relevant predictors. The objective of this study is to explore Machine Learning (ML) models that best predict PLOS.

METHODS

Our dataset was collected from the French Medico-Administrative database (PMSI) as a retrospective cohort study of all discharges in the year 2015 from a large university hospital in France (APHM). The study outcomes were LOS transformed into a binary variable (long vs. short LOS) according to the 90^th percentile (14 days). Logistic regression (LR), classification and regression trees (CART), random forest (RF), gradient boosting (GB) and neural networks (NN) were applied to the collected data. The predictive performance of the models was evaluated using the area under the ROC curve (AUC).

RESULTS

Our analysis included 73,182 hospitalizations, of which 7,341 (10.0%) led to PLOS. The GB classifier was the most performant model with the highest AUC (0.810), superior to all the other models (all p-values <0.0001). The performance of the RF, GB and NN models (AUC ranged from 0.808 to 0.810) was superior to that of the LR model (AUC = 0.795); all p-values <0.0001. In contrast, LR was superior to CART (AUC = 0.786), p < 0.0001. The variable most predictive of the PLOS was the destination of the patient after hospitalization to other institutions. The typical clinical profile of these patients (17.5% of the sample) was the elderly patient, admitted in emergency, for a trauma, a neurological or a cardiovascular pathology, more often institutionalized, with more comorbidities notably mental health problems, dementia and hemiplegia.

DISCUSSION

The integration of ML, particularly the GB algorithm, may be useful for health-care professionals and bed managers to better identify patients at risk of PLOS. These findings underscore the need to strengthen hospitals through targeted allocation to meet the needs of an aging population.

C-reactive protein as a non-linear predictor of prolonged length of intensive care unit stay after gastrointestinal cancer surgery

BACKGROUND

The relationship between C-reactive protein (CRP) levels and prolonged intensive care unit (ICU) length of stay (LoS) has not been well defined.

AIM

To explore the association between CRP levels at ICU admission and prolonged ICU LoS in gastrointestinal cancer (GC) patients after major surgery.

METHODS

A retrospective study was performed to quantify serum CRP levels and to establish their association with prolonged ICU LoS (≥ 72 h) in GC patients admitted to the ICU. Univariate and multivariate regression analyses were conducted, and restricted cubic spline curves with four knots (5%, 35%, 65%, 95%) were used to explore non-linearity assumptions.

RESULTS

A total of 408 patients were enrolled. Among them, 83 (20.3%) patients had an ICU LoS longer than 72 h. CRP levels were independently associated with the risk of prolonged ICU LoS [odds ratio (OR) 1.47, 95% confidence interval (CI) 1.00–2.17]. Restricted cubic spline analysis revealed a non-linear relationship between CRP levels and OR for the prolonged ICU LoS (P = 0.035 for non-linearity). After the cut-off of 2.6 (log transformed mg/L), the OR for prolonged ICU LoS significantly increased with CRP levels. The adjusted regression coefficient was 0.70 (95%CI 0.31–1.57, P = 0.384) for CRP levels less than 2.6, whereas it was 2.43 (95%CI 1.39–4.24, P = 0.002) for CRP levels higher than 2.6.

CONCLUSION

Among the GC patients, CRP levels at ICU admission were non-linearly associated with prolonged ICU LoS in survivors. An admission CRP level > 2.6 (log transformed mg/L) was associated with increased risk of prolonged ICU LoS.

Preoperative red cell distribution width to lymphocyte ratio as biomarkers for prolonged intensive care unit stay among older patients undergoing cardiac surgery: a retrospective longitudinal study

Introduction: Our aim was to use the red cell distribution width-lymphocyte ratio (RLR) as a novel biomarker to predict prolonged intensive care unit (ICU) length of stay (LOS) among older patients undergoing cardiovascular surgery. Methods: This longitudinal study included older patients admitted to a tertiary cardiovascular surgery hospital between January 2017 and January 2022. Results: A total of 574 patients were studied, including 83 patients (14.5%) who had prolonged ICU LOS and 471 (85.5%) control subjects. After adjustment for the European System for Cardiac Operative Risk Evaluation 2, the RLR score showed a 10% increased risk of prolonged ICU LOS (odds ratio: 1.10; CI: 1.05-1.16; p = 0.01). Conclusion: Preoperative RLR can be used to predict the risk of long-term intensive care stay in older cardiac surgery patients.

Outcome and Midterm Survival after Heart Transplantation Is Independent from Donor Length of Stay in the Intensive Care Unit

Prolonged treatment of organ donors in the intensive care unit (ICU) may be associated with complications influencing the outcome after heart transplantation (HTx). We therefore aim to explore the potential impact of the donor length of stay (LOS) in the ICU on outcomes in our cohort. We included all patients undergoing HTx in our center between September 2010 and April 2022 (n = 241). Recipients were divided around the median into three groups regarding their donor LOS in the ICU: 0 to 3 days (≤50th percentile, n = 92), 4 to 7 days (50th-75th percentile, n = 80), and ≥8 days (≥75th percentile, n = 69). Donor LOS in the ICU ranged between 0 and 155 days (median 4, IQR 3-8 days). No association between the LOS in the ICU and survival after HTx was observed (AUC for overall survival 0.514). Neither the Kaplan-Meier survival analysis up to 5 years after HTx (Log-Rank p = 0.789) nor group comparisons showed significant differences. Baseline recipient characteristics were comparable between the groups, while the donor baselines differed in some parameters, such as less cardiopulmonary resuscitation prior to HTx in those with a prolonged LOS. However, regarding the recipients' peri- and postoperative parameters, the groups did not differ in all of the assessed parameters. Thus, in this retrospective analysis, although the donors differed in baseline parameters, the donor LOS in the ICU was not associated with altered recipient survival or outcome after HTx.

Textbook outcome among voluntary donors undergoing major living donor hepatectomy

Purpose

Textbook outcome (TO) is a composite measure of outcome and provides superior assessment of quality of care after surgery. TO after major living donor hepatectomy (MLDH) has not been assessed. The objective of this study was to determine the rate of TO and its associated factors, after MLDH.

Methods

This was a single center retrospective review of living liver donors who underwent MLDH between 2012 and 2021 (n = 1022). The rate of TO and its associated factors was determined.

Results

Among 1022 living donors (of whom 693 [67.8%] were males, median age 26 [range, 18–54] years), TO was achieved in 714 (69.9%) with no donor mortality. Majority of donors met the cutoffs for individual outcome measures: 908 (88.8%) for no major complications, 904 (88.5%) for ICU stay ≤ 2 days, 900 (88.1%) for hospital stay ≤ 10 days, 990 (96.9%) for no perioperative blood transfusion, 1004 (98.2%) for no 30-day re-admission, and 1014 (99.2%) for no post-hepatectomy liver failure. Early donation era (before streamlining of donor operative pathways) was associated with failure to achieve TO [OR 1.4, CI 1.1–1.9, P = 0.006]. TO was achieved in 506/755 (67%) donors in the early donation era versus 208/267 (77.9%) in the later period (P = 0.001).

Conclusion

Despite zero mortality and low complication rate, TO was achieved in approximately 70% donors. TO was modifiable and improved with changes in donor operative pathway.

Percutaneous versus surgical femoral access in minimally invasive cardiac operations

OBJECTIVES

Both surgical and percutaneous femoral accesses for the establishment of extracorporeal circulation are used in minimally invasive cardiac surgeries. The goal of this study was to compare the outcomes with the MANTA vascular closure device after percutaneous arterial decannulation via the surgical approach.

METHODS

Between November 2018 and January 2021, a total of 490 consecutive patients underwent minimally invasive cardiac operations at our institution. Cannulation and decannulation of femoral vessels were under direct vision surgically or percutaneously. The MANTA system was used to close the femoral artery in all patients with percutaneous cannulation. Demographic, clinical and procedural data were collected retrospectively.

RESULTS

Surgical cut-down and suture closure of the femoral artery was performed in 222 patients (45.3%); percutaneous access and closure with the MANTA system was used in 268 patients (54.7%). The surgical group presented a significantly higher incidence of any access site complication compared to the percutaneous group [18 patients (8.1%) vs 6 patients (2.2%); P = 0.003]. Lymph fistula and wound healing disorders occurred more frequently in the surgical group (3.2% vs 0% [P = 0.004] and 3.6% vs 0% [P = 0.002], respectively). Median procedural duration and stays in the intensive care unit were significantly lower in the percutaneous group {127 [interquartile range (IQR) 97-158] min vs 150 (IQR 117-185) min (P < 0.001) and 1 (IQR 1-2) day vs 2 (IQR 1-3) days (P = 0.008), respectively}.

CONCLUSIONS

Percutaneous access and closure with the MANTA system are feasible, safe and associated with lower incidences of all-cause access site complications and shorter stays in the intensive care unit compared to surgical access and closure in minimally invasive cardiac surgeries.

Impact of length of donor ICU stay on outcome of patients after pediatric liver transplantation with whole and ex situ split liver grafts

BACKGROUND

Patients who have a prolonged stay in the intensive care unit (ICU) are often excluded for organ donation because of supposed deleterious effects of a lengthy ICU stay. We aimed to determine the effects of a prolonged donor stay in the ICU on the outcome of liver transplantation (LT) in children.

METHODS

Retrospective review of 89 pediatric LT patients, age 0-18 years, period 2003-2018, including patients having undergone whole organ or in situ split LT. The patients were divided into two groups according to the donor length of stay in the ICU. A prolonged stay was defined as >5 days. Recipient, graft, and donor characteristics were compared; outcome parameters included recipient and graft survival rates and postoperative complications.

RESULTS

Group short (donor ICU stay <5 days) included 75 patients, group long (donor ICU stay >5 days) 14 patients. Baseline characteristics between recipients did not differ. Donors in group long had significantly more infectious complications and a higher gamma glutamyl transferase (gGT) the day of organ recovery. Incidence of biliary complications post-LT was significantly higher in group long (p = .029). Patient and graft survival rates did not differ significantly between groups.

CONCLUSIONS

Donors with a prolonged stay in the ICU should still be considered for liver donation if they fulfill most other selection criteria. Recipients from donors having stayed in ICU >5 days may be at increased risk of biliary complications.

Does tuberculosis affect surgical outcomes following pericardiectomy for chronic constrictive pericarditis? Twelve years’ experience from a tertiary care center in India

Introduction and purpose

Tuberculosis (TB) is the commonest cause of chronic constrictive pericarditis (CCP) in India, unlike in the western countries. Pericardiectomy is the treatment of choice for CCP. Surgery in TB CCP is considerably more difficult than it is for other etiologies. The role of TB as an independent predictor for adverse surgical outcomes had not been properly evaluated in the Indian scenario. Hence, the aim of this study was to retrospectively analyze our results of surgery for CCP and the pre-operative factors that influenced post-operative outcomes.

Methods

The data of all adult patients who underwent pericardiectomy for CCP, between the years 2009 and 2020, maintained in a live database in our institute, were retrieved and analyzed.

Results

There were 124 patients in the study. The average age was 32 years. The male to female ratio was 3:1. TB was the commonest cause of CCP, identified in 64 (51.6%) patients. Complete anterior pericardiectomy (CAP) was possible in 122 (98.3%) patients. All the patients had significant drop in their central venous pressure (CVP) (10.25 ± 3.47 mmHg) after surgery. The operative time (p = 0.008), intra-operative blood loss (p = 0.02), intensive care unit (ICU) stay (p = 0.03), and hospital stay (p = 0.028) were significantly higher in the TB group. Apart from TB, the other pre-operative variables that predicted adverse outcomes were male sex, presence of pleural effusion or ascites, and advanced New York Heart Association (NYHA) class. There were 7 (5.6%) post-operative complications and 3 (2.4%) in-hospital deaths.

Conclusion

The high incidence of TB CCP makes a pericardiectomy in developing countries technically more challenging resulting in increased operative time, more blood loss, and prolonged ICU and hospital stay, but did not affect in-hospital mortality or morbidity.

Risk factors for prolonged intensive care unit stays in patients after cardiac surgery with cardiopulmonary bypass: A retrospective observational study

Objectives

Patients after cardiac surgery with cardiopulmonary bypass (CPB) require a stay in the ICU postoperatively. This study aimed to investigate the incidence of prolonged length of stay (LOS) in the ICU after cardiac surgery with CPB and identify associated risk factors.

Methods

The current investigation was an observational, retrospective study that included 395 ICU patients who underwent cardiac surgery with CPB at a tertiary hospital in Guangzhou from June 2015 to June 2017. Data were obtained from the hospital database. Binary logistic regression modeling was used to analyze risk factors for prolonged ICU LOS.

Results

Of 395 patients, 137 (34.7%) had a prolonged ICU LOS (>72.0 h), and the median ICU LOS was 50.9 h. Several variables were found associated with prolonged ICU LOS: duration of CPB, prolonged mechanical ventilation and non-invasive assisted ventilation use, PaO₂/FiO₂ ratios within 6 h after surgery, type of surgery, red blood cell infusion during surgery, postoperative atrial arrhythmia, postoperative ventricular arrhythmia (all P < 0.05).

Conclusions

These findings are clinically relevant for identifying patients with an estimated prolonged ICU LOS, enabling clinicians to facilitate earlier intervention to reduce the risk and prevent resulting delayed recovery.

Predictors and reasons for inappropriate hospitalization days for surgical patients in a tertiary hospital in Wuhan, China: a retrospective study

BACKGROUND

Inappropriate hospitalization day (IHD) is recognized as an important indication of the excessive demand for health-care services, especially for surgical patients. We aim to examine the degree of IHDs, predictors associated with higher incidences of IHDs, and reasons for each IHD in different periods of hospitalization.

METHODS

A total of 4586 hospital days from 408 cases were evaluated by a cross-sectional and retrospective audit program carried out in a tertiary hospital with 5613 beds and 9623 faculty in Wuhan, China. This study used the revised Chinese version of the Appropriateness Evaluation Protocol (C-AEP) to assess IHDs, and the Delay Tool to ascertain each reason for IHDs. A binary logistic regression model was performed to examine the predictors of higher incidences of IHDs.

RESULTS

The average frequency of IHDs was 23.24 %, and a total of 322 cases (78.92 %) were reported to have experienced at least one IHD. The multivariate analysis showed that patients at the age of 60-69 with respect to under 50, and with overlength of stay were predictors of higher incidences of preoperative IHDs, while admission from outpatient, multiple diagnosis, higher surgical incision level, and overlength of stay were predictors of higher incidence of postoperative IHDs. The most frequent reasons related to health providers for IHDs were doctor's conservative views of patient management and delays in inspection, prescription, appointment, or result report. Patient factors gave rise to nearly a quarter of postoperative IHDs.

CONCLUSIONS

Findings from this study indicate that measures including paying more attention to the construction of MDT for diagnosis and treatment in general surgery, reducing laboratory turnaround time, dispelling distrust among health-care providers and patients, setting stricter discharge standards and, providing integrated out-of-hospital services could be adopted accordingly to improve the inappropriateness of hospital stays.

Risk factors associated with longer stays in cardiovascular surgical intensive care unit after CABG

BACKGROUND/PURPOSE

Monitoring ICU length of stay (LOS) after CABG and examining its risk factors can guide initiatives on the improvement of care. But few have evaluated this issue to include personal and clinical factors, and demands of ICU care. This study applied Donabedian model to identify risk factors for longer ICU stays after CABG. Lifestyle, clinical factors during and after CABG, TISS were viewed as structure factors, and infection and organ failures during ICU did as process factors.

METHODS

This retrospective cohort study used data via medical records at a medical center. A stratified randomized sample of 230 adults from a cohort of 690 isolated CABGs was to reflect the rate of 34.7% longer than 3-day-ICU LOS. The sample comprised of longer-stay group (n = 150) and shorter-stay group (n = 80).

RESULT

Hierarchical logistic regression analysis revealed that potential signs of infection (3-day average WBC higher than 10,000/μL, OR: 3.41 and the body temperature higher than 38 °C, OR:5.67) and acute renal failure (OR: 8.97) remained as the most significant predicted factors of stay longer than 3 ICU days. Along with higher TISS score within 24 hours (OR:1.06), structure factors of female gender (OR:4.16) smoking(OR: 4.87), higher CCI before surgery(OR:1.49), bypass during CABG (OR:3.51) had higher odds of risk to stay longer.

CONCLUSION

Further quality improvement initiatives to shorten ICU stay after CABG may include the promotion of a smoking cessation program in clinical practice, and better management of the manpower allocation, infection control and renal failure.

Adherence to blood product transfusion guidelines-An observational study of the current transfusion practice in a medical intensive care unit

BACKGROUND

Blood transfusions though life-saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the 'Choosing Wisely campaign'. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost.

OBJECTIVES

In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre-transfusion haemoglobin (Hb) ≥7 g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions.

METHODS

We conducted a retrospective observational study in a 64-bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N = 957) requiring packed red blood cell transfusion between January 2015 and December 2015.

RESULTS

In total, 3140 units were transfused with a mean pre-transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty-four (30%) transfusion events occurred with a pre-transfusion Hb ≥7 g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre-transfusion Hb ≥7 g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.88; p = 0.02) and LOS in patients with chronic blood loss (β₁ .8.26, 95% CI 4.09-12.43; p < 0.01).

CONCLUSION

A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.

The impact of pulmonary artery catheter use in cardiac surgery

OBJECTIVE

Pulmonary artery catheterization provides continuous monitoring of hemodynamic parameters that may aid in the perioperative management of patients undergoing cardiac surgery. However, prior data suggest that pulmonary artery catheterization has limited benefit in intensive care and surgical settings. Thus, this study sought to determine the impact of pulmonary artery catheter insertion on short-term postoperative outcomes in a large, contemporaneous cohort of patients undergoing open cardiac surgery compared with standard central venous pressure monitoring.

METHODS

This was an observational study of open cardiac surgeries from 2010 to 2018. Patients with pulmonary artery catheter insertion were identified and matched against patients without pulmonary artery catheter insertion via 1:1 nearest neighbor propensity matching. Multivariable analysis was performed to assess the impact of pulmonary artery catheterization on operative mortality in the overall cohort, as well as recent heart failure, mitral valve disease, and tricuspid insufficiency subgroups.

RESULTS

Of the 11,820 patients undergoing (Society of Thoracic Surgeons indexed) coronary or valvular surgery, 4605 (39.0%) had pulmonary artery catheter insertion. Propensity score matching yielded 3519 evenly balanced pairs. Compared with central venous pressure monitoring, pulmonary artery catheter use was not associated with improved operative mortality in the overall cohort or in the recent heart failure, mitral valve disease, or tricuspid insufficiency subgroups. Intensive care unit length of stay was longer (P < .001), and there were more packed red blood cell transfusions in the pulmonary artery catheterization group (P < .001); however, postoperative outcomes were otherwise similar, including stroke, sepsis, and new renal failure (P > .05).

CONCLUSIONS

These findings suggest that pulmonary artery catheterization may have limited benefit in cardiac surgery.

The long-term effects of prolonged intensive care stay postcardiac surgery

OBJECTIVES

Short-term outcomes for those with a prolonged length of stay (LOS) in intensive care (ITU) following cardiac surgery are poor, with higher rates of in-hospital mortality and morbidity. Consequently, discharge from hospital has been considered the key measure of success. However, there has been a shift towards long-term outcomes, functional recovery and quality of life (QoL) as measures of surgical quality. The aim of this review is to compare and critique the findings of multiple studies to determine the long-term effects of prolonged ITU stay postcardiac surgery.

METHODS

A computerized literature search of CINAHL, EMBASE and Google Scholar databases, based on keywords "long-term effects," "prolonged ITU stay," "cardiac surgery," with rigorous CASP critique was undertaken.

RESULTS

The search yielded 12 papers meeting the inclusion criteria, with eight retrospective and four prospective studies. Eight of these 12 papers identified inferior long-term survival or higher mortality rates for those who had prolonged LOS in ITU in comparison to "normal" LOS or a control. The greatest burden of mortality was 6 months to 1 year postdischarge. Three papers found that quality of life was adversely affected or worse for those who had experienced prolonged LOS in ITU.

CONCLUSIONS

Further research is required to provide better quality evidence into QoL, following prolonged stay in ICU postcardiac surgery. The evidence reviewed suggests that the risk of mortality in this demographic of patients is higher, especially within the first year and, therefore, more frequent medical surveillance of these patients is recommended.

A Nomogram for Predicting Long Length of Stay in The Intensive Care Unit in Patients Undergoing CABG: Results From the Multicenter E-CABG Registry

OBJECTIVE

Many papers evaluated predictive factors for prolonged intensive care unit (ICU) stay after cardiac surgery, but efforts in translating those models in practical clinical tools is lacking. The aim of this study was to build a new nomogram score and test its calibration and discrimination power for predicting a long length of stay in the ICU among patients undergoing coronary artery bypass graft surgery (CABG).

DESIGN

Retrospective analysis of an international registry.

SETTING

Multicentric.

PARTICIPANTS

Based on the european multicenter study on coronary artery bypass grafting (E-CABG) registry (NCT02319083), a total of 7,352 consecutive patients who underwent isolated CABG were analyzed.

INTERVENTIONS

A "long length of stay" in the ICU was considered when equal to or more than 3 days. Predictive factors were analyzed through a multivariate logistic regression model that was used for the nomogram.

RESULTS

Long length of ICU stay was observed in 2,665 patients (36.2%). Ten independent variables were included in the final regression model: the SYNTAX score class critical preoperative state, left ventricular ejection fraction class, angina at rest, poor mobility, recent potent antiplatelet use, estimated glomerular filtration rate class, body mass index, sex, and age. Based on this 10-risk factors logistic regression model, a nomogram has been designed.

CONCLUSION

The authors defined a nomogram model that can provide an individual prediction of long length of ICU stay in cardiovascular surgical patients undergoing CABG. This type of model would allow an early recognition of high-risk patients who might receive different preoperative and postoperative treatments to improve outcomes.

Adverse outcomes of delayed intensive care unit

OBJECTIVE

To examine the impact of delayed transfer from the emergency room into the intensive care unit on the length of intensive care unit stay and death.

METHODS

This prospective, cohort study performed in a tertiary academic hospital obtained data from 1913 patients admitted to the emergency room with a documented request for admission into the intensive care unit. The patients admitted directly into the medical-surgical intensive care unit (n = 209) were categorized into tertiles according to their waiting time for intensive care unit admission (Group 1: < 637 min, Group 2: 637 to 1602 min, and Group 3: > 1602 min). Patients who stayed in the intensive care unit for longer than 3.2 days (median time of intensive care unit length of stay of all patients) were considered as having a prolonged intensive care unit stay.

RESULTS

A total of 6,176 patients were treated in the emergency room during the study period, among whom 1,913 (31%) required a bed in the intensive care unit. The median length of stay in the emergency room was 17 hours [9 to 33 hours]. Hospitalization for infection/sepsis was an independent predictor of prolonged intensive care unit stay (OR 2.75 95%CI 1.38 - 5.48, p = 0.004), but waiting time for intensive care unit admission was not. The mortality rate was higher in Group 3 (38%) than in Group 1 (31%) but the difference was not statistically significant.

CONCLUSION

Delayed admission into the intensive care unit from the emergency room did not result in an increased intensive care unit stay or mortality.

Epidemiology of long-stay patients in the pediatric intensive care unit: prevalence, characteristics, resource consumption and complications

Background

The impact of pediatric intensive care unit (PICU) utilization and resource consumption among long-stay patients has not been characterized recently. This study aimed to describe the resource consumption and characteristics of long-stay patients in a PICU.

Methods

This was a single-center descriptive cohort study of 1309 patients admitted to a PICU in 2017. The main outcome was ICU length of stay (LOS). Patients were divided into prolonged LOS (PLS) and non-PLS groups if they had an LOS of ≥ 28 or < 28 days, respectively. Two groups were compared to characterize PLS.

Results

Thirty-two (2.4%) patients had a PLS and utilized 33% of PICU bed days. Factors associated with PLS with odds ratio [95% confidence interval (CI)] were being a neonate (7.8 [2.5-25.4], p = <0.001), being an infant (2.9 [1.0-9.0], p = 0.04), admission for a respiratory ailment (7.3 [1.6-44.2], p = 0.003), cardiovascular dysfunction (24.1 [4.8-152.1], p = <0.001), post-cardiac operation (8.0 [1.7-50.1], p = 0.003), post-cardiopulmonary arrest (22.8 [1.7-211.9], p = 0.01), and transfer from another facility (4.2 [1.8-10.7], p = 0.001). PLS patients developed more nosocomial infections and disproportionately received monitoring and therapeutic resources.

Conclusions

A PLS was associated with substantial PICU utilization and complication rates. Future studies should aim to alleviate both institutional and patient-related issues in the affected population harboring possible risk factors for PLS.

Associations Between Perioperative Crystalloid Volume and Adverse Outcomes in Five Surgical Populations

BACKGROUND

Optimal administration of fluids is an important part of enhanced recovery after surgery (ERAS) protocols. We sought to examine the relationship between perioperative crystalloid volume and adverse outcomes in five common types of surgical procedures with ERAS fluid guidelines in place where large randomized controlled trials have not been conducted: breast reconstruction, bariatric, major urologic, gynoncologic, and head and neck oncologic procedures.

METHODS

This retrospective cohort study included patients who had undergone any one of the aforementioned procedures within any facility in a large multihospital alliance (Premier, Inc, Charlotte, NC) between 2008 and 2014. We used multivariable generalized additive models to examine relationships between the total crystalloid volume (TCV) on the day of surgery and a composite adverse outcome of prolonged (>75th percentile) hospital or intensive care unit stay or in-hospital mortality. Models were constructed separately within each surgical category and adjusted for demographic, clinical, and hospital characteristics. Informed consent requirements were waived because deidentified data were used.

RESULTS

We identified 83,685 patients within 312 US hospitals undergoing breast reconstruction (n = 8738), bariatric surgery (n = 8067), major urologic surgery (n = 28,654), gynoncologic surgery (n = 34,559), and head/neck oncology surgery (n = 3667). There was significant patient-independent variation in TCV. Probabilities of adverse outcomes increased at a TCV below 3 L and above 6 L for all types of surgeries except bariatric surgery, where larger volumes were associated with progressively better outcomes.

CONCLUSIONS AND RELEVANCE

Relationships between TCV and adverse outcomes were generally J shaped with higher volumes (>6 L) associated with increased risk. As per current ERAS guidelines, it is important to avoid excessive crystalloid volume in most surgical procedures except for bariatric surgery.

The Impact of an Attending Intensivist on the Clinical Outcomes of Patients Admitted to the Cardiac Surgical Intensive Care Unit after Coronary Artery Bypass Grafting

Background

We aimed to investigate the associations of critical care provided in a cardiac surgical intensive care unit (CSICU) staffed by an attending intensivist with improvements in intensive care unit (ICU) quality and reductions in postoperative complications.

Methods

Patients who underwent elective isolated coronary artery bypass grafting (CABG) between January 2007 and December 2012 (the control group) were propensity-matched (1:1) to CABG patients between January 2013 and June 2018 (the intensivist group).

Results

Using propensity score matching, 302 patients were extracted from each group. The proportion of patients with at least 1 postoperative complication was significantly lower in the intensivist group than in the control group (17.2% vs. 28.5%, p=0.001). In the intensivist group, the duration of mechanical ventilation (6.4±13.7 hours vs. 13.7±49.3 hours, p=0.013) and length of ICU stay (28.7±33.9 hours vs. 41.7±90.4 hours, p=0.018) were significantly shorter than in the control group. The proportions of patients with prolonged mechanical ventilation (2.3% vs. 7.6%, p=0.006), delirium (1.3% vs. 6.3%, p=0.003) and acute kidney injury (1.3% vs. 5.3%, p=0.012) were significantly lower in the intensivist group than in the control group.

Conclusion

A transition from an open ICU model with trainee coverage to a closed ICU model with attending intensivist coverage can be expected to yield improvements in CSICU quality and reductions in postoperative complications.

Pediatric Trauma Patient Intensive Care Resource Utilization in U.S. Military Operations in Iraq and Afghanistan

Children represent a unique patient population treated by military personnel during wartime, as seen in the recent conflicts in Iraq and Afghanistan. We sought to describe ICU resource utilization by U.S. military personnel treating pediatric trauma patients in Iraq and Afghanistan.

Volume-outcome relationship in pediatric neurotrauma care: analysis of two national databases

OBJECTIVE

Previous research has demonstrated the association between increased hospital volume and improved outcomes for a wide range of neurosurgical conditions, including adult neurotrauma. The authors aimed to determine if such a relationship was also present in the care of pediatric neurotrauma patients.

METHODS

The authors identified 106,146 pediatric admissions for traumatic intracranial hemorrhage (tICH) in the National Inpatient Sample (NIS) for the period 2002–2014 and 34,017 admissions in the National Trauma Data Bank (NTDB) for 2012–2015. Hospitals were stratified as high volume (top 20%) or low volume (bottom 80%) according to their pediatric tICH volume. Then the association between high-volume status and favorable discharge disposition, inpatient mortality, complications, and length of stay (LOS) was assessed. Multivariate regression modeling was used to control for patient demographics, severity metrics, hospital characteristics, and performance of neurosurgical procedures.

RESULTS

In each database, high-volume hospitals treated over 60% of pediatric tICH admissions. In the NIS, patients at high-volume hospitals presented with worse severity metrics and more frequently underwent neurosurgical intervention over medical management (all p < 0.001). After multivariate adjustment, admission to a high-volume hospital was associated with increased odds of a favorable discharge (home or short-term facility) in both databases (both p < 0.001). However, there were no significant differences in inpatient mortality (p = 0.208). Moreover, high-volume hospital patients had lower total complications in the NIS and lower respiratory complications in both databases (all p < 0.001). Although patients at high-volume hospitals in the NTDB had longer hospital stays (β-coefficient = 1.17, p < 0.001), they had shorter stays in the intensive care unit (β-coefficient = 0.96, p = 0.024). To determine if these findings were attributable to the trauma center level rather than case volume, an analysis was conducted with only level I pediatric trauma centers (PTCs) in the NTDB. Similarly, treatment at a high-volume level I PTC was associated with increased odds of a favorable discharge (OR 1.28, p = 0.009), lower odds of pneumonia (OR 0.60, p = 0.007), and a shorter total LOS (β-coefficient = 0.92, p = 0.024).

CONCLUSIONS

Pediatric tICH patients admitted to high-volume hospitals exhibited better outcomes, particularly in terms of discharge disposition and complications, in two independent national databases. This trend persisted when examining level I PTCs exclusively, suggesting that volume alone may have an impact on pediatric neurotrauma outcomes. These findings highlight the potential merits of centralizing neurosurgery and pursuing regionalization policies, such as interfacility transport networks and destination protocols, to optimize the care of children affected by traumatic brain injury.

Cardiac protective effects of remote ischaemic preconditioning in children undergoing tetralogy of fallot repair surgery: a randomized controlled trial

Aims

Remote ischaemic preconditioning (RIPC) by inducing brief ischaemia in distant tissues protects the heart against myocardial ischaemia-reperfusion injury (IRI) in children undergoing open-heart surgery, although its effectiveness in adults with comorbidities is controversial. The effectiveness and mechanism of RIPC with respect to myocardial IRI in children with tetralogy of Fallot (ToF), a severe cyanotic congenital cardiac disease, undergoing open heart surgery are unclear. We hypothesized that RIPC can confer cardioprotection in children undergoing ToF repair surgery.

Methods and results

Overall, 112 ToF children undergoing radical open cardiac surgery using cardiopulmonary bypass (CPB) were randomized to either a RIPC group (n = 55) or a control group (n = 57). The RIPC protocol consisted of three cycles of 5-min lower limb occlusion and 5-min reperfusion using a cuff-inflator. Serum inflammatory cytokines and cardiac injury markers were measured before surgery and after CPB. Right ventricle outflow tract (RVOT) tissues were collected during the surgery to assess hypoxia-inducible factor (Hif)-1α and other signalling proteins. Cardiac mitochondrial injury was assessed by electron microscopy. The primary results showed that the length of stay in the intensive care unit (ICU) was longer in the control group than in the RIPC group (52.30 ± 13.43 h vs. 47.55 ± 10.34 h, respectively, P = 0.039). Patients in the control group needed longer post-operative ventilation time compared to the RIPC group (35.02 ± 6.56 h vs. 31.96 ± 6.60 h, respectively, P = 0.016). The levels of post-operative serum troponin-T at 12 and 18 h, CK-MB at 24 h, as well as the serum h-FABP levels at 6 h, after CPB were significantly lower, which was coincident with significantly higher protein expression of cardiac Hif-1α, p-Akt, p-STAT3, p-STAT5, and p-eNOS and less vacuolization of mitochondria in the RIPC group compared to the control group.

Conclusion

In ToF children undergoing open heart surgery, RIPC attenuates myocardial IRI and improves the short-term prognosis.

Survival, Quality of Life, and Functional Status Following Prolonged ICU Stay in Cardiac Surgical Patients: A Systematic Review

OBJECTIVES

Compared with noncardiac critical illness, critically ill postoperative cardiac surgical patients have different underlying pathophysiologies, are exposed to different processes of care, and thus may experience different outcome trajectories. Our objective was to systematically review the outcomes of cardiac surgical patients requiring prolonged intensive care with respect to survival, residential status, functional recovery, and quality of life in both hospital and long-term follow-up.

DATA SOURCES

MEDLINE, Embase, CINAHL, Web of Science, and Dissertations and Theses Global up to July 21, 2017.

STUDY SELECTION

Studies were included if they assessed hospital or long-term survival and/or patient-centered outcomes in adult patients with prolonged ICU stays following major cardiac surgery. After screening 10,159 citations, 114 articles were reviewed in full; a final 34 articles met criteria for data extraction.

DATA EXTRACTION

Two reviewers independently extracted data and assessed risk of bias using the National Institutes of Health Quality Assessment Tool for Observational Studies. Extracted data included the used definition of prolonged ICU stay, number and characteristics of prolonged ICU stay patients, and any comparator short stay group, length of follow-up, hospital and long-term survival, residential status, patient-centered outcome measure used, and relevant score.

DATA SYNTHESIS

The definition of prolonged ICU stay varied from 2 days to greater than 14 days. Twenty-eight studies observed greater in-hospital mortality among all levels of prolonged ICU stay. Twenty-five studies observed greater long-term mortality among all levels of prolonged ICU stay. Multiple tools were used to assess patient-centered outcomes. Long-term health-related quality of life and function was equivalent or worse with prolonged ICU stay.

CONCLUSIONS

We found consistent evidence that patients with increases in ICU length of stay beyond 48 hours have significantly increasing risk of hospital and long-term mortality. The significant heterogeneity in exposure and outcome definitions leave us unable to precisely quantify the risk of prolonged ICU stay on mortality and patient-centered outcomes.

Faster Transition From Intravenous to Oral Antihypertensives Associated With Improved Outcomes After Aortic Dissection

Background: After stabilization with intravenous (IV) antihypertensives, the impact of speed-of-transition from IV to enteral (PO) medications in the intensive care unit (ICU) is unknown. Objective: To assess ICU length of stay (LOS) based on transition time from IV to PO antihypertensive therapy. Methods: Retrospective study of aortic dissection patients admitted from June 2013 to July 2017 at a tertiary teaching hospital. Patients were grouped based on achieving full transition to PO medications in either ≤72 hours or >72 hours from the first PO dose. Secondary end points included hospital LOS, IV infusion volume, medication cost, and time spent with arterial/central lines. Results: A total of 56 patients transitioned completely from IV to PO therapy in ≤72 hours, and 72 patients required more than 72 hours. Demographics, IV and PO medication choices, and timing of first PO medication administration were similar between groups. ICU LOS was shorter in the group transitioned in ≤72 hours compared with those who took longer to transition (3.6 vs 10.5 days; P < 0.001). Hospital LOS, IV infusion volume, and cost were also significantly lower in the ≤72-hour group (P < 0.001). The rapid transition group also spent less time with arterial lines (44 vs 156 hours, P < 0.001) and central lines (45 vs 242 hours, P < 0.001). Conclusion and Relevance: In this cohort, transitioning to PO antihypertensives in ≤72 hours was associated with shorter ICU LOS and improvement in other measured outcomes. These observational data are the first to describe a potentially critical juncture in postdissection care; a prospective study is warranted.

Effects of Remote Ischemic Preconditioning in Patients Undergoing Off-Pump Coronary Artery Bypass Graft Surgery

Purpose

This study aimed to evaluate effects of remote ischemic preconditioning (RIPC) on myocardial injury in patients undergoing off-pump coronary artery bypass graft surgery (OPCABG).

Methods

Sixty-five patients scheduled for the OPCABG were randomly assigned to control (n = 32) or RIPC group (n = 33). All patients received general anesthesia. Before the surgical incision, RIPC was induced on an upper limb with repeated 5-min ischemia and 5-min reperfusion for four times. Blood samples were collected from right internal jugular vein. Plasma levels of IL-6, IL-8, IL-10, TNF-α, cTnT, HFABP, IMA, and MDA were detected at pre-operatively and 0, 6, 18, 24, 48, 72, and 120 h after the surgery. Left internal mammary artery (LIMA) and great saphenous vein (GSV) was cut into 2–3 mm for Western blot analysis of Hif-1α.

Results

In the present study, RIPC treatment significantly reduced plasma levels of cardiac troponin T (p < 0.05), heart-type fatty acid binding protein (p < 0.05), ischemia modified albumin (p < 0.05), malondialdehyde (p < 0.05), as well as plasma levels of pro-inflammatory cytokines including IL-6, IL-8, and TNF-α (P < 0.05, respectively). RIPC treatment significantly increased hypoxia-inducible factor-1α (p < 0.05) expression as well. Mechanical ventilation time for postoperative patients was shortened in RIPC group than those in control group (17.4 ± 3.8 h vs. 19.7 ± 2.9 h, respectively, p < 0.05).

Conclusion

RIPC by upper limb ischemia shortens mechanical ventilation time in patients undergoing OPCABG. RIPC treatment reduces postoperative myocardial enzyme expression and pro-inflammatory cytokine production. RIPC is a protective therapeutic approach in the coronary artery bypass graft surgery.

Prolonged Intensive Care Unit Stay Following Transcatheter Aortic Valve Replacement

PURPOSE

Postoperative intensive care unit (ICU) stay after cardiac surgeries has been extensively studied, but little attention has been given to ICU stay following transcatheter aortic valve replacement (TAVR). This study examined ICU stay after TAVR.

METHODS

Two hundred and forty-five patients who underwent TAVR between April 2010 and October 2016 were studied retrospectively. We investigated the status of ICU stay, the predictors of prolonged ICU stay (PICUS), and its impact on short- and long-term outcomes. Prolonged ICU stay was defined as post-TAVR ICU stay longer than 2 days (day of TAVR + 1 day).

RESULTS

Length of ICU stay was 2.6 ± 4.9 days, and PICUS was identified in 14.7% of the patients. The predominant reason for PICUS was congestive heart failure or circulatory failure (41.7%). Pulmonary dysfunction and nontransfemoral approach were independent predictors of PICUS (pulmonary dysfunction: odds ratio = 2.64, 95% confidence interval [CI]: 1.05-7.35; nontransfemoral approach: odds ratio = 2.81, 95% CI: 1.15-6.89). Prolonged ICU stay was associated with higher rate of 30-day combined end point (PICUS vs non-PICUS: 44.4% vs 3.3%, P < .0001), longer postoperative hospital stay (49.9 ± 141.9 days vs 12.0 ± 6.0 days, P < .0001), and lower rate of discharge home (77.8% vs 95.2%, P = .0002). Patients with PICUS had worse long-term survival (P < .0001), and PICUS was a predictor of mortality (hazard ratio: 4.21, 95% CI: 2.09-8.22).

CONCLUSION

Prolonged ICU stay following TAVR was found in 14.7%, and pulmonary dysfunction and nontransfemoral approach were associated with PICUS. Short- and long-term prognoses were worse in patients with PICUS than those without.

Impact of Obesity on Intensive Care Unit Resource Utilization After Cardiac Operations

BACKGROUND

Much has been published about the effect of obesity on adverse outcomes after cardiac operations, yet little is known regarding the effect of obesity on intensive care unit (ICU) resource utilization. This study examined the effect of obesity on ICU resource utilization after cardiac operations.

METHODS

All patients with a body mass index (BMI) of 18.5 kg/m² or higher who underwent a cardiac surgical procedure between 2006 and 2013 were stratified into the following weight categories: normal (BMI 18.5 to 24.99 kg/m²), preobese (BMI 25 to 29.99 kg/m²), obese class I (BMI 30 to 34.99 kg/m²), obese class II (BMI 35 to 39.99 kg/m²), and obese class III (BMI ≥40 kg/m²). Comparisons between weight categories were done, and the risk-adjusted effect of weight category on prolonged ICU stay, prolonged ventilation, and ICU readmission was determined.

RESULTS

Of the 5,365 included patients, 1,948 were obese. Patients with greater obesity experienced longer ICU time, longer ventilation time, and increased ICU readmission. After adjustment, increasing obesity remained independently associated with greater likelihood of prolonged ICU stay (obese class II: odds ratio [OR], 2.4; 95% confidence interval [CI], 1.55 to 3.61; obese class III: OR, 4.1; 95% CI, 2.38 to 7.05), prolonged ventilation (obese class III: OR, 3.4; 95% CI, 1.57 to 7.22), and ICU readmission (obese class II: OR, 3.0; 95% CI, 1.70 to 5.31; obese class III: OR, 2.9; 95% CI, 1.32 to 6.36).

CONCLUSIONS

Increasing obesity was associated with a significant increase in ICU resource utilization after cardiac operations. Further study is needed to determine the mechanisms underlying this association and how the adverse effects of obesity may be mitigated.

[Predictors of prolonged ICU stay following elective adult cardiac surgery: Monocentric retrospective study on 5 and half years]

AIM

The aim of our study was to identify predictors for prolonged ICU stay following elective adult cardiac surgery under cardiopulmonary bypass.

PATIENTS AND METHODS

A retrospective study was conducted during 5 years and a half period. Were included, patients age≥18 years old, underwent elective cardiac surgery under cardiopulmonary bypass. Patients who died within 48hours of surgery were excluded. Prolonged ICU stay was defined as stay in the ICU for 48hours or more.

RESULTS

During the review period, 610 patients were included. One hundred and sixty-four patients have required a prolonged ICU stay (26.9 %). In multivariate analysis, 5 predictors were identified: ejection fraction<30 % (OR 19.991, IC 95 % [1.382-289.1], P=0.028], pulmonary hypertension (OR 2.293, IC 95 % [1.058-4.973], P=0.036), prolonged ventilation (≥12hours) (OR 4.026, IC 95 % [2.407-6.733], P<0.001). Number of blood units transfused (OR 1.568, IC 95 % [1.073-2.291], and postoperative acute renal failure (OR 2.620, IC 95 % [1.026-6.690], P=0.044]. Prolonged ICU stay is significantly associated with prolonged hospital stay (17 days vs 13 days ; P<0.001) and higher in hospital mortality (22 % vs. 3 %, P<0.001).

CONCLUSION

The identification of these patients at risk of prolonged ICU stay is crucial. It will aid to plan prophylactic measures to optimize their support.

Outcomes of Patients With Prolonged Intensive Care Unit Length of Stay After Cardiac Surgery

OBJECTIVE

To determine in-hospital and post-discharge long-term survival in patients with prolonged intensive care unit (ICU) stays after cardiac surgery.

DESIGN

Retrospective, cohort study of cardiac surgery patients from May 2007 to June 2012.

SETTING

Single-center cardiac surgery ICU.

PARTICIPANTS

Patients were grouped according to length of ICU stay: between 1 and 2 weeks, between 2 and 4 weeks, and>4 weeks.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 4,963 patients, 3.3%, 1.6%, and 2.9% of patients stayed 1 to 2 weeks, 2 to 4 weeks, and>4 weeks in the ICU, respectively. In-hospital mortality was 11.1%, 26.6%, and 31.0% for patients with 1 to 2 weeks, 2 to 4 weeks, and>4 weeks ICU stay, respectively. Patients with ICU stays between 1 and 2 weeks had 6 months, 1 year, and 2 year survival rates of 84.4%, 80.0%, and 75.3% after discharge, respectively. Patients with ICU stay between 2 and 4 weeks had similar 6 months, 1 year, and 2 year survival rates of 84.7%, 79.9%, and 74.1%, respectively. In contrast, patients with>4 week ICU stays had significantly lower postdischarge survival rates of 63.3%, 56.4%, and 41.1% at 6 months, 1 year, and 2 years, respectively. Postoperative stroke conferred the greatest risk of death within 1 year after discharge (odds ratio 7.6, p = 0.0140).

CONCLUSIONS

In-hospital mortality rates post-cardiac surgery correlate with length of ICU stay but appear to plateau after 4 weeks. However, a>4 week ICU length of stay confers a worse long-term outcome post-hospital discharge, especially in patients with postoperative stroke.

Post-intubation tracheal stenosis after management of complicated aortic dissection: a case series

BACKGROUND

Patients undergoing total aortic arch replacement or aortic dissecting aneurysmectomy are generally managed with medications to control hypotension and blood coagulation to minimize mortality and morbidity. However, prolonged mechanical ventilation via tracheal intubation increases the risk of tracheal stenosis in such patients.

CASE PRESENTATION

We present 2 cases (a 49-year-old woman and a 62-year-old man) of post-intubation tracheal stenosis occurring after surgery for the correction of complicated aortic dissection; both cases were successfully managed by tracheal cryotherapy.

CONCLUSION

Continuous monitoring of cuff pressure and regular cuff palpation are necessary to minimize the incidence of tracheal stenosis. If the patients have concomitant local or systemic infection, adequate preventive measures should be taken to reduce the incidence of post-intubation tracheal stenosis. Tracheal cryotherapy is recommendable for the management of post-intubation tracheal stenosis.

Transfusion of 1 and 2 units of red blood cells does not increase mortality and organ failure in patients undergoing isolated coronary artery bypass grafting

OBJECTIVES

In cardiac surgery, the association between red blood cell (RBC) transfusion and clinical outcome is elusive. We investigated in a large cohort of patients who underwent isolated coronary artery bypass grafting (CABG) the effect of transfusion of 1-2 units of leucocyte-depleted RBCs on mortality and multiorgan failure.

METHODS

The investigation included all patients from July 2009 to June 2014 who underwent CABG at our institution and received no (n = 1478) or 1-2 units of RBCs (n = 1528). The primary end-point was 30-day mortality; secondary end-points were major organ dysfunction. A subgroup analysis assessed the effect of the duration of RBC storage on patient outcome. Statistical analysis was performed using propensity score (PS) adjustment.

RESULTS

The 30-day mortality rate was 0.3% in the RBC- group and 0.2% in the RBC+ group. Compared with the RBC- group, PS-adjusted odds ratio (OR) of 30-day mortality in the RBC+ group was 0.29 [95% confidence interval (CI): 0.06-1.50; P = 0.14]. PS-adjusted OR of a 'prolonged intensive care unit (ICU) stay' (>48 h) was significantly higher in the RBC+ group than in the RBC- group [OR 1.49 (95% CI: 1.14-1.95); P = 0.004], but major clinical complications such as low cardiac output syndrome, stroke, haemofiltration, wound infection and prolonged mechanical ventilator support (>24 h) did not differ significantly between groups. Duration of blood storage was not independently associated with clinical outcome.

CONCLUSIONS

Our data do not indicate a transfusion-related increase in mortality and multiorgan failure in patients undergoing isolated CABG.

Inclusion of 'ICU-Day' in a Logistic Scoring System Improves Mortality Prediction in Cardiac Surgery

Background

Prolonged intensive care unit (ICU) stay is a predictor of mortality. The length of ICU stay has never been considered as a variable in an additive scoring system. How could this variable be integrated into a scoring system? Does this integration improve mortality prediction?

Material/Methods

The ‘modified CArdiac SUrgery Score’ (CASUS) was generated by implementing the length of stay as a new variable to the ‘additive CASUS’. The ‘logistic CASUS’ already considers this variable. We defined outcome as ICU mortality and statistically compared the three CASUS models. Discrimination, comparison of receiver operating characteristic curves (DeLong’s method), and calibration (observed/expected ratio) were analyzed on days 1–13.

Results

Between 2007 and 2010, we included 5207 cardiac surgery patients in this prospective study. The mean age was 67.2±10.9 years. The mean length of ICU stay was 4.6±7.0 days and ICU mortality was 5.9%. All scores had good discrimination, with a mean area under the curve of 0.883 for the additive and modified, and 0.895 for the ‘logistic CASUS’. DeLong analysis showed superiority in favor of the logistic model as from day 5. The calibration of the logistic model was good. We identified overestimation (days 1–5) and accurate (days 6–9) calibration for the additive and ‘modified CASUS’. The ‘modified CASUS’ remained accurate but the ‘additive CASUS’ tended to underestimate the risk of mortality (days 10–13).

Conclusions

The integration of length of ICU stay as a variable improves mortality prediction significantly. An ‘ICU-day’ variable should be included into a logistic but not an additive model.

A meta-analysis to derive literature-based benchmarks for readmission and hospital mortality after patient discharge from intensive care

Introduction

We sought to derive literature-based summary estimates of readmission to the ICU and hospital mortality among patients discharged alive from the ICU.

Methods

We searched MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials from inception to March 2013, as well as the reference lists in the publications of the included studies. We selected cohort studies of ICU discharge prognostic factors that in which readmission to the ICU or hospital mortality among patients discharged alive from the ICU was reported. Two reviewers independently abstracted the number of patients readmitted to the ICU and hospital deaths among patients discharged alive from the ICU. Fixed effects and random effects models were used to estimate the pooled cumulative incidence of ICU readmission and the pooled cumulative incidence of hospital mortality.

Results

The analysis included 58 studies (n = 2,073,170 patients). The majority of studies followed patients until hospital discharge (n = 46 studies) and reported readmission to the ICU (n = 46 studies) or hospital mortality (n = 49 studies). The cumulative incidence of ICU readmission was 4.0 readmissions (95% confidence interval (CI), 3.9 to 4.0) per 100 patient discharges using fixed effects pooling and 6.3 readmissions (95% CI, 5.6 to 6.9) per 100 patient discharges using random effects pooling. The cumulative incidence of hospital mortality was 3.3 deaths (95% CI, 3.3 to 3.3) per 100 patient discharges using fixed effects pooling and 6.8 deaths (95% CI, 6.1 to 7.6) per 100 patient discharges using random effects pooling. There was significant heterogeneity for the pooled estimates, which was partially explained by patient, institution and study methodological characteristics.

Conclusions

Using current literature estimates, for every 100 patients discharged alive from the ICU, between 4 and 6 patients on average will be readmitted to the ICU and between 3 and 7 patients on average will die prior to hospital discharge. These estimates can inform the selection of benchmarks for quality metrics of transitions of patient care between the ICU and the hospital ward.

Factors influencing prolonged ICU stay after open heart surgery

Background:

There are different risk factors that affect the intensive care unit (ICU) stay after cardiac surgery.

Objectives:

The aim of this study was to evaluate possible risk factors influencing prolonged ICU stay in a large referral hospital.

Patients and Methods:

We conducted a case-control study to determinate causes of prolonged ICU stay in 280 adult patients undergoing cardiac surgery in a tertiary care center for cardiovascular patients, Tehran, Iran. These patients were divided into two groups according to ICU stay ≤ 96 and > 96 hours. We evaluated perioperative risk factors of ICU stay > 96 hours.

Results:

Among the 280 patients studied, 184 (65.7%) had stayed ≤ 96 hours and 96 (34.3%) had stayed > 96 hours in ICU. Frequency of prolonged ICU stay was 34.2% in patients undergoing coronary artery bypass graft (CABG), 30.8% in patients with valve surgery, and 44.8% in patients with CABG plus valve surgery. Patients with > 96 hours of ICU stay received more blood transfusion and intravenous inotropes. They also had longer anesthesia, cardiopulmonary bypass, and postoperative intubation time. There were higher incidence of postoperative tamponade, re-exploration, re-intubation, hemodialysis, and hypotension in this group (P < 0.05 for all comparisons).

Conclusions:

In this study, about one-third of patients had prolonged ICU stay. Factors influencing prolonged ICU stay were medical and some non-medical factors. In the present study, up to 30% of the patients had a prolonged ICU stay of > 96 hours. Additional data from well-designed investigations are needed for further assessment of the factors influencing prolonged ICU stay after cardiac surgery.