Sustainability of clinical pathway guided care in cardiac surgery ICU patients; 9-years experience in over 7500 patients

2018 ◽  
Vol 31 (6) ◽  
pp. 456-463
Author(s):  
B M van der Kolk ◽  
M van den Boogaard ◽  
J G van der Hoeven ◽  
L Noyez ◽  
P Pickkers
Keyword(s):  
Cardiac Surgery ◽  
Intensive Care ◽  
Clinical Outcome ◽  
Clinical Pathway ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Icu Patients ◽  
Complex Patients ◽  
Intensive Care Stay ◽  
Over Time

Abstract Objective To determine trends over time regarding inclusion of post-operative cardiac surgery intensive care unit (ICU) patients in a clinical pathway (CP), and the association with clinical outcome. Design Retrospective cohort study. Setting ICU of an academic hospital. Participants All cardiac surgery patients operated between 2007 and 2015. Measures and Results A total of 7553 patients were operated. Three patient groups were identified: patients treated according to CP (n = 6567), patients excluded from the CP within the first 48 h (n = 633) and patients never included in CP (n = 353). Patients treated according to CP increased significantly over time from 74% to 95% and the median Log EuroSCORE (predicted mortality score) in this group increased significantly over time (P = 0.016). In-hospital length of stay (LOS) decreased in all groups, but significantly in CP group (P < 0.001). Overall, the in-hospital, and 1-year mortality decreased from 1.5 to 1.1% and 3.7 to 2.9%, respectively (both P < 0.05). Patients with a Log EuroSCORE >10 were more likely excluded from CP (P < 0.001), but, if included in CP, these patients had a significantly shorter Intensive Care stay and in-hospital stay compared to excluded patients with a Log EuroSCORE >10 (both P < 0.001). Conclusions The use of a CP for all post-operative cardiac surgery patients in the ICU is sustainable. While more complex patients were treated according to the CP, clinical outcome improved in the CP group.

Cardiac Safety of Clonidine and Quetiapine in Post-Cardiac Surgery Intensive Care Unit Patients

2021 ◽  
pp. 089719002110446
Author(s):  
Abdulrahman I. Alshaya ◽  
James F. Gilmore ◽  
Rebecca M. Nashett ◽  
Mary P. Kovacevic ◽  
Kevin M. Dube ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Length Of Stay ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Apache Ii Score ◽  
Cardiac Safety ◽  
Icu Patients ◽  
Safety Outcomes

Background: Clonidine and quetiapine are frequently used medications in the cardiac surgery intensive care unit (ICU). Objective: The purpose of this study is to assess the impact of clonidine compared to quetiapine on cardiac safety outcomes in adult cardiac surgery ICU patients. Methods: This was a single-center, retrospective observational analysis at a tertiary care, academic medical center. Results: One hundred and sixty-one cardiac surgery patients who were administered clonidine or quetiapine during their ICU stay were included between June 2015 and May 2017. The major endpoint of this study was a cardiac safety composite of bradycardia, hypotension, and QTc prolongation. Minor endpoints included ICU and hospital length of stay, and in-hospital mortality. There were 115 patients included in the clonidine arm and 46 patients in the quetiapine arm. There was no difference between groups with regard to the major endpoint (30.43% vs 33.15%; P < .8). There was a shorter ICU and hospital length of stay in the clonidine arm compared to quetiapine P < .0001. All other endpoints were not statistically significant. Conclusion: Patients who received clonidine tended to have undergone less complex procedures, be younger, and have a lower APACHE II score than patients who received quetiapine. The incidence of composite cardiac safety outcomes was not different in clonidine compared to quetiapine in cardiac surgery ICU patients.

scholarly journals Impact of Bedside Re-Explorations in a Cardiovascular Surgery Intensive Care Unit Led by Surgeons

2021 ◽  
Vol 10 (19) ◽  
pp. 4288
Author(s):  
Alessandro Affronti ◽  
Elena Sandoval ◽  
Anna Muro ◽  
Jose Hernández-Campo ◽  
Eduard Quintana ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Primary Outcome ◽  
Kidney Injury ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Deep Sternal Wound Infection ◽  
Major Morbidity ◽  
Prolonged Intubation

Surgical re-explorations represent 3–5% of all cardiac surgery. Concerns regarding mortality and major morbidity of re-explorations in the intensive care unit (ICU) setting exist. We sought to investigate whether they may have different outcomes compared with those performed in the operating room (OR). Single center retrospective review of patients who underwent mediastinal re-exploration in the ICU or in the OR after cardiac surgery. Mediastinal re-explorations were also classified as: “planned” and “unplanned”. Primary outcome was 30-day mortality, secondary outcomes include deep sternal wound infection (DSWI), sepsis, ICU and hospital length of stay, prolonged intubation (>72 h), tracheostomy, pneumonia, acute kidney injury requiring dialysis and stroke. Between 2010 and 2019, 195 of 7263 patients (2.7%) underwent mediastinal re-exploration after cardiac surgery. More patients in the ICU group experienced two or more re-explorations (30.3% vs 2.3%, p < 0.001), a higher incidence of postoperative pneumonia (22% vs 7%, p = 0.004), prolonged intubation (46.8% vs 19.8%, p < 0.001) and longer hospital stay (30.3 ± 34.2 vs. 20.8 ± 18.3 days, p = 0.014). There were no differences in mortality between ICU and OR (16.5% vs. 13.9%, p = 0.24) nor in sepsis (14.7% vs 7%, p = 0.91) and DSWI rates (1.8% vs 1.2%, p = 0.14). Re-explorations in the ICU were not associated with increased mortality, sepsis and mediastinitis rate.

scholarly journals Sedative use of Dexmedetomidine vs. Propofol after Cardiac Surgery: A critical review and meta-analysis.

2019 ◽  
Author(s):  
Hesham Abowali ◽  
Matteo Paganini ◽  
Garrett A Enten ◽  
Ayman Elbadawi ◽  
Enrico Camporesi
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Length Of Stay ◽  
Hospital Length ◽  
Time Dependent ◽  
Hospital Length Of Stay ◽  
Ventilation Time ◽  
Mechanical Ventilation Time

Abstract Abstract Background : The use of dexmedetomidine for sedation post-cardiac surgery is controversial compared to the use of propofol. Methods : A computerized search on Medline, EMBASE, Web of Science, and Agency for Healthcare Research and Quality databases was performed for up to July 2019. Trials evaluating the efficacy of dexmedetomidine versus propofol in the postoperative sedation of cardiac surgery patients were selected. Primary study outcomes were classified as time-dependent (mechanical ventilation time; time to extubation; length of stay in the intensive care unit and the hospital) and non-time dependent (delirium, bradycardia, and hypotension). Results : Our final analysis included 11 RCTs published between 2003 and 2019 and involved a total of 1184 patients. Time to extubation was significantly reduced in the dexmedetomidine group (Standardized Mean Difference (SMD) = -0.61, 95% Confidence Interval (CI): -1.06 to -0.16, p=0.008), however no difference in mechanical ventilation time was observed (SMD= -0.72, 95% CI: -1.60 to 0.15, N.S.). Moreover, the dexmedetomidine group showed a significant reduction in Intensive Care Unit length of stay (SMD= -0.70, 95% CI: -0.98 to -0.42, p=0.0005) this did not translate into a reduced hospital length of stay (SMD= -1.13, 95% CI: -2.43 to 0.16, N.S). For non-time dependent factors: incidence of delirium was unaffected between groups (OR: 0.68, 95% CI: 0.43 to 1.06, N.S.), while the propofol group of patients had higher rates of bradycardia (OR: 3.39, 95% CI: 1.20 to 9.55, p=0.020) and hypotension (OR: 1.68, 95% CI: 1.09 to 2.58, p=0.017). Conclusion : Despite the ICU time advantages afforded by dexmedetomidine over propofol, the former does not contribute to an overall reduction in hospital length of stay or an overall improvement in postoperative outcomes for heart valve surgery and CABG patients. Time-dependent outcomes confounded by several factors including variability in staff, site-protocols, and complication rates between individual surgical cases. Keywords: dexmedetomidine; propofol; cardiac surgery; postoperative sedation.

scholarly journals Impact of COVID-19 on the hospitalization, treatment, and outcomes of intracerebral and subarachnoid hemorrhage in the United States

PLoS ONE ◽  
2021 ◽  
Vol 16 (4) ◽  
pp. e0248728
Author(s):  
Vijay M. Ravindra ◽  
Ramesh Grandhi ◽  
Alen Delic ◽  
Samuel Hohmann ◽  
Ernie Shippey ◽  
...  
Keyword(s):  
Intensive Care ◽  
Subarachnoid Hemorrhage ◽  
Death Rate ◽  
The United States ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Hospital Death ◽  
Logistic Regression Models ◽  
Intensive Care Stay ◽  
Hispanic Patients

Objective To examine the outcomes of adult patients with spontaneous intracranial and subarachnoid hemorrhage diagnosed with comorbid COVID-19 infection in a large, geographically diverse cohort. Methods We performed a retrospective analysis using the Vizient Clinical Data Base. We separately compared two cohorts of patients with COVID-19 admitted April 1–October 31, 2020—patients with intracerebral hemorrhage (ICH) and those with subarachnoid hemorrhage (SAH)—with control patients with ICH or SAH who did not have COVID-19 admitted at the same hospitals in 2019. The primary outcome was in-hospital death. Favorable discharge and length of hospital and intensive-care stay were the secondary outcomes. We fit multivariate mixed-effects logistic regression models to our outcomes. Results There were 559 ICH-COVID patients and 23,378 ICH controls from 194 hospitals. In the ICH-COVID cohort versus controls, there was a significantly higher proportion of Hispanic patients (24.5% vs. 8.9%), Black patients (23.3% vs. 20.9%), nonsmokers (11.5% vs. 3.2%), obesity (31.3% vs. 13.5%), and diabetes (43.4% vs. 28.5%), and patients had a longer hospital stay (21.6 vs. 10.5 days), a longer intensive-care stay (16.5 vs. 6.0 days), and a higher in-hospital death rate (46.5% vs. 18.0%). Patients with ICH-COVID had an adjusted odds ratio (aOR) of 2.43 [1.96–3.00] for the outcome of death and an aOR of 0.55 [0.44–0.68] for favorable discharge. There were 212 SAH-COVID patients and 5,029 controls from 119 hospitals. The hospital (26.9 vs. 13.4 days) and intensive-care (21.9 vs. 9.6 days) length of stays and in-hospital death rate (42.9% vs. 14.8%) were higher in the SAH-COVID cohort compared with controls. Patients with SAH-COVID had an aOR of 1.81 [1.26–2.59] for an outcome of death and an aOR of 0.54 [0.37–0.78] for favorable discharge. Conclusions Patients with spontaneous ICH or SAH and comorbid COVID infection were more likely to be a racial or ethnic minority, diabetic, and obese and to have higher rates of death and longer hospital length of stay when compared with controls.

scholarly journals Postoperative cardiac surgery complications and hospital length of stay

2018 ◽  
Vol 12 (8) ◽  
pp. 2105
Author(s):  
Alexandre Lins Werneck ◽  
Ligia Marcia Contrin ◽  
Lucia Marinilza Beccaria ◽  
Gabriela Taparo De Castro ◽  
Carolina Varine Teixeira ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Intensive Care ◽  
Length Of Stay ◽  
Cross Sectional Study ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Cross Sectional ◽  
Cardiac Surgery Complications ◽  
Set Up ◽  
Previous Disease

RESUMOObjetivo: associar as principais complicações com pacientes submetidos à cirurgia cardíaca e o tempo de internação. Método: estudo quantitativo, transversal, descritivo e correlacional, para identificar os registros médicos de pacientes submetidos a cirurgias cardíacas e aqueles no pós-operatório na Unidade de Terapia Intensiva. O teste de Regressão Linear Multivariada foi utilizado para a análise e a previsão de independência entre as variáveis. Resultados: dos 103 pacientes submetidos a cirurgias cardíacas, 26 apresentaram complicações pós-operatórias. As complicações mais prevalentes foram cardíacas, pulmonares e infecciosas. Nove pacientes morreram. A doença anterior mais prevalente foi hipertensão arterial sistêmica. Em relação aos dias de hospitalização, o predomínio foi de um a três dias, seguido de três a seis dias. Conclusão: a revascularização miocárdica foi a principal cirurgia realizada, seguida de endarterectomia e as complicações observadas foram cardíacas, seguidas das pulmonares. A duração hospitalar dos pacientes variou de um a três dias. Este estudo mostrou que é imprescindível o planejamento da alta do paciente o mais precocemente possível para a diminuição do tempo de internação e possíveis complicações. Descritores: Complicações; Cirurgias Cardíacas; Pacientes; Tempo de Internação; Tempo de Internação; Alta do Paciente; Unidade de Terapia Intensiva.ABSTRACT Objective: to associate the main complications experienced by patients submitted to cardiac surgery and the length of stay in a Cardiac ICU. Method: this was a quantitative, cross-sectional study using descriptive and correlation designs. We identified medical records of patients undergoing cardiac surgeries and those who were in the postoperative period in the Intensive Care Unit. Multivariate Linear Regression test was used for THE analysis and THE prediction of independence between variables. Results: twenty-six out of 103 patients submitted to cardiac surgeries presented postoperative complications. The most prevalent complications were cardiac, pulmonary, and infectious ones. Nine patients died. The most prevalent previous disease was systemic arterial hypertension. Regarding the hospital length of stay, the predominance was ONE to THREE days, followed by THREE to six days. Conclusion: The hospital length of stay ranged from ONE to THREE days long. This STUDY showed that planning is essential to set up the patient’s discharge as early as possible, as well as to reduce the hospital length of stay and potential complications. Descriptor: Complications; Thoracic Surgery; Patients; Length of Stay; Discharge Plannings; Intensive Care Unit.RESUMENObjetivo: Asociar las principales complicaciones con pacientes sometidos a la cirugía y con el tempo de internación. Método: Estudio cuantitativo, transversal, descriptivo y correlacional del banco de datos del hospital para identificar los registros médicos de pacientes sometidos a cirugías torácicas y de aquellos en el postoperatorio en la Unidad de Cuidados Intensivos. Se utilizó la prueba de Regresión Lineal Múltiple para análisis y predicción de independencia entre las variables.  Resultados: De los 103 pacientes sometidos a cirugías torácicas, 26 presentaron complicaciones postoperatorias. Las complicaciones más prevalentes fueron las cardíacas, las pulmonares y las infecciosas. Nueve pacientes murieron. La enfermedad anterior más prevalente ha sido la hipertensión arterial sistémica. Acerca de los días de hospitalización, el período predominante fue de UNO a TRES días, seguido de TRES a SEIS días. Conclusión: La cirugía de revascularización coronaria ha sido la principal cirugía, seguida de la endarterectomía, y las complicaciones observadas fueron las cardíacas, seguidas de las pulmonares. El tiempo de internación de los pacientes varió de UNO a TRES días. Eso ESTUDIO ha mostrado que es imprescindible planificar el egreso del paciente lo más temprano posible, para reducción del tiempo de internación y de las posibles complicaciones. Descriptores: Complicaciones; Cirurgía Torácica; Pacientes; Tiempo de Internación; Alta del Paciente; Unidades de Cuidados Intensivos.

Implementation of a Protocol Using the 5-Item Brief Alcohol Withdrawal Scale for Treatment of Severe Alcohol Withdrawal in Intensive Care Units

2020 ◽  
pp. 088506662095276
Author(s):  
Darius A. Rastegar ◽  
Andrew S. Jarrell ◽  
Edward S. Chen
Keyword(s):  
Intensive Care ◽  
Intensive Care Units ◽  
Alcohol Withdrawal ◽  
Demographic Data ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Duration Of Treatment ◽  
Icu Patients ◽  
Severe Withdrawal ◽  
Item Scale

Background: There is variation in the treatment of patients with severe alcohol withdrawal and a need for effective protocols. The purpose of this study was to evaluate the implementation of a symptom-triggered benzodiazepine protocol using the 5-item Brief Alcohol Withdrawal Scale (BAWS) for treatment of alcohol withdrawal in intensive care units (ICUs). Methods: This retrospective study included admissions to ICUs of 2 hospitals over 6 months who had an alcohol withdrawal protocol ordered and experienced severe withdrawal. Records were reviewed to collect demographic data, benzodiazepine exposure, duration of treatment, and withdrawal severity. Results: The protocol was ordered and implemented in 279 admissions; 48 (17.9%) had severe withdrawal defined as a BAWS of 6 or more. The majority of the 48 patients were from the emergency department (79.2%); mean hospital length of stay was 11.2 days and mean ICU stay 6.6 days; 31.3% required mechanical ventilation. A little more than half were treated only with the protocol (53.2%); 25.0% received additional benzodiazepines, 20.8% dexmedetomidine, 10.4% propofol, 25.0% antipsychotics and 2.0% phenobarbital. Conclusion: Among ICU patients treated for alcohol withdrawal with a symptom-triggered benzodiazepine protocol using a novel 5-item scale, most did not develop severe withdrawal, and of those who did, approximately half were treated with the protocol alone.

scholarly journals The Association between Early Arterial Oxygenation and Mortality Post Cardiac Surgery

2014 ◽  
Vol 42 (6) ◽  
pp. 730-735 ◽  
Author(s):  
A. D. J. Sutton ◽  
M. Bailey ◽  
R. Bellomo ◽  
G. M. Eastwood ◽  
D. V. Pilcher
Keyword(s):  
Cardiac Surgery ◽  
Intensive Care ◽  
New Zealand ◽  
Length Of Stay ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Arterial Oxygenation ◽  
Icu Mortality ◽  
Patient Database ◽  
The Impact

Many studies have been conducted to investigate the relationship between hyperoxia and mortality in cohorts of intensive care unit (ICU) patients with varied and often contradictory results. The impact of early hyperoxia post ischaemia remains uncertain in various ICU cohorts. We aimed to investigate the association between arterial oxygenation (PaO2) in the first 24 hours in ICU and mortality in patients following cardiac surgery, using a retroespective cohort study of data from the Australian and New Zealand Intensive Care Society adult patient database. Participants were adults admitted to the ICU following cardiac surgery in Australia and New Zealand between 2003 and 2012. Patients were divided according to worst PaO2 level or alveolar-arterial O2 gradient in the 24 hours from admission. We defined ‘hyperoxia’ as PaO2 ≥300 mmHg, ‘hypoxia/poor O2 transfer’ as either PaO2 <60 mmHg or ratio of PaO2 to fraction of inspired oxygen <300 and ‘normoxia’ as between hypoxia and hyperoxia. The primary outcome was mortality at hospital discharge. Secondary outcomes were ICU mortality and ICU and hospital length-of-stay. Of the 83,060 patients 12,188 (14.7%) had hyperoxia, 54,420 (65.5%) had hypoxia/poor O2 transfer and 16,452 (19.8%) had normoxia. There was no association between hyperoxia and in-hospital or ICU mortality compared to normoxia. There was a small increased hospital and ICU length-of-stay for hyperoxic compared to normoxic patients. We concluded that there was no association between mortality and hyperoxia in the first 24 hours in ICU after cardiac surgery.

scholarly journals Restrictive Versus Liberal Red Blood Cell Transfusion for Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 3821-3821
Author(s):  
Babikir Kheiri ◽  
Ahmed Abdalla ◽  
Mohamed Osman ◽  
Tarek Haykal ◽  
Sai Chintalapati ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Length Of Stay ◽  
Clinical Research ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Significant Difference ◽  
Rbc Transfusion ◽  
Research Institute

Abstract Introduction:Patients undergoing cardiac surgery are among the most common recipients of allogenic red blood cell (RBC) transfusions. However, whether restrictive RBC transfusion strategies for cardiac surgery achieve a similar clinical outcome in comparison with liberal strategies remains unclear. Methods:We searched PubMed, Embase, the Cochrane Collaboration Central Register of Controlled Trials, and conference proceedings from inception to December 2017 for all randomized trials (RCTs). The primary outcome was mortality. Secondary outcomes were stroke, respiratory morbidity, renal morbidity, infections, myocardial infarction (MI), cardiac arrhythmia, gut morbidity, reoperation, intensive care unit (ICU) length of stay (hours), and hospital length of stay (days). We calculated the risk ratios (RR) and weighted mean difference (MD) for the clinical outcomes using a random-effects model. Results:We included 9 RCTs with a total of 9,005 patients. There was no significant difference in mortality between groups (RR 1.03; 95% CI 0.74-1.45; P=0.86). In addition, there were no significant differences between groups in the clinical outcomes of infections (RR 1.09; 95% CI 0.94-1.26; P=0.26), stroke (RR 0.98; 95% CI 0.72-1.35; P=0.91), respiratory morbidity (RR 1.05; 95% CI 0.89-1.24; P=0.58), renal morbidity (RR 1.02; 95% CI 0.94-1.09; P=0.68), myocardial infarction (RR 1.00; 95% CI 0.80-1.24; P=0.99), cardiac arrhythmia (RR 1.05; 95% CI 0.88-1.26; P=0.56), gastrointestinal morbidity (RR 1.93; 95% CI 0.81-4.63; P=0.14), or reoperation (RR 0.90; 95% CI 0.67-1.20; P=0.46). There was a significant difference in the intensive care unit length of stay (hours) (MD 4.29; 95% CI: 2.19-6.39, P<0.01) favoring the liberal group. However, there was no significant difference in the hospital length of stay (days) (MD 0.15; 95% CI -0.18-0.48; P=0.38). Conclusion:This meta-analysis showed that restrictive strategies for RBC transfusion are as safe as liberal strategies in patients undergoing cardiac surgery. Key points: Restrictive strategies for red blood cell transfusion are as safe as liberal approaches in patients undergoing cardiac surgery. Longer duration of stay in the intensive care unit is more common in patients managed with a restrictive transfusion approach. However, the overall hospital length of stay appeared to be similar between both groups. Further studies are needed to ascertain threshold triggers for RBC transfusion. Figure. Figure. Disclosures Hassan: abott: Other: grant. Bhatt:American Heart Association Quality Oversight Committee: Other: chair; Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSof: Membership on an entity's Board of Directors or advisory committees; Medscape Cardiology: Consultancy; Regado Biosciences: Consultancy; Elsevier Practice Update Cardiology: Consultancy, trustee; cardax: Consultancy; Abbott, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Idorsia, Ironwood, Ischemix, Lilly, Medtronic, PhaseBio, Pfizer, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines: Research Funding; Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic, Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, Population: Other: Data monitoring committee; American College of Cardiology; Unfunded Research: FlowCo, Merck, PLx Pharma, Takeda.: Other: trustee; ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim), Belvoir Publications (Editor in Chief, Harvard Heart Letter),: Other: board member; American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org: Honoraria.

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