Diarrhoea: interventions, consequences and epidemiology in the intensive care unit (DICE-ICU): a protocol for a prospective multicentre cohort study

IntroductionDiarrhoea is a frequent concern in the intensive care unit (ICU) and is associated with prolonged mechanical ventilation, increased length of ICU stay, skin breakdown and renal dysfunction. However, its prevalence, aetiology and prognosis in the critically ill have been poorly studied. The primary objectives of this study are to determine the incidence, risk factors and consequences of diarrhoea in critically ill adults. The secondary objectives are to estimate the incidence ofClostridium difficile-associated diarrhoea (CDAD) in ICU patients and to validate the Bristol Stool Chart and Bliss Stool Classification System characterising bowel movements in the ICU. Our primary outcome is the incidence of diarrhoea . Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay.Methods and analysisThis international prospective cohort study will enrol patients over 10 weeks in 12 ICUs in Canada, the USA, Poland and Saudi Arabia. We will include all patients 18 years of age and older who are admitted to the ICU for at least 24 hours and follow them daily until ICU discharge. Our primary outcome is the incidence of diarrhoea based on the WHO definition, during the ICU stay. Our secondary outcomes include: CDAD, ICU and hospital mortality and ICU and hospital length of stay. We will use logistic regression to identify factors associated with diarrhoea (as defined using WHO criteria) and the kappa statistic to measure agreement on diarrhoea rates between the WHO definition and the Bristol Stool Chart and Bliss Stool Classification System.Ethics and disseminationThe protocol has been approved by the research ethics board of all participating centres. The diarrhoea interventions, consequences and epidemiology in the intensive care unit (DICE-ICU) study will generate evidence about diarrhoea and its frequency, predisposing factors and consequences, to inform critical care practice and future research.Lay summaryDiarrhoea is a frequent clinical problem for hospitalised patients including those who are critically ill in the ICU. Diarrhoea can cause complications such as skin damage, dehydration and kidney problems. It is not clear how common diarrhoea is in the ICU, the factors that cause it or the best way for clinicians to assess it. The DICE-ICU study is an international prospective observational study to examine the frequency, risk factors and outcomes of diarrhoea during critical illness.

Download Full-text

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

Journal of Clinical Medicine ◽

10.3390/jcm10194288 ◽

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.

Download Full-text

Association between Malnutrition and Hospital Mortality and Duration of Intensive Care Unit Admission in the Critically Ill: A Prospective Cohort Study

10.20944/preprints201711.0066.v1 ◽

2017 ◽

Author(s):

Charles Chin Han Lew ◽

Gabriel Jun Yung Wong ◽

Ka Po Cheung ◽

Ai Ping Chua ◽

Mary Foong Fong Chong ◽

...

Keyword(s):

Intensive Care Unit ◽

Cohort Study ◽

Intensive Care ◽

Hospital Mortality ◽

Critically Ill ◽

Prospective Cohort Study ◽

Critically Ill Patients ◽

Prospective Cohort ◽

Unit Length ◽

Increased Risk

There is limited evidence for the association between malnutrition and hospital mortality as well as Intensive Care Unit length-of-stay (ICU-LOS) in critically ill patients. We aimed to examine the aforementioned associations by conducting a prospective cohort study in an ICU of a Singapore tertiary hospital. Between August 2015 and October 2016, all adult patients with ≥24 h of ICU-LOS were included. The 7-point Subjective Global Assessment (7-point SGA) was used to determine patients’ nutritional status within 48 hours of ICU admission. Multivariate analyses were conducted in two ways: 1) presence versus absence of malnutrition, and 2) dose-dependent association for each 1-point decrease in the 7-point SGA. There were 439 patients of which 28.0% were malnourished, and 29.6% died before hospital discharge. Malnutrition was associated with an increased risk of hospital mortality [adjusted-RR 1.39 (95%CI: 1.10–1.76)], and this risk increased with a greater degree of malnutrition [adjusted-RR 1.09 (95%CI: 1.01–1.18) for each 1-point decrease in the 7-point SGA]. No significant association was found between malnutrition and ICU-LOS. Conclusion: There was a clear association between malnutrition and higher hospital mortality in critically ill patients. The association between malnutrition and ICU-LOS could not be replicated and hence requires further evaluation.

Download Full-text

Association of natural light exposure and delirium according to the presence or absence of windows in the intensive care unit

Acute and Critical Care ◽

10.4266/acc.2021.00556 ◽

2021 ◽

Vol 36 (4) ◽

pp. 332-341

Author(s):

Hyo Jin Lee ◽

Eunhye Bae ◽

Hong Yeul Lee ◽

Sang-Min Lee ◽

Jinwoo Lee

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Cumulative Incidence ◽

Light Exposure ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Natural Light ◽

Single Room ◽

Secondary Outcomes ◽

Pharmacologic Treatments

Background: Patients in the intensive care unit (ICU) have increased risks of delirium, which is associated with worse outcomes. As pharmacologic treatments for delirium are ineffective, prevention is important. Nonpharmacologic preventive strategies include exposure to natural light and restoring circadian rhythm. We investigated the effect of exposure to natural light through windows on delirium in the ICU.Methods: This retrospective cohort study assessed all patients admitted to the medical ICU of a university-affiliated hospital between January and June 2020 for eligibility. The ICU included 12 isolation rooms, six with and six without windows. Patients with ICU stays of >48 hours were included and were divided into groups based on their admission to a single room with (window group) or without windows (windowless group). The primary outcome was the cumulative incidence of delirium. The secondary outcomes were the numbers of delirium- and mechanical ventilation-free days, ICU and hospital length of stay, and in-ICU and 28-day mortalities.Results: Of the 150 included patients (window group: 83 [55.3%]; windowless group: 67 [44.7%]), the cumulative incidence of delirium was significantly lower in the window group than in the windowless group (21.7% vs. 43.3%; relative risk, 1.996; 95% confidence interval [CI], 1.220–3.265). Other secondary outcomes did not differ between groups. Admission to a room with a window was independently associated with a decreased risk of delirium (adjusted odds ratio, 0.318; 95% CI, 0.125–0.805).Conclusions: Exposure to natural light through windows was associated with a lower incidence of delirium in the ICU.

Download Full-text

Epidurals for Coarctation Repair in Children Are Associated with Decreased Postoperative Anti-Hypertensive Infusion Requirement as Measured by a Novel Parameter, the Anti-Hypertensive Dosing Index (ADI)

Children ◽

10.3390/children6100112 ◽

2019 ◽

Vol 6 (10) ◽

pp. 112

Author(s):

J. Matthew Kynes ◽

Matthew S. Shotwell ◽

Camila B. Walters ◽

David P. Bichell ◽

Jason T. Christensen ◽

...

Keyword(s):

Intensive Care Unit ◽

Cohort Study ◽

Intensive Care ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Reduce Blood Pressure ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Coarctation Repair ◽

Hospital Stays

Background: Sympathetically-associated hypertension after coarctation repair is a common problem often requiring anti-hypertensive infusions in an intensive care unit. Epidurals suppress sympathetic output and can reduce blood pressure but have not been studied following coarctation repair in children. We sought to determine whether epidurals for coarctation repair in children were associated with decreased requirement for postoperative anti-hypertensive infusions, if they were associated with changes in hospital course, or with complications. Methods: In this observational retrospective cohort study, we evaluated all patients age 1–18 years undergoing coarctation repair at our institution during a 10-year period and compared the requirement for postoperative anti-hypertensive infusions in patients with and without epidurals using an anti-hypertensive dosing index (ADI) incorporating total dose-hours of all anti-hypertensive infusions (primary outcome). We also assessed intensive care unit (ICU) and hospital length of stay, discharge on oral anti-hypertensive medication, and complications potentially related to epidurals (secondary outcomes). Results: Children undergoing coarctation repair with epidurals had decreased requirements for postoperative anti-hypertensive infusions compared to children without epidurals (cumulative ADI 65.0 [28.5–130.3] v. 157.0 [68.6–214.7], p = 0.021; mean ADI 49.0 [33.3–131.2] v. 163.0 [66.6–209.8], p = 0.01). After multivariable cumulative logit mixed-effects regression analysis, mean ADI was decreased in patients with epidurals throughout the postoperative period (p < 0.001). Patients with epidurals were 1.6 years older and weighed 10.6 kg more than patients without epidurals but were otherwise comparable. Epidural complications included pruritus (three patients), agitation (one patient), somnolence (one patient), and transient orthostatic hypotension (one patient). Duration of intensive care unit admission, duration of hospital stays, and requirement for anti-hypertensive medication at discharge were similar in patients with and without epidurals. Conclusions: This is the first study of children receiving an epidural for surgical repair of aortic coarctation via open thoracotomy. In this small, single-institution, observational retrospective cohort study, epidurals for coarctation repair in children were associated with decreased postoperative anti-hypertensive infusion requirements. Epidurals were not associated with length of ICU or hospital stay, or with discharge on anti-hypertensive medication. No significant epidural complications were noted. Prospective study of larger populations will be necessary to confirm these associations, address causality, verify safety, and assess other effects.

Download Full-text

Development and Implementation of a Multicomponent Protocol to Promote Sleep and Reduce Delirium in a Medical Intensive Care Unit

Annals of Pharmacotherapy ◽

10.1177/10600280211043278 ◽

2021 ◽

pp. 106002802110432

Author(s):

Adrienne Darby ◽

Kalynn Northam ◽

C. Adrian Austin ◽

Lydia Chang ◽

Stacy Campbell-Bright

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Hospital Mortality ◽

Medical Intensive Care Unit ◽

Severity Of Illness ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Poor Sleep ◽

Medical Intensive Care ◽

The Impact

Background: Evidence suggests that poor sleep increases risk of delirium. Because delirium is associated with poor outcomes, institutions have developed protocols to improve sleep in critically ill patients. Objective: To assess the impact of implementing a multicomponent sleep protocol. Methods: In this prospective, preimplementation and postimplementation evaluation, adult patients admitted to the medical intensive care unit (ICU) over 42 days were included. Outcomes evaluated included median delirium-free days, median Richards-Campbell Sleep Questionnaire (RCSQ) score, median optimal sleep nights, duration of mechanical ventilation (MV), ICU and hospital length of stay (LOS), and in-hospital mortality. Results: The preimplementation group included 78 patients and postimplementation group, 84 patients. There was no difference in median delirium-free days (1 day [interquartile range, IQR, = 0-2.5] vs 1 day [IQR = 0-2]; P = 0.48), median RCSQ score (59.4 [IQR = 43.2-71.6] vs 61.2 [IQR = 49.9-75.5]; P = 0.20), median optimal sleep nights (1 night [IQR = 0-2] vs 1 night [IQR = 0-2]; P = 0.95), and in-hospital mortality (16.7% vs 17.9%, P = 1.00). Duration of MV (8 days [IQR = 4-10] vs 4 days [IQR = 2-7]; P = 0.03) and hospital LOS (13 days [IQR = 7-22.3] vs 8 days [IQR = 6-17]; P = 0.05) were shorter in the postimplementation group, but both were similar between groups after adjusting for age and severity of illness. Conclusions and Relevance: This report demonstrates that implementation of a multicomponent sleep protocol in everyday ICU care is feasible, but limitations exist when evaluating impact on measurable outcomes. Additional evaluations are needed to identify the most meaningful interventions and best practices for quantifying impact on patient outcomes.

Download Full-text

Clinical and Economic Outcomes of Telemedicine Programs in the Intensive Care Unit: A Systematic Review and Meta-Analysis

Journal of Intensive Care Medicine ◽

10.1177/0885066617726942 ◽

2017 ◽

Vol 33 (7) ◽

pp. 383-393 ◽

Cited By ~ 33

Author(s):

Jing Chen ◽

Dalong Sun ◽

Weiming Yang ◽

Mingli Liu ◽

Shufan Zhang ◽

...

Keyword(s):

Systematic Review ◽

Intensive Care Unit ◽

Intensive Care ◽

Length Of Stay ◽

Hospital Mortality ◽

Meta Analysis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Icu Length Of Stay ◽

The Impact

Objective: To evaluate the impact of telemedicine programs in intensive care unit (Tele-ICU) on ICU or hospital mortality or ICU or hospital length of stay and to summarize available data on implementation cost of Tele-ICU. Methods: Controlled trails or observational studies assessing outcomes of interest were identified by searching 7 electronic databases from inception to July 2016 and related journals and conference literatures between 2000 and 2016. Two reviewers independently screened searched records, extracted data, and assessed the quality of included studies. Random-effect models were applied to meta-analyses and sensitivity analysis. Results: Nineteen of 1035 records fulfilled the inclusion criteria. The pooled effects demonstrated that Tele-ICU programs were associated with reductions in ICU mortality (15 studies; risk ratio [RR], 0.83; 95% confidence interval [CI], 0.72 to 0.96; P = .01), hospital mortality (13 studies; RR, 0.74; 95% CIs, 0.58 to 0.96; P = .02), and ICU length of stay (9 studies; mean difference [MD], −0.63; 95% CI, −0.28 to 0.17; P = .007). However, there is no significant association between the reduction in hospital length of stay and Tele-ICU programs. Summary data concerning costs suggested approximately US$50 000 to US$100 000 per Tele-ICU bed was required to implement Tele-ICU programs for the first year. Hospital costs of US$2600 reduction to US$5600 increase per patient were estimated using Tele-ICU programs. Conclusions: This systematic review and meta-analysis provided limited evidence that Tele-ICU approaches may reduce the ICU and hospital mortality, shorten the ICU length of stay, but have no significant effect in hospital length of stay. Implementation of Tele-ICU programs substantially costs and its long-term cost-effectiveness is still unclear.

Download Full-text

Comparison of clinical characteristics and outcomes between alcohol-induced and gallstone-induced acute pancreatitis: An Australian retrospective observational study

SAGE Open Medicine ◽

10.1177/20503121211030837 ◽

2021 ◽

Vol 9 ◽

pp. 205031212110308

Author(s):

Santiago Cegarra Garcia ◽

Michael Toolis ◽

Max Ubels ◽

Taha Mollah ◽

Eldho Paul ◽

...

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Acute Pancreatitis ◽

Intensive Care ◽

Length Of Stay ◽

Hospital Mortality ◽

Intensive Care Unit Mortality ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Index Of Severity

Objectives: To compare the characteristics and outcomes of patients presenting to hospital with alcohol-induced and gallstone-induced acute pancreatitis. Methods: Retrospective study of all patients with alcohol-induced or gallstone-induced pancreatitis during the period 1 June 2012 to 31 May 2016. The primary outcome measure was hospital mortality. Secondary outcome measures included hospital length of stay, requirements for intensive care unit admission, intensive care unit mortality, mechanical ventilation, renal replacement therapy, requirement of inotropes and total parenteral nutrition. Results: A total of 642 consecutive patients (49% alcohol; 51% gallstone) were included. No statistically significant differences were found between alcohol-induced and gallstone-induced acute pancreatitis with respect to hospital mortality, requirement for intensive care unit admission, intensive care unit mortality and requirement for mechanical ventilation, renal replacement therapy, inotropes or total parenteral nutrition. There was significant difference in hospital length of stay (3.07 versus 4.84; p < 0.0001). On multivariable regression analysis, Bedside Index of Severity in Acute Pancreatitis score (estimate: 0.393; standard error: 0.058; p < 0.0001) and admission haematocrit (estimate: 0.025; standard error: 0.008; p = 0.002) were found to be independently associated with prolonged hospital length of stay. Conclusion: Hospital mortality did not differ between patients with alcohol-induced and gallstone-induced acute pancreatitis. The duration of hospital stay was longer with gallstone-induced pancreatitis. Bedside Index of Severity in Acute Pancreatitis score and admission haematocrit were independently associated with hospital length of stay.

Download Full-text

The clinical traits of acute pancreatitis in aging patients: a retrospective analysis of 473 cases

10.21203/rs.2.24010/v1 ◽

2020 ◽

Author(s):

Nonghua Lu ◽

Bingjun Yu ◽

Fengwen Xie

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Acute Pancreatitis ◽

Intensive Care ◽

Abdominal Pain ◽

Length Of Stay ◽

Organ Failure ◽

Death Rate ◽

Hospital Length ◽

Hospital Length Of Stay

Abstract Background The incidence of acute pancreatitis in aging patients has increasing in recent years. Controversial results about clinical outcomes of acute pancreatitis in aging patients were reported in different literature. The aim of our study was to compare the clinical outcomes of AP in aging patients between 60-79 years old and over 80 years old. Methods 80 patients aged ≥ 80 years old(oldest group) were compared to 393 patients aged 60 to 79 years old(older group). The clinical course, biochemical, radiological data were enrolled. The primary endpoint was to compare the death rate, intensive care unit admission rate and in-hospital length of stay(LOS). The secondary endpoint was operative treatment and the complications of AP. Results Abdominal symptom of abdominal pain (61.3% vs 46.3%, P=0.013) was less in oldest group, while diarrhea(18.3% vs 30.0%, P=0.018), jaundice(8.9% vs 17.5%, P=0.021), dyspnea(11.5% vs 26.3%, P=0.001) were more obvious in older group than oldest group. A higher death rate (8.9% vs 16.3%, P = 0.003) and longer hospital length of stay (11.51±10.19 vs 15.26±11.04, P = 0.001) were found in aging patients aged ≥80 years old. Mean BMI was lower in oldest group compared to older group(22.36±2.89 vs 21.07±3.18, P = 0.001). Multivariate analysis identified aged over 80 years(OR 3.299, 95%CI 1.316-8.269, P=0.011) and organ failure(P<0.05) as independent risk factors of mortality. More severe of AP(OR 11.722, 95%CI 4.780-28.764, P=0.001), abdominal pain(OR 1.906, 95%CI 1.052-3.453, P=0.033) and organ failure(P<0.05) were recognized as influencing intensive care unit rate. Aging patients aged over 80 years old(OR 0.149, 95%CI 2.027-6.268, P=0.001), more severe of AP(OR 0.218, 95%CI 1.567-4.322, P=0.001), female(OR 0.093, 95%CI 0.336-3.542, P=0.018), Jaundice(OR 0.080, 95%CI 0.146-5.324, P=0.038), operative treatment(P<0.05) and organ failure(P<0.05) were the risk factors for LOS.

Download Full-text

696. Optimal Duration of Prophylactic Antibiotics in Patients with Cirrhosis and Upper Gastrointestinal Bleeding

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.893 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S449-S449

Author(s):

Kristin C Davis ◽

Lindsay Reulbach ◽

John Schrank ◽

Alex Ewing ◽

Emily Johnson

Keyword(s):

Hospital Mortality ◽

Antibiotic Prophylaxis ◽

Primary Outcome ◽

Hospital Length ◽

Prophylactic Antibiotics ◽

Hospital Length Of Stay ◽

Variceal Hemorrhage ◽

Bacterial Peritonitis ◽

Clostridioides Difficile ◽

Secondary Outcomes

Abstract Background Spontaneous bacterial peritonitis (SBP) is a serious complication of variceal hemorrhage. Guidelines recommend a maximum of seven days of antibiotics after variceal hemorrhage to prevent SBP and reduce rates of rebleeding and mortality. However, studies supporting these guidelines used varied durations of therapy including those with less than seven days. The objective of this study was to determine if less than seven days of antibiotic prophylaxis was noninferior to seven or more days in patients with cirrhosis and variceal hemorrhage. Methods This was a single-center, retrospective cohort conducted from August 2019 to August 2020 including adult patients who received treatment for variceal hemorrhage and antibiotics for prevention of SBP during hospitalization. Patients were excluded if they were diagnosed with non-variceal hemorrhage, received treatment with antibiotics within 72 hours prior to the variceal hemorrhage, or expired or transitioned to end of life care within 48 hours of hospital admission. The primary outcome was in-hospital mortality. Secondary outcomes included SBP within the first 30 days after variceal hemorrhage, 30-day mortality, 30-day readmission rate, incidence of rebleeding at seven and 30 days, incidence of Clostridioides difficile infection, and intensive care unit and hospital length of stay. Results 64 patients were included with 45 patients in the less than seven days group and 19 patients in the seven or more days of antibiotic prophylaxis group. In each group, patients were primarily male with a median age of approximately 60 years. There was no difference in the primary outcome of in-hospital mortality between the less than seven days group as compared to the seven or more days group (22.2% vs 0%, p=1). No difference was identified between the less than seven days group as compared to the seven or more days group for any of the secondary outcomes. Conclusion This study identified no difference in patient-centered outcomes when comparing less than seven days of prophylactic antibiotics to seven or more days in patients with variceal hemorrhage. Less than seven days of prophylactic antibiotics may be a reasonable duration for prevention of SBP. Disclosures All Authors: No reported disclosures

Download Full-text