Prophylactic Enoxaparin in Critically Ill Trauma Patients: Evaluation of the Initial Dose

2021 ◽  
pp. 001857872110673
Author(s):  
Kaitlyn J. Agedal ◽  
Elizabeth A. Feldman ◽  
Robert W. Seabury ◽  
William Darko ◽  
Luke A. Probst ◽  
...  
Keyword(s):  
Critically Ill ◽  
Patient Population ◽  
Trough Level ◽  
Statistical Tests ◽  
Coagulation Cascade ◽  
Surgical Intensive Care Unit ◽  
Trauma Patients ◽  
Surgical Intensive Care ◽  
Increased Risk ◽  
Trough Levels

Background: Trauma patients are at increased risk of developing venous thromboembolism given alterations in the coagulation cascade. Chemoprophylaxis with standard dosing of enoxaparin 30 mg subcutaneously twice daily has evolved to incorporate the use of anti-factor Xa (AFXa) trough level monitoring given concerns for decreased enoxaparin bioavailability in this patient population. Current available evidence suggests low rates of goal AFXa trough level achievement with standard enoxaparin dosing. Our study aims to identify the incidence of critically ill trauma patients that did not achieve goal AFXa trough levels and attempts to identify predictors that may influence the lack of achievement of goal levels. Methods: This was a retrospective, cohort analysis performed at a single academic medical center. Adult patients 18 years or older admitted to the surgical intensive care unit secondary to trauma who were initiated on standard prophylactic enoxaparin and had at least 1 AFXa trough level representative of steady state were included. Patient demographics and clinical data were collected, and descriptive statistics were utilized. All statistical tests were 2-tailed and a P < .05 was considered significant. Variables with a P < .10 on univariable analysis were included in a multivariable logistic regression analysis. Results: A majority of our patient population did not achieve goal AFXa trough levels while receiving standard doses of prophylactic enoxaparin (82.4% [108/131]). Sub-target AFXa levels were associated with higher creatinine clearance values. Positive predictors of obtaining target AFXa levels included automobile versus pedestrian mechanism of injury and requiring an enoxaparin dose escalation to at least 40 mg twice daily. Conclusions: Our study found low rates of achievement of goal AFXa trough levels in critically ill trauma patients receiving standard prophylactic enoxaparin dosing. Certain variables were identified as negative and positive predictors for achievement of goal AFXa trough levels, although the biologic plausibility of these predictors is questionable and requires further investigation.

Diurnal salivary cortisol measurement in the neurosurgical-surgical intensive care unit in critically ill acute trauma patients

2014 ◽  
Vol 21 (12) ◽  
pp. 2150-2154 ◽  
Author(s):  
Viktor Bartanusz ◽  
Michael G. Corneille ◽  
Salvador Sordo ◽  
Marianne Gildea ◽  
Joel E. Michalek ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critically Ill ◽  
Salivary Cortisol ◽  
Surgical Intensive Care Unit ◽  
Trauma Patients ◽  
Surgical Intensive Care ◽  
Acute Trauma

Implementing Volume-Based Feeding to Optimize Delivery of Enteral Nutrition

2021 ◽  
Vol 41 (2) ◽  
pp. 16-26
Author(s):  
Angela Bonomo ◽  
Diane Lynn Blume ◽  
Katie Davis ◽  
Hee Jun Kim
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Quality Improvement ◽  
Enteral Nutrition ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Educational Approach ◽  
Lecture Demonstration

Background At least 80% of ordered enteral nutrition should be delivered to improve outcomes in critical care patients. However, these patients typically receive 60% to 70% of ordered enteral nutrition volume. In a practice review within a 28-bed medical-surgical adult intensive care unit, patients received a median of 67.5% of ordered enteral nutrition with standard rate-based feeding. Volume-based feeding is recommended to deliver adequate enteral nutrition to critically ill patients. Objective To use a quality improvement project to increase the volume of enteral nutrition delivered in the medical-surgical intensive care unit. Methods Percentages of target volume achieved were monitored in 73 patients. Comparisons between the rate-based and volume-based feeding groups used nonparametric quality of medians test or the χ2 test. A customized volume-based feeding protocol and order set were created according to published protocols and then implemented. Standardized education included lecture, demonstration, written material, and active personal involvement, followed by a scenario-based test to apply learning. Results Immediately after implementation of this practice change, delivered enteral nutrition volume increased, resulting in a median delivery of 99.8% of ordered volume (P = .003). Delivery of a mean of 98% ordered volume was sustained over the 15 months following implementation. Conclusions Implementation of volume-based feeding optimized enteral nutrition delivery to critically ill patients in this medical-surgical intensive care unit. This success can be attributed to a comprehensive, individualized, and proactive process design and educational approach. The process can be adapted to quality improvement initiatives with other patient populations and units.

scholarly journals Chlorhexidine Gluconate Bathing Program to Reduce Health Care–Associated Infections in Both Critically Ill and Non–Critically Ill Patients

2021 ◽  
Vol 41 (5) ◽  
pp. e1-e8
Author(s):  
Leigh Chapman ◽  
Lisa Hargett ◽  
Theresa Anderson ◽  
Jacqueline Galluzzo ◽  
Paul Zimand
Keyword(s):  
Health Care ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
Critically Ill ◽  
Chlorhexidine Gluconate ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Telemetry Unit ◽  
Health Care Associated Infections ◽  
The Impact

Background Critical care nurses take care of patients with complicated, comorbid, and compromised conditions. These patients are at risk for health care–associated infections, which affect patients’ lives and health care systems in various ways. Objective To gauge the impact of routinely bathing patients with 4% chlorhexidine gluconate solution on the incidence of health care–associated infections in a medical-surgical intensive care unit and a postoperative telemetry unit; to outline the framework for a hospital-wide presurgical chlorhexidine gluconate bathing program and share the results. Methods A standard bathing protocol using a 4% chlorhexidine gluconate solution was developed. The protocol included time studies, training, monitoring, and surveillance of health care–associated infections. Results Consistent patient bathing with 4% chlorhexidine gluconate was associated with a 52% reduction in health care–associated infections in a medical-surgical intensive care unit. The same program in a postoperative telemetry unit yielded a 45% reduction in health care–associated infections. Conclusion A comprehensive daily 4% chlorhexidine gluconate bathing program can be implemented with standardized protocols and detailed instructions and can significantly reduce the incidence of health care–associated infections in intensive care unit and non–intensive care unit hospital settings.

Protein C Concentrations Correlate with Organ Dysfunction and Predict Outcome Independent of the Presence of Sepsis

2007 ◽  
Vol 107 (1) ◽  
pp. 15-23 ◽  
Author(s):  
Frank Brunkhorst ◽  
Yasser Sakr ◽  
Stefan Hagel ◽  
Konrad Reinhart
Keyword(s):  
Critically Ill ◽  
Organ Dysfunction ◽  
Protein C ◽  
Multivariable Analysis ◽  
Risk Groups ◽  
University Hospital ◽  
Surgical Intensive Care Unit ◽  
Icu Mortality ◽  
Surgical Intensive Care ◽  
Time Courses

Abstract Background: Characterizing the evolution of protein C concentrations in critically ill patients may help in identifying high risk groups and potential therapeutic targets. The authors investigated the time courses of protein C concentrations and their relation to the presence of sepsis, organ dysfunction/failure, and outcome. Methods: This observational cohort study, in a university hospital surgical intensive care unit (ICU), included 312 consecutive patients with an estimated ICU length of stay more than 48 h. Plasma protein C concentrations and parameters of organ dysfunction were measured daily until discharge or death. Results: Protein C concentrations were below the lower limit of normal in 50.6% of patients (n = 158) on admission and decreased to a nadir within 3–4 days after admission before almost normalizing by 2 weeks thereafter, irrespective of the presence of sepsis, sex, source and type of admission, and type of surgery. The minimum protein C concentration was lower in patients with severe sepsis/septic shock (n = 54) than in those with sepsis (n = 63) and those who never had sepsis (n = 195), and was negatively correlated to the maximum Sequential Organ Failure Assessment score (R2 = 0.345, P &lt; 0.001). Protein C levels were lower in nonsurvivors (n = 46; 14.7%) than in survivors, especially in the first 4 days after admission. In a multivariable analysis with ICU mortality as the dependent variable, a minimum protein C concentration less than 45% was an independent risk factor for ICU death. Conclusions: In critically ill surgical patients, protein C concentrations were generally low, associated with organ dysfunction/failure, and independently associated with a higher risk of ICU mortality.

Survey of Physiotherapy Practice in Ontario Cardiac Surgery Intensive Care Units

2021 ◽  
pp. e20200069
Author(s):  
Anastasia N.L. Newman ◽  
Michelle E. Kho ◽  
Jocelyn E. Harris ◽  
Alison Fox-Robichaud ◽  
Patricia Solomon
Keyword(s):  
Intensive Care Unit ◽  
Critical Care ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Critically Ill ◽  
Outcome Measures ◽  
Median Number ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Physiotherapy Practice

Purpose: This article describes current physiotherapy practice for critically ill adult patients requiring prolonged stays in critical care (> 3 d) after complicated cardiac surgery in Ontario. Method: We distributed an electronic, self-administered 52-item survey to 35 critical care physiotherapists who treat adult cardiac surgery patients at 11 cardiac surgical sites. Pilot testing and clinical sensibility testing were conducted beforehand. Participants were sent four email reminders. Results: The response rate was 80% (28/35). The median (inter-quartile range) reported number of cardiac surgeries performed per week was 30 (10), with a median number of 14.5 (4) cardiac surgery beds per site. Typical reported caseloads ranged from 6 to 10 patients per day pe therapist, and 93% reported that they had initiated physiotherapy with patients once they were clinically stable in the intensive care unit. Of 28 treatments, range of motion exercises (27; 96.4%), airway clearance techniques (26; 92.9%), and sitting at the edge of the bed (25; 89.3%) were the most common. Intra-aortic balloon pump and extracorporeal membrane oxygenation appeared to limit physiotherapy practice. Use of outcome measures was limited. Conclusions: Physiotherapists provide a variety of interventions with critically ill cardiac surgery patients. Further evaluation of the limited use of outcome measures in the cardiac surgical intensive care unit is warranted.

Management of Pulseless and Apneic Trauma Patients: Are Aggressive Measures Justified?

2007 ◽  
Vol 73 (1) ◽  
pp. 62-66
Author(s):  
Chong-Jeh Lo ◽  
Wen-Ling Chang
Keyword(s):  
Cardiopulmonary Resuscitation ◽  
Emergency Room ◽  
Operating Room ◽  
Spontaneous Respiration ◽  
Surgical Intensive Care Unit ◽  
Trauma Patients ◽  
Surgical Intensive Care ◽  
Female Ratio ◽  
Surgical Exploration ◽  
Resuscitated Patients

This study prospectively examined the care of trauma patients in extremis on presentation to a tertiary medical center between January 2000 and August 31, 2002. There were 144 patients who presented without a pulse or spontaneous respiration and required cardiopulmonary resuscitation (mean age, 41.5 ± 2.3 years; male-to-female ratio, 105:39). Successfully resuscitated patients, who were either admitted to the surgical intensive care unit (SICU) or who were taken to the operating room for surgical exploration, had significantly shorter duration of cardiopulmonary resuscitation (14.55 ± 1.64 minutes vs. 33.32 ± 1.23 minutes; P < 0.001) and received less amounts of epinephrine than those who died in the emergency room ( P < 0.05). One hundred sixteen patients died in the emergency room. Nineteen admitted patients died within 24 hours of presentation. Nine patients survived beyond 24 hours and all of them were admitted directly to the SICU for the management of brain injury. Six patients were taken to the operating room for surgical exploration to control the bleeding; all of them died in the operating room or shortly thereafter in the SICU. No patient in this study survived to be discharged. The financial cost of successfully resuscitated patients was significantly higher than that of patients who died in the emergency room ( P < 0.001). Instead of insisting on aggressive measures to resuscitate trauma patients in extremis on presentation, the authors suggest we should redirect that fervor toward efforts made to promote trauma awareness and injury prevention programs.

scholarly journals Biomarker-assisted identification of sepsis-related acute liver impairment: a frequent and deadly condition in critically ill patients

2019 ◽  
Vol 57 (9) ◽  
pp. 1422-1431 ◽  
Author(s):  
Jens-Ulrik Stæhr Jensen ◽  
Lars Peters ◽  
Theis S. Itenov ◽  
Morten Bestle ◽  
Katrin M. Thormar ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Prognostic Impact ◽  
Surgical Intensive Care ◽  
Positive Interaction ◽  
Liver Impairment ◽  
Risk Of Death ◽  
Increased Risk ◽  
Co Morbidity ◽  
All Cause Mortality

Abstract Background The prognostic impact of mild/moderate liver impairment among critically ill patients is not known. We aimed to determine whether acute liver impairment, as measured by several biomarkers, (i) is frequent, (ii) influences prognosis and (iii) to determine whether such an effect is specific for infected critically ill patients. Methods A biomarker and clinical cohort study based on a randomized controlled trial. All-cause mortality was the primary endpoint. Biomarkers hyaluronic acid (HA), bilirubin, albumin, alkaline phosphatase and the international normalized ratio (INR) were determined. Multivariable statistics were applied to estimate risk increase according to liver biomarker increase at baseline and the model was adjusted for age, APACHE II, severe sepsis/septic shock vs. milder infection, chronic alcohol abuse Charlson’s co-morbidity index, cancer disease, surgical or medical patient, body mass index, sex, estimated glomerular filtration rate, mechanical ventilation and the other biomarkers. Time-to-event graphs were used. The patients were critically ill patients (n = 1096) from nine mixed medical/surgical intensive care units without known hepatobiliary disease. Results HA levels differed between infected patients (median 210.8 ng/mL [IQR: 93.2–556.6]) vs. the non-infected (median 56.8 ng/mL [IQR: 31.9–116.8], p < 0.001). Serum HA quartiles 2, 3 and 4 were independent predictors of 90-day all-cause mortality for the entire population (infected and non-infected). However, the signal was driven by the infected patients (positive interaction test, no signal in non-infected patients). Among infected patients, HA quartiles corresponded directly to the 90-day risk of dying: 1st quartile: 57/192 = 29.7%, 2nd quartile: 84/194 = 43.3%, 3rd quartile: 90/193 = 46.6%, 4th quartile: 101/192 = 52.3 %, p for trend: <0.0001. This finding was confirmed in adjusted analyses: hazard ratio vs. 1st quartile: 2nd quartile: 1.3 [0.9–1.8], p = 0.14, 3rd quartile: 1.5 [1.1–2.2], p = 0.02, 4th quartile: 1.9 [1.3–2.6], p < 0.0001). High bilirubin was also an independent predictor of mortality. Conclusions Among infected critically ill patients, subtle liver impairment, (elevated HA and bilirubin), was associated with a progressive and highly increased risk of death for the patient; this was robust to adjustment for other predictors of mortality. HA can identify patients at high risk.

Prognosis of Critically Ill Patients With Cancer and Acute Renal Dysfunction

2006 ◽  
Vol 24 (24) ◽  
pp. 4003-4010 ◽  
Author(s):  
Márcio Soares ◽  
Jorge I.F. Salluh ◽  
Marilia S. Carvalho ◽  
Michael Darmon ◽  
José R. Rocco ◽  
...  
Keyword(s):  
Renal Dysfunction ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Cox Model ◽  
Mortality Rates ◽  
Surgical Intensive Care Unit ◽  
Surgical Intensive Care ◽  
Acute Renal Dysfunction ◽  
Patients With Cancer ◽  
Organ Failures

Purpose To evaluate the outcomes of critically ill patients with cancer and acute renal dysfunction. Patients and Methods Prospective cohort study conducted at a 10-bed oncologic medical-surgical intensive care unit (ICU) over a 56-month period. Results Of 975 patients, 309 (32%) had renal dysfunction and were studied. Their mean age was 60.9 ± 15.9 years; 233 patients (75%) had solid tumors and 76 (25%) had hematologic malignancies. During the ICU stay, 98 patients (32%) received dialysis. Renal dysfunction was multifactorial in 56% of the patients, and the main associated factors were shock/ischemia (72%) and sepsis (63%). Overall hospital and 6-month mortality rates were 64% and 73%, respectively. Among patients who required dialysis, mortality rates were lower in patients who received dialysis on the first day of ICU in comparison with those who required it thereafter. In a multivariable Cox model, age more than 60 years, uncontrolled cancer, impaired performance status, and more than two associated organ failures were associated with increased 6-month mortality. Renal function was completely re-established in 82% and partially re-established in 12%, and only 6% of survivors required chronic dialysis. Conclusion Acute renal dysfunction is frequent in critically ill patients with cancer. Although mortality rates are high, selected patients can benefit from ICU care and advanced organ support. When evaluating prognosis and the appropriateness of dialysis in these patients, older age, functional capacity, cancer status and the severity of associated organ failures are important variables to take into consideration.

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