Implementing a Goal-Directed Therapy Protocol for Fluid Resuscitation in the Cardiovascular Intensive Care Unit

2020 ◽  
Vol 31 (4) ◽  
pp. 364-370
Author(s):  
Lori Dugan Brien ◽  
Marilyn H. Oermann ◽  
Margory Molloy ◽  
Catherine Tierney
Keyword(s):  
Fluid Resuscitation ◽  
Simulation Training ◽  
Kidney Injury ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Intravenous Fluids ◽  
Goal Directed Therapy ◽  
Cardiovascular Intensive Care ◽  
Vasoactive Medications ◽  
Therapy Protocol

Background Balancing fluid administration and titration of vasoactive medications is critical to preventing postoperative complications in cardiac surgical patients. Objective To evaluate the impact of implementing a goal-directed therapy protocol in the cardiovascular intensive care unit on total intravenous fluids administered on the day of surgery, rates of acute kidney injury, and hospital length of stay. Methods A fluid resuscitation protocol using dynamic assessment of fluid responsiveness with stroke volume index was developed, and nurses were prepared for its implementation using simulation training. Results After implementation of the new protocol, the total amount of intravenous fluids administered on the day of surgery was significantly reduced (P = .003). There were no significant changes in hospital length of stay (P = .83) or rates of acute kidney injury (P = .86). There were significant increases in nurses’ knowledge of (P < .001) and confidence in (P < .001) fluid resuscitation and titration of vasoactive medications after simulation training. Conclusions Use of a fluid resuscitation protocol resulted in a reduction in the amount of intravenous fluids administered on the day of surgery. The simulation training increased nurses’ knowledge of and confidence in fluid resuscitation and titration of vasoactive medications.

Controlled Study of Decision-Making Algorithms for Kidney Replacement Therapy Initiation in Acute Kidney Injury

2021 ◽  
pp. CJN.02060221
Author(s):  
Yvelynne Kelly ◽  
Kavita Mistry ◽  
Salman Ahmed ◽  
Shimon Shaykevich ◽  
Sonali Desai ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Length Of Stay ◽  
Kidney Injury ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Controlled Study ◽  
Control Group ◽  
Inpatient Mortality ◽  
Icu Length Of Stay ◽  
Kidney Replacement Therapy

Background: Acute kidney injury (AKI) requiring kidney replacement therapy (KRT) is associated with high mortality and utilization. We evaluated the use of an AKI-Standardized Clinical Assessment and Management Plan (SCAMP) on patient outcomes including mortality, hospital and ICU length of stay. Methods: We conducted a 12-month controlled study in the ICUs of a large academic tertiary medical center. We alternated use of the AKI-SCAMP with use of a "sham" control form in 4-6-week blocks. The primary outcome was risk of inpatient mortality. Pre-specified secondary outcomes included 30-day mortality, 60-day mortality and hospital and ICU length of stay. Generalized estimating equations were used to estimate the impact of the AKI-SCAMP on mortality and length of stay. Results: There were 122 patients in the AKI-SCAMP group and 102 patients in the control group. There was no significant difference in inpatient mortality associated with AKI-SCAMP use (41% vs 47% control). AKI-SCAMP use was associated with significantly reduced ICU length of stay (mean 8 (95% CI 8-9) vs 12 (95% CI 10-13) days; p = <0.0001) and hospital length of stay (mean 25 (95% CI 22-29) vs 30 (95% CI 27-34) days; p = 0.02). Patients in the AKI-SCAMP group less likely to receive KRT in the context of physician-perceived treatment futility than those in the control group (2% vs 7%, p=0.003). Conclusions: Use of the AKI-SCAMP tool for AKI-KRT was not significantly associated with inpatient mortality but was associated with reduced ICU and hospital length of stay and use of KRT in cases of physician-perceived treatment futility.

scholarly journals Evaluating the Role of Staphylococcus aureus Nasal PCR in Pediatric Head and Neck Infections

2021 ◽  
Vol 26 (7) ◽  
pp. 734-739
Author(s):  
Chandni Patel ◽  
Guru Bhoojhawon ◽  
Lukasz Weiner ◽  
Danelle Wilson ◽  
Derek Zhorne ◽  
...  
Keyword(s):  
Staphylococcus Aureus ◽  
Treatment Failure ◽  
Head And Neck ◽  
Pediatric Patients ◽  
Total Duration ◽  
Kidney Injury ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Head And Neck Infections

OBJECTIVE Vancomycin is often empirically used in the management of head and neck infections (HNIs) in children. The objective of this study was to determine the utility of Staphylococcus aureus (SA) nasal PCR to facilitate de-escalation of vancomycin for pediatric HNIs. METHODS This was a single-center, retrospective cohort study of pediatric patients who received empiric intravenous vancomycin for a diagnosis of HNIs between January 2010 and December 2019. Subjects were excluded if they met any of the following: confirmed/suspected coinfection of another site, dialysis, immunocompromised status, admission to the NICU, alternative diagnosis that did not require antibiotics, or readmission for HNIs within 30 days of previous admission. The primary outcome was time to de-escalation of vancomycin. Total duration of antibiotics, treatment failure, hospital length of stay (LOS), and incidence of acute kidney injury (AKI) were also assessed. RESULTS Of the 575 patients identified, 124 patients received an SA nasal PCR. The median time to de-escalation was 39.5 hours in those patients compared with 53.7 hours in patients who did not have a SA nasal PCR (p = 0.002). No difference was noted in total duration of all methicillin-resistant Staphylococcus aureus antibiotics, hospital LOS, treatment failure, and AKI. CONCLUSIONS In a large cohort of pediatric patients with HNIs, those who underwent testing with an SA nasal PCR spent less time receiving intravenous vancomycin, although their LOS was not significantly reduced. Further investigation is needed to better define the role of SA nasal PCRs in determining antibiotic therapy for HNIs.

scholarly journals 2669. Evaluation of Post-Operative Acute Kidney Injury with Piperacillin–Tazobactam Combined with Vancomycin for Lung Transplant Prophylaxis

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S936-S936
Author(s):  
Natasha N Pettit ◽  
Cynthia T Nguyen ◽  
Lisa Potter ◽  
Jennifer Pisano
Keyword(s):  
Acute Kidney Injury ◽  
Antibiotic Prophylaxis ◽  
Lung Transplant ◽  
Statistical Significance ◽  
Prophylactic Antibiotic ◽  
Kidney Injury ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Transplant Patients ◽  
The Difference

Abstract Background Several studies have identified that the addition of vancomycin (VAN) to piperacillin–tazobactam (PT) is associated with a higher incidence of nephrotoxicity when compared with other antibiotic regimens. Beginning in June 2017, our lung transplant antibiotic prophylaxis regimen was modified from PT monotherapy to VAN and PT. Methods All adult lung transplant patients between January 1, 2015 and November 10, 2018 were included. Patients were excluded if acute kidney injury (AKI) was present prior to transplant. Rates of AKI within 7 days of transplant were compared between those who received prophylaxis with PT and VAN vs. those receiving alternative regimens (AR). Patients receiving less than 1 dose of vancomycin or less than 3 doses PT (less than 24hours) were deemed to be in the alternative regimen group. AKI was defined as either an increase in serum creatinine (SCr) by ≥0.3 mg/dL within 48 hours or increase in SCr to ≥1.5 times baseline (within 7 days post-transplant). Secondary outcomes included duration of initial prophylactic antibiotic regimens, hospital length of stay (LOS), and all-cause inpatient mortality. Results Eighty-six patients were included, 44 (51%) patients received PT/VAN. Baseline characteristics and results shown in Table 1. Of those receiving PT/VAN for prophylaxis, 24 (54%) developed AKI within 7 days of transplant while 15 (36%) of 42 patients receiving AR developed AKI (P = 0.08). Conclusion A larger proportion of patients that received PT/VAN for transplant antibiotic prophylaxis experienced AKI within 7 days. Although the difference did not reach statistical significance, a 19% higher incidence of AKI warrants need for further investigation. Disclosures All authors: No reported disclosures.

scholarly journals Impact of Changes in Serum Calcium Levels on In-Hospital Mortality

Medicina ◽  
2020 ◽  
Vol 56 (3) ◽  
pp. 106 ◽  
Author(s):  
Charat Thongprayoon ◽  
Wisit Cheungpasitporn ◽  
Panupong Hansrivijit ◽  
Juan Medaura ◽  
Api Chewcharat ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Serum Calcium ◽  
Reference Group ◽  
Kidney Injury ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Absolute Difference ◽  
Systemic Level ◽  
Patient Database ◽  
Independent Association

Background and objectives: Calcium concentration is strictly regulated at both the cellular and systemic level, and changes in serum calcium levels can alter various physiological functions in various organs. This study aimed to assess the association between changes in calcium levels during hospitalization and mortality. Materials and Methods: We searched our patient database to identify all adult patients admitted to our hospital from January 1st, 2009 to December 31st, 2013. Patients with ≥2 serum calcium measurements during the hospitalization were included. The serum calcium changes during the hospitalization, defined as the absolute difference between the maximum and the minimum calcium levels, were categorized into five groups: 0–0.4, 0.5–0.9, 1.0–1.4, 1.5–1.9, and ≥2.0 mg/dL. Multivariable logistic regression was performed to assess the independent association between calcium changes and in-hospital mortality, using the change in calcium category of 0–0.4 mg/dL as the reference group. Results: Of 9868 patients included in analysis, 540 (5.4%) died during hospitalization. The in-hospital mortality progressively increased with higher calcium changes, from 3.4% in the group of 0–0.4 mg/dL to 14.5% in the group of ≥2.0 mg/dL (p < 0.001). When adjusted for age, sex, race, principal diagnosis, comorbidity, kidney function, acute kidney injury, number of measurements of serum calcium, and hospital length of stay, the serum calcium changes of 1.0–1.4, 1.5–1.9, and ≥2.0 mg/dL were significantly associated with increased in-hospital mortality with odds ratio (OR) of 1.55 (95% confidence interval (CI) 1.15–2.10), 1.90 (95% CI 1.32–2.74), and 3.23 (95% CI 2.39–4.38), respectively. The association remained statistically significant when further adjusted for either the lowest or highest serum calcium. Conclusion: Larger serum calcium changes in hospitalized patients were progressively associated with increased in-hospital mortality.

Prolonged Length of Stay After Liver Transplantation

ICU Director ◽  
2012 ◽  
Vol 3 (2) ◽  
pp. 75-79
Author(s):  
Andrew T. Young ◽  
Gebhard Wagener
Keyword(s):  
Liver Transplantation ◽  
Length Of Stay ◽  
Hospital Stay ◽  
Kidney Injury ◽  
Hospital Length ◽  
Meld Score ◽  
Hospital Length Of Stay ◽  
Prolonged Hospital Stay ◽  
Prolonged Length ◽  
Prolonged Hospital

Prolonged hospital length of stay after liver transplantation uses a large amount of hospital resources. The authors evaluated factors associated with prolonged hospital stay in a large single center series. Prolonged hospital stay was defined as more than 30 days. A total of 578 adult cadaveric liver transplants were included, and of these, 160 (27.7%) had a prolonged hospital stay. These patients had shorter waitlist time, higher preoperative MELD (model for end-stage liver disease) scores and received organs from donors with lower donor risk indices. In multivariate analysis, only preoperative MELD score remained significant. Postoperatively, there was no difference in the incidence of acute kidney injury; however, patients with prolonged hospital stay were more likely to have early allograft dysfunction and a higher 90-day mortality.

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.

Association of Hyperchloremia With Unfavorable Clinical Outcomes in Adults With Diabetic Ketoacidosis

2019 ◽  
Vol 35 (11) ◽  
pp. 1307-1313 ◽  
Author(s):  
Nathan T. Goad ◽  
Rita N. Bakhru ◽  
James L. Pirkle ◽  
Michael T. Kenes
Keyword(s):  
Diabetic Ketoacidosis ◽  
Primary Outcome ◽  
Cox Regression ◽  
Kidney Injury ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Cox Regression Analysis ◽  
Serum Chloride ◽  
Hospital Development ◽  
Median Hospital

Objective: Hyperchloremia is associated with worsened outcomes in various clinical situations; however, data are limited in patients with diabetic ketoacidosis (DKA). The purpose of this study was to determine the effect of hyperchloremia on time to DKA resolution. Methods: We conducted a retrospective cohort study of adult patients admitted with incident DKA from January 2013 through October 2017 and stratified by the development of hyperchloremia versus maintaining normochloremia. The primary outcome was time to final DKA resolution. Secondary outcomes included time to initial DKA resolution, incidence of acute kidney injury (AKI) on admission, in-hospital development of AKI, and hospital length of stay (LOS). Results: Of the 102 patients included, 52 developed hyperchloremia. Patients with hyperchloremia had longer times to final DKA resolution compared to those with normochloremia (median 22.3 [interquartile range, IQR, 15.2-36.9] vs 14.2 [IQR 8.8-21.1] hours; P = .001). Time to initial DKA resolution was also longer in patients who developed hyperchloremia compared to those who did not (median 16.3 vs 10.9 hours; P = .024). More patients with hyperchloremia developed in-hospital AKI (26.9% vs 8.0%; P = .01). Median hospital LOS was significantly longer in the hyperchloremia cohort ( P < .001). On Cox regression analysis, time to DKA resolution was significantly longer with each 1 mmol/L increase in serum chloride (HR 0.951; P < .001). Conclusion: The presence of hyperchloremia in patients with DKA was associated with increased time to DKA resolution, risk of in-hospital AKI, and hospital LOS. Further evaluation of the avoidance or treatment of hyperchloremia in DKA is needed.

Incidence of Acute Kidney Injury in Intermittent Versus Continuous Infusion of Polymyxin B in Hospitalized Patients

2019 ◽  
Vol 53 (9) ◽  
pp. 886-893 ◽  
Author(s):  
Yarelis Alvarado Reyes ◽  
Raquel Cruz ◽  
Julia Gonzalez ◽  
Yeiry Perez ◽  
William R. Wolowich
Keyword(s):  
Acute Kidney Injury ◽  
Hospital Mortality ◽  
Continuous Infusion ◽  
Kidney Injury ◽  
Polymyxin B ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Baseline Serum ◽  
Increased Risk ◽  
Dosing Strategies

Background: Studies evaluating the risk of developing acute kidney injury (AKI) with different dosing strategies of polymyxin B are limited. Objectives: To compare the incidence of AKI in patients treated with intermittent versus continuous polymyxin B therapy. Secondary objectives included time to onset of AKI, hospital length of stay (LOS), and all-cause hospital mortality. Variables associated with an increased risk of AKI were evaluated. Methods: A retrospective record review was conducted at a single center in Puerto Rico. Adult patients (≥18 years old) treated with polymyxin B (first course) for at least 48 hours from 2013-2015 were evaluated. Patients with a creatinine clearance <10 mL/min and/or on renal replacement were excluded. Results: A total of 69 patients were included: 42 in the continuous infusion and 27 in the intermittent dosing group. Incidence of AKI was not significantly different between the groups (intermittent 41% vs continuous 31%, P = 0.4). No difference was found in the onset of nephrotoxicity, hospital LOS, or all-cause hospital mortality. Variables associated with increased risk of AKI were baseline serum creatinine, age, and intensive care unit admission. Patients with a body mass index (BMI) >25 kg/m2 on polymyxin B via continuous infusion had a significantly higher cumulative incidence of AKI ( P = 0.016). Conclusion and Relevance: No difference in the risk of polymyxin B nephrotoxicity was found between intermittent and continuous infusion administration. Administration of polymyxin B via a continuous infusion may result in a higher risk of AKI in patients with a BMI >25 kg/m2.

scholarly journals Immunoglobulin Deficiency as an Indicator of Disease Severity in Patients with COVID-19

2020 ◽  
Author(s):  
Faeq Husain-Syed ◽  
István Vadász ◽  
Jochen Wilhelm ◽  
Hans-Dieter Walmrath ◽  
Werner Seeger ◽  
...  
Keyword(s):  
Risk Factors ◽  
Disease Severity ◽  
Disease Onset ◽  
Kidney Injury ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Limited Information ◽  
Igg Deficiency ◽  
Associated Risk Factors ◽  
Lower Ratio

Despite the pandemic status of COVID-19, there is limited information about host risk factors and treatment beyond supportive care. Immunoglobulin G (IgG) could be a potential treatment target. Our aim was to determine the incidence of IgG deficiency and associated risk factors in a cohort of 62 critical ill COVID-19 patients admitted to two German ICUs (72.6% male, median age: 61 years). 13 (21.0%) of the patients displayed IgG deficiency (IgG <7 g/L) at baseline (predominant for the IgG1, IgG2, and IgG4 subclasses). IgG-deficient patients had worse measures of clinical disease severity than those with normal IgG levels (shorter duration from disease onset to ICU admission, lower ratio of PaO2 to FiO2, higher Sequential Organ Failure Assessment score, and higher levels of ferritin, neutrophil-to-lymphocyte ratio and serum creatinine). IgG-deficient patients were also more likely to have sustained lower levels of lymphocyte counts and higher levels of ferritin throughout the hospital stay. Furthermore, IgG-deficient patients compared to those with normal IgG levels displayed higher rates of acute kidney injury (76.9% vs. 26.5%; p=0.005) and death (46.2% vs. 14.3%; p=0.012), longer ICU (28 [6-48] vs. 12 [3-18] days; p=0.012) and hospital length of stay (30 [22-50] vs. 18 [9-24] days; p=0.004). Multivariable logistic regression showed increasing odds of 90-day overall mortality associated with IgG-deficiency (OR 12.8, 95% CI 1.5-108.4; p=0.019). IgG deficiency might be common in critically ill COVID-19 patients, and warrants investigation as both a marker of disease severity as well as a potential therapeutic target.

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