Systematic review of factors influencing length of stay in ICU after adult cardiac surgery

Intensive care unit (ICU) care is associated with costly and often scarce resources. In many parts of the world, ICUs are being perceived as major bottlenecks limiting downstream services such as operating theatres. There are many clinical, surgical and contextual factors that influence length of stay. Knowing these factors can facilitate resource planning. However, the extent at which this knowledge is put into practice remains unclear. The aim of this systematic review was to identify factors that impact the duration of ICU stay after cardiac surgery and to explore evidence on the link between understanding these factors and patient and resource management.We conducted electronic searches of Embase, PubMed, ISI Web of Knowledge, Medline and Google Scholar, and reference lists for eligible studies.Twenty-nine papers fulfilled inclusion criteria. We recognised two types of objectives for identifying influential factors of ICU length of stay (LOS) among the reviewed studies. These were general descriptions of predictors and prediction of prolonged ICU stay through statistical models. Among studies with prediction models, only two studies have reported their implementation. Factors most commonly associated with increased ICU LOS included increased age, atrial fibrillation/ arrhythmia, chronic obstructive pulmonary disease (COPD), low ejection fraction, renal failure/ dysfunction and non-elective surgery status.Cardiac ICUs are major bottlenecks in many hospitals around the world. Efforts to optimise resources should be linked to patient and surgical characteristics. More research is needed to integrate patient and surgical factors into ICU resource planning

An investigation into the effects of commencing haemodialysis in the critically ill

<b>Introduction:</b> We have aimed to describe haemodynamic changes when haemodialysis is instituted in the critically ill. 3 hypotheses are tested: 1)The initial session is associated with cardiovascular instability, 2)The initial session is associated with more cardiovascular instability compared to subsequent sessions, and 3)Looking at unstable sessions alone, there will be a greater proportion of potentially harmful changes in the initial sessions compared to subsequent ones. <b>Methods:</b> Data was collected for 209 patients, identifying 1605 dialysis sessions. Analysis was performed on hourly records, classifying sessions as stable/unstable by a cutoff of >+/-20% change in baseline physiology (HR/MAP). Data from 3 hours prior, and 4 hours after dialysis was included, and average and minimum values derived. 3 time comparisons were made (pre-HD:during, during HD:post, pre-HD:post). Initial sessions were analysed separately from subsequent sessions to derive 2 groups. If a session was identified as being unstable, then the nature of instability was examined by recording whether changes crossed defined physiological ranges. The changes seen in unstable sessions could be described as to their effects: being harmful/potentially harmful, or beneficial/potentially beneficial. <b>Results:</b> Discarding incomplete data, 181 initial and 1382 subsequent sessions were analysed. A session was deemed to be stable if there was no significant change (>+/-20%) in the time-averaged or minimum MAP/HR across time comparisons. By this definition 85/181 initial sessions were unstable (47%, 95% CI SEM 39.8-54.2). Therefore Hypothesis 1 is accepted. This compares to 44% of subsequent sessions (95% CI 41.1-46.3). Comparing these proportions and their respective CI gives a 95% CI for the standard error of the difference of -4% to 10%. Therefore Hypothesis 2 is rejected. In initial sessions there were 92/1020 harmful changes. This gives a proportion of 9.0% (95% CI SEM 7.4-10.9). In the subsequent sessions there were 712/7248 harmful changes. This gives a proportion of 9.8% (95% CI SEM 9.1-10.5). Comparing the two unpaired proportions gives a difference of -0.08% with a 95% CI of the SE of the difference of -2.5 to +1.2. Hypothesis 3 is rejected. Fisher’s exact test gives a result of p=0.68, reinforcing the lack of significant variance. <b>Conclusions:</b> Our results reject the claims that using haemodialysis is an inherently unstable choice of therapy. Although proportionally more of the initial sessions are classed as unstable, the majority of MAP and HR changes are beneficial in nature

Autonomic nervous system assessment in critically ill patients undergoing a cognitive rehabilitation therapy

Recent clinical and electrophysiological studies reveal a high incidence of autonomic nervous system (ANS) dysfunction in patients treated in Intensive Care Units (ICUs). Cognitive rehabilitation (CR) is a behavioral therapy that has proven to be effective improving cognitive deficits in clinical populations with abnormalities in brain activation patterns. A total of 17 critically ill patients received CR aimed to improve the ANS status, which was quantified in terms of HRV. The CR included cognitive exercises aimed to improve prefrontal activation. HRV was obtained during pre-CR, CR and post-CR. Power in the low (PLF) and high (PHF) frequency bands related to sympathetic and parasympathetic systems was computed. PHF was obtained within a band centered at respiratory rate. Comparing with baseline values, 7 patients showed an increased PHF in post-CR, suggesting an increase of parasympathetic activity

Year in review in Intensive Care Medicine 2012. II: Pneumonia and infection, sepsis, coagulation, hemodynamics, cardiovascular and microcirculation, critical care organization, imaging, ethics and legal issues.

Journal ArticleSCOPUS: re.jSCOPUS: re.jinfo:eu-repo/semantics/publishe

Risk factors for delirium in ICU: a double-centre trial

Risk factors for delirium in ICU Background Delirium is a syndrome characterized by acute brain dysfunction. This syndrome is under-recognized in the intensive care unit (ICU) with not fully elucidated causing mechanisms. The identification of risk factors associated with delirium may prevent the onset of delirium and help in the management. Aim of this study is to estimate the incidence of delirium in ICU and to identify related risk factors in two different ICU. Methods This study was carried out in collaboration with the Intensive Care Unit of Santa Chiara Hospital, Pisa University, Italy, and the Intensive Care Unit of South Egypt Cancer Institute, Assiut University, Egypt. During a 3 months research period patients admitted to the referred ICU were enrolled. The Confusion Assessment Method for ICU was used as methodology for diagnosing delirium. Patients were assessed twice a day. Haemodynamic parameters, arterial blood gas values, electrolytes, presence of sepsis, type of ventilation and type of sedation were assessed at the same intervals. We also recorded daily laboratory investigations, age, diagnosis, length of ICU stay, incidence of complications and general condition at discharge. Data were statistically analyzed with Mann-Whitney test, Wilcoxon test and the Chi-square test. Results 111 patients in the first ICU and 51 patients in the second ICU were enrolled. ICU delirium was found to be significantly related to sepsis, mechanical ventilation and sedation (P-value <0,05). Conclusion We believe that the early identification of risk factors that may lead to the occurrence of delirium in ICU, associated with the appropriate treatment may reduce the incidence of delirium in ICU and delirium related complications

The use of clonidine in elderly patients with delirium; pharmacokinetics and hemodynamic responses

Background The Oslo Study of Clonidine in Elderly Patients with Delirium (LUCID) is an RCT investigating the effect of clonidine in medical patients > 65 years with delirium. To assess the dosage regimen and safety measures of this study protocol, we measured the plasma concentrations and hemodynamic effects of clonidine in the first 20 patients. Methods Patients were randomised to clonidine (n = 10) or placebo (n = 10). The treatment group was given a loading dose (75μg every 3rd hour up to a maximum of 4 doses) to reach steady state, and further 75μg twice daily until delirium free for 2 days, discharge or a maximum of 7 days. Blood pressure (BP) and heart rate (HR) were measured just before every dose. If the systolic BP was < 100 mmHg or HR < 50 beats per minute the next dose was omitted. Plasma concentrations of clonidine were measured 3 h after each drug intake on day 1, just before intake (day 2 and at steady state day 4–6) and 3 h after intake at steady state (Cmax). Our estimated pre-specified plasma concentration target range was 0.3–0.7μg/L. Results 3 h after the first dose of 75μg clonidine, plasma concentration levels rose to median 0.35 (range 0.24–0.40)μg/L. Median trough concentration (C0) at day 2 was 0.70 (0.47–0.96)μg/L. At steady state, median C0 was 0.47 (0.36–0.76)μg/L, rising to Cmax 0.74 (0.56–0.95)μg/L 3 h post dose. A significant haemodynamic change from baseline was only found at a few time-points during the loading doses within the clonidine group. There was however extensive individual BP and HR variation in both the clonidine and placebo groups, and when comparing the change scores (delta values) between the clonidine and the placebo groups, there were no significant differences. Conclusions The plasma concentration of clonidine was at the higher end of the estimated therapeutic range. Hemodynamic changes during clonidine treatment were as expected, with trends towards lower blood pressure and heart rate in patients treated with clonidine, but with dose adjustments based on SBP this protocol appears safe. Trial registration ClinicalTrials.gov NCT01956604, 09.25.2013. EudraCT Number: 2013–000815-26, 03.18.2013. Enrolment of first participant: 04.24.2014

Circadian Rhythms in Anesthesia and Critical Care Medicine

The rotation of the earth and associated alternating cycles of light and dark—the basis of our circadian rhythms—are fundamental to human biology and culture. However, it was not until 1971 that researchers first began to describe the molecular mechanisms for the circadian system. During the past few years, groundbreaking research has revealed a multitude of circadian genes affecting a variety of clinical diseases, including diabetes, obesity, sepsis, cardiac ischemia, and sudden cardiac death. Anesthesiologists, in the operating room and intensive care units, manage these diseases on a daily basis as they significantly affect patient outcomes. Intriguingly, sedatives, anesthetics, and the intensive care unit environment have all been shown to disrupt the circadian system in patients. In the current review, we will discuss how newly acquired knowledge of circadian rhythms could lead to changes in clinical practice and new therapeutic concepts