Critical Care Reviews Newsletter 296 13th August 2017

The critcal care reviews296th Critical Care Reviews Newsletter, contains the best critical care research and open access articles from across the medical literature in the last week.  The highlights of this issue are the LICORN randomized clinical trial, evaluating levosimendan in low output states post cardiac surgery; an expert statement on the management of atypical hemolytic uremic syndrome; and narrative reviews on paroxysmal sympathetic hyperactivity after acute brain injury, perioperative fluid management and persistent air leaks.

The full text of the newsletter can be accessed via this link.

Readmission to the Intensive Care Unit: Incidence, Risk Factors, Resource Use, and Outcomes. A Retrospective Cohort Study

This article in the Annals of the American Thoracic Society August 2017 issue was produced by Ponzoni et al.

Rationale:  Readmission to the intensive care unit (ICU) is associated with poor clinical outcomes, increased length of ICU and hospital stay, and higher costs. Nevertheless, knowledge of epidemiology of ICU readmissions, risk factors, and attributable outcomes is restricted to developed countries.

Objectives:  To determine the effect of ICU readmissions on in-hospital mortality, determine incidence of ICU readmissions, identify predictors of ICU readmissions and hospital mortality, and compare resource use and outcomes between readmitted and non-readmitted patients in a developing country.

Methods:  This retrospective single-centre cohort study was conducted in a 40-bed, open medical-surgical ICU of a private, tertiary care hospital in São Paulo, Brazil. The Local Ethics Committee at Hospital Israelita Albert Einstein approved the study protocol, and the need for informed consent was waived. All consecutive adult (≥18 yr) patients admitted to the ICU between June 1, 2013 and July 1, 2015 were enrolled in this study.

Results:  Comparisons were made between patients readmitted and not readmitted to the ICU. Logistic regression analyses were performed to identify predictors of ICU readmissions and hospital mortality. Out of 5,779 patients admitted to the ICU, 576 (10%) were readmitted to the ICU during the same hospitalization. Compared with non-readmitted patients, patients readmitted to the ICU were more often men (349 of 576 patients [60.6%] vs. 2,919 of 5,203 patients [56.1%]; P = 0.042), showed a higher (median [interquartile range]) severity of illness (Simplified Acute Physiology III score) at index ICU admission (50 [41-61] vs. 42 [32-54], respectively, for readmitted and non-readmitted patients; P < 0.001), and were more frequently admitted due to medical reasons (425 of 576 [73.8%] vs. 2,998 of 5,203 [57.6%], respectively, for readmitted and non-readmitted patients; P < 0.001). Simplified Acute Physiology III score (P < 0.001), ICU admission from the ward (odds ratio [OR], 1.907; 95% confidence interval [CI], 1.463-2.487; P < 0.001), vasopressors need during index ICU stay (OR, 1.391; 95% CI, 1.130-1.713; P = 0.002), and length of ICU stay (P = 0.001) were independent predictors of ICU readmission. After adjusting for severity of illness, ICU readmission (OR, 4.103; 95% CI, 3.226-5.518; P < 0.001), admission source, presence of cancer, use of vasopressors, mechanical ventilation or renal replacement therapy, length of ICU stay, and night time ICU discharge were associated with increased risk of in-hospital death.

Conclusions:  Readmissions to the ICU were frequent and strongly related to poor outcomes. The degree to which ICU readmissions are preventable as well as the main causes of preventable ICU readmissions need to be further determined.

The full paper can be accessed by subscribers to “Annals of the American Thoracic Society” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.


Analysis of Unplanned Postoperative Admissions to the Intensive Care Unit

This article in Journal of Intensive Care Medicine August 2017 was written by Quinn and colleagues.

Purpose:  To investigate factors associated with unplanned postoperative admissions to the intensive care unit (ICU).

Methods:  Data from the National Anesthesia Clinical Outcomes Registry (NACOR) were analyzed. We performed univariate and multivariate logistic regression to identify patient- and surgery-specific characteristics associated with unplanned postoperative ICU admission. We also recorded the prevalence of Current Procedural Terminology (CPT) and International Classification of Diseases, ninth revision (ICD-9) billing codes and outcomes for unplanned postoperative ICU admissions.

Results:  Of 23 341 130 records in the database, 2 910 738 records met our inclusion criteria. A higher American Society of Anesthesiologists physical status (ASA PS) class, case duration greater than 4 hours, and advanced age were associated with a greater likelihood of unplanned ICU admission. Vascular and thoracic surgery patients were more likely to have an unplanned ICU admission. The most common CPT and ICD-9 codes involved repair of femur/hip fracture, bowel resection, and acute postoperative pain. Large community hospitals were more likely than university hospitals to have unplanned postoperative ICU admissions. Patients in the unplanned postoperative ICU admission group were more likely to have experienced intraoperative cardiac arrest, hemodynamic instability, or respiratory failure and were more likely to die in the immediate perioperative period.

Conclusion:  Our study is the first diverse analysis of unplanned postoperative ICU admissions in the literature across multiple specialties and practice models. We found an association of advanced age, higher ASA PS class, and duration of procedure with unplanned ICU admission after surgery. Surgical specialties and procedures with the most unplanned ICU admissions could be areas for quality improvement and clinical pathways in the future.

The full paper can be accessed by subscribers to “Journal of Intensive Care Medicine” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

An Ethnographic Study of Health Information Technology Use in Three Intensive Care Units

This article in the August 2017 issue of Health Services Research was written by Leslie and colleagues.

Objectives:  To identify the impact of a full suite of health information technology (HIT) on the relationships that support safety and quality among intensive care unit (ICU) clinicians.

Data Sources:  A year-long comparative ethnographic study of three academic ICUs was carried out. A total of 446 hours of observational data was collected in the form of field notes. A subset of these observations-134 hours-was devoted to job-shadowing individual clinicians and conducting a time study of their HIT usage.

Principal Findings:  Significant variation in HIT implementation rates and usage was noted. Average HIT use on the two “high-use” ICUs was 49 percent. On the “low-use” ICU, it was 10 percent. Clinicians on the high-use ICUs experienced “silo” effects with potential safety and quality implications. HIT work was associated with spatial, data, and social silos that separated ICU clinicians from one another and their patients. Situational awareness, communication, and patient satisfaction were negatively affected by this siloing.

Conclusions:  HIT has the potential to accentuate social and professional divisions as clinical communications shift from being in-person to electronically mediated. Socio-technically informed usability testing is recommended for those hospitals that have yet to implement HIT. For those hospitals already implementing HIT, we suggest rapid, locally driven qualitative assessments focused on developing solutions to identified gaps between HIT usage patterns and organizational quality goals.

The full paper can be accessed by subscribers to “Health Services Research” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Recent anti-seizure medications in the Intensive Care Unit

This article by Orinx and colleagues was published in Minerva Anesthesiologica in August 2017

Background:  Seizures and status epilepticus (SE), both clinical and subclinical, are frequent in critically ill patients. The list of available antiseizure medications (ASMs) is expanding and now includes older and widely used drugs as well as more recent medications with a better safety and pharmacokinetics profile.

Methods:  We review a selection of recent publications about the indications and administration of ASMs in critical care for the prophylaxis and treatment of seizures and SE, focusing on recent ASMs available as intravenous formulation and emphasizing pharmacokinetics and safety issues in relation to several aspects of critical illness.

Results:  Levetiracetam, lacosamide and more recently brivaracetam, represent interesting alternatives to older ASMs, mostly due to a more favorable safety and pharmacokinetic profile. Low-quality studies suggest that this profile results in better tolerability in treated patients. Ketamine might represent a useful addition in our anesthetic armamentarium for refractory SE, due to its different mechanism of action and cardiovascular properties. Little evidence is available however to support the prophylactic use of ASMs in critically ill patients, except in specific settings (traumatic brain injury and subarachnoid hemorrhage). Head-to-head studies comparing recent and older ASMs in the treatment of acute seizures and SE are ongoing or awaiting publication. Administration of ASMs to critically ill patients needs to be adapted to organ dysfunction, and especially to renal dysfunction for recent drugs.

Conclusions:  Recent ASMs and could represent better treatment choices in critically ill patients than older ones but this needs to be confirmed in randomized controlled studies. In general, further studies are required to clarify the indications and optimal use of ASMs in the critical care setting.

The full paper can be accessed by subscribers to “Minerva Anesthesiologica” via this link.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Critical Care Reviews Newsletter 295 6th August 2017

This latest edition of the Critical Care Reviews Newsletter includes randomised controlled trials on “Intensive versus standard physical rehabilitation therapy in the critically ill (EPICC)” and “Effect of Endovascular Contact Aspiration vs Stent Retriever on Revascularization in Patients with Acute Ischemic Stroke and Large Vessel Occlusion.”  Systematic reviews and meta-analysis include “Could remifentanil reduce duration of mechanical ventilation in comparison with other opioids for mechanically ventilated patients?” and “Intensive versus standard lowering of blood pressure in the acute phase of intracranial haemorrhage: a systematic review and meta-analysis.”  Also included are observational studies on “Feasibility and safety of virtual-reality-based early neurocognitive stimulation in critically ill patients” and “How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study.”

The full text of the newsletter can be accessed via this link.

Ear Care for the Most Vulnerable Infants

Each year, approximately 6,000 newborns-of the nearly 4 million births in the U.S.-are diagnosed with permanent hearing loss, and premature infants are 50 percent more likely than full-term infants to develop hearing loss | ASHA Leader

Infants’ experiences in the neonatal intensive care unit (NICU) are highly variable, depending on the complexity of their cases and degree of prematurity. Those with more severe or chronic medical and neurodevelopmental conditions present particular challenges to the audiology team.

Complications of their conditions can delay hearing screening, and the medical equipment helping to support them may interfere with the screening itself. The NICU environment can also be noisy for this vulnerable population. Yet another challenge is the emotional fragility of these infants’ parents.

Although audiology isn’t part of the primary NICU care team, every infant receives a hearing screen, and any infant with a failed screen receives diagnostic audiological testing. This means the hearing-screening staff and audiology team play an important role, particularly after a baby does not pass the hearing screening. Audiologists can also play a key role in the development, implementation and oversight of the newborn hearing program (see more on newborn hearing screening on the ASHA Practice Portal: on.asha. org/newborn-screening). In these cases, the audiologist serves as the primary source of hearing-related information for the parents and the medical team.

To address the particular challenges of the NICU population, audiologists need to communicate and work closely with the NICU staff as soon as it’s appropriate, consider the effects of medical equipment, communicate with parents with a great deal of sensitivity, and work at coordinating discharge planning and follow-up care with the infant’s parents and other providers.

Full reference: McGrath, A. P., & Vohr, B. R. (2017). Ear care for the most vulnerable infants. ASHA Leader, 22(8), 20-22.