Impact of Fluid Balance on Intensive Care Unit Length of Stay in Critically Ill Trauma Patients.

BACKGROUND: There is significant data in the medical and surgical literature supporting the correlations between positive volume balance and negative outcomes such as AKI, prolonged mechanical ventilation, intensive care unit and hospital length of stay and increased mortality. METHODS: This single-center, retrospective chart review included adult patients identified from a Trauma Registry database. The primary outcome was the total ICU LOS. Secondary outcomes include hospital LOS, ventilator-free days, incidence of compartment syndrome, acute respiratory distress syndrome (ARDS), renal replacement therapy (RRT), and days of vasopressor therapy. RESULTS: In general, baseline characteristics were similar between groups with the exception of mechanism of injury, FAST exam, and disposition from the ED. The ICU LOS was shortest in the negative fluid balance and longest in the positive fluid balance group (4 days vs 6 days, P = .001). Hospital LOS was also shorter in the negative balance group than that of the positive balance group (7 days vs 12 days, P < .001). More patients in the positive balance group experienced acute respiratory distress syndrome compared to the negative balance group (6.3% vs 0%, P = .004). There was no significant difference in the incidence of renal replacement therapy, days of vasopressor therapy, or ventilator-free days. DISCUSSION: A negative fluid balance at seventy-two hours was associated with a shorter ICU and hospital LOS in critically ill trauma patients. Our observed correlation between positive volume balance and total ICU days merits further exploration with prospective, comparative studies of lower volume resuscitation to key physiologic endpoints compared with routine standard of care.

Management of Paroxysmal Sympathetic Hyperactivity with Dexmedetomidine and Propranolol Following Traumatic Brain Injury in a Pediatric Patient.

We report a case of pharmacologic management of pediatric paroxysmal sympathetic hyperactivity (PSH) in a patient who experienced symptomatic resolution with dexmedetomidine and propranolol. Following a blunt traumatic subdural hematoma and diffuse axonal injury, an 8-year-old male developed PSH on approximately day 5 of the hospitalization. PSH symptoms identified in this patient were hyperthermia, tachycardia, posturing, and hypertension with associated elevations in intracranial pressure. Episodes of PSH continued to be observed despite appropriate titration of opiates, sedatives, and traditional blood pressure management. Dexmedetomidine and propranolol were subsequently initiated to attenuate acute episodes of PSH. A reduction in sedative requirements and improvement in symptoms followed, which facilitated successful extubation. The combination of propranolol and dexmedetomidine was followed by a decrease in the frequency and severity of acute episodes of PSH. After utilization of multiple treatment modalities to control PSH episodes in our patient, propranolol and dexmedetomidine may have helped attenuate PSH signs and symptoms.

Evaluation of Neuroleptic Utilization in the Intensive Care Unit During Transitions of Care.

PURPOSE: The purpose of this study was to identify risk factors associated with inappropriate continuation of neuroleptics postdischarge from the intensive care unit (ICU) and hospital. MATERIALS AND METHODS: A retrospective chart review was performed including all patients greater than 18 years of age who received neuroleptic medications in an ICU. RESULTS: One hundred sixty-one patients were included during the 12- month study period. There were 85 (53%) patients discharged from the ICU with inappropriate continuation of a neuroleptic medication. There were 54 (34%) patients discharged from the hospital with inappropriate continuation of a neuroleptic medication. Patients were more likely to be discharged from the ICU with an inappropriate neuroleptic if they were prescribed multiple neuroleptics ( P = .02), did not have a urine drug screen collected at admission ( P = .023), or if trazodone was utilized in their therapy ( P = .004). Patients were more likely to be discharged from the hospital with a neuroleptic if they had multiple neuroleptic orders ( P = .0001) or if trazodone was utilized in their therapy ( P = .0023). CONCLUSION: Risk factors associated with the continuation of inappropriate neuroleptic medications upon discharge from the ICU or the hospital include multiple neuroleptic medications prescribed, the lack of a urine drug screen upon admission, and the utilization of trazodone.

Failure of chemical thromboprophylaxis in critically ill medical and surgical patients with sepsis.

PURPOSE: Critically ill patients who develop sepsis may be at a higher risk of venous thromboembolism (VTE) prophylaxis failure; however, studies in this population are limited. The objective of this study was to identify the incidence of VTE prophylaxis failure in this population. METHODS: This retrospective review of patients admitted to the intensive care unit between February 2013 and September 2015 included patients who were diagnosed with sepsis and received heparin or enoxaparin VTE prophylaxis. RESULTS: Of the 355 patients included, 42 (12.5%) developed a VTE. Acute respiratory distress syndrome (ARDS) (31% vs 16.7%, P = .0272) and higher positive end expiratory pressure (10 vs 8, P = .0066) were associated with increased risk of VTE prophylaxis failure. Logistic regression identified ARDS an event risk factor (odds ratio, 2.58; 95% confidence interval, 1.22-5.42). The VTE was associated with an increased intensive care unit (14 vs 9 days, P = .01) and hospital length of stay (26 vs 15 days, P < .0001). The median time from sepsis diagnosis to VTE event was 9 days (interquartile range, 5-13). CONCLUSION: Critically ill patients with sepsis had a high rate of VTE prophylaxis failure with ARDS being identified as a risk factor for VTE prophylaxis failure.

The role of inhaled prostacyclin in treating acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is a syndrome of acute lung injury that is characterized by noncardiogenic pulmonary edema and severe hypoxemia second to a pathogenic impairment of gas exchange. Despite significant advances in the area, mortality remains high among ARDS patients. High mortality and a limited spectrum of therapeutic options have left clinicians searching for alternatives, spiking interest in selective pulmonary vasodilators (SPVs). Despite the lack of robust evidence, SPVs are commonly employed for their therapeutic role in improving oxygenation in patients who have developed refractory hypoxemia in ARDS. While inhaled epoprostenol (iEPO) also impacts arterial oxygenation by decreasing ventilation-perfusion (V/Q) mismatching and pulmonary shunt flow, this effect is not different from inhaled nitric oxide (iNO). The most effective and safest dose for yielding a clinically significant increase in PaO2 and reduction in pulmonary artery pressure (PAP) appears to be 20-30 ng/kg/min in adults and 30 ng/kg/min in pediatric patients. iEPO appears to have a ceiling effect above these doses in which no additional benefit may be derived. iNO and iEPO have shown similar efficacy profiles; however, they differ with respect to cost and ease of therapeutic administration. The most beneficial effects of iEPO have been seen in adult patients with secondary ARDS as compared with primary ARDS, most likely due to the difference in etiology of the two disease states, and in patients suffering from baseline right ventricular heart failure. Although iEPO has demonstrated improvements in hemodynamic parameters and oxygenation in ARDS patients, due to the limited number of randomized clinical trials and the lack of studies investigating mortality, the use of iEPO cannot be recommended as standard of care in ARDS. iEPO should be reserved for those refractory to traditional therapies.

The incidence of thrombocytopenia associated with continuous renal replacement therapy in critically ill patients.

INTRODUCTION: Thrombocytopenia in the intensive care unit (ICU) is a commonly experienced complication; the pathology is not always easily understood. Continuous renal replacement therapy (CRRT) provides a method to dialyze unstable critically ill patients. We hypothesized that CRRT may precipitate a form of thrombocytopenia. In trials thrombocytopenia occurred at rates as high as 70%. The etiology remains unknown and results in additional diagnostic workup, as well as possible drug therapy. The extent, duration and temporal relation of thrombocytopenia remain to be determined. OBJECTIVES: Identify a pattern in platelet fluctuations after the initiation of CRRT and its impact on health care. METHODS: A retrospective study was conducted in patients receiving CRRT for >24 h with no pre-existing thrombocytopenia. Patients initiated on CRRT had daily platelet counts monitored, and CRRT attributes and therapeutic interventions were collected. Platelets were assessed for time to nadir, degree of decline and time to return to baseline after discontinuation of CRRT. RESULTS: Forty-nine patients met inclusion criteria. Thirty-seven percent of patients receiving heparinoids were tested for heparin-induced thrombocytopenia (HIT), during CRRT, with 39% of these patients having therapy changed to non-heparinoid agents due to suspected HIT; no HIT antibodies were positive. Eleven patients (22%) receiving anticoagulants, prophylactically or therapeutically had them held for a drop in platelets. There was a mean decline in platelets of 48% with a mean of 4.6 days to the nadir. An average 2.48 days were observed until rebound to >150 × 10(3)/mm(3). Statistical analysis failed to identify any patient attributes that correlated with the probability of thrombocytopenia. CONCLUSION: CRRT appears to be associated with a drop in platelets within the first 5 days of therapy with an average decline of 48%. However, platelets appear to return to >150 × 10(3)/mm(3) after cessation of CRRT. This fluctuation should be considered in the setting of patients developing thrombocytopenia after initiation of CRRT.

Analysis of the structural integrity of SU-8-based optofluidic systems for small-molecule crystallization studies.

The use of SU-8-based optofluidic systems (OFS) is validated as an affordable and easy alternative to expensive glass device manufacturing for small-molecule crystallization studies and, in comparison with other polymers, able to withstand most organic solvents. A comparison between two identical OFS (using SU-8 and poly(dimethylsiloxane), PDMS) against the 36 most commonly used organic solvents for small-molecule crystallization studies have confirmed both the structural and optical stability of the SU-8, whereas PDMS suffered from unsealing or tearing in most cases. In order to test its compatibility, measurements before and after 24 h of continued exposure against solvents have been pursued. Here, three aspects have been considered: in the macroscale, swelling has been determined by analyzing the variations in the optical path in the OFS. For determining compatibility at microscale, fabricated SU-8 micropatterns were solvent-etched and subsequently characterized by scanning electron microscopy (SEM). Roughness of the polymer has also been studied through atomic force microscopy (AFM) measurements at the nanoscale. Experimental measurements of PDMS swelling were in accordance with previously reported observations, while SU-8 displayed a great stability against all the tested solvents. Through this experimental procedure we also show that the OFS are suitable for real-time, on-chip, UV-vis spectroscopy. Micro- and nanoscale observations did not show apparent corrosion on SU-8 surface. Also, two commonly used carrier fluids for microdroplet generation (FC-70 Fluorinert oil and silicone oil) were also tested against the different solvents with the aim of providing useful information for later microbatch experiments.