Dynamic Assessment of Fluid Responsiveness in Surgical ICU Patients Through Stroke Volume Variation is Associated With Decreased Length of Stay and Costs: A Systematic Review and Meta-Analysis.

Static indices, such as the central venous pressure, have proven to be inaccurate predictors of fluid responsiveness. An emerging approach uses dynamic assessment of fluid responsiveness (FT-DYN), such as stroke volume variation (SVV) or surrogate dynamic variables, as more accurate measures of volume status. Recent work has demonstrated that goal-directed therapy guided by FT-DYN was associated with reduced intensive care unit (ICU) mortality; however, no study has specifically assessed this in surgical ICU patients. This study aimed to conduct a systematic review and meta-analysis on the impact of employing FT-DYN in the perioperative care of surgical ICU patients on length of stay in the ICU. As secondary objectives, we performed a cost analysis of FT-DYN and assessed the impact of FT-DYN versus standard care on hospital length of stay and mortality. We identified all randomized controlled trials (RCTs) through MEDLINE, EMBASE, and CENTRAL that examined adult patients in the ICU who were randomized to standard care or to FT-DYN from inception to September 2017. Two investigators independently reviewed search results, identified appropriate studies, and extracted data using standardized spreadsheets. A random effect meta-analysis was carried out. Eleven RCTs were included with a total of 1015 patients. The incorporation of FT-DYN through SVV in surgical patients led to shorter ICU length of stay (weighted mean difference [WMD], -1.43d; 95% confidence interval [CI], -2.09 to -0.78), shorter hospital length of stay (WMD, -1.96d; 95% CI, -2.34 to -1.59), and trended toward improved mortality (odds ratio, 0.55; 95% CI, 0.30-1.03). There was a decrease in daily ICU-related costs per patient for those who received FT-DYN in the perioperative period (WMD, US$ -1619; 95% CI, -2173.68 to -1063.26). Incorporation of FT-DYN through SVV in the perioperative care of surgical ICU patients is associated with decreased ICU length of stay, hospital length of stay, and ICU costs.

Nutrition therapy in intensive care unit setting: what can be learned from a 6 months survey in a large academic hospital?

BACKGROUND: Malnutrition in Intensive Care Unit patients has been associated with worse clinical outcomes such as mortality and length of stay (LOS) in Intensive Care Unit (ICU), and nutritional status of Intensive Care Unit patients in particular seemed to be a significant predictor of mortality. Promptness of clinical nutrition administration is a key of nutritional support whenever volitional intake is unfeasible. Early enteral nutrition is associated with better clinical outcomes (reduced complications, LOS in ICU and in Hospital). The aim of this study is to investigate the nutrition therapy management in a large Academic Hospital, evaluating its effects on mortality and LOS in ICU and in the Hospital. STUDY DESIGN: Data were collected retrospectively from clinical records. Six physicians were trained on the data collection protocol and they reviewed every clinical record of patients included in the survey. METHODS: Data of 426 patients admitted to ICUs between November 2016, 1st and April 2017, 30th were collected. A multivariate logistic adjusted regression, with backward variables selection method, was performed in order to identify predictors of enteral and parenteral nutrition conducted within 48 hours after admission to the ICU. The relation between medical nutrition therapy, mortality and LOS in ICU and in the Hospital were also evaluated. RESULTS: Patients were given prompt parenteral and enteral nutrition in 25.12% and 27.46% of cases, respectively. No association was found between medical nutrition therapy and ICU or hospital mortality. Predictors of early enteral nutrition were type of admission and surgery before admission; early parenteral nutrition predictors were gender, ICU (A vs B), impaired immunity status and Central Venous Catheter presence at admission. CONCLUSIONS: Our study stresses the need of monitoring nutrition prescribing behaviors in acute hospitals in order to better set up tailored interventions to standardize clinicians' practices and to focus on specific training targets.

Systemic Inflammatory Response Index (SIRI) as a Predictive Marker for Adverse Outcomes in Children with New-Onset Type 1 Diabetes Mellitus.

(1) Background: Although most cases of new-onset type 1 diabetes mellitus (T1DM) are managed without serious events, life-threatening complications do arise in a subset of patients. Our objective was to assess the correlation between elevated SIRI values and adverse events related to the onset of T1DM. (2) Methods: This retrospective study, spanning ten years, included 187 patients with new-onset T1DM divided into three groups based on SIRI tertiles. The primary outcome was the occurrence of acute complications during hospital admission, while the secondary outcome was prolonged Intensive Care Unit (ICU) admission. (3) Results: Patients with high SIRI values were more likely to experience higher disease activity, leading to longer ICU admission times and more frequent complications. Multivariate logistic regression analysis revealed that the SIRI was independently associated with acute complications (p = 0.003) and prolonged ICU length of stay (p = 0.003). Furthermore, receiver operating characteristic analysis demonstrated the SIRI's superior predictive accuracy compared to venous pH (AUC = 0.837 and AUC = 0.811, respectively) and to the individual component cell lineages of the SIRI. (4) Conclusions: These findings emphasize the potential utility of the SIRI as a prognostic marker in identifying patients at increased risk during T1DM hospital admissions.

Predictors of in-ICU length of stay among congenital heart defect patients using artificial intelligence model: A pilot study.

Objective: This study aims to develop a predictive model using artificial intelligence to estimate the ICU length of stay (LOS) for Congenital Heart Defects (CHD) patients after surgery, improving care planning and resource management. Design: We analyze clinical data from 2240 CHD surgery patients to create and validate the predictive model. Twenty AI models are developed and evaluated for accuracy and reliability. Setting: The study is conducted in a Brazilian hospital's Cardiovascular Surgery Department, focusing on transplants and cardiopulmonary surgeries. Participants: Retrospective analysis is conducted on data from 2240 consecutive CHD patients undergoing surgery. Interventions: Ninety-three pre and intraoperative variables are used as ICU LOS predictors. Measurements and main results: Utilizing regression and clustering methodologies for ICU LOS (ICU Length of Stay) estimation, the Light Gradient Boosting Machine, using regression, achieved a Mean Squared Error (MSE) of 15.4, 11.8, and 15.2 days for training, testing, and unseen data. Key predictors included metrics such as "Mechanical Ventilation Duration", "Weight on Surgery Date", and "Vasoactive-Inotropic Score". Meanwhile, the clustering model, Cat Boost Classifier, attained an accuracy of 0.6917 and AUC of 0.8559 with similar key predictors. Conclusions: Patients with higher ventilation times, vasoactive-inotropic scores, anoxia time, cardiopulmonary bypass time, and lower weight, height, BMI, age, hematocrit, and presurgical oxygen saturation have longer ICU stays, aligning with existing literature.

Comparison of Four Machine Learning Techniques for Prediction of Intensive Care Unit Length of Stay in Heart Transplantation Patients.

Background: Post-operative heart transplantation patients often require admission to an intensive care unit (ICU). Early prediction of the ICU length of stay (ICU-LOS) of these patients is of great significance and can guide treatment while reducing the mortality rate among patients. However, conventional linear models have tended to perform worse than non-linear models. Materials and Methods: We collected the clinical data of 365 patients from Wuhan Union Hospital who underwent heart transplantation surgery between April 2017 and August 2020. The patients were randomly divided into training data (N = 256) and test data (N = 109) groups. 84 clinical features were collected for each patient. Features were validated using the Least Absolute Shrinkage and Selection Operator (LASSO) regression's fivefold cross-validation method. We obtained Shapley Additive explanations (SHAP) values by executing package "shap" to interpret model predictions. Four machine learning models and logistic regression algorithms were developed. The area under the receiver operating characteristic curve (AUC-ROC) was used to compare the prediction performance of different models. Finally, for the convenience of clinicians, an online web-server was established and can be freely accessed via the website https://wuhanunion.shinyapps.io/PredictICUStay/. Results: In this study, 365 consecutive patients undergoing heart transplantation surgery for moderate (NYHA grade 3) or severe (NYHA grade 4) heart failure were collected in Wuhan Union Hospital from 2017 to 2020. The median age of the recipient patients was 47.2 years, while the median age of the donors was 35.58 years. 330 (90.4%) of the donor patients were men, and the average surgery duration was 260.06 min. Among this cohort, 47 (12.9%) had renal complications, 25 (6.8%) had hepatic complications, 11 (3%) had undergone chest re-exploration and 19 (5.2%) had undergone extracorporeal membrane oxygenation (ECMO). The following six important clinical features were selected using LASSO regression, and according to the result of SHAP, the rank of importance was (1) the use of extracorporeal membrane oxygenation (ECMO); (2) donor age; (3) the use of an intra-aortic balloon pump (IABP); (4) length of surgery; (5) high creatinine (Cr); and (6) the use of continuous renal replacement therapy (CRRT). The eXtreme Gradient Boosting (XGBoost) algorithm presented significantly better predictive performance (AUC-ROC = 0.88) than other models [Accuracy: 0.87; sensitivity: 0.98; specificity: 0.51; positive predictive value (PPV): 0.86; negative predictive value (NPV): 0.93]. Conclusion: Using the XGBoost classifier with heart transplantation patients can provide an accurate prediction of ICU-LOS, which will not only improve the accuracy of clinical decision-making but also contribute to the allocation and management of medical resources; it is also a real-world example of precision medicine in hospitals.

C-reactive protein as a non-linear predictor of prolonged length of intensive care unit stay after gastrointestinal cancer surgery.

BACKGROUND: The relationship between C-reactive protein (CRP) levels and prolonged intensive care unit (ICU) length of stay (LoS) has not been well defined. AIM: To explore the association between CRP levels at ICU admission and prolonged ICU LoS in gastrointestinal cancer (GC) patients after major surgery. METHODS: A retrospective study was performed to quantify serum CRP levels and to establish their association with prolonged ICU LoS (≥ 72 h) in GC patients admitted to the ICU. Univariate and multivariate regression analyses were conducted, and restricted cubic spline curves with four knots (5%, 35%, 65%, 95%) were used to explore non-linearity assumptions. RESULTS: A total of 408 patients were enrolled. Among them, 83 (20.3%) patients had an ICU LoS longer than 72 h. CRP levels were independently associated with the risk of prolonged ICU LoS [odds ratio (OR) 1.47, 95% confidence interval (CI) 1.00-2.17]. Restricted cubic spline analysis revealed a non-linear relationship between CRP levels and OR for the prolonged ICU LoS (P = 0.035 for non-linearity). After the cut-off of 2.6 (log transformed mg/L), the OR for prolonged ICU LoS significantly increased with CRP levels. The adjusted regression coefficient was 0.70 (95%CI 0.31-1.57, P = 0.384) for CRP levels less than 2.6, whereas it was 2.43 (95%CI 1.39-4.24, P = 0.002) for CRP levels higher than 2.6. CONCLUSION: Among the GC patients, CRP levels at ICU admission were non-linearly associated with prolonged ICU LoS in survivors. An admission CRP level > 2.6 (log transformed mg/L) was associated with increased risk of prolonged ICU LoS.

Attention to detail: A dedicated rib fracture consultation service leads to earlier operation and improved clinical outcomes.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) has been correlated with improved outcomes, including decreased length of stay (LOS). We hypothesized that an SSRF consultation service would increase the frequency of SSRF and improve outcomes. METHODS: A prospective observational study was performed to compare outcomes before and after implementing an SSRF service. Primary outcome was time from admission to surgery; secondary outcomes included LOS, mortality and morphine milligram equivalents (MME) prescribed at discharge. RESULTS: 1865 patients met consultation criteria and 128 patients underwent SSRF. Mortality decreased (6.3% vs. 3%) and patients were prescribed fewer MME at discharge (328 MME vs. 124 MME) following implementation. For the operative cohort, time from admission to surgery decreased by 1.72 days and ICU LOS decreased by 2.6 days. CONCLUSION: Establishment of an SSRF service provides a mechanism to maximize capture and evaluation of operative candidates, provide earlier intervention, and improve patient outcomes. Additional study to determine which elements and techniques are most beneficial is warranted. LEVEL OF EVIDENCE: III.

Effects of Pre-Operative Risk Factors on Intensive Care Unit Length of Stay (ICU-LOS) in Major Oral and Maxillofacial Cancer Surgery.

OBJECTIVE: This study aimed to investigate the effect of certain pre-operative parameters directly on the post-operative intensive care unit (ICU)-length of stay (LOS), in order to identify at-risk patients that are expected to need prolonged intensive care management post-operatively. MATERIAL AND METHODS: Retrospectively, patients managed in an ICU after undergoing major oral and maxillofacial surgery were analyzed. Inclusion criteria entailed: age 18-90 years, major primary oral cancer surgery including tumor resection, neck dissection and microvascular free flap reconstruction, minimum operation time of 8 h. Exclusion criteria were: benign/borderline tumors, primary radiation, other defect reconstruction than microvascular, treatment at other centers. Separate parameters used within the clinical routine were set in correlation with ICU-LOS, by applying single testing calculations (t-tests, variance analysis, correlation coefficients, effect sizes) and a valid univariate linear regression model. The primary outcome of interest was ICU-LOS. RESULTS: This study included a homogenous cohort of 122 patients. Mean surgery time was 11.4 (±2.2) h, mean ICU-LOS was 3.6 (±2.6) days. Patients with pre-operative renal dysfunction (p < 0.001), peripheral vascular disease-PVD (p = 0.01), increasing heart failure-NYHA stage categories (p = 0.009) and higher-grade categories of post-operative complications (p = 0.023) were identified as at-risk patients for a significantly prolonged post-operative ICU-LOS. CONCLUSIONS: At-risk patients are prone to need a significantly longer ICU-LOS than others. These patients are those with pre-operative severe renal dysfunction, PVD and/or high NYHA stage categories. Confounding parameters that contribute to a prolonged ICU-LOS in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.

Partial warfarin reversal prior to hip fracture surgical intervention in geriatric trauma patients effects on blood loss and transfusions.

BACKGROUND: Warfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear. METHODS: This was a retrospective cohort study. Geriatric patients (≥65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the "wait and watch" method. An INR of ≤ 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery. RESULTS: There were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p = 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p = 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p = 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery. CONCLUSIONS: Partial reversal may be safe for blood loss and blood product transfusions for geriatric patients with isolated hip fractures. Complete warfarin reversal may not be necessary prior to hip fracture surgery, especially for mildly elevated INRs.

Morbidity After cardiac surgery under cardiopulmonary bypass and associated factors: A retrospective observational study.

BACKGROUND: The present study aimed to assess the morbidity after cardiac surgery and identify the preoperative and intraoperative factors associated with postoperative morbidity. METHODS: A retrospective observational study was conducted including 362 adult patients aged 18-75 years who underwent open-heart surgery under cardiopulmonary bypass at Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India, during the period from June 2016 to May 2017. Using a structured schedule, preoperative and intraoperative data were collected from the hospital's cardiac surgery database, whereas the postoperative data were collected from the intensive care unit (ICU) database and the hospital's clinical information system database. RESULTS: Of 362 patients, 254 (70.2%) had at least one major complication, and the most frequently occurring complication was low cardiac output state (29.8%). The ICU length of stay (LOS) was for > 2 days in 23.2% of patients, and the hospital LOS was for > 7 days in almost 60% of the patients. Multivariate logistic regression analyses revealed that gender, type of surgery, body weight, blood lactate level at ICU admission, and 12-h blood lactate level were significant predictors of complications; gender and 24-h blood lactate level were significantly associated with the prolonged ICU LOS, whereas type of surgery and 24-h blood lactate level were significantly associated with prolonged hospital LOS. CONCLUSION: The appropriate patient management strategy can be tailored based on the personal attributes, surgery type, and blood lactate level for individual patients undergoing cardiac surgery to reduce the likelihood of postoperative complications, ICU LOS, and hospital LOS.

Isolated hip fracture in the elderly and time to surgery: is there an outcome difference?

BACKGROUND: Early operative intervention for hip fractures in the elderly is advised to reduce mortality and morbidity. Postoperative complications impose a significant burden on patient outcomes and cost of medical care. Our aim was to determine the relationship between time to surgery and postoperative complications/mortality in patients with hip fracture. METHODS: This is a retrospective review of data collected from our institution's trauma registry for patients ≥65 years old with isolated hip fracture and subsequent surgery from 2015 to 2017. Patients were stratified into two groups based on time to surgery after admission: group 1: <48 hours versus group 2: >48 hours. Demographic variables included age, gender, race, and Injury Severity Score (ISS). The outcome variables included intensive care unit length of stay (ICU-LOS), deep venous thrombosis (DVT), pulmonary embolism (PE) rate, mortality, and 30-day readmission rates. Analysis of variance was used for analysis, with significance defined as a p value <0.05. RESULTS: A total of 485 patients with isolated hip fracture required surgical intervention. Of those, 460 had surgery <48 hours and 25 had surgery >48 hours postadmission. The average ISS was the same in both groups. The average ICU-LOS was significantly higher in the >48 hours group compared with the <48 hours group (4.0 vs. 2.0, p<0.0002). There was no statistically significant difference between groups when comparing DVTand PE rate, 30-day readmission, or mortality rates. DISCUSSION: Time to surgery may affect overall ICU-LOS in patients with hip fracture requiring surgical intervention. Time to surgery does not affect complication rates, 30-day readmission, or mortality. Future research should investigate long-term outcomes such as functional status and disability-adjusted life years. LEVEL OF EVIDENCE: III. Retrospective/ prognostic cohort study.

Education program on medical nutrition and length of stay of critically ill patients.

BACKGROUND & AIMS: To evaluate the impact of a multifaceted nutritional educational intervention on the quality of nutritional therapy and clinical outcomes in critically ill patients. METHODS: We conducted a prospective, non-blinded study with a non-contemporaneous control group at a 16-bed intensive care unit (ICU) at the Hospital das Clinicas, Department of Gastroenterology, University of Sao Paulo Medical School in Sao Paulo, Brazil. There were three phases. Phase 1: the quality of NT was evaluated in 50 newly admitted intensive care unit patients in a pre-educational program (Pre-EP). Phase 2: nutritional protocols were created and an education program was implemented. Phase 3: another 50 patients were enrolled and observed in a post-educational program (Post-EP) using phase 1 methodology. Nutritional Therapy practice was evaluated through nutritional assessments, adequacy of energy requirements, duration of fasting, and use of early enteral nutrition. Intensive care unit length of stay and hospital length of stay were measured as primary end-points. RESULTS: The pre-educational program and post-educational program groups did not differ in age, APACHE II score, gender, or nutritional assessment. The mean ± SD duration of fasting decreased (Pre-EP 3.8 ± 3.1 days vs. Post-EP: 2.2 ± 2.6 days; p = 0.002), the adequacy of nutritional therapy improved (Pre-EP 74.2% ± 33.3% vs. Post-EP 96.2% ± 23.8%; p < 0.001), and enteral nutrition was initiated earlier than 48 h more commonly (Pre-EP 24% vs. Post-E 60%; p = 0.001). Median intensive care unit length of stay decreased (Pre-EP: 18.5 days vs. Post-EP: 9.5 days; p < 0.001) although hospital length of stay did not. CONCLUSION: Implementing a multifaceted nutritional educational intervention could improve the quality of nutritional therapy and may decrease intensive care unit length of stay in critically ill patients.