Failure to rescue in the surgical patient: a review.

PURPOSE OF REVIEW: Evaluating patient outcomes is essential in a healthcare environment focused on quality. Mortality after surgery has been considered a useful quality metric. More important than mortality rate, failure to rescue (FTR) has emerged as a metric that is important and may be improveable. The purpose of this review is to define FTR, describe patient and hospital level factors that lead to FTR, and highlight possible solutions to this problem. RECENT FINDINGS: FTR is defined as a death following a complication. Depending on the patient population, FTR rates vary from less than 1% to over 40%. Numerous patient factors including frailty, congestive heart failure (CHF), renal failure, serum albumin <3.5, COPD, cirrhosis, and higher ASA class may predispose patients to FTR. Hospital factors including technology, teaching status, increased nurse-to-patient ratios, and closed ICUs may help reduce FTR. More difficult to measure variables, such as hospital culture and teamwork may also influence FTR rates. Early warning systems may allow earlier identification of the deteriorating patient. SUMMARY: FTR is a major clinical concern and efforts aimed at optimizing patient and hospital factors, culture and communication, as well as early identification of the deteriorating patient may improve FTR rate.

Multimodality Monitoring in Neurocritical Care: Decision-Making Utilizing Direct And Indirect Surrogate Markers.

Substantial progress has been made to create innovative technology that can monitor the different physiological characteristics that precede the onset of secondary brain injury, with the ultimate goal of intervening prior to the onset of irreversible neurological damage. One of the goals of neurocritical care is to recognize and preemptively manage secondary neurological injury by analyzing physiologic markers of ischemia and brain injury prior to the development of irreversible damage. This is helpful in a multitude of neurological conditions, whereby secondary neurological injury could present including but not limited to traumatic intracranial hemorrhage and, specifically, subarachnoid hemorrhage, which has the potential of progressing to delayed cerebral ischemia and monitoring postneurosurgical interventions. In this study, we examine the utilization of direct and indirect surrogate physiologic markers of ongoing neurologic injury, including intracranial pressure, cerebral blood flow, and brain metabolism.

Acute respiratory distress syndrome and outcomes after near hanging.

PURPOSE: The purpose of this study is to assess the case rate of acute respiratory distress syndrome (ARDS) after near hanging and the secondary outcomes of traumatic and/or anoxic brain injury and death. Risk factors for the outcomes were assessed. METHOD: The method is a single-center, statewide retrospective cohort study of consecutive patients admitted between August 2002 and September 2011, with a primary diagnosis of nonjudicial "hanging injury." RESULTS: Of 56 patients, 73% were male. The median age was 31 (Interquartile range (IQR), 16-56). Upon arrival, 9% (5/56) did not have a pulse, and 23% (13/56) patients were intubated. The median Glasgow Coma Scale (GCS) was 13 (IQR, 3-15); 14% (8/56) had a GCS = 3. Acute respiratory distress syndrome developed in 9% (5/56) of patients. Traumatic anoxic brain injury resulted in 9% (5/56) of patients. The in-hospital case fatality was 5% (3/56). Lower median GCS (3 [IQR, 3-7] vs 14 [IQR, 3-15]; P = .0003) and intubation in field or in trauma resuscitation unit (100% [5/5] vs 16% [8/51]; P = .0003) were associated with ARDS development. Risk factors of death were GCS = 3 (100% [3/3] vs 9% [5/53]; P = .002), pulselessness upon arrival of emergency medical services (100% [3/3] vs 4% [2/53]; P < .001], and abnormal neurologic imaging (50% [1/2] vs zero; P = .04). CONCLUSIONS: The ARDS case rate after near hanging is similar to the general trauma population. Low GCS and intubation are associated with increased risk of ARDS development. The rate of traumatic and/or anoxic brain injury in this population is low.

Increased ICU resource needs for an academic emergency general surgery service*.

OBJECTIVE: ICU needs of nontrauma emergency general surgery patients are poorly described. This study was designed to compare ICU utilization of emergency general surgery patients admitted to an acute care emergency surgery service with other general surgery patients. Our hypothesis is that tertiary care emergency general surgery patients utilize more ICU resources than other general surgical patients. DESIGN: Retrospective database review. SETTING: Academic, tertiary care, nontrauma surgical ICU. PATIENTS: All patients admitted to the surgical ICU over age 18 between March 2004 and June 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Six thousand ninety-eight patients were evaluated: 1,053 acute care emergency surgery, 1,964 general surgery, 1,491 transplant surgery, 995 facial surgery/otolaryngology, and 595 neurosurgery. Acute care emergency surgery patients had statistically significantly longer ICU lengths of stay than other groups: acute care emergency surgery (13.5 ± 17.4 d) versus general surgery (8.7 ± 12.9), transplant (7.8 ± 11.6), oral-maxillofacial surgery (5.5 ± 4.2), and neurosurgery (4.47 ± 9.8) (all p< 0.01). Ventilator usage, defined by percentage of total ICU days patients required mechanical ventilation, was significantly higher for acute care emergency surgery patients: acute care emergency surgery 73.4% versus general surgery 64.9%, transplant 63.3%, oral-maxillofacial surgery 58.4%, and neurosurgery 53.1% (all p < 0.01). Continuous renal replacement therapy usage, defined as percent of patients requiring this service, was significantly higher in acute care emergency surgery patients: acute care emergency surgery 10.8% versus general surgery 4.3%, transplant 6.6%, oral-maxillofacial surgery 0%, and neurosurgery 0.5% (all p < 0.01). Acute care emergency surgery patients were more likely interhospital transfers for tertiary care services than general surgery or transplant (24.5% vs 15.5% and 8.3% respectively, p < 0.001 for each) and more likely required emergent surgery (13.7% vs 6.7% and 3.5%, all p < 0.001). Chronic comorbidities were similar between acute care emergency surgery and general surgery, whereas transplant had fewer. CONCLUSIONS: Emergency general surgery patients have increased ICU needs in terms of length of stay, ventilator usage, and continuous renal replacement therapy usage compared with other services, perhaps due to the higher percentage of transfers and emergent surgery required. These patients represent a distinct population. Understanding their resource needs will allow for better deployment of hospital resources.

Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury.

INTRODUCTION: Acute kidney injury (AKI) can evolve quickly and clinical measures of function often fail to detect AKI at a time when interventions are likely to provide benefit. Identifying early markers of kidney damage has been difficult due to the complex nature of human AKI, in which multiple etiologies exist. The objective of this study was to identify and validate novel biomarkers of AKI. METHODS: We performed two multicenter observational studies in critically ill patients at risk for AKI - discovery and validation. The top two markers from discovery were validated in a second study (Sapphire) and compared to a number of previously described biomarkers. In the discovery phase, we enrolled 522 adults in three distinct cohorts including patients with sepsis, shock, major surgery, and trauma and examined over 300 markers. In the Sapphire validation study, we enrolled 744 adult subjects with critical illness and without evidence of AKI at enrollment; the final analysis cohort was a heterogeneous sample of 728 critically ill patients. The primary endpoint was moderate to severe AKI (KDIGO stage 2 to 3) within 12 hours of sample collection. RESULTS: Moderate to severe AKI occurred in 14% of Sapphire subjects. The two top biomarkers from discovery were validated. Urine insulin-like growth factor-binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinases-2 (TIMP-2), both inducers of G1 cell cycle arrest, a key mechanism implicated in AKI, together demonstrated an AUC of 0.80 (0.76 and 0.79 alone). Urine [TIMP-2]·[IGFBP7] was significantly superior to all previously described markers of AKI (P <0.002), none of which achieved an AUC >0.72. Furthermore, [TIMP-2]·[IGFBP7] significantly improved risk stratification when added to a nine-variable clinical model when analyzed using Cox proportional hazards model, generalized estimating equation, integrated discrimination improvement or net reclassification improvement. Finally, in sensitivity analyses [TIMP-2]·[IGFBP7] remained significant and superior to all other markers regardless of changes in reference creatinine method. CONCLUSIONS: Two novel markers for AKI have been identified and validated in independent multicenter cohorts. Both markers are superior to existing markers, provide additional information over clinical variables and add mechanistic insight into AKI. TRIAL REGISTRATION: ClinicalTrials.gov number NCT01209169.

Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial.

IMPORTANCE: Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria. OBJECTIVE: To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care. DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012. INTERVENTIONS: In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room. MAIN OUTCOMES AND MEASURES: The primary outcome was acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care­associated infections, and adverse events. RESULTS: From the 26,180 patients included, 92,241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95% CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, −1.71 acquisitions per 1000 person-days, 95% CI, −6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference, 0.89 acquisitions per 1000 person-days; 95% CI, −4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, −2.98 acquisitions per 1000 person-days; 95% CI, −5.58 to −0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, −0.96; 95% CI, −1.71 to −0.21, P = .02), increased room-exit hand hygiene compliance (78.3% vs 62.9%, difference, 15.4%; 95% CI, 8.99% to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, −15.7; 95% CI, −40.7 to 9.2, P = .24). CONCLUSIONS AND RELEVANCE: The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT0131821.

Traumatic Popliteal Artery Occlusion Following Lower Extremity Crush Injury Presenting With Isolated Patellar Dislocation.

While traumatic popliteal artery injury historically has a low incidence, failure to acutely recognize the vascular insult poses a significant risk of limb loss and functional impairment. A 71-year-old male presented with left lower extremity pain in setting of a crush injury working underneath a vehicle resulting in an isolated lateral dislocation of his patella and complete occlusion of the distal popliteal artery. He was taken to the operating room for an in-situ bypass and four-compartment fasciotomy. His hospital stay included three staged washouts/debridements with eventual closure. He was discharged after 38 days to a rehabilitation facility with ability to self-ambulate with assistance within one month. This patient's presentation is unique for his isolated patellar dislocation without associated injuries characteristically associated with a traumatic vascular injury of the popliteal artery and serves to remind the importance of complete examination in the setting of blunt trauma.

Surgical management of pancreatic necrosis: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Pancreatic or peripancreatic tissue necrosis confers substantial morbidity and mortality. New modalities have created a wide variation in approaches and timing of interventions for necrotizing pancreatitis. As acute care surgery evolves, its practitioners are increasingly being called upon to manage these complex patients. METHODS: A systematic review of the MEDLINE database using PubMed was performed. English language articles regarding pancreatic necrosis from 1980 to 2014 were included. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included operative timing, the use of adjuvant therapy and the type of operative repair. Grading of Recommendations, Assessment, Development and Evaluations methodology was applied to question development, outcome prioritization, evidence quality assessments, and recommendation creation. RESULTS: Eighty-eight studies were included and underwent full review. Increasing the time to surgical intervention had an improved outcome in each of the periods evaluated (72 hours, 12-14 days, 30 days) with a significant improvement in outcomes if surgery was delayed 30 days. The use of percutaneous and endoscopic procedures was shown to postpone surgery and potentially be definitive. The use of minimally invasive surgery for debridement and drainage has been shown to be safe and associated with reduced morbidity and mortality. CONCLUSION: Acute Care Surgeons are uniquely trained to care for those with pancreatic necrosis due their training in critical care and complex surgery with ongoing shock. In adult patients with pancreatic necrosis, we recommend that pancreatic necrosectomy be delayed until at least day 12. During the first 30 days of symptoms with infected necrotic collections, we conditionally recommend surgical debridement only if the patients fail to improve after radiologic or endoscopic drainage. Finally, even with documented infected necrosis, we recommend that patients undergo a step-up approach to surgical intervention as the preferred surgical approach. LEVEL OF EVIDENCE: Systematic review/guideline, level III.

Epidemiology and outcomes of acute kidney injury in critically ill surgical patients.

PURPOSE: Acute kidney injury (AKI) is common in critically ill patients but is poorly defined in surgical patients. We studied AKI in a representative cohort of critically ill surgical patients. METHODS: This was a retrospective 1-year cohort study of general surgical intensive care unit patients. Patients were identified from a prospective database, and clinical data were reviewed. Acute kidney injury events were defined by risk, injury, failure, loss, and end-stage renal classification criteria. Outcomes were inpatient and 1-year mortality, inpatient lengths of stay, and discharge renal function. Risk factors for AKI and outcomes were compared by univariate and multivariate analyses. RESULTS: Of 624 patients, 296 (47%) developed AKI. Forty-two percent of events were present upon admission, whereas 36% occurred postoperatively. Risk, injury, failure, loss, and end-stage renal classification distributions by grade were as follows: risk, 152 (51%); injury, 69 (23%); and failure, 75 (25%). Comorbid diabetes, emergency admission, major surgery, sepsis, and illness severity were independently associated with renal dysfunction. Patients with AKI had significantly worse outcomes, including increased inpatient and 1-year mortality. Acute kidney injury starting before admission was associated with worse renal dysfunction and greater renal morbidity than de novo inpatient events. CONCLUSIONS: Acute kidney injury is common in critically ill surgical patients and is associated with increased mortality, persisting renal impairment and greater resource use.

Acute Kidney Injury in Critically Ill Vascular Surgery Patients is Common and Associated with Increased Mortality.

INTRODUCTION: Vascular surgery patients have multiple risk factors for renal dysfunction, but acute kidney injury (AKI) is poorly studied in this group. The purpose of this study was to define the incidence, risk factors, and outcomes of AKI in high-risk vascular patients. METHODS: Critically ill vascular surgery patients admitted during January-December 2012 were retrospectively analyzed with 1-year follow-up. The endpoint was AKI by established RIFLE creatinine criteria. The primary analysis was between patients with or without AKI, with secondary analysis of post-operative AKI. Outcomes were inpatient and 1-year mortality, inpatient lengths of stay, and discharge renal function. RESULTS: One-hundred and thirty six vascular surgery patients were included, representing 27% of all vascular surgery admissions during the study period. Sixty-five (48%) developed AKI. Independent global risk factors for AKI were diabetes, increasing critical illness severity, and sepsis. While intraoperative blood loss and hypotension were associated with subsequent renal dysfunction, post-operative AKI rates were similar for patients undergoing aortic, carotid, endovascular, or peripheral vascular procedures. All RIFLE grades of AKI were associated with worse outcomes. Overall, patients with AKI had significantly increased short- and long-term mortality, longer inpatient lengths of stay, and worse discharge renal function. CONCLUSION: AKI is common among critically ill vascular surgery patients. Importantly, the type of surgical procedure appears to be less important than intra- and perioperative management in determining renal dysfunction. Regardless of its severity, AKI is a clinically significant complication that is associated with substantially worse patient outcomes.

Update on the status and future of acute care surgery: 10 years later.

BACKGROUND: Ten years ago, the specialty of trauma surgery was considered to be in crisis. Since then, the Eastern Association for the Surgery of Trauma (EAST) created a position paper, and acute care surgery (ACS) has matured. A repeat survey of EAST members is indicated to evaluate the progress of ACS. METHODS: A survey was e-mailed to EAST members. Results were evaluated and compared with the previous position paper and survey. RESULTS: The response rate was 15%. More than three fourths of the respondents were male, and just less than one fourth of them were female. More than half of the respondents were in practice for less than 10 years. Seventy-three percent were involved in research, although only 16% were allotted protected time. Most respondents felt that reimbursement for their effort was inadequate: 54% thought reimbursement was fair for trauma care, 59% for critical care, 49% for nontrauma ACS, and 62% for general surgery. The biggest incentive to a career in ACS was that it was a challenging and exciting activity; the biggest disincentive was working at night. Seventy-two percent expressed satisfaction with their career profile, and 92% were either very or somewhat happy with their career. Sixty-six percent did feel either somewhat or very burned out. Surgeons were interested in learning more about contract negotiation, business/managerial issues, and billing/coding. Compared with the previous survey, overall career satisfaction seems stable. CONCLUSION: Most surgeons are satisfied with a career in ACS. There are still some facets of the career that warrant improvement. Focus on surgeon satisfaction may lead to enhancements in patient care.

Recurrent kidney injury in critically ill surgical patients is common and associated with worse outcomes.

UNLABELLED: Supplemental digital content is available in the text. BACKGROUND: Acute kidney injury (AKI) is common in critically ill surgery patients. Patients who recover are at risk for recurrence, but recurrent kidney injury (RKI) is not well studied. METHODS: This was a retrospective 12-month cohort study of adults consecutively admitted to a noncardiac, non-trauma surgical intensive care unit. Patients were identified from a prospective critical care database, and kidney injury events were diagnosed and graded by RIFLE criteria. Patients who recovered from AKI were analyzed, and the primary end point was RKI (defined as kidney injury occurring after recovery from an index AKI event). Outcomes were inpatient and 1-year mortality, inpatient lengths of stay, and discharge creatinine. RESULTS: Of 624 patients, 296 (47%) had AKI and 216 (73%) recovered. Of these, 68 (31%) developed RKI. AKI in progress on hospital admission was associated with recurrence, but otherwise RKI and non-RKI patients had similar demographics, comorbidities, and inpatient clinical factors. Recurrence was associated with significantly higher inpatient and 12-month mortality, greater resource use, and worse discharge renal function. CONCLUSION: RKI is common among critically ill surgical patients who recover from an index episode. Recurrence is a clinically significant event and is associated with worse renal and patient outcomes. Future studies should further define this process. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Blood alcohol content, injury severity, and adult respiratory distress syndrome.

BACKGROUND: Elevated blood alcohol content (BAC) is a risk factor for injury. Associations of BAC with adult respiratory distress syndrome (ARDS) have not been conclusively established.We evaluated the association of a BAC greater than 0 mg/dL with the intermediate outcomes, Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score, and their association with ARDS development. METHODS: This is an observational retrospective cohort study of 26,305 primary trauma admissions to a statewide referral trauma center from July 11, 2003, to October 31, 2011. Logistic regression was performed to assess the relationship between admission BAC, ISS, GCS score, and ARDS development within 5 days of admission. RESULTS: The case rate for ARDS was 5.5% (1,447). BAC greater than 0 mg/dL was associated with ARDS development in adjusted analysis (odds ratio, 1.50; 95% confidence interval [CI], 1.33-1.71; p < 0.001). High ISS (≥16) had a stronger association with ARDS development (odds ratio, 17.99; 95% CI, 15.51-20.86), as did low GCS score (≤8) (odds ratio, 8.77; 95% CI, 7.64-10.07; p < 0.001). Patients with low GCS score and high ISS had the most frequent ARDS (33.6%) and the highest case-fatality rate without ARDS (24.7%). CONCLUSION: Elevated BAC is associated with ARDS development. In the analysis of alcohol exposure, ISS and GCS score occur after alcohol ingestion, making them intermediate outcomes. ISS and GCS score were strong predictors of ARDS and may be useful to identify at-risk patients. Elevated BAC may increase the frequency of the ARDS through influence on injury severity or independent molecular mechanisms, which can be discriminated only in experimental models. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Successful implementation of a unit-based quality nurse to reduce central line-associated bloodstream infections.

BACKGROUND: Central line (CL)-associated bloodstream infections (CLABSI) are an important cause of patient morbidity and mortality. Novel strategies to prevent CLABSI are needed. METHODS: We described a quasiexperimental study to examine the effect of the presence of a unit-based quality nurse (UQN) dedicated to perform patient safety and infection control activities with a focus on CLABSI prevention in a surgical intensive care unit (SICU). RESULTS: From July 2008 to March 2012, there were 3,257 SICU admissions; CL utilization ratio was 0.74 (18,193 CL-days/24,576 patient-days). The UQN program began in July 2010; the nurse was present for 30% (193/518) of the days of the intervention period of July 2010 to March 2012. The average CLABSI rate was 5.0 per 1,000 CL-days before the intervention and 1.5 after the intervention and decreased by 5.1% (P = .005) for each additional 1% of days of the month that the UQN was present, even after adjusting for CLABSI rates in other adult intensive care units, time, severity of illness, and Comprehensive Unit-based Safety Program participation (5.1%, P = .004). Approximately 11.4 CLABSIs were prevented. CONCLUSION: The presence of a UQN dedicated to perform infection control activities may be an effective strategy for CLABSI reduction.

Surgical intensive care unit admission variables predict subsequent readmission.

Intensive care unit (ICU) readmissions are associated with increased resource use. Defining predictors may improve resource use. Surgical ICU patients requiring readmission will have different characteristics than those who do not. We conducted a retrospective cohort study of a prospectively maintained database. The Acute Physiology and Chronic Health Evaluation (APACHE) IV quality database identified patients admitted January 1 through December 31, 2011. Patients were divided into groups: NREA = patients admitted to the ICU, discharged, and not readmitted versus REA = patients admitted to the ICU, discharged, and readmitted. Comparisons were made at index admission, not readmission. Categorical variables were compared by Fisher's exact testing and continuous variables by t test. Multivariate logistic regression identified independent predictors of readmission. There were 765 admissions. Seventy-seven patients required readmission 94 times (12.8% rate). Sixty-two patients died on initial ICU admission. Admission severity of illness was significantly higher (APACHE III score: 69.54 ± 21.11 vs 54.88 ± 23.48) in the REA group. Discharge acute physiology scores were equal between groups (47.0 ± 39.2 vs 44.2 ± 34.0, P = nonsignificant). In multivariate analysis, REA patients were more likely admitted to emergency surgery (odds ratio, 1.9; 95% confidence interval, 1.01 ± 3.5) more likely to have a history of immunosuppression (2.7, 1.4 ± 5.3) or higher Acute Physiology Score (1.02; 1.0 ± 1.03) than NREA. Patients who require ICU readmission have a different admission profile than those who do not "bounce back." Understanding these differences may allow for quality improvement projects such as instituting different discharge criteria for different patient populations.

Practical considerations for the dosing and adjustment of continuous renal replacement therapy in the intensive care unit.

Familiarity with the initiation, dosing, adjustment, and termination of continuous renal replacement therapy (CRRT) is a core skill for contemporary intensivists. Guidelines for how to administer CRRT in the intensive care unit are not well documented. The purpose of this review is to discuss the modalities, terminology, and components of CRRT, with an emphasis on the practical aspects of dosing, adjustments, and termination. Management of electrolyte and acid-base derangements commonly encountered with acute renal failure is emphasized. Knowledge regarding the practical aspects of managing CRRT in the intensive care unit is a prerequisite for achieving desired physiological end points.

Improving family satisfaction and participation in decision making in an intensive care unit.

Background Survey data revealed that families of patients in a surgical intensive care unit were not satisfied with their participation in decision making or with how well the multidisciplinary team worked together. Objectives To develop and implement an evidence-based communication algorithm and evaluate its effect in improving satisfaction among patients' families. Methods A multidisciplinary team developed an algorithm that included bundles of communication interventions at 24, 72, and 96 hours after admission to the unit. The algorithm included clinical triggers, which if present escalated the algorithm. A pre-post design using process improvement methods was used to compare families' satisfaction scores before and after implementation of the algorithm. Results Satisfaction scores for participation in decision making (45% vs 68%; z = -2.62, P = .009) and how well the health care team worked together (64% vs 83%; z = -2.10, P = .04) improved significantly after implementation. Conclusions Use of an evidence-based structured communication algorithm may be a way to improve satisfaction of families of intensive care patients with their participation in decision making and their perception of how well the unit's team works together.

Risk factors for central line-associated bloodstream infections in the era of best practice.

BACKGROUND: Best clinical practice aims to eliminate central line-associated blood stream infections (CLABSIs). However, CLABSIs still occur. This study's aim was to identify risk factors for CLABSI in the era of best practice. METHODS: Critically ill surgical patients admitted over 2 years to the intensive care unit (ICU) for ≥ 4 days were studied. Patients with CLABSI as cause for ICU admission were excluded. Patients who developed CLABSI (National Healthcare Safety Network definition) were compared with those who did not. Hand hygiene, maximal sterile barriers, chlorhexidine scrub, avoidance of femoral vein, and proper maintenance were emphasized. Variables collected included demographics, diagnosis, and severity of illness using the Acute Physiology and Chronic Health Evaluation (APACHE) IV database and the hospital central data repository. RESULTS: Of 961 patients studied, 51 patients (5.2%) developed 59 CLABSIs. Mean time from ICU admission to CLABSI was 26 days ± 26 days. The CLABSI group was more likely to be male (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.02-3.68), more critically ill on ICU admission (APACHE IV score 85.2 ± 21.9 vs. 65.6 ± 23.2, p < 0.01), more likely admitted to the emergency surgery service (OR 1.92, 95% CI 1.02-3.61), and had an association with reopening of recent laparotomy (OR 2.08, 95% CI 1.10-3.94). CONCLUSION: In the era of best practice, patients who develop CLABSI are clinically distinct from those who do not develop CLABSI. These CLABSIs may be due to deficiencies of the CLABSI definition or represent patient populations requiring enhanced prevention techniques. LEVEL OF EVIDENCE: III, prognostic study.

Effect of glycemic state on hospital mortality in critically ill surgical patients.

Intensive insulin therapy can reduce mortality. Hypoglycemia related to intensive therapy may worsen outcomes. This study compared risk adjusted mortality for different glycemic states. A retrospective review of patients admitted to a surgical intensive care unit over 4 years was performed. Patients were divided into glycemic groups: HYPER (≥1 episode > 180 mg/dL, any <60), HYPO (≥1 episode < 60 mg/dL, any >180), BOTH (≥1 episode < 60 and ≥1 episode > 180 mg/dL), NORMO (all episodes 60-180 mg/dL), HYPER-Only (≥1 episode > 180, none <60 mg/dL), and HYPO-Only (≥1 episode < 60, none >180 mg/dL). Observed to expected Acute Physiology and Chronic Health Evaluation (APACHE) III mortality ratios (O/E) were studied. Number of adverse glycemic events was compared with mortality. Hypoglycemia and hyperglycemia occurred in 18 per cent and 50 per cent of patients. Mortality was 12.4 per cent (O/E = 0.88). BOTH had the highest O/E ratio (1.43) with HYPO the second highest (1.30). Groups excluding hypoglycemia (NORMO and HYPER-only) had the lowest O/E ratios: 0.56 and 0.88. Increasing number of hypoglycemic events were associated with increasing O/E ratio: 0.69 O/E for no events, 1.19 for 1-3 events, 1.35 for 4-6 events, 1.9 for 7-9 events, and 3.13 for ≥ 10 events. Ten or more hyperglycemic events were needed to significantly associate with worse mortality (O/E 1.53). Hyper- and hypoglycemia increase mortality compared with APACHE III expected mortality, with highest mortality risk if both are present. Hypoglycemia is associated with worse risk. Glucose control may need to be loosened to prevent hypoglycemia and reduce glucose variability.

Association of 6% hetastarch resuscitation with adverse outcomes in critically ill trauma patients.

BACKGROUND: Six percent hetastarch is used as a volume expander but has been associated with poor outcomes. The aim of this study was to evaluate trauma patients resuscitated with hetastarch. METHODS: A retrospective review was performed of adult trauma patients. Demographics, injury severity, laboratory values, outcomes, and hetastarch use were recorded. RESULTS: A total of 2,225 patients were identified, of whom 497 (22%) received hetastarch. There were no differences in age, gender, injury mechanism, lactate, hematocrit, or creatinine. The mean injury severity score was different: 29.7 ± 12.6 with hetastarch versus 27.5 ± 12.6 without hetastarch. Acute kidney injury developed in 65 hetastarch patients (13%) and in 131 (8%) without hetastarch (relative risk, 1.73; 95% confidence interval [CI], 1.30-2.28). Hetastarch mortality was 21%, compared with 11% without hetastarch (relative risk, 1.84; 95% CI, 1.48-2.29). Multivariate logistic regression demonstrated hetastarch use (odds ratio, 1.96; 95% CI, 1.49-2.58) as independently significant for death. Hetastarch use was independently significant for renal dysfunction as well (odds ratio, 1.70; 95% CI, 1.22-2.36). CONCLUSIONS: Because of the detrimental association with renal function and mortality, hetastarch should be avoided in the resuscitation of trauma patients.