Predictors of Prolonged Length of Stay in General Surgical Intensive Care Unit.

Objective: The aims of this study were to explore the incidence, clinical factors, severity scores and outcome associated with prolonged length of intensive care unit (ICU) stay >3 days. Material and Method: This study was a prospective observational study on the noncardiac surgical patients who were admitted to surgical intensive care unit in a tertiary university hospital. The cardiothoracic, neurosurgical and traumatic surgical patients or the patients who died within the first 3 days of ICU admission were excluded. Patient demographic data, preoperative predictors and severity scores (APACHE II, APACHE III, SOFA, SAPS II and MODS scores) at day 1 and day 3 of ICU admission were recorded. Results: A total of 948 patients were observed. The incidence of prolonged ICU stay was 20.1%. Patients with prolonged ICU stay had significantly higher ventilator hours (p<0.001) and ICU length of stay (p<0.001). On the multivariable analysis model of preoperative variables, the significant predictors of prolonged ICU stay were preoperative serum albumin less than 2.6 mg/dL (p = 0.023), preoperative hematocrit less than 34% (p = 0.035), emergency surgery (p = 0.003), having surgical complications (p = 0.017), having anesthetic complications (p = 0.017), admission for respiratory support with or without unstable hemodynamic (p<0.001), and sepsis on ICU admission (p = 0.003). Regarding the multivariable analysis of severity scoring system, the significant severity predictors were found only the preoperative ASA class IV (p<0.001) and emergency ASA status (p<0.001). Conclusion: About one-fifth of the study patients had prolonged ICU stay (>3 days). Low preoperative serum albumin (<2.6 mg/dL), low preoperative hematocrit (<34%), ASA physical status class IV, underwent emergency surgery, having anesthetic complications, surgical complications, sepsis on ICU admission, having respiratory support with or without unstable hemodynamic were significantly associated with prolonged ICU stay.

Use of different approaches of acid-base derangement to predict mortality in critically ill patients.

BACKGROUND: There have been controversial data regarding the application of acid-base analysis based on Stewart methodology to predict clinical outcome in different populations. OBJECTIVE: To compare predictive ability of the physicochemical approach and the traditional bicarbonate approach of acid-base analysis in critically ill patients in relation to 28-days mortality and to evaluate the use of the physico chemical approach determined by the strong ion gap (SIG) in 1) medical compared to surgical critically ill patients; and 2) sepsis compared to non-sepsis patients. MATERIAL AND METHOD: This retrospective cohort study included 410 critically ill patients in the adult medical and surgical intensive care units (ICU) at a tertiary care hospital over a 2-year period. For each patient, values derived from the bicarbonate approaches including anion gap (AG), corrected anion gap (cAG) and lactate and those obtained from the physicochemical approach like SIG were simultaneously computed at ICU admission. The comparison of predictive ability between different approaches was assessed by forward stepwise logistic regression and the area under the receiver operating characteristic (aROC) curves. RESULTS: Of the 410 patents enrolled, 205 (50%) were admitted in the medical ICU and 226 patients (55%) were male. Overall 28-day mortality was 44.6% (183/410). The comparison between medical and surgical patients showed no difference in age (59 vs. 64 yr), APACHE II score (21 vs. 20), presence of sepsis (71% vs. 70%) and 28-day mortality (45% vs. 44%). Acid-base disturbance in non-survivors (n = 183) and survivors (n = 227) determined by pH (7.39 +/- 0.04 vs. 7.41 +/- 0.01), serum bicarbonate (16.0 +/- 6.1 vs. 17.9 +/- 7.4) and PaCO2 (32.4 +/- 13.4 vs. 29.4 +/- 8.2) were comparable. However non-survivors had higher levels of SIG (9.7 +/- 6.2 vs. 6.4 +/- 5.2) and cAG (27.5 +/- 8.8 vs. 20.3 +/- 8.6) than survivors did. According to a ROC curves, the predictive ability to discriminate between survivors and non-survivors of lactate, cAG AG and SIG are 0.77, 0.72, 0.68 and 0.67, respectively. Correlations between the SIG and values derived from bicarbonate approach are fair. There was no difference in SIG values between surgical and medical patients with the same severity scores. Sepsis patients (n = 291) had significantly higher SIG than non-sepsis patients (n = 129) did (8.81 +/- 6.38 vs. 5.74 +/- 4.14; p = 0.01). CONCLUSION: Compared to the traditional approach, an alternative Stewart approach does not provide any greater advantage to predict mortality in the studied population. Because of complex calculation, the usefulness of such approach on the routine clinical practice may be limited.