Development of a Manually Operated Communication System (MOCS) for patients in intensive care units.

Nonvocal alert patients in the intensive care unit (ICU) setting often struggle to communicate due to inaccessible or unavailable tools for augmentative and alternative communication. Innovation of a hand-operated non-touchscreen communication system for nonvocal ICU patients was guided by design concepts including speech output, simplicity, and flexibility. A novel communication tool, the Manually Operated Communication System (MOCS), was developed for use in intensive care settings with patients unable to speak. MOCS is a speech-output technology designed for patients with manual dexterity impairments preventing legible writing. MOCS may have the potential to improve communication for nonvocal patients with limited manual dexterity.

Lumbar drain complications in patients undergoing fenestrated or branched endovascular aortic aneurysm repair: Development of an institutional protocol for lumbar drain management.

OBJECTIVE: Lumbar drain placement with cerebrospinal fluid (CSF) drainage is an effective adjunct for reducing the risk of spinal cord ischemia in patients undergoing complex aortic aneurysm repair. However, lumbar drain placement is a challenging procedure with potential for significant complications. We sought to characterize complications of lumbar drain placement in a large, single-center experience of patients who underwent fenestrated or branched endovascular aneurysm repair (F/BEVAR). METHODS: All patients who underwent F/BEVAR and attempted lumbar drain placement from 2010 to 2019 were retrospectively reviewed. All lumbar drains were placed by four cardiovascular anesthesiologists who compose the complex aortic anesthesia team. Lumbar drain placement was guided by a set protocol and used whenever the aortic stent graft coverage was planned to extend more proximal than 40 mm above the celiac artery. Details relating to lumbar drain placement, management, and frequency and type of associated complications were characterized. RESULTS: During the study period, 256 patients underwent F/BEVAR, of whom 100 (39%) were planned for lumbar drain placement. Successful placement occurred in 98 (98%) of the cases. All lumbar drains were placed before induction of general anesthesia, using fluoroscopy guidance in 28 cases (28%). The most common level of placement was L4-5 (n = 42 [42%]). The majority (n = 82 [82%]) were left in place ≤48 hours; 21% were removed during the first 24 hours, and 61% were removed between 24 and 48 hours. Nonfunctionality was the most common complication, occurring in 16 (16%) patients. Catheter dislodgment or fracture, CSF leak, and postdural puncture headache were observed in 4 (4%), 7 (7%), and 4 (4%) patients, respectively. The most common bleeding complication was the presence of asymptomatic blood in the CSF (n = 11 [11%]), whereas subarachnoid hemorrhage combined with intraventricular hemorrhage occurred in three patients (3%); none of these patients required surgical drainage or intervention. No infectious complications were observed. CONCLUSIONS: Lumbar drain placement for CSF drainage is a commonly employed adjunct to prevent spinal cord ischemia in F/BEVAR. Our experience demonstrates that lumbar drain placement can be performed successfully but is associated with a significant rate of nonfunctionality and a diverse range of complications that, fortunately, do not commonly have significant long-term sequelae.

Airway Management in Critical Illness: An Update.

Expertise in airway management is a vital skill for any provider caring for critically ill patients. A growing body of literature has identified the stark difference in periprocedural outcomes of elective intubation in the operating room when compared with emergency intubation in the ICU. A number of strategies to reduce the morbidity and mortality associated with airway management in the critically ill have been described. In this review, we provide an updated framework for airway assessment before direct laryngoscopy and video laryngoscopy, and use of newer pharmacologic agents; comment on current concepts in tracheal intubation in the ICU; and address human factors around critical decision-making during ICU airway management.

Microvascular response to transfusion in elective spine surgery.

AIM: To investigate the microvascular (skeletal muscle tissue oxygenation; SmO2) response to transfusion in patients undergoing elective complex spine surgery. METHODS: After IRB approval and written informed consent, 20 patients aged 18 to 85 years of age undergoing > 3 level anterior and posterior spine fusion surgery were enrolled in the study. Patients were followed throughout the operative procedure, and for 12 h postoperatively. In addition to standard American Society of Anesthesiologists monitors, invasive measurements including central venous pressure, continual analysis of stroke volume (SV), cardiac output (CO), cardiac index (CI), and stroke volume variability (SVV) was performed. To measure skeletal muscle oxygen saturation (SmO2) during the study period, a non-invasive adhesive skin sensor based on Near Infrared Spectroscopy was placed over the deltoid muscle for continuous recording of optical spectra. All administration of fluids and blood products followed standard procedures at the Hospital for Special Surgery, without deviation from usual standards of care at the discretion of the Attending Anesthesiologist based on individual patient comorbidities, hemodynamic status, and laboratory data. Time stamps were collected for administration of colloids and blood products, to allow for analysis of SmO2 immediately before, during, and after administration of these fluids, and to allow for analysis of hemodynamic data around the same time points. Hemodynamic and oxygenation variables were collected continuously throughout the surgery, including heart rate, blood pressure, mean arterial pressure, SV, CO, CI, SVV, and SmO2. Bivariate analyses were conducted to examine the potential associations between the outcome of interest, SmO2, and each hemodynamic parameter measured using Pearson's correlation coefficient, both for the overall cohort and within-patients individually. The association between receipt of packed red blood cells and SmO2 was performed by running an interrupted time series model, with SmO2 as our outcome, controlling for the amount of time spent in surgery before and after receipt of PRBC and for the inherent correlation between observations. Our model was fit using PROC AUTOREG in SAS version 9.2. All other analyses were also conducted in SAS version 9.2 (SAS Institute Inc., Cary, NC, United States). RESULTS: Pearson correlation coefficients varied widely between SmO2 and each hemodynamic parameter examined. The strongest positive correlations existed between ScvO2 (P = 0.41) and SV (P = 0.31) and SmO2; the strongest negative correlations were seen between albumin (P = -0.43) and cell saver (P = -0.37) and SmO2. Correlations for other laboratory parameters studied were weak and only based on a few observations. In the final model we found a small, but significant increase in SmO2 at the time of PRBC administration by 1.29 units (P = 0.0002). SmO2 values did not change over time prior to PRBC administration (P = 0.6658) but following PRBC administration, SmO2 values declined significantly by 0.015 units (P < 0.0001). CONCLUSION: Intra-operative measurement of SmO2 during large volume, yet controlled hemorrhage, does not show a statistically significant correlation with either invasive hemodynamic, or laboratory parameters in patients undergoing elective complex spine surgery.

A 10-Year Review of Total Hospital-Onset ICU Bloodstream Infections at an Academic Medical Center.

BACKGROUND: The rates of central line-associated bloodstream infections (CLABSIs) in U.S. ICUs have decreased significantly, and a parallel reduction in the rates of total hospital-onset bacteremias in these units should also be expected. We report 10-year trends for total hospital-onset ICU-associated bacteremias at a tertiary-care academic medical center. METHODS: This was a retrospective analysis of all positive-result blood cultures among patients admitted to seven adult ICUs for fiscal year 2005 (FY2005) through FY2014 according to Centers for Disease Control and Prevention National Healthcare Safety Network definitions. The rate of change for primary and secondary hospital-onset BSIs was determined, as was the distribution of organisms responsible for these BSIs. Data from three medical, two general surgical, one combined neurosurgical/trauma, and one cardiac/cardiac surgery adult ICU were analyzed. RESULTS: Across all ICUs, the rates of primary BSIs progressively fell from 2.11/1,000 patient days in FY2005 to 0.32/1,000 patient days in FY2014; an 85.0% decrease (P < .0001). Secondary BSIs also progressively decreased from 3.56/1,000 to 0.66/1,000 patient days; an 81.4% decrease (P < .0001). The decrease in BSI rates remained significant after controlling for the number of blood cultures obtained and patient acuity. CONCLUSIONS: An increased focus on reducing hospital-onset infections at the academic medical center since 2005, including multimodal multidisciplinary efforts to prevent central line-associated BSIs, pneumonia, Clostridium difficile disease, surgical site infections, and urinary tract infections, was associated with progressive and sustained decreases for both primary and secondary hospital-onset BSIs.

Comparison of Point-of-Care Activated Clotting Time Methods in Different Clinical Settings in a Large Academic Medical Center.

OBJECTIVES: This study is a comparative analysis of measured activated clotting time (ACT) values by use of 5 different point-of-care (POC) ACT methods spanning the range detected during different clinical procedures at our institution. METHODS: We determined the correlation, imprecision, and differences in measured ACT values with use of 4 POC ACT methods compared with a reference ACT method in 41 venous whole blood samples collected from 25 adult patients undergoing interventional procedures. The POC ACT methods evaluated included the i-STAT with kaolin activator in prewarm mode, i-STAT with Celite activator in prewarm and nonprewarm modes, ACTPlus, and HMSPlus, which was designated the reference method. Each venous whole blood patient sample was tested in duplicate on each POC ACT test system (total n = 410 ACT measurements). Analyses of imprecision and differences in measured ACT values were stratified by moderate (100-299 s) and high (≥300 s) ACT ranges. RESULTS: In this study population, measured ACT values ranged from 100-835 s with use of the HMSPlus. All methods demonstrated good correlation (r ≥ 0.95) in ACT values compared to the reference method. Imprecision varied by method with ranges of 1.7%-2.7% CV in the moderate ACT range and 2.5%-4.8% CV in the high ACT range. ACTPlus and i-STAT-Celite-prewarm methods exhibited proportional differences in measured ACT values whereas the i-STAT-Celite-nonprewarm and i-STAT-kaolin-prewarm demonstrated constant differences in measured ACT values compared to HMSPlus. CONCLUSIONS: ACT values correlate well between POC methods. Imprecision and difference profiles vary by method; notably, imprecision exceeds systematic differences in the high ACT range and contributes to intermethod differences that are limitations worthy of consideration when contemplating a change in ACT methods.

Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial.

BACKGROUND: Immobilisation predicts adverse outcomes in patients in the surgical intensive care unit (SICU). Attempts to mobilise critically ill patients early after surgery are frequently restricted, but we tested whether early mobilisation leads to improved mobility, decreased SICU length of stay, and increased functional independence of patients at hospital discharge. METHODS: We did a multicentre, international, parallel-group, assessor-blinded, randomised controlled trial in SICUs of five university hospitals in Austria (n=1), Germany (n=1), and the USA (n=3). Eligible patients (aged 18 years or older, who had been mechanically ventilated for <48 h, and were expected to require mechanical ventilation for ≥24 h) were randomly assigned (1:1) by use of a stratified block randomisation via restricted web platform to standard of care (control) or early, goal-directed mobilisation using an inter-professional approach of closed-loop communication and the SICU optimal mobilisation score (SOMS) algorithm (intervention), which describes patients' mobilisation capacity on a numerical rating scale ranging from 0 (no mobilisation) to 4 (ambulation). We had three main outcomes hierarchically tested in a prespecified order: the mean SOMS level patients achieved during their SICU stay (primary outcome), and patient's length of stay on SICU and the mini-modified functional independence measure score (mmFIM) at hospital discharge (both secondary outcomes). This trial is registered with ClinicalTrials.gov (NCT01363102). FINDINGS: Between July 1, 2011, and Nov 4, 2015, we randomly assigned 200 patients to receive standard treatment (control; n=96) or intervention (n=104). Intention-to-treat analysis showed that the intervention improved the mobilisation level (mean achieved SOMS 2·2 [SD 1·0] in intervention group vs 1·5 [0·8] in control group, p<0·0001), decreased SICU length of stay (mean 7 days [SD 5-12] in intervention group vs 10 days [6-15] in control group, p=0·0054), and improved functional mobility at hospital discharge (mmFIM score 8 [4-8] in intervention group vs 5 [2-8] in control group, p=0·0002). More adverse events were reported in the intervention group (25 cases [2·8%]) than in the control group (ten cases [0·8%]); no serious adverse events were observed. Before hospital discharge 25 patients died (17 [16%] in the intervention group, eight [8%] in the control group). 3 months after hospital discharge 36 patients died (21 [22%] in the intervention group, 15 [17%] in the control group). INTERPRETATION: Early, goal-directed mobilisation improved patient mobilisation throughout SICU admission, shortened patient length of stay in the SICU, and improved patients' functional mobility at hospital discharge. FUNDING: Jeffrey and Judy Buzen.

Blood Transfusions May Have Limited Effect on Muscle Oxygenation After Total Knee Arthroplasty.

BACKGROUND: Traditionally, blood transfusions in the perioperative setting are used to maintain adequate delivery of nutrients and oxygen to organs. However, the effect of blood administration on tissue oxygenation in the perioperative setting remains poorly understood. QUESTIONS/PURPOSES: The aim of this study was to determine changes in muscle tissue oxygenation saturation (SmO2) in response to perioperative blood transfusions. PATIENTS AND METHODS: Patients undergoing total knee arthroplasty were enrolled. SmO2, continuous hemoglobin (SpHb), stroke volume (SV), cardiac index, and standard hemodynamic parameters including heart rate (HR), mean arterial blood pressure (MAP), and arterial oxygen saturation (SO2) were recorded. To assess fluid responsiveness, a passive leg raise (PLR) test was performed before the transfusions were started. RESULTS: Twenty-eight patients were included in the analysis. Mean (±SD) SmO2 before transfusion was 63.18 ± 10.04%, SpHb was 9.27 ± 1.16 g/dl, and cardiac index was 2.62 ± 0.75 L/min/m(2). A significant increase during the course of blood transfusion was found for SmO2 (+3.44 ± 5.81% [95% confidence interval (CI) 1.04 to 5.84], p = 0.007), SpHb (0.74 ± 0.92 g/dl [95% CI 0.35 to 1.12], p < 0.001), and cardiac index (0.38 ± 0.51 L/min/m2 [95% CI 0.15 to 0.60], p = 0.002), respectively. However, the correlation between SmO2 and SpHb over the course of the transfusion was negligible (ρ = 0.25 [95% CI -0.03 to 0.48]). A similar lack of correlation was found when analyzing data of those patients who showed a positive leg raise test before the start of the transfusion (ρ = 0.37 [95% CI -0.11 to 0.84]). CONCLUSION: We detected a statistically significant increase in SmO2 during the course of a single unit blood transfusion compared to baseline. However, there was no evidence of a correlation between longitudinal SmO2 and SpHb measurements.

The bundle "plus": the effect of a multidisciplinary team approach to eradicate central line-associated bloodstream infections.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) have decreased significantly over the last decade. Further reductions in CLABSI rates should be possible. We describe a multidisciplinary approach to the reduction of CLABSIs. METHODS: This was an observational study of critically ill patients requiring central venous catheters in 8 intensive care units in a tertiary medical center. We implemented a catheter bundle that included hand hygiene, education of providers, chlorhexidine skin preparation, use of maximum barrier precautions, a dedicated line cart, checklist, avoidance of the femoral vein for catheter insertion, chlorhexidine-impregnated dressings, use of anti-infective catheters, and daily consideration of the need for the catheter. Additional measures included root cause analyses of all CLABSIs, creation of a best practice atlas for internal jugular catheters, and enhanced education on blood culture collection. Data were analyzed using the Poisson test and regression. RESULTS: CLABSI, catheter use, and microbiology were tracked from 2004 to 2012. There was a 92% reduction in CLABSIs (95% lower confidence limit: 67.4% reduction, P < 0.0001). Central venous catheter use decreased significantly from 2008 to 2012 (P = 0.032, -151 catheters per year, 95% confidence limits: -277 to -25), whereas peripherally inserted central catheter use increased (P = 0.005, 89 catheters per year, 95% confidence limits: 50 to 127). There was no apparent association between unit-specific Acute Physiology And Chronic Health Evaluation III/IV scores and CLABSI. Three units have not had a CLABSI in more than a year. The most common organism isolated was coagulase-negative staphylococcus. Since the implementation of minocycline/rifampin catheters, no cases of methicillin-resistant Staphylococcus aureus CLABSI have occurred. CONCLUSIONS: The implementation of a standard catheter bundle combined with chlorhexidine dressings, minocycline/rifampin catheters, and other behavioral changes was associated with a sustained reduction in CLABSIs.

Critical care in patients undergoing lumbar spine fusion: a population-based study.

BACKGROUND: Data on the utilization of critical care services (CCSs) among patients who underwent spine fusion are rare. Given the increasing popularity of this procedure, information regarding demographics and risk factors for the use of these advanced services is needed in order to appropriately allocate resources, educate clinical staff, and identify targets for future research. METHODS: We analyzed hospital discharge data of patients who underwent lumbar spine fusion in approximately 400 US hospitals between 2006 and 2010. Patient, procedure, and health care system-related demographics for those requiring CCS were compared to those who did not. Outcomes such as mortality, complications, disposition status, and hospital charges were compared among groups and risk factors for the utilization of CCS identified. RESULTS: A total of 95 434 entries of patients who underwent posterior lumbar spine fusion surgery between 2006 and 2010 were identified. Approximately 10% of the patients required CCS. On average, patients requiring CCS were older and had a higher comorbidity burden, developed more complications, had longer hospital stays and higher costs, and were less likely to be discharged home compared to non-CCS patients. Risk factors with increased odds for requiring CCS included advanced age, increasing comorbidity burden, increasing surgical invasiveness, and presence of postoperative complications, especially pulmonary. CONCLUSIONS: Approximately, 10% of the patients undergoing lumbar spine surgery require CCS. Utilizing the present data, critical care physicians and administrators can identify patients at risk, educate clinical staff, identify targets for intervention, and allocate resources to meet the needs of this particular patient population.

Mortality of patients with respiratory insufficiency and adult respiratory distress syndrome after surgery: the obesity paradox.

INTRODUCTION: Obesity has long been considered a risk factor for the development of various pathologies, yet evidence supporting increased risk of perioperative mortality in obese individuals developing postoperative complications is limited. Therefore, we sought to characterize the demographics of obese and nonobese individuals developing postoperative respiratory insufficiency (RI)/adult respiratory distress syndrome (ARDS) and to quantify the impact of obesity on in-hospital mortality among this patient population utilizing data collected for the Nationwide Inpatient Sample (NIS). METHODS: Nationwide Inpatient Sample data for each year between 1998 and 2007 were accessed. Entries were included if they underwent a surgical procedure and had a diagnosis of RI/ARDS following surgery. Patients fulfilling entry criteria were divided into those with and without obesity. In-hospital mortality was the primary outcome. A logistic regression model was fitted to elucidate if obesity was associated with increased odds for the outcome while controlling for age, gender, admission and procedure type, and comorbidity burden. RESULTS: We identified 9 149 030 admissions that underwent the included surgical procedures between 1998 and 2007. Of those, 5.48% had a diagnosis of obesity. The incidence of RI/ARDS was 1.82% among obese and 2.01% among nonobese patients. Obese patients whose postoperative course was complicated by RI/ARDS had a significantly lower incidence of the need for mechanical ventilation (50% vs 55%). In-hospital mortality was significantly lower compared to nonobese patients (5.45% vs 18.72%). For those patients with RI/ARDS requiring intubation, the in-hospital mortality rate was 11% for obese and 25% for nonobese patients. In the multivariate regression analysis, obesity was associated with a 69% reduction in the odds of in-hospital mortality in postoperative patients with RI/ARDS. CONCLUSION: In our analysis, obesity was associated with a decreased incidence and adjusted odds for in-hospital mortality after surgery. Our results support the emerging concept of the "obesity paradox."

Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery.

BACKGROUND: Although patients with sleep apnea (SA) are considered to be at increased risk for postoperative complications, evidence supporting increased risk of perioperative pulmonary morbidity is limited. The objective of this study, therefore, was to analyze perioperative demographics and pulmonary outcomes of patients with SA after orthopedic and general surgical procedures using a population-based sample. We hypothesized that SA is an independent risk factor for perioperative pulmonary complications, thus providing a basis for an increase in the utilization of resources, including intensive monitoring and development of strategies to prevent and treat these events. METHODS: National Inpatient Sample data for each year between 1998 and 2007 were accessed. Orthopedic and general surgical procedures were included and discharges with a diagnosis code for SA were identified. Patients with the diagnosis of SA were matched to those without the disease based on demographic variables using the propensity scoring method. Aspiration pneumonia, adult respiratory distress syndrome (ARDS), pulmonary embolism (PE), and the need for intubation and mechanical ventilation were the primary outcomes. Odds ratio (OR) and absolute risk reduction along with 95% confidence interval were reported. RESULTS: We identified 2,610,441 entries for orthopedic and 3,441,262 for general surgical procedures performed between 1998 and 2007. Of those, 2.52% and 1.40%, respectively, carried a diagnosis of SA. Patients with SA developed pulmonary complications more frequently than their matched controls after both orthopedic and general surgical procedures, respectively (i.e., aspiration pneumonia: 1.18% vs 0.84% and 2.79% vs 2.05%; ARDS: 1.06% vs 0.45% and 3.79% vs 2.44%; intubation/mechanical ventilation: 3.99% vs 0.79% and 10.8% vs 5.94%, all P values <0.0001). Comparatively, PE was more frequent in SA patients after orthopedic procedures (0.51% vs 0.42%, P = 0.0038) but not after general surgical procedures (0.45% vs 0.49%, P = 0.22). SA was associated with a significantly higher adjusted OR of developing pulmonary complications after both orthopedic and general surgical procedures, respectively, with the exception of PE (OR for aspiration pneumonia: 1.41 [1.35, 1.47] and 1.37 [1.33, 1.41]; for ARDS: 2.39 [2.28, 2.51] and 1.58 [1.54, 1.62]; for PE: OR 1.22 [1.15, 1.29] and 0.90 [0.84, 0.97]; for intubation/mechanical ventilation: 5.20 [5.05, 5.37] and 1.95 [1.91, 1.98]). CONCLUSION: SA is an independent risk factor for perioperative pulmonary complications. Our results may be used for hypothesis generation for clinical studies targeted to improve perioperative outcomes in this patient population.

Perioperative mortality in patients with pulmonary hypertension undergoing major joint replacement.

BACKGROUND: There is a paucity of perioperative outcomes data for patients with chronic pulmonary hypertension (PHTN) undergoing noncardiac surgery. Clinicians, therefore, have little information on which to evaluate the risk for morbidity and mortality in this patient population. In this study, we evaluated the incidence and risks of perioperative morbidity and mortality in patients with PHTN undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: Using the largest inpatient database in the United States (National Inpatient Sample), we identified entries for THA and TKA between the years of 1998 and 2006. Patients with the diagnosis of PHTN were identified and matched to those without the disease based on health-related demographic variables. Perioperative mortality was considered the primary outcome. Multivariate logistic regression models were fitted to assess the impact of PHTN on in-hospital mortality. RESULTS: We identified 670,516 entries for TKA and 360,119 for THA. Of those patients, 2184 (0.3%) and 1359 (0.4%), respectively, had the diagnosis of PHTN (average annual rate of 1180 for TKA [range, 507-2073] and 739 for THA [range, 467-1054]). Patients with PHTN undergoing THA experienced an approximately 4-fold increased adjusted risk of mortality (2.4% vs 0.6%), and those undergoing TKA a 4.5-fold increased adjusted risk of mortality (0.9% vs 0.2%) compared with patients without PHTN in the matched sample (P < 0.001 for each comparison). Patients with primary PHTN undergoing THA experienced the highest mortality rate (5% [95% CI, 2.3%-7.7%]). CONCLUSIONS: This analysis demonstrates that patients with PHTN are at increased risk for perioperative mortality after THA and TKA.