Treatment of acute renal failure in the intensive care unit: lower costs by intermittent dialysis than continuous venovenous hemodiafiltration

Intermittent and continuous renal replacement therapies (RRTs) are available for the treatment of acute renal failure (ARF) in the intensive care unit (ICU). Although at present there are no adequately powered survival studies, available data suggest that both methods are equal with respect to patient outcome. Therefore, cost comparison between techniques is important for selecting the modality. Expenditures were prospectively assessed as a secondary end point during a controlled, randomized trial comparing intermittent hemodialysis (IHD) with continuous venovenous hemodiafiltration (CVVHDF). The outcome of the primary end points of this trial, that is, ICU and in-hospital mortality, has been previously published. One hundred twenty-five patients from a Swiss university hospital ICU were randomized either to CVVHDF or IHD. Out of these, 42 (CVVHDF) and 34 (IHD) were available for cost analysis. Patients' characteristics, delivered dialysis dose, duration of stay in the ICU or hospital, mortality rates, and recovery of renal function were not different between the two groups. Detailed 24-h time and material consumption protocols were available for 369 (CVVHDF) and 195 (IHD) treatment days. The mean daily duration of CVVHDF was 19.5 +/- 3.2 h/day, resulting in total expenditures of Euro 436 +/- 21 (21% for human resources and 79% for technical devices). For IHD (mean 3.0 +/- 0.4 h/treatment), the costs were lower (Euro 268 +/- 26), with a larger proportion for human resources (45%). Nursing time spent for CVVHDF was 113 +/- 50 min, and 198 +/- 63 min per IHD treatment. Total costs for RRT in ICU patients with ARF were lower when treated with IHD than with CVVHDF, and have to be taken into account for the selection of the method of RRT in ARF on the ICU.

Body salt and water balances in cardiothoracic surgery patients with intensive care unit-acquired hyponatremia

PURPOSE Hyponatremia is frequently observed in intensive care unit (ICU) patients, but there is still lack information on the physiological mechanisms of development. MATERIALS AND METHODS In this retrospective analysis we performed tonicity balances in 54 patients with ICU acquired hyponatremia. We calculated fluid and solute in and outputs during 24 hours in 106 patient days with decreasing serum-sodium levels. RESULTS We could observe a positive fluid balance as a single reason for hyponatremia in 25% of patients and a negative solute balance in 57%. In 18% both factors contributed to the decrease in serum-sodium. Hyponatremic patients had renal water retention, measured by electrolyte free water clearance calculation in 79% and positive input of free water in 67% as reasons for decline of serum-sodium. The theoretical change of serum sodium during 24 hours according to the calculations of measured balances correlated well with the real change of serum sodium (r = 0.78, P < .01). CONCLUSIONS Balance studies showed that renal water retention together with renal sodium loss and high electrolyte free water input are the major contributors to the development of hyponatremia. Control of renal water and sodium handling by urine analysis may contribute to a better fluid management in the ICU population.

A Time-Motion Study of Registered Nurses’ Workflow in Intensive Care Unit Remote Monitoring

Utilizing advanced information technology, Intensive Care Unit (ICU) remote monitoring allows highly trained specialists to oversee a large number of patients at multiple sites on a continuous basis. In the current research, we conducted a time-motion study of registered nurses’ work in an ICU remote monitoring facility. Data were collected on seven nurses through 40 hours of observation. The results showed that nurses’ essential tasks were centered on three themes: monitoring patients, maintaining patients’ health records, and managing technology use. In monitoring patients, nurses spent 52% of the time assimilating information embedded in a clinical information system and 15% on monitoring live vitals. System-generated alerts frequently interrupted nurses in their task performance and redirected them to manage suddenly appearing events. These findings provide insight into nurses’ workflow in a new, technology-driven critical care setting and have important implications for system design, work engineering, and personnel selection and training.

The role of Acinetobacter baumannii as a nosocomial pathogen for dogs and cats in an intensive care unit.

Acinetobacter baumannii is a nosocomial pathogen associated with high morbidity and mortality in humans. Whereas infections with strains of Acinetobacter species have been reported in various situations, the importance of A baumannii as a nosocomial pathogen in veterinary hospitals has not been studied so far. In this retrospective case series, we describe 17 dogs and 2 cats from which A baumannii had been isolated during a 2 1/2-year period. In 7 dogs, A baumannii induced systemic signs of illness, whereas 12 animals showed signs of local infection. In all animals with systemic infection, and in 2 with localized infection, A baumannii contributed to the death of the animal or contributed to euthanasia; the remaining 8 dogs and both cats recovered. Molecular typing of the isolates with restriction polymorphisms of ribosomal DNA provided evidence of nosocomial spread of this pathogen and for the presence of several strains of A baumannii in the hospital environment.

Association of lectin pathway proteins with intra-abdominal Candida infection in high-risk surgical intensive-care unit patients. A prospective cohort study within the fungal infection network of Switzerland

OBJECTIVES Human studies on the role of mannose-binding lectin (MBL) in patients with invasive candidiasis have yielded conflicting results. We investigated the influence of MBL and other lectin pathway proteins on Candida colonization and intra-abdominal candidiasis (IAC) in a cohort of high-risk patients. METHODS Prospective observational cohort study of 89 high-risk intensive-care unit (ICU) patients. Levels of lectin pathway proteins at study entry and six MBL2 single-nucleotide polymorphisms were analyzed by sandwich-type immunoassays and genotyping, respectively, and correlated with development of heavy Candida colonization (corrected colonization index (CCI) ≥0.4) and occurrence of IAC during a 4-week period. RESULTS Within 4 weeks after inclusion a CCI ≥0.4 and IAC was observed in 47% and 38% of patients respectively. Neither serum levels of MBL, ficolin-1, -2, -3, MASP-2 or collectin liver 1 nor MBL2 genotypes were associated with a CCI ≥0.4. Similarly, none of the analyzed proteins was found to be associated with IAC with the exception of lower MBL levels (HR 0.74, p = 0.02) at study entry. However, there was no association of MBL deficiency (<0.5 μg/ml), MBL2 haplo- or genotypes with IAC. CONCLUSION Lectin pathway protein levels and MBL2 genotype investigated in this study were not associated with heavy Candida colonization or IAC in a cohort of high-risk ICU patients.

Impact of a communication strategy on family satisfaction in the intensive care unit.

BACKGROUND Family satisfaction of critically ill patients has gained increased interest as important indicator to evaluate the quality of care in the intensive care unit (ICU). The family satisfaction in the ICU questionnaire (FS-ICU 24) is a well-established tool to assess satisfaction in such settings. We tested the hypothesis that an intervention, aiming at improved communication between health professionals and patients' next of kin in the ICU improves family satisfaction, as assessed by FS-ICU 24. METHODS Using a multicenter before-and-after study design, we evaluated medium-term effectiveness of VALUE, a recently proposed strategy aiming at improved communication. Satisfaction was assessed using the FS-ICU 24 questionnaire. Performance-importance plots were generated in order to identify items highly correlated with overall satisfaction but with low individual score. RESULTS A total of 163 completed family questionnaires in the pre-intervention and 118 in the post-intervention period were analyzed. Following the intervention, we observed: (1) a non-significant increase in family satisfaction summary score and sub-scores; (2) no decline in any individual family satisfaction item, and (3) improvement in items with high overall impact on satisfaction but quoted with low degree of satisfaction. CONCLUSION No significant improvement in family satisfaction of critically ill adult patients could be found after implementing the VALUE strategy. Whether these results are due to insufficient training of the new strategy or a missing effect of the strategy in our socio-economic environment remains to be shown.

Study of length of stay in the cardiovascular intensive care unit

Coronary artery bypass graft (CABG) surgery is among the most common operations performed in the United States and accounts for more resources expended in cardiovascular medicine than any other single procedure. CABG surgery patients initially recover in the Cardiovascular Intensive Care Unit (CVICU). The post-procedure CVICU length of stay (LOS) goal is two days or less. A longer ICU LOS is associated with a prolonged hospital LOS, poor health outcomes, greater use of limited resources, and increased medical costs. ^ Research has shown that experienced clinicians can predict LOS no better than chance. Current CABG surgery LOS risk models differ greatly in generalizability and ease of use in the clinical setting. A predictive model that identified modifiable pre- and intra-operative risk factors for CVICU LOS greater than two days could have major public health implications as modification of these identified factors could decrease CVICU LOS and potentially minimize morbidity and mortality, optimize use of limited health care resources, and decrease medical costs. ^ The primary aim of this study was to identify modifiable pre-and intra-operative predictors of CVICU LOS greater than two days for CABG surgery patients with cardiopulmonary bypass (CPB). A secondary aim was to build a probability equation for CVICU LOS greater than two days. Data were extracted from 416 medical records of CABG surgery patients with CPB, 50 to 80 years of age, recovered in the CVICU of a large teaching, referral hospital in southeastern Texas, during the calendar year 2004 and the first quarter of 2005. Exclusion criteria included Diagnosis Related Group (DRG) 106, CABG surgery without CPB, CABG surgery with other procedures, and operative deaths. The data were analyzed using multivariate logistic regression for an alpha=0.05, power=0.80, and correlation=0.26. ^ This study found age, history of peripheral arterial disease, and total operative time equal to and greater than four hours to be independent predictors of CVICU LOS greater than two days. The probability of CVICU LOS greater than two days can be calculated by the following equation: -2.872941 +.0323081 (age in years) + .8177223 (history of peripheral arterial disease) + .70379 (operative time). ^

Nosocomial infections and their relationship to non-traditional risk factors in a medical intensive care unit

Background. Nosocomial infections are a source of concern for many hospitals in the United States and worldwide. These infections are associated with increased morbidity, mortality and hospital costs. Nosocomial infections occur in ICUs at a rate which is five times greater than those in general wards. Understanding the reasons for the higher rates can ultimately help reduce these infections. The literature has been weak in documenting a direct relationship between nosocomial infections and non-traditional risk factors, such as unit staffing or patient acuity.^ Objective. To examine the relationship, if any, between nosocomial infections and non-traditional risk factors. The potential non-traditional risk factors we studied were the patient acuity (which comprised of the mortality and illness rating of the patient), patient days for patients hospitalized in the ICU, and the patient to nurse ratio.^ Method. We conducted a secondary data analysis on patients hospitalized in the Medical Intensive Care Unit (MICU) of the Memorial Hermann- Texas Medical Center in Houston during the months of March 2008- May 2009. The average monthly values for the patient acuity (mortality and illness Diagnostic Related Group (DRG) scores), patient days for patients hospitalized in the ICU and average patient to nurse ratio were calculated during this time period. Active surveillance of Bloodstream Infections (BSIs), Urinary Tract Infections (UTIs) and Ventilator Associated Pneumonias (VAPs) was performed by Infection Control practitioners, who visited the MICU and performed a personal infection record for each patient. Spearman's rank correlation was performed to determine the relationship between these nosocomial infections and the non-traditional risk factors.^ Results. We found weak negative correlations between BSIs and two measures (illness and mortality DRG). We also found a weak negative correlation between UTI and unit staffing (patient to nurse ratio). The strongest positive correlation was found between illness DRG and mortality DRG, validating our methodology.^ Conclusion. From this analysis, we were able to infer that non-traditional risk factors do not appear to play a significant role in transmission of infection in the units we evaluated.^

An outbreak of Multi-Drug Resistant Acinetobacter in the burn intensive care unit of a large tertiary care center

Risk factors for Multi-Drug Resistant Acinetobacter (MDRA) acquisition were studied in patients in a burn intensive care unit (ICU) where there was an outbreak of MDRA. Forty cases were matched with eighty controls based on length of stay in the Burn ICU and statistical analysis was performed on data for several different variables. Matched analysis showed that mechanical ventilation, transport ventilation, number of intubations, number of bronchoscopy procedures, total body surface area burn, and prior Methicillin Resistant Staphylococcus aureus colonization were all significant risk factors for MDRA acquisition. ^ MDRA remains a significant threat to the burn population. Treatment for burn patients with MDRA is challenging as resistance to antibiotics continues to increase. This study underlined the need to closely monitor the most critically ill ventilated patients during an outbreak of MDRA as they are the most at risk for MDRA acquisition.^

Prediction of sepsis in the burn intensive care unit patient

Sepsis is a significant cause for multiple organ failure and death in the burn patient, yet identification in this population is confounded by chronic hypermetabolism and impaired immune function. The purpose of this study was twofold: 1) determine the ability of the systemic inflammatory response syndrome (SIRS) and American Burn Association (ABA) criteria to predict sepsis in the burn patient; and 2) develop a model representing the best combination of clinical predictors associated with sepsis in the same population. A retrospective, case-controlled, within-patient comparison of burn patients admitted to a single intensive care unit (ICU) was conducted for the period January 2005 to September 2010. Blood culture results were paired with clinical condition: "positive-sick"; "negative-sick", and "screening-not sick". Data were collected for the 72 hours prior to each blood culture. The most significant predictors were evaluated using logistic regression, Generalized Estimating Equations (GEE) and ROC area under the curve (AUC) analyses to assess model predictive ability. Bootstrapping methods were employed to evaluate potential model over-fitting. Fifty-nine subjects were included, representing 177 culture periods. SIRS criteria were not found to be associated with culture type, with an average of 98% of subjects meeting criteria in the 3 days prior. ABA sepsis criteria were significantly different among culture type only on the day prior (p = 0.004). The variables identified for the model included: heart rate>130 beats/min, mean blood pressure<60 mmHg, base deficit<-6 mEq/L, temperature>36°C, use of vasoactive medications, and glucose>150 mg/d1. The model was significant in predicting "positive culture-sick" and sepsis state, with AUC of 0.775 (p < 0.001) and 0.714 (p < .001), respectively; comparatively, the ABA criteria AUC was 0.619 (p = 0.028) and 0.597 (p = .035), respectively. SIRS criteria are not appropriate for identifying sepsis in the burn population. The ABA criteria perform better, but only for the day prior to positive blood culture results. The time period useful to diagnose sepsis using clinical criteria may be limited to 24 hours. A combination of predictors is superior to individual variable trends, yet algorithms or computer support will be necessary for the clinician to find such models useful. ^