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A positive fluid balance post cardiac surgery results in prolonged ventilation, intensive care unit and hospital length of stay
The 36th Australian and New Zealand Scientific Meeting on Intensive Care around central line insertion, management and elimination of guidewire retention. Tools to support safe practice (including consensus guidelines) were developed and a 2009 safety alert on guidewire retention was issued. Objectives: To quantify improvements and ongoing improvement areas. Methods: NSW incident data (April 08—March 11) on central venous access devices, related to insertion and management was reviewed to identify themes. Search terms included: central line, central venous catheter, central venous line, CVC, peripherally inserted central catheter, PICC. The narratives of 572 incidents where ICU was an involved service were reviewed. Results: Unplanned removal represented 23% of incidents (n = 131). Inadequate fixation by suture or fixation device was identified as the contributing factor in 41 reports. Where fixation was not identified, issues included patient movement, confusion, aggression and limited supervision. There were 71 insertion complications. Notably there were 15 retained guidewires and 25 incidents of arterial puncture, of which 13 went unrecognised and fluid and medication was infused. 84 incidents made specific reference to various policy breaches. Post insertion care incidents (n = 72) indicated inadequate staff knowledge particularly in relation to lumen choice, drug compatibility, dilution of drugs and fluid therapies. Conclusions: Central line insertion and management remains variable despite guidelines and supportive tools in NSW. The guidewire safety alert did not reduce the number of retained guidewires. Mechanisms to further support and embed guidelines needs to be explored to sustain practice change. doi:10.1016/j.aucc.2011.12.041 A positive fluid balance post cardiac surgery results in prolonged ventilation, intensive care unit and hospital length of stay B. Pearse 1,2,∗ , C. Cole 1 , A. Barnett 3 , P. Pohlner 1 , J. Fraser 1,2 1 Cardiac
Surgery Program, The Prince Charles Hospital, Australia 2 Aneasthetic Program, The Prince Charles Hospital, Australia 3 Critical Care Research Group, Australia Cardiac surgical patients routinely receive many litres of fluid in the pre, peri and post-operative period.
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Liberal fluid administration has been shown to be associated with poor outcomes in respiratory and non-cardiac surgery admissions to the Intensive Care Unit (ICU). We hypothesised that the volume of fluid gain post cardiac surgery, would negatively affect morbidity and ICU length of stay. We weighed 300 consecutive on-pump, cardiac surgical patients pre and post-operatively and each morning, excluding patients with prolonged ventilation or those too large to fit in the weigh chair. An increase in weight from baseline of 1% resulted in significantly prolonged hospital length of stay (LOS) (Hazard ratio (HR) of discharge 0.95, p < 0.001). The prolonged LOS due to a 1% increase in weight, was equivalent to a 5 year increase in age (HR 0.95, p = 0.007). For all patients, there was an increase in length of ventilation hours associated with a 1000 ml increase in day one 24 h fluid balance (HR 0.78, p < 0.001) and day one crystalloid total (HR 0.61, p < 0.001). Length of ICU stay and total length of hospital stay were also prolonged (p < 0.05), associated with a 1000 ml increase in postoperative totals for fluid balance and colloid administration in the first 24 h. Ventilation and length of ICU stay increased for every 1000 ml of crystalloid (HR 0.58, p < 0.001: HR 0.41, p < 0.001) or colloid (HR 0.53, p < 0.001: HR 0.08, p < 0.001), given on day one. These parameters were statistically significant when corrected for ejection fraction and pre-existing renal impairment. Patients post cardiac surgery should be kept dry to minimise ventilation time, ICU stay and hospital stay. doi:10.1016/j.aucc.2011.12.042 Analgesia and sedation audits—–Facilitating change to optimise patient comfort D. Rajbhandari 1,2,∗ , H. Koelzow 1 , A. Stirling 1 1 Royal 2 The
Prince Alfred Hospital, Australia George Institute for Global Health, Australia
Analgesia and sedation are important components of intensive care treatment. Pain in ICU patients is caused by surgery, therapeutic devices and nursing interventions. Unrelieved pain contributes to inadequate sleep, agitation, delirium and the physiological stress response and possibly to post-traumatic stress disorder. Sedation relieves anxiety and agitation and facilitates ventilation and other interventions. Oversedation is associated with prolonged ventilation and ICU stay. Thus patient comfort without coma is an important ICU patient outcome.
Surgery Program, The Prince Charles Hospital, Australia 2 Aneasthetic Program, The Prince Charles Hospital, Australia 3 Critical Care Research Group, Australia Cardiac surgical patients routinely receive many litres of fluid in the pre, peri and post-operative period.
137
Liberal fluid administration has been shown to be associated with poor outcomes in respiratory and non-cardiac surgery admissions to the Intensive Care Unit (ICU). We hypothesised that the volume of fluid gain post cardiac surgery, would negatively affect morbidity and ICU length of stay. We weighed 300 consecutive on-pump, cardiac surgical patients pre and post-operatively and each morning, excluding patients with prolonged ventilation or those too large to fit in the weigh chair. An increase in weight from baseline of 1% resulted in significantly prolonged hospital length of stay (LOS) (Hazard ratio (HR) of discharge 0.95, p < 0.001). The prolonged LOS due to a 1% increase in weight, was equivalent to a 5 year increase in age (HR 0.95, p = 0.007). For all patients, there was an increase in length of ventilation hours associated with a 1000 ml increase in day one 24 h fluid balance (HR 0.78, p < 0.001) and day one crystalloid total (HR 0.61, p < 0.001). Length of ICU stay and total length of hospital stay were also prolonged (p < 0.05), associated with a 1000 ml increase in postoperative totals for fluid balance and colloid administration in the first 24 h. Ventilation and length of ICU stay increased for every 1000 ml of crystalloid (HR 0.58, p < 0.001: HR 0.41, p < 0.001) or colloid (HR 0.53, p < 0.001: HR 0.08, p < 0.001), given on day one. These parameters were statistically significant when corrected for ejection fraction and pre-existing renal impairment. Patients post cardiac surgery should be kept dry to minimise ventilation time, ICU stay and hospital stay. doi:10.1016/j.aucc.2011.12.042 Analgesia and sedation audits—–Facilitating change to optimise patient comfort D. Rajbhandari 1,2,∗ , H. Koelzow 1 , A. Stirling 1 1 Royal 2 The
Prince Alfred Hospital, Australia George Institute for Global Health, Australia
Analgesia and sedation are important components of intensive care treatment. Pain in ICU patients is caused by surgery, therapeutic devices and nursing interventions. Unrelieved pain contributes to inadequate sleep, agitation, delirium and the physiological stress response and possibly to post-traumatic stress disorder. Sedation relieves anxiety and agitation and facilitates ventilation and other interventions. Oversedation is associated with prolonged ventilation and ICU stay. Thus patient comfort without coma is an important ICU patient outcome.