- Email: [email protected]
Critical Care Outcomes 11:00 am-12:30 pm
Monday, October 28, 1996 Bronchoscopy Techniques, continued FLEXIBLE FIBEROPTIC BRONCHOSCOPY - A SAFE AND EFFECTIVE METHOD FOR ENDOBRONCHIAL METAL STENT IMPLANTATION Hubert Hautmann, MD 1; Rudolf M Huber 1, MD; Klaus J Pfeife~, MD- Klinikum Innenstadt der LMU , Medizinische Klinik, Pneumologyl, Radiologl, Munich, Germany Purpose: Endoscopic bronchoplastic procedures such as metal stent implantation are mainly performed using rigid bronchoscopy. Flexible bronchoscopy, however, is less invasive and is assumed to be equally safe and effective. Methods: Fifty nine patients with malignant tumors (n=44) or benign bronchial collapse (n= 15) were treated for airway obstruction by the insertion of an expandable metal stent (27 Strecker Stents, 18 Wallstents, 14 Nitinolstents) into the trachea or a main bronchus using a fiberoptic bronchoscope. In 57 cases the patients received intrave nous anaesthesia (propofol/alfentanil) and high frequency jet ventilation. Positioning of the prostheses was performed under fluoroscopic guidance. Measurements were done in 28 patients before and after stenting and included pulmonary function tests as well as performance status. Results: Acute complications have not been observed. In 3 cases the stent had to be removed due to misplacement and after an unsuccessful attempt to reposition the prosthesis. Late complications (obstruction by accumulated secretions, penetration of tumor, loss of stent elasticity) were rare and not associated with the technique of flexible implantation, however, occasionally (n= 7) led to removal and replacement of the stent within the same procedure. In those patients in whom measurements were performed 79% showed symptomatic improvement. FEV1 improved from 1.84 I to 2.13 I; PEF from 2081/min to 252 1/min. Karnofsky performance status increased from 59 to 65% (p<0.05). Conclusions: Flexible fiberoptic bronchoscopy is a safe and effective method to perform endobronchial metal stent implantation without having to expect acute complications. Rare cases of initial misplacement of the prosthesis may necessitate removal and replacement in the same procedure. Clinical Implications: Insertion of expandable metal stents into airways has become an integral part of therapeutic pulmology. It should be as little invasive as possible with a maximum of safety and efficiency. Therefore, flexible fiberoptic bronchoscopy offers a practical alternative to rigid bronchoscopy.
ESTIMATING ICU COST SAVINGS: REDUCING LOW RISK-MONITORED ONLY (LRM) PATIENTS USING RISK ADJUSTED HOSPITAL OUTCOME DATA Mary Beth Coleman, RN , MBA; CA Sirio, MD; Derek Angus, MB ChB, MPH, N Pristas, RN , University of Pittsburgh, Pittsburgh, PA Purpose: Appropriate allocation of critical care resources is a focus of scrutiny as ICU care is estimated to comprise up to 30% of hospital cost. ICU utilization rates for patients at low risk of requiring active ICU intervention vary between 5.9% and 57% in the US. Thus, the need for active ICU care by LRM patients may be small but variable. We first assessed LRM rates across our institution and then developed an approach to quantitate potential savings in direct orerating costs by reducing LRM admissions to the ICU using risk adjusted predictions o the likelihood of ever r equiring active ICU therapy (one of 33 active TISS elements). Methods: APACHE III data was collected on a random sample of 1621 adult patients admitted to 8 ICUs (general medical [2] , surgical [2], cardiac, cardiothoracic [CT] , trauma [T], and neurologic) in a tertiary care hospital between F eb. and Oct. 1994. Risk predictions were calculated for several endpoints including the likelihood of requiring active ICU intervention at any point during an admission. LRM patients were defined as having a >10% predicted rate of requiring such intervention. Patient care cost was calculated using the average cost of nursing labor (cost x hours of care/pt day), and the direct cost of the average utilization of ancillary services (radiology and laboratory)/pt day for ICU and step-down. Cost savings were defined as the difference between the average direct cost per ICU day and step-down day. Results: 29% of patients admitted to ICUs were classified as LRM. The range of LRM was from 7% to 45.7%. All units except the CT and T ICUs had a LRM rate of >20%. Reduction of the LRM rate to 20% in all units would result in savings of $2.6 million in year one. Approximately 33% of the savings would be in direct labor, and 66% in ancillary services.
Conclusions: There is wide intra-institutional variation in the use of ICUs for LRM patients. Cost savings associated with decreasing the rate of ICU admission for LRM patients can be calculated and are large. Implications: The ability to link predicted risk adjusted rates ofLRM patients to cost savings can serve as the basis for developing strategies for decreasing the utilization of ICU resources. Facilities planning and staffing decisions may be facilitated by using volume estimates of LRM patients. Changes in admission location to less intensive units for LRM patients requires active triage and potentially a revision in ICU admission and discharge criteria, and should be linked to strategies to monitor risk adjusted outcomes for patients excluded from ICU care.
Critical Care Outcomes 11:00 am-12:30 pm THE EFFECT OF A FULL-TIME MEDICAL INTENSIVIST ON PATIENT CARE IN A COMMUNITY TEACHING HOSPITAL. Constantine A Manthous, Y amoateng-Adjepong, B. Jacob, W Chatila, H Alnuaimat, JB Hall*. Bridgeport Hospital, Yale University and University of Chicago.* Few studies have quantified the effects of adding intensivists to direct hospital intensive care units (ICUs). Methods: We retrospectively reviewed outcomes of all patients admitted to an 8-bed medical ICU in a 270-bed community, teaching hospital before (BD) and after (AD) adding a full-time medical intensivist to direct the ICU. Results: 514 BD patients were compared to 576 AD patients. APACHE II scores were significantly higher in the AD (17.3::'::0.5) compared to the BD period (12.5::'::0.5, p<0.01). Monthly in-hospital mortalities decreased from 31.1::'::10.0% BD to 23.4::'::6.9% AD (p<0.01), while in-ICU mortalities decreased from 16.7::'::5.6% BD to 10.9::'::5.4% AD (p<0.01). This 25% reduction in case mortality rate from all causes was similar across categories of disease. A more detailed analysis of a representative sample of homogeneous patients, those admitted with pneumonia, demonstrated that groups were similar with regard to age, sex, acuity of illness, point of origin and need for mechanical ventilation. Mortality from pneumonia was reduced to 32% AD as compared to 48% BD and was consistent across ranges of APACHE II, age and point of origin. ICU length of stay was reduced from 5.7::'::2.0 BD to 4.8::'::1.5 days AD (p<0.05). Eaucational outcomes, as measured by performance on a 40-question examination, improved significantly in all groups of trainees. Conclusions: We conclude that addition of a medical intensivist to a teaching community hospital improved patient outcomes, reduced ICU length of stay and improved housestaff education.
OBESITY AND TRAUMA PATIENT OUTCOME Alex Desouza MD, A Chendrasekhar MD, GA Timberlake MD-West Virginia University, Morgantown, WV, USA Purpose: The effect of obesity on the severely injured trauma patient has not been described in detail. We hypothesize that obesity adversely effects trauma patients with respect to its various outcome parameters such as intensive care unit (ICU) length of stay, ventilator days, frequency of complications, hospital length of stay, and survival. Methods: A retrospective chart review of 100 consecutive severely traumatized adults was performed (ISS>20). Charts were reviewed for demographic data (age, gender, and associated medical problems), Body mass index (BMI), and outcome data (ICU length of stay, ventilator days, frequency of complications, hospital length of stay and survival). Associated medical problems were limited to coronary artery disease, hypertension and diabetes. Complications were defmed as nosocomial infection or deep venous thrombosis. Obesity was defined as BMI >30 kgtcm2, overweight was defined as 302:BMI2:25 kg'cm2, and normal range was defined as BMI <25 kg'cm2. Statistical analysis was performed using one way analysis of variance with repeated measures comparing normal patients' data to obese and overweight patients. Results: Normal (n=37) ICU days 2.1 ± 1.2 Vent days 1.2±0.5 Comp freq 26.7% H-los (days) 9.3± 1.5 *p<0.05, Mean values±SEM.
Overweight (n=35) 7.8±1.7* 5.8±1.4* 66.7% * 19.8±3.3*
Obese (n=28) 12.7±2.1* 12.1±2.7* 90.9%* 26.3±4.5*
Demographic data (age, gender, and associated medical problems) were not statistically different between the 3groups. Survival was not statistically different between the 3 groups. Conclusions: Obesity adversely effects ICU days, ventilator days, complication frequency, and hospital length of stay in severely injured trauma patients. Survival however is not effected. Clinical Implications: Obesity is an independent risk factor in trauma patients.
CHEST I 110 I 4 I OCTOBER, 1996 SUPPLEMENT
7S
Monday, October 28, 1996 Critical Care Outcomes, continued THE IMPACT OF WEIGHT ON ICU COST IN PATIENTS WITH UNEXPLAINED HYPOTENSION Paul A. H eidenreich, E Foster, NH Cohen, Stanford University, Stanford, CA and University of California, San Francisco, CA, USA Purpose: 1) To determine the intensive care unit (ICU) costs for treatment of patients admitted with unexplained hypotension. 2) To determine patient related predictors of ICU cost. Methods: We examined ICU charges, length of stay and mortality for 69 consecutive patients admitted to the ICU with unexplained hypotension. Patient related variables upon admission were evaluated to dete rmine association with ICU charges. ·weight was considered elevated for women >80kg and for rnen >85kg (N=25). Results: The 69 patients had a mean age of 58:': 18 years and 55% were male. The mean ICU charge for the entire group was $31,800:'::59,900. The only patient related variable directly associated with ICU charge was increased weight ($16,000:'::15,000 for low to normal weight, vs. $46,000:'::68,000 for increased weight, P<0.01 ). Increased weight was associated witl1 both a longer length of stay (14:'::22 vs. 6:':: 5 days P=0.03) and a higher ICU charge/day ($3,700:'::1 ,300 vs. $2900:'::1100, P=0.02). The survival rate for patients with increased weight (40%) was equal to survival for lower weight patients (40%, P>0.9). APACHE II scores were also similar (21 for boili weight groups). Patients wiili increased weight had a higher creatinine level (2.9:'::2.0 mgldl vs. 1.6:'::1.1, P<0.01 ) and were more likely to have liver disease (20% vs. 5%, P=0.06). However, when patients with hepatic and renal disease were excluded, increased weight remained a significant predictor of ICU charges. Neiilier etiology of hypotension nor admitting diagnosis were predictive of ICU charges. After controlling for potential confounding variables with multivariate analysis weight remained the only variable significantly associated with ICU charge (P <0. 05). Conclusions: Increased weight on admission was the only patient variable associated 'vith a longer length of stay and greater ICU costs per day. Clinical Implications: Development of treatment strategies for high weight patients may help to reduce morbidity and cost of treatment . No outside funding source.
A MORTALITY MODEL FOR CRITICALLY ILL CANCER PATIENTS JeffreyS Groeger1 , D Nierman2 , K Price 3, M Crespo 1, D Horak4 , J Klar, S Lemeshow. Memorial Sloan-Kettering Cancer Center (MSKCC), 1275 York Avenue, New York, NY, USA Purpose: ICU outcome scoring systems have not been validated for patients wiili malignancies. vVe present a prospectively developed and validated outcome model for patients \villi cancer. Methods: Beginning July 1994, distinct continuous or categorical variables were collected on consecutive patients wiili cancer admitted to the ICU at MSKCC 1, City of Hope National Medical Center4 , Duarte, CA, Mount Sinai Medical Center", New York, NY, and MD Anderson Cancer Cente~, Houston, TX to develop a model for probability of hospital survival at ICU admission. Variables recorded were both cancer and critical illness related. A preliminary model was developed from 1483 patients and then validated on an additional230 patients. Multiple logistic regression modeling was used to develop ilie models and subsequently evaluated by Goodness-of-fit and ROC analysis. Results: The observed hospital mortality rate was 37.7%. Continuous variables used in the ICU admission model are Pa02/Fi02 ratio, platelet count, respiratory rate, systolic blood pressure and days of pre-ICU hospitalization. Categorical entries include presence of intracranial mass effect, allogeneic bone marrow transplantation, recurrent or progressive cancer, albumin <2.5 gldl, bilirubin ~2 mg!dl, Glasgow Coma Score <6, protime > 15 sec, BUN >50 mg!dl, intubation, performance status (ECOG) before hospitalization and CPR. The p-values for ilie fit of the preliminary and validation models are 0.939 and 0.314 respectively and ilie areas under the ROC curves .812 and .802. Conclusions: An ICU admission mortality model now exists for critically ill cancer patients. Clinical Implications: Cancer patient and oncologist alike can now be provided with an objective probability of a patients' prospects of hospital survival when admitted to an ICU. Additionally, we can stratifY patients for clinical research and can compare hospitals on the ratio of observed to expected deaths based on this model.
Developments in Cardiopulmonary Bypass Surgery-11 :00 am-12:30 pm RELATIONSHIP OF PREOPERATIVE VARIABLES TO PROLONGED MECHANICAL VENTILATION IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING William P Thomas, MD; W McD Anderson, MD; S Novitskv. MD; EK Grosmaire, 'VIS , RRT-JA Haley VA Hospital, Tampa, Florida, USA ' Purpose: Prolonged mechanical ventilation is associated with increased morbidity and mortality after coronary artery bypass grafting (CABG). Multiple clinical variables including pulmonary function tests (PFTS) are prospectively recorded on surgical patients as part of the VA Cardiac Surgery Risk Assessment Program (CSRAP) from this facility. We hypothesized that preoperative variables could predict prolonged post operative mechanical ventilation and intensive care unit (ICU) stay. Methods: A retrospective review of VA CSRAP procedures (418 patients) was conducted at this medical center from 10/9lto 08/95. Preoperative variables include: PFTs, sur1,>ical p1iority, ASA classification, number of CABG distal anastomoses with vein or inte rnal mammary artery, and past history of CABG, peripheral vascular disease (PVD), cerebral vascular disease (CVD ), diabetes mellitus, chronic obstructive pulmonary disease (COPD), angina, New York Heart Association (NYHA) classification for congestive heart failure (CHF), and preoperative use ofintravenous nitroglycerin (IV NTG), digoxin or intra-aortic balloon pump (IABP). Statistics were analyzed using the Epi Info program designed by the Center for Disease Control. Continuous variables were calculated with the Mantel Heanzel equation. Results: Preoperative Variables Preoperative Variables For ICU Stay >72 hours For Ventilator Stay >48 (P<0.05) hours (P<0.05) PVD CVD ASA Classiflcation ;;,:4 Emergent Surgical Priority FEVl % predicted <66%* *P<0.066
CVD IV NTG.48 hrs. pre-op ASA Classification ;;,:4 Emergent Surgical Priority Left Main Stenosis History of COPD NYHA function class ;;e:II FEVl % predicted <66% Conclusions: Multiple preoperative variables including FEVl are predictive of prolonged mechanical ventilation and prolonged ICU stay following CABG. Preoperative FEVl can predict individuals at high risk These indi,~duals have moderate to severe reduction in percent predicted FEVl ( <66%) . Clinical implications: FEVl is a useful variable for predicting postoperative complications in CABG patients.
85
THE EFFECT OF KPI-185 ADMINISTRATION ON POST-CARDIOPULMONARY BYPASS PULMONARY PATHOPHYSIOLOGY AND HEMOGLOBIN LOSS Alon Stamler, MD; Douglas E. Aguirre, MD; Alvin Franklin, MS; Mukesh Hariawala, MD; Robert G. Johnson, MD-Beth Israel Hospital, Harvard Medical School, Boston, MA Purpose: To examine the effect of ilie novel genetically engineered protein Kunitz protease inhibitor-185 (KPI-185) on ilie pulmonary derangements and hemoglobin loss associated \vith cardiopulmonary bypass (CPB). Methods: A Double blind study was performed. Anesthetized sheep (n=18), randomized to drug or placebo treatment, were subjected to 90 minutes of hypothermic CPB and 3 hours of closed chest monitoring postCPB. H emodynamic, lung lymph and oxygenation parameters were monitored during the experiment. Total blood and hemoglobin loss were measured. Results: Oxygenation: PaOz recovery after CPB was significantly better in ilie KPI group compared to control. The A-a 0 2 gradient and Qs/Qt fraction recovered more rapidly in ilie KPI group. Blood loss. Total blood (TBL) and total hemoglobin (THL) losses were significantly reduced in ilie KPI-185 treated animals compared to the placebo animals [TBL=214.4:'::22.7 ml vs 322.2:'::38.58 ml, respectively; p<0.05, and THL=4.65:'::0.65 mg % vs 13.05:'::3.22 mg%, respectively; p<0.05]. Conclusions: Treatment of animals wiili the recombinant serine protease inhibitor KPI-185 resulted in a significant decrease in total blood loss and marked decrease in hemoglobin loss. Additionally, KPI was associated with an improvement in parameters of oxygenation immediately after CPB. Clinical Implications: The role of protease inhibitors may extend beyond improved hemostasis to an improvement in pulmonary function post-CPB. Supported by Scios Nova Pharmaceuticals.
Abstracts of Original Investigations, CHEST 1996
ESTIMATING ICU COST SAVINGS: REDUCING LOW RISK-MONITORED ONLY (LRM) PATIENTS USING RISK ADJUSTED HOSPITAL OUTCOME DATA Mary Beth Coleman, RN , MBA; CA Sirio, MD; Derek Angus, MB ChB, MPH, N Pristas, RN , University of Pittsburgh, Pittsburgh, PA Purpose: Appropriate allocation of critical care resources is a focus of scrutiny as ICU care is estimated to comprise up to 30% of hospital cost. ICU utilization rates for patients at low risk of requiring active ICU intervention vary between 5.9% and 57% in the US. Thus, the need for active ICU care by LRM patients may be small but variable. We first assessed LRM rates across our institution and then developed an approach to quantitate potential savings in direct orerating costs by reducing LRM admissions to the ICU using risk adjusted predictions o the likelihood of ever r equiring active ICU therapy (one of 33 active TISS elements). Methods: APACHE III data was collected on a random sample of 1621 adult patients admitted to 8 ICUs (general medical [2] , surgical [2], cardiac, cardiothoracic [CT] , trauma [T], and neurologic) in a tertiary care hospital between F eb. and Oct. 1994. Risk predictions were calculated for several endpoints including the likelihood of requiring active ICU intervention at any point during an admission. LRM patients were defined as having a >10% predicted rate of requiring such intervention. Patient care cost was calculated using the average cost of nursing labor (cost x hours of care/pt day), and the direct cost of the average utilization of ancillary services (radiology and laboratory)/pt day for ICU and step-down. Cost savings were defined as the difference between the average direct cost per ICU day and step-down day. Results: 29% of patients admitted to ICUs were classified as LRM. The range of LRM was from 7% to 45.7%. All units except the CT and T ICUs had a LRM rate of >20%. Reduction of the LRM rate to 20% in all units would result in savings of $2.6 million in year one. Approximately 33% of the savings would be in direct labor, and 66% in ancillary services.
Conclusions: There is wide intra-institutional variation in the use of ICUs for LRM patients. Cost savings associated with decreasing the rate of ICU admission for LRM patients can be calculated and are large. Implications: The ability to link predicted risk adjusted rates ofLRM patients to cost savings can serve as the basis for developing strategies for decreasing the utilization of ICU resources. Facilities planning and staffing decisions may be facilitated by using volume estimates of LRM patients. Changes in admission location to less intensive units for LRM patients requires active triage and potentially a revision in ICU admission and discharge criteria, and should be linked to strategies to monitor risk adjusted outcomes for patients excluded from ICU care.
Critical Care Outcomes 11:00 am-12:30 pm THE EFFECT OF A FULL-TIME MEDICAL INTENSIVIST ON PATIENT CARE IN A COMMUNITY TEACHING HOSPITAL. Constantine A Manthous, Y amoateng-Adjepong, B. Jacob, W Chatila, H Alnuaimat, JB Hall*. Bridgeport Hospital, Yale University and University of Chicago.* Few studies have quantified the effects of adding intensivists to direct hospital intensive care units (ICUs). Methods: We retrospectively reviewed outcomes of all patients admitted to an 8-bed medical ICU in a 270-bed community, teaching hospital before (BD) and after (AD) adding a full-time medical intensivist to direct the ICU. Results: 514 BD patients were compared to 576 AD patients. APACHE II scores were significantly higher in the AD (17.3::'::0.5) compared to the BD period (12.5::'::0.5, p<0.01). Monthly in-hospital mortalities decreased from 31.1::'::10.0% BD to 23.4::'::6.9% AD (p<0.01), while in-ICU mortalities decreased from 16.7::'::5.6% BD to 10.9::'::5.4% AD (p<0.01). This 25% reduction in case mortality rate from all causes was similar across categories of disease. A more detailed analysis of a representative sample of homogeneous patients, those admitted with pneumonia, demonstrated that groups were similar with regard to age, sex, acuity of illness, point of origin and need for mechanical ventilation. Mortality from pneumonia was reduced to 32% AD as compared to 48% BD and was consistent across ranges of APACHE II, age and point of origin. ICU length of stay was reduced from 5.7::'::2.0 BD to 4.8::'::1.5 days AD (p<0.05). Eaucational outcomes, as measured by performance on a 40-question examination, improved significantly in all groups of trainees. Conclusions: We conclude that addition of a medical intensivist to a teaching community hospital improved patient outcomes, reduced ICU length of stay and improved housestaff education.
OBESITY AND TRAUMA PATIENT OUTCOME Alex Desouza MD, A Chendrasekhar MD, GA Timberlake MD-West Virginia University, Morgantown, WV, USA Purpose: The effect of obesity on the severely injured trauma patient has not been described in detail. We hypothesize that obesity adversely effects trauma patients with respect to its various outcome parameters such as intensive care unit (ICU) length of stay, ventilator days, frequency of complications, hospital length of stay, and survival. Methods: A retrospective chart review of 100 consecutive severely traumatized adults was performed (ISS>20). Charts were reviewed for demographic data (age, gender, and associated medical problems), Body mass index (BMI), and outcome data (ICU length of stay, ventilator days, frequency of complications, hospital length of stay and survival). Associated medical problems were limited to coronary artery disease, hypertension and diabetes. Complications were defmed as nosocomial infection or deep venous thrombosis. Obesity was defined as BMI >30 kgtcm2, overweight was defined as 302:BMI2:25 kg'cm2, and normal range was defined as BMI <25 kg'cm2. Statistical analysis was performed using one way analysis of variance with repeated measures comparing normal patients' data to obese and overweight patients. Results: Normal (n=37) ICU days 2.1 ± 1.2 Vent days 1.2±0.5 Comp freq 26.7% H-los (days) 9.3± 1.5 *p<0.05, Mean values±SEM.
Overweight (n=35) 7.8±1.7* 5.8±1.4* 66.7% * 19.8±3.3*
Obese (n=28) 12.7±2.1* 12.1±2.7* 90.9%* 26.3±4.5*
Demographic data (age, gender, and associated medical problems) were not statistically different between the 3groups. Survival was not statistically different between the 3 groups. Conclusions: Obesity adversely effects ICU days, ventilator days, complication frequency, and hospital length of stay in severely injured trauma patients. Survival however is not effected. Clinical Implications: Obesity is an independent risk factor in trauma patients.
CHEST I 110 I 4 I OCTOBER, 1996 SUPPLEMENT
7S
Monday, October 28, 1996 Critical Care Outcomes, continued THE IMPACT OF WEIGHT ON ICU COST IN PATIENTS WITH UNEXPLAINED HYPOTENSION Paul A. H eidenreich, E Foster, NH Cohen, Stanford University, Stanford, CA and University of California, San Francisco, CA, USA Purpose: 1) To determine the intensive care unit (ICU) costs for treatment of patients admitted with unexplained hypotension. 2) To determine patient related predictors of ICU cost. Methods: We examined ICU charges, length of stay and mortality for 69 consecutive patients admitted to the ICU with unexplained hypotension. Patient related variables upon admission were evaluated to dete rmine association with ICU charges. ·weight was considered elevated for women >80kg and for rnen >85kg (N=25). Results: The 69 patients had a mean age of 58:': 18 years and 55% were male. The mean ICU charge for the entire group was $31,800:'::59,900. The only patient related variable directly associated with ICU charge was increased weight ($16,000:'::15,000 for low to normal weight, vs. $46,000:'::68,000 for increased weight, P<0.01 ). Increased weight was associated witl1 both a longer length of stay (14:'::22 vs. 6:':: 5 days P=0.03) and a higher ICU charge/day ($3,700:'::1 ,300 vs. $2900:'::1100, P=0.02). The survival rate for patients with increased weight (40%) was equal to survival for lower weight patients (40%, P>0.9). APACHE II scores were also similar (21 for boili weight groups). Patients wiili increased weight had a higher creatinine level (2.9:'::2.0 mgldl vs. 1.6:'::1.1, P<0.01 ) and were more likely to have liver disease (20% vs. 5%, P=0.06). However, when patients with hepatic and renal disease were excluded, increased weight remained a significant predictor of ICU charges. Neiilier etiology of hypotension nor admitting diagnosis were predictive of ICU charges. After controlling for potential confounding variables with multivariate analysis weight remained the only variable significantly associated with ICU charge (P <0. 05). Conclusions: Increased weight on admission was the only patient variable associated 'vith a longer length of stay and greater ICU costs per day. Clinical Implications: Development of treatment strategies for high weight patients may help to reduce morbidity and cost of treatment . No outside funding source.
A MORTALITY MODEL FOR CRITICALLY ILL CANCER PATIENTS JeffreyS Groeger1 , D Nierman2 , K Price 3, M Crespo 1, D Horak4 , J Klar, S Lemeshow. Memorial Sloan-Kettering Cancer Center (MSKCC), 1275 York Avenue, New York, NY, USA Purpose: ICU outcome scoring systems have not been validated for patients wiili malignancies. vVe present a prospectively developed and validated outcome model for patients \villi cancer. Methods: Beginning July 1994, distinct continuous or categorical variables were collected on consecutive patients wiili cancer admitted to the ICU at MSKCC 1, City of Hope National Medical Center4 , Duarte, CA, Mount Sinai Medical Center", New York, NY, and MD Anderson Cancer Cente~, Houston, TX to develop a model for probability of hospital survival at ICU admission. Variables recorded were both cancer and critical illness related. A preliminary model was developed from 1483 patients and then validated on an additional230 patients. Multiple logistic regression modeling was used to develop ilie models and subsequently evaluated by Goodness-of-fit and ROC analysis. Results: The observed hospital mortality rate was 37.7%. Continuous variables used in the ICU admission model are Pa02/Fi02 ratio, platelet count, respiratory rate, systolic blood pressure and days of pre-ICU hospitalization. Categorical entries include presence of intracranial mass effect, allogeneic bone marrow transplantation, recurrent or progressive cancer, albumin <2.5 gldl, bilirubin ~2 mg!dl, Glasgow Coma Score <6, protime > 15 sec, BUN >50 mg!dl, intubation, performance status (ECOG) before hospitalization and CPR. The p-values for ilie fit of the preliminary and validation models are 0.939 and 0.314 respectively and ilie areas under the ROC curves .812 and .802. Conclusions: An ICU admission mortality model now exists for critically ill cancer patients. Clinical Implications: Cancer patient and oncologist alike can now be provided with an objective probability of a patients' prospects of hospital survival when admitted to an ICU. Additionally, we can stratifY patients for clinical research and can compare hospitals on the ratio of observed to expected deaths based on this model.
Developments in Cardiopulmonary Bypass Surgery-11 :00 am-12:30 pm RELATIONSHIP OF PREOPERATIVE VARIABLES TO PROLONGED MECHANICAL VENTILATION IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING William P Thomas, MD; W McD Anderson, MD; S Novitskv. MD; EK Grosmaire, 'VIS , RRT-JA Haley VA Hospital, Tampa, Florida, USA ' Purpose: Prolonged mechanical ventilation is associated with increased morbidity and mortality after coronary artery bypass grafting (CABG). Multiple clinical variables including pulmonary function tests (PFTS) are prospectively recorded on surgical patients as part of the VA Cardiac Surgery Risk Assessment Program (CSRAP) from this facility. We hypothesized that preoperative variables could predict prolonged post operative mechanical ventilation and intensive care unit (ICU) stay. Methods: A retrospective review of VA CSRAP procedures (418 patients) was conducted at this medical center from 10/9lto 08/95. Preoperative variables include: PFTs, sur1,>ical p1iority, ASA classification, number of CABG distal anastomoses with vein or inte rnal mammary artery, and past history of CABG, peripheral vascular disease (PVD), cerebral vascular disease (CVD ), diabetes mellitus, chronic obstructive pulmonary disease (COPD), angina, New York Heart Association (NYHA) classification for congestive heart failure (CHF), and preoperative use ofintravenous nitroglycerin (IV NTG), digoxin or intra-aortic balloon pump (IABP). Statistics were analyzed using the Epi Info program designed by the Center for Disease Control. Continuous variables were calculated with the Mantel Heanzel equation. Results: Preoperative Variables Preoperative Variables For ICU Stay >72 hours For Ventilator Stay >48 (P<0.05) hours (P<0.05) PVD CVD ASA Classiflcation ;;,:4 Emergent Surgical Priority FEVl % predicted <66%* *P<0.066
CVD IV NTG.48 hrs. pre-op ASA Classification ;;,:4 Emergent Surgical Priority Left Main Stenosis History of COPD NYHA function class ;;e:II FEVl % predicted <66% Conclusions: Multiple preoperative variables including FEVl are predictive of prolonged mechanical ventilation and prolonged ICU stay following CABG. Preoperative FEVl can predict individuals at high risk These indi,~duals have moderate to severe reduction in percent predicted FEVl ( <66%) . Clinical implications: FEVl is a useful variable for predicting postoperative complications in CABG patients.
85
THE EFFECT OF KPI-185 ADMINISTRATION ON POST-CARDIOPULMONARY BYPASS PULMONARY PATHOPHYSIOLOGY AND HEMOGLOBIN LOSS Alon Stamler, MD; Douglas E. Aguirre, MD; Alvin Franklin, MS; Mukesh Hariawala, MD; Robert G. Johnson, MD-Beth Israel Hospital, Harvard Medical School, Boston, MA Purpose: To examine the effect of ilie novel genetically engineered protein Kunitz protease inhibitor-185 (KPI-185) on ilie pulmonary derangements and hemoglobin loss associated \vith cardiopulmonary bypass (CPB). Methods: A Double blind study was performed. Anesthetized sheep (n=18), randomized to drug or placebo treatment, were subjected to 90 minutes of hypothermic CPB and 3 hours of closed chest monitoring postCPB. H emodynamic, lung lymph and oxygenation parameters were monitored during the experiment. Total blood and hemoglobin loss were measured. Results: Oxygenation: PaOz recovery after CPB was significantly better in ilie KPI group compared to control. The A-a 0 2 gradient and Qs/Qt fraction recovered more rapidly in ilie KPI group. Blood loss. Total blood (TBL) and total hemoglobin (THL) losses were significantly reduced in ilie KPI-185 treated animals compared to the placebo animals [TBL=214.4:'::22.7 ml vs 322.2:'::38.58 ml, respectively; p<0.05, and THL=4.65:'::0.65 mg % vs 13.05:'::3.22 mg%, respectively; p<0.05]. Conclusions: Treatment of animals wiili the recombinant serine protease inhibitor KPI-185 resulted in a significant decrease in total blood loss and marked decrease in hemoglobin loss. Additionally, KPI was associated with an improvement in parameters of oxygenation immediately after CPB. Clinical Implications: The role of protease inhibitors may extend beyond improved hemostasis to an improvement in pulmonary function post-CPB. Supported by Scios Nova Pharmaceuticals.
Abstracts of Original Investigations, CHEST 1996