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Predictors of glyaemic variability in the intensive care unit
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PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
and 2.7 (1.5, 5.7) days for sitting. In-hospital mortality was 14.3% (n=491) for patients who did not participate in exercise interventions, compared to 2.6% (n=89) for patients who exercised whilst in ICU. http://dx.doi.org/10.1016/j.aucc.2017.02.029 Treatment effect of recombinant human soluble thrombomodulin (RTM) alone on septic disseminated intravascular coagulation (DIC) Naotsugu Ohashi ∗ , Kenta Takeda, Aisa Matoi, Takeshi Ide, Naoto Hori, Hanako Kohama, Shinichi Nishi Intensive Care Unit, Hyogo College Of Medicine, Nishinomiya, Japan Introduction Septic disseminated intravascular coagulation (DIC) causes multiple organ dysfunction syndromes and must be controlled with the care of the original illness. In Japan, recombinant human soluble thrombomodulin (rTM) has been produced as a replacement for active protein C since 2008. Objectives To investigate the efficasy and safety of rTM alone without other anticoagulants administration for septic DIC. Methods A retrospective study of 14 septic DIC patients in our ICU from August 2010 to May 2016 was performed. These patients were treated only with rTM for septic DIC. Samples were collected on “day 0” when rTM was administrated and on “day 7”, which was 7 days after rTM administration, or the day of ICU discharge The following parameters were recorded: Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score,Japanese Association for Acute Medicine-defined(JAAM) DIC score, SIRS score, platelet count, prothrombin time ratio, D-dimer, AT activity, side effect of bleeding, and mortality after 28 days. Results The measured mortality rate after 28 days (7.1%) was lower than the predicted mortality rate (47.4%) based on the APACHE II score. The study group showed significantly improvement JAAM-DIC score, prothrombin time ratio, D-dimer at “day7” than “day0” (p<0.05). Conclusion The rTM administration without another DIC drug rather be a safe and effective medical intervention for septic DIC. http://dx.doi.org/10.1016/j.aucc.2017.02.030
The incidence, characteristics and outcomes of pneumothorax in Thai surgical intensive care units (Thai-SICU) study Sujaree Poopipatpab a , Konlawij Trongtrakul b,∗ , Chompunoot Pathonsamit a,∗ , Siriporn Siraklow a , Kaweesak Chittawatanarat c , Thai-SICU study group a
Anaesthesiology, Faculty of Medicine Vajira Hospital, Navamindradhiraj Univeristy b Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok c surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Introduction Pneumothorax, one of the most serious pleural diseases complication in intensive care unit (ICU), is limited report in surgical critically ill patients. Study Objectives To identify incidence, characteristics, and outcomes of pneumothorax among patients who specifically stayed in surgical ICU. Methods This was a multicenter prospective cohort study conducted in 9 University-affiliated SICUs in Thailand. Incidence of pneumothorax and its outcomes were evaluated from June 2010 to March 2011. Result A total of 4,652 patients who were admitted to SICU were enrolled. The incidence of pneumothorax was 0.5% (25 cases) in our study. Significant characteristics were found in the pneumothorax group, including: lower BMI, underlying malignancy and COPD, higher APACHE-II and SOFA score within 24 hours of first ICU admission, pulmonary infiltration pattern of chest imaging and usage of mechanical ventilation. In terms of outcome, there were higher SICU mortality and 28-day hospital mortality in pneumothorax than non-pneumothorax patients at 28% vs 10%, p = 0.002 and at 44% vs 14%, p<0.001, respectively. Conclusions From Thai-SICUs Study, patients admitted to surgical intensive care units who developed pneumothorax had higher risk of intensive care unit mortality and 28-day hospital mortality than non-pneumothorax patients. http://dx.doi.org/10.1016/j.aucc.2017.02.031 Predictors of glyaemic variability in the intensive care unit Anurag Saxena b,∗ , John Moran a a b
ICU, The Queen Elizabeth Hospital, Adelaide Lyell Mcewin Hospital, South Australia
Glycaemic variability is an independent risk factor for adverse outcomes in intensive care (ICU). Little is known about predictors of glycaemic variability in ICU patients. This knowledge may improve management of blood glucose in ICU setting. The objective of the study was to identify the predictors of glucose variability in ICU patients. This was a retrospective cohort study conducted in Flinders Medical Centre (FMC) Adelaide, a tertiary level mixed ICU, from June 2014 till June 2015. We collected blood glucose readings of 60 patients during early (first 48 hours in ICU) and late (last 24 hours in ICU) period and calculated mean blood glucose level, standard deviation and coefficient of variation (COV = SD/Mean). Association of possible predictors including age, gender, systemic steroid prescription, insulin prescription, enteral feeding, preexisting dia-
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
betes mellitus, need to mechanically ventilate and severity of illness measured as SOFA score with COV was studied using a random effects linear model (early period) and multivariable linear regression model (late period). Systemic steroids, enteral feeding and insulin therapy did not predict COV. Severity of disease, presence of diabetes and mechanical ventilation had a significant relationship with COV in the early and late period. Age effect was seen only in late period. We concluded that glucose variability could be usefully predicted by the presence of some common clinical variable and interventions: age, presence of diabetes, need to mechanically ventilate and SOFA score. Studies with larger sample size are needed to confirm these findings. It may be more accurate to study variability and its predictors with continuous glucose monitoring in future research. http://dx.doi.org/10.1016/j.aucc.2017.02.032 A statistical approach for evaluating risk-adjusted disparities in length of stay in Australian and New Zealand ICUs Lahn Straney a,∗ , Aidan Burrell a,b , Andrew Udy a,b,c , David Pilcher a,b,c a
Monash University Alfred Hospital c Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society (ANZICS), Melbourne, Australia b
The relevance of length of stay (LOS) as a measure of performance in the ICU is two-fold. First, it relates to the efficiency of the intensive care process, and thus costs within the ICU and the institution overall. Second, it may serve as an indirect marker of the quality of care; more effective therapy results in more rapid recovery while complications and errors potentially result in extended LOS. There are limited methods available for evaluating disparities in risk-adjusted ICU LOS. We extracted de-identified data from the ANZICS Adult Patient Database for admissions January 1 2011 to December 31 2015. We used a mixed-effects log-normal regression model to predict LOS using patient and admission characteristics. We calculated a resource use index (RUi) by dividing the geometric mean observed LOS by the exponent of the expected Ln-LOS for each site and year. The RUi is scaled such that values less than one indicate a LOS that is shorter than expected, while values greater than one indicate a LOS which is longer than expected. Secondary mixed effects regression modelling was used to assess the stability of the estimate in units over time. During the study period there were a total of 660,724 admissions to 168 units (median annual admissions=767, IQR:426-1121). The mean observed LOS was 3.21 days over the entire period, and declined on average 1.97 hours per year (95%CI:1.76-2.18). The RUi varied considerably between units, ranging from 0.35 to 2.34 indicating large differences in discharge practice after accounting for case-mix. Secondary modelling indicated that 92% of the RUi variance was explained by unit level differences and differences in linear trends; indicating that the index provided a stable estimate of performance over time. There are large disparities in risk-adjusted LOS among Australian and New Zealand ICUs which may reflect differences in resource utilization. http://dx.doi.org/10.1016/j.aucc.2017.02.033
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A national survey of intensive care senior physiotherapists regarding respiratory management of intubated adults with community acquired pneumonia Lisa van der Lee a,b,∗ , Anne-Marie Hill c , Shane Patman a a
School of Physiotherapy, The University of Notre Dame Australia b Allied Health, Fiona Stanley Hospital c School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia Introduction Clinical physiotherapy practice is anecdotally variable for critically patients with severe community acquired pneumonia, who commonly present to ICU for intubation and mechanical ventilation. Limited evidence exists to guide clinicians regarding respiratory intervention in this patient cohort. Study objectives To explore current physiotherapy practice for intubated adult patients with community acquired pneumonia in intensive care units within Australia. Methods A cross-sectional, mixed methods survey was conducted. Senior intensive care physiotherapists, with a minimum of one year experience in the position, were recruited from 72 Australian public and private hospitals. An online questionnaire was developed and piloted to explore current clinical practice and clinical reasoning. The domains were structured based on common aspects of physiotherapy assessment, rationale and intervention options for intubated and mechanically ventilated patients. Quantitative data were collected using categorical and Likert scales and qualitative data were collected using open ended responses. Results There were 75 respondents (72% response rate). Respondents’ main rationale for intervention were improved airway clearance (98%), alveolar recruitment (75%) and gas exchange (32%). Intervention included positioning alternate side lying (81%) or affected lung uppermost (83%), vibrations (53%), hyperinflation techniques (60%), and suction (92%). Vibrations were used when sputum is excessive (20%). Manual hyperinflation was chosen for high sputum load (30%) due to specific aspects of the technique (21%). Ventilator hyperinflation was chosen if there were concerns about ventilator disconnection (30%), such as loss of high positive end expiratory pressure (64%) or risk of airborne pathogen transmission (18%). Conclusion Senior physiotherapists rationalise that a significant physiotherapy role exists during the intubated period for community acquired pneumonia. http://dx.doi.org/10.1016/j.aucc.2017.02.034
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
and 2.7 (1.5, 5.7) days for sitting. In-hospital mortality was 14.3% (n=491) for patients who did not participate in exercise interventions, compared to 2.6% (n=89) for patients who exercised whilst in ICU. http://dx.doi.org/10.1016/j.aucc.2017.02.029 Treatment effect of recombinant human soluble thrombomodulin (RTM) alone on septic disseminated intravascular coagulation (DIC) Naotsugu Ohashi ∗ , Kenta Takeda, Aisa Matoi, Takeshi Ide, Naoto Hori, Hanako Kohama, Shinichi Nishi Intensive Care Unit, Hyogo College Of Medicine, Nishinomiya, Japan Introduction Septic disseminated intravascular coagulation (DIC) causes multiple organ dysfunction syndromes and must be controlled with the care of the original illness. In Japan, recombinant human soluble thrombomodulin (rTM) has been produced as a replacement for active protein C since 2008. Objectives To investigate the efficasy and safety of rTM alone without other anticoagulants administration for septic DIC. Methods A retrospective study of 14 septic DIC patients in our ICU from August 2010 to May 2016 was performed. These patients were treated only with rTM for septic DIC. Samples were collected on “day 0” when rTM was administrated and on “day 7”, which was 7 days after rTM administration, or the day of ICU discharge The following parameters were recorded: Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score,Japanese Association for Acute Medicine-defined(JAAM) DIC score, SIRS score, platelet count, prothrombin time ratio, D-dimer, AT activity, side effect of bleeding, and mortality after 28 days. Results The measured mortality rate after 28 days (7.1%) was lower than the predicted mortality rate (47.4%) based on the APACHE II score. The study group showed significantly improvement JAAM-DIC score, prothrombin time ratio, D-dimer at “day7” than “day0” (p<0.05). Conclusion The rTM administration without another DIC drug rather be a safe and effective medical intervention for septic DIC. http://dx.doi.org/10.1016/j.aucc.2017.02.030
The incidence, characteristics and outcomes of pneumothorax in Thai surgical intensive care units (Thai-SICU) study Sujaree Poopipatpab a , Konlawij Trongtrakul b,∗ , Chompunoot Pathonsamit a,∗ , Siriporn Siraklow a , Kaweesak Chittawatanarat c , Thai-SICU study group a
Anaesthesiology, Faculty of Medicine Vajira Hospital, Navamindradhiraj Univeristy b Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok c surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Introduction Pneumothorax, one of the most serious pleural diseases complication in intensive care unit (ICU), is limited report in surgical critically ill patients. Study Objectives To identify incidence, characteristics, and outcomes of pneumothorax among patients who specifically stayed in surgical ICU. Methods This was a multicenter prospective cohort study conducted in 9 University-affiliated SICUs in Thailand. Incidence of pneumothorax and its outcomes were evaluated from June 2010 to March 2011. Result A total of 4,652 patients who were admitted to SICU were enrolled. The incidence of pneumothorax was 0.5% (25 cases) in our study. Significant characteristics were found in the pneumothorax group, including: lower BMI, underlying malignancy and COPD, higher APACHE-II and SOFA score within 24 hours of first ICU admission, pulmonary infiltration pattern of chest imaging and usage of mechanical ventilation. In terms of outcome, there were higher SICU mortality and 28-day hospital mortality in pneumothorax than non-pneumothorax patients at 28% vs 10%, p = 0.002 and at 44% vs 14%, p<0.001, respectively. Conclusions From Thai-SICUs Study, patients admitted to surgical intensive care units who developed pneumothorax had higher risk of intensive care unit mortality and 28-day hospital mortality than non-pneumothorax patients. http://dx.doi.org/10.1016/j.aucc.2017.02.031 Predictors of glyaemic variability in the intensive care unit Anurag Saxena b,∗ , John Moran a a b
ICU, The Queen Elizabeth Hospital, Adelaide Lyell Mcewin Hospital, South Australia
Glycaemic variability is an independent risk factor for adverse outcomes in intensive care (ICU). Little is known about predictors of glycaemic variability in ICU patients. This knowledge may improve management of blood glucose in ICU setting. The objective of the study was to identify the predictors of glucose variability in ICU patients. This was a retrospective cohort study conducted in Flinders Medical Centre (FMC) Adelaide, a tertiary level mixed ICU, from June 2014 till June 2015. We collected blood glucose readings of 60 patients during early (first 48 hours in ICU) and late (last 24 hours in ICU) period and calculated mean blood glucose level, standard deviation and coefficient of variation (COV = SD/Mean). Association of possible predictors including age, gender, systemic steroid prescription, insulin prescription, enteral feeding, preexisting dia-
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
betes mellitus, need to mechanically ventilate and severity of illness measured as SOFA score with COV was studied using a random effects linear model (early period) and multivariable linear regression model (late period). Systemic steroids, enteral feeding and insulin therapy did not predict COV. Severity of disease, presence of diabetes and mechanical ventilation had a significant relationship with COV in the early and late period. Age effect was seen only in late period. We concluded that glucose variability could be usefully predicted by the presence of some common clinical variable and interventions: age, presence of diabetes, need to mechanically ventilate and SOFA score. Studies with larger sample size are needed to confirm these findings. It may be more accurate to study variability and its predictors with continuous glucose monitoring in future research. http://dx.doi.org/10.1016/j.aucc.2017.02.032 A statistical approach for evaluating risk-adjusted disparities in length of stay in Australian and New Zealand ICUs Lahn Straney a,∗ , Aidan Burrell a,b , Andrew Udy a,b,c , David Pilcher a,b,c a
Monash University Alfred Hospital c Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society (ANZICS), Melbourne, Australia b
The relevance of length of stay (LOS) as a measure of performance in the ICU is two-fold. First, it relates to the efficiency of the intensive care process, and thus costs within the ICU and the institution overall. Second, it may serve as an indirect marker of the quality of care; more effective therapy results in more rapid recovery while complications and errors potentially result in extended LOS. There are limited methods available for evaluating disparities in risk-adjusted ICU LOS. We extracted de-identified data from the ANZICS Adult Patient Database for admissions January 1 2011 to December 31 2015. We used a mixed-effects log-normal regression model to predict LOS using patient and admission characteristics. We calculated a resource use index (RUi) by dividing the geometric mean observed LOS by the exponent of the expected Ln-LOS for each site and year. The RUi is scaled such that values less than one indicate a LOS that is shorter than expected, while values greater than one indicate a LOS which is longer than expected. Secondary mixed effects regression modelling was used to assess the stability of the estimate in units over time. During the study period there were a total of 660,724 admissions to 168 units (median annual admissions=767, IQR:426-1121). The mean observed LOS was 3.21 days over the entire period, and declined on average 1.97 hours per year (95%CI:1.76-2.18). The RUi varied considerably between units, ranging from 0.35 to 2.34 indicating large differences in discharge practice after accounting for case-mix. Secondary modelling indicated that 92% of the RUi variance was explained by unit level differences and differences in linear trends; indicating that the index provided a stable estimate of performance over time. There are large disparities in risk-adjusted LOS among Australian and New Zealand ICUs which may reflect differences in resource utilization. http://dx.doi.org/10.1016/j.aucc.2017.02.033
121
A national survey of intensive care senior physiotherapists regarding respiratory management of intubated adults with community acquired pneumonia Lisa van der Lee a,b,∗ , Anne-Marie Hill c , Shane Patman a a
School of Physiotherapy, The University of Notre Dame Australia b Allied Health, Fiona Stanley Hospital c School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia Introduction Clinical physiotherapy practice is anecdotally variable for critically patients with severe community acquired pneumonia, who commonly present to ICU for intubation and mechanical ventilation. Limited evidence exists to guide clinicians regarding respiratory intervention in this patient cohort. Study objectives To explore current physiotherapy practice for intubated adult patients with community acquired pneumonia in intensive care units within Australia. Methods A cross-sectional, mixed methods survey was conducted. Senior intensive care physiotherapists, with a minimum of one year experience in the position, were recruited from 72 Australian public and private hospitals. An online questionnaire was developed and piloted to explore current clinical practice and clinical reasoning. The domains were structured based on common aspects of physiotherapy assessment, rationale and intervention options for intubated and mechanically ventilated patients. Quantitative data were collected using categorical and Likert scales and qualitative data were collected using open ended responses. Results There were 75 respondents (72% response rate). Respondents’ main rationale for intervention were improved airway clearance (98%), alveolar recruitment (75%) and gas exchange (32%). Intervention included positioning alternate side lying (81%) or affected lung uppermost (83%), vibrations (53%), hyperinflation techniques (60%), and suction (92%). Vibrations were used when sputum is excessive (20%). Manual hyperinflation was chosen for high sputum load (30%) due to specific aspects of the technique (21%). Ventilator hyperinflation was chosen if there were concerns about ventilator disconnection (30%), such as loss of high positive end expiratory pressure (64%) or risk of airborne pathogen transmission (18%). Conclusion Senior physiotherapists rationalise that a significant physiotherapy role exists during the intubated period for community acquired pneumonia. http://dx.doi.org/10.1016/j.aucc.2017.02.034