Seminars in Cardiothoracic and Vascular Anesthesia, May 29, 2014
The key determinants of organ perfusion are (a) generation of a blood pressure within the range t... more The key determinants of organ perfusion are (a) generation of a blood pressure within the range that allows end-organs to maintain constant blood flow and (b) delivery of oxygen at values exceeding the current rate of consumption. Deliberate evaluation of these physiologic relationships throughout cardiac surgery and postoperatively can be used to define an individual’s risk for organ dysfunction and to establish end points of resuscitation. A consistent focus on these parameters is relevant to all patient conditions regardless of whether the patient is in or out of the operating room, or whether receiving extracorporeal support. While the focus of this issue of SCVA is on cardiopulmonary bypass, optimizing oxygen delivery is relevant to all high-risk operative patients and their postoperative care. The reader will note that some of the monitoring modalities are more appropriate for use in the operating room than intensive care unit, and vice versa. Matching key patient problems to the different performance characteristics and anatomical constraints of each monitoring modality demands a focused yet flexible mindset.
www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives... more www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: We conducted a retrospective study of admissions to a mixed med/surg ICU and hypothesized that being admitted to a ward bed and subsequently transferred to the ICU within 24hrs increased mortality compared to direct ICU admits. We looked at other admission characteristics including cardiac arrest, sepsis, RRT call, readmission and age. Methods: Generated data on ICU admissions and patients admitted to the ICU after admitted to regular wards (< 24h) were analyzed over a five year period from 2008 to 2013. Additional data for code and RRT calls, sepsis and mortality were used to compare outcomes. Pre-established outcomes were mortality at 30days, one year, and ICU and post ICU length of stay. Mortality significance was determined using contingency tables. Age stratification and a multivariable analysis were performed to analyze variables with a significant effect on mortality and ICU length of stay. Septic patients were analyzed separately. Results: 3860 ICU patients analyzed, 420 admitted from units where they stayed less than 24 hrs; they did not have worse survival than other ICU patients. Surgical patients had increased 1 year mortality with < 24h status, admitted at night, if had a rapid response, or cardiac arrest prior to ICU admission. Medical patients had increased mortality if they had a cardiac arrest but no higher mortality rates were seen with < 24h status, emergency call, weekend/night admission, or sepsis. Age stratification with patients with 24h events increased mortality with increased age. Multivariable analysis showed < 24h status did not impact 1yr mortality or ICU length of stay. ICU readmission, age, prior emergency call, and cardiac arrest were significant predictors of mortality. Similar risks were found present in septic patients. Conclusions: 24-hour admit status did not increase mortality. ICU readmissions are associated with worst outcomes. While sepsis alone was not a strong predictor of mortality, being older, a medical patient and being readmitted are all predictors of poor outcomes for septic patients.
Seminars in Cardiothoracic and Vascular Anesthesia, May 29, 2014
The key determinants of organ perfusion are (a) generation of a blood pressure within the range t... more The key determinants of organ perfusion are (a) generation of a blood pressure within the range that allows end-organs to maintain constant blood flow and (b) delivery of oxygen at values exceeding the current rate of consumption. Deliberate evaluation of these physiologic relationships throughout cardiac surgery and postoperatively can be used to define an individual’s risk for organ dysfunction and to establish end points of resuscitation. A consistent focus on these parameters is relevant to all patient conditions regardless of whether the patient is in or out of the operating room, or whether receiving extracorporeal support. While the focus of this issue of SCVA is on cardiopulmonary bypass, optimizing oxygen delivery is relevant to all high-risk operative patients and their postoperative care. The reader will note that some of the monitoring modalities are more appropriate for use in the operating room than intensive care unit, and vice versa. Matching key patient problems to the different performance characteristics and anatomical constraints of each monitoring modality demands a focused yet flexible mindset.
www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives... more www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: We conducted a retrospective study of admissions to a mixed med/surg ICU and hypothesized that being admitted to a ward bed and subsequently transferred to the ICU within 24hrs increased mortality compared to direct ICU admits. We looked at other admission characteristics including cardiac arrest, sepsis, RRT call, readmission and age. Methods: Generated data on ICU admissions and patients admitted to the ICU after admitted to regular wards (< 24h) were analyzed over a five year period from 2008 to 2013. Additional data for code and RRT calls, sepsis and mortality were used to compare outcomes. Pre-established outcomes were mortality at 30days, one year, and ICU and post ICU length of stay. Mortality significance was determined using contingency tables. Age stratification and a multivariable analysis were performed to analyze variables with a significant effect on mortality and ICU length of stay. Septic patients were analyzed separately. Results: 3860 ICU patients analyzed, 420 admitted from units where they stayed less than 24 hrs; they did not have worse survival than other ICU patients. Surgical patients had increased 1 year mortality with < 24h status, admitted at night, if had a rapid response, or cardiac arrest prior to ICU admission. Medical patients had increased mortality if they had a cardiac arrest but no higher mortality rates were seen with < 24h status, emergency call, weekend/night admission, or sepsis. Age stratification with patients with 24h events increased mortality with increased age. Multivariable analysis showed < 24h status did not impact 1yr mortality or ICU length of stay. ICU readmission, age, prior emergency call, and cardiac arrest were significant predictors of mortality. Similar risks were found present in septic patients. Conclusions: 24-hour admit status did not increase mortality. ICU readmissions are associated with worst outcomes. While sepsis alone was not a strong predictor of mortality, being older, a medical patient and being readmitted are all predictors of poor outcomes for septic patients.
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