Modifiable Risk Factors for Delirium in Critically Ill Trauma Patients: A Multicenter Prospective Study (Kolli)

Duceppe MA, Williamson DR, Elliott A, Para M, Poirier MC, Delisle MS, Deckelbaum D, Razek T, Desjardins M, Bertrand JC, Bernard F, Rico P, Burry L, Frenette AJ, Perreault M. Modifiable Risk Factors for Delirium in Critically Ill Trauma Patients: A Multicenter Prospective Study. J Intensive Care Med. 2019 Apr;34(4):330-336. PMID: 28335673.

OBJECTIVE: Intensive care unit (ICU)-acquired delirium has been associated with increased morbidity and mortality. Prevention strategies including modification of delirium risk factors are emphasized by practice guidelines. No study has specifically evaluated modifiable delirium risk factors in trauma ICU patients. Our goal was to evaluate modifiable risk factors for delirium among trauma patients admitted to the ICU.

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Analysis of Unplanned Intensive Care Unit Admissions in Postoperative Pediatric Patients. (Sirignano)

Landry EK, et al. Analysis of Unplanned Intensive Care Unit Admissions in Postoperative Pediatric Patients. J Intensive Care Med. 2016 Aug 15. [Epub ahead of print]

BACKGROUND: Currently, there are only a few retrospective, single-institution studies that have addressed the prevalence and risk factors associated with unplanned admissions to the pediatric intensive care unit (ICU) after surgery. Based on the limited amount of studies, it appears that airway and respiratory complications put a child at increased risk for unplanned ICU admission. A more extensive and diverse analysis of unplanned postoperative admissions to the ICU is needed to address risk factors that have yet to be revealed by the current literature.

AIM: To establish a rate of unplanned postoperative ICU admissions in pediatric patients using a large, multi-institution data set and to further characterize the associated risk factors.

METHODS: Data from the National Anesthesia Clinical Outcomes Registry were analyzed. We recorded the overall risk of unplanned postoperative ICU admission in patients younger than 18 years and performed univariate and multivariate logistic regression analysis to identify the associated patient, surgical, and anesthetic-related characteristics.

RESULTS: Of the 324 818 cases analyzed, 211 reported an unexpected ICU admission. There was an increased likelihood of unplanned postoperative ICU in infants (age <1 year) and children who were classified as American Society of Anesthesiologists physical status classification of III or IV. Likewise, longer case duration and cases requiring general anesthesia were also associated with unplanned ICU admissions.

CONCLUSION: This study establishes a rate of unplanned ICU admission following surgery in the heterogeneous pediatric population. This is the first study to utilize such a large data set encompassing a wide range of practice environments to identify risk factors leading to unplanned postoperative ICU admissions. Our study revealed that patient, surgical, and anesthetic complexity each contributed to an increased number of unplanned ICU admissions in the pediatric population.

Potassium abnormalities in a pediatric intensive care unit: frequency and severity. (Williams)

Cummings BM, Macklin EA, Yager PH, Sharma A, Noviski N. Potassium abnormalities in a pediatric intensive care unit: frequency and severity. J Intensive Care Med. 2014 Sep;29(5):269-74.

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BACKGROUND: Potassium abnormalities are common in critically ill patients. We describe the spectrum of potassium abnormalities in our tertiary-level pediatric intensive care unit (PICU).

METHODS: Retrospective observational cohort of all the patients admitted to a single-center tertiary PICU over a 1-year period. Medical records and laboratory results were obtained through a central electronic data repository.

RESULTS: A total of 512 patients had a potassium measurement. Of a total of 4484 potassium measurements, one-third had abnormal values. Hypokalemia affected 40% of the admissions. Mild hypokalemia (3-3.4 mmol/L) affected 24% of the admissions. Moderate or severe hypokalemia (K < 3.0 mmol/L) affected 16% of the admissions. Hyperkalemia affected 29% of the admissions. Mild hyperkalemia (5.1-6.0 mmol/L) affected 17% of the admissions. Moderate or severe hyperkalemia (>6.0 mmol/L) affected 12%. Hemolysis affected 2% of all the samples and 24% of hyperkalemic values. On univariate analysis, severity of hypokalemia was associated with mortality (odds ratio 2.2, P = .003).

CONCLUSIONS: Mild potassium abnormalities are common in the PICU. Repeating hemolyzed hyperkalemic samples may be beneficial. Guidance in monitoring frequencies of potassium abnormalities in pediatric critical care is needed.

Fluid resuscitation in septic shock the effect of increasing fluid balance on mortality. (Ruth)

Sadaka F, Juarez M, Naydenov S, O’Brien J. Fluid resuscitation in septic shock the effect of increasing fluid balance on mortality. J Intensive Care Med. 2013 Feb 27;29(4):213-217. [Epub ahead of print]

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PURPOSE: To determine whether progressively increasing fluid balance after initial fluid resuscitation for septic shock is associated with increased mortality.

METHODS: A retrospective review of the use of intravenous fluids in patients with septic shock in a large university affiliated hospital with 56 medical-surgical intensive care unit beds. We analyzed the data of 350 patients with septic shock who were managed according to the Surviving Sepsis Campaign guidelines. Based on net fluid balance at 24 hours, we examined the results of increase in positive fluid balance on the risk of in-hospital mortality. Patients were divided into 4 groups based on the amount of fluid balance by 24 hours, based on 6-L aliquots.

RESULTS: At 24 hours, the average fluid balance was +6.5 L. After correcting for age and sequential organ failure assessment score, a more positive fluid balance at 24 hours significantly increased the risk of in-hospital mortality. Using Cox proportional hazard analysis, excess 12-, 18-, and 24-L positive fluid balance had higher risk of mortality than those patients with a neutral to positive 6-L fluid balance (reference group). Adjusted hazard ratios, 1.519 (95% confidence interval [CI], 1.353-1.685), 1.740 (95% CI, 1.467-2.013), and 1.620 (95% CI, 1.197-2.043), respectively, P < .05.

CONCLUSION: In patients with septic shock resuscitated according to current guidelines, a more positive fluid balance at 24 hours is associated with an increase in the risk of mortality. Optimal survival occurred at neutral fluid balance and up to 6-L positive fluid balance at 24 hours after the development of septic shock.