Adam J. Kingeter

Fluids and Organ Dysfunction: A Narrative Review of the Literature and Discussion of 5 Controversial Topics

Evidence-based clinical decision making is at the forefront of modern cardiothoracic anesthesia practice. Therefore, as a field, cardiac anesthesiologist should strive to ensure that the available evidence is of the highest possible quality. In this narrative review, 5 important topics that the authors believe require additional investigation in cardiothoracic anesthesia and critical care related to fluid therapy and organ dysfunction are outlined briefly. In particular, the authors believe that the areas of pulmonary artery catheter use, restrictive versus liberal transfusion strategies, cardiopulmonary bypass prime composition, colloid use in resuscitation and its effects on acute kidney injury, and management of acute kidney injury after cardiac surgery hold many unanswered questions and opportunities for continued improvement in the specialty of cardiac anesthesia. This article accompanies a presentation at the 46th Association of Cardiac Anesthesiologists Annual Meeting on October 22, 2017.

1172: PHYSICIAN AWARENESS OF ICU CHARGE ENVIRONMENT AND EFFECTS ON COST OF CARE

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Intensive care unit (ICU) care is expensive, representing an estimated 13.4% of all hospital care costs. Cost transparency (CT) to providers has been proposed as a means of decreasing costs of care, but evidence in the literature is conflicting. We designed an interactive dashboard that allowed ICU providers to access detailed charge information for all patients under their care. We hypothesized this level of CT would decrease charges perpatient-per-day, and decrease the number of commonly ordered laboratory tests. Methods: A prospective, observational, sequential single-center study in 5 ICUs was performed consisting of two alternating 12-week periods of CT separated by a 14-week period of no transparency and ending with a 12 week period of no transparency. All ICUs were on the same schedule to avoid cross-contamination by providers covering different units. CT was via an interactive dashboard built in Tableau (Tableau Software, Seattle WA) that displayed comprehensive charge data from the hospital master charge list for all patients in a given ICU. This dashboard was easily accessible via e-mailed link or iPads in the ICUs. Primary outcome was average charges-per-patient-per-day and secondary outcome was average number of commonly ordered laboratory tests (CBC, BMP, ABG, CXR, EKG) per-patient-per-day. Results: 11,787 encounters (10,720 patients) were included in the study, with 5,526 encounters in the CT periods and 6,261 in the control periods. Overall charges-per-patient-per-day did not differ between CT periods [Median (25th, 75th percentile)] [

Association between albumin administration and survival in cardiac surgery: a retrospective cohort study

9825 (

Daily Lowest Hemoglobin and Risk of Organ Dysfunctions in Critically Ill Patients

6230,

Electrolytes and Acid-Base Analysis

16737)] and control periods [

The Risk of Oxygen during Cardiac Surgery (ROCS) trial: study protocol for a randomized clinical trial

10018 (

Association entre l'administration d'albumine et la survie en chirurgie cardiaque : une étude de cohorte rétrospective.

6277,

A Survey of Charge Sensitivity and Charge Awareness Among Intensive Care Unit Providers in a Large Academic Medical Center

16876; p = 0.21)]. Overall number of commonly ordered laboratory tests perpatient-per-day did not differ between CT periods [Median (25th, 75th percentile)] [3.2 (1.6, 5.0)] and control periods [3.1 (1.7, 5.0; p = 0.97)]. Both of these findings held true in subset analysis for each separate ICU. Conclusions: We found no evidence that comprehensive charge transparency to providers in the form of an interactive dashboard resulted in a reduction of average charges-per-patient-per-day or in average number of commonly ordered labs-per-patient-perday in ICU patients. Challenges remain in combining decision support with CT, as well as with incorporating CT into clinical workflow, and are important areas of continued research.

When Managing Patients with Left Ventricular Assist Devices Undergoing Noncardiac Surgery, Less Is Not More

PurposeAlbumin is widely used during and after on-pump cardiac surgery, although it is unclear whether this therapy improves clinical outcomes.MethodsThis observational study utilized the Cerner Health Facts® database (a large HIPAA-compliant clinical-administrative database maintained by Cerner Inc., USA) to identify a cohort of 6,188 adults that underwent on-pump cardiac surgery for valve and/or coronary artery procedures between January 2001 and March 2013. Of these, 1,095 patients who received 5% albumin with crystalloid solutions and 1,095 patients who received crystalloids alone on the day of or the day following cardiac surgery were selected by propensity-score matching. The primary outcome was all-cause in-hospital mortality. Three secondary outcomes analyzed include acute kidney injury severity, major morbidity composite, and all-cause 30-day readmissions.ResultsIn the propensity-score matched cohort, receipt of perioperative 5% albumin was associated with decreased risk of in-hospital mortality (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.3 to 0.9; P = 0.02) and lower all-cause 30-day readmission rates (OR, 0.7; 98.3% CI, 0.5 to 0.9; P < 0.01). Albumin therapy was not associated with differences in overall major morbidity (OR, 0.9; 98.3% CI, 0.7 to 1.2; P = 0.39; composite) or acute kidney injury severity (OR, 0.9; 98.3% CI, 0.6 to 1.4; P = 0.53) compared with therapy with crystalloid solutions.ConclusionsIn this large retrospective study, use of 5% albumin solution was associated with significantly decreased odds of in-hospital mortality and all-cause 30-day readmission rate compared with administration of crystalloids alone in adult patients undergoing on-pump cardiac surgery. These results warrant further studies to examine fluid receipt, including 5% albumin, in surgical populations via randomized-controlled trials.RésuméObjectifL’albumine est largement utilisée au cours de la chirurgie cardiaque pendant et après la circulation extra-corporelle (CEC), bien qu’on ne sache pas si ce traitement améliore l’évolution clinique.MéthodesCette étude observationnelle a utilisé la base de données Cerner Health Facts® (une grande base de données clinico-administrative conforme à la réglementation HIPAA et tenue par Cerner Inc., aux États-Unis) pour identifier une cohorte de 6188 adultes ayant bénéficié d’une chirurgie cardiaque sous CEC pour des procédures valvulaires et/ou coronariennes entre janvier 2001 et mars 2013. Parmi eux, 1095 patients ayant reçu de l’albumine à 5% et des solutions de cristalloïdes, d’une part, et 1095 patients ayant reçu des cristalloïdes seuls le jour même ou le jour suivant la chirurgie, d’autre part, ont été sélectionnés par appariement de score de propension. Le principal critère d’évaluation était la mortalité toutes causes confondues durant l’hospitalisation. Trois critères d’évaluation secondaires ont été analysés: la sévérité des lésions rénales aiguës, un critère composite de morbidité majeure et le nombre de réhospitalisations dans les 30 jours indépendamment de la cause.RésultatsDans la cohorte appariée selon le score de propension, l’administration périopératoire d’albumine à 5% a été associée à une baisse du risque de mortalité à l’hôpital (rapport de cotes [OR], 0,5; intervalle de confiance [IC] à 95%: 0,3 à 0,9; P = 0,02) et à un plus faible taux de réhospitalisation toutes causes confondues (OR, 0,7; IC à 98,3%, 0,5 à 0,9; P < 0,01). Le traitement avec l’albumine n’a pas été associé à des différences de morbidité majeure globale (OR, 0,9; IC à 98,3%, 0,7à 1,2; P = 0,39; composite) ou de sévérité des lésions rénales aiguës (OR, 0,9; IC à 98,3%, 0,6 à 1,4; P = 0,53) comparativement au traitement avec des solutions de cristalloïdes.ConclusionsDans cette grande étude rétrospective, l’utilisation d’une solution d’albumine à 5% a significativement diminué les risques de mortalité hospitalière et de réhospitalisation dans les 30 jours comparativement aux cristalloïdes seuls chez des patients subissant une chirurgie cardiaque sous CEC. Ces résultats justifient des études supplémentaires sous forme d’essais contrôlés randomisés pour analyser l’administration des fluides, dont l’albumine à 5% dans les populations chirurgicales.

Not All Calcium Formulations Are Alike

Objectives: To determine the association between hemoglobin levels and the daily risk of individual organ dysfunctions in critically ill patients. Design: Post hoc analysis of prospectively collected data. Setting: Vanderbilt University Medical Center and Saint Thomas Hospital Medical and Surgical ICUs. Patients: Medical and surgical ICU patients admitted with respiratory failure or shock. Interventions: Baseline demographic data, and detailed in-ICU and hospital data, including daily lowest hemoglobin, were collected up to hospital day 30. We assessed patients daily for brain dysfunction (delirium, using Confusion Assessment Method for ICU), for renal and respiratory dysfunction (using the ordinal renal and respiratory Sequential Organ Failure Assessment score), and for ICU mortality. Associations between the lowest hemoglobin on a given day and organ dysfunctions the following day were assessed using multivariable regressions, adjusting for age, Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity index, Framingham Stroke Risk Profile, ICU day, ICU type, sepsis, and current organ dysfunction status. A sensitivity analysis further adjusted for daily transfusions and fluid balance in a subset of our patients. Measurements and Main Results: We enrolled 821 patients with a median (interquartile range) age of 61 (51–71) years, Acute Physiology and Chronic Health Evaluation II score of 25 (19–31), and hemoglobin level of 10.0 (9.0–11.1) g/dL. There was no evidence of an association between lowest daily hemoglobin and brain dysfunction (p = 0.69 for delirium), renal dysfunction (p = 0.30), or ICU mortality (p = 0.95). The lowest hemoglobin on a given day was significantly associated with the respiratory Sequential Organ Failure Assessment score the following day; for each increasing hemoglobin unit, the odds of worsened respiratory Sequential Organ Failure Assessment score the following day were decreased by 36% (OR, 0.64; 95% CI, 0.53–0.77; p < 0.001). The sensitivity analysis including daily transfusions and fluid balance (in a subset of 518 patients) did not qualitatively change any of these associations. Conclusions: In this study in ICU patients, lower hemoglobin was associated with a higher probability of worsening respiratory dysfunction scores the following day. There was no evidence of association between hemoglobin and brain or renal dysfunction, or ICU mortality. The possible differential effects of anemia on organ dysfunctions seen in this hypothesis-generating study will have to be studied in a larger prospective study before any alterations to present restrictive transfusion guidelines can be recommended.