Ashok Palagiri

Telemedicine Intervention Improves ICU Outcomes

Telemedicine for the intensive care unit (Tele-ICU) was founded as a means of delivering the clinical expertise of intensivists located remotely to hospitals with inadequate access to intensive care specialists. This was a retrospective pre- and postintervention study of adult patients admitted to a community hospital ICU. The patients in the preintervention period (n = 630) and during the Tele-ICU period (n = 2193) were controlled for baseline characteristics, acute physiologic scores (APS), and acute physiologic and health evaluation (APACHE IV) scores. Mean APS scores were 37.1 (SD, 22.8) and 37.7 (SD, 19.4) (P = 0.56), and mean APACHE IV scores were 49.7 (SD, 24.8) and 50.4 (SD, 21.0) (P = 0.53), respectively. ICU mortality was 7.9% during the preintervention period compared with 3.8% during the Tele-ICU period (odds ratio (OR) = 0.46, 95% confidence interval (CI), 0.32–0.66, P < 0.0001). ICU LOS in days was 2.7 (SD, 4.1) compared with 2.2 (SD, 3.4), respectively (hazard ratio (HR) = 1.16, 95% CI, 1.00–1.40, P = 0.01). Implementation of Tele-ICU intervention was associated with reduced ICU mortality and ICU LOS. This suggests that there are benefits of a closed Tele-ICU intervention beyond what is provided by daytime bedside physicians.

Placement of intracranial pressure monitors by neurointensivists: Case series and a systematic review

Primary objective: Placement of an intracranial pressure (ICP) monitor to guide the management of patients with severe traumatic brain injury (TBI) has been historically performed by neurosurgeons. It is hypothesized that ICP monitors can be placed by non-surgeon neurointensivists, with placement success and complication rates comparable to neurosurgeons. Research design: Retrospective review and systematic review of the literature. Methods and procedures: This study reviewed the medical records of patients with TBI who required insertion of parenchymal ICP monitors performed by four neurointensivists in a large level I trauma centre. Patient data recorded were age, gender, CT findings, ICP monitor placement, location and length of placement, complications related to the ICP monitor and patient outcomes. Main outcomes and results: Thirty-eight (38) monitors (Camino) were placed. Patients’ average age was 43.0 years (SD = 21.6); 76% were males. The location of monitor was right frontal in 89% and left frontal in 11%. Mean ICP was 24 (SD = 15), duration of ICP monitor was 4.9 days (SD = 3.6). All monitors were placed successfully. There were no major technical complications, no episodes of major catheter-induced intracranial haemorrhage and no infectious complications. These findings were comparable to published outcomes from neurosurgeon placements. Conclusions: It is believed that insertion of ICP monitors by neurointensivists is safe and may aid in providing prompt monitoring of patients with severe TBI.

Therapeutic Hypothermia: Adverse Events, Recognition, Prevention and Treatment Strategies

© 2013 Lakshmanan et al., licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Therapeutic Hypothermia: Adverse Events, Recognition, Prevention and Treatment Strategies

Therapeutic Hypothermia in Traumatic Brain Injury

Traumatic brain injury (TBI) is a major source of death and severe disability worldwide. In the USA alone, this type of injury causes 290,000 hospital admissions, 51,000 deaths, and 80,000 permanently disabled survivors [1,2]. Intracranial hypertension develops commonly in acute brain injury related to trauma [3,4]. Raised Intracranial pressure (ICP) is an important predictor of mortality in patients with severe TBI, and aggressive treatment of elevated ICP has been shown to reduce mortality and improve outcome [4-11]. Guidelines for the Management of Severe TBI, published in the Journal of Neurotrauma in 2007 [12] make a Level II recommendation that ICP should be monitored in all salvageable patients with a severe TBI (Glasgow Coma Scale [GCS] score of 3–8 after resuscitation) and an abnormal computed tomography (CT) scan. ICP monitoring is also recommended in patients with severe TBI and a normal CT scan if two or more of the following features are noted at admission: age over 40 years, unilateral or bilateral motor posturing, or systolic blood pressure < 90 mm Hg (Level III recommendation). Furthermore, ICP should be maintained less than 20 mmHg and cerebral perfusion pressure (CPP) between 50 and 70 mmHg (Level III).

Using survival analysis to predict septic shock onset in ICU patients

Purpose: To determine the efficacy of survival analysis for predicting septic shock onset in ICU patients. Materials and Methods: We performed a retrospective analysis on ICU cases from Mercy Hospital St. Louis from 2012 to 2016. As part of the procedure for inclusion in the Apache Outcomes database, each case is reviewed by critical care clinicians to identify septic shock patients as well as the time of septic shock onset. We used survival analysis to predict septic shock onset in these cases and employed lagging to compensate for uncertainties in septic shock onset time. Results: Survival analysis was highly effective at predicting septic shock onset, producing AUC values of >0.87. The methodology was robust to lag times as well as the specific method of survival analysis used. Conclusions: This methodology has the potential to be implemented in the ICU for real time prediction and can be used as a building block to expand the approach to other hospital wards or care environments.

894: Proton Pump Inhibitors Versus Histamine 2 Receptor Antagonists for Stress Ulcer Prophylaxis

was a significance difference in the incidence of RAW between these hospitals (p<0.001), and hospital 1 had significantly more RAW admissions than all the rest (p<0.001). Of the 2,229 non-resistant (nRAW) admissions, which represented 1762 unique patients, 76% were male with a mean (SD) age of 52 (12). Conclusions: The presence of RAW is a marker for worsening clinical outcomes compared to withdrawal patients with nRAW. We identified a RAW incidence of 15% in patients with severe alcohol withdrawal. Future efforts to identify risk factors and standardize the care of this unique population are warranted.

886: STRESS ULCER PROPHYLAXIS IN CRITICALLY ILL PATIENTS

Introduction: Critically ill patients may develop bleeding caused by stress ulceration (SU). Stress ulcer prophylaxis (SUP) is commonly used in the intensive care unit (ICU) to prevent SU but may be associated with complications including Clostridium difficile (CD) infection and nosocomial pneumonia