Paul Yodice

Clarithromycin use preceding fulminant hepatic failure.

determined based on the real-time measurement of anti-HBs titer using lumipuls (Fuji Rebio, Tokyo, Japan), which takes only 1 h. The first patient took 2,000 U of HBIG per 4 days for maintaining over 500 U/ml and then 2,000 U/month was given 2 months after LRLT. One year after transplantation, HBIG was stopped and HBV vaccination (4) was administered. A second patient also underwent the same therapy regimen as the first; however, HBIG treatment was stopped in this patient after 5 months so as to be able to maintain anti-HBV titer above 200 U/ml without the administration of HBIG. Real-time measurement of anti-HBs titer might obviate HBIG treatment, which could spare the patient the cost of

Ruptured thoracic aortic aneurysm infected with Listeria monocytogenes : Case report and review of world wide literature

7,000 in the 1st operative wk. We also have performed donor-specific transfusion via the portal vein after LRLT (5, 6). In these patients, steroid therapy was withdrawn within 1 month and FK506 rapidly reduced to 1 mg/day, and 0.5 mg/14 days by 4 months after LRLT. The rapid reduction of immunosuppressants might lead to success in the reduction of HBIG and the vaccination of HBV. In conclusion, i.m. HBIG combined with lamivudine or low dose HBIG combined with lamivudine have been demonstrated (7, 8); however, our clinical trial by intraportal donor-specific transfusion and further understanding of the immunological mechanism in LRLT might contribute to the reduction of HBIG and prevent the recurrence of HBV.

1083: RISK FACTORS ASSOCIATED WITH UNPLANNED EXTUBATIONS

Abstract: Listeria monocytogenes is an increasingly recognized cause of human disease especially in immunosuppressed hosts; vascular infections involving Listeria had been rarely reported in the literature. We are reporting a case of L. monocytogenes infection in the descending thoracic aorta in a non-immunosuppressed patient presenting only with hemoptysis after contained rupture of the aneurysm by the lung. This was treated successfully by surgery and 6 weeks of oral levofloxacin. We also summarized all the available literature of listerial vascular infection since the first report by Navarrette in 1965.

1263: INTERVENTION FOR PREVENTION: REDUCING CATHETER-ASSOCIATED URINARY TRACT INFECTION IN THE ICU.

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Unplanned Extubations (UE) are associated with increased mortality and morbidity along with length of stay, and increased health care costs. The factors associated with unplanned extubations remain to be clearly defined. A better understanding of the risk factors leading to UE is essential for developing interventions to decrease the incidence of UE. The primary objective of this study was to establish risk factors associated with unplanned extubations. Secondary goals of the study were areas of improvement to decrease the total number of unplanned extubations. Methods: Seventy two unplanned extubations occurred between June 2012 and May 2017 at a single tertiary care academic center. The variables included in the primary analyses are age, gender, time of the day (categorised into 4 hour intervals) presence of restraints, the use of sedation (fentanyl, versed or propofol), and whether the patient was on a weaning protocol at the time of extubation (SBT). Primary analyses included univariate analysis such as linear regression for continuous variables and chi square for categorical variables associated with unplanned extubations. Results: Seventy two unplanned extubations occurred out of a total of 2667 mechanically ventilated patients (2.7%) during the study period. The study cohort consisted of 58% males with mean age of 67 years. Twenty one (29%) patients were undergoing a SBT at the time of self extubation. Thirty seven (51%) were continuously sedated while thirty (42%) were on restraints. In our cohort, increasing age was significantly associated with occurrence of UE (p-value = 0.0022). Even though, most of the UE occurred between 8 am and 12 noon (35%, p = 0.0027), sedation was decreased to perform spontaneous breathing trial. Conclusions: Our study shows that increasing age is a possible risk factor for unplanned extubation. Despite the UEs occurring on weekday mornings, it is confounded due to decreased sedation and occurrence of SBT. The limitations of the study include small sample size which preclude multivariate analyses. Our results may suggest that elderly population may be at higher risk of unplanned extubation and would benefit from dedicated supervision. Cautiously, we also recommend dedicated physician or nursing supervision to be performed during the SBT. Future studies are needed to identify high risk patients especially elderly to reduce the incidence of unplanned extubations.

Impact of a Hospital wide policy on Clostridium difficile Testing using Cepheid System

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) that a rounding tool designed to reduce variability and promote best practices for lab and imaging utilization will cut costs and painful procedures, all while improving patient safety and comfort. Methods: We are conducting a cohort study with historic controls, examining effectiveness of a daily rounding checklist in reducing patient “pokes” defined as 1) painful procedures, labs and imaging studies and 2) IV/IM/SQ medications. We included all patients hospitalized in our 25-bed tertiary care PICU. In 2014 our PICU adopted a structured interdisciplinary bedside rounding model, which provided a platform for curbing overutilization. During a set time on rounds, the nurse reports how many “pokes” are anticipated that day and suggests ways to reduce them, followed by a team discussion of the proposed interventions. In addition we conducted an educational campaign and provided a lab pricing “menu” for resident physicians. Our primary outcome was the total number of “pokes” per patient per week. Secondary outcomes included utilization of individual lab and imaging tests and associated costs. Results: In a cohort of 2449 patients and 546 historic controls we observed a decrease in the total number of “pokes” from 21.5 to 19.7 per patient per week, p<0.012. Preliminary analysis of secondary outcomes revealed a decrease in metabolic panels for patients with status asthmaticus (1.70 to 1.19 per patient per day, p<0.0001), while individual potassium checks increased. For patients with hypo/hypernatremia, metabolic panels decreased from 2.06 to 1.73 per patient per day, p<0.0001, with a concomitant increase in individual sodium checks. Conclusions: A checklist tool within the structured interdisciplinary bedside rounding framework, decreased utilization of labs, imaging and painful interventions. Further analysis of ensuing reduction in patient harm and costs, is in progress.

Rapid irreversible encephalopathy associated with anti‐D immune globulin treatment for idiopathic thrombocytopenic purpura

Bonnie Schleder APN, MS, CCRN, TNS, Advanced Practice Nurse, Critical Care, Advocate Good Shepherd Hospital; Mr. John T. Brown RN, Registered Staff Nurse, Advocate Good Shepherd Hospital; Ms. Patricia Moore RN, Registered Nurse, Advocate Good Shepherd Hospital; Mr. John J. Vesely RN, TNCC Jr, RN, Patient Care Leader, Advocate Good Shepherd Hospital; Ms. Charisma R. Trinidad RN, BSN, CCRN, Patient Care Leader, Registered Nurse, Advocate Good Shepherd Hospital