Treatment of Hyponatremia in Patients with Acute Neurological Injury.

BACKGROUND: Little data exist regarding the practice of sodium management in acute neurologically injured patients. This study describes the practice variations, thresholds for treatment, and effectiveness of treatment in this population. METHODS: This retrospective, multicenter, observational study identified 400 ICU patients, from 17 centers, admitted for ≥48 h with subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), intraparenchymal hemorrhage, or intracranial tumors between January 1, 2011 and July 31, 2012. Data collection included demographics, APACHE II, Glascow Coma Score (GCS), serum sodium (Na+), fluid rate and tonicity, use of sodium-altering therapies, intensive care unit (ICU) and hospital length of stay, and modified Rankin score upon discharge. Data were collected for the first 21 days of ICU admission or ICU discharge, whichever came first. Sodium trigger for treatment defined as the Na+ value prior to treatment with response defined as an increase of ≥4 mEq/L at 24 h. RESULTS: Sodium-altering therapy was initiated in 34 % (137/400) of patients with 23 % (32/137) having Na+ >135 mEq/L at time of treatment initiation. The most common indications for treatment were declining serum Na+ (68/116, 59 %) and cerebral edema with mental status changes (21/116, 18 %). Median Na+ treatment trigger was 133 mEq/L (IQR 129-139) with no difference between diagnoses. Incidence and treatment of hyponatremia was more common in SAH and TBI [SAH (49/106, 46 %), TBI (39/97, 40 %), ICH (27/102, 26 %), tumor (22/95, 23 %); p = 0.001]. The most common initial treatment was hypertonic saline (85/137, 62 %), followed by oral sodium chloride tablets (42/137, 31 %) and fluid restriction (15/137, 11 %). Among treated patients, 60 % had a response at 24 h. Treated patients had lower admission GCS (12 vs. 14, p = 0.02) and higher APACHE II scores (12 vs. 10, p = 0.001). There was no statistically significant difference in outcome when comparing treated and untreated patients. CONCLUSION: Sodium-altering therapy is commonly employed among neurologically injured patients. Hypertonic saline infusions were used first line in more than half of treated patients with the majority having a positive response at 24 h. Further studies are needed to evaluate the impact of various treatments on patient outcomes.

Impact of a hospital-acquired/ventilator-associated/healthcare-associated pneumonia practice guideline on outcomes in surgical trauma patients.

BACKGROUND: Evidence-based guidelines for managing nosocomial pneumonia were published in 2005. Subsequently, our surgical critical care service developed and implemented an adaptation of this guideline for use in our surgical trauma intensive care unit (STICU). This study examined outcomes for two STICU cohorts treated for pneumonia before and after guideline implementation. METHODS: A total of 130 charts were evaluated. The guideline cohort (GC) consisted of 65 patients with pneumonia managed by the surgical critical care service. These patients were prospectively identified for inclusion if they met specified clinical criteria for pneumonia diagnosis. The historical control cohort was identified retrospectively using ICD-9 coding. The primary outcome measure was ICU length of stay (LOS). Secondary outcome measures included overall LOS, mechanical ventilation days, mortality, and total cost of admission. The study was designed to have 80% power to detect a 1-day decrease in mean ICU LOS in a multivariable regression analysis. Descriptive differences were compared using two-sample t tests for continuous variables and chi for categorical variables. RESULTS: Baseline characteristics were not significantly different between cohorts. The multivariable regression analysis indicated a mean decrease of 4.6 days, 9.5 days, and 3.9 days for ICU LOS, overall LOS, and mechanical ventilation days, respectively, in the GC, with an expected mean cost reduction per admission of $23,322 (all significant at p