Burden of fever and hospital mortality in patients admitted to the intensive care unit with isolated traumatic brain injury-A retrospective cohort study using continuous temperature data.

BACKGROUND: Fever has been shown to be associated with poor outcomes in patients with traumatic brain injury. Earlier studies have used peak daily temperature to derive the burden of fever. The association between hospital mortality and fever burden calculated as the area under the temperature-time curve for the entire duration of intensive care unit (ICU) stay has not been studied before. OBJECTIVES: The objective of this study was to investigate the association between the burden of fever and hospital mortality in patients with isolated traumatic brain injury admitted to the ICU. METHODS: We conducted this retrospective cohort study using an electronic database in a tertiary ICU in Sydney. We included all adult patients admitted to the ICU with isolated traumatic brain injury over 3 years from 1 July 2017 to 30 June 2020. We collected data on demographics, clinical characteristics, and interventions for all patients. We defined the burden of fever as an area under the temperature-time curve above 37 °C. The primary outcome was hospital mortality. We used multivariable logistic regression to determine the association between burden of fever and hospital mortality. We assessed the importance of the burden of fever in a predictive model using machine-learning methods (Bagging and Random Forest). RESULTS: A total of 88 patients (76% males, mean age: 54 ± 23 years, mean Acute Physiology and Chronic Health Evaluation [APACHE] II score: 15 ± 7) were included in the study, and 18 (20.5%) of the 88 patients died in hospital. Compared to survivors, the nonsurvivors had lower mean Glasgow Coma Scale (GCS) score at the scene, higher mean APACHE II and III scores, and higher rates of intracranial pressure monitoring, surgery, mechanical ventilation, use of vasopressors, and cooling. On multivariable logistic regression, age (odds ratio: 1.05, 95% confidence interval: 1.02-1.09, p = 0.01) was found to be an independent predictor of hospital mortality. A higher GCS score at the scene (odds ratio: 0.81, 95% confidence interval: 0.66-0.98, p = 0.03) was associated with survival. The burden of fever was not associated with hospital mortality. The top three important variables in the predictive model were APACHE III, GCS score at scene, and age. CONCLUSION: The burden of fever was not an independent predictor of hospital mortality. The results of this study need to be confirmed in a large multicenter study.

A retrospective validation of ROTEM algorithms for detecting hyperfibrinolysis demonstrates poor agreement for prediction of in-hospital mortality and transfusion requirement in a general, non-cardiac, surgical population.

INTRODUCTION: Hyperfibrinolysis diagnosed on Rotational Thromboelastography (ROTEM) is associated with increased transfusion requirements and mortality in trauma. The diagnosis and significance of hyperfibrinolysis in a mixed, non-cardiac, general surgical population has not been investigated. We aimed to measure agreement between four ROTEM algorithms for diagnosing hyperfibrinolysis and transfusion requirements and mortality in general surgical patients. These algorithms mostly incorporate measures of early or late clot amplitude reduction on the Extrinsic Clotting Pathway Test with Tissue Factor (EXTEM) channel. METHOD: Four hospital administrative data sets were linked from 2019 to 2022. Adults >18 years were included if a ROTEM was performed during their surgery (intraoperative period) or within 24-h of the surgery completion (postoperative period). The four hyperfibrinolysis criteria were applied to the ROTEM data and assessed for their agreement, intraoperative and postoperative transfusion requirements and in-patient mortality. RESULTS: We linked 933 ROTEMs to 558 patient-procedures. One algorithm identified hyperfibrinolysis on only three patients so was excluded. Agreement between the remaining three was slight (Cohens Kappa 0.18 (p < 0.001)) with hyperfibrinolysis diagnosed between 22 and 69 % of the procedures. The association between hyperfibrinolysis diagnosis and intraoperative or postoperative transfusion requirement was inconsistent between the criteria. However, an algorithm put forward by Goerling et al. was more often associated with transfusion requirement and inpatient mortality. DISCUSSION: The poor agreement between criteria suggests that some ROTEM criteria may not transfer directly to general surgical patients. Future research should focus on optimising hyperfibrinolysis cut-off values to update algorithms for bleeding general surgical patients.

The accuracy of a point of care measurement of activated partial thromboplastin time in intensive care patients.

Point of care (POC) devices are increasingly being used in intensive care units to obtain faster results. Data are limited on the performance of these devices in critically ill patients, especially those on heparin infusion. The objective of this study was to assess the agreement between POC activated partial thromboplastin time (APTT) and laboratory APTT results in patients on heparin infusion and to determine its impact on the clinical decisions regarding heparin dosage. We screened all patients admitted to the intensive care unit (ICU) at St George Hospital, Sydney, over a 7-month period and enrolled those who were receiving intravenous heparin infusion. We measured APTT by two methods: bedside POC test (Hemochron Junior Signature Plus) and central laboratory method (STA analyser). We used the Bland-Altman method to test the statistical agreement between the two measurements and Cohen's kappa statistic to test the clinical agreement regarding heparin dosing decision. A total of 176 paired samples from 44 patients (mean age 63 years, 64% males, mean APACHE 18) were analysed. The mean turnaround time for the point of care APTT result was significantly shorter than the central laboratory result (5.0±0.2 min vs 64.6±2.7 min, p<0.0001). Despite the statistically significant correlation, the overall agreement tested by the Bland-Altman method was poor. The 95% limits of agreement were widest (-27.266 to 64.791) and mean percentage bias was highest (24%) for the comparison between POC APTT using citrated blood and laboratory APTT. When POC APTT results of less than 90 seconds using whole blood were compared to laboratory APTT results, the limits of the agreement became narrower (-23.243 to 28.419), and the mean percentage bias decreased to 5%. The agreement between clinical decisions regarding heparin dosage based on the two methods was poor for plain and citrated blood (kappa 0.35 and 0.11, respectively). The POC APTT results were not sufficiently accurate for use in patients on heparin infusion compared to laboratory APTT assay.

Perceived Discomfort in Patients admitted to Intensive Care (DETECT DISCOMFORT 1): a prospective observational study.

BACKGROUND: Discomfort experienced by patients admitted to intensive care units (ICUs) is an important indicator of the quality of care provided, but few studies have evaluated the incidence and magnitude of discomfort in critically ill patients. The IPREA (Inconforts des Patients de REAnimation) discomfort questionnaire is a tool developed by French intensivists and validated in the French language with good internal consistency (Cronbach's α, 0.78). OBJECTIVES: To translate and validate in English the IPREA discomfort questionnaire, to evaluate discomfort perceived by patients in intensive care, and to identify predictors of discomfort. DESIGN, SETTING AND PARTICIPANTS: After translating the IPREA questionnaire using published methods that use principles of good practice for translating and culturally adapting patient-reported outcomes measures, all eligible patients (aged > 18 years, Glasgow Coma Scale score of 15, English speaking) admitted to our ICU over the 6-month period from April 2017 to September 2017 were surveyed within 24 hours of ICU discharge. Patient-perceived discomfort was measured using the translated IPREA questionnaire. The patients were asked to score their discomfort for each of 16 items on a scale of 0 (no discomfort) to 100 (maximum discomfort). An overall discomfort score was computed as the mean score of the 16 individual discomfort scores. Multivariate analysis was performed to identify predictors of discomfort. MAIN OUTCOME MEASURES: Translated questionnaire internal consistency. Individual and overall discomfort scores. RESULTS: A total of 168 patients (58% men; mean age, 60.1 ± 14.8 years; mean APACHE [Acute Physiology and Chronic Health Evaluation] II score, 13.8 ± 5.6) completed the questionnaire. The translated questionnaire had good internal consistency (Cronbach's α, 0.82), and good content and construct validity (average inter-item correlation, 0.23). The mean overall discomfort score was 18.4 ± 12.5, and discomfort scores did not differ between men and women or between types of ICUs (general ICU, cardiothoracic ICU or high dependency unit). On multivariate analysis, increasing age was an independent predictor of a low discomfort score (ß, -0.27; 95% CI, -0.42 to -0.12; P = 0.001). CONCLUSION: Patients admitted to our ICU reported low overall discomfort. There was an inverse relationship between age and perceived discomfort. The translated questionnaire for measuring discomfort performed well in our setting and could be applied to the Australian population.

Evaluation of cognitive load and emotional states during multidisciplinary critical care simulation sessions.

BACKGROUND: The simulation in critical care setting involves a heterogeneous group of participants with varied background and experience. Measuring the impacts of simulation on emotional state and cognitive load in this setting is not often performed. The feasibility of such measurement in the critical care setting needs further exploration. METHODS: Medical and nursing staff with varying levels of experience from a tertiary intensive care unit participated in a standardised clinical simulation scenario. The emotional state of each participant was assessed before and after completion of the scenario using a validated eight-item scale containing bipolar oppositional descriptors of emotion. The cognitive load of each participant was assessed after the completion of the scenario using a validated subjective rating tool. RESULTS: A total of 103 medical and nursing staff participated in the study. The participants felt more relaxed (-0.28±1.15 vs 0.14±1, P<0.005; d=0.39), excited (0.25±0.89 vs 0.55±0.92, P<0.005, d=0.35) and alert (0.85±0.87 vs 1.28±0.73, P<0.00001, d=0.54) following simulation. There was no difference in the mean scores for the remaining five items. The mean cognitive load for all participants was 6.67±1.41. There was no significant difference in the cognitive loads among medical staff versus nursing staff (6.61±2.3 vs 6.62±1.7; P>0.05). CONCLUSION: A well-designed complex high fidelity critical care simulation scenario can be evaluated to identify the relative cognitive load of the participants' experience and their emotional state. The movement of learners emotionally from a more negative state to a positive state suggests that simulation can be an effective tool for improved knowledge transfer and offers more opportunity for dynamic thinking.

Sustained multimodal antimicrobial stewardship in an Australian tertiary intensive care unit from 2008-2015: an interrupted time-series analysis.

The long-term outcomes and sustainability of antimicrobial stewardship (AMS) in the intensive care unit (ICU) require evaluation. This study analysed the effect of a multimodal ICU AMS introduced in a 15-bed medical-surgical tertiary Australian adult ICU in November 2008, using interrupted time-series analysis of antibiotic usage, Gram-negative resistance and cost from November 2005 to October 2015, including national ICU average usage as a control. Overall ICU mortality, 30-day blood stream infection (BSI) mortality and length of stay (LOS) were compared over the same period. There were 2512 patients admitted to ICU before and 6435 after AMS intervention. Post-AMS there was a reduction in the trend of aminoglycoside usage both absolute from 63.3 DDD/1000 occupied bed days (OBD)/month (-1.1; 95% confidence interval [CI] -2.2, -0.1; P = 0.033) and relative to the national trend (-1.3; 95%CI -2.4, -0.3; P = 0.016). Vancomycin usage increased both absolute from 161.2 DDD/1000 OBD/month (1.8; 95%CI 0.03, 3.6; P = 0.046) and relative to the national trend (1.8; 95%CI -0.3, 3.9; P = 0.092). There were sustained post-AMS downward trends in carbapenem, antipseudomonal penicillin, third-generation cephalosporin and fluoroquinolone use that did not reach statistical significance. Post-AMS, antipseudomonal penicillin resistance declined (-12.8%; 95%CI -24.9, -0.6; P = 0.040). Antimicrobial acquisition costs declined by AUD$0.5/OBD/month (95%CI -1.1, 0.1; P = 0.096). Over the study period, severity-adjusted ICU mortality declined from 12.9% to 10.4%; risk ratio (RR) 0.92 (95%CI 0.82, 1.03) and BSI 30-day mortality from 37.9% to 26.3%; RR, 0.76 (95%CI 0.56, 1.03). Median ICU LOS for ICU survivors increased from 2.3 to 2.6 days. Multimodal AMS sustainably embedded in ICU was associated with reductions in broad-spectrum Gram-negative antibiotic use, overall antibiotic costs and Gram-negative resistance, without adverse clinical impact.