Albumin restriction in the cardiac surgery intensive care unit was feasible and safe. Significant reductions in utilization and cost with no changes in morbidity or mortality were demonstrated. These findings may provide a strategy for reducing cost while maintaining quality of care.
In the management of multidrug-resistant infections in critically ill patients with multiorgan dysfunction, consideration must be given to the pharmacokinetics and pharmacodynamics of an antimicrobial agent to optimize dosing. We describe a 25-year-old woman who was undergoing thrice-weekly hemodialysis and developed multidrug-resistant Pseudomonas aeruginosa bacteremia secondary to infected left and right ventricular assist devices. After multiple courses of antibiotics, her blood cultures revealed that the infecting organism was becoming progressively more resistant to antibiotic options. Cefepime 2 g administered over 3 hours/day (in combination with colistimethate) provided adequate drug levels for multidrug-resistant, cefepime-intermediate P. aeruginosa bacteremia in this patient. We present the clinical case of this patient, followed by a discussion of possible therapeutic approaches to be considered, including illustration of the principles of using extended-infusion antimicrobial regimens, and present the patient's resulting clinical course.
Background:Cardiac transplantation can be complicated by refractory hemorrhage particularly in cases where explantation of a ventricular assist device is necessary. Recombinant activated factor VII (rFVIIa) has been used to treat refractory bleeding in cardiac surgery patients, but little information is available on its efficacy or cost in heart transplant patients.Methods:Patients who had orthotopic heart transplantation between January 2009 and December 2014 at a single center were reviewed. Postoperative bleeding and the total costs of hemostatic therapies were compared between patients who received rFVIIa and those who did not. Propensity scores were created and used to control for the likelihood of receiving rFVIIa in order to reduce bias in our risk estimates.Results:Seventy-six patients underwent heart transplantation during the study period. Twenty-one patients (27.6%) received rFVIIa for refractory intraoperative bleeding. There was no difference in postoperative red blood cell transfusion, chest tube output, or surgical re-exploration between patients who received rFVIIa and those who did not, even after adjusting with the propensity score (P = 0.94, P = 0.60, and P = 0.10, respectively). The total cost for hemostatic therapies was significantly higher in the rFVIIa group (median $10,819 vs. $1,985; P < 0.0001). Subgroup analysis of patients who underwent redo-sternotomy with left ventricular assist device explantation did not show any benefit for rFVIIa either.Conclusions:In this relatively small cohort, rFVIIa use was not associated with decreased postoperative bleeding in patients undergoing heart transplantation; however, it led to significantly higher cost.
Learning Objectives: Relationship between center volume and cardiac arrest rate (or survival after an arrest) in children with critical illness has not been investigated to date. It is hypothesized that a high center volume may help maintain a team approach and adherence to protocol, and thereby decrease incidence of cardiac arrest and improve outcomes for patients with cardiac arrest. To address these knowledge gaps, we undertook this study of epidemiology and outcomes of in-hospital cardiac arrest among critically ill children across centers of varying center volume using the Virtual PICU Systems (VPS, LLC) Database. Methods: Patients <18 years of age in the VPS, LLC Database (2009-2013) were included. Patients with both cardiac and non-cardiac diagnoses were included. Data on demographics, patient diagnosis, cardiac arrest, severity of illness and outcomes were collected. Hierarchical cluster analysis was performed to categorize all the participating centers into low, low-medium, high-medium, and high volume groups using the center volume characteristics. Multivariable models were used to evaluate association of center volume with incidence of cardiac arrest, and mortality after cardiac arrest, adjusting for patient and center characteristics. Results: Of 329,982 patients (108 centers), 2.2% (n= 7,390) patients had cardiac arrest with an associated mortality of 35% (n=2,586). In multivariable models controlling for patient and center characteristics, center volume was not associated with either the incidence of cardiac arrest (OR: 1.00; 95% CI: 0.95-1.06; p=0.98), or mortality in those with cardiac arrest (OR: 0.93; 95% CI: 0.82-1.06; p=0.27). These associations were similar across cardiac and non-cardiac disease categories. Conclusions: Both incidence of cardiac arrest, and mortality in those with cardiac arrest vary substantially across hospitals. However, center volume is not associated with either of these outcomes, after adjusting for patient and center characteristics.
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