A Descriptive Study of Late Intensive Care Unit Admissions After Adult Solitary Kidney Transplantation

ObjectiveKidney transplant recipients are at lifetime risk of requiring high acuity care. In the current study, we aimed to assess the reasons for delayed (> 30 days) intensive care unit (ICU) admissions post-transplant and causes of ICU-related mortality.MethodsThis is a retrospective study of a cohort of adult kidney transplant patients from January 1, 2007, through December 31, 2016, who required ICU admission after 30 days of transplantation. The admissions were divided into 3 groups based on their timeline between transplantation and ICU admission: 1. group 1 from 30 days to 6 months, 2. group 2 between 6-24 months, and 3. group 3 after 2 years. All admissions were categorized according to the primary organ system involved.ResultsA total of 285 (group 1: 50, group 2: 89, group 3: 146) patients required 404 ICU admissions (group 1: 57, group 2: 108, group 3: 239). Overall, cardiovascular system-related admissions (29.9%, 18.5%, 15.9%), infections (19.3%, 25.9%, 27.2%), and respiratory-related admissions (12.3%, 8.3%, 8.8%) were main causes in all 3 groups. A total of 24 (8.4%) patients died in the ICU. Most of the deaths occurred in men (79.2%), infection-related admissions (45.8%), and individuals with a functioning allograft (66.7%). Infections (45.8%) were the main causes of ICU-related mortality. Median time from transplantation to death was 2.3 years (interquartile range: 1.2-4.6).ConclusionKidney transplant patients continue to be at risk of requiring high acuity care long after transplantation. Most of these admissions are related to cardiopulmonary system involvement or infections. Overall, infections were the leading cause of ICU-related mortality.     

The Significant Prognostic Factors in Prolonged Intensive/High Care Unit Stay After Living Donor Liver Transplantation

BackgroundProlonged stay in an intensive/high care unit (ICU/HCU) after living donor liver transplantation (LDLT) is a significant event with possible mortality.MethodsAdult-to-adult LDLTs (n = 283) were included in this study. Univariate and multivariate analyses were performed for the factors attributed to the prolonged ICU/HCU stay after LDLT.ResultsRecipients who stayed in the ICU/HCU 9 days or longer were defined as the prolonged group. The prolonged group was older (P = .0010), had a higher model for end-stage liver disease scores (P < .0001), and had higher proportions of patients with preoperative hospitalization (P < .0001). Delirium (P < .0001), pulmonary complications (P < .0001), sepsis (P < .0001), reintubation or tracheostomy (P < .0001), relaparotomy due to bleeding (P = .0015) or other causes (P < .0001), and graft dysfunction (P < .0001) were associated with prolonged ICU/HCU stay. Only sepsis (P = .015) and graft dysfunction (P = .019) were associated with in-hospital mortality among patients with prolonged ICU/HCU stay or graft loss within 9 days of surgery. Among these patients, grafts from donors aged <42 years and with a graft-to-recipient weight ratio of >0.76% had significantly higher graft survival than grafts from others (P = .0013 and P < .0001, respectively).ConclusionProlonged ICU/HCU stay after LDLT was associated with worse short-term outcomes. The use of grafts of sufficient volume from younger donors might improve graft survival.     

Liver Transplantation Complications in the Intensive Care Unit and at 6 Months

Objective

This study sought to determine the factors that influence the 6-month outcomes of liver transplants.

Patients and Methods

One hundred ninety-six variables (donor, recipient, operation, intensive care unit [ICU], evolution at 3 and 6 months) were collected from the first 74 consecutive liver transplantation performed from 2002 to 2004. The primary endpoint was patient survival at 6 months. The statistical analysis included a screening univariate analysis followed by a stepwise logistic regression with forward inclusion to test independent associations and finally generation of receiver-operator characteristic (ROC) curves to evaluate predictive factors.

Results

Patient survival at 6 months was 86%, namely 10 deaths, including 4 intraoperatively and 6 postoperatively due to sepsis. Complications in the ICU were classified as reoperations due to biliary problems, vascular complications, and peritonitis. Late complications included 51% rejection episodes, 24% infections, 11% pleural effusions, and 16% diabetes mellitus. Logistic regression analysis showed independent negative predictors of survival were the number of packed red cells during transplantation, the number of fresh frozen plasma units administered in the ICU, blood urea nitrogen (BUN) concentration in the ICU, and graft complications. The odds ratios of these variables were 10.2, 5.2, 42.1, and 36.9, respectively. The area under the curve (AUC) of the ROC was 0.99; the sensitivity was 94%; and the specificity was 100%. The independent predictors of surgical complications were the length of the operation, the need for pressor support, and the number of fresh frozen plasma units administered in the operating room, with odds ratios of 1.0, 7.7, and 1.1, respectively.

Conclusion

This study revealed specific operative and ICU variables that correlated with the evolution of our patients.     

Non-infectious Fever After Acute Spinal Cord Injury in the Intensive Care Unit

Objective: The aim of the present study is to evaluate the frequency, etiology, risk factors and clinical outcomes in acute traumatic SCI patients who develop fever and to evaluate the relationship between fever and mortality.

Design: Retrospective data were collected between January 2007 and August 2016 from patients diagnosed with persistent fever from SCI cases observed in the ICU.

Participants: Among 5370 intensive care patients, 435 SCI patients were evaluated for the presence of fever. A total of 52 patients meeting the criteria were evaluated.

Outcome measures: Fever characteristics were evaluated by dividing the patients into two groups: infectious (group-1) and non-infectious (group-2) fever. Demographic and clinical data, ICU and hospital stay, and mortality were evaluated.

Results: In the patients with noninfectious fever, mortality was significantly higher compared to the group with infectious fever (P < 0.001). Of 52 acute SCI cases, 25 (48.1%) had neurogenic fever that did not respond to treatment in intensive care follow-up, and 22 (88%) of these patients died. Maximal fever was 39.10 ± 0.64 °C in Group-1 and 40.22 ± 1.10 ° C in Group-2 (P?=?0.001). There was a significant difference in the duration of ICU stay and hospital stay between the two groups (P?=?0.005, P?=?0.001, respectively), while there was no difference in the duration of mechanical ventilation between the groups (P?=?0.544).

Conclusion: This study demonstrates that patients diagnosed with neurogenic fever following SCI had higher average body temperature and higher rates of mortality compared to patients diagnosed with infectious fever.     

Early Postoperative Care of Liver Transplantation for Infants With Biliary Atresia During Pediatric Intensive Care Unit Stay

Subject

The aim of this study was to present our institutional experience with the pediatric intensive care unit (PICU) stays of liver recipients to understand prevention of complications.

Methods

This retrospective review included 22 infants who weighed 8.8 kg or less and underwent 23 transplantations. No grafts were from executed prisoners. We summarized the diagnosis, evaluation, medicine usage, and therapeutic intervention associated with subjects experiencing complications of rejection episodes, surgery, or infection during their ICU stay.

Results

There was one perioperative death from primary graft nonfunction. The most common postoperative complications were infections, gastrointestinal bleeding, and vascular complications. Rejection episodes occurred among 25% of patients. The most common isolated pathogenic bacteria was Staphylococcus epidermidis. Median initial ICU stay was 10 days. Mean requirement for artificial ventilation was 37.6 hour. Mean times of use of dobutamine, prostaglandin E1, and dopamine was 3.3, 7.5, and 8.8 days, respectively. Parenteral nutrition was started at a mean of 12 hours and oral food intake at a mean of 72 hours.

Conclusions

Although challenging, orthotopic liver transplantation (OLT) in small infants can be successfully performed with meticulous surgical technique and keen postoperative surveillance.     

High-dose fluconazole therapy in Intensive Care Unit

AIM: Fungal infections have become one of the emerging complications in intensive care patients and the morbidity and mortality linked to these infections underlines the importance of managing these pathologies. METHODS: The clinical and laboratory difficulties of diagnosing candidiasis prompted us to identify patients at risk and to intervene as soon as possible, where there was the "suspicion" of active infection, using adequate, so-called "empiric" treatment. The major risk factors include the use of invasive devices (central venous catheters), the administration of multiple antibiotic treatment and parenteral nutrition. In our Intensive Care ward (multi-purpose), we examined 1933 patients who had undergoing 1211 urine cultures (following consolidated clinical criteria). "Empiric treatment" was used in 378 high-risk patients with unstable clinical symptoms and positive urinary fungal colonisations using high-dose fluconazole (800 mg/die) according to the guidelines set down by BSAC. The mean duration of treatment was 12+2 days and urine cultures became negative in all patients after 1 or 2 weeks of treatment. RESULTS: We observed that fluconazole was generally well tolerated: only 10% of patients presented augmented hepatic transaminase. This phenomenon was always transient. Renal function remained unchanged (creatinine clearance). A severe infection with hematogenous dissemination was reported in 6 cases: "empiric treatment" was used in 5 cases with 800 mg/die of fluconazole and 1 case received amphotericin B 1 mg/kg/die (because no clinical improvement was observed after 48-72 hours of fluconazole treatment). Three of these 6 cases died, 2 of which were not directly linked to fungal infection, and 3 patient were discharged from the ward. CONCLUSIONS: We found that fluconazole offers a treatment option that is less toxic, less expensive and equally effective for these infections, provided that it is used at an adequate dose and that high-risk patients are identified for "empiric treatment". No significant increases in resistance were noted, as is demonstrated by the fact that only 1 case of candidemia required conversion to amphotericin B.