A total of 13,980 (6.1%) patients were readmitted to the ICUs. Characteristics associated with ICU readmission were similar to those previously reported. In addition to illness severity at initial admission, readmission was associated with complications, poor response to therapy, or persistent physiologic abnormalities at ICU discharge. Patients who were readmitted to the ICU had a risk-adjusted, fourfold greater probability of in-hospital mortality and a 2.5-fold increase in length of hospital stay.
Data were obtained solely from hospitals with an APACHE system, and included only one hospital from the Northeast. Not all ICUs from a single-study hospital were included. DNR orders were not available in the database for analysis.
Bottom line: Persistent physiologic derangements at ICU discharge are as influential on ICU readmission and poor outcomes as other known risk factors, potentially warranting slightly longer ICU stays for these specific patients.
Citation: Kramer AA, Higgins TL, Zimmerman JE. Intensive care unit readmissions in U.S. hospitals: patient characteristics, risk factors, and outcomes. Crit Care Med. 2012;40:3-10.
Clopidogrel Might Not Worsen Bleeding Complications During Surgery
Clinical question: Does clopidogrel cause bleeding complications during vascular surgery?
Background: There is no consensus and few large trials to decide if preoperative clopidogrel use causes bleeding complications in vascular surgeries.
Study design: Prospective.
Setting: New England academic and community centers.
Synopsis: The authors enrolled 10,406 patients from 15 academic and community centers in New England. These patients underwent carotid endarterectomy, lower-extremity bypass, and abdominal aortic aneurysm repair. Ruptured aortic aneurysms were excluded. The use of aspirin, clopidogrel, both, or no anti-platelet therapy within 48 hours before surgery was recorded. The outcomes measured were postoperative bleeding requiring reoperation and the need for packed red blood cell transfusions.
Clopidogrel therapy (n=229) compared with no anti-platelet therapy (n=2,010) did well when measured by reoperation (clopidogrel 0.9%, none 1.5%, P=0.74), incidence of transfusion (clopidogrel 0%, none 18%, P=0.1), and volume of transfusion (clopidogrel 0 units, none 0.7 units, P=0.1). However, the significance, especially for reoperation, is not impressive.
The power of the study could be improved with more clopidogrel users. Another limitation is that the aspirin and clopidogrel platelet effect lasts longer than the 48-hour cutoff. As there were more bleeding complications in the no-anti-platelet group, there is a concern for bias in how the patients were selected and treated.
Bottom line: Clopidogrel might be safe to continue in vascular surgeries, but larger and more valid studies are needed.
Citation: Stone DH, Goodney PP, Schanzer A, et al. Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery. J Vasc Surg. 2011;54:779-784.
Tissue-Defined TIAs Have Better Prognostic Benefits Than Time-Defined TIAs
Citation: Is risk stratification for recurrent stroke better when brain imaging is performed after a transient ischemic attack (TIA)?
Background: The presence of a TIA is a known risk factor for recurrent stroke. There is debate in changing the definition of TIA from time-based to tissue-based. However, it is not known if this will improve management.
Study design: Multicenter observation cohort.
Setting: Twelve independent international research centers.
Synopsis: The current definition of a TIA is a neurological deficit that resolves within 24 hours. To determine the urgency of an admission and work-up, the ABCD2 score (age, blood pressure, clinical symptoms, duration, and diabetes) is often used as a prognostic tool for recurrent stroke. The authors enrolled 4,574 patients with the traditional diagnosis of TIA. In addition to calculating their ABCD2 score, they were then classified as tissue-positive (infarction) or tissue-negative per MRI or CT. At both seven and 90 days after TIA, both imaging modalities when combined with ABCD2 were able to identify risk for recurrent stroke better than if they were used alone.