Gastric feed intolerance is not increased in critically ill patients with type II diabetes mellitus

Objective To examine the occurrence of feed intolerance in critically ill patients with previously diagnosed type II diabetes mellitus (DM) who received prolonged gastric feeding. Design and setting Retrospective study in a level 3 mixed ICU. Patients All mechanically ventilated, enterally fed patients (n = 649), with (n = 118) and without type II DM (n = 531) admitted between January 2003 and July 2005. Interventions Patients with at least 72 h of gastric feeding were identified by review of case notes and ICU charts. The proportion that developed feed intolerance was determined. All patient received insulin therapy. Results The proportion of patients requiring gastric feeding for at least 72 h was similar between patients with and without DM (42%, 50/118, vs. 42%, 222/531). Data from patients with DM were also compared with a group of 50 patients matched for age, sex and APACHE II score, selected from the total non-diabetic group. The occurrence of feed intolerance (DM 52% vs. matched non-DM 50% vs. unselected non-diabetic 58%) and the time taken to develop feed intolerance (DM 62.6 ± 43.8 h vs. matched non-DM 45.3 ± 54.6 vs. unselected non-diabetic 50.6 ± 59.5) were similar amongst the three groups. Feed intolerance was associated with a greater use of morphine/midazolam and vasopressor support, a lower feeding rate and a longer ICU length of stay. Conclusions In critically ill patients who require prolonged enteral nutrition, a prior history of DM type II does not appear to be a further risk factor for feed intolerance. This research was supported by the National Health and Medical Research Council of Australia An erratum to this article can be found at     

Elevated troponin T concentrations in critically ill patients

Objective To determine the incidence of troponin T elevations among a selected group of critically ill patients, to correlate these findings to electrocardiographs, and to compare troponin T-positive and T-negative patients in relation to clinical parameters.Design Prospective study.Setting Mixed surgical and medical intensive care unit.Patients Thirty-four consecutive critically ill patients who were mechanically ventilated or underwent thoracic or vascular surgery.Interventions Blood samples were collected at admission, the next morning, and 24 h after the second blood sampling. These samples were used for troponin T measurement and electrocardiographs were made when troponin T levels were elevated.Main results Eleven of 34 patients (32%) had elevated troponin T levels, which were already present upon admission in eight out of 11 patients (73%). Most patients underwent surgery prior to ICU admission (21 of 34 patients). Significantly (P=0.0055) more troponin T-positive patients underwent acute surgery, and significantly more (P=0.045) troponin T-positive patients suffered from hypotension. Only four of the troponin T-positive patients were diagnosed as suffering from an acute myocardial infarction based on electrocardiographs. All troponin T-positive patients had coronary artery disease: nine had a history of CAD and two had actual CAD. No difference in mortality rates was observed between troponin T-positive and T-negative patients.Conclusions An unexpectedly high percentage of included patients had troponin T elevations, which could be corroborated by electrocardiographs in only four cases suggesting that a high percentage of critically ill patients with a history of CAD suffer from clinically unrecognised (minor) myocardial damage.     

肌钙蛋白I测定在急重症患者监测中的作用

目的探讨急重症患者的肌钙蛋白I（cTnI）变化,并分析其与预后的关系.方法 136例急重症患者,于入院后6 h及24 h测定cTnI浓度.记录患者的性别、年龄、心电图变化及预后等,评估其cTnI升高率.分析cTnI与肌酸激酶及其同工酶的相关性.结果 47例患者cTnI升高,升高率为35%.cTnI与肌酸激酶及其同工酶呈明显正相关.cTnI升高的前6位疾病为心功能不全、心律失常、肺部感染、休克、电解质紊乱和肺栓塞.cTnI升高组病死率较正常组高.结论急重症患者cTnI升高,与肌酸激酶及其同工酶相关.cTnI升高患者预后差.cTnI测定可作为急重症患者预后监测的一项可靠指标.     

危重患者早期肠内营养相关并发症分析

目的 观察综合性ICU危重症患者早期肠内营养支持中，相关并发症的发生及其相关因素。方法 119例入住ICU接受早期肠内营养支持患者，入ICU后根据24小时内各项监护指标及血常规、血气分析及肝肾功能检查，进行APACHE-Ⅱ评分。观察肠内营养量、速度、血清白蛋白(Alb)及肠内营养的耐受情况。总结各种肠内营养并发症的发生率。结果 随APACHE-Ⅱ评分的增加，肠内营养耐受的最大维持量降低、达最大维持量的时间延长、相关并发症的发生率增加。腹泻发生与Alb水平呈负相关，与APACHE-Ⅱ评分呈正相关。肠内营养并发症中以腹泻最为常见。结论 肠内营养相关并发症与疾病严重程度、血清蛋白水平等因素相关，一些危重患者无法过渡到完全肠内营养(TEN)，而需以静脉营养(PN) 肠内营养(EN)形式实现营养支持。     

Polymicrobial bacteremia in critically ill patients

Objective To characterize the epidemiology of polymicrobial bacteremia (PMB) among critically ill patients.Design Prospective clinical study.Setting University medical center.Patients All patients with positive blood cultures in a medical-surgical ICU.Measurements PMB represents 8.4% of all true bacteremia in our ICU. Most of these patients were post-operative but none had malignancies or significant immunodepression. Over three-quarters of the episodes were nosocomial. No significant differences in factors associated with PMB were found when they were compared with a cohort of 154 monomicrobial episodes. Enterobacteriaceae were the most common organisms. Intravascular devices (42.8%) were the most common source of PMB, followed by intra-abdominal origin (21.4%). The overall mortality was 7.1%, a lower rate than has previously been described.Conclusions We suggest catheter replacement in patients who develop PMB and improving techniques of catheter maintenance in order to reduce its incidence.     

Glycated hemoglobin A1C and diabetes mellitus in critically ill patients

BACKGROUND:

Hyperglycemia has been detected in many critically ill patients in the department of emergency medicine. But its mechanism and prognosis have not been well elucidated. In this study, we measured the serum level of glycated hemoglobin A1C (HbA1c) in critically ill patients to evaluate the effects of hyperglycemia on the prognosis of the patients.

METHODS:

A total of 826 critically ill patients, who had been treated at the Department of Emergency Medicine of Chaoyang Hospital during October 2006 and November 2007, were divided into a diabetes mellitus group (n=184) and a non-diabetes mellitus group (642) according to whether they had diabetes mellitus. Fasting glucose and HbA1c were measured in all patients. Those in the diabetes mellitus group were further assigned to a drug therapy subgroup and a non-drug therapy subgroup; the serum level of HbA1c and its relationship with short-term outcome were evaluated.

RESULTS:

Fasting glucose increased in 78.8% of the patients (88.6% in the diabetes mellitus group, and 75.9% in the non-diabetes mellitus group, P<0.05), and HbA1c was elevated in 45.5% of the patients (78.3% in the diabetes mellitus group, and 36.1% in the non-diabetes mellitus group, P<0.01). Fasting glucose, HbA1c and 28-day mortality were improved more significantly (P<0.01) in the drug therapy subgroup than in the non-drug therapy subgroup. The 28-day mortality was more significantly different in patients with fasting blood glucose >8.33 mmol/L than in those with fasting blood glucose <8.33 mmol/L.

CONCLUSIONS:

Hyperglycemia of critically ill patients could not totally attribute to stress response, especially in those who have no history of diabetes mellitus. Prognosis of hyperglycemia may vary among critically ill patients.KEY WORDS: Glycosylated hemoglobin A1C, Diabetes mellitus, Hyperglycemia, Prognosis, Critically ill patients     

Computer-assisted glucose control in critically ill patients

OBJECTIVE: Intensive insulin therapy is associated with the risk of hypoglycemia and increased costs of material and personnel. We therefore evaluated the safety and efficiency of a computer-assisted glucose control protocol in a large population of critically ill patients. DESIGN AND SETTING: Observational cohort study in three intensive care units (32 beds) in a 1,300-bed university teaching hospital. PATIENTS: All 2,800 patients admitted to the surgical, neurosurgical, and cardiothoracic units; the study period started at each ICU after implementation of Glucose Regulation for Intensive Care Patients (GRIP), a freely available computer-assisted glucose control protocol. MEASUREMENTS AND RESULTS: We analysed compliance in relation to recommended insulin pump rates and glucose measurement frequency. Patients were on GRIP-ordered pump rates 97% of time. Median measurement time was 5[Symbol: see text]min late (IQR 20[Symbol: see text]min early to 34[Symbol: see text]min late). Hypoglycemia was uncommon (7% of patients for mild hypoglycemia, <[Symbol: see text]3.5[Symbol: see text]mmol/l; 0.86% for severe hypoglycemia, <[Symbol: see text]2.2[Symbol: see text]mmol/l). Our predefined target range (4.0-7.5[Symbol: see text]mmol/l) was reached after a median of 5.6[Symbol: see text]h (IQR 0.2-11.8) and maintained for 89% (70-100%) of the remaining stay at the ICU. The number of measurements needed was 5.9 (4.8-7.3) per patient per day. In-hospital mortality was 10.1%. CONCLUSIONS: Our computer-assisted glucose control protocol provides safe and efficient glucose regulation in routine intensive care practice. A low rate of hypoglycemic episodes was achieved with a considerably lower number of glucose measurements than used in most other schemes.     

Coagulation biomarkers in critically ill patients

This article discusses coagulation biomarkers in critically ill patients where coagulation abnormalities occur frequently and may have a major impact on the outcome. An adequate explanation for the cause is important, since many underlying disorders may require specific treatment and supportive therapy directed at the underlying condition. Deficiencies in platelets and coagulation factors in bleeding patients or patients at risk for bleeding can be achieved by transfusion of platelet concentrate or plasma products, respectively. Prohemostatic treatment may be beneficial in case of severe bleeding, whereas restoring physiological anticoagulant pathways may be helpful in patients with sepsis and disseminated intravascular coagulation.     

Thiamine deficiency in critically ill patients with sepsis

ObjectiveThe objective of the study was to determine the prevalence of absolute thiamine deficiency (TD) in critically ill patients with sepsis and to examine the association between thiamine levels and lactic acidosis.DesignThis was a prospective, observational study.SettingThe setting was an urban, tertiary care center with approximately 50 000 emergency department visits per year and intensive care units numbering approximately 50 total beds.PatientsThirty study patients admitted with clinical suspicion of infection and evidence of tissue hypoperfusion, as defined by a lactic acid level greater than 4 mmol/L or hypotension (systolic blood pressure <90 mm Hg) requiring vasopressor support, were enrolled. A control group of 30 patients presenting to the emergency department with minor emergencies was also enrolled.InterventionsThere were no interventions.Measurements and Main ResultsPlasma thiamine levels were measured at 0, 24, 48, 72, and 162 hours for patients in the study group. Absolute TD was defined as less than or equal to 9 nmol/L derived from established abnormal ranges per Quest laboratory. In the study group, 3 (10%) of 30 had absolute TD upon presentation; and an additional 3 patients (6/30, 20%) developed TD within 72 hours. None of the 30 controls (0/30, 0%) exhibited absolute TD. Of the vasopressor-dependent population, 7.7% (2/26) displayed TD on presentation. For the group overall, there was no correlation between thiamine and lactic acidosis. However, in patients without liver dysfunction, thiamine was statistically significantly negatively correlated with lactic acidosis (r = ?.50; P = .02). The relationship between thiamine and lactic acidosis held after multivariable regression analysis controlling for age, sex, and comorbid disease (P < .02).ConclusionsThese preliminary findings indicate that critically ill patients may present with TD or develop this deficiency during their acute illness. We also identified a potential association between thiamine levels and lactic acidosis in patients without significant liver injury.     

早期肠内营养对危重患者的影响

目的通过对危重患者入院24～48h内早期肠内营养支持的研究，了解其对危重患者的影响。方法选择我院综合性ICU中的危重患者，随机分为实验组和对照组。实验组在入院24～48h内开始肠内营养；对照组在入院48h后开始肠内营养。检测两组患者的营养指标、感染发生率、机械通气时间。结果共有206例危重患者进入实验。实验组的热量摄入、氮平衡优于对照组，感染发生率降低。结论早期肠内营养能更好地改善危重患者的营养摄入，降低感染发生率。     

Etiology of troponin elevation in critically ill patients

Purpose

The aim of this study was to assess the etiology of cardiac troponin elevation among patients admitted to the intensive care unit (ICU) and to examine whether etiology affects mortality and length of stay.

Methods

All patients admitted over 2 months underwent screening with troponin measurements and were included if 1 or more measurements were elevated. Two adjudicators retrospectively reviewed patient charts to determine the likely cause of troponin elevation.

Results

Of 103 patient admissions, 52 (50.5%) had 1 or more elevated troponin measurements, and 49 (94.2%) had medical charts available for review. Troponin elevation was adjudicated as myocardial infarction (MI) in 53.1% of patients, sepsis in 18.4%, renal failure in 12.2%, and other causes in 16.3%. Overall ICU mortality was 16.0%; 2.0% for patients with no troponin elevation, 23.1% in patients with MI, and 39.1% in patients with troponin elevation not due to MI. Having an elevated troponin level not due to MI was significantly associated with increased hospital mortality compared with having no troponin elevation.

Conclusions

The most common cause of troponin elevation among critically ill patients was MI. Patients with elevated troponin had worse outcomes compared with patients without troponin elevation, and troponin elevation not due to MI was predictive of increased hospital mortality.     

Perioperative plasma melatonin concentration in postoperative critically ill patients: Its association with delirium

Purpose

Delirium is a common complication in postoperative critically ill patients. Although abnormal melatonin metabolism is thought to be one of the mechanisms of delirium, there have been few studies in which the association between alteration of perioperative plasma melatonin concentration and postoperative delirium was assessed.

Materials

We conducted a prospective observational study to assess the association of perioperative alteration of plasma melatonin concentration with delirium in 40 postoperative patients who required intensive care for more than 48 hours. We diagnosed postoperative delirium using Confusion Assessment Method for the intensive care unit and measured melatonin concentration 4 times (before the operation as the preoperative value, 1 hour after the operation, postoperative day 1, and postoperative day 2).

Results

Postoperative delirium occurred in 13 (33%) of the patients. Although there was no significant difference in preoperative melatonin concentration, Δ melatonin concentration at 1 hour after the operation was significantly lower in patients with delirium than in those without delirium (− 1.1 vs 0 pg/mL, P = .036). After adjustment of relevant confounders, Δ melatonin concentration was independently associated with risk of delirium (odds ratio, 0.50; P = .047).

Conclusions

Delta melatonin concentration at 1 hour after the operation has a significant independent association with risk of postoperative delirium.     

危重症患者早期肠内营养供给量的研究进展

对危重症患者而言,早期启用肠内营养（EN）不仅是补充营养,更重要的是发挥其在维持肠道功能和肠道微生态中的特殊重要作用。任何药物治疗产生的效果都与剂量相关,营养治疗亦是如此。理想的EN目标在于供给的量与质能够带给危重症患者最大获益与最小伤害,而充分营养供给并避免医源性营养不良是最终的理想目标。但是,早期EN的不耐受是危重症患者常面临的困难与挑战,不恰当的供给将会产生不良影响,甚至危害。认识这些可能的风险并予以规避是ICU医护人员需要重视与了解的必要知识。在一些严重的或特殊疾病状态下,及时评估及调整EN治疗方案才可能实现其理想目标,使患者最大获益。     

The P50 is reduced in critically ill patients

A prospective study was designed to measure the P50 in 20 critically ill patients, and compare it with the P50 measured in 20 normal individuals. Arterial blood gases, lactate, haemoglobin (Hb) and phosphate (PO₄) levels were also measured and compared with the P50 in the critically ill patients. The mean P50 of the critically ill patients was 24.5 mmHg (SD±2.9) and was significantly lower than the mean P50 of 26.2 (SD±2.2) in the normal individuals (p<0.05). In the critically ill patients, strong correlations were observed between the P50 and the arterial pH and base excess (BE) levels, with coefficients of 0.79 and 0.69 respectively whereas correlations between the P50 and arterial oxygen tension (PO₂), carbon dioxide tension (PCO₂), lactate, Hb and PO₄ levels were poor, with correlations of 0.001, 0.008, 0.07, 0.13 respectively. It is concluded that the P50 is commonly reduced in critically ill patients, and has a strong correlation with arterial pH and BE.     

Serum selenium and zinc levels in critically ill surgical patients

Purpose

The authors designed this study to determine how serum selenium and zinc affect the outcomes of critically ill surgical patients.

Methods

The medical records of 162 patients admitted to a surgical intensive care unit (ICU) from October 2010 to July 2012 and managed for more than 3 days were retrospectively investigated.

Results

Overall, the mean patient age was 61.2 ± 15.0 years, and the median ICU stay was 5 (3-115) days. The mean Acute Physiologic and Chronic Health Evaluation II score was 18.0 ± 8.0. Eighteen (11.1%) of the study subjects died in ICU. mean selenium levels were 83.5 ± 23.8 ng/dL in the survivor group and 83.3 ± 29.6 ng/dL in the nonsurvivor group, and corresponding mean zinc levels were 46.3 ± 21.7 and 65.6 ± 41.6 μg/dL, respectively. Mean selenium concentrations were significantly different in patients with and without shock (77.9 ± 25.4 and 87.2 ± 23.1 ng/dL, P = .017). Furthermore, mean serum selenium was lower in patients with sepsis than in traumatic or simply postoperative patients (P < .001 and P = .038). Serum Zn was significantly lower in patients with sepsis than in patients with trauma (43.4 ± 25.4 μg/dL vs 54.8 ± 28.1 μg/dL, P = .038).

Conclusions

To determine the effects of serum selenium and zinc levels on critically ill surgical patients, a large-scale prospective study is needed.     

危重病人床头抬高依从性的调查分析

目的了解ICU危重病人床头抬高30°～45°依从性的执行情况。方法由经过培训的护理人员对1 485例ICU危重病人,从6个不同时间点:8∶00、12∶00、16∶00、20∶00、24∶00、4∶00对床头抬高依从性进行调查,并比较护士年资、班别对床头抬高依从性的影响。结果符合床头抬高30°～45°的共352例次,依从性仅23.7%,白天平均床头抬高依从性较夜晚高31.87%;护士年资、班别比较差异有显著意义(P<0.05)。结论ICU危重病人床头抬高30°～45°依从性低,影响依从性的因素比较多,在执行过程中应积极采取培训及干预措施.以提高床头抬高依从性效果。     

Challenges in hyperglycemia management in critically ill patients with COVID-19

Hyperglycemia is commonly associated with adverse outcomes especially in patients requiring intensive care unit stay. Data from the corona virus disease 2019 (COVID-19) pandemic indicates that individuals with diabetes appear to be at similar risk for COVID-19 infection to those without diabetes but are more likely to experience increased morbidity and mortality. The proposed hypothesis for hyperglycemia in COVID-19 include insulin resistance, critical illness hyperglycemia (stress- induced hyperglycemia) secondary to high levels of hormones like cortisol and catecholamines that counteract insulin action, acute cytokine storm and pancreatic cell dysfunction. Diabetic patients are more likely to have severe hyperglycemic complications including diabetic ketoacidosis and hyperosmolar hyperglycemic state. Management of hyperglycemia in COVID-19 is often complicated by use of steroids, prolonged total parenteral or enteral nutrition, frequent acute hyperglycemic events, and restrictions with fluid management due to acute respiratory distress syndrome. While managing hyperglycemia special attention should be paid to mode of insulin delivery, frequency of glucose monitoring based on patient and caregiver safety thereby minimizing exposure and conserving personal protective equipment. In this article we describe the pathophysiology of hyperglycemia, challenges encountered in managing hyperglycemia, and review some potential solutions to address them.     

强化胰岛素治疗危重病患者40例

目的观察强化胰岛素治疗在危重病患者中的临床疗效。方法80例危重病患者随机分为两组,治疗组（40例）给予强化胰岛素治疗,使血糖维持在4．4—6．1mmol／L;对照组（40例）给予常规胰岛素治疗,使血糖控制在10．0—11．1mmol／L。观察两组患者使用抗生素的天数、使用呼吸机的天数、血透发生率、院内感染发生率及病死率。结果治疗组中使用抗生素天数（15±5）d,使用呼吸机天数（6±4）d,需行血透6例（15．0％）,院内感染6例（15．0％）,病死率17．5％,均明显低于对照组,P〈0．05,差异有统计学意义。结论对于危重病患者,当出现应激性高血糖时,强化胰岛素治疗可改善危重病患者的预后,降低其病死率。     

P-选择素在危重病患者心肌损伤中的作用

目的 :本课题对综合性重症监护病房患者的心肌损伤进行研究 ,旨在探讨危重病患者心肌损伤的可能机制。方法 :利用心肌肌钙蛋白T和P 选择素两项指标测定 ,对综合性重症监护病房内 1 5例APACHEⅡ≥ 1 6危重病患者和 2 0例健康献血员进行对比研究。结果 :①危重病患者心肌肌钙蛋白T浓度明显高于健康献血员 ,且其中死亡组又明显高于存活组 (P <0 0 1或P <0 0 5) ;②危重病患者的P 选择素在发病后 4、 2 4、 1 2 0h 3个时点均显著高于献血员 (P<0 0 1 ) ,死亡组危重病患者P 选择素浓度在发病 2 4h达峰值且显著高于存活组患者 (P <0 0 5) ;③在危重病患者发病后第 4、 2 4hcTnT与P 选择素两者呈显著正相关 (γ4=0 73 48,P <0 0 1 ;γ2 4 =0 6865,P <0 0 1 )。结论 :①在危重病患者中存在急性心肌损伤 ,且心肌损伤程度与患者的预后相关 ;②P 选择素在危重病患者心肌损伤的发生发展过程中起了重要作用。     

Evaluation of hemostatic biomarker abnormalities that precede platelet count decline in critically ill patients with sepsis

Purpose

The hemostatic biomarkers for early diagnosis of sepsis-associated coagulopathy have not been identified. The purpose of this study was to evaluate hemostatic biomarker abnormalities preceding a decrease in platelet count, which is a surrogate indicator of overt coagulopathy in sepsis.

Materials and Methods

Seventy-five septic patients with a platelet count more than 80 × 10³/μL were retrospectively analyzed. Hemostatic biomarkers at intensive care unit admission were compared between patients with and patients without a subsequent decrease in platelet count (≥ 30% within 5 days), and the ability of biomarkers to predict a decrease in platelet count was evaluated.

Results

Forty-two patients (56.0%) developed a subsequent decrease in platelet count. Severity of illness, incidence of organ dysfunction, and 28-day mortality rate were higher in patients with a subsequent decrease in platelet count. There were significant differences between patients with and patients without a subsequent decrease in platelet count in prothrombin time–international normalized ratio, fibrinogen, thrombin-antithrombin complex, antithrombin, protein C (PC), plasminogen, and α₂-plasmin inhibitor (α₂-PI). Receiver operating characteristic curve analysis showed that PC (area under the curve, 0.869; 95% confidence interval, 0.699-0.951) and α₂-PI (area under the curve, 0.885; 95% confidence interval, 0.714-0.959) were strong predictors of a subsequent decrease in platelet count.

Conclusions

Decreased PC and α₂-PI activity preceded a decrease in platelet count in intensive care unit patients with sepsis.