Benefits of intensive insulin therapy on neuromuscular complications in routine daily critical care practice: a retrospective study

Introduction  

Intensive insulin therapy (IIT) reduced the incidence of critical illness polyneuropathy and/or myopathy (CIP/CIM) and the need for prolonged mechanical ventilation (MV ≥ 14 days) in two randomised controlled trials (RCTs) on the effect of IIT in a surgical intensive care unit (SICU) and medical intensive care unit (MICU). In the present study, we investigated whether these effects are also present in daily clinical practice when IIT is implemented outside of a study protocol.     

The impact of do-not-resuscitate order on triage decisions to a medical intensive care unit

Purpose

To determine whether the presence of a do-not-resuscitate (DNR) order impacts on triage decisions to a medical intensive care unit (MICU) of an academic medical center.

Methods

Data were collected on 179 patients in whom MICU consultation was sought and included demographic, clinical information, diagnoses, ICU admission decision, Acute Physiological and Chronic Health Evaluation II (APACHE II) score, and the presence of DNR order. Functional status was determined retrospectively using the Modified Rankin Score.

Results

The only factor that influenced MICU admission was the presence of DNR order at the time of MICU consultation (odds ratio, 0.25; 95% confidence interval, 0.09-0.71, P < .006). There was no difference between the age, APACHE II scores, or functional status between admitted or refused. Medical intensive care unit admission was associated with increased length of stay without difference in mortality.

Conclusion

The presence of a DNR order at the time of MICU consultation was significantly associated with the decision to refuse a patient to the MICU.     

Circadian rhythm disruption in severe sepsis: the effect of ambient light on urinary 6-sulfatoxymelatonin secretion

Purpose  

Properly regulated circadian rhythm supports physical and immunologic function. This rhythm is disrupted in patients with critical illness. We assessed the association between ambient light and circadian melatonin release, measured by urinary 6-sulfatoxymelatonin (6-SMT), in medical intensive care unit (MICU) patients with severe sepsis.     

Expansion of the medical intensive care unit: clinical consequences in a large urban hospital

We examined how a permanent expansion of the medical ICU (MICU) affected resource utilization and severity of illness for intensive care admissions within a 700-bed urban teaching hospital. On our 162-bed medical service, construction of a separate cardiac care unit and the expansion of the MICU increased the number of core intensive care beds by 100%. We prospectively analyzed noncardiology MICU admissions 2 months before, immediately after, and 4 months after MICU expansion. Although the volume of MICU patients increased by 51% after MICU expansion, the severity of illness as determined by the Acute Physiology and Chronic Health Evaluation (APACHE II) score and types of admission diagnoses remained the same. Moreover, there was no change in MICU occupancy and length of stay, hospital or MICU mortality, or MICU readmission rate. The increased MICU patient volume came from the ED, transfers from other hospitals, and from other ICUs within our hospital. In contrast, the volume and severity of illness of MICU transfers from the inpatient medical floor service were constant in all time periods. These results suggest that, while MICU expansion increased patient volume, physician utilization of the MICU resources was unchanged. Our physicians used high-intensity ICU beds in a consistent fashion in response to external factors, such as ED activity, intramural ICU transfers, and referrals from other hospitals.     

A model for increasing palliative care in the intensive care unit: enhancing interprofessional consultation rates and communication

Background

Only a minority of patients who die in the medical intensive care unit (MICU) receive palliative care services. At the South Texas Veterans Health Care System Audie L. Murphy Hospital, only 5% of patients who died in the MICU from May to August 2010 received a palliative care consultation.

Measures

We measured the percentage of MICU patients for which there was a palliative care consultation during the intervention period.

Intervention

Starting October 1, 2010 and ending April 30, 2011, the palliative care and MICU teams participated in daily “pre-rounds” to identify patients at risk for poor outcomes, who may benefit from a palliative care consultation.

Outcomes

Palliative care consultation increased significantly from 5% to 59% for patients who died in the MICU during the intervention period. Additionally, palliative care consultation increased from 5% to 21% for all patients admitted to the MICU during the intervention period.

Conclusions/Lessons Learned

Daily pre-rounds between the palliative care and MICU teams increased palliative care services for MICU patients at risk for poor outcomes, who may benefit from a palliative care consultation.     

Pattern of end-of-life decisions in two Tunisian intensive care units: the role of culture and intensivists' training

Purpose  

End-of-life (EOL) decisions are not well studied in developing countries. We report EOL decision patterns in two Tunisian intensive care units [ICUs, medical (MICU) and surgical (SICU)] belonging to the same teaching hospital.     

Inter-hospital transport of critically ill patients; expect surprises

Introduction

Inter-hospital transport of critically ill patients is increasing. When performed by specialized retrieval teams there are less adverse events compared to transport by ambulance. These transports are performed with technical equipment also used in an Intensive Care Unit (ICU). As a consequence technical problems may arise and have to be dealt with on the road. In this study, all technical problems encountered while transporting patients with our mobile intensive care unit service (MICU) were evaluated.

Methods

From March 2009 until August 2011 all transports were reviewed for technical problems. The cause, solution and, where relevant, its influence on protocol were stated.

Results

In this period of 30 months, 353 patients were transported. In total 55 technical problems were encountered. We provide examples of how they influenced transport and how they may be resolved.

Conclusion

The use of technical equipment is part of intensive care medicine. Wherever this kind of equipment is used, technical problems will occur. During inter-hospital transports, without extra personnel or technical assistance, the transport team is dependent on its own ability to resolve these problems. Therefore, we emphasize the importance of having some technical understanding of the equipment used and the importance of training to anticipate, prevent and resolve technical problems. Being an outstanding intensivist on the ICU does not necessarily mean being qualified for transporting the critically ill as well. Although these are lessons derived from inter-hospital transport, they may also apply to intra-hospital transport.     

Ambient light levels and critical care outcomes

Purpose

Guidelines for the construction of critical care units require windows in room design to ensure a contribution of natural sunlight to ambient lighting. However, few studies have been published with evidence assessing this recommendation. We investigated the association of ambient light levels with clinical outcomes and sedative/analgesic/neuroleptic use in a medical intensive care unit (MICU).

Methods

This is a retrospective, observational study at a tertiary care facility with a 29-bed MICU. First/single MICU admissions between April 19, 2006, and June 30, 2009 (N = 3577), were analyzed with respect to clinical outcomes and sedation use according to MICU room orientation and corresponding light levels.

Results

Light levels were low but varied among the 4 room orientations. There were no significant differences in MICU mortality (north, 14.0%; east, 13.5%; west, 16.2%; south, 15.6%; P = .451), hospital mortality (20.8%, 20.9%, 22.2%, 22.3%; P = .796), 28-day intensive care unit–free days (17.6 ± 10.2, 18.0 ± 10.1, 17.7 ± 10.5, 17.2 ± 10.4; P = .555), 28-day ventilator-free days (16.3 ± 11.1, 16.5 ± 11.1, 15.5 ± 11.5, 15.4 ± 11.4; P = .273). No clinically significant differences in intravenous sedative/analgesic use occurred across room orientations.

Conclusions

Despite differing ambient light, room orientation was not associated with critical care outcomes or differences in sedative/analgesic/neuroleptic use. Current guidelines positing that windows alone are necessary or sufficient for MICU room light management may require further investigation and consideration.     

Early use of imipenem/cilastatin and vancomycin followed by de-escalation versus conventional antimicrobials without de-escalation for patients with hospital-acquired pneumonia in a medical ICU: a randomized clinical trial

Introduction

Although early use of broad-spectrum antimicrobials in critically ill patients may increase antimicrobial adequacy, uncontrolled use of these agents may select for more-resistant organisms. This study investigated the effects of early use of broad-spectrum antimicrobials in critically ill patients with hospital-acquired pneumonia.

Methods

We compared the early use of broad-spectrum antimicrobials plus subsequent de-escalation (DE) with conventional antimicrobial treatment (non-de-escalation, NDE) in critically ill patients with hospital-acquired pneumonia (HAP). This open-label, randomized clinical trial was performed in patients in a tertiary-care center medical intensive care unit (MICU) in Korea. Patients (n = 54) randomized to the DE group received initial imipenem/cilastatin plus vancomycin with subsequent de-escalation according to culture results, whereas patients randomized to the NDE group (n = 55) received noncarbapenem, nonvancomycin empiric antimicrobials.

Results

Between November 2004 and October 2006, 109 MICU patients with HAP were enrolled. Initial antimicrobial adequacy was significantly higher in the DE than in the NDE group for Gram-positive organisms (100% versus 14.3%; P < 0.001), but not for Gram-negative organisms (64.3% versus 85.7%; P = 0.190). Mean intensive care unit (ICU) stay, and 14-day, 28-day, and overall mortality rates did not differ in the two groups. Among culture-positive patients, mortality from methicillin-resistant Staphylococcus aureus (MRSA) pneumonia was higher in the DE group, even after early administration of vancomycin. Multidrug-resistant organisms, especially MRSA, were more likely to emerge in the DE group (adjusted hazard ratio for emergence of MRSA, 3.84; 95% confidence interval, 1.06 to 13.91).

Conclusions

The therapeutic advantage of early administration of broad-spectrum antimicrobials, especially with vancomycin, was not evident in this study.     

Obstetric intensive care unit admission: a 2-year nationwide population-based cohort study

Purpose  

As part of a larger nationwide enquiry into severe maternal morbidity, our aim was to assess the incidence and possible risk factors of obstetric intensive care unit (ICU) admission in the Netherlands.     

Prolonged mechanical ventilation in a respiratory-care setting: a comparison of outcome between tracheostomized and translaryngeal intubated patients

Introduction  

Mechanical ventilation of patients may be accomplished by either translaryngeal intubation or tracheostomy. Although numerous intensive care unit (ICU) studies have compared various outcomes between the two techniques, no definitive consensus indicates that tracheostomy is superior. Comparable studies have not been performed in a respiratory care center (RCC) setting.     

Predictive factors of death in primary lung cancer patients on admission to the intensive care unit

OBJECTIVE: To assess the lung cancer patient's prognosis in the intensive care unit with early predictive factors of death. DESIGN: Retrospective study from July 1986 to February 1996. SETTING: Medical intensive care unit at a university hospital. PATIENTS: Fifty-seven patients with primary lung cancer admitted to our medical intensive care unit (MICU). MEASUREMENTS AND RESULTS: Data collection included demographic data (age, sex, underlying diseases, MICU admitting diagnosis) and evaluation of tumor (pathologic subtypes, metastases, lung cancer staging, treatment options). Three indexes were calculated for each patient: Karnofsky performance status, Simplified Acute Physiology Score (SAPS) II, and multisystem organ failure score (ODIN score). Mortality was high in the MICU: 66% of patients died during their MICU stay, and hospital mortality reached 75%. In multivariate analysis, acute pulmonary disease and Karnofsky performance status < 70 were associated with a poor MICU and post-MICU prognosis. For the survivors, long-term survival after MICU discharge depended exclusively on the severity of the lung cancer. CONCLUSIONS: We confirmed the high mortality rate of lung cancer patients admitted to the MICU. Two predictive factors of death in MICU were identified: performance status < 70 and acute pulmonary disease.     

Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project

Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project.

Objectives

To (1) reduce deep sedation and delirium to permit mobilization, (2) increase the frequency of rehabilitation consultations and treatments to improve patients' functional mobility, and (3) evaluate effects on length of stay.

Design

Seven-month prospective before/after quality improvement project.

Setting

Sixteen-bed medical intensive care unit (MICU) in academic hospital.

Participants

57 patients mechanically ventilated 4 days or longer.

Intervention

A multidisciplinary team focused on reducing heavy sedation and increasing MICU staffing to include full-time physical and occupational therapists with new consultation guidelines.

Main Outcome Measures

Sedation and delirium status, rehabilitation treatments, functional mobility.

Results

Compared with before the quality improvement project, benzodiazepine use decreased markedly (proportion of MICU days that patients received benzodiazepines [50% vs 25%, P=.002]), with lower median daily sedative doses (47 vs 15mg midazolam equivalents [P=.09] and 71 vs 24 mg morphine equivalents [P=.01]). Patients had improved sedation and delirium status (MICU days alert [30% vs 67%, P<.001] and not delirious [21% vs 53%, P=.003]). There were a greater median number of rehabilitation treatments per patient (1 vs 7, P<.001) with a higher level of functional mobility (treatments involving sitting or greater mobility, 56% vs 78%, P=.03). Hospital administrative data demonstrated that across all MICU patients, there was a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4-3.8) and 3.1 (0.3-5.9) days, respectively, and a 20% increase in MICU admissions compared with the same period in the prior year.

Conclusions

Using a quality improvement process, intensive care unit delirium, physical rehabilitation, and functional mobility were markedly improved and associated with decreased length of stay.     

Location of patients before transfer to a tertiary care intensive care unit: Impact on outcome

Objective

To evaluate the impact of the source of patients transferred to a tertiary care intensive care unit (ICU) (referring hospital ICU vs referring hospital emergency department [ED]) on outcomes of transferred patients.

Design and Setting

We performed a retrospective review of data contained in the Project Impact database of a medical-surgical ICU at a university hospital.

Patients and Participants

A total of 503 patients transferred from local community hospitals, 283 from EDs and 220 from ICUs, were identified and included. In addition to comparing all ED transfers with all ICU transfers, comparisons between the 2 populations were made for the subgroups of patients with intracranial hemorrhage (group 1), nonhemorrhagic stroke (group 2), and all other patients (group 3).

Measurements and Results

Patients were evaluated for a variety of outcome parameters, including mortality and ICU and hospital length of stay (LOS) according to their location at the referring hospital at the time of transfer: ICU (ICUtx) or ED (EDtx). Mortality was significantly lower among EDtx in all transferred patients as well as in groups 2 and 3 with no difference in mortality identified in group 1. Intensive care unit LOS was shorter for EDtx and the 3 groups, and hospital LOS was shorter among all EDtx and those in group 3. Group 3 EDtx also had lower than predicted mortality.

Conclusions

Transfer of patients to a tertiary care ICU from the ED of a referring hospital is associated with significantly better outcomes than transfers from referring hospital ICUs.     

Clinical presentation,management and outcomes in the Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF)

Purpose  

We performed a survey on acute heart failure (AHF) in nine countries in four continents. We aimed to describe characteristics and management of AHF among various countries, to compare patients with de novo AHF versus patients with a pre-existing episode of AHF, and to describe subpopulations hospitalized in intensive care unit (ICU) versus cardiac care unit (CCU) versus ward.     

Outcomes and prognostic factors of patients with lung cancer and pneumonia-induced respiratory failure in a medical intensive care unit: A single-center study

Purpose

To evaluate the outcomes and prognostic factors of 28-day mortality following medical intensive care unit (MICU) admission of patients with lung cancer and pneumonia-induced respiratory failure.

Materials and methods

Patients admitted to the MICU of a tertiary referral hospital between 2000 and 2009 were retrospectively studied.

Results

In total, 143 patients were included. Their mean age was 65 ± 8 years and 94% were male. The 28-day mortality rate was 57%. Multivariate analysis was performed to identify variables associated with 28-day mortality. At 72 hours after admission, a history of radiotherapy (OR = 2.80, 95% CI: 1.15-6.78), Pao₂/Fio₂ (P/F) ratio at admission of < 100 mmHg (OR = 5.62, 95% CI: 2.10-15.07), P/F ratio after 72 hours of < 100 mmHg (OR = 4.61, 95% CI: 1.24-17.15), and arterial pH after 72 hours of < 7.30 (OR = 5.78, 95% CI: 1.15-28.89) were associated with increased mortality.

Conclusions

The prognosis of patients with lung cancer and severe pneumonia after 72 hours of MICU management mainly depends on the severity of the underlying lung injury, which is reflected by a history of radiotherapy and a low P/F ratio, rather than on cancer stage or disease status.     

Towards a feasible algorithm for tight glycaemic control in critically ill patients: a systematic review of the literature

Introduction  

Tight glycaemic control is an important issue in the management of intensive care unit (ICU) patients. The glycaemic goals described by Van Den Berghe and colleagues in their landmark study of intensive insulin therapy appear difficult to achieve in a real life ICU setting. Most clinicians and nurses are concerned about a potentially increased frequency of severe hypoglycaemic episodes with more stringent glycaemic control. One of the steps we took before we implemented a glucose regulation protocol was to review published trials employing insulin/glucose algorithms in critically ill patients.     

The prevalence of undiagnosed diabetes mellitus and the association of baseline glycemic control on mortality in the intensive care unit: A prospective observational study

Purpose

Hyperglycemia is common during critical illness and can adversely affect clinical outcomes. We sought to determine the prevalence of undiagnosed diabetes among medical intensive care unit (MICU) patients with stress hyperglycemia and the association between baseline glycemic control and mortality.

Materials and methods

A prospective, observational cohort study was performed at a tertiary care MICU. Hemoglobin A1c (HbA1c) levels were obtained from any patient who developed hyperglycemia and all known diabetic patients. We assessed the prevalence of undiagnosed diabetes (defined by HbA1c) among patients with stress hyperglycemia, and the association between baseline glycemic control and mortality.

Results

We enrolled 299 patients. One hundred two (34.1%) had no history and 197 (65.9%) had a history of diabetes. Of the nondiabetic patients, 14 (13.7%) had an HbA1c of at least 6.5%. There was a significant difference in mortality between patients with HbA1c less than 6.5% and those with HbA1c of at least 6.5% (19.3% vs 11.7%, P = .038), despite similar Acute Physiology and Chronic Health Evaluation II scores. There was no significant difference in demographic characteristics between these groups. Multivariable logistic regression revealed lower HbA1c levels to be significantly associated with increased hospital mortality (odds ratio, 1.92; 95% confidence interval, 1.30-2.85; P = .001).

Conclusion

A significant number of MICU patients with stress hyperglycemia have undiagnosed diabetes. Hyperglycemia with lower baseline HbA1c was associated with increased mortality.     

Cognitive improvement during continuous sedation in critically ill, awake and responsive patients: the Acute Neurological ICU Sedation Trial (ANIST)

Introduction  

Most anxiolytics and sedative regimens in the intensive care unit (ICU) impair intellectual function, reducing patient autonomy, and often add to patient morbidity. Using an ICU-validated cognitive assessment tool Adapted Cognitive Exam (ACE), we performed a comparison between dexmedetomidine (DEX) and propofol (PRO) to evaluate which sedative regimen offered the least decrement in intellectual capacity.