Short acting insulin analogues in intensive care unit patients

Blood glucose control in intensive care unit(ICU) patients, addressed to actively maintain blood glucose concentration within defined thresholds, is based on two major therapeutic interventions: to supply an adequate calories load and, when necessary, to continuously infuse insulin titrated to patients needs: intensive insulin therapy(IIT). Short acting insulin analogues(SAIA) have been synthesized to improve the chronic treatment of patients with diabetes but, because of the pharmacokinetic characteristics that include shorter onset and off-set, they can be effectively used also in ICU patients and have the potential to be associated with a more limited risk of inducing episodes of iatrogenic hypoglycemia. Medical therapies carry an intrinsic risk for collateral effects; this can be more harmful in patients with unstable clinical conditions like ICU patients. To minimize these risks, the use of short acting drugs in ICU patients have gained a progressively larger room in ICU and now pharmaceutical companies and researchers design drugs dedicated to this subset of medical practice. In this article we report the rationale of using short acting drugs in ICU patients(i.e., sedation and treatment of arterial hypertension) and we also describe SAIA and their therapeutic use in ICU with the potential to minimize iatrogenic hypoglycemia relatedto IIT. The pharmacodynamic and pharmachokinetic characteristics of SAIA will be also discussed.     

胰岛素受体改变及血糖控制对危重症患者的影响

目的 探讨术后重症患者胰岛素受体的变化规律及严格血糖控制对其功能的影响.方法 以19例APACHEⅡ评分≥10分的术后重症患者为研究对象,根据血糖控制目标随机分为严格血糖控制组(控制血糖在4.4～6.7 mmol/L)和高血糖组(控制血糖在8.3～10.0 mmol/L).持续静脉泵入胰岛素控制血糖,记录血糖值和胰岛素用量.同时测定红细胞胰岛素受体(InsR)数目和亲和常数(K).结果 全部患者均出现血糖升高;术后第1天的红细胞胰岛素受体数目及亲和常数均明显低于正常,第2、4、7天逐渐恢复,但仍低于正常水平;APACHEⅡ评分≥15分者,第1天红细胞胰岛素受体数目、亲和常数明显低于APACHEⅡ评分＜15分的患者;平均每日胰岛素用量随红细胞胰岛素受体的恢复而逐渐减少,两者呈负相关;严格血糖控制组红细胞胰岛素受体数目和亲和常数的恢复明显好于高血糖组.两组间每日平均胰岛素用量无明显差异.结论 胰岛素受体的改变在应激性高血糖的发生中起一定作用,血糖正常化可能有助于胰岛素受体的恢复.     

短期胰岛素强化治疗对围手术期高血糖患者胰岛β细胞功能的影响

【摘要】 目的 探讨短期胰岛素强化治疗对围手术期高血糖患者β细胞功能的影响。方法回顾性分析2011年1月~2013年7月我院短期胰岛素强化治疗围手术期高血糖的患者临床资料,其中采用持续性皮下胰岛素输注治疗患者25例(CSII组),采用多次皮下胰岛素注射治疗患者20例(MSII组)。治疗2周后,比较两组的血糖控制(FBG、2hPG、GSP)、β细胞功能、胰岛素敏感性指标以及TNF-α、IL-1β、CRP、APN的变化情况。结果〓CSII组与MSII组的FBG、2hPG、GSP水平均较治疗前显著降低,差异具有统计学意义(P<0.05);治疗后CSII组的FBG、2hPG、GSP水平与MSII组比较,差异不显著(P>0.05)。CSII组与MSII组的GSP、Homa-IR水平均较治疗前显著降低,Homa-β较治疗前显著升高,且与MSII组比较改善更显著(P<0.05);同样CSII组TNF-α、IL-1β、CRP水平与MSII组比较也改善更显著(P<0.05)。结论〓持续性皮下胰岛素输注治疗可有效控制血糖,显著改善胰岛β功能及提高胰岛素敏感性,其机制可能与下调炎性因子有关。     

Techniques of tracheostomy for intensive care unit patients

The author and his colleagues believe that the surgical technique used constructing a tracheostomy can have a profound effect on the safety and care of patients in the intensive care unit particularly in the first few days after the operation. The Bj?rk procedure is commended to the surgeons.     

Assessing critical care unit performance: a global measure using graphical analysis

Outcome measurement in critical care is difficult because of the wide variety of patients treated and the diverse therapeutic options and pathways available. Individual outcome measures for critical care are available but are naturally limited to only a single aspect of performance. Most importantly, better performance in one aspect of care may compromise the standard of care in another. A global measure of performance would be helpful. For the year 1999-2000, the five hospitals in the East Anglian Critical Care Network provided data on capacity, workload and performance. The data was transformed and displayed graphically on a radar chart so that the area of the polygon within the radar chart was proportional to each unit's overall performance. The results from the five hospitals suggest that there is little overall difference in the units' global performance but the graphical representation highlighted some individual deficiencies. Graphical analysis of complex processes such as critical care delivery may facilitate performance assessment, providing that the measures chosen, weightings assigned and scales used are standardised with care.     

The role of a critical care unit in an epidemic

The role of a critical care unit in life-threatening situations is well established. The management of 52 children with acute gastroenteritis and 22 children with acute paralytic poliomyelitis as part of recent epidemics is described. The solutions to the problems in the critical care management of these 74 victims (out of a total of 6197 patients admitted during the epidemics) are discussed.     

Reasons for withdrawing treatment in patients receiving intensive care

We studied the frequency with which treatment was withdrawn in intensive care patients and the primary reason for reaching this decision. The medical records of patients having had active treatment withdrawn between August 1992 and February 1996 inclusive were reviewed. Patients were classified into an imminent death group consisting of those expected to die, a qualitative group who had treatment withdrawn on quality of life considerations and a lethal conditions group who had associated disease that precluded long-term survival. There were 1745 patients admitted, of whom 338 (19.4%) died in ICU. In 220 patients death followed the withdrawal of treatment (12.6% of all ICU admissions), 203 dying on ICU (60% of ICU deaths) and a further 17 soon after discharge to a ward. The primary reason for treatment withdrawal was imminent death in 45% of patients, qualitative considerations in 50% and lethal conditions in 5%. The reason varied significantly depending on the patient's age. Treatment is withdrawn commonly in ICU, the primary reason being quality of life considerations as often as because death is the expected outcome.     

Intensive care patients in district hospitals. A case for transfer?

Patients, admitted and primarily treated in a rural hospital, who required varying periods of intensive care management have been reviewed. The criteria for transfer of such patients to more specialised units and the hazards associated with ambulance travel are discussed. We describe measures to reduce these hazards and also a scheme for more uniform documentation and follow-up of such cases by the anaesthetist involved in primary care.     

Occupancy of a teaching hospital adult intensive care unit by high dependency patients

We assessed the hourly occupancy of our intensive care unit by high dependency patients over an 8-week period using the criteria established by the Working Group on Guidelines on Admission to and Discharge from Intensive Care and High Dependency Units published by the National Health Service Executive. High dependency patients accounted for 1914 bed hours (21.6%) out of a potential available total of 8880 hours. Measurement of Therapeutic Intervention Scoring System points and Acute Physiology and Chronic Health Evaluation II scores confirmed that categorising patients according to the new guidelines produced significantly different populations of patients. Mean (standard deviation) Therapeutic Intervention Scoring System points for intensive care status patients were 38.57 (10.40) compared to 21.66 (5.98) points for high dependency status patients (p < 0.001). Median (range) Acute Physiology and Chronic Health Evaluation II score for intensive care status patients was 16 (1–45) compared to 11 (1–27) for high dependency status patients (p < 0.0001). Calculating bed occupancy with different definitions for the whole of our intensive care unit population during the 8 weeks revealed a range of occupancies between 85.3% and 107.3%. We recommend that intensive care unit bed occupancy should be calculated in a standard manner nationally to allow comparison between units. We suggest that hourly occupancy be adopted as the universal method.     

French survey on current use of ultrasound in the critical care unit: ECHOREA

Introduction

Over the last ten years, ultrasound became standard procedure in the intensive care unit (ICU).

Study design

A national survey to evaluate the use of this technique in French ICUs.

Methods

Three hundred and twenty-seven units were contacted from the listing of the Société de réanimation de langue française (SRLF). A survey containing 20 questions addressing the availability, the training for, and the use of ultrasound was sent to the ICUs. Collection of data took place over a period of three months.

Results

We received 132 completed surveys out of the 327 sent out (40%). Seventy-nine percent of the public community and private centers and 94% of the university centers had an available device in the unit. Forty percent of the units carried out five to ten examinations per week. Seventy-two percent had staff trained in echocardiography. Fifty-five percent used association of monitoring techniques for the haemodynamic assessment of patients with shock. Only 73% carried out formalized reports after examination. In more than 80%, the echocardiograph was also used for the evaluation of other organs.

Conclusion

Ultrasound, and particularly echocardiography, has taken on a more prominent role in the routine assessment of critically ill patients. The availability of equipment and of training has increased over the last ten years, but the demand for training in this area remains strong. This French survey confirms this technique became the “extension of the hand” of the intensivist in ICU.     

Antibiotic-treated infections in intensive care patients in the UK

The purpose of this audit was to study reasons for starting antibiotic therapy, duration of antibiotic treatment, reasons for changing antibiotics and the agreement between clinical suspicion and microbiological results in intensive care practice. We conducted a multicentre observational audit of 316 patients. Data on demographic details, site, treatment and nature of infection were collected. The median duration of antibiotic therapy was 7 days. Infections were community-acquired in 160 patients (55%). Antibiotics were started on clinical suspicion of infection in 237 patients (75%). Pulmonary infections were the most common, representing 52% of all proven infections. Gram-negative organisms were the most common cause of proven infections (n = 90 (50%)). The antibiotic spectrum was narrowed in light of microbiology results in 78 patients (43%) and changed due to antibiotic resistance in 38 patients (21%). We conclude that the mean duration of treatment contrasts with existing published guidelines, highlighting the need for further studies on duration and efficacy of treatment in intensive care.     

Conventional insulin vs insulin infusion therapy in acute coronary syndrome diabetic patients

AIM:To evaluate the impact on glucose variability(GLUCV)of an nurse-implemented insulin infusion protocol when compared with a conventional insulin treatment during the day-to-day clinical activity.METHODS:We enrolled 44 type 2 diabetic patients(n=32 males;n=12 females)with acute coronary syndrome(ACS)and randomy assigned to standard a subcutaneous insulin treatment(n=23)or a nurse-implemented continuous intravenous insulin infusion protocol(n=21).We utilized some parameters of GLUCV representing well-known surrogate markers of prognosis,i.e.,glucose standard deviation(SD),the mean dailyδglucose(mean of daily difference between maximum and minimum glucose),and the coefficient of variation(CV)of glucose,expressed as percent glucose(SD)/glu-cose(mean).RESULTS:At the admission,first fasting blood glucose,pharmacological treatments(insulin and/or anti-diabetic drugs)prior to entering the study and basal glycated hemoglobin(HbA1c)were observed in the two groups treated with subcutaneous or intravenous insulin infusion,respectively.When compared with patients submitted to standard therapy,insulin-infused patients showed both increased first 24-h(median 6.9 mmol/L vs 5.7mmol/L P0.045)and overall hospitalizationδglucose(median 10.9 mmol/L vs 9.3 mmol/L,P0.028),with a tendency to a significant increase in first 24-h glycaemic CV(23.1%vs 19.6%,P0.053).Severe hypoglycaemia was rare(14.3%),and it was observed only in 3 patients receiving insulin infusion therapy.HbA1c values measured during hospitalization and 3 mo after discharge did not differ in the two groups of treatment.CONCLUSION:Our pilot data suggest that no real benefit in terms of GLUCV is observed when routinely managing blood glucose by insulin infusion therapy in type 2 diabetic ACS hospitalized patients in respect to conventional insulin treatment     

Mathematical modelling and simulation for planning critical care capacity

Using average number of patients expected in a year, average length of stay and a target occupancy level to calculate the number of critical care beds needed is mathematically incorrect because of nonlinearity and variability in the factors that control length of stay. For a target occupancy in excess of 80%, this simple calculation will typically underestimate the number of beds required. More seriously, it provides no quantitative guidance information about other aspects of critical care demand such as the numbers of emergency patients transferred, deferral rates for elective patients and overall utilisation. The combination of appropriately analysing raw data and detailed mathematical modelling provides a much better method for estimating numbers of beds required. We describe this modelling approach together with evidence of its performance.     

超声心动图对重症监护室患者管理重要性的研究

目的 超声心动图对重症监护室(intensive care unit,ICU)患者的管理有着重要的作用,研究分析由具备基本心脏超声检查能力的ICU医师完成的超声检查对ICU患者管理的意义.方法 采用回顾性临床观察研究的方法,纳入并记录2009年8月～2010年5月本院ICU中行经胸超声心动图(trans-thoraci...     

ICU management of patients with Parkinson's disease or Parkinsonism

Parkinson's disease (PD) is a common neurodegenerative disorder, occurring in at least 1% of patients older than 65 years of age and characterized by bradykinesia, rigidity, and tremor. Parkinsonism is a broad term for patients with PD and Parkinson's like disorders. Due to the aging population, the number of patients admitted to the intensive care unit (ICU) with PD or disorders with Parkinsonism is expected to rise in the future. For optimal ICU care, PD co-morbidities of memory impairment, aspiration, and dysautonomia require special attention. Withdrawal of dopaminergic medications in the perioperative state or ICU can lead to worsened PD symptoms, chest wall rigidity complicating ventilator management, and a severe hyperpyrexia, rigid, encephalopathic state termed neuroleptic malignant syndrome (NMS). PD patients are also sensitive to antipsychotic and antiemetic medications, which can exacerbate rigidity and aspiration. Elderly patients with PD are more sensitive to sedative medications and more susceptible to develop post-operative or ICU delirium, which has increased morbidity and mortality. PD patients are at increased risk of increased perioperative aspiration pneumonia and its associated morbidity and mortality. Specialized ICU management strategies for patients with PD are described.