Admission blood glucose is an independent predictive factor for hospital mortality in polytraumatised patients

Purpose  The goal of this study was to analyse a possible association of admission blood glucose with hospital mortality of polytraumatised patients and to develop an outcome prediction model for this patient group. Methods  The outcome of adult polytraumatised patients admitted to the University Hospital of Berne, Switzerland, between 2002 and 2004 with an ISS ≥ 17, and more than one severely injured organ system was retrospectively analysed. Results  The inclusion criteria were met by 555 patients, of which 108 (19.5%) died. Hyperglycaemia proved to be an independent predictor for hospital mortality (P < 0.0001), following multiple regression analysis. After inclusion of admission blood glucose, the calculated mortality prediction model performed better than currently described models (P < 0.0001, AUC 0.924). Conclusion  In this retrospective, single-centre study in polytraumatised patients, admission blood glucose proved to be an independent predictor of hospital mortality following regression analysis controlling for age, gender, injury severity and other laboratory parameters. A reliable admission blood glucose-based mortality prediction model for polytraumatised patients could be established. This observation may be helpful in improving the precision of future outcome prediction models for polytraumatised patients. These observations warrant further prospective evaluation.     

重症患者床旁血糖监测的准确性评价及影响因素分析

目的 评价重症患者床旁快速血糖监测的准确性,探讨其相关的临床影响因素.方法 选择240例重症医学科收治年龄≥18岁的重症患者,血糖调控期间依据血糖检测值将患者分为3组:①低血糖组,血糖值＜4.5 mmol/L,32例;②目标血糖组,血糖值4.5 ～ 8.3 mmol/L,138例;③高血糖组,血糖值＞8.3 mmol/L,70例.试验期间,床旁同步采集患者静脉血、动脉血、指端血,分别采用葡萄糖氧化酶法(GOD法)和葡萄糖脱氧酶法(GDH法)快速检测血糖值,同时以中心实验室己糖激酶法(HK法)测定的血糖值作为标准对照进行准确性评估;对可能影响床旁快速血糖检测准确性的各因素进行logistic回归分析.结果 ①低血糖组患者静脉血、动脉血、指端血快速血糖检测错误率(GDH法:25.00％、40.62％、40.62％,GOD法:59.38％、71.88％、71.88％)显著高于同类受检血样的目标血糖组(GDH法:2.90％、9.42％、7.97％,GOD法:18.12％、27.54％、27.54％)和高血糖组(GDH法:1.43％、8.57％、4.28％,GOD法:11.43％、8.57％、11.43％,均P＜0.01).②低血糖组患者快速血糖检测值与实验室对照值间的差值平均水平为0.41～0.69 mmol/L(GDH法)和0.92～1.18 mmol/L( GOD法);目标血糖组分别为0.16～0.33 mmol/L和0.77～0.90 mmol/L;高血糖组相应降至-0.06～0.18 mmol/L和0.56～0.76 mmol/L.③低血糖组患者快速血糖检测值与实验室对照值间相关系数仅为0.812～0.853(GDH法)及0.723～0.816(GOD法);目标血糖组达0.862～0.890及0.768～0.857;高血糖组患者相应升至0.922～0.957及0.896～0.922(均P＜0.01).④Logistic回归分析显示,患者血糖水平、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、红细胞比容能进入回归方程.结论 重症患者血糖调控期间,血糖、红细胞比容及病情程度等因素影响床旁血糖监测的准确性.低血糖状态下,快速血糖检测的准确性显著降低,更易高估患者的实际血糖水平.     

Hyperglycaemia and mortality in critically ill patients

Objective To describe hyperglycaemia as a possible marker of morbidity and mortality in critically ill medical and surgical patients admitted to a multidisciplinary ICU.Design Prospective cohort study.Setting A 13-bed non-cardiac multidisciplinary ICU in a university hospital.Patients and participants Adult patients consecutively admitted to the ICU in a 6-month period. Patients with fewer than 2 days stay in the ICU and patients with known diabetes were excluded.Measurements and results At admission a registration form was filled in including demographic data, first and second day APACHE II scores, infections and daily maximum blood glucose level. In surgical patients, high maximum blood glucose level during the stay in ICU was correlated with increased mortality, morbidity and frequency of infection. In medical patients, we found a non-significant trend towards a correlation between hyperglycaemia and morbidity and mortality, respectively.Conclusions High blood glucose level during the stay in ICU was a marker of increased morbidity and mortality in critically ill surgical patients. In medical patients the same trend was found, but non-significant. The population of patients in the present study are heterogeneous and the results from surgical critically ill patients should not be generalised to medical patients.     

In ICU state anxiety is not associated with posttraumatic stress symptoms over six months after ICU discharge: A prospective study

BackgroundPosttraumatic stress symptoms are common after intensive care treatment. The influence of anxiety during critical illness on the development of posttraumatic stress symptoms needs to be investigated.ObjectiveTo determine the association between anxiety during critical illness (state and trait components) and posttraumatic stress symptoms over six months after ICU discharge.MethodsProspective study including 141 patients admitted ≥24 h to a closed mixed adult ICU in a tertiary hospital. State anxiety was assessed with the Faces Anxiety Scale during ICU stay. Trait anxiety was measured with the State-Trait Anxiety Inventory Form Y-2. Posttraumatic stress symptoms were measured at three and six months after ICU discharge using the Post-Traumatic Stress Symptoms 10-Question Inventory. Clinical and demographical data were also collected. Mixed effect regression models were used to determine if state and trait anxiety were factors significantly associated with posttraumatic stress symptoms over time.ResultsModerate to severe levels of state anxiety in ICU were reported by 81 (57%) participants. Levels of trait anxiety (median 36 IQR: 29–47) were similar to the Australian population. High levels of posttraumatic stress symptoms occurred at three (n = 19, 19%) and six months (n = 15, 17%). Factors independently associated with posttraumatic stress symptoms were trait anxiety (2.2; 95% CI, 0.3–4.1; p = 0.02), symptoms of anxiety after ICU discharge (0.6; 95% CI, 0.2–1.1; p = 0.005), younger age (−1.4; 95% CI, −2.6 to −0.2; p = 0.02) and evidence of mental health treatment prior to the ICU admission (5.2; 95% CI, 1.5–8.9; p = 0.006).ConclusionsPosttraumatic stress symptoms occurred in a significant proportion of ICU survivors and were significantly associated with higher levels of trait anxiety, younger age, mental health treatment prior to the ICU admission and more symptoms of anxiety after ICU discharge. Early assessment and interventions directed to reduce state and trait anxiety in ICU survivors may be of benefit.     

Inadvertent hypothermia and mortality in critically ill adults: Systematic review and meta-analysis

Objective

Considering that inadvertent hypothermia (IH) is common in Intensive Care Unit (ICU) patients and can be followed by severe complications, this systematic review identified, appraised and synthesised the published literature about the association between IH and mortality in adults admitted to the ICU.

Evaluation of lacrimal fluid as an alternative for monitoring glucose in critically ill patients

Objective This study evaluated the use of lacrimal fluid glucose concentrations as a minimally invasive, alternative sampling strategy for monitoring glucose concentrations in surgical/trauma ICU patients.Design and setting Prospective, paired sample study in an adult surgical/trauma ICU.Patients Patients receiving subcutaneous or intravenous insulin requiring routine capillary blood glucose measurements. Patients receiving ocular lubricants, artificial tears, or routinely administered ophthalmic medications and patients with facial injuries were excluded.Interventions Lacrimal fluid was collected using glass capillary tube placed near the cul-de-sac of the eye. Capillary blood glucose was determined using a bedside glucose meter as per routine ICU care.Measurements and results Lacrimal fluid glucose concentration was analyzed using high-performance liquid chromatography with pulse amperometric detection. Forty-four paired samples from five patients were analyzed. Pearson correlation between lacrimal fluid (µM) and blood glucose (mM) concentrations and the proportional change from baseline revealed no significant associations. Due to the very poor association, enrollment was discontinued after five patients.Conclusions Lacrimal fluid and blood glucose concentrations were poorly correlated, suggesting that the former is not a reliable alternative to blood glucose monitoring in surgical/trauma ICU patients requiring insulin therapy.     

Diabetes mellitus is an independent risk factor for ICU-acquired bloodstream infections

Objective  To investigate the role of diabetes as risk factor for ICU-acquired bloodstream infections (BSI). Design  Prospective observational study. Setting  A general eight-bed ICU of a tertiary hospital. Patients  Three hundred and forty-three consecutive patients (63 diabetic and 280 nondiabetic) admitted in the ICU. Methods  BSI episodes in the ICU were recorded and classified as primary, secondary, catheter-related and mixed according to strict criteria. In all patients, blood glucose was strictly controlled with a continuous insulin infusion within a range of 80–120 mg/dl. Results  One-hundred and eighteen patients (34.4%) developed at least one BSI episode. Diabetic patients had an increased probability of developing at least one BSI episode compared with nondiabetic patients (hazard ratio = 1.66, 95% confidence interval 1.04–2.64, P = 0.034) in a Cox proportional hazards regression model adjusting for age, gender, admission category and APACHE II score at admission in the ICU and comorbidities. Conclusions  Despite strict glycemic control, diabetic patients have a 1.7-fold probability of developing an ICU-acquired BSI compared to nondiabetic subjects.     

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.     

Good nursing care to ICU patients on the edge of life

Critically ill patients are admitted to intensive care units (ICUs) to receive advanced technological and medical treatment. Some patients seem not to benefit from the treatment, and sometimes questions are raised as to whether treatment should be withheld or withdrawn. This study was conducted using ICU nurses' experiences with the aim of acquiring a deepened understanding of what good nursing care is for these patients. The study was performed at an adult ICU in Norway, where 14 ICU female nurses were included as participants. The research design was based on interpretative phenomenology and data was collected by group interviews inspired by focus-group methodology. The participants were divided into two groups and each group was interviewed four times. Colaizzi's model was used in the process of analysis. The results show that good nursing care depended on several basic conditions: continuity, knowledge, competence and cooperation, and included clear goals to give appropriate life-saving -- or end-of-life treatment and care. Cornerstones in good nursing care were nurses' verbal communication and nurses' use of their hands. The study emphasises several consequences for future ICU nursing practice and education to enhance good nursing care to patients on the edge of life.     

Low-molecular-weight heparin thromboprophylaxis in medical-surgical critically ill patients: A systematic review

Purpose

The study aimed to systematically review the effect of low-molecular-weight heparin (LMWH) thromboprophylaxis in medical-surgical critically ill patients in the intensive care unit.

Methods

In duplicate and independently, we searched for relevant articles using MEDLINE and EMBASE; we also contacted experts and reviewed reference lists. For included studies, we abstracted data on study and patient characteristics, LMWH use, clinical outcomes (venous thromboembolism [VTE], bleeding, and mortality), laboratory outcomes (anti-Xa levels and thrombocytopenia), and methodological quality.

Results

We included 8 prospective cohort studies and 1 randomized trial, with a total of 629 patients. Eight studies (n = 406 patients) reported anti-Xa levels and only 3 studies (n = 240 patients) reported on at least one clinical outcome. Low-molecular-weight heparin does not appear to bioaccumulate based on repeated measurements of trough anti-Xa levels. Thrombocytopenia occurred in 9.3% of patients receiving LMWH; heparin-induced thrombocytopenia was not reported. In studies reporting clinical outcomes, the frequency of VTE in patients receiving LMWH ranged from 5.1% to 15.5%, bleeding complications ranged from 7.2% to 23.1%, and mortality ranged from 1.4% to 7.4%.

Conclusions

Low-molecular-weight heparin may be effective for thromboprophylaxis in medical-surgical critically ill patients, but no trials have compared LMWH against an alternative active strategy; thus, LMWH cannot be recommended routinely. Trials testing LMWH thromboprophylaxis are required, which examine patient-important end points such as the incidence and clinical consequences of VTE, bleeding, heparin-induced thrombocytopenia, and mortality.     

Therapeutic plasma exchange in an intensive care unit (ICU): A 10-year, single-center experience

Therapeutic plasma exchange (TPE) is a blood purification method that effectively allows for the removal of waste substances by separating out plasma from other components of blood and the removed plasma is replaced with solutions such as albumin and/or plasma, or crystalloid/colloid solutions. Plasma exchange therapies are becoming increasingly essential, being used in daily practice in critical care settings for various indications, either as a first-line therapeutic intervention or as an adjunct to conventional therapies. This retrospective clinical study analyzes 10-year therapeutic plasma exchange activity experience in an 18-bed ICU at a tertiary care university hospital with a large, critically-ill patient population. Medical records of 1188 plasma exchange procedures on 329 patients with different diagnoses admitted from January 2000 to July 2010 were evaluated. The aim of the study was to determine the TPE indications and outcomes of the patients who underwent TPE in the ICU with conventional therapy. The secondary endpoints were to determine the differences between different patient groups (septic vs. non-septic indications) in terms of adverse events and procedural differences.     

危重孕产妇住重症监护病房时间延长的危险因素分析——北京市3家医院5年回顾性研究

目的 评估危重孕产妇重症监护病房(ICU)住院时间延长的危险因素.方法 回顾性分析2006年1月1日至2010年12月31日北京市3家医院ICU危重孕产妇的临床资料,包括患者的基本特征、转入ICU的疾病种类、急性生理学与慢性健康状况评分系统I(APACHE I)评分、发病至转入ICU时间、各种检查结果、治疗措施、ICU住院时间以及孕产妇病死率.采用单因素比较和多因素Logistic回归分析危重孕产妇ICU住院时间延长的危险因素.结果 5年内共有207例危重孕产妇收入ICU,占所有孕产妇的0.42%;平均年龄(31.74±2.32)岁,平均孕龄(34.86+4.72)周.其中4例孕产妇死亡,病死率1.93%.207例危重孕产妇中,138例为产科重症,69例并发严重内科疾病.转入ICU最常见的产科病因为产后大出血(42例,20.29%)和妊娠相关性高血压(36例,17.39%),其次为妊娠急性脂肪肝(AFLP,27例,13.04%)和产科弥散性血管内凝血(DIC,23例,11.11%);最常见的内科病因为急性心功能衰竭(26例,12.56%)和急性呼吸衰竭(22例,10.63%),其次为重症急性胰腺炎(SAP,11例,5.31%).109例患者(占52.66%)ICU住院时间延长(ICU滞留时间＞3 d).单因素分析显示,未行规律产前检查、血肌酐、凝血酶原时间国际标准化比值(INR)、氧合指数(PaO2/FiO2)、AFLP、产科DIC、SAP、机械通气、血管活性药物、血液净化治疗和发病至转入ICU时间＞24 h与ICU住院时间延长有关.多因素Logistic回归分析显示,未行规律产前检查[优势比(OR)1.68,95%可信区间(95%CI)1.14～2.69,P=0.011]、PaO2/FiO2(OR 4.73,95%CI 1.46～11.37,P=0.013)、AFLP(OR 3.21,95%CI 1.13～4.76,P=0.026)、产科DIC(OR 2.73,95%CI 1.28～4.02,P=0.018)、SAP(OR 4.78,95%CI 1.83～7.42,P=0.021)、血管活性药物(OR 1.96,95%CI 1.24～3.15,P=0.001)、血液净化治疗(OR 11.02,95%CI 3.04～58.02,P=0.015)和发病至转入ICU时间＞24 h(OR 2.04,95%CI 1.21～4.25,P＜0.001)是ICU住院时间延长的独立危险因素.结论 危重孕产妇ICU住院时间延长的发生率较高.临床上可以根据危险因素预测危重孕产妇ICU住院时间延长,加强规律产前检查、避免产科及内科严重并发症;发病后尽快转入ICU并在ICU内加强各器官功能支持可能有助于缩短ICU住院时间.