Acute and Chronic Glucose Control in Critically Ill Patients With Diabetes: The Impact of Prior Insulin Treatment

Background:Emerging data highlight the interactions of preadmission glycemia, reflected by admission HbA1c levels, glycemic control during critical illness, and mortality. The association of preadmission insulin treatment with outcomes is unknown.Methods:This observational cohort study includes 5245 patients admitted to the medical-surgical intensive care unit of a university-affiliated teaching hospital. Three groups were analyzed: patients with diabetes with prior insulin treatment (DM-INS, n = 538); patients with diabetes with no prior insulin treatment (DM-No-INS, n = 986); no history of diabetes (NO-DM, n = 3721). Groups were stratified by HbA1c level: <6.5%; 6.5%-7.9% and >8.0%.Results:Among the three strata of HbA1c, mean blood glucose (BG), coefficient of variation (CV), and hypoglycemia increased with increasing HbA1c, and were higher for DM-INS than for DM-No-INS. Among patients with HbA1c < 6.5%, mean BG ≥ 180 mg/dL and CV > 30% were associated with lower severity-adjusted mortality in DM-INS compared to patients with mean BG 80-140 mg/dL and CV < 15%, (P = .0058 and < .0001, respectively), but higher severity-adjusted mortality among DM-No-INS (P = .0001 and < .0001, respectively) and NON-DM (P < .0001 and < .0001, respectively). Among patients with HbA1c ≥ 8.0%, mean BG ≥ 180 mg/dL was associated with lower severity-adjusted mortality for both DM-INS and DM-No-INS than was mean BG 80-140 mg/dL (p < 0.0001 for both comparisons).Conclusions:Significant differences in mortality were found among patients with diabetes based on insulin treatment and HbA1c at home and post-admission glycemic control. Prospective studies need to confirm an individualized approach to glycemic control in the critically ill.     

Diaphragm Evaluation and Lung Ultrasound Score during Weaning

How to cite this article: Blanco JB, Esquinas A. Diaphragm Evaluation and Lung Ultrasound Score during Weaning. Indian J Crit Care Med 2022;26(9):1054–1055.     

治未病调理脾胃干预亚健康状态

随着单纯生物医学模式发展为生物-心理-社会医学模式,"亚健康"状态得到更多关注。干预亚健康状态,减少慢性病发病率,提高健康水平,减轻医疗负担有着极其重要而深远的意义。"治未病"思想和"亚健康"联系紧密,符合从疾病医学到健康医学的模式转化,即从"治已病"到"治未病"的转化。"治未病"包含未病先防、扶正祛邪,见微知著、及早诊治,既病防变、防邪深入,病后调理、防止复发四个方面。脾胃与五脏六腑关系密切,且中土之气为人体"一气周流"的枢轴,从调理脾胃入手(生活方式调整、药物干预、环境改善)干预亚健康,可达到健康促进最终目标。     

重症患者失禁性皮炎预防管理的研究进展

阐述了重症患者失禁性皮炎的危险因素及预防管理措施。除一般危险因素外,危重疾病本身也是失禁性皮炎发展的风险因素。重症患者失禁性皮炎的预防管理主要包括基于信息化平台构建失禁性皮炎预防管理系统,基于循证制定预防管理干预措施,以及借助新型敷料与药物实现多元化皮肤干预。提出重症患者失禁性皮炎的预防管理较为复杂,需要临床护理人员进行持续深入探索。     

基层医院临床药师参与救治重症手足口病患者回顾

目的:探讨基层医院临床药师参与临床会诊用药的作用,促进合理用药。方法:以临床药师参与1例重症手足口病患者临床会诊和抢救过程为例,具体描述临床药师对医师处方、用药的辅助作用。结果:基层医院医师的时间和精力有限,而基层医院中的护士对一些药品的适应证和用法用量知之甚少,临床用药存在或多或少的不合理性,临床药师的参与可以弥补这些不足。结论:基层医院临床药师参与临床会诊用药,对提高临床诊疗水平和保障患者用药安全、合理、有效有很大的帮助和促进作用。     

重症患者转运前核查程序的设计及应用研究

目的 评价重症患者转运前核查程序对重症患者转运质量的影响.方法 自行设计、应用重症患者转运前核查程序.观察重症患者院内转运708例次,逢单数进入对照组,双数进入观察组.对照组转运人员凭经验完成转运前准备,观察组按书面核查程序执行.结果 观察组患者主要不良事件发生率分别为心血管系统0.57%、呼吸系统1.98%、呼吸机适应0.00%及医疗设备相关0.28%,都低于对照组（P＜0.05）.转运前准备时间缩短,物品携带齐全率100%;患者或家属及转运人员对转运服务质量满意度分别为99.44%、98.87%,都优于对照组（P＜0.01）.结论 重症患者转运前核查程序可行,有效,可显著降低危重患者转运风险,提高转运效率,保证转运质量.     

连续性血液净化(CBP)治疗危重症患者对机体氧化抗氧化指标的影响研究

目的:分析危重症采用连续性血液净化对治疗机体氧化抗氧化指标的影响。方法:选我院22例重症监护室行CBP治疗的患者,不同时间段取血,并检测血清过氧脂质(LPO)与谷胱甘肽氧化物酶(GSH-Px)的水平,行APACHEIII的评分。结果:相较于健康对照组,LPO升高,GSH-Px降低;在CBP的不同时间段治疗后,APACHEIII评分有着明显改善;LPO、GSH-Px与APACHEIII的评分分别呈正、负相关。结论:CBP可改善患者氧化抗氧化紊乱,从而减轻氧化损伤,促进危重症患者病情得到较好的改善,而LPO及GSH-Px是检测危重症患者病情轻重的关键指标,可作为判断预后与CBP停止的时机起到了重要的依据。     

Beta-blocker treatment in the critically ill: a systematic review and meta-analysis

BackgroundCritical illness may lead to activation of the sympathetic system. The sympathetic stimulation may be further increased by exogenous catecholamines, such as vasopressors and inotropes. Excessive adrenergic stress has been associated with organ dysfunction and higher mortality. β-Blockers may reduce the adrenergic burden, but they may also compromise perfusion to vital organs thus worsening organ dysfunction. To assess the effect of treatment with β-blockers in critically ill adults, we conducted a systematic review and meta-analysis of randomized controlled trials.Materials and methodsWe conducted a search from three major databases: Ovid Medline, the Cochrane Central Register for Controlled Trials and Scopus database. Two independent reviewers screened, selected, and assessed the included articles according to prespecified eligibility criteria. We assessed risk of bias of eligible articles according to the Cochrane guidelines. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.ResultsSixteen randomized controlled trials comprising 2410 critically ill patients were included in the final review. A meta-analysis of 11 trials including 2103 patients showed a significant reduction in mortality in patients treated with β-blockers compared to control (risk ratio 0.65, 95%CI 0.53–0.79; p < .0001). There was no significant difference in mean arterial pressure or vasopressor load. Quality of life, biventricular ejection fraction, blood lactate levels, cardiac biomarkers and mitochondrial function could not be included in meta-analysis due to heterogenous reporting of outcomes.ConclusionsIn this systematic review we found that β-blocker treatment reduced mortality in critical illness. Use of β-blockers in critical illness thus appears safe after initial hemodynamic stabilization. High-quality RCT’s are needed to answer the questions concerning optimal target group of patients, timing of β-blocker treatment, choice of β-blocker, and choice of physiological and hemodynamic parameters to target during β-blocker treatment in critical illness.

KEY MESSAGES

• A potential outcome benefit of β-blocker treatment in critical illness exists according to the current review and meta-analysis. Administration of β-blockers to resuscitated patients in the ICU seems safe in terms of hemodynamic stability and outcome, even during concomitant vasopressor administration. However, further studies, preferably large RCTs on β-blocker treatment in the critically ill are needed to answer the questions concerning timing and choice of β-blocker, patient selection, and optimal hemodynamic targets.

     

微白蛋白尿与危重患者预后

微白蛋白尿被认为是反映全身毛细血管渗透性增加的一个重要指标.目前,已经发现许多常见的内科疾病如:糖尿病、肾脏疾病和心血管疾病,都会出现微白蛋白尿,且有文献报道微白蛋白尿与危重患者的预后相关.本文就微白蛋白尿与危重患者预后的关系、预测危重患者疾病严重程度的价值进行简要综述.     

高流量鼻导管氧疗在术后脱机患者预防急性呼吸衰竭中的研究进展

术后脱机患者出现急性呼吸衰竭是术后患者入住重症医学科（ICU）的主要原因,常出现肺不张和肺部感染等肺部并发症。高流量鼻导管氧疗（HFNC）具有良好的舒适度和耐受性,能产生呼吸末正压效应,冲刷鼻咽部解剖死腔,提高肺泡通气量等临床应用优势,其在术后脱机患者的氧气支持治疗中具有良好的治疗效果,但在胸外科、腹部外科等不同手术后脱机患者群体中产生的不同疗效还需要更多研究证据支持。本文就HFNC在预防术后脱机患者急性呼吸衰竭中的临床应用进展进行综述。