Thursday May 31, 2007
Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery

Since we are getting obsessive about tight control of blood glucose, concerns have been expressed about potential hypoglycemia. Many studies have shown that hypoglycemia during "tight" blood glucose control is a real danger with significant morbidity and mortality.

One recent study from Mayo Clinic, Rochester, MN compared intensive intraoperative insulin therapy with conventional glucose management during cardiac surgery. Patients were randomly assigned to tight glucose control (80-100 mg/dL) with continuous insulin infusion) or conventional treatment (n = 201).

• Patients in the conventional treatment group were given insulin during surgery if glucose levels were greater than 200 mg/dL.
• Both groups were treated with insulin infusion to maintain normoglycemia after surgery.

Results:

• Eighty two of 185 patients (44%) in the intensive treatment group and 86 of 186 patients (46%) in the conventional treatment group had an event.
• More deaths (4 deaths vs. 0 deaths) and strokes (8 strokes vs. 1 strokes) occurred in the intensive treatment group.

Study concluded that Intensive insulin therapy during cardiac surgery does not reduce perioperative death or morbidity. The increased incidence of death and stroke in the intensive treatment group raises concern about routine implementation of this intervention.


Reference: click to get abstract/article

Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery, A Randomized Trial, Annals of internal Medicine, 20 February 2007 Volume 146 Issue 4 Pages 233-243

Monday May 28, 2007
Impact of delayed transfer of critically ill patients from emergency department to ICU


This is well known to Critical Care practitioners that critically ill patients does not desired treatment, if they continue to 'boarder' in emergency department. A very important study published this month in Criticare Care Medicine 1 regarding Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit.

50,322 patients were divided into two groups: emergency department boarding more than/= 6 hrs (delayed n=1036) vs. emergency department boarding less than 6 hrs. (nondelayed n=49,286). Main outcomes were ICU and hospital survival and ICU and hospital length of stay.

Results:

• the median hospital length of stay was 7.0 (delayed) vs. 6.0 days (nondelayed).
• ICU mortality was 10.7% (delayed) vs. 8.4% (nondelayed).
• In-hospital mortality was 17.4% (delayed) vs. 12.9% (nondelayed).

Study concluded that, Critically ill emergency department patients with a more than/= 6-hr delay in intensive care unit transfer had increased hospital length of stay and higher intensive care unit and hospital mortality.

As said in discussion, the various factors which led to relatively poor outcome in ED 'boarders' icludes busy nature of ED practice, which entails simultaneous responsibilities for numerous patients of varying severities of illness, ED physicians and nurses may not be able to provide the focused one-on-one care that a critically ill patient may require, ED overcrowding and high patient acuity relative to the clinical staffing of the ED. ICU is a clinical environment that, by definition, enables close attention to the critically ill and allows for expeditious recognition of physiologic change and sudden deterioration, the ED under most circumstances is neither designed nor staffed to provide extended longitudinal care for the critically ill patient. It is also possible that there may be a different level of critical care expertise among the physicians and nurses who care for the patients who await ICU transfer, compared with the critical care expertise of the practitioners in the ICU setting.



Reference: click to get abstract

Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit - Critical Care Medicine. 35(6):1477-1483, June 2007.

Saturday May 26, 2007
Bedside trick - suspecting tracheal aspiration !

One quick method of suspecting tracheal aspiration or atleast ruling out tracheal aspiration is checking glucose concentration by regular bedside glucose meters. A glucose concentration of more than 20 mg/dl of bloodless tracheal aspirate doesn't confirm but atleast enhance the suspicion of tracheal aspiration .Though literature is full of conflicting data for this method but still it is a very quick, effective and easy way of suspecting or ruling out tracheal aspiration.

References: click to get abstracts / articles

1. Clinical implications of the glucose test strip method for early detection of pulmonary aspiration in nasogastric tube- fed patients - Taehan Kanho Hakhoe Chi. 2004 Dec;34(7):1215-23
2. Comparison of blue dye visualization and glucose oxidase test strip methods for detecting pulmonary aspiration of enteral feedings in intubated adults - Chest, Vol 103, 117-121
3. Glucose content of tracheal aspirates: Implications for the detection of tube feeding aspiration. Crit Care Med 1994; 22:1557-1562
4. Glucose Content of Tracheal Aspirates - Letter to the Editor - Critical Care Medicine: Volume 23(8) August 1995 pp 1451-1452

Thursday May 24, 2007
Restless Legs syndrome

Restless legs syndrome is a common condition in non-intubated patients which may get aggravated by ICU enviroment. Major factors associated with Restless Leg Syndrome in ICU are

• Iron-deficiency anemia
• Peripheral neuropathy
• Withdrawal from vasodilator drugs and sedatives
• Cigarette smoking, alcohol and caffeine withdrawal
• Various drugs including phenytoin, antidepressant drugs, H2 blockers, lithium, beta-blockers and antipsychotics
• Hypomagnesemia
• Renal insufficiency (uremia)

Various pharmacological agents have been described and used with success including benzodiazepines, carbamazepine and clonidine. In ICU situation, one useful drug in this regard is Ropinirole which is a Dopamine agonist. One of the effect of Ropinirole is heavy sleepiness, which can be use as a bonus benefit in ICU. Dose can be initiated from .25 mg PO QHS upto 4 mg PO QHS.


References: (click to get abstract)

1. Restless Legs Syndrome: Detection and Management in Primary Care - NATIONAL HEART, LUNG, AND BLOOD INSTITUTE WORKING GROUP ON RESTLESS LEGS SYNDROME - Vol. 62/No. 1 (July 1, 2000) - American Family Physician.

2. Ropinirole is effective in the treatment of restless legs syndrome. TREAT RLS 2: a 12-week, double-blind, randomized, parallel-group, placebo-controlled study - Mov Disord. 2004 Dec;19(12):1414-23.