The optimal blood glucose level for critically ill adult patients

Shaoning, L.V. et al. Nursing in Critical Care. Published online 27 February 2017

Background: Glycaemic control is recognized as one of the important aspects in managing critically ill patients. Both hyperglycaemia and hypoglycaemia independently increase the risk of patient mortality. Hence, the identification of optimal glycaemic control is of paramount importance in the management of critically ill patients.

 

Conclusion: This literature review provides a recommendation for targeting the optimal blood glucose level for critically ill patients within moderate blood glucose level target range (8–10 mmol/L). The need for uniformed glucometrics for unbiased reporting and further research for optimal blood glucose target is required, especially in light of new technological advancements in closed-loop insulin delivery and monitoring devices.

Relevance to clinical practice: This literature review has revealed a need to call for consensus in the measurement and reporting of glycaemic control using standardized glucometrics.

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Increased risk of dementia in patients hospitalized with acute kidney injury

Tsai, H. et al. (2017) PloS one. 12(2) p. e0171671

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Purpose: To determine whether acute kidney injury (AKI) is a risk factor for dementia.

Conclusions: We found that patients with AKI exhibited a significantly increased risk of developing dementia. This study provides evidence on the association between AKI and long-term adverse outcomes. Additional clinical studies investigating the related pathways are warranted.

Read the full abstract and article here

Most Recent Issue of “Intensive Care Medicine” Volume 43 Number 2

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To access Intensive Care Medicine’s latest issue’s contents page follow this link.

Articles in this issue include “The optimal target for acute glycemic control in critically ill patients: a network meta analysis” and “A family information brochure and dedicated website to improve the ICU experience for patients’ relatives; an Italian multicentre before and after study”.

Articles in this issue include a systematic review on “Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness” and “Severe hypercapnia and outcome of mechanically ventilated patients with moderate or severe acute respiratory distress syndrome.”

To access the full text of these articles from the journal’s homepage requires a personal subscription to the journal.  Individual articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make article requests online via this link.

The full text of articles from issues older than one year ago is available via this link to an archive of issues of Intensive Care Medicine.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial.

This paper from the Clinical Research in Intensive Care and Sepsis (CRICS) Group was published in JAMA February 2017 vol 317 no 5 pp483-93.  The full text is available in the Health Care Library on Level D of Rotherham Hospital

In the intensive care unit (ICU), orotracheal intubation can be associated with increased risk of complications because the patient may be acutely unstable, requiring prompt intervention, often by a practitioner with nonexpert skills. Video laryngoscopy may decrease this risk by improving glottis visualization. Objective To determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients.
Design, Setting, and Participants Randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between May 2015 and January 2016; there was 28 days of follow-up. Interventions Intubation using a video laryngoscope (n = 186) or direct laryngoscopy (n = 185). All patients received general anesthesia.
Main Outcomes and Measures The primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications.
Results Among 371 randomized patients (mean [SD] age, 62.8 [15.8] years; 136 [36.7%] women), 371 completed the trial. The proportion of patients with successful first-pass intubation did not differ significantly between the video laryngoscopy and direct laryngoscopy groups (67.7% vs 70.3%; absolute difference, -2.5% [95% CI, -11.9% to 6.9%]; P = .60). The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with video laryngoscopy vs 83.2% with direct laryngoscopy; absolute difference 1.2% [95% CI, -6.3% to 8.6%]; P = .76). The median time to successful intubation was 3 minutes (range, 2 to 4 minutes) for both video laryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0]; P = .95).  Video laryngoscopy was not associated with life-threatening complications (24/180 [13.3%] vs 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, -2.7% to 10.4%]; P = .25). In post hoc analysis, video laryngoscopy was associated with severe life-threatening complications (17/179 [9.5%] vs 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; P = .01) but not with mild to moderate life-threatening complications (10/181 [5.4%] vs 14/181 [7.7%]; absolute difference, -2.3% [95% CI, -7.4% to 2.8%]; P = .37).
Conclusions and Relevance Among patients in the ICU requiring intubation, video laryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications. Further studies are needed to assess the comparative effectiveness of these 2 strategies in different clinical settings and among operators with diverse skill levels.

Sodium Bicarbonate Versus Sodium Chloride for Preventing Contrast-Associated Acute Kidney Injury in Critically Ill Patients: A Randomized Controlled Trial

This paper by Valette and colleagues was published in Critical Care Medicine in February 2017.  The full text of the article is available to subscribers to this journal via this link.  The Library and Knowledge Service can obtain the full text of the article for registered members by requesting it via the library website document request form.

Objectives:  To test whether hydration with bicarbonate rather than isotonic sodium chloride reduces the risk of contrast-associated acute kidney injury in critically ill patients.

Design:  Prospective, double-blind, multicentre, randomized controlled study

Setting:  Three French ICUs.  Patients:  Critically ill patients with stable renal function (n = 307) who received intravascular contrast media.  Interventions:  Hydration with 0.9% sodium chloride or 1.4% sodium bicarbonate administered with the same infusion protocol: 3 mL/kg during 1 hour before and 1 mL/kg/hr during 6 hours after contrast medium exposure.

Measurements and Main Results:  The primary endpoint was the development of contrast-associated acute kidney injury, as defined by the Acute Kidney Injury Network criteria, 72 hours after contrast exposure. Patients randomized to the bicarbonate group (n = 151) showed a higher urinary pH at the end of the infusion than patients randomized to the saline group (n = 156) (6.7 ± 2.1 vs 6.2 ± 1.8, respectively; p < 0.0001). The frequency of contrast-associated acute kidney injury was similar in both groups: 52 patients (33.3%) in the saline group and 53 patients (35.1%) in the bicarbonate group (absolute risk difference, -1.8%; 95% CI [-12.3% to 8.9%]; p = 0.81). The need for renal replacement therapy (five [3.2%] and six [3.9%] patients; p = 0.77), ICU length of stay (24.7 ± 22.9 and 23 ± 23.8 d; p = 0.52), and mortality (25 [16.0%] and 24 [15.9%] patients; p > 0.99) were also similar between the saline and bicarbonate groups, respectively.

Conclusions: Except for urinary pH, none of the outcomes differed between the two groups. Among ICU patients with stable renal function, the benefit of using sodium bicarbonate rather than isotonic sodium chloride for preventing contrast-associated acute kidney injury is marginal, if any.

Occupational therapy for delirium management in elderly patients

Álvarez, E.A. et al. (2017) Journal of Critical Care. 37(2) pp. 85–90

Purpose: Delirium has negative consequences such as increased mortality, hospital expenses and decreased cognitive and functional status. This research aims to determine the impact of occupational therapy intervention in duration, incidence and severity of delirium in elderly patients in the intensive care unit; secondary outcome was to assess functionality at hospital discharge.

Conclusions: Occupational therapy is effective in decreasing duration and incidence of delirium in nonventilated elderly patients in the intensive care unit and improved functionality at discharge.

Read the full abstract here

Learning from Patient Safety Incidents

It is estimated that 1:10 patients in health care sustain harm that is potentially avoidable and which often highlight system errors that were not appreciated | Faculty of Intensive Care Medicine

Investigation results in the identification of these system errors and the generation of solutions to prevent future incidents. Sharing and implementing these lessons improves patient safety.

National Patient Safety Alerts relevant to intensive care

National alerts are produced in response to analysis of centrally reported patient safety incidents. Details of all alerts may be found on the Central Alerting System website (https://www.cas.dh.gov.uk/Home.aspx).

Lessons from adverse incidents

Lessons from local incidents may not be shared widely and to improve wider patient safety, the Joint Standards Committee of the Faculty and the Intensive Care Society has created this forum to allow lessons from local investigations into adverse incidents to be disseminated to the intensive care community.

We welcome you to share important safety lessons that have occurred in your own departments that may have general relevance. Please use the form below (or your local form if you would prefer) to submit an anonymised summary of the incident, the learning arising and any changes that have been implemented to prevent future a reoccurrence.

SAFETY MATTERS: Local Incident Lessons

Read the full overview here