Journal of intensive care medicine
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J Intensive Care Med · Mar 2015
The effect of a hypoglycemia treatment protocol on glycemic variability in critically ill patients.
Hypoglycemia and glucose variability are independently associated with increased mortality in septic, surgical, and mixed intensive care unit (ICU) patients. Treatment of hypoglycemia with dextrose 50% can overcorrect blood glucose levels and increase glucose variability. The purpose of this study is to evaluate the effect of a hypoglycemia treatment protocol focused on minimizing glucose variability in critically ill patients. ⋯ Implementation of the hypoglycemia treatment protocol described led to a reduction in glucose variability, while still providing a safe and effective way to manage hypoglycemia in critically ill patients.
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J Intensive Care Med · Mar 2015
Mature trauma intensivist model improves intensive care unit efficiency but not mortality.
Although the Leap Frog intensivist staffing model has been shown to improve outcomes in the intensive care unit (ICU), to date, no one has examined the effect of an intensivist model in a dedicated trauma ICU. With stricter adherence to evidence-based protocols and 24-hour availability, we hypothesized that a mature intensivist model in a trauma ICU would decrease mortality. ⋯ A total of 3527 patients (2999 excluding do not resuscitate status) were reviewed. Age ≥65 (odds ratio [OR] 2.38, P < .001), ISS ≥17 (OR 3.3, P < .001), coagulopathy (OR 1.64, P = .004), and anemia (OR 1.73, P = .02) were independent predictors of mortality. Multivariate logistic model encompassing these factors found no statistically significant differences in mortality across the 6-year period. The ICU efficiency showed significant improvements in terms of ventilator days (30.1% EARLY vs 24.4% MATURE; P < .001), decreases in mean consultant use per patient (0.55 ± 0.85 EARLY vs 0.40 ± 0.74 MATURE; P < .001), and increase in number of bedside procedures per patient (0.09 ± 0.48 EARLY vs 0.40 ± 0.74 MATURE; P < .001 CONCLUSIONS: Our mature intensivists staffing model shows improvement in ICU throughput (ventilator days, ICU days, decreased consultant use, and increased bedside procedures) but no survival benefit. Further improvements in overall trauma mortality may lie in the resuscitative and operative phase of patient care.
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J Intensive Care Med · Mar 2015
Case ReportsBronchoscopic intubation during continuous nasal positive pressure ventilation in the treatment of hypoxemic respiratory failure.
Endotracheal intubation is difficult in patients with hypoxemic respiratory failure who deteriorate despite treatment with noninvasive positive pressure ventilation (NIPPV). Maintaining NIPPV during intubation may prevent alveolar derecruitment and deterioration in gas exchange. We report a case series of 10 nonconsecutive patients with NIPPV failure who were intubated via a flexible bronchoscope during nasal mask positive pressure ventilation. ⋯ This method of intubation may extend the benefits of preoxygenation throughout the whole process of endotracheal intubation. It requires an experienced operator and partially cooperative patients. A prospective trial is necessary to determine the best intubation method for NIPPV failure.
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J Intensive Care Med · Feb 2015
ReviewDo clinical parameters predict first planned extubation outcome in the pediatric intensive care unit?
There is absence of evidence-based guidelines to determine extubation readiness in the pediatric intensive care unit (PICU). ⋯ Physician judgment to determine extubation readiness led to a first planned extubation success rate of 91%. Age and the length of MV were primary risk factors for failed extubation. In patients with ≤1 day of MV, our findings suggest that confidence in extubation readiness following weaning to low ventilator rates may not be justified. Furthermore, reliance on preextubation ventilator settings and blood gas results to determine extubation readiness may lead to unnecessary prolongation of MV, thereby increasing the PICU LOS and excess cost. These findings are hypothesis generating and require further study for confirmation.
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J Intensive Care Med · Feb 2015
ReviewIntracerebral hemorrhage in patients receiving oral anticoagulation therapy.
Intracerebral hemorrhage (ICH) in patients with oral anticoagulation therapy is an increasingly prevalent problem in large part due to the aging population and the increased use of anticoagulants for patients at high risk of thrombosis. Warfarin has been virtually the only outpatient anticoagulant choice until fairly recently. The development of subcutaneously injected heparinoids, and more recently, of direct thrombin inhibitors, has made the treatment and prognostication of ICH in anticoagulated patients more difficult. ⋯ We review the evidence of the 4 major reversal agents for warfarin, vitamin K, prothrombin complex concentrates, activated factor VII, and fresh frozen plasma as well as rational treatment choices. We offer possible treatments for the newer anticoagulants based on the limited evidence available. Finally, we review recommendations from the major societies and studies that support early and aggressive therapies in intensive care units with dedicated neurological specialists.