Search

This article describes the unique practice of nurse-driven titration of continuous insulin infusion in post-cardiac surgery patients in the intensive care unit at a tertiary care teaching hospital. A prospective quality assurance study was conducted to support our innovative practice.

Summary Purpose Study the relationship between moral distress (MD) and futile care in the critical care unit (CCU). Subjects and methods A cross-sectional survey consisting of 38 clinical situations associated with MD related to 6 categories: physician practice, nursing practice, institutional factors, futile care, deception and euthanasia was distributed to 100 nurses at a single CCU. The intensity and frequency of MD were scored with Likert scale: 0—lowest and 6—highest. Results The survey was completed by 44 (44%) nurses. Median age was 33 years, 80% females. Median intensity of MD was high for the six categories and had no relationship with age, time in CCU or nursing practice. The encounter frequency of MD for futile care was the highest and was significantly related to age >33 years ( p =0.03), time in CCU >4 years ( p =0.04) and nursing practice >7 years ( p =0.01). Conclusion MD associated with clinical situations representing futile care increased with time in CCU. Future interventions are required to minimize the exposure to futile care situations and develop mechanisms to mitigate the effects of MD in the CCU.

OBJECTIVES To determine the provider cost of administering intensive care unit (ICU) services, comparing 3 different staffing models for ICU coverage, and to compare the costs of using house staff vs nonphysician providers (NPPs). METHODS Data were collected on total staff composition and number of beds in ICUs from January 1, 2004, through December 31, 2004, at the 3 Mayo Clinic sites: Rochester, Minn; Jacksonville, Fla; and Scottsdale, Ariz. Institutional or national average staff salaries were used to determine total staffing costs per ICU bed per year at each site. Medicare medical education reimbursements were also taken into account. RESULTS Costs per ICU bed for physician staffing were $18,630 in Rochester, $37,515 in Jacksonville, and $38,010 in Scottsdale. When NPPs were substituted for house staff, the costs per bed were $72,466 in Rochester, $61,291 in Jacksonville, and $49,909 in Scottsdale. Incremental costs per ICU bed using NPPs were $53,836 in Rochester, $23,776 in Jacksonville, and $11,899 in Scottsdale. CONCLUSION Use of residents and fellows in ICU staffing at a major tertiary health center is more cost-efficient than use of NPPs. This finding could have implications for the cost of physician services in nonteaching community hospitals and the methods by which care is provided.

OBJECTIVE To clarify the relationship of patient and critical illness characteristics (including any history of diabetes mellitus) to glycemic control with insulin and hospital mortality. PATIENTS AND METHODS A case-control descriptive study was performed of patients admitted to a tertiary-care center multi-disciplinary closed intensive care unit (ICU) at Mayo Clinic Hospital in Phoenix, Ariz, between January 1, 1999, and December 31, 2003, after implementation of a glycemic management protocol. Hospital mortality, the primary outcome, was examined in nondiabetic and diabetic ICU patients receiving insulin and in patients not requiring insulin (control group). RESULTS Of 7285 patients, 2826 (39%) required insulin, 1083 of whom (15% of total) had a history of diabetes mellitus. The control group had a median (10th-90th percentile) glucose level of 118 mg/dL (range, 97–153 mg/dL) and a 5% mortality rate. The median glucose level was 134 mg/dL (range, 110–181 mg/dL) in nondiabetic patients and 170 mg/dL (121–238 mg/dL) in diabetic patients ( P P .001). Compared with nondiabetic survivors, nondiabetic nonsurvivors had longer periods with glucose levels greater than 144 mg/dL. Diabetic nonsurvivors vs diabetic survivors had longer periods with glucose levels greater than 200 mg/dL. Poor glycemic control in nondiabetic patients was associated with increased insulin requirement and increased mortality. Critical illness characteristics that predicted poor glycemic control were advanced age, history of diabetes, cardiac surgery, postoperative complications, severity of illness, nosocomial infections, prolonged mechanical ventilation, or concurrent medications. CONCLUSIONS Critical illness characteristics determined glycemic control and clinical outcome in ICU patients. Acute insulin resistance was associated with worse outcomes in nondiabetic patients. Although critical illness characteristics influenced glycemic control, future evaluation of the effect of insulin administration and optimal glycemic control in ICU patients is necessary.

Background Traumatic brain injury (TBI) is common and confers a high rate of disability and mortality. Current treatments are primarily supportive. Therapeutic hypothermia has been proposed for severe TBI because of its ability to reduce intracranial pressure and putative neuroprotective effects. Objective To critically appraise the current evidence concerning the efficacy of therapeutic hypothermia in the treatment of severe TBI. Methods The objective was addressed through the development of a structured, critically appraised topic. This incorporated a clinical scenario, background information, a structured question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and critical care and neurocritical care content experts. Results A recent multicenter randomized controlled trial was selected for critical assessment; meta-analyses were also reviewed. Subjects with severe TBI were randomized to either rapid cooling to 33°C for 48 hours (treatment, n=52) or normothermia (control, n=45). Outcome assessments included mortality and disability at 6 months as measured by the Glasgow Outcome Scale. Initiation of hypothermia began within 2.5 hours of injury and patients were rewarmed over a mean of 17.2 hours. The study was terminated for futility; no difference in outcome or mortality was detected between treatment groups. Post hoc subgroup analysis showed that among subjects who required hematoma evacuation, hypothermia was associated with a lower rate of poor clinical outcome (number needed to treat=2.8; 95% confidence interval, 1.4-78.3, P=0.02) and a trend toward a decrease in mortality (P=0.16). Conclusions Current cumulative evidence does not support general use of therapeutic hypothermia for acute severe TBI. However, further investigation of the role of therapeutic hypothermia may be warranted for specific TBI subgroups.

Use of corticosteroids for adrenal supplementation and attenuation of the inflammatory and immune response is widespread in acute critical illness. The study hypothesis was that exposure to corticosteroids influences the mortality and morbidity in acute critical illness. This case–control retrospective study was performed in a single multidisciplinary intensive care unit at a tertiary care institution and consisted of 10,285 critically ill patients admitted between 1 January 1999 and 31 December 2004. Demographics, comorbidities, acute illness characteristics including severity measured by Sequential Organ Failure Assessment, concurrent medications, therapeutic interventions and incidence of infections were obtained from electronic medical records, were examined with multiple regression analysis and were adjusted for propensity of corticosteroid exposure. The primary outcome was hospital death, and the secondary outcome was transfer to a care facility at hospital discharge. Corticosteroid exposure in 2,632 (26%) patients was characterized by younger age, more females, higher Charlson comorbidity and maximal daily Sequential Organ Failure Assessment scores compared with control patients. Corticosteroids potentiated metabolic and neuromuscular sequels of critical illness with increased requirements for diuretics, insulin, protracted weaning from mechanical ventilation, need for tracheostomy and discharge to a care facility. Early exposure to corticosteroids predisposed to recurrent and late onset of polymicrobial and fungal hospital-acquired infections. Corticosteroids increased the risk for death or disability after adjustments for comorbidities and acute illness characteristics. Corticosteroids increased the risk for death or disability in critical illness. Hospital-acquired infections and metabolic and neuromuscular sequels of critical illness were exacerbated by corticosteroids. Careful appraisal of the indications for use of corticosteroids is necessary to balance the benefits and risks from exposure in acute critical illness.