Non-intensive Care Unit Setting Research Articles

Managing diabetic ketoacidosis in non-intensive care unit setting: Role of insulin analogs

Aim:To compare the efficacy and safety of rapid acting insulin analog lispro given subcutaneously with that of standard low-dose intravenous regular insulin infusion protocolin patients with mild to moderate diabetic ketoacidosis.Materials and Methods:In this prospective, randomized and open trial, 50 consecutive patients of mild to moderate diabetic ketoacidosis were randomly assigned to two groups. The patients in group 1 were treated with intravenous regular insulin infusion and admitted in intensive care unit. The patients in group 2 were treated with subcutaneous insulin lispro 2 hourly and managed in the emergency medical ward. Response to therapy was assessed by duration of treatment and amount of insulin administered until resolution of hyperglycemia and ketoacidosis, total length of hospital stay, and number of hypoglycemic events in the two study groups.Results:The baseline clinical and biochemical parameters were similar between the two groups. There were no differences in the mean duration of treatment and amount of insulin required for correction of hyperglycemia and ketoacidosis. There was no mortality and no difference in the length of hospital stay between the two groups. The length of stay and amount of insulin required for correction of hyperglycemia was greater in patients who had infection as the precipitating cause than those with poor compliance. The hypoglycemic events were higher in the regular insulin group (2 vs1) than in the lispro group.Conclusion:Patients with uncomplicated diabetic ketoacidosis can be managed in the medical wards with appropriate supervision and careful monitoring. Rapid acting insulin analog lispro is a safe and effective alternative to intravenous regular insulin for this subset of patients.

Inpatient diabetes management in general medical and surgical settings: evidence and update

A quarter of patients who are hospitalized for any reason have diabetes as a comorbid condition. Despite this, management of diabetes among inpatients has historically been a low clinical priority. Since the publication of several landmark trials demonstrating the benefits of intensive glycemic control in the surgical intensive care unit, inpatient glycemic control on general hospital wards has received increased attention. Physicians and healthcare organizations in the USA have recently advocated more aggressive treatment of inpatient hyperglycemia despite the lack of data to guide evidence-based management in general (non-intensive care unit) settings. These calls to action have prompted a series of studies that demonstrate effective systems-based strategies for measuring and improving inpatient glycemic control, even though it is not yet clear how aggressively this goal should be pursued. While the data on improved long-term outcomes related to improved glycemic control in general inpatient settings are sparse, at the very least, inpatient diabetes management is likely to be beneficial if it prevents extremes of hyper- and hypoglycemia, decreases medication error, and facilitates improved outpatient medication regimens and self-management skills, which, in turn, may lead to improved glycemic control after discharge.

Impact of rapid in situ hybridization testing on coagulase-negative staphylococci positive blood cultures

To evaluate the impact of the rapid differentiation of Staphylococcus aureus from coagulase-negative staphylococci (CoNS) in blood cultures using peptide nucleic acid fluorescence in situ hybridization (PNA FISH) on vancomycin usage, length of patient hospital stay and hospital costs. This was a retrospective, cost-effective analysis of PNA FISH in its initial 3 month implementation period in 2004 in a 650 bed academic medical centre. Blood cultures with Gram-positive cocci in clusters (GPCC) that were negative for S. aureus using the PNA FISH assay were compared with an untested control group in the same period that had similar illness severity and location. We evaluated the effectiveness of the early identification of CoNS by ruling out S. aureus in conjunction with an antimicrobial team (AMT) on antimicrobial therapy, patient length of stay and hospital costs. A total of 139 blood cultures positive with GPCC had PNA FISH results while 84 in the control group did not. Evaluable criteria were met in 53 patients in the PNA FISH group and 34 in the control group. When comparing the results obtained from using the PNA FISH assay with those for the control group, there was a significant reduction in median length of hospital stay from 6 to 4 days (P < 0.05, CI 0.95-1.87) and a trend towards less vancomycin usage with a decrease in associated hospital costs of approximately Dollars 4000 per patient. The PNA FISH assay is rapid, accurate and reliable and in association with an AMT could decrease hospital length of stay in patients with CoNS bacteraemia in non-intensive care unit settings and prevent excessive vancomycin usage.

Is continuous transcutaneous monitoring of P CO2(Tc P CO2) over 8 h reliable in adults?

Monitoring of non-invasive ventilation (NIV) in a non-intensive care unit (non-ICU) setting requires a method of evaluating nocturnal P aCO2, such as transcutaneous CO2monitoring (Tc P CO2). However, changing the probe site after 4 h and recalibrating (as recommended) is time-consuming and impractical. Continuous (8-h) Tc P CO2monitoring at a lower electrode temperature (43°C) in this setting has never been formally studied.Patients under intermittent NIV were studied (n=28, aged 69±9 years, P aO2: 71±13 mmHg, P aCO2: 49±9 mmHg). After calibration and stabilization of TcP CO2(Radiometer®Tina TCM3 capnograph), arterial blood gases (ABG) were measured and compared with transcutaneous readings. In 10 patients who underwent continuous 8-h Tc P CO2recording, ABGs were also measured after 4 and 8 h.The correlation between Tc P CO2and P aCO2was highly significant (r2=0·92, P<0·0001). Mean (Tc P CO2–P aCO2) gradient (bias) was: −2·8±3·8 mmHg; limits of agreement were: (−10·4; +4·8 mmHg). Tc P CO2–P aCO2gradient was lowest (i.e. within-bias±2 mmHg) between 40 and 54 mmHg, increasing below and above these values. Over 8 h, no significant drift of the Tc P CO2signal occurred (ANOVA). No discomfort or skin lesion was noted.In conclusion, with an electrode temperature of 43°C, 8-h continuous monitoring of Tc P CO2was well tolerated, without any local side-effects or significant drift of Tc P CO2signal; when compared to previous reports, lowering the electrode temperature did not decrease performance for CO2monitoring.

Weaning injured patients with prolonged pulmonary failure from mechanical ventilation in a non-intensive care unit setting.

Injured patients with pulmonary failure often require prolonged length of stay in an intensive care unit (ICU), which includes weaning from ventilatory support. In the last decade, noninvasive ventilation modes have been established as safe and effective. One method for accomplishing this mode of ventilation uses a simple bilevel ventilator. Because this ventilator has been successfully used in hospital wards, we postulated that bilevel ventilators could provide sufficient support during weaning from mechanical ventilation of injured patients in a non-ICU setting. A retrospective review of trauma patients (August 1996-January 1999) undergoing bilevel positive pressure ventilation as the final phase of weaning was conducted. Before ward transfer with bilevel ventilation, conventionally ventilated ICU patients were changed to bilevel ventilation and were required to tolerate this mode for at least 24 hours. All patients had a tracheostomy as a secure airway. Outcomes analyzed included ICU length of stay, hospital length of stay, duration of mechanical ventilation, weaning success, complications, and survival. Fifty-one patients (39 men, 12 women) with a mean age of 53 received more than 24 hours of bilevel positive pressure ventilation. Mean Injury Severity Score was 29, with blunt mechanisms of injury occurring in 90%. Chest or spinal cord injuries that affected pulmonary mechanics were present in 75% of patients. Ventilator-associated pneumonia was treated in 43% of patients. Mean ICU length of stay and hospital length of stay were 21 and 34 days, respectively. Weaning was successful in 89% of patients, whereas 11% were discharged to skilled nursing facilities still receiving bilevel positive pressure ventilation. Two patients died, neither from a pulmonary nor airway complication. Of the remaining 49 patients, 12 were weaned in the ICU and 37 were transferred to the ward with bilevel ventilatory support. The average length of ward ventilation was 6.5 +/- 5.4 days (n = 37). Implementation of a program using bilevel ventilation to support the terminal phase of weaning seriously injured patients from mechanical ventilation was successful. After initiating this mode in the ICU, it was satisfactorily continued in standard surgical wards. Because this method enabled the withdrawal of ventilatory support in a non-ICU setting, its major advantage was reducing ICU length of stay.

Urokinase Infusion: Feasibility of Monitoring for Complications in a Non-Intensive Care Setting

In an effort to more effectively use critical care facilities and to reduce costs, during a 2 1/2-year period, the condition of 32 patients who received 37 local intraarterial urokinase (UK) infusions was monitored in a non-intensive care unit (ICU) setting. Techniques of infusion, mean total dose of lytic agent used (1.7 million IU), and mean duration of infusion (22 hours) were similar to those reported previously in series of patients monitored in the ICU. Complete lysis (no angiographically detectable residual clot within the treated segment) was achieved in 28 of 37 infusions (76%). Major complications occurred during two infusions (5.4%). In 33 of the 37 cases, systemic heparin was administered during UK infusion. No cases of pericatheter thrombosis were encountered. At the authors' institution, patients can be safely monitored during local UK infusion in a non-ICU setting without compromising effectiveness of therapy. This approach has resulted in enhanced cost-effectiveness of thrombolytic therapy and more effective use of critical care facilities.