Adult Surgical Intensive Care Unit Research Articles

Arterial catheter-related bloodstream infections: Results of an 8-year survey in a surgical intensive care unit*

To determine whether a policy based on provisional replacement of catheters every 5 days had an impact on the incidence of arterial catheter-related bloodstream infections in a population of adult surgical intensive care unit patients. Prepost study in which all patients with an arterial catheter who were admitted between 1997 and 2004 were observed. Scheduled replacement of arterial catheters every 5 days during period A (before 2000) was compared to nonscheduled replacement during period B (after 2000). A 20-bed surgical intensive care unit at a French university hospital. All intensive care unit patients requiring an arterial catheter. Modification to the catheter maintenance policies between period A and period B. A total of 1,672 consecutive patients were included, and 3,247 arterial catheters were analyzed, yielding an average number of 1.9 (sd, 1.7) arterial catheters per patient. The rate of colonization (14.2% before 2000 vs. 16.4% after 2000; p = .10) and the incidence density of arterial catheter colonization (31.32 [95% confidence interval] 27.07-36.25 per 1,000 catheter-days before 2000 vs. 29.79 [95% confidence interval, 26.72-33.21] per 1,000 catheter-days after 2000; p = .11) did not differ significantly between the two periods. However, the rate of arterial catheter-related bloodstream infections (1.4% before 2000 vs. 0.6% after 2000; p = .01) and the arterial catheter-related bloodstream infections incidence density (3.13 [95% confidence interval, 1.97-4.97] before 2000 vs. 1.01 [95% confidence interval, 0.56-1.82] per 1,000 catheter-days after 2000; p < .0001) was significantly higher before 2000. Discontinuation of scheduled replacement of arterial catheters every 5 days did not increase the risk of colonization but decreased the risk of bloodstream infections.

Risk factors and mortality of nosocomial infections of methicillin-resistant Staphylococcus aureus in an intensive care unit

Purpose Methicillin-resistant Staphylococcus aureus (MRSA) infections are an increasing worldwide problem. We determined risk factors and predictors of mortality of MRSA nosocomial infections (NIs). Materials and Methods A prospective cohort study was performed in an adult mixed medical and surgical intensive care unit from 2003 to 2007. Stratified analyses and generalized linear modeling were used to assess risk factors and predictors of infection and mortality. Results A total of 184 infections (3.6% of all infections) were due to S aureus, and 97.8% of these were methicillin resistant. The most common infection sites were respiratory tract (35.6%) and bloodstream (30.6%). Stratified analyses of length of stay (LOS) before onset of MRSA NI and death indicated that MRSA infection (odds ratio [OR], 38.49; 95% confidence interval [CI], 25.53-58.09) and mortality (OR, 4.72; 95% CI, 1.92-11.99) were more likely for LOS more than 15 days than for LOS less than 7 days. After controlling for potentially confounding factors by use of generalized linear modeling analysis, we identified the following as independent risk factors: LOS before onset of MRSA infection (OR, 1.03; 95% CI, 0.01-1.04), serum creatinine (OR, 5.87; 95% CI, 1.37-9.21) level, use of mechanical ventilator (OR, 6.71; 95% CI, 1.58-8.5), and central venous catheter (OR, 1.13; 95% CI, 1.05-1.31). Conclusions Methicillin resistance is very common with S aureus infection. In our intensive care unit, use of invasive devices/procedures and LOS were the most important risk factors for infection.

The role of advanced oxidation protein products in intensive care unit patients with acute kidney injury

Introduction Oxidative stress (OS) is an imbalance between the production of oxidizing chemical species and the antioxidant defense. It is known that OS increases in critically ill patients with acute kidney injury (AKI). Measurement of advanced oxidation protein products (AOPPs) has been found to be a simple tool for monitoring OS. Aims The aims of this study were to evaluate OS in intensive care unit (ICU) patients by AOPP levels and compare its levels between patients with and without AKI; we also wanted to assess the ability of AOPP to predict the development of AKI in this population. Patients, Material, and Methods We performed a prospective cohort study to compare AOPP levels between critically ill AKI (as defined by Risk-Injury-Failure-Loss-End Stage Renal Disease [RIFLE] criteria) and non-AKI patients. Blood samples were collected from all consecutively admitted patients upon arrival to ICU and daily for up to 4 days. We collected 234 blood samples from 86 adult medical and surgical ICU patients. The levels of AOPP were determined in the plasma and measured by spectrophotometry at 340 nm and compared between non-AKI (n = 71) and AKI patients (n = 15). We further subdivided the AKI patients according to severity of AKI (worst RIFLE class attained in ICU). Results Among the 86 patients, 15 (17.44%) developed AKI during their stay in ICU, whereas 71 patients (82.56%) did not. Among the AKI patients, 5 had AKI on ICU admission, whereas 10 developed it later. The levels of AOPP were significantly higher among AKI patients compared with non-AKI patients (153.8 ± 117.8 versus 129.0 ± 114.9 μmol/L, respectively; P = .034). Patients with the most severe AKI (RIFLE class Failure) had markedly elevated AOPP levels compared with RIFLE class Risk and Injury patients ( P = .012). Area under the curve of receiver operating characteristic for prediction of AKI within 48 hours after first blood sample collection was 0.5835 ( P = not significant). Conclusions This is the first study to explore the relationship between severity of AKI and AOPP. In our adult ICU population, AOPP levels were higher in AKI compared with non-AKI critically ill patients. On the other hand, AOPP levels were not found to be a useful biomarker for AKI, as it was unable to identify patients who developed AKI within 24, 48, 76, and 96 hours.

Centralized Triage for Multiple Intensive Care Units: The Central Intensivist Physician

Subspecialization of critical care units and overall increasing demand for critical care services has led to inefficiencies in allocation of critical care resources with potential impacts on hospital economics and patient outcomes. Centralized management of critical care resource allocation within an institution may improve use while simultaneously ensuring quality of patient care. The authors' institution has implemented a Central Intensivist Physician (CIP) program to oversee resource allocation within the adult surgical intensive care units (ICUs). The result has been an improvement in patient flow throughout the surgical ICUs manifested by steady case cancellation rates despite increasing acuity and length of stay. Additionally, triage duties have been shifted from the individual unit physician to the CIP, resulting in improved provider satisfaction from improved continuity of rounds. The authors conclude that the CIP program may improve overall critical care resource use while maintaining unit specialization within a large tertiary care hospital setting.

Dynamic characteristics of blood glucose time series during the course of critical illness: Effects of intensive insulin therapy and relative association with mortality*

To assess the effect of intensive insulin therapy on blood glucose amplitude variation and pattern irregularity in critically ill patients. To assess the association of these blood glucose signal characteristics with hospital mortality, independent of blood glucose level. Retrospective analysis of the databases of two previously published randomized controlled trials. University hospital, 56-bed adult surgical intensive care unit and 17-bed medical intensive care unit. One thousand five-hundred forty-eight surgical intensive care unit patients, admitted between February 2000 and January 2001, and 1200 medical intensive care unit patients, admitted between March 2002 and May 2005. In the two randomized controlled trials, patients were randomized to receive either intensive insulin therapy (targeting normoglycemia, between 4.4 and 6.1 mmol/L) or conventional insulin therapy (infusing insulin when blood glucose levels were >12 mmol/L and stopping at 10 mmol/L). Intensive insulin therapy significantly lowered mean blood glucose (5.8 vs. 8.4 mmol/L), hyperglycemic index (0.8 vs. 3.2 mmol/L), and glycemic penalty index (26 vs. 53), but it increased the mean daily difference between minimum and maximum blood glucose (mean daily delta blood glucose; 4.0 vs. 3.3 mmol/L). There was no significant effect on the standard deviation of the blood glucose measurements or on jack-knifed approximate entropy. In multivariable logistic regression analysis, corrected for baseline risk factors, blood glucose levels outside the normoglycemic range, higher mean daily delta blood glucose, higher standard deviation blood glucose, and higher jack-knifed approximate entropy were independently associated with hospital mortality. The Leuven intensive insulin therapy strategy increased mean daily delta blood glucose while not affecting standard deviation blood glucose and jack-knifed approximate entropy. Increased blood glucose amplitude variation and pattern irregularity were associated with mortality, irrespective of blood glucose level. The reduced mortality observed with intensive insulin therapy in the Leuven trials cannot be attributed to an effect on blood glucose amplitude variation or entropy. Reducing amplitude variation and entropy of the blood glucose signal, irrespective of blood glucose concentration, may produce clinical benefits.

SHA 37. “Moving into a technological era” electronic patient care documentation in adult cardiac surgical ICU

SHA 37. “Moving into a technological era” electronic patient care documentation in adult cardiac surgical ICU

Évaluation des pratiques de gestion des cathéters veineux centraux dans les réanimations chirurgicales universitaires françaises

Introduction Recommendations on insertion and maintenance of central venous catheters (CVC) in intensive care unit (ICU) patients were updated in 2002. The aim of this study was to estimate their knowledge and/or application by physicians in French university hospital ICUs. Methods Two forms were sent to 124 professors of anaesthesia and intensive care encouraging them to participate to the survey. The first one was completed by the physician in charge of each unit and concerned the structure and activity of the unit in 2006. The second one was filled by each junior or senior physician working in the units and asked for experience, CVC insertion modalities and knowledge of CVC care protocols. Results Forty-one (75 %) university hospitals with at least one adult surgical ICU took part to the study. A questionnaire was filled by 124 senior (75 % of the staff) and 53 junior (43 % of the staff) physicians inserting an average of 10 CVC per month (range, 1–35). A written protocol for CVC insertion was known by 127 (72 %) of them. CVC insertion was done while wearing sterile gown (97 %), cap (100 %) and surgical mask (100 %) and using large sterile draps (96 %). The antiseptic solution used for cutaneous antisepsis was povidone iodine in aqueous (36 %) or alcoholic solution (40 %), or an alcoholic solution of chlorhexidine (24 %) applied one (9 %), two (64 %) or three (27 %) times before insertion. A 4-times disinfection sequence (washing, rinsing, drying and disinfection) was performed by 161 (91 %) physicians. Ultrasound-guided insertion was realized by only eight (5 %) operators. CVCs were made of polyurethane (84 %), usually multi-lumens (> 96 %) and rarely tunnelised (14 %). Only two physicians (1 %) sometimes use catheters coated with antibiotics or antiseptics. The site for catheter insertion was mostly the sub-clavian (47 %) or internal jugular vein (34 %), and rarely the femoral vein (20 %). CVCs were secured with a thread (99 %) and covered with a semi-permeable dressing (76 %). Concerning CVCs maintenance, 91 % of physicians acknowledged the existence of a written protocol in the unit. Dressings were changed every day (10 %), every two days (49 %), every three days (29 %) or every four days or more (12 %) by using the same antiseptic solution and semi-permeable transparent dressing in 78 % of cases. Venous lines changes were done during dressing maintenance (48 %), every day in case of administration of lipids (32 %) or just after administration of blood products via the catheter (32 %). Routine change of CVC was rarely recommended (11 %). Conclusion The high number of answers allows setting of a precise state of CVCs insertion practices in adult surgical ICUs. Recommendations for central venous catheter insertion and maintenance are not still known and\\or applied.

External validation of six mortality prediction systems for intensive care unit patients

This study investigates the prognostic quality of six prediction models (APACHE II score, SAPS II, SAPS II (Expanded), SAPS 3, MPM and MPM II0) for assessment in an adult surgical ICU in the Netherlands.

Systemic Metabolic Changes of Traumatic Critically Ill Patients Revealed by an NMR-Based Metabonomic Approach

Progression of critically ill patients from Systemic Inflammatory Response Syndrome (SIRS) to Multiple Organ Dysfunction Syndrome (MODS) accounts for more than 75% of deaths in adult surgical intensive care units. Currently, there is no practical clinical technique to predict the progression of SIRS or MODS. In this report, we describe an NMR-based metabonomic method to aid detection of these conditions based on abnormal metabolic signatures. We applied pattern recognition methods to analyze one-dimensional (1)H NMR spectra of SIRS and MODS patient sera. By using Principal Component Analysis (PCA) and Partial Least Squares-Discriminant Analysis (PLS-DA), we could distinguish critically ill patients (n = 52) from healthy controls (n = 26). After noise reduction by Orthogonal Signal Correction (OSC), PLS-DA was also able to clearly discriminate SIRS and MODS patients. The corresponding coefficients indicated that spectra responsible for the discrimination were located in delta3.06-3.86 NMR integral regions from SIRS, mainly composed of sugars, amino acids and glutamine signals, and delta1.18-1.3 and delta4.02-4.1 integral regions of MODS serum samples, principally consisted of various proton signals of fatty acyl chains and glycerol backbone of lipids, along with creatinine and lactate. Our results are consistent with the clinical observations that carbohydrate and amino acid levels changes in the early course of critical illness (SIRS stage) and significant disturbances in fat metabolism and development of organ abnormalities become the characteristics in the late stage (MODS). These data suggest that NMR-based metabonomic approach can be developed to diagnose the disease progress of critically ill patients.

Walk the Talk: Promoting Control of Nursing Practice and a Patient-Centered Culture

Walk the Talk: Promoting Control of Nursing Practice and a Patient-Centered Culture

Glycemic variability: A strong independent predictor of mortality in critically ill patients*

To determine the effect of glycemic variability, assessed by the standard deviation of each patient's mean glucose level, on mortality in a population of critically ill adult patients. Retrospective review of a large cohort of prospectively evaluated patients. Fourteen-bed medical surgical adult intensive care unit of a university affiliated community hospital. Three thousand two hundred fifty-two patients consecutively admitted between October 1999 and October 2007 with at least three venous glucose samples. None. The mean (sd) Acute Physiology and Chronic Health Evaluation II score of the 3252 patients was 20.0 (8.9) and their mortality was 24.4%, ranging from 18.1% among patients with mean glucose level 70 mg/dL to 99 mg/dL to 35.9% among patients with mean glucose level 180+ mg/dL. The relationship between glycemic variability and mortality was strongest in the euglycemic range. For the 410 patients with mean glucose level 70 mg/dL to 99 mg/dL, mortality ranged from 5.9% in the first quartile of glycemic variability to 30.1% in the fourth; for the 1031 patients with mean glucose level 100 mg/dL to 119 mg/dL the corresponding range was 9.7% to 31.0%. Mortality among patients in the entire cohort with the lowest quartile of glycemic variability was 12.1%, increasing to 19.9%, 27.7%, and 37.8% in the second, third, and fourth quartiles. Intensive care unit length of stay was shorter among patients in the first quartile compared with those in the other three (p < .001). This study demonstrates that increasing glycemic variability conferred a strong independent risk of mortality in this heterogeneous population of critically ill patients. Previously published interventional studies of glycemic control may be reinterpreted using the metric of glycemic variability. Measures to ensure a low degree of glycemic variability may improve outcomes in intensive care unit's implementing glycemic control. Finally, ongoing and future investigations should consider including this new metric in their study design.

A Randomized Comparative Crossover Study to Assess the Affect on Circuit Life of Varying Pre-Dilution Volume Associated with CVVH and CVVHDF

To determine if circuit life is influenced by a higher pre-dilution volume used in CVVH when compared with a lower pre-dilution volume approach in CVVHDF. A comparative crossover study. Cases were randomized to receive either CVVH or CVVHDF followed by the alternative treatment. All patients >or= 18 yrs of age who required CRRT while in ICU were eligible to participate, but excluded if coagulopathic, thrombocytopenic or unable to receive heparin. Based on an intention-to-treat, 45 patients were randomized to receive either CVVH or CVVHDF followed by the alternative treatment. A 24-bed, tertiary, medical and surgical adult intensive care unit (ICU). Blood flow rate, vascular access device and insertion site, hemofilter, anticoagulation and machine hardware were standardized. An ultrafiltrate dose of 35 ml/ kg/h delivered pre-filter was used for CVVH. A fixed pre-dilution volume of 600 mls/h with a dialysate dose of 1 L was used for CVVHDF. Thirty-one patients received CVVH or CVVHDF out of 45 participants followed by the alternative technique. There was a significant increase in circuit life in favor of CVVHDF (median=16 h 5 min, range=40 h 23 min) compared with CVVH (median=6 h 35 min, range=30 h 45 min). A Mann-Whitney U test was performed to compare circuit life between the two different CRRT modes (Z=-3.478, p<0.001). Measurements of circuit life on the 93 circuits which survived to clotting (50 CVVH and 43 CVVHDF) were log transformed prior to under taking a standard multiple regression analysis. None of the independent variables - activated prothrombin time (aPTT), platelet count, heparin dose, patient hematocrit or urea - had a coefficient partial correlation >0.09 (coefficient of the determination=0.117) or a linear relationship which could be associated with circuit life (p=0.228). Pre-diluted CVVHDF appeared to have a longer circuit life when compared to high volume pre-diluted CVVH. The choice of CRRT mode may be an important independent determinant of circuit life.

Potential Influence of Antisecretory Therapy on the Development of Candida-Associated Intraabdominal Infection

Concerns surrounding the potential extra gut complication of gastric acid suppression are becoming increasingly realized. To determine whether chronic antisecretory treatment with a proton pump inhibitor (PPI) or histamine(2)-receptor antagonist (H(2)RA) is associated with the presence of Candida spp. in cases of complicated intraabdominal infection. We conducted a case-controlled study of adult surgical intensive care unit patients with complicated intraabdominal infection during a 5-year period. Exclusion criteria consisted of primary peritonitis, diagnosis of intraabdominal infection more than 72 hours before hospital admission, or a stay in the intensive care unit of less than 72 hours. Patients were categorized into either the antisecretory group (H(2)RA or PPI therapy prior to admission) or control group (no prior antisecretory therapy). One hundred eighteen patients met inclusion criteria. Chronic antisecretory (n = 41) and control (n = 77) patients were similar except in median age (69.0 vs 59.0 y; p = 0.026) and preadmission antibiotic use (36.6% vs 15.6%; p = 0.010). The 2 groups had a similar proportion of patients with Candida (30.3% vs 32.1%; p = 0.857); the cultures included C. albicans, C. glabrata, and C. parapsilosis. Yeast was recovered more often in patients diagnosed with community-acquired intraabdominal infection and in patients who had used PPIs before hospital admission (p = 0.066). Additionally, Candida was cultured more often in antisecretory patients with a history of prior abdominal surgery than in control patients (91.7% vs 62.5%; p = 0.066). No significant difference was found in the number of patients in the antisecretory and control groups from whom peritoneal Candida was recovered. However, patients with prior abdominal surgery and those in the community with chronic PPI use may be predisposed to Candida-associated intraabdominal infections.

High Mortality Rate for Patients Requiring Intensive Care After Surgical Revision Following Bariatric Surgery

To report the prognosis and management of patients reoperated for severe intraabdominal sepsis (IAS) after bariatric surgery (S0) and admitted to the surgical intensive care unit (ICU) for organ failure. A French observational study in a 12-bed adult surgical intensive care unit in a 1,200-bed teaching hospital with expertise in bariatric surgery. From January 2001 to August 2006, 27 morbidly obese patients (18 transferred from other institutions) developed severe postoperative IAS (within 45 days). Clinical signs, biochemical and radiologic findings, and treatment during the postoperative course after S0 were reviewed. Time to reoperation, characteristics of IAS, demographic data, and disease severity scores at ICU admission were recorded and their influence on prognosis was analyzed. The presence of respiratory signs after S0 led to an incorrect diagnosis in more than 50% of the patients. Preoperative weight (body mass index [BMI] > 50 kg/m2) and multiple reoperations were associated with a poorer prognosis in the ICU. The ICU mortality rate was 33% and increased with the number of organ failures at reoperation. During the initial postoperative course after bariatric surgery, physical examination of the abdomen is unreliable to identify surgical complications. The presence of respiratory signs should prompt abdominal investigations before the onset of organ failure. An urgent laparoscopy, as soon as abnormal clinical events are detected, is a valuable tool for early diagnosis and could shorten the delay in treatment.

Nosocomial Infections in a Medical-Surgical Intensive Care Unit

Objective: We aimed to describe the pattern of nosocomial infections in an adult medical-surgical intensive care unit (ICU). Subjects and Methods: A 2-year prospective cohort study of nosocomial infection surveillance in a 15-bed adult combined medical and surgical ICU of Farwaniya Hospital, Kuwait, was carried out. Data were collected between January 2004 and December 2005 using the standard surveillance protocols and nosocomial infection site definitions of the National Nosocomial Infections Surveillance System’s ICU surveillance component. Results: Of 1,173 patients hospitalized in the ICU for an aggregate duration of 6,855 days, 89 patients acquired a total of 140 nosocomial infections; 46 (33%) ventilator-associated pneumonia (VAP), 33 (24%) central-line-associated bloodstream infection and 15 (11%) catheter-associated urinary tract infection, 22 (16%) cutaneous infection and 24 (17%) other infections. The overall patient day rate was 20.6/1,000 patient days. The patient infection rate was 10.6/100 patients at risk. The mean VAP rate was 9.1/1,000 ventilator days (95% CI, 5–13.2), the central-line-associated bloodstream infection rate 5.5/1,000 central line days (95% CI, 3.2–7.8) and the catheter-associated urinary tract infection rate 2.3/1,000 catheter days (95% CI, 1.2–3.4). Of all nosocomial infections, 119 (85%) were culture-confirmed and 21 (15%) were clinically defined culture-negative infections. Of the culture-confirmed nosocomial infections, 81 (68%) were Gram-negative, 32 (27%) Gram-positive and 6 (5%) fungal. The most frequent organism was Pseudomonas aeruginosa (20, 17%), followed by Acinetobacter baumannii (15, 13%), Klebsiella spp. (13, 11%) and Escherichia coli (10, 8%). The crude mortality was 27% among ICU-infected patients. Conclusion: VAP was the most common nosocomial infection in our ICU. Gram-negative organisms were more commonly reported as etiologic agents of ICU infections.

Minute Ventilation Recovery Time Measured Using a New, Simplified Methodology Predicts Extubation Outcome

Extubation failure is associated with poor intensive care unit and hospital outcomes. Minute ventilation recovery time, an integrative measure of a patient's respiratory reserve, has been shown in a pilot study to predict extubation outcome; however, the methodology is subjective and impractical for routine use. The authors hypothesize that minute ventilation recovery time, measured using an objective and simpler method, would predict extubation outcome. A prospective cohort study was performed in adult medical and surgical intensive care unit patients intubated for >24 hours who were weaning from mechanical ventilation. Minute ventilation recovery time was measured using a new, simplified, and objective method following the final spontaneous breathing trial prior to extubation. The primary outcome was extubation failure, defined as reintubation within 7 days. The study cohort comprised 88 patients, of whom 22 (25%) failed extubation after a median of 3 days. Demographic data, weaning parameters, and the proportion of patients who passed an extubation screen were similar between groups (P > .05). Minute ventilation recovery time was significantly longer in patients who failed extubation (15 [5-15] vs 2 [1-5] minutes, P < .001), consistent in both medical and surgical subgroups. Operating characteristics for a preliminary threshold (minute ventilation recovery time >or=5 minutes) for prediction of extubation failure were sensitivity = 0.78, specificity = 0.71, positive predictive value = 0.47, negative predictive value = 0.90, correctly classified = 0.72. Adjustment for significant covariates did not alter the relationship between minute ventilation recovery time >or=5 minutes and extubation failure (odds ratio = 4.9, 95% confidence interval 1.45-16.2, P < .02). C statistic was 0.79 +/- 0.17. It was concluded that minute ventilation recovery time, measured using a feasible methodology, can predict extubation outcome in medical and surgical intensive care unit patients.

Enoxaparin vs. unfractionated heparin for anticoagulation during continuous veno-venous hemofiltration: a randomized controlled crossover study

The purpose of this study was to evaluate the efficacy and safety of the low molecular weight heparin enoxaparin as anticoagulant in continuous veno-venous hemofiltration (CVVH) compared with unfractionated heparin. Prospective randomized controlled crossover study. Medical and Surgical Intensive Care Unit of a University Hospital. Forty consecutive adult medical and surgical ICU patients with normal anticoagulation parameters requiring CVVH. CVVH was performed with pre-filter fluid replacement at 2500 ml/h and blood flow rates of 180 ml/min. Heparin-treated patients received an initial pre-filter bolus of 30 IU/kg and a maintenance infusion at 7 units/kg h(-1), titrated to achieve a systemic activated partial thromboplastin time (aPTT) of 40-45 s. Enoxaparin-treated patients received an initial pre-filter bolus of 0.15 mg/kg and a maintenance infusion starting at 0.05 mg/kg h(-1), which was subsequently adjusted to maintain systemic anti-factor Xa activity (anti-Xa) at 0.25-0.30 IU/ml. Each patient received both regimens in a crossover design. Maximum treatment duration for each set was 72 h. Patients included had a mean APACHE II score of 22 (10-35). Thirty-seven patients completed both study arms. Mean filter life span was 21.7 h (+/- 16.9 h) for heparin and 30.6 h (+/- 25.3) for enoxaparin (p = 0.017, ANOVA for repeated measures). One major bleeding episode occurred during heparin as well as during enoxaparin treatment. Cost analysis showed average daily costs of 270 and 240 euro for heparin and enoxaparin, respectively. Enoxaparin can be safely used for anticoagulation during CVVH resulting in higher filter lifespan compared with unfractionated heparin.

Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients

Acute brain dysfunction or delirium occurs in the majority of mechanically ventilated (MV) medical intensive care unit (ICU) patients and is associated with increased mortality. Unfortunately delirium often goes undiagnosed as health care providers fail to recognize in particular the hypoactive form that is characterized by depressed consciousness without the positive symptoms such as agitation. Recently, clinical tools have been developed that help to diagnose delirium and determine the subtypes. Their use, however, has not been reported in surgical and trauma patients. The objective of this study was to identify the prevalence of the motoric subtypes of delirium in surgical and trauma ICU patients. Adult surgical and trauma ICU patients requiring MV longer than 24 h were prospectively evaluated for arousal and delirium using well validated instruments. Sedation and delirium were assessed using the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method in the ICU (CAM-ICU), respectively. Patients were monitored for delirium for a maximum of 10[Symbol: see text]days or until ICU discharge. A total of 100 ICU patients (46 surgical and 54 trauma) were enrolled in this study. Three patients were excluded from the final analysis because they stayed persistently comatose prior to their death. Prevalence of delirium was 70% for the entire study population with 73% surgical and 67% trauma ICU patients having delirium. Evaluation of the subtypes of delirium revealed that in surgical and trauma patients, hypoactive delirium (64% and 60%, respectively) was significantly more prevalent than the mixed (9% and 6%) and the pure hyperactive delirium (0% and 1%). The prevalence of the hypoactive or "quiet" subtype of delirium in surgical and trauma ICU patients appears similar to that of previously published data in medical ICU patients. In the absence of active monitoring with a validated clinical instrument (CAM-ICU), however, this subtype of delirium goes undiagnosed and the prevalence of delirium in surgical and trauma ICU patients remains greatly underestimated.

Glucose Control in Pediatric Intensive Care Unit Patients Using an Insulin–Glucose Algorithm

Control of hyperglycemia in adult medical and surgical intensive care units (ICUs) has been shown to dramatically decrease morbidity and mortality. Algorithms to achieve glycemic control in the ICU setting are evolving. We have evaluated the use of a discrete proportional-integral-derivative (PID) algorithm to control hyperglycemia in pediatric ICU (PICU) patients both with and without diabetes. Six PICU patients [four with diabetic ketoacidosis (DKA) and two with glucocorticoid-induced hyperglycemia] with glucose values >150 mg/dL were enrolled. Their hyperglycemia was managed with a PID algorithm that provided recommendations for both changes in the intravenous insulin infusion rate and the time to obtain the next discrete glucose value. Glucose targets were adjusted based on clinical circumstances. Patients (mean age 9.2 years; range 1.8-14 years) utilized the algorithm for a total of 454.4 h. Mean time to the initial glucose target was 8.7 h (range 1.3-15.1 h) in five patients. One subject with hyperosmolar DKA did not achieve target before discharge from the PICU, and another was at target when the algorithm was initiated. After the glucose target was achieved, the mean SD was 23.5 mg/dL, and glucose values were >40 mg/dL above target 13% of the time and <40 mg/dL below target 1% of the time. There were no glucose values <55 mg/dL. The PID algorithm safely and effectively controlled hyperglycemia in a PICU, despite multiple changes in intravenous fluids, steroid doses (including high-dose pulses), and hemodialysis.

Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients

Objective:To determine whether treatment with corticosteroids decreases the incidence of postextubation airway obstruction in an adult intensive care unit.Design:Clinical experiment.Setting:Adult medical and surgical intensive care unit of a teaching hospital.Patients:One hundred twenty-eight patien