ABSTRACT
A novel, multi-dimensional protocol named GENIE has been in use for intensive insulin therapy (IIT, target glucose <140 mg/dL) in the surgical intensive care unit (SICU) after open heart surgery (OHS) at VA Pittsburgh since 2005. Despite concerns over increased mortality from IIT after the publication of the NICE-SUGAR Trial, it remains in use, with ongoing monitoring under the MAGIC GENIE Project showing that GENIE performance over 12 years (2005-2016) aligns with the current consensus that IIT with target blood glucose (BG) <140 mg/dL is advisable only if it does not provoke severe hypoglycemia (SH). Two studies have been conducted to monitor glucometrics and outcomes during GENIE use in the SICU. One compares GENIE (n = 382) with a traditional IIT protocol (FORMULA, n = 289) during four years of contemporaneous use (2005-2008). The other compares GENIE's impact overall (n = 1404) with a cohort of patients who maintained euglycemia after OHS (euglycemic no-insulin [ENo-I], n = 111) extending across 12 years (2005-2016). GENIE performed significantly better than FORMULA during contemporaneous use, maintaining lower time-averaged glucose, provoking less frequent, severe, prolonged, or repetitive hypoglycemia, and achieving 50% lower one-year mortality, with no deaths from mediastinitis (0 of 8 cases vs 4 of 9 on FORMULA). Those benefits were sustained over the subsequent eight years of exclusive use in OHS patients, with an overall one-year mortality rate (4.2%) equivalent to the ENo-I cohort (4.5%). The results of the MAGIC GENIE Project show that GENIE can maintain tight glycemic control without provoking SH in patients undergoing OHS, and may be associated with a durable survival benefit. The results, however, await confirmation in a randomized control trial.
Subject(s)
Cardiac Surgical Procedures , Hypoglycemia , Blood Glucose , Critical Care , Expert Systems , Humans , InsulinABSTRACT
BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a major pathogen in hospital-acquired infections. MRSA-colonized inpatients who may benefit from undergoing decolonization have not been identified. OBJECTIVE: To identify risk factors for MRSA infection among patients who are colonized with MRSA at hospital admission. DESIGN: A case-control study. SETTING: A 146-bed Veterans Affairs hospital. PARTICIPANTS: Case patients were those patients admitted from January 2003 to August 2011 who were found to be colonized with MRSA on admission and then developed MRSA infection. Control subjects were those patients admitted during the same period who were found to be colonized with MRSA on admission but who did not develop MRSA infection. METHODS: A retrospective review. RESULTS: A total of 75 case patients and 150 control subjects were identified. A stay in the intensive care unit (ICU) was the significant risk factor in univariate analysis (P<.001). Prior history of MRSA (P=.03), transfer from a nursing home (P=.002), experiencing respiratory failure (P<.001), and receipt of transfusion (P=.001) remained significant variables in multivariate analysis. Prior history of MRSA colonization or infection (P=.02]), difficulty swallowing (P=.04), presence of an open wound (P=.02), and placement of a central line (P=.02) were identified as risk factors for developing MRSA infection for patients in the ICU. Duration of hospitalization, readmission rate, and mortality rate were significantly higher in case patients than in control subjects (P < .001, .001, and <.001, respectively). CONCLUSIONS: MRSA-colonized patients admitted to the ICU or admitted from nursing homes have a high risk of developing MRSA infection. These patients may benefit from undergoing decolonization.
