The Use of a Checklist to Optimize Electrolyte Replacement in the ICU.

Electrolyte replacement protocols are routinely used in intensive care units (ICU) to guide magnesium replacement. Guided by serum levels, these protocols include no patient-specific factors despite a literature showing ICU patients routinely have significant deficits despite normal serum levels. The authors developed a checklist to help identify patients requiring more aggressive magnesium replacement than the electrolyte replacement protocol would provide. The checklist included risk factors for having significant magnesium deficits and for developing arrhythmias. The checklist was retrospectively applied to 364 medical ICU patients. Diabetic patients prescribed outpatient diuretics were defined as the highest-risk population. A total of 88% of patients in this subgroup had normal magnesium levels. Despite averaging 3.4 risk factors per patient, only 3 of 32 patients received magnesium. Applying the checklist would have suggested additional repletion for at least 85% of patients. A checklist can help identify ICU patients who may require more aggressive magnesium supplementation than protocols will provide.

The Impact of Regional Citrate Anticoagulation on Magnesium Replacement During CRRT.

A patient admitted to the ICU with shock and acute kidney injury required continuous renal replacement therapy (CRRT). CRRT was initiated using regional citrate anticoagulation (RCA) with an initial magnesium (Mg) level of 1.7 mg/dL. Over 12 days the patient received 68 g of Mg sulfate. After 58 g the patient's Mg level was 1.4 mg/dL. On day 13, CRRT was changed to a heparin circuit from concerns of citrate toxicity. Over the next 7 days the patient required no Mg replacement with a mean Mg level of 2.22. This was significantly higher than the final 7 days on RCA (1.99; P = .00069). This case illustrates the challenges in maintaining Mg stores during CRRT. RCA is now the preferred method of circuit anticoagulation, with prolonged filter life and fewer bleeding complication compared to heparin circuits. Citrate inhibits coagulation within the circuit by chelating ionized calcium (Ca2+). Free Ca2+ and Ca-citrate complexes diffuse across the hemofilter with a percentual calcium loss as high as 70%, requiring continuous post-filter infusions of calcium to prevent systemic hypocalcemia. Magnesium loss during CRRT is also significant and may approach 15% to 20% of the total body pool within a week. Citrate chelates Mg with percentual losses comparable to calcium. Twenty-two CRRT patients on RCA had median losses >6 g/day. Doubling the Mg content in the dialyzate of 45 CRRT patients significantly improved Mg balance, but with the potential risk of increased citrate toxicity. A major obstacle to replacing Magnesium loss with the same precision as calcium is few hospitals can measure ionized Mg++ levels and must rely on total magnesium levels to guide replacement, despite a literature showing poor correlation with total body stores. Post-circuit continuous replacement of magnesium, as with calcium, in the absence of ionized magnesium levels would likely be very inexact and arduous. Being aware of the losses that can occur with CRRT, especially with RCA, and adjusting magnesium replacement empirically on rounds may be the only pragmatic action plan for this clinical issue.

A More Directive Living Will for Older Adult Patients with End-Stage Medical Conditions?

OBJECTIVES: Many older adult patients want to be treated aggressively for reversible conditions, even when their current quality of life is limited; however, most standard living wills focus on the very end of life and provide little guidance to acute care providers (ACPs) should their older adult patient be admitted with a potentially treatable acute condition and temporarily lose capacity. We developed what we believe is a more informational and directive living will for this population. We sought to determine whether ACPs would find our pilot living will more helpful when caring for their older adult patients. METHODS: Convenience sample of members of the Society of Hospital Medicine (SHM). Respondents were asked to compare the pilot living will with their state form and then answer five attitudinal questions. RESULTS: In total, 125 providers from 39 states completed the survey: 86% indicated that the pilot living will better helped them understand their patients' general end-of-life preferences, 87.5% indicated the pilot living will would be more helpful in making specific treatment decisions for their patients, and 85% indicated the pilot living will would better facilitate end-of-life discussions with surrogates. CONCLUSIONS: Our results suggest that it is possible to design a functional advanced directive that better reflects the wishes of the older adult patient who wants to be treated aggressively in selected clinical situations. By more clearly defining these wishes, acute providers (eg, hospitalists, intensivists) can make more informed, patient-centered recommendations to surrogates.

A pilot study on the utility of a more informative living will.

Most written advance directives are designed to help people prescribe the care they would desire at the very end of their life. They provide little guidance for elderly patients with potentially treatable diseases who may be temporarily incapacitated and thus unable to articulate their wishes. The authors developed an alternative living will format with the intent of better documenting the care wishes of this population. A convenience survey of patients, surrogates and physicians compared the pilot version with the commonly available West Virginia Living Will to determine whether the pilot version was able to provide clearer direction for health care providers and surrogate decision makers. The majority of respondents indicated the pilot version better met their needs when compared to the commonly utilized version. This study suggests there is a need for an alternative living will that addresses the needs of those not at the very end of their life.

Visual hallucinations in a patient with adult onset acid maltase deficiency disorder.

A 66-year-old male presented with visual hallucinations. He had chronically elevated serum creatine kinase (CK) levels without muscle weakness. His hospital course was complicated by hypercapnic respiratory failure requiring mechanical ventilation. His hallucinations completely subsided on mechanical ventilation. Elevated CK levels prompted a muscle biopsy, which showed myopathy consistent with acid maltase deficiency disorder (AMDD). This is the first reported case of adult onset AMDD presenting with psychiatric symptoms. Our objective in reporting this case is to encourage early recognition of neuromuscular respiratory failure in AMDD and to reinforce that respiratory failure may develop without associated extremity muscle weakness.

Are blood gases necessary in mechanically ventilated patients who have successfully completed a spontaneous breathing trial?

BACKGROUND: The utility of routinely obtaining arterial blood gas analyses (ABGs) prior to extubation in patients who have successfully completed a spontaneous breathing trial is not known. OBJECTIVE: Review our practices and determine our extubation success rate with a policy of selective ABG utilization. METHODS: Retrospective chart review. RESULTS: We reviewed 54 extubations of 52 patients. Sixty-five percent of the extubations were performed without obtaining an ABG after the spontaneous breathing trial. The extubation success rate was 94% for the entire group and was the same regardless of whether an ABG measurement was obtained (94.7% vs 94.3%, respectively). CONCLUSION: ABG measurement does not appear to be a prerequisite to extubation following a clinically successful spontaneous breathing trial.

Stress ulcer prophylaxis.

Preview Which critically ill patients are at increased risk for gastrointestinal hemorrhage from stress ulcers? Do prophylactic agents effectively reduce the morbidity and mortality associated with stress-related hemorrhage? The author, former director of a medical intensive care unit, reviews recent literature on stress ulcer prophylaxis and outlines the risks and benefits of providing preventive therapy.