Laboratory alerts to guide early intensive care team review in surgical patients: A feasibility, safety, and efficacy pilot randomized controlled trial.

AIM: Common blood tests can help identify patients at risk of death, unplanned intensive care unit (ICU) admission, or rapid response team (RRT) call. We aimed to test whether early ICU-team review triggered by such laboratory tests (lab alert) is feasible, safe, and can alter physiological variables, clinical management, and clinical outcomes. METHODS: In prospective pilot randomized controlled trial in surgical wards of a tertiary hospital, we studied patients admitted for >24 h. We applied a previously validated risk assessment tool to each set of common laboratory tests to identify patients at risk and generate a "lab-alert". We randomly allocated such lab-alert patients to receive early ICU-team review (intervention) or usual care (control). RESULTS: We studied 205 patients (males 54.1%; average age 79 years; 103 randomized to intervention and 102 to usual care). Intervention patients were more likely to trigger RRT activation during their first lab-alert (10.7 vs. 2.0%; P < 0.001) but less likely to receive an allied health referral (18.0% vs. 24.5%; p = 0.007). They were less likely to trigger RRT activation in the 24-h before subsequent alerts (18.4 vs. 22.4%; p = 0.008) and less likely to generate further alerts (204 vs. 320; p < 0.001), but more likely to receive a not for resuscitation or endotracheal intubation status in the 24-h before subsequent alerts (26.6 vs. 17.3%; p = 0.05). Mortality at 24 h was 1.9% for the intervention group vs. 2.9% in the control group (p = 0.63). Finally, overall mortality was 19.4% for intervention patients vs. 23.5% for control patients (p = 0.50). CONCLUSION: Among surgical patients, lab alerts identify patients with a high mortality. Lab alert-triggered interventions are associated with more first alert-associated RRT activations; more changes in resuscitation status toward a more conservative approach; fewer subsequent alert-associated RRT activations; fewer subsequent alerts, and decreased allied health interventions (ANZCTRN12615000146594).

Liberal Glucose Control in ICU Patients With Diabetes: A Before-and-After Study.

OBJECTIVES: To assess the feasibility, biochemical efficacy, and safety of liberal versus conventional glucose control in ICU patients with diabetes. DESIGN: Prospective, open-label, sequential period study. SETTING: A 22-bed mixed ICU of a tertiary hospital in Australia. PATIENTS: We compared 350 consecutive patients with diabetes admitted over 15 months who received liberal glucose control with a preintervention control population of 350 consecutive patients with diabetes who received conventional glucose control. INTERVENTIONS: Liberal control patients received insulin therapy if glucose was greater than 14 mmol/L (target: 10-14 mmol/L [180-252 mg/dL]). Conventional control patients received insulin therapy if glucose was greater than 10 mmol/L (target: 6-10 mmol/L [108-180 mg/dL]). MEASUREMENTS AND MAIN RESULTS: We assessed separation in blood glucose, insulin requirements, occurrence of hypoglycemia (blood glucose ≤ 3.9 mmol/L [70 mg/dL]), creatinine and white cell count levels, and clinical outcomes. The median (interquartile range) time-weighted average blood glucose concentration was significantly higher in the liberal control group (11.0 mmol/L [8.7-12.0 mmol/L]; 198 mg/dL [157-216 mg/dL]) than in the conventional control group (9.6 mmol/L [8.5-11.0 mmol/L]; 173 mg/dL [153-198 mg/dL]; p < 0.001). Overall, 132 liberal control patients (37.7%) and 188 conventional control patients (53.7%) received insulin in ICU (p < 0.001). Hypoglycemia occurred in 6.6% and 8.6%, respectively (p = 0.32). Among 314 patients with glycated hemoglobin A1c greater than or equal to 7%, hypoglycemia occurred in 4.1% and 9.6%, respectively (p = 0.053). Trajectories of creatinine and white cell count were similar in the groups. In multivariable analyses, we found no independent association between glucose control and mortality, duration of mechanical ventilation, or ICU-free days to day 30. CONCLUSIONS: In ICU patients with diabetes, during a period of liberal glucose control, insulin administration, and among patients with hemoglobin A1c greater than or equal to 7%, the prevalence of hypoglycemia was reduced, without negatively affecting serum creatinine, the white cell count response, or other clinical outcomes. (Trial Registration: Australian New Zealand Clinical Trials Registry; ACTRN12615000216516).

Use of evidence-based recommendations in an antibiotic care bundle for the intensive care unit.

PURPOSE: To drive decisions on antibiotic therapy in the intensive care unit (ICU), we developed an antibiotic care bundle (ABC-Bundle) with evidence-based recommendations (EBRs) for antibiotic prescriptions. METHODS: We conducted a three-step prospective study. First, a systematic review was performed of the literature reporting EBRs for antibiotic usage in the ICU. Second, we developed an ABC-Bundle through a two-round, RAND-modified Delphi method with an international expert panel, including the most relevant EBRs on a 9-point Likert scale. Those EBRs that were considered mandatory by >50% of the experts were included in the bundle. Third, we assessed the adherence to and applicability of the bundle in two mixed university ICUs. RESULTS: Out of 1190 potentially relevant articles, 14 (four guidelines, four randomised controlled trials and six systematic reviews) fulfilled the eligibility criteria. Six EBRs were classified as relevant: 1. Provide rationale for antibiotic start; 2. Perform appropriate microbiological sampling; 3. Prescribe empirical antibiotic therapy according to guidelines (Day 1); 4. Review diagnosis; 5. Evaluate de-escalation based on microbiological results (Days 2-5); and 6. Consider discontinuation of treatment (Days 3-5). Daily adherence to the ABC-Bundle, prospectively assessed in 861 days of therapy in 142 ICU patients, ranged from 2% to 37%. CONCLUSION: The ABC-Bundle is a novel tool to improve delivery of appropriate antibiotic therapy to ICU patients. The low adherence in the prospective cohorts confirms the significant role that the ABC-Bundle could play in an antibiotic stewardship programme in the ICU setting.

Liberal Versus Conventional Glucose Targets in Critically Ill Diabetic Patients: An Exploratory Safety Cohort Assessment.

OBJECTIVES: To assess the feasibility, safety, and impact on relative hypoglycemia of liberal versus conventional blood glucose concentration targets in critically ill diabetic patients. DESIGN: Prospective, open-label, sequential-period exploratory study. SETTING: A 22-bed multidisciplinary ICU of a tertiary care hospital in Australia. PATIENTS: Eighty adult diabetic patients, 40 from the conventional before period and 40 from the liberal after period. INTERVENTIONS: Blood glucose concentration targets were 6-10 mmol/L during the before period and 10-14 mmol/L during the after period. MEASUREMENTS AND MAIN RESULTS: We used admission glycated hemoglobin to estimate premorbid baseline blood glucose concentration. We defined glycemic distance as the difference between blood glucose concentration in ICU and baseline blood glucose concentration. During the first 48 ICU hours, we recorded absolute (blood glucose concentration, < 3.9 mmol/L) and relative (glycemic distance, > 30% below baseline) hypoglycemia rates, insulin administration, and outcomes. The groups had similar baseline characteristics. We observed a negative glycemic distance in 248 of 488 blood glucose concentrations (50.8%) during the before period and 164 of 485 (33.8%) during the after period (p < 0.001). We detected relative hypoglycemia in 20 (50.0%) and nine (22.5%) patients in the before and after periods, respectively (p = 0.01). On day 1, 50.0% and 16.7% received insulin in the before and after periods (p = 0.007). ICU and hospital length of stay and mortality were similar between groups. CONCLUSIONS: In a safety cohort of critically ill diabetic patients, a blood glucose concentration target of 10-14 mmol/L resulted in fewer episodes of negative glycemic distance or relative hypoglycemia and reduced insulin administration compared with a target of 6-10 mmol/L.

Clinical impact of pulmonary sampling site in the diagnosis of ventilator-associated pneumonia: A prospective study using bronchoscopic bronchoalveolar lavage.

PURPOSE: It is unclear whether ventilator-associated pneumonia (VAP) is actually a bilateral and multifocal process. In addition, the diagnostic role of chest x-ray is under debate. Assuming a low microbiologic concordance between the left and right lungs, the reliability of a single pulmonary sampling becomes questionable. The purpose of this study was to determine whether the choice of the pulmonary sampling area is clinically relevant in the management of VAP. METHODS: In 79 patients admitted to a university general intensive care unit with clinically suspected VAP, right- and left-lung bronchoalveolar lavage (BAL) samples were taken with separate bronchoscopes and quantitatively cultured. Primary end-point variable was microbiologic concordance rate between right- and left-lung BAL cultures. Secondary outcomes included predictors of microbiologic concordance, rates of appropriate antibiotic treatment, and diagnostic accuracy of chest x-ray. RESULTS: BAL cultures were bilaterally negative in 21 (27%) of 79 patients, bilaterally positive in 36 (46%), and unilaterally positive (right in 12, left in 10) in 22 (28%). Intra-patient concordance was observed in 47 (59.5%) of 79 cases and independently associated with purulent secretions and bilateral infiltrates on chest x-ray. In simulated prescribing experiments, treatments chosen based on right or left cultures alone were as appropriate as those based on bilateral data in >90% of cases. The presence of a radiographic infiltrate in the sampling area predicted BAL culture positivity with a positive predictive value of only 61%. CONCLUSIONS: In patients with clinically suspected VAP (especially those without purulent secretions or without radiographically documented bilateral infiltrates), quantitative culture of a single BAL sample may provide an incomplete assessment of lung microbiology, without having a relevant impact on the appropriateness of antimicrobial treatment. These findings suggest that single sampling of respiratory secretions, regardless radiographic opacity, seems to be a reliable diagnostic method in the management of VAP.

The role of arthroscopy in articular fracture management: the lower limb.

The management of articular fracture is always a matter of concern. While each articular fracture is different from one another, besides the classification system used and the surgical or non-surgical indication given by the specialist, main goals remain the same: anatomical reduction, stable fixation, loose body removal, and minimal invasiveness. Open procedures are the actual compromise, but unfortunately, it is not always possible to perfectly meet every treatment goal, associated lesions could pass unnoticed or delayed in treatment, and even in a best-case scenario, there could be several complications developing in the long term. In the last decades, arthroscopic joint surgery underwent an exponential evolution, expanding its application also in the trauma field with the development of arthroscopic and arthroscopically assisted reduction and internal fixation (ARIF) techniques; main advantages are an accurate diagnosis of fracture and associated soft tissue involvement, the potential for concomitant treatments, anatomical reduction, and minimal invasiveness. ARIF techniques have been applied to treat fractures affecting several joints: shoulder, elbow, wrist, hip, knee, and ankle. The purpose of this paper was to provide a review of the most recent literature about arthroscopic and arthroscopically assisted reduction and internal fixation for articular and periarticular fractures of the lower limb, analyzing the results and suggesting clinical applications.