Early versus late intravenous insulin administration in critically ill patients.

OBJECTIVE: To investigate whether timing of intensive insulin therapy (IIT) after intensive care unit (ICU) admission influences outcome. DESIGN AND SETTING: Single-center prospective cohort study in the 14-bed medical ICU of a 1,171-bed tertiary teaching hospital. PATIENTS: The study included 127 patients started on ITT within 48 h of ICU admission (early group) and 51 started on ITT thereafter (late group); the groups did not differ in age, gender, race, BMI, APACHE III, ICU steroid use, admission diagnosis, or underlying comorbidities. MEASUREMENTS AND RESULTS: The early group had more ventilator-free days in the first 28 days after ICU admission (median 12 days, IQR 0-24, vs. 1 day, 0-11), shorter ICU stay (6 days, IQR 3-11, vs. 11 days, vs. 7-17), shorter hospital stay (15 days, IQR 9-30, vs. 25 days, 13-43), lower ICU mortality (OR 0.48), and lower hospital mortality (OR 0.27). On multivariate analysis, early therapy was still associated with decreased hospital mortality (ORadj 0.29). The strength and direction of association favoring early IIT was consistent after propensity score modeling regardless of method used for analysis. CONCLUSIONS: Early IIT was associated with better outcomes. Our results raise questions about the assumption that delayed administration of IIT has the same benefit as early therapy. A randomized study is needed to determine the optimal timing of therapy.

Utilization of bronchodilators in ventilated patients without obstructive airways disease.

OBJECTIVE: To examine physician practice in, and the costs of, prescribing inhaled bronchodilators to mechanically ventilated patients who do not have obstructive lung disease. METHODS: This was a prospective cohort study at 2 medical intensive care units at 2 tertiary-care academic medical centers, over a 6-month period. Included were the patients who required > or = 24 hours of mechanical ventilation but did not have obstructive lung disease. Excluded were patients who had obstructive lung disease and/or who had undergone > 24 hours of mechanical ventilation outside the study intensive care units. RESULTS: Of the 206 patients included, 74 (36%) were prescribed inhaled bronchodilators without clear indication. Sixty-five of those 74 patients received both albuterol and ipratropium bromide, usually within the first 3 days of intubation (58 patients). Patients prescribed bronchodilators were more hypoxemic; their mean P(aO(2))/F(IO(2)) ratio was lower (188 mm Hg versus 238 mm Hg, p = 0.004), and they were more likely to have pneumonia (53% vs 33%, p = 0.007). The mean extra cost for bronchodilators was 449.35 dollars per patient. Between the group that did receive bronchodilators and the group that did not, there was no significant difference in the incidence of ventilator-associated pneumonia, tracheostomy, or mortality. The incidence of tachyarrhythmias was similar (15% vs 22%, p = 0.25). CONCLUSION: A substantial proportion of mechanically ventilated patients without obstructive lung disease received inhaled bronchodilators.

Effect of a convenient single 90-mg pamidronate dose on biochemical markers of bone metabolism in patients with acute spinal cord injury.

BACKGROUND/OBJECTIVE: To describe the biochemical and adverse effects of a convenient single 90 mg pamidronate dose in patients with acute spinal cord injury (SCI) and compare these effects with those observed in a previous similar study using a 30 mg/d x 3-day pamidronate dosing regimen. STUDY DESIGN: Retrospective cohort study. SETTING: University-based rehabilitation center in New York City. METHODS: A total of 32 patients with SCI were evaluated for biochemical response and adverse events associated with pamidronate therapy. All patients were screened at or near admission for acute rehabilitation, received calcium (1,000 mg daily) and calcitriol (0.25 micrg daily) therapy daily, and on day 4, received a single dose of pamidronate, 90 mg by intravenous infusion, over 4 hours. Serum calcium and phosphate levels were closely monitored, and 2 weeks after pamidronate, biochemical bone markers were re-evaluated. RESULTS: Responses of biochemical markers of bone resorption (N-telopeptide and 24-hour urinary calcium excretion) to pamidronate 90 mg were consistent with an antiresorptive effect, although less than that observed with a 30 mg/d x 3-day pamidronate dosing regimen. The frequency of hypocalcemia was greater, and hypophosphatemia was less than the 30 mg/d x 3-day pamidronate dosing regimen. Fever was more frequent (78%) with the 90-mg single dose of pamidronate compared with the 30 mg/d x 3-day pamidronate dosing regimen (20%). CONCLUSIONS: Single-dose pamidronate 90 mg is effective at reducing biochemical markers of bone hyperresorption in patients with acute SCI but is associated with a greater incidence of fever compared with a 30 mg/d x 3-day dosing regimen.

Improving medical student intensive care unit communication skills: a novel educational initiative using standardized family members.

OBJECTIVE: To determine whether intensive care unit (ICU) communication skills of fourth-year medical students could be improved by an educational intervention using a standardized family member. DESIGN: Prospective study conducted from August 2003 to May 2004. SETTING: Tertiary care university teaching hospital. PARTICIPANTS: All fourth-year students were eligible to participate during their mandatory four-week critical care medicine clerkship. INTERVENTIONS: The educational intervention focused on the initial meeting with the family member of an ICU patient and included formal teaching of a communication framework followed by a practice session with an actor playing the role of a standardized family member of a fictional patient. At the beginning of the critical care medicine rotation, the intervention group received the educational session, whereas students in the control group did not. MEASUREMENTS AND MAIN RESULTS: At the end of each critical care medicine rotation, all students interacted with a different standardized family member portraying a different fictional scenario. Sessions were videotaped and were scored by an investigator blinded to treatment assignment using a standardized grading tool across four domains: a) introduction; b) gathering information; c) imparting information; and d) setting goals and expectations. A total of 106 (97% of eligible) medical students agreed to participate in the study. The total mean score as well as the scores for the gathering information, imparting information, setting goals, and expectations domains for the intervention group were significantly higher than for the control group (p < .01). CONCLUSIONS: The communication skills of fourth-year medical students can be improved by teaching and then practicing a framework for an initial ICU communication episode with a standardized family member.

Gonadal steroids in critical illness.

Gonadal steroids are metabolized in target cells and then interact with specific receptors to exert genomic and nongenomic effects. Complex feedback loops that involve the immune-neuroendocrine axis, limbic system, and gonadal steroids play a vital role in the adaptation to critical illness. Preclinical studies demonstrate adverse physiological effects of androgens on the cardiovascular and immune systems despite its purported anabolic effects. Similar models also demonstrate salutary effects of estrogens on these systems. Thus, during the catabolic phases of acute and chronic critical illness, estrogen, and not androgen, therapy may prove to be a valuable intervention. However, during the post-critical illness recovery phase, when anabolism is critical, androgen therapy may still be useful and safe.

Probability of mortality of critically ill cancer patients at 72 h of intensive care unit (ICU) management.

GOALS: To develop and validate a model for probability of hospital mortality for cancer patients at 72 h of intensive care unit (ICU) management. PATIENTS AND METHODS: This is an inception cohort study performed at four ICUs of academic medical centers in the United States. Defined continuous and categorical variables were collected on consecutive patients with cancer admitted to the ICU. A preliminary model was developed from 827 patients and then validated on an additional 415 patients. Multiple logistic regression modeling was used to develop the models, which were subsequently evaluated for discrimination and calibration. The main outcome measure is in-hospital death. RESULTS: A probability of mortality model, which incorporates ten discrete categorical variables, was developed and validated. All variables were collected at 72 h of ICU care. Variables included evidence of disease progression, performance status before hospitalization, heart rate >100 beats/min, Glasgow coma score 40 mg/dl, and a urine output of <150 ml for any 8 h in the previous 24 h. The p values for the fit of the preliminary and validation models were 0.535 and 0.354 respectively, and the areas under the receiver operating characteristic (ROC) curves were 0.809 and 0.820. CONCLUSIONS: We report a multivariable logistic regression model to estimate the probability of hospital mortality in critically ill cancer patients at 72 h of ICU care. The model is comprised of ten unambiguous and readily available variables. When used in conjunction with clinical judgment, this model should improve discussions about goals of care of these patients. Additional validation in a community hospital setting is warranted.

Professionalism and the teaching of clinical medicine: perspectives of teachers and students.

Principles of medical professionalism include humanistic values, altruism, ethical and moral behavior, and a lifelong commitment to scholarship and learning. These principles can provide behavioral guidelines to residents, fellows and their teacher-physicians during the formative years of postgraduate training. This short paper presents some of the challenging professional questions raised during these years of training, where medical professionalism may help to guide us.

A structure of care for the chronically critically ill.

The chronically critically ill (CCI) are complicated, labor-intensive, and costly patients to care for. A defined structure of care with different focuses at the beginning, middle, and end of a care episode may improve their outcomes and resource utilization. This article reviews the prediction of CCI, outlines some unifying processes of care during an episode of chronic critical illness, and explores some of the difficulties in defining consistent goals of care for this patient population.

Critical illness neuromuscular abnormalities.

CINMAs occur commonly in acutely critically ill inflamed patients, and can prolong respiratory failure, lead to ventilator dependency, and contribute to the development of chronic critical illness. The etiology of NMDs are diverse and overlap, and distinguishing different disease entities by clinical exam and electrophysiologic studies can be difficult. CIP, which has been the most widely studied CINMA, represents the peripheral nervous system manifestation of the MODS. Patients with CIP, particularly those with severely reduced nerve function, have a prolonged rehabilitation and a high mortality rate. Although there are no definitive treatments, diagnosing a CINMA may provide helpful prognostic information. Future preventative measures may include immunoglobulin, nerve growth factors, or strict glycemic control, although in the CCI phase general supportive care is given, including prevention of iatrogenic complications, nutritional support, psychosocial support, and physical therapy. The early recognition of CINMAs and prevention of associated complications are important to enabling CCI patients with CINMAs to recover and return home with an acceptable functional level and quality of life.

Pressure ulcers in the chronically critically ill patient.

All chronically critically ill patients are at high risk for development and progression of pressure ulcers. Constant surveillance including daily examination of the skin must be part of the care protocol. All pressure ulcers are chronic wounds that have an inherent, physiologic impairment to healing. As soon as a pressure ulcer develops, intervention should begin immediately, and a treatment plan should be determined. We believe that early intervention and appropriate treatment, guided by the paradigm we have described, can retard progression and promote healing [49]. Treatment decisions should be made within the context of the patient's overall care goals.

Microscopic Pulmonary Tumor Emboli: An Unusual Presentation of Breast Cancer.

We report a rare case of microscopic pulmonary tumor embolism from breast cancer in a young woman with no prior medical history. The patient presented with progressive dyspnea and questionable abnormalities of the left breast and axilla on physical examination. Results of an axillary lymph node biopsy and subsequent radiologic studies raised the possibility of either microscopic pulmonary tumor emboli or lymphangitic spread of cancer as a cause of the dyspnea. The patient died due to advanced breast cancer confirmed at autopsy despite chemotherapy.