Failure to achieve glycemic control despite intensive insulin therapy in a medical ICU: incidence and influence on ICU mortality.

OBJECTIVE: Intensive insulin therapy reduces mortality in subgroups of intensive care unit (ICU) patients, and awareness of the importance of blood glucose level (BGL) control has increased among ICU physicians and nurses. The impact of insulin treatment strategies on mortality may be influenced by their efficacy in achieving the target BGL range. We assessed the efficacy of an insulin treatment strategy in maintaining BGL within the target range, and we compared ICU mortality in patients who did and did not reach the BGL target. DESIGN: Prospective cohort study. SETTING: 12-bed medical ICU in a tertiary teaching hospital. PATIENTS AND PARTICIPANTS: Adults consecutively admitted over a 9-month period to an ICU where standard care included an insulin treatment strategy aimed at maintaining BGL7 mmol/l after initial hyperglycemia correction) occurred in 32 patients (31.1%) and was associated with a significant increase in ICU mortality (56.2 vs. 23.3% in patients with successful BGL control). In the multivariate analysis, failure to control BGL independently predicted death in the ICU (OR 5.9, 2.1-16.6, p<0.001). CONCLUSIONS: Failure to control BGL despite intensive insulin therapy was common and independently associated with ICU mortality. Failure to control BGL may considerably affect the overall impact of insulin treatment strategies on mortality.

Adaptation to the Intensive Care Environment (ATICE): development and validation of a new sedation assessment instrument.

OBJECTIVE: To develop a valid, reliable, and responsive bedside instrument assessing Adaptation to the Intensive Care Environment (ATICE) in mechanically ventilated adult intensive care unit (ICU) patients. DESIGN: Instrument development and prospective clinimetric evaluation. SETTING: University-affiliated medical ICU. PATIENTS: Consecutive patients with expected mechanical ventilation of >/=12 hrs. INTERVENTIONS: Administration of ATICE. MEASUREMENTS AND MAIN RESULTS: Item generation for the ATICE involved focus groups and literature review. The ATICE consists of five items: Awakeness and Comprehension combined in a Consciousness domain, and Calmness, Ventilator Synchrony, and Face Relaxation combined in a Tolerance domain. Clinical sensibility of the ATICE assessed by ten ICU physicians and 20 ICU nurses not involved in the development of the ATICE was rated highly (median values 5-7 on a 7-point scale). The ATICE was administered to 80 patients during a total of 152 assessments. Each assessment was performed by three raters (ICU physician, ICU nurse, research nurse), concomitantly with independent scoring of four scales (Ramsay Scale, Riker Scale, Glasgow Coma Scale, and Comfort Scale) and six visual analog scales. Internal consistency was high, as reflected by Cronbach's alpha for the Consciousness and Tolerance domains of .87 and .67, respectively. Intraclass correlation coefficients for the Consciousness and the Tolerance domains ranged from .92 to .99, indicating high interrater reliability. Cross-sectional and longitudinal validity was confirmed for the overall ATICE and the Consciousness and Tolerance domains, as reflected by strong correlations between ATICE and the relevant items or domains of the Ramsay Scale, Riker Scale, Glasgow Coma Scale, Comfort Scale, each of the visual analog scales, and the amounts of sedatives and analgesics administered. CONCLUSIONS: The ATICE measures the adaptation of mechanically ventilated patients to the ICU environment. After rigorous multidisciplinary development, we demonstrated high reliability, validity, and responsiveness of this instrument.