Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024

RATIONALE

Maintaining glycemic control of critically ill patients may impact outcomes such as survival, infection, and neuromuscular recovery, but there is equipoise on the target blood levels, monitoring frequency, and methods.

OBJECTIVES

The purpose was to update the 2012 Society of Critical Care Medicine and American College of Critical Care Medicine (ACCM) guidelines with a new systematic review of the literature and provide actionable guidance for clinicians.

PANEL DESIGN

The total multiprofessional task force of 22, consisting of clinicians and patient/family advocates, and a methodologist applied the processes described in the ACCM guidelines standard operating procedure manual to develop evidence-based recommendations in alignment with the Grading of Recommendations Assessment, Development, and Evaluation Approach (GRADE) methodology. Conflict of interest policies were strictly followed in all phases of the guidelines, including panel selection and voting.

METHODS

We conducted a systematic review for each Population, Intervention, Comparator, and Outcomes question related to glycemic management in critically ill children (≥ 42 wk old adjusted gestational age to 18 yr old) and adults, including triggers for initiation of insulin therapy, route of administration, monitoring frequency, role of an explicit decision support tool for protocol maintenance, and methodology for glucose testing. We identified the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as a good practice statement. In addition, "In our practice" statements were included when the available evidence was insufficient to support a recommendation, but the panel felt that describing their practice patterns may be appropriate. Additional topics were identified for future research.

RESULTS

This guideline is an update of the guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. It is intended for adult and pediatric practitioners to reassess current practices and direct research into areas with inadequate literature. The panel issued seven statements related to glycemic control in unselected adults (two good practice statements, four conditional recommendations, one research statement) and seven statements for pediatric patients (two good practice statements, one strong recommendation, one conditional recommendation, two "In our practice" statements, and one research statement), with additional detail on specific subset populations where available.

CONCLUSIONS

The guidelines panel achieved consensus for adults and children regarding a preference for an insulin infusion for the acute management of hyperglycemia with titration guided by an explicit clinical decision support tool and frequent (≤ 1 hr) monitoring intervals during glycemic instability to minimize hypoglycemia and against targeting intensive glucose levels. These recommendations are intended for consideration within the framework of the patient's existing clinical status. Further research is required to evaluate the role of individualized glycemic targets, continuous glucose monitoring systems, explicit decision support tools, and standardized glycemic control metrics.

The turn team: a novel strategy for reducing pressure ulcers in the surgical intensive care unit

BACKGROUND

Pressure ulcers cause significant morbidity and mortality in the surgical intensive care unit (SICU). The purpose of this study was to determine if a dedicated team tasked with turning and repositioning all hemodynamically stable SICU patients could decrease the formation of pressure ulcers.

STUDY DESIGN

A total of 507 patients in a 20-bed SICU in a university hospital were assessed for pressure ulcers using a point prevalence strategy, between December 2008 and September 2010, before and after implementation of a team tasked with turning and repositioning all hemodynamically stable patients every 2 hours around the clock.

RESULTS

At baseline, when frequent turning was encouraged but not required, a total of 42 pressure ulcers were identified in 278 patients. After implementation of the turn team, a total of 12 pressure ulcers were identified in 229 patients (p < 0.0001). The preintervention group included 34 stage I and II ulcers and 8 higher stage ulcers. After implementation of the turn team, there were 7 stage I and II ulcers and 5 higher stage ulcers. The average Braden score was 16.5 in the preintervention group and 13.4 in the postintervention group (p = 0.04), suggesting that pressure ulcers were occurring in higher risk patients after implementation of the turn team.

CONCLUSIONS

A team dedicated to turning SICU patients every 2 hours dramatically decreased the incidence of pressure ulcers. The majority of stage I and stage II ulcers appear to be preventable with an aggressive intervention aimed at pressure ulcer prevention.

Digestion of butyrate glycerides by pancreatic lipase

The racemic triglycerides, glyceryl-1-palmitate-2,3-dibutyrate (PBB), glyceryl-1-butyrate-2,3-dipalmitate (PPB), glyceryl-2-butyrate-1,3-dipalmitate (PBP), and the diglyceride, racemic glyceryl-1-palmitate-3-butyrate (P-B) were synthesized and digested with pancreatic lipase. Each triglyceride was mixed with equimolar amounts of triolein (OOO) prior to incubation.The following order of digestion rates was observed: PBB>PPB>PBP>P-B. There was no evidence for short-chain fatty acid specificity; however the triglycerides containing butyric acid were hydrolyzed more rapidly than OOO. Based upon the fatty acid composition of partial glycerides, digestion of butyrate glycerides was not a simple phenomenon. For example, in the digestion of PBB, butyric acid accumulated faster than palmitic acid in the diglycerides, and monobutyrin was found to accumulate when the diglyceride, P-B, was digested. As evidenced by the fatty acid composition of the monoglycerides, positional specificity of pancreatic lipase was always maintained.

Patient-care time allocation by nurse practitioners and physician assistants in the intensive care unit

Introduction

Use of nurse practitioners and physician assistants ("affiliates") is increasing significantly in the intensive care unit (ICU). Despite this, few data exist on how affiliates allocate their time in the ICU. The purpose of this study was to understand the allocation of affiliate time into patient-care and non-patient-care activity, further dividing the time devoted to patient care into billable service and equally important but nonbillable care.

Methods

We conducted a quasi experimental study in seven ICUs in an academic hospital and a hybrid academic/community hospital. After a period of self-reporting, a one-time monetary incentive of $2,500 was offered to 39 affiliates in each ICU in which every affiliate documented greater than 75% of their time devoted to patient care over a 6-month period in an effort to understand how affiliates allocated their time throughout a shift. Documentation included billable time (critical care, evaluation and management, procedures) and a new category ("zero charge time"), which facilitated record keeping of other patient-care activities.

Results

At baseline, no ICUs had documentation of 75% patient-care time by all of its affiliates. In the 6 months in which reporting was tied to a group incentive, six of seven ICUs had every affiliate document greater than 75% of their time. Individual time documentation increased from 53% to 84%. Zero-charge time accounted for an average of 21% of each shift. The most common reason was rounding, which accounted for nearly half of all zero-charge time. Sign out, chart review, and teaching were the next most common zero-charge activities. Documentation of time spent on billable activities also increased from 53% of an affiliate's shift to 63%. Time documentation was similar regardless of during which shift an affiliate worked.

Conclusions

Approximately two thirds of an affiliate's shift is spent providing billable services to patients. Greater than 20% of each shift is spent providing equally important but not reimbursable patient care. Understanding how affiliates spend their time and what proportion of time is spent in billable activities can be used to plan the financial impact of staffing ICUs with affiliates.

Severe hemodynamic impairment and border zone--region infarction

PURPOSE

To investigate the relationship between the patterns of cerebral infarction that have been associated with hemodynamic impairment and the presence of severe chronic hemodynamic compromise (increased oxygen extraction fraction) in a large prospectively enrolled group of patients with carotid artery occlusion.

MATERIALS AND METHODS

At enrollment in a prospective study of cerebral hemodynamics, 110 patients with carotid occlusion underwent (a) positron emission tomography for the measurement of cerebral oxygen extraction fraction and (b) computed tomographic (CT) or magnetic resonance (MR) examinations of the brain. Infarcts were categorized retrospectively by vascular territory, location, and pattern. The association of these findings with hemodynamic impairment (increased oxygen extraction fraction) was investigated.

RESULTS

No border zone-region infarctions were found in 35 asymptomatic patients. In 75 symptomatic patients, cortical border zone-region infarction was found in seven of 36 patients with increased oxygen extraction fraction, and in two of 39 with normal oxygen extraction fraction (P =.08, difference not significant). The pattern of multiple white matter lesions arranged parallel to the lateral ventricle was observed only in symptomatic patients with increased oxygen extraction fraction (eight of 36 patients; P =.002; sensitivity, 22%; specificity, 100%). This finding was more frequent with MR imaging (seven of 14 patients) than with CT (one of 22 patients).

CONCLUSION

Multiple white matter infarctions, arranged parallel to the lateral ventricle, are associated with severe hemodynamic impairment. This pattern of infarction is likely due to a hemodynamic mechanism.

Absence of selective deep white matter ischemia in chronic carotid disease: a positron emission tomographic study of regional oxygen extraction

BACKGROUND AND PURPOSE

Deep white matter may be the location of an internal arterial border zone. The purpose of this study was to determine whether the deep white matter was subject to a greater degree of ischemia than was the cortex among patients with chronic carotid occlusion.

METHODS

Thirty-six patients with carotid occlusion and structurally normal deep white matter were studied with positron emission tomography. Measurements of oxygen extraction fraction were made in superficial (cortical and subcortical) regions in the middle cerebral artery territory and in deep white matter (internal border zone) regions. The presence of selective ischemia of the deep white matter was assessed by the ratio of deep white matter:superficial oxygen extraction fraction. Ipsilateral hemispheric ratios among patients were assessed as a group as compared with contralateral hemispheric ratios and as compared with normal hemispheric ratios from 15 control volunteers.

RESULTS

Mean deep white matter to superficial oxygen extraction fraction ratios (+/-95% confidence limits) were 0.99 (+/-0.07), 1.01 (+/-0.06), and 1.02 (+/-0.08) for ipsilateral, contralateral, and normal hemispheres, respectively. No statistically significant difference was found between ipsilateral and contralateral (P = .691) or normal hemispheres (P = .68), nor was any statistically significant difference found when the analysis was limited to patients with increased superficial oxygen extraction fraction (n = 9). Individual deep white matter:superficial ratios were within the normal range for all patients.

CONCLUSION

Normal deep white matter among patients with carotid occlusion is not subject to a greater degree of ischemia than is the overlying cortex. It is unlikely that deep white matter infarctions observed among patients with carotid occlusion are owing to chronic selective hemodynamic compromise occurring at an internal arterial border zone.

Motion parallax information for direction of rotation in depth: order and direction components

The work of Hershberger and his associates has demonstrated the effectiveness for judging direction of rotation in depth of several components of motion parallax. Confounding and conflicting results have made the status of two of these transformations, labeled Direction and Order, unclear. A study is reported in which the problems encountered in previous studies have been eliminated. College students correctly judged the direction of rotation of horizontal rows of dots which appeared to rotate in depth, which demonstrates that Direction and Order can, in fact, provide useful information about direction of motion in depth.

Early selective visual experience and pattern discrimination in hooded rats

The early visual experience of hooded rats was restricted to either vertical or horizontal stripes. In a discrimination task pairing a gray surface and stripes of either the same orientation or an orientation orthogonal to that experienced during rearing, the rats made significantly fewer correct choices with the orthogonal orientation. However, the relatively lower overall performance of the vertically reared-horizontally tested animals was a major factor in the main effect of testing condition. We conclude that functional of the rat visual system through early selective visual experience is possible.

Lipid composition of selected margarines

Results of analytical studies on the composition of 10 selected margarines representative of consumeravailable hard and soft types are presented. Paired hard and soft products from the same manufacturer were chosen where possible. All of the margarines were compared on the basis of total fatty acid composition, polyunsaturated to saturated fatty acid ratios, totaltrans and thetrans content of the monoene and diene fractions, location of the double bond in the monoene isomers, per cent conjugation, distribution of the fatty acids at the 2 position of the triglycerides, tocopherol content, and the ratios of α‐tocopherol to polyunsaturated fatty acids. As expected the soft margarines contained more polyunsaturated fatty acids than their companion hard types, but all soft margarines did not contain more polyunsaturated fatty acids than all of the hard margarines. The one margarine containing safflower oil had the highest polyunsaturated to saturated ratio. Eight of the ten margarines contained more than 15%trans monoene and nine contained less than 5%trans diene. Positional isomers in the monoene fraction were Δ6 toΔ12 with thecis Δ9 isomer predominating. All of the margarines contained less than 1.9% conjugation. The percentage oftrans monoene at the 2 position was greater for some margarines than that in the total fatty acid. This was attributed to the preferential placement of polyunsaturated fatty acids at the 2 position in the original vegetable oils. The forms of tocopherol found were characteristic of the original vegetable oils. Ratios of α‐tocopherol to PUFA varied from 0.1 to 0.5 mg/g. Determination of the relationship of the amount of tocopherol content to either source or hardness is not possible on the basis of our data.