The practice of critical care medicine. A national survey report. ACCP Council on Critical Care

Aggressive reimbursement reform has been an imposing directive for care providers of ICU medicine. Timely knowledge of actual care routines obtained from a large sample of actively practicing physicians should be mandatory when developing any guidelines or practice standards. A questionnaire was therefore designed by the steering committee of the ACCP Council on Critical Care and sent to its members. The 1,294 responses were analyzed for demographics of the individual practitioner, local aspects of ICU staffing and policies, reimbursement, and a specific practice issue, nutrition. The typical respondent was aged 41 to 50 (41 percent), was a pulmonary subspecialist (68 percent), was not critical care certified (55 percent), worked 25 to 50 percent of his or her total time in the ICU (40 percent), and would continue ICU practice despite poor reimbursement (82 percent). Physicians practiced within a group (53 percent), in a 100- to 500-bed hospital (69 percent), with house staff available (60 percent), and predominantly cared for Medicare patients (55 percent). The following data may allow better judgments to be made pertaining to the implementation of care policies in the current ICU environment.

Is the prevalence of dementia changing?

We compared the point prevalence rates of dementing illnesses in the population of Rochester, Minnesota, on January 1, 1980, with the previously published rates of January 1, 1975, by using extensive health care records available from all sources of care in the community, in order to identify and classify cases with standard diagnostic criteria derived from DSM-III. The overall age- and sex-adjusted prevalence rate per 100,000 population for dementia on January 1, 1980, was 402.5 compared with 388.4 on January 1, 1975; for Alzheimer's disease it was 259.8 in 1980 and 259.5 in 1975. The stability of the rates suggests no change in the incidence and mortality associated with these conditions. The prevalence rates for Rochester, Minnesota, are similar to many other rates estimated in other North American communities, but they differ from two other population-based estimates from East Boston and California. Case definitions and methods of assessment probably account for the differences in estimated prevalence.

Glucose management in patients undergoing operation for insulinoma removal

Medical records of 38 patients undergoing anesthesia and surgery for removal of an insulinoma were reviewed to determine 1) the safety of avoiding intraoperative glucose, 2) the appropriate frequency of plasma glucose analysis, and 3) the accuracy of using rebound hyperglycemia as an indication of tumor removal. Plasma glucose was determined approximately every 15 min during operative and recovery-room periods. The changes in plasma glucose concentrations before tumor removal were compared with those occurring after the resection in each patient by separate linear regressions of glucose concentration versus time. The slopes of the preresection regression lines averaged +0.196 (+/- SD 0.577) mg X dl-1 X min-1. The mean of the postresection slopes was +0.624 (+/- SD 0.339) mg X dl-1 X min-1. The mean difference in slope (post- minus pre-) was +0.426 (+/- SD 0.748) mg X dl-1 X min-1, indicating that a significant (P less than 0.02) increase in post-resection slope had occurred. In no case did a preresection plasma glucose concentration decrease to less than 50 mg X dl-1 if the previous value had been 60 mg X dl-1 or greater. Nonetheless, there were nine patients whose plasma glucose did decrease to less than 50 mg X dl-1 at some time during the operative course. Only 39% of patients showed a rebound of 20 mg X dl-1 or more in the first 30 min after resection. The authors conclude that intermittent sampling is safe as long as plasma glucose is kept above 60 mg X dl-1 by infusing glucose.(ABSTRACT TRUNCATED AT 250 WORDS)

The lipoprotein profile of chylous and nonchylous pleural effusions

The lipoprotein electrophoregrams and the cholesterol and triglyceride levels of the pleural fluid were evaluated for patients with chylous pleural effusions, as defined by the presence of a distinctive band of chylomicrons on the lipoprotein electrophoregram, and in patients with nonchylous effusions of various causes. One hundred forty-one patients were studied during a 3-year period. The chylous effusions had strikingly higher triglyceride levels (median 249, range 49 to 2,270 mg/dl) than the nonchylous group (median 33, range 13 to 107 mg/dl); there were no significant differences in cholesterol or protein between the two groups. The gross description of the fluid was a poor indicator of its origin, being described as consistent with chyle in less than 50% of cases of chylous effusions. The triglyceride values distinguished chylous effusion from nonchylous effusion; values greater than 110 mg/dl are highly suggestive of a chylous effusion. Equivocal cases--triglyceride values between 50 and 110 mg/dl--required lipoprotein analysis. Pleural effusions of undetermined cause, regardless of gross appearance of the fluid, require that a screening triglyceride value be obtained to rule out a chylous effusion.