Glycaemic control and long-term outcomes following transition from modified intensive insulin therapy to conventional glycaemic control.

This retrospective observational cohort study compared glycaemic control and long-term outcomes following transition from a modified intensive insulin therapy (mIIT) regimen to conventional glycaemic control (CGC) in adult patients admitted to a tertiary adult general intensive care unit, during two 24-month periods, before and after the publication of the Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR) trial. The before NICE-SUGAR cohort received mIIT (target glycaemic ranges 4.4 to 7.0 mmol/l), while the after NICE-SUGAR cohort received CGC (target glycaemic range 7.1 to 9.0 mmol/l). A total of 5202 patients were included in the study. With transition from mIIT to CGC, the mean time-weighted glucose increased from 6.94 mmol/l to 8.2 mmol/l (P <0.0001). A similar increase was observed in other glycaemic indices (mean, highest and lowest glucose values, P <0.0001 for all). The adjusted 90-day odds ratio for mortality decreased by 47% with transition from mIIT to CGC (odds ratio 1.47 (95% confidence interval, 1.22 to 1.78) (P <0.0001). The rate of severe and moderate hypoglycaemia also decreased from 1.2 to 0.4% (P=0.004) and from 23.3 to 5.9% (P <0.0001), respectively. mIIT was associated with an increased risk of moderate and severe hypoglycaemia compared to CGC (odds ratio 3.1 (1.51 to 6.39) (P=0.002), 6.29 (5.1 to 7.75) (P <0.0001)). Changes in recommended glycaemic control were translated into practice, with increased glycaemic indices and decreased rates of severe and moderate hypoglycaemia after the introduction of CGC. The associated decrease in 90-day mortality suggests mIIT was not superior to CGC, despite a lower hypoglycaemia rate than in previous IIT trials. Our findings support the continued use of CGC.

Continuous hemofiltration: nursing perspectives in critical care.

Daily hemofiltration circuit management in Australian ICUs is a nursing activity predominantly utilizing venovenous access and a BMM 10-1 (Gambro, Lund, Sweden) blood pump. The design of the hemofiltration circuit should enable the easy addition of replacement fluids, the administration of anticoagulant drugs, and the collection of ultrafiltrate (UF). The ability to measure circuit pressures both before and after the filter may assist in the understanding of circuit dynamics and the prediction of filter dysfunction. Ultrafiltration (vol/hr) can be maximized using readily available intravenous pumps; however, the limitations of this (i.e., volume accuracy) need to be considered. The day-to-day nursing management of patients undergoing continuous venovenous hemofiltration (CVVH) requires continuous assessment and monitoring to prevent complications associated with fluid/electrolyte imbalance, blood and heat loss, infection, poor UF production, and foreign substance reaction. We have found that the nursing staff, therefore, requires a variety of educational strategies to gain expertise and, thus, provide a high standard of nursing management for this therapy. Quality assurance is also a necessary adjunct to the safe and efficient use of CVVH.