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.

Corneal Injury Risk Reduction During Sedation for Colonoscopy: An Evidence Based Practice Change.

PURPOSE: This evidence-based practice change project examined the use of supine positioning as a substitute for lateral positioning after sedation for endoscopic procedures for the purpose of preventing corneal injuries in this patient population. DESIGN: This study used a pre and post implementation design. METHODS: Retrospective data was collected over 12 months, including 4,422 endoscopic procedures for comparison to the prospective data collected after implementing the practice change, which totaled eight months and 3080 procedures. FINDINGS: Incidence rates for corneal injury and eye irritation were 0.158% before the practice change, with a decrease in incidence to 0.097% after the change. Using a two-sided Fisher's exact test, the results were not statistically significant (P => .05). Additionally, linear regression showed a slight downward trend with implementation; however, these results were also not statistically significant. CONCLUSIONS: The intervention did not have a statistically significant impact on the incidence of corneal injury. It is possible that more than one risk factor was contributing to corneal injury in this setting and the intervention only addressed one potential risk factor.

Delays in Cardiopulmonary Resuscitation, Defibrillation, and Epinephrine Administration All Decrease Survival in In-hospital Cardiac Arrest.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Rapid response to witnessed, pulseless cardiac arrest is associated with increased survival. WHAT THIS ARTICLE TELLS US THAT IS NEW: Assessment of witnessed, pulseless cardiac arrests occurring at 538 hospitals during a 9-yr period indicates that CPR did not occur immediately at 0 min in 5.7% of patients despite guidelines for instantaneous initiation. Delay in initiation of CPR was associated with significantly decreased survival.Time to initiation of CPR and subsequent time to initiation of administration of defibrillation shock (for shockable arrhythmias) and epinephrine were both associated with reduced patient survival. BACKGROUND: Because the extent to which delays in initiating cardiopulmonary resuscitation (CPR) versus the time from CPR to defibrillation or epinephrine treatment affects survival remains unknown, it was hypothesized that all three independently decrease survival in in-hospital cardiac arrest. METHODS: Witnessed, index cases of cardiac arrest from the Get With The Guidelines-Resuscitation Database occurring between 2000 and 2008 in 538 hospitals were included in this analysis. Multivariable risk-adjusted logistic regression examined the association of time to initiation of CPR and time from CPR to either epinephrine treatment or defibrillation with survival to discharge. RESULTS: In the overall cohort of 57,312 patients, there were 9,802 survivors (17.1%). Times to initiation of CPR greater than 2 min were associated with a survival of 14.7% (91 of 618) as compared with 17.1% (9,711 of 56,694) if CPR was begun in 2 min or less (adjusted odds ratio [95% CI], 0.68 [0.54 to 0.87]; P < 0.002). Times from CPR to either defibrillation or epinephrine treatment of 2 min or less were associated with a survival of 18.0% (7,654 of 42,475), as compared with 15.0% (1,680 of 11,227) for 3 to 5 min (reference, 0 to 2 min; adjusted odds ratios [95% CI], 0.83 [0.78 to 0.88]; P < 0.001), 12.8% (382 of 2,983) for 6 to 8 min (0.67 [0.60 to 0.76], P < 0.001), and 13.7% (86 of 627) for 9 to 11 min (0.54 [0.42 to 0.69], P < 0.001). CONCLUSIONS: Delays in the initiation of CPR and from CPR to defibrillation or epinephrine treatment were each associated with lower survival.

Effect of a simulation educational intervention on knowledge, attitude, and patient transfer skills: from the simulation laboratory to the clinical setting.

INTRODUCTION: Musculoskeletal injury in the workplace is the primary work-related factor in loss of nursing personnel from the workforce. Moving or transferring patients is the dominant contributing event. A simulation educational approach has not been closely studied in this area but may have advantages over traditional approaches. Specific aims were to (1) evaluate the effect of a simulation intervention on success of patient transfers in a clinical setting and (2) measure change in participants' knowledge and attitude as a result of the intervention. METHODS: A prospective, observational, longitudinal design was used. Baseline patient transfer observations were conducted on control and intervention units. An optimum task set was developed using hierarchical task analysis methods. Subjects (N = 71) completed pre- and postintervention knowledge and attitude assessments. The intervention consisted of simulated patient transfers using a mannequin, education, and training, followed by repeated simulated transfers using a mannequin with debriefing. Observations of patient transfers in patient care areas were repeated at 4 and 12 weeks. RESULTS: Patient transfer success improved from 66% at baseline to 88% at the 4-week measurement point (t = 7.447, P ≤ 0.0004). At 12 weeks, transfer success had decreased to 71%, with addition of new employees between weeks 4 and 12 confounding the 12-week measurement. Knowledge improved from a baseline of 65% to 95% postsimulation intervention (z = -6.634, P ≤ 0.0004). Attitude change was also evaluated with significance seen with 12 of 15 items (P ≤ 0.05). CONCLUSIONS: A simulation intervention was successful in significantly improving knowledge and changing subject perceptions with regard to this task. Skills acquired through simulation successfully transferred to the clinical setting. Improvement in success for patient moves not trained in the simulation laboratory suggests that acquired skills were generalizable and supports application to different settings.

Willingness to perform mouth-to-mouth ventilation by health care providers: a survey.

BACKGROUND: During cardiopulmonary resuscitation (CPR), mouth-to-mouth ventilation (MTM) is only effective if rescuers are willing to perform it. METHODS: To assess the degree of willingness or reluctance in performing MTM, a survey including 17 hypothetical scenarios was created. In each scenario health hazards for the rescuer needed to be balanced against the patient's need for MTM. Respondents were recruited from health care workers attending courses at a medical simulation center. Respondents reported their willingness or reluctance to perform MTM for each scenario using a 4 point scale. RESULTS: The questionnaire had responses by 560 health care workers. Reluctance to perform MTM varied with the scenario. Some health care workers refused to ventilate patients who could benefit from MTM. In all scenarios even when resuscitation was both futile and potentially hazardous, some health care workers were willing to perform MTM. Age and level of experience tend to reduce the propensity to engage in MTM. Parental propensity to ventilate one's own child was stronger than any other motivator. CONCLUSIONS: HIV infection is not the only condition for which rescuers hesitate to perform MTM. Bag-valve-mask devices for mechanical ventilation should be available in all locations where health care workers may be called upon to resuscitate apneic patients making the decision to perform MTM moot.