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.

Nursing workforce characteristics and effect on life expectancy and under-five mortality in the ASEAN.

AIM: To assess the effects of the nursing workforce and advanced nursing practice on the outcomes of patients and life expectancy, including mortality rates of under-five children in Cambodia, and to develop policy recommendations to increase the influence of the nursing workforce. BACKGROUND: In low-middle-income nations, life expectancy and under-five mortality are important measures of public health. However, there is still a dearth of literature related to the nursing workforce in Southeast Asia. METHOD: The authors retrieved the data from the World Nursing Report produced by the World Health Organization 2020 for 10 member states. The transparent reporting of a multivariable prediction model for individual prognosis or diagnosis checklist has guided this study. The univariate linear regression model was applied to categorize the potential predictors for each outcome assessment. In addition, the Spearman rank correlation test was selected to assess the potential predictors, and a multivariate statistical analysis was carried out for each of the five outcomes. RESULTS: According to the study's findings, nurse density and advanced practice nursing improve both female and male life expectancy. The existence of advanced nursing roles is associated with decreased under-five mortality. CONCLUSIONS: There are great opportunities to improve the nursing workforce within Cambodia and other Association of Southeast Asian Nations member states to increase patient outcomes. Investment in nursing is essential for improved patient outcomes. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Health policy investments in these projects and future initiatives intended to advance nurse density, education, and practice are based on this study's results. Policy initiatives should focus on increasing density because nursing appears to impact life expectancy and other outcomes.

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.

Accuracy of Temporal Artery Thermometry as an Indicator of Core Body Temperature in Patients Receiving General Anesthesia.

PURPOSE: To evaluate the agreement of temporal artery temperature (Tat) with esophageal temperature (Tes) and oral temperature (Tor), and explore potential factors associated with the level of agreement between the thermometry methods in different clinical settings. DESIGN: A prospective repeated measures (induction, emergence, and postanesthesia care unit) design was used. METHODS: Temperature data were collected for 54 patients receiving general anesthesia. Analyses included descriptive statistics, paired t tests for the within-patient comparison of temperature methods, Bland-Altman plots to examine agreement between methods, and multiple linear regression to identify factors associated with the agreement between methods. FINDINGS: Tat was significantly higher compared with Tes and Tor (P < .05) and was poor at detecting hypothermia. The use of a muscle relaxant and surgical site were suggested to be associated with the difference between Tat and Tes at emergence. CONCLUSIONS: Tat is more convenient, but less accurate, than other thermometry methods. These inaccuracies are exacerbated by common anesthetic medications.

Comparison of Quantitative and Qualitative Oxygen Extraction Fraction (OEF) in Acute Stroke Patients with Large Vessel Occlusion.

The superficial temporal artery-middle cerebral artery bypass (STA-MCA) bypass surgery developed by Donaghy and Yarsagil in 1967 provided relief for patients with acute stroke and large vessel occlusive vascular disease. Early reports showed low morbidity and good outcomes. However, a large clinical trial in 1985 reported a failure of extracranial-intracranial (EC/IC) bypass to show benefit in reducing the risk of stroke compared to best medical treatment. Problems with the study included cross overs to surgery from best medical treatment, patients unwilling to be randomized and chose EC/IC surgery, and loss of patients to follow-up. Most egregious is the fact that the study did not attempt to identify and select the patients at high risk for a second stroke. Based on these shortcomings of the EC/IC bypass study, a carotid occlusion surgery study (COSS) was proposed by Dr. William Powers and colleagues using qualitative hemispheric oxygen extraction fraction (OEF) by positron emission tomography (PET) between the contralateral and ipsilateral hemispheres with a ratio of 1.16 indicative of hemodynamic compromise. To increase patient enrollment, several compromises were made mid study. First. The ratio threshold was lowered to 1.12 and the level of occlusion in the carotid reduced from 70% to 60%. Despite these compromises the study was closed for futility, apparently because the stroke rate in the medically treated group was too low. Thus, the question as to the benefit of EC/IC bypass surgery remains unresolved. In our NIH funded study Quantitative Occlusive Vascular Disease Study (QUOVADIS), we used quantitative OEF to evaluate stroke risk and compared it to the qualitative count-rate ratio method used in the COSS study and found that these two methods did not identify the same patients at increased risk for stroke, which may explain the reason for the failure of the COSS study as our results show that qualitative OEF ratios do not identify the same patients as quantitative OEF.

Development and psychometric testing of a competency of nursing process questionnaire.

Objectives: This study aimed to develop and evaluate a competency of nursing process questionnaire (CNPQ) for registered nurses in Cambodia. Methods: Guided by the nursing process, an initial questionnaire was generated through focus group discussion, literature review, and the expert consultation. Finally, the validity and reliability of the questionnaire were validated through a questionnaire survey online of 260 registered nurses selected from Complimentary Package Activities 1, 2, 3, and national hospitals from January to February 2022 in five geographic areas of Cambodia. Results: The content validity index was 1.00. The Cronbach's α coefficient for the whole questionnaire was 0.963, and the range for the five dimensions was 0.963-0.964, which shows that the questions were consistent. The test-retest reliability was 0.769. The exploratory factor analysis led to a list of 24 items that were grouped into five dimensions: assessment, diagnosis, planning, implementation, and evaluation. The cumulative variance contribution rate was 70.08%. Conclusions: The CNPQ developed in this study showed good reliability and validity and can be used to assess the competency of registered nurses by themselves and help nursing managers to develop the relevant policies.

Evaluation of nursing process competencies, nursing quality, and patient safety using virtual simulation with debriefing: A quasi-experimental study.

Background: Investing in clinical education is important for adult urgent and emergency surgery and traumatology as it promotes registered nurses' competencies by providing professional development training to respond to urgent or emergency surgeries. Objective: To examine registered nurses' self-assessment of the effects of virtual video simulation with an immediate debriefing approach on nursing process competencies, nursing care quality, incomplete care, and patient safety in surgical units. Methods: This study used a quasi-experimental two-group pre- and post-test design. The study was conducted at two provincial hospitals in Cambodia. Participants included registered nurses employed in surgical units. The experimental group (n = 46) completed a virtual video simulation and immediate debriefing. The control group (n = 35) completed virtual training on the nursing process. Data were collected two months after a successful second-week follow-up using Competency of Nursing Process, Cambodian Nursing Care Quality, Care Left Undone, and Patient Safety scales. Wilcoxon signed-rank test and Mann-Whitney U test were used to evaluate the differences before and after the sessions. Generalized linear model was used to compare the differences between the two groups. Results: The results showed statistically significant improvements in the experimental group on competency, nursing care quality, patient safety, and reducing care left undone after the intervention. However, the control group revealed statistically insignificant differences. In addition, the experimental group provided positive feedback, such as experiencing a real patient scenario, developing critical-thinking, improving communication skills, and having an opportunity to ask questions. Conclusion: Our study showed that VVS and immediate debriefing have the potential to support in-service training of RNs from diverse backgrounds. Particularly, integrating virtual video simulation and immediate debriefing may to promote competency in the nursing process and improve care outcomes.

Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients.

OBJECTIVE: To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point. METHODS: Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear. RECOMMENDATIONS: The article is focused on a suggested glycemic control end point such that a blood glucose ≥ 150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤ 70 mg/dL) and to minimize glycemic variability.Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate monitoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients. CONCLUSIONS: While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infusion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy.

Use of personal protective equipment among health care personnel: Results of clinical observations and simulations.

BACKGROUND: Very little is known about how health care personnel (HCP) actually use personal protective equipment (PPE). METHODS: The clinical PPE practices of 50 HCP from selected units at the University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital were videotaped with HCP consent. For 2 PPE simulation sessions (simple and full-body sets), 82 HCP were recruited throughout the UPMC system. Simulation practices were videotaped and examined using fluorescent powder with ultraviolet lighting. All participants completed an electronic survey. For a follow-up evaluation simulation, 12 HCP were recruited among simulation participants. RESULTS: Among 130 total sessions from 65 participants, contamination occurred in 79.2% of simulations during the doffing process with various PPE items: simple set (92.3%) and full-body set (66.2%). Among 11 follow-up evaluation participants, contaminations still occurred in 82% after receiving individual feedback, but the overall contamination level was reduced. Using the contamination information gained during the simulation analysis, 66% of potential contamination was estimated for the clinical observation. Concerns and barriers in PPE use from HCP survey responses were as follows: time-consuming, cumbersomeness, and PPE effectiveness. CONCLUSIONS: Although HCP knew they were being videotaped, contamination occurred in 79.2% of the PPE simulations. Devising better standardized PPE protocols and implementing innovative PPE education are necessary to ensure HCP safety.

Case report: proximal tubule impairment following volatile anesthetic exposure.

The safety of contemporary volatile anesthetic agents with respect to kidney function is well established, and growing evidence suggests that volatile anesthetics even protect against ischemic nephropathy. However, studies examining effects of volatile anesthetics on kidney function frequently demonstrate transient proteinuria and glycosuria following exposure to these agents, although the cause of these findings has not been thoroughly examined. We describe the case of a patient who underwent a neurosurgical procedure, then experienced glycosuria without hyperglycemia that resolved within days. Following a second neurosurgical procedure, the patient again developed glycosuria, now associated with ketonuria. Further examination demonstrated nonalbuminuric proteinuria in conjunction with urinary wasting of phosphate and potassium, indicative of proximal tubule impairment. We suggest that transient proximal tubule impairment may play a role in the proteinuria and glycosuria described following volatile anesthetic exposure and discuss the relationship between these observations and the ability of these agents to protect against ischemic nephropathy.

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.

Increased cerebral oxygen metabolism and ischemic stress in subjects with metabolic syndrome-associated risk factors: preliminary observations.

Hypertension, diabetes, obesity, and dyslipidemia are risk factors that characterize metabolic syndrome (MetS), which increases the risk for stroke by 40%. In a preliminary study, our aim was to evaluate cerebrovascular reactivity and oxygen metabolism in subjects free of vascular disease but with one or more of these risk factors. Volunteers (n=15) 59±15 (mean±SD)years of age clear of cerebrovascular disease by magnetic resonance angiography but with one or more risk factors were studied by quantitative positron emission tomography for measure ment of cerebral blood flow, oxygen consumption, oxygen extraction fraction (OEF), and acetazolamide cerebrovascular reactivity. Eight of ten subjects with MetS risk factors had OEF >50%. None of the five without risk factors had OEF >50%. The presence of MetS risk factors was highly correlated with OEF >50% by Fisher's exact test (p<0.007). The increase in OEF was significantly (P<0.001) correlated with cerebral metabolic rate for oxygen. Increased OEF was not associated with compromised acetazolamide cerebrovascular reactivity. Subjects with one or more MetS risk factors are characterized by increased cerebral oxygen consumption and ischemic stress, which may be related to increased risk of cerebrovascular disease and stroke.

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.