Transition from intravenous insulin to subcutaneous long-acting insulin in critical care patients on enteral or parenteral nutrition / Transición de insulina intravenosa a insulina de acción prolongada subcutánea en pacientes de cuidados críticos con nutrición enteral o parenteral

Background and aims: The optimal initial dose of subcutaneous (SC) insulin after intravenous (IV) infusion is controversial, especially in patients receiving continuous enteral nutrition (EN) or total parenteral nutrition (TPN). The aim of this study was to evaluate the strategy used at our hospital intensive care unit (ICU) in patients switched from IV insulin to SC insulin glargine while receiving EN or TPN. Design and methods: A retrospective analysis was made of 27 patients on EN and 14 on TPN switched from IV infusion insulin to SC insulin. The initial dose of SC insulin was estimated as 50% of the daily IV insulin requirements, extrapolated from the previous 12h. A corrective dose of short-acting insulin (lispro) was used when necessary. Results: Mean blood glucose (BG) level during SC insulin treatment was 136±35mg/dL in the EN group and 157±37mg/dL in the TPN group (p=0.01). In the TPN group, mean BG was >180mg/dL during the first three days after switching, and a 41% increase in the glargine dose was required to achieve the target BG. In the EN group, mean BG remained <180mg/dL throughout the days of transition and the dose of glargine remained unchanged. Conclusions: In the transition from IV to SC insulin therapy, initial insulin glargine dose estimated as 50% of daily IV insulin requirements is adequate for patients on EN, but inadequate in those given TPN (AU)

Introducción y objetivo: La dosis óptima inicial de insulina subcutánea (SC) después de la infusión intravenosa (IV) es controvertida, especialmente en pacientes que reciben nutrición enteral continua (NE) o nutrición parenteral total (NPT). El objetivo de este estudio fue evaluar la estrategia utilizada en nuestra unidad de cuidados intensivos (UCI) en pacientes sometidos a transición de infusión IV a insulina glargina SC mientras recibían NE o NPT. Diseño y métodos: Se analizaron retrospectivamente 27 pacientes con NE y 14 con NPT que cambiaron de infusión IV a insulina SC. La dosis inicial de insulina SC se estimó como el 50% de los requerimientos diarios de insulina IV, extrapolado de las 12 horas anteriores. Se utilizó dosis correctiva de insulina ultrarrápida (lispro), cuando fue necesaria. Resultados: La media de glucemia plasmática (GP) con insulina SC fue de 136,35mg/dl en el grupo NE y de 157,37mg/dl en el grupo NPT, p=0.01. En el grupo de NPT la GP media fue>180mg/dL durante los tres primeros días después de la transición y fue necesario un aumento del 41% en la dosis de glargina para alcanzar la GP objetivo. En el grupo NE, la GP media permaneció<180mg/dl durante los días de transición y la dosis de glargina permaneció sin cambios. Conclusiones: En la transición de la terapia de insulina IV a insulina SC, la dosis inicial de insulina glargina estimada como el 50% de los requerimientos diarios de insulina IV es adecuada para los pacientes que reciben NE, pero insuficiente para los que reciben NPT (AU)

Transition from intravenous insulin to subcutaneous long-acting insulin in critical care patients on enteral or parenteral nutrition.

BACKGROUND AND AIMS: The optimal initial dose of subcutaneous (SC) insulin after intravenous (IV) infusion is controversial, especially in patients receiving continuous enteral nutrition (EN) or total parenteral nutrition (TPN). The aim of this study was to evaluate the strategy used at our hospital intensive care unit (ICU) in patients switched from IV insulin to SC insulin glargine while receiving EN or TPN. DESIGN AND METHODS: A retrospective analysis was made of 27 patients on EN and 14 on TPN switched from IV infusion insulin to SC insulin. The initial dose of SC insulin was estimated as 50% of the daily IV insulin requirements, extrapolated from the previous 12h. A corrective dose of short-acting insulin (lispro) was used when necessary. RESULTS: Mean blood glucose (BG) level during SC insulin treatment was 136±35mg/dL in the EN group and 157±37mg/dL in the TPN group (p=0.01). In the TPN group, mean BG was >180mg/dL during the first three days after switching, and a 41% increase in the glargine dose was required to achieve the target BG. In the EN group, mean BG remained <180mg/dL throughout the days of transition and the dose of glargine remained unchanged. CONCLUSIONS: In the transition from IV to SC insulin therapy, initial insulin glargine dose estimated as 50% of daily IV insulin requirements is adequate for patients on EN, but inadequate in those given TPN.

Factors Associated with the Development of Tertiary Peritonitis in Critically Ill Patients.

BACKGROUND: Critically ill surgical patients remain at a high risk of adverse outcomes as a result of secondary peritonitis (SP). The risk is even higher if tertiary peritonitis (TP) develops. Factors related to the development of TP, however, are scarce in the literature. The main aim of our study was to identify factors associated with the development of TP in patients with SP in the intensive care unit (ICU), and also to report differences in microbiologic patterns and antibiotic therapy in patients with the two conditions. PATIENTS AND METHODS: A prospective, observational study was conducted at our institution from 2010 to 2014. Baseline characteristics on admission, outcomes, microbiologic results, and antibiotic therapy were recorded for analysis. RESULTS: We included 343 patients with SP, of whom TP developed in 185 (53.9%). Almost two-thirds (64.4%) were male; mean age was 63.7 ± 14.3 years, and mean APACHE was 19.4 ± 7.8. In-hospital death was 42.6% (146). Multivariable analysis showed that longer ICU stay (odds ratio [OR]: 1.019; 95% confidence interval [CI]: 1.004-1.034; p = 0.010), urgent operation on hospital admission (OR: 3.247; 95% CI: 1.392-7.575; p = 0.006), total parenteral nutrition (TPN) (OR: 3.079; 95% CI: 1.535-6.177; p = 0.002) and stomach-duodenum as primary infection site (OR: 4.818; 95% CI: 1.429-16.247; p = 0.011) were factors associated with the development of TP, whereas patients with localized peritonitis were less prone to have TP develop (OR: 0.308; 95% CI: 0.152-0.624; p = 0.001). Higher incidences of Candida spp. (OR: 1.275; 95% CI: 1.096-1.789; p = 0.016), Enterococcus faecium (OR: 1.085; 95% CI: 1.018-1.400; p = 0.002), and Enterococcus spp. (OR: 1.370; 95% CI: 1.139-1.989; p = 0.047) were found in TP, and higher rates of cephalosporin use in SP (OR: 3.51; 95% CI: 1.139-10.817; p = 0.035). CONCLUSIONS: Complicated peritonitis remains a cause of a high numbers of deaths in the ICU. The need for TPN, urgent operation on hospital admission, and particularly surgical procedures in the proximal gastrointestinal tract were factors associated with development of TP and may potentially help to identify patients with SP at risk for development of TP. Physicians should be aware concerning multi-drug-resistant germs when treating these patients.

Outcomes of abdominal surgery in patients with liver cirrhosis.

Patients suffering from liver cirrhosis (LC) frequently require non-hepatic abdominal surgery, even before liver transplantation. LC is an important risk factor itself for surgery, due to the higher than average associated morbidity and mortality. This high surgical risk occurs because of the pathophysiology of liver disease itself and to the presence of contributing factors, such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction, which all lead to poor outcomes. Careful evaluation of these factors and the degree of liver disease can help to reduce the development of complications both during and after abdominal surgery. In the emergency setting, with the presence of decompensated LC, alcoholic hepatitis, severe/advanced LC, and significant extrahepatic organ dysfunction conservative management is preferred. A multidisciplinary, individualized, and specialized approach can improve outcomes; preoperative optimization after risk stratification and careful management are mandatory before surgery. Laparoscopic techniques can also improve outcomes. We review the impact of LC on surgical outcome in non-hepatic abdominal surgeries required in this cirrhotic population before, during, and after surgery.

Urinary Neutrophil Gelatinase-Associated Lipocalin as Predictor of Short- or Long-Term Outcomes in Cardiac Surgery Patients.

OBJECTIVES: To determine the ability of urinary neutrophil gelatinase-associated lipocalin (uNGAL) to predict cardiac surgery-associated acute kidney injury (CSA-AKI), continuous renal replacement therapy (CRRT), mortality, and a composite outcome of major adverse kidney events at 365 days (MAKE365), and to investigate the influence of cardiopulmonary bypass (CPB) on NGAL release. DESIGN: A prospective observational study. SETTING: A single-center university hospital. PARTICIPANTS: A cohort of 288 adult cardiac surgery patients. INTERVENTIONS: uNGAL was measured at baseline, immediately after surgery, and on days 1 and 2 postoperatively. The authors used the recent Kidney Disease Improving Global Outcomes consensus criteria to define CSA-AKI. MEASUREMENTS AND MAIN RESULTS: CSA-AKI occurred in 36.1% of patients. uNGAL rapidly became significantly higher in patients who developed AKI, with peak value immediately after surgery (349.9 [76.6-1446.6] v 90.1 [20.8-328] ng/mg creatinine; p<0.001). No measure of uNGAL (peak, postsurgery, day 1 or 2 postsurgery) accurately predicted CSA-AKI, CRRT, mortality, or MAKE365. However, immediately after surgery, CPB induced greater uNGAL release compared with off-pump surgery (265.5 µmol/L [71-989.6] v 48.7 ng/mg creatinine [17-129.8]; p<0.001). Moreover, such early uNGAL release correlated with CPB duration (r = 0.505; p<0.001) but not with peak serum creatinine values on day 3 or 7 after surgery. CONCLUSIONS: uNGAL had a limited predictive ability for CSA-AKI or other relevant clinical outcomes after cardiac surgery and appeared to be more closely related to the use and duration of CPB. Thus, its levels may represent the aggregate effect of an inflammatory response to CPB as well as a renal response to cardiac surgery and inflammation.

B-type natriuretic peptides for prediction and diagnosis of weaning failure from cardiac origin.

AIM: To evaluate and compare BNP and NT-proBNP concentrations to predict weaning failure from mechanical ventilation (MV) due to heart failure (HF) before a spontaneous breathing trial (SBT) and to identify HF as the cause of failure. METHODS: Prospective, observational study in a university hospital. The sample included 100 patients on MV for over 48 h who underwent an SBT. Echocardiography and sampling for natriuretic peptides were performed immediately before and at the end of SBT. HF was diagnosed by pulmonary artery occlusion pressure >18 mm Hg or signs of elevated filling pressures in echocardiography. RESULTS: Thirty-two patients failed the SBT, 12 due to HF and 20 due to respiratory failure (RF). Before SBT, BNP and NT-proBNP were higher in patients failing due to HF than RF or in successfully weaned patients. Cut-off values using ROC curve analyses to predict HF were 263 ng/L for BNP (p < 0.001) and 1,343 ng/L for NT-proBNP (p = 0.08). BNP and NT-proBNP increased significantly during SBT in patients failing due to HF. Increases in BNP and NT-proBNP of 48 and 21 ng/L, respectively, showed a diagnostic accuracy for HF of 88.9 and 83.3% (p < 0.001). BNP performed better than NT-proBNP for HF prediction (p = 0.01) and diagnosis (p = 0.009). CONCLUSION: B-type natriuretic peptides, particularly BNP, can predict weaning failure due to HF before an SBT; increases in natriuretic peptides during SBT are diagnostic of HF as the cause of weaning failure. BNP performs better than NT-proBNP in prediction and diagnosis of HF.