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.

Unattended Sleep Studies in a VA Population: Initial Evaluation by Chart Review Versus Clinic Visit by a Midlevel Provider.

OBJECTIVES: Obstructive sleep apnea (OSA) is a prevalent disorder that is associated with multiple medical consequences. Although in-laboratory polysomnography is the gold standard for the diagnosis of OSA, portable monitors have been developed and studied to help increase efficiency and ease of diagnosis. We aimed to assess the adequacy of a midlevel provider specializing in sleep medicine to risk-stratify patients for OSA based on a chart review versus a comprehensive clinic evaluation before scheduling an unattended sleep study. METHODS: This study was an observational, nonrandomized, retrospective data collection by chart review of patients accrued prospectively who underwent an unattended sleep study at the Sleep Health Center at the Memphis Veterans Affairs Medical Center during the first 13 months of the program (May 1, 2011-May 31, 2012). A total of 205 patients were included in the data analysis. RESULTS: Analysis showed no statistically significant differences between chart review and clinic visit groups (P = 0.54) in terms of OSA diagnosis. Although not statistically significant, the analysis shows a trend toward higher mean age (50.3 vs 47.4 years; P = 0.10) and lower mean body mass index (34.4 vs 36.0; P = 0.08) in individuals who were evaluated during a comprehensive clinic visit. A statistically significant difference is seen in terms of the pretest clinical probability of OSA being moderate or high in 62.2% of patients in the clinic visit group and 95.7% in the chart review group, with a χ2P ≤ 0.0001. CONCLUSIONS: In the Veterans Health Administration's system, the assessment of pretest probability may be determined by a midlevel provider using chart review with equal efficacy to a comprehensive face-to-face evaluation in terms of OSA diagnosis via unattended sleep studies.

Association of incident obstructive sleep apnoea with outcomes in a large cohort of US veterans.

RATIONALE: There is a paucity of large cohort studies examining the association of obstructive sleep apnoea (OSA) with clinical outcomes including all-cause mortality, coronary heart disease (CHD), strokes and chronic kidney disease (CKD). OBJECTIVES: We hypothesised that a diagnosis of incident OSA is associated with higher risks of these adverse clinical outcomes. METHODS, MEASUREMENTS: In a nationally representative cohort of over 3 million (n=3 079 514) US veterans (93% male) with baseline estimated glomerular filtration rate (eGFR)≥60 mL/min/1.73 m(2), we examined the association between the diagnosis of incident OSA, treated and untreated with CPAP, and: (1) all-cause mortality, (2) incident CHD, (3) incident strokes, (4)incident CKD defined as eGFR<60 mL/min/1.73 m(2), and (5) slopes of eGFR. MAIN RESULTS: Compared with OSA-negative patients, untreated and treated OSA was associated with 86% higher mortality risk, (adjusted HR and 95% CI 1.86 (1.81 to 1.91) and 35% (1.35 (1.21 to 1.51)), respectively. Similarly, untreated and treated OSA was associated with 3.5 times (3.54 (3.40 to 3.69)) and 3 times (3.06 (2.62 to 3.56)) higher risk of incident CHD; 3.5 times higher risk of incident strokes (3.48 (3.28 to 3.64) and 3.50 (2.92 to 4.19)) for untreated and treated OSA, respectively. The risk of incident CKD was also significantly higher in untreated (2.27 (2.19 to 2.36)) and treated (2.79 (2.48 to 3.13)) patients with OSA. The median (IQR) of the eGFR slope was -0.41 (-2.01 to 0.99), -0.61 (-2.69 to 0.93) and -0.87 (-3.00 to 0.70) mL/min/1.73 m(2) in OSA-negative patients, untreated OSA-positive patients and treated OSA-positive patients, respectively. CONCLUSIONS: In this large and contemporary cohort of more than 3 million US veterans, a diagnosis of incident OSA was associated with higher mortality, incident CHD, stroke and CKD and with faster kidney function decline.

Patient Demographics and Socioeconomic Characteristics of an Ambulatory Care Clinic Served by a University PCCM Training Program.

OBJECTIVES: Continuity clinics are an important aspect of pulmonary medicine fellowship training. We provide a description of a pulmonary outpatient clinic in an inner city, county-owned, university-affiliated hospital. METHODS: This is a descriptive study of administrative data on consecutive patient visits to the University of Tennessee Regional One Health at Memphis ambulatory clinic (Medplex) between January 2000 and August 2006. We describe demographics, socioeconomic characteristics, and the frequency of a pulmonary diagnosis of the outpatient population served by our training program. Continuous data were described by mean ± standard deviations and categorical data were described by percentage. RESULTS: The dataset included 2549 patients, 81% were African American with a mean age of 48.7 ± 13.7, 64.4% were women. Female/male body mass index was 34.6 ± 11.6 vs. 29.2 ± 10.3. Tenncare (Medicaid) covered 59.6 % of patients, whereas 11.1% were uninsured. CONCLUSIONS: We provide evidence that one clinical setting may not be enough exposure to the entire lung pathology for pulmonary trainees. There is a need for further, larger, and prospective data collections to evaluate and guide changes regarding the structure of training programs.

Surfactant therapy using vibrating-mesh nebulizers in adults with COVID-19-induced ARDS: A case series.

Coronavirus adult respiratory distress syndrome, characterized by decreased surfactant due to lysis of type II pneumocytes and hyaline membrane formation, contributes to severe hypoxemia. The administration of surfactant via high-flow nasal cannula (HFNC) may positively affect lung structure and function in this context. In this study, we report on five clinical cases, encompassing patients aged 40-60 years of both sexes, who tested positive for coronavirus disease 2019 via real-time polymerase chain reaction and exhibited significant pulmonary compromise with elevated inflammatory biomarkers. These patients were treated with aerosol therapy using surfactant delivered through vibrating-mesh nebulizers alongside HFNC. Of these patients, four demonstrated positive responses to the treatment, suggesting that aerosol therapy with surfactant through vibrating-mesh nebulizers could be a viable rescue therapy in adults receiving HFNC oxygen therapy for hypoxemic respiratory failure caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Unfortunately, one patient had a negative outcome and succumbed. The findings from these cases indicate that the use of aerosol therapy with vibrating-mesh nebulizers as rescue therapy might offer an alternative approach for managing adults with hypoxemic respiratory failure due to SARS-CoV-2, as evidenced by the positive outcomes in four out of the five cases presented.

Intravenous gammaglobulin as rescue therapy in a patient with sickle cell and septic shock.

INTRODUCTION: We present a case involving a patient with sickle cell and hyposplenism, in which refractory septic shock quickly responded after the infusion of intravenous gammaglobulin (IV-GG) given as an adjuvant-rescue therapy CASE DESCRIPTION: A 30-year-old African-American female with history of Sickle Cell disease was admitted for acute chest syndrome, septic shock and respiratory failure. Despite aggressive therapy the patient remained on two vasopressors and with persistent bacteremia. Within one day of starting IV-GG, both vasopressors (norepinephrine and vasopressin) were able to be discontinued. DISCUSSION: Patients with hyposplenism have functional opsonization failure. Infusion of IV-GG has been shown to improve such function in patients with hyposplenism. We were able to document a temporal association between IV-GG rescue therapy and septic shock improvement. CONCLUSION: The utilization of intravenous gammaglobulin should be considered in patients with sickle cell disease and hyposplenism as an adjuvant therapy for refractory septic shock.

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.

Pulmonary Evaluation of Post-COVID-19 Patients: An Ecuadorian Experience.

Background: Despite the growing concerns related to the potential of long-term pulmonary sequelae due to COVID-19, data about intermediate and long-term changes in the respiratory function of patients who recover is relatively sparse, particularly in developing countries. Objectives: To assess the characteristics and pulmonary function at follow-up in a sample of Ecuadorian patients that recovered from the virus. Methods: We conducted a cross-sectional study that included 43 patients after symptomatic COVID infection, who were evaluated by spirometry, single breath DLCO, and 6MWT. For statistical analysis we performed point biserial correlations, and chi squared tests. Results: Overall, 30.3% of patients (n = 13) reported persistent symptoms, with fatigue being the most common (23.3%, n = 10). Around 34.9% (n = 15) of the sample had a restrictive spirometry pattern, 18.6% (n = 8) had an abnormally decreased adjusted DLCO. A restrictive spirometry pattern was associated with an abnormally low adjusted DLCO (χ2(2) = 11,979, p = 0.001). Conclusion: We found that a considerable proportion of patients presented with persistent symptoms and alterations in pulmonary function following COVID-19, mainly a restrictive respiratory pattern and abnormally low DLCO. Further studies are needed to determine which patients may benefit from the follow-up with specific pulmonary function tests.

Diabetic ketoacidosis presenting with acute pancreatitis and visceral vein thrombosis.

Abdominal pain is a frequent manifestation in patients presenting with Diabetic Ketoacidosis (DKA). Usually it is attributed to severe metabolic acidosis but it can be due to underlying abdominal pathologies (i.e., pancreatitis, appendicitis). We report a case of a 19-year-old female who presented with DKA and severe abdominal pain and was found on further examination to have underlying pancreatitis and visceral vein thrombosis. The patient improved with treatment for the mentioned co-morbidities, including anticoagulation.

Management of Sickle Cell Disease Complications Beyond Acute Chest Syndrome.

Sickle cell disease results in numerous complications that can lead to significant morbidity and mortality. Amongst them, acute chest syndrome is the leading cause of mortality. As a result, most providers are in tune with this complication and well versed with management. As sickle cell patients now live longer, they face a multitude of other complications that if left unattended, can lead to significant morbidity and mortality as well. It is critical to look beyond acute chest syndrome and adopt a more comprehensive approach to the management of the sickle cell patient.

Obstructive sleep apnea and immunity: relationship of lymphocyte count and apnea hypopnea index.

OBJECTIVES: The impact of chronic poor quality sleep on immunity as seen in obstructive sleep apnea (OSA) has not been evaluated. We aim to explore the relationship between lymphocytes, neutrophil, and total leukocyte counts with severity stratified apnea hypopnea index (AHI) in patients with OSA. METHODS: A retrospective review of 119 patients' medical records diagnosed with OSA from October 2005 to July 2006 was performed. Data collected included demographics, comorbidities, total leukocyte, neutrophil, and lymphocyte count, body mass index (BMI), AHI, and Epworth sleepiness scores (ESS). Three AHI strata were constructed: mild (5-14), moderate (15-29), and severe (>30). Data were fitted in a linear regression model on which lymphocyte counts were the dependent variable against age, BMI, and AHI. An interaction product was also explored (age*BMI). All tests were two-sided; a P < 0.05 was considered statistically significant. We used Statview Version 5.01 (SAS Institute, Inc., Cary, NC) for the analysis. RESULTS: Our study showed a linear association among AHI and BMI (P = 0.0017), but did not show association between lymphocyte count with either BMI (P = 0.33) or AHI (P = 0.90). A negative association between lymphocytes and age (P = 0.02) that persisted after adjustments for BMI and AHI was found. An interaction product (age*AHI) was not associated with lymphocyte count (P = 0.87). No correlation was found between peripheral blood count (P = 0.29) or neutrophil counts (P = 0.38) and AHI. CONCLUSION: We found OSA-induced sleep interruption not associated with lymphocyte, neutrophil, or peripheral blood cell count alterations. This information is useful for researchers evaluating the influence of sleep disruption on immunity.

Evidence for strict inpatient blood glucose control: time to revise glycemic goals in hospitalized patients.

Inpatient hyperglycemia in patients with and without a history of diabetes is common and is associated with increased hospital morbidity and mortality. The objectives of this communication are to examine results of randomized clinical trials of strict inpatient glucose control in medical and surgical intensive care units and to provide guidelines for achieving and maintaining glycemic control in patients admitted to critical and noncritical settings. We propose a more conservative approach of glycemic control than current American Association of Clinical Endocrinology recommendations until results of prospective, multicenter, randomized studies become available.

Rhabdomyolysis in a patient with West Nile encephalitis and flaccid paralysis.

West Nile Virus (WNV), a flavivirus, was first documented in the United States by the Center for Disease Control in 1999. WNV has been associated with a variety of clinical features from a subclinical febrile illness to a neuroinvasive disease. Rhabdomyolysis, however, has not been a clinically well-described occurrence during WNV illness. We report a case of a 56 year-old African-American male with WNV infection who developed neuroinvasive encephalitis, flaccid paralysis, and rhabdomyolysis. During his illness, creatinine kinase (CK) values peaked at 45,276 U/L. We discuss the temporal relationship of the development of rhabdomyolysis, the course of his paralytic illness, imaging results, and present supporting evidence that rhabdomyolysis was not a sequel of another clinical condition. With the increasing spread of WNV, it is important to recognize rhabdomyolysis and flaccid paralysis as important manifestations of neuroinvasive WNV infection.

Association of Chronic Insomnia With Mortality and Adverse Renal Outcomes.

OBJECTIVE: To examine whether chronic insomnia is associated with an increased risk of adverse renal outcomes and all-cause mortality. PATIENTS AND METHODS: We examined associations of chronic insomnia (defined as the presence of both International Classification of Diseases, Ninth Revision codes 307.42, 307.49, and 780.52 and long-term use of insomnia medications) with adverse renal outcomes (end-stage renal disease, incidence of estimated glomerular filtration rate [eGFR] ≤45 mL/min per 1.73 m2, and eGFR slopes <-3.0 mL/min per 1.73 m2 per year) and all-cause mortality in a national cohort of 1,639,090 US veterans by using Cox proportional hazards and logistic regression models with multivariable adjustments. RESULTS: A total of 36,741 patients (2.24%) had chronic insomnia; 32,985 (89.8%) were male and 28,090 (76.5%) were white, with a mean baseline eGFR of 84.1±16.4 mL/min per 1.73 m2. Chronic insomnia was associated with a significantly higher risk of eGFR 45 mL/min per 1.73 m2 or less (multivariable-adjusted hazard ratio [HR], 1.39; 95% CI, 1.34-1.44; P<.001), and rapid loss of kidney function (odds ratio, 1.07; 95% CI, 1.03-1.12; P=.002), but not end-stage renal disease (HR, 1.25; 95% CI, 0.81-1.93; P=.32). Chronic insomnia was not associated with a higher risk of all-cause mortality (HR, 1.00; 95% CI, 0.97-1.03; P=.99). CONCLUSION: Chronic insomnia is associated with a higher risk of development and progression of chronic kidney disease, but not ESRD. Further studies are needed to establish the underlying mechanisms of action and to determine whether treatment of insomnia could be beneficial to prevent deteriorating kidney function.