Critical Care Minutes

The Endocrine Society is an multi-national, multidiscipline organization with ~14,000 members from over 100 countries. It was founded in 1916 and publishes 4 peer-reviewed journals. On March 26th, 2009 immediately after the NICE SUGAR study was published they released a statement which supports loosening glycemic control in ICU patients may now be more prudent.  They state that we should be targeting glucose values between 144-180 mg/dl “until we better understand the reasons for these somewhat counterintuitive findings.”
Below is an excerpt from the statement which can be viewed in its entirety here   –>

The Endocrine Society commends the NICE-SUGAR investigators for producing an important and provocative addition to the medical literature and draws the following conclusions and recommendations from their data. First, near-normalization of blood sugar does not clearly improve outcomes in all critically ill hyperglycemic ICU patients, and there is even a suggestion that such an approach may worsen outcomes. Second, looser control of hyperglycemia, i.e., target blood glucose of 144-180 mg/dl, is a reasonable, and perhaps preferable, option in this particular group of very sick patients. Third, it is essential to assess clinically meaningful outcomes, such as mortality, as well as surrogate or intermediate endpoints, such as blood sugar level, in studies of diabetes treatment as the NICE-SUGAR study has done; improvement of blood sugar control may not always translate to better clinical results.

Here is another fantastic ICU 2.0 resource. You can subscribe to these podcasts in iTunes or listen to them directly on the website. Dr. Jeffrey S. Guy has taken topics he discussed on teaching rounds in the Burn ICU at Vanderbilt and brought them to you as onDemand solutions! It is these sort of resources that are inspirational for me and truly on the forefront of teaching in the 21st century. Well Done Dr. Guy! I hope you enjoy and become a subscriber (as I did).

BTW. Look out for the Critical Care Minutes podcast and vodcast series which will be starting up very soon. Stay Tuned!

You can now follow along with us by signing up for our twitter updates. Just click on the link below. Also you can always subscribe to the site with your favorite RSS reader. Stay tuned, exciting new ICU 2.0 features will be coming to the site very soon including the ability to join in our LIVE! web conferences. Click the logo to follow along!

This week’s issue of NEJM features another in a long debated series of trials that investigates the benefits of  “tight” vs “conventional” glycemic control in the ICU.  Is this the one that finally gives us the answer? Let’s find out…

The NICE-SUGAR Study Investigators are a multinational, multicenter and multidisciplinary collaboration. The primary objective of this trial was to find the optimal glycemic level for critically ill patients. Patients expected to stay in the ICU for >3 days were enrolled within 24 hours of admission to the ICU. They were randomized to either recive INTENSIVE (81-108 mg/dl) or CONVENTIONAL (<180 mg/dl) therapy. The primary endpoint was 90 day mortality (any cause / after randomization).

After enrolling 6104 patients, 3054 received intensive rx and 3050 received conventional rx. Groups were relatively well matched at baseline.  The major difference in primary outcome was a RRR of ~ 9% in the conventional group (24.5% vs 27.5%). This corresponded to an odds ratio of 1.14 (95% CI 1.02-1.28),  p=0.02. There was no differernce in the treatment effect when looking at medical vs. surgical patients.  Of note, severe hypoglycemia (<40) occured ~13x more often in the intensive group (0.5% vs 6.8%    p<0.001). No other significant differences upon subgroup analysis or secondary outcomes were found.

Read more…

Here is another excellent and thorough resource I found online in the blogger community that reviews several procedures including Central Line Placement, Thoracentesis, Paracentesis, Arterial Line, Lumbar Puncture, etc. The review is not video based but does have very detailed images used to illustrate the techniques as well as nice decriptive explanations. ClinicalCases.org is a free online case-based curriculum of clinical medicine and is one of the most popular medical blogs on internet. A lot of the information may not be relevant to the ICU but it is still a good resource for topic reviews. I would encourage you to browse the site and get your learn on Incidentally, this website has significant input from the Cleveland Clinic and the Case Western Lerner College of Medicine – The blog was developed by Dr. Vesselin Dimov (Internal Medicine, CCF).

ClinicalCases.org was featured in the British Medical Journal and Medscape.com, and was referenced several times in the medical education literature. The project is hyperlinked in the web sites of 11 medical schools in the U.S., Canada and Europe. This case-based curriculum was started by physicians at Cleveland Clinic and Case Western Reserve University (St. Vincent/St. Luke) Internal Medicine Residency Program for the purpose of medical education.

Check it out Clinicalcases.org.

Here is a link to the Procedural guides.

***Excerpt taken from SICU Handbook Cleveland Clinic SICU

1. Maintain your availability in the SICU

The nurses and other personnel who work in the unit are seasoned, experienced professionals. Unfortunately, as in other aspects of health care, they are being forced to “do more with less,” which means that frequently there is one nurse to two (or three!) patients; so-called one-on-one nursing assignments are extremely rare. This means that the nurses are busier, and the one thing that they shouldn’t have to do is constantly hunt for you. The usual response to this statement is “I have Read more…