Blood glucose management in the intensive care unit : insulin infusion protocol

Stress hyperglycaemia is associated with poor clinical outcomes in critically ill patients. Factors contributing to hyperglycemia in critical illness include the release of stress hormones, the use of medications, the release of mediators in sepsis and trauma and insulin resistanc

Enteral Nutrition in Intensive Care: 'Tiger Tube'-For Small Bowel Feeding in Acute Pancreatitis. Case Report.

Nutritional support is vital in improving the clinical outcomes of the critically ill patients. Almost all published guidelines regarding nutritional support in the critically ill recommend the use of enteral nutrition over parenteral nutrition. In acute pancreatitis, trial of enteral feeding should be given into the small bowel. The success rate of small bowel feeding tube is highest if inserted endoscopically. In this case report, a simple bedside procedure which did not require endoscopic feeding tube placement offered a good alternative. Self advancing small bowel feeding tube, Tiger tube was inserted successfully to provide nutritional support in moderately severe acute pancreatitis

Acute airway obstruction due to Ascaris Lumbricoides in a ventilated child

Ascaris lumbricoides or roundworm is a nematode causing infestation in about 1.3 billion people worldwide. We report a case of a 7-year-old patient who had head injury. He was admitted to the intensive care unit for mechanical ventilation after craniotomy and evacuation of extradural haemorrhage at the left temporoparietal area. While weaning off mechanical ventilation two days after admission, he developed an acute airway obstruction. Flexible bronchoscopy revealed a tube like foreign body obstructing the right and left bronchus. Emergency rigid bronchoscopy under general anaesthesia extracted an eight-centimetre long Ascaris lumbricoides. The patient’s ventilation and oxygenation improved drastically and he was discharged home 3 weeks later

Refeeding syndrome in a Malaysian intensive care unit: an assessment of incidence, risk factors and outcome

Objective: Refeeding hypophosphataemia (RH) is characterised by acute electrolyte derangement following the start of nutrition. Complications associated with this syndrome include heart failure, respiratory failure, paraesthesia, seizure and death. We aim to assess its incidence, risk factors, and outcome in our local intensive care unit (ICU). Methods: This is a preliminary analysis prospective observational study at the ICU of Hospital Tengku Ampuan Afzan Kuantan. The study was registered under the National Medical Research Register (NMRR-14-803-19813) and has received ethical approval. Inclusion criteria includes adult admission longer than 48 hours who were started on enteral feeding in the ICU. Chronic renal failure patients and those receiving dialysis were excluded. RH was considered if plasma phosphate was less than 0.65 mmol/l within 7 days of ICU admission. Results: A total of 108 patients were recruited into the study. Of this, 51 (47.2%) had RH. Patients with RH had higher SOFA score compared to those without RH (7.1±3.0 vs 5.7±3.4, p=0.02). There were no differences in the APACHE II score (16±6 vs 15±6, p=0.30), and in the NUTRIC score (2.9±1.7 versus 2.7±1.7, p=0.63) between patients with and without RH. Patients with RH had lower albumin concentration compared to those without RH (23 vs 25, p=0.04). There were lower trend of magnesium, calcium and potassium concentration, however these were not statistically significant. All four patients with hypomagnesaemia (less than 0.5 mmol/l) had RH (p=0.04). There were no differences in mortality, length of hospital or ICU stay and duration of mechanical ventilation. Conclusion: Refeeding hypophosphataemia is common, occurring in almost half of ICU admission. Patients with RH had higher organ failure score, and lower albumin level. There were no differences in the NUTRIC score and in short-term outcomes. Further studies could evaluate the association between RH and long-term outcome

025 Estimates of glomerular filtration rate in the critically ill with sepsis

Accurate assessment of glomerular filtration rate (GFR) in ICU patients is very important for institution of supportive therapy, preventive therapy, early renal support, drug dosing modification or avoidance of nephrotoxic drugs. Kinetic estimate of GFR (keGFR) takes into account the changes of creatinine over time, creatinine production rate, and the volume of distribution, hence postulated to be a more accurate estimate of GFR in the acute setting, where there are rapidly changing kidney functions as in the critically ill. We evaluated the association of the keGFR with estimated GFR (eGFR) by conventional method

Deteriorating patients and risk assessment among nurses and junior doctors: a review

The presence of nurses and junior doctors in the ward environment are crucial, especially in detecting deteriorating patients. However, there is consistent evidence that warning signs may not always be identified or acted upon. This paper aimed to analyse the incidence of deteriorating patients, and the concept of risk assessment of these patients by nurses and junior doctors in general ward, through a review on relevant literature. An extensive literature search was conducted through online research databases, i.e. CINAHL, MEDLINE (Ovid), Science Direct and ProQuest. Professional journals were hand searched for relevant literature based on reference lists and citations made in key publications, and attempts were also made to obtain any relevant grey literature (unpublished materials). A total of eleven papers which focused on patient’s assessment, response to deteriorating patients and knowledge in medication, and a guideline were reviewed. Most of the studies were carried out in the United Kingdom (n=4), followed by Australia (n=2), Sweden (n=2), the Netherlands (n=1) and Taiwan (n=1). Meanwhile, among these studies, the chosen research designs include, qualitative (n=6), quantitative (n=3) and systematic review (n=1). This review concluded that nurses and junior doctors in general ward have a lack of knowledge in risk assessment of deteriorating patients

Nutritional management of the critically ill obese patient

Purpose of review: The prevalence of obesity in Malaysia has increased four folds over the past two decades. Epidemiologic studies suggest that there are increased numbers of overweight and obese patients admitted to the intensive care unit (ICU). Increased morbidity and mortality along with longer duration of ICU stay and time on mechanical ventilator have been shown to be associated with this particular body habitus. This review will discuss the recent findings and evidence-based approaches to provide nutrition therapy for this ICU population. Recent findings: Nutrition therapy plays a vital role in improving their outcome; however, clinicians need knowledge of certain obstacles that are unique to obese patients. Nutrition assessment should be comprehensive, because the presence of malnutrition is always underestimated. The increased basal insulin level suppresses lipid mobilisation but increases protein breakdown in obesity, thus leading to protein malnutrition. Large variations in body composition among the obese make estimation of caloric requirements very difficult. There is no consensus as to which predictive equation is most suitable, leading to the recommendation to perform indirect calorimetry when available. A more balanced nitrogen profile has been shown following a high-protein, hypocaloric feeding regimen as compared to a eucaloric one while also demonstrating better outcomes. Summary: Future studies should focus on finding a method to determine appropriate energy requirements and validate the benefits of a high-protein, hypocaloric feeding regimen in critically ill obese patients

Urine output in diagnosing acute kidney injury and predicting mortality

Background: Urine output is the oldest biomarker of AKI. Clinically it can be the first indication of kidney dysfunction, especially in critical care settings where hourly urine outputs are routinely measured. It has been shown that the ideal urine output threshold for prediction of mortality or dialysis was 0.3 ml/kg/h for moving block of 6 hours. Objectives: We aim to assess this threshold in mortality prediction in our ICU population. Methods: This was a secondary analysis of a single centre, prospective observational study. Admission of less than 48 hours, post-elective surgery and ICU readmission were excluded. A moving average urine output over 6 hours over body weight was calculated for the first 48th hour post ICU admission. AKIuo was defined if urine output less than 0.5 ml/kg/h, and UO0.3 less than 0.3 ml/kg/h. Results: A total of 143 patients were recruited, of these 87 (61%) had AKIuo, and 52 (36%) had UO0.3. The AUC of AKIuo in predicting mortality was 0.62 (0.51 to 0.72), and UO0.3 was 0.66 (0.55 to 0.77). There were lower survival in patients with AKIuo and UO0.3 compared to those without (p=0.01, and 0.001, respectively). However, after adjusting for covariates (age and SOFA score without renal score), only UO0.3 but not AKIuo independently predicted mortality (HR 2.44 (1.15 to 5.18)). AKUuo assessed over 6 hours or longer independently predicted mortality, whereas UO0.3 assessed over 2 hours or longer predicted mortality. Conclusions: A threshold of 6 hourly urine output of 0.3 ml/kg/h but not 0.5 ml/kg/h was independently predictive of mortality. Duration of urine output assessed as low as 2 hours can be used when utilisng the stricker definiton, whereas at 6 hours is needed using the standard criteria. This support previous finding of a more stricker urine output definition in acute kidney injury