Glycaemic variability, infections and mortality in a medical-surgical intensive care unit.

In critically ill patients, glycaemic variability (GV) was reported as a better predictor of mortality than mean blood glucose level (BGL). We compared the ability of different GV indices and mean BGLs to predict mortality and intensive care unit-acquired infections in a population of ICU patients.Retrospective study on adult ICU patients with ≥ three BGL measurements. GV was assessed by SD, coefficient of variation (CV) and mean amplitude of glycaemic excursion (MAGE), and by one timeweighted index, the glycaemic lability index (GLI), and compared with mean BGL. We studied 2782 patients admitted to the 12-bed medical-surgical ICU of a teaching hospital from January 2004 until December 2010.Logistic regression analyses were performed to assess the association between GV and ICU mortality and ICU-acquired infections. The areas under receiver operating characteristic curves were calculated to compare the discriminatory ability of GV and mean BGL for infections and mortality.Mortality was 16.6%, and 30% of patients had at least one infection. Patients with infections or diabetes or who were treated with insulin had a higher mean BGL and GV than other patients. GLI, SD, CV and MAGE were significantly associated with infections and mortality; mean BGL was not. Quartiles of increasing GLI were independently associated with higher mortality and an increased infection rate. Patients in the upper quartile of mean BGL and GLI had the strongest association with infections (odds ratio, 5.044 [95% CI, 1.695-15.007]; P = 0.004).High GV is associated with higher risk of ICUCrit acquired infection and mortality

Process for increasing yield of Dextrose production process, by membrane technology

The invention relates to a process for increasing the dextrose recovery from a dextrose containing solution. In particular, the invention relates to a process for increasing the dextrose yield of a starch hydrolysis process. The process comprises membrane filtration of a dextrose containing solution and an enzyme treatment of the retentate of the filtration

A rare case of central venous catheter malpositioning in polytraumatic patient not recognized by chest x-ray.

Central venous catheter (CVC) insertion is one of the most widely practiced procedures in the intensive care unit (ICU) and the most common complications of this procedure are pneumothorax, artery puncture and malposition. The location of malpositioned subclavian vein catheters may include the ipsilateral internal jugular vein, the controlateral brachiocephalic vein and loop formation. The cannulation of tributaries of the main intra-thoracic vein is a rare complication (1). A 40-year-old man was admitted to our ICU for polytrauma following an eight meter fall into a manhole left accidentally uncovered. He reported a thoracic trauma and pelvic fractures. The patient was sedated, intubated and mechanically ventilated and a CVC was inserted through the left subclavian vein without complications. No resistance was felt during insertion and venous blood was aspirated through the lumen without signs of obstruction. A chest x-ray was performed to verify the correct position of the central line and no complication was recognized (Fig. 1). A chest CT scan was then performed to control the lung contusion and this revealed that the CVC tip was controlaterally inserted into the right internal thoracic vein (Fig. 2). Thus, the catheter was removed and inserted into the right internal jugular vein. Most of the cases reported in literature associate this complication with left internal jugular vein cannulation with the catether tip into the ipsilateral internal thoracic vein. Other possibilities are azygos vein or pericardiophrenic vein cannulation. Finally, some congenital variant could be present such as the persistence of the left superior vena cava (2). The peculiarity of our case (the first of this kind) is left subclavian vein cannulation with the catheter tip into the controlateral internal thoracic vein. A predisposition of this complication in patients with portal hypertension has been reported because of engorgement of the venous system (3). Patients can be symptomatic or asymptomatic. Symptoms include chest pain, especially during hyperosmolar solution infusion (e.g., total parenteral nutrition) and during high flow infusion rate. Other complications may include venous thrombosis or thrombophlebitis, extravasation of infusate, pleural effusion, pulmonary edema and chest wall abscess (4). Central venous pressure (CVP) waveform analysis could help us suspect this rare complication, by showing flattened waves instead of the typical a, c, v, x, y waves (5). Conclusion: The chest x-ray cannot always demonstrate CVC malpositioning since the catheter can be projected into the vena cava profile (2). We must suspect this complication in case of difficult catheter insertion, typical symptoms or altered CVP waveform. In these cases other diagnostic tests for correct catheter placement should be considered if chest x-ray is negative

Extracorporeal membrane oxygenation with spontaneous breathing as a bridge to lung transplantation

OBJECTIVES: A large number of transplantation centres consider extracorporeal membrane oxygenation as an inappropriate option for bridging critical patients to lung transplantation. Technical improvements such as the introduction of a polymethylpentene membrane, new centrifugal pumps and heparin-coated circuits have led to a safer application of extracorporeal membrane oxygenation, and an increasing number of centres are reporting their positive experiences. The aim of this study was to review our practice in bridging critical candidates to lung transplantation with extracorporeal membrane oxygenation, by comparing patients with invasive mechanical ventilation with patients with spontaneous breathing. METHODS: The records of candidates for lung transplantation treated with extracorporeal membrane oxygenation have been revised. RESULTS: From February 2008 to 2012, 11 patients who experienced an abrupt worsening of their respiratory conditions were treated with extracorporeal membrane oxygenation; mean age: 33.9 \ub1 13.2 years, male/female ratio: 5/6, 6 patients were affected by cystic fibrosis, 2 had chronic rejection after transplantation, 2 had pulmonary fibrosis and 1 had systemic sclerosis. Seven patients were awake, while 4 patients received invasive mechanical ventilation. The sequential organ failure assessment score significantly increased during bridging time and this increase was significantly higher in the intubated patients. All the patients had bilateral lung transplantation. Spontaneously breathing patients showed a tendency to require a shorter duration of invasive mechanical ventilation, intensive care unit stay and hospital stay after transplantation. One-year survival rate was 85.7% in patients with spontaneous breathing vs 50% in patients with invasive mechanical ventilation. CONCLUSIONS: Extracorporeal membrane oxygenation in spontaneously breathing patients is a feasible, effective and safe bridge to Lung transplantation

Variations of thoracoabdominal volumes after lung transplantation measured by opto-electronic plethysmography

BACKGROUND: Lung function after lung transplantation (LTx) has been widely studied. On the contrary, the thoracoabdominal volume rearrangement after LTx has yet to be investigated. METHODS: Patients with cystic fibrosis and listed for double LTx at our institution were enrolled for the prospective study to explore the effects of LTx on the rearrangement of respiratory volumes in patients affected by cystic fibrosis, by utilizing the opto-electronic plethysmography (OEP), a noninvasive method to study the volume and motion of the human trunk. Rib cage and abdominal volumes were tested with OEP (OEP system, BTS, Milano, Italy). RESULTS: Eight patients were enrolled (male-to-female ratio: 1:3; mean age 29.3 \ub1 7.8 years). After LTx the volume changes analyzed with OEP revealed a significant decrease of the total lung capacity (TLC) as well as the functional residual capacity and residual volume when the chest wall volume was considered. Dividing the whole respiratory volume in the three compartments showed different trends. CONCLUSIONS: We consider OEP a particularly useful device in patients with severe respiratory disease, in that it allows a noninvasive estimate of the volume change of the chest wall. This study demonstrates a significant reduction of thoracoabdominal volumes in patients affected by cystic fibrosis treated with bilateral LTx. Abdomen and upper rib cage were congruent with the volume reduction, while the lower rib cage showed an opposite tendency

Epidemiology and clinical outcome of Healthcare-Associated Infections: a 4-year experience of an Italian ICU

Due to their impact on the outcome, hospital-acquired infections (HAIs) in ICUs represent a critical issue of patients' assistance. This study describes microbiological and clinical findings of a surveillance program covering 4 years in an Italian ICU

Nutritional assessment in head injured patients through the study of rapid turnover visceral proteins.

Nutritional monitoring of rapid turnover visceral protein is important in the recognition of malnutrition in patients admitted to the Intensive Care Unit (ICU). We studied prealbumin and retinol-binding protein in patients who received three different kinds of artificial nutrition in order to evaluate the appropriateness of artificial nutrition.45 consecutive head injury patients received enteral (Group A), parenteral (Group B) or both enteral and parenteral nutrition (Group C) at random. We considered these parameters: prealbumin, retinol binding protein and nitrogen balance before (T1), after 3 (T2), 7 (T3) and 11 (T4) days after the beginning of study. Statistical analysis was performed with Kruskal-Wallis test and Bonferroni's t -test.Plasma prealbumin and Retinol binding protein (RBP) showed an increasing of basal values during the study period in all groups (< 0.0001) and more significantly in group A (Enteral nutrition P < 0. 001 vs Total parenteral nutrition (TPN) and Enteral P< 0.01 vs Enteral and parenteral nutrition).Data obtained in the present study indicate that a laboratory is essential for monitoring nutritional assessment and for checking the appropriateness of nutritional therapy. We found prealbumin to be the most sensitive measure and found it to be the test of choice for early assessment and intervention