Intensive Insulin Therapy in Intensive Care: An Example of the Struggle to Implement Evidence-Based Medicine

Schultz and colleagues discuss the factors hindering implementation of intensive insulin therapy

Biological markers for kidney injury and renal function in the intensive care unit

The purpose of the investigations described in this thesis was to seek for answers to two relevant questions in ICUs in resource-rich settings, i.e., can new biological markers play a role in early recognition of AKI, and can new biological markers predict recovery of renal function in patients who receive CVVH? A second aim was to answer a relevant question in ICUs in resource-poor settings, i.e., can novel biological markers predict development of AKI and need for RRT in patients with severe P. falciparum malaria? Both CyC and NGAL have been suggested promising endogenous biological markers for AKI in ICU patients. Results from the prospective observational SCARF study suggests that neither CyC nor NGAL are useful biological markers for AKI and need for RRT. The patient population in SCARF is rather heterogeneous. We believe this cohort better reflects the patient populations seen in the ICU in whom the abovementioned questions are relevant. Based on the findings in the SCARF study and its secondary analyses we conclude CyC and NGAL cannot serve as biological markers in clinical practice. As suPAR has a good prognostic value in patients with the systemic inflammatory response syndrome, sepsis or bacteremia, we speculated suPAR to have pathogenetic role in patients with severe P. falciparum. The investigation described in this thesis suggests this to be true. But a prognostic value for suPAR with AKI in this specific patient group was not confirmed

Serum levels of N-terminal proB-type natriuretic peptide in mechanically ventilated critically ill patients--relation to tidal volume size and development of acute respiratory distress syndrome

Serum levels of N-terminal proB-type natriuretic peptide (NT-proBNP) are elevated in patients acute respiratory distress syndrome (ARDS). Recent studies showed a lower incidence of acute cor pulmonale in ARDS patients ventilated with lower tidal volumes. Consequently, serum levels of NT-proBNP may be lower in these patients. We investigated the relation between serum levels of NT-proBNP and tidal volumes in critically ill patients without ARDS at the onset of mechanical ventilation. Secondary analysis of a randomized controlled trial of lower versus conventional tidal volumes in patients without ARDS. NT-pro BNP were measured in stored serum samples. Serial serum levels of NT-pro BNP were analyzed controlling for acute kidney injury, cumulative fluid balance and presence of brain injury. The primary outcome was the effect of tidal volume size on serum levels of NT-proBNP. Secondary outcome was the association with development of ARDS. Samples from 150 patients were analyzed. No relation was found between serum levels of NT-pro BNP and tidal volume size. However, NT-proBNP levels were increasing in patients who developed ARDS. In addition, higher levels were observed in patients with acute kidney injury, and in patients with a more positive cumulative fluid balance. Serum levels of NT-proBNP are independent of tidal volume size, but are increasing in patients who develop ARD