Brenda G. Fahy

Critical glucose control: the devil is in the details.

This issue of Mayo Clinic Proceedings contains 3 articles on maintaining normal glucose levels in hospitalized patients. 1-3 The report by Desachy et al 1 ddresses a concept—reliably measuring glucose in critically ill patients—that is important to understanding the other 2 articles. The accuracy of point-of-care (POC) glucometers and variability of glucose measurement in the intensive care unit (ICU) are where the details meet the devil. 1 The potential effect of inaccurate glucose measurements on tight glycemic control (TGC) protocols using intensive insulin therapy (IIT) must be appreciated. Variability in measurement technique and results could explain some of the conflicting opinions about the advisability of aggressive control of glucose levels in critically ill patients. 4,5

Intraoperative and perioperative complications with a vagus nerve stimulation device

Vagus nerve stimulation (VNS) for medically refractory seizures has been an approved therapy by the Food and Drug Administration since 1997, with additional approval as an adjunct therapy for major depression granted in 2005. Potential applications for VNS therapy in obesity, neuropsychiatric disorders, and chronic pain syndromes are under investigation. Bradyarrhythmias, including asystole, may occur during VNS device placement or as a delayed complication. A peritracheal hematoma may develop following VNS device placement, necessitating emergent management. Other respiratory complications may include vocal cord movement abnormalities with potential for aspiration. Vagus nerve stimulation results in sleep-related breathing pattern changes, with an associated increase in the number of obstructive apneas and hypopneas in both children and adults, which may impact perioperative care.

The utility of the clinical pulmonary infection score.

The most common infectious complication in critically ill patients is ventilator-associated pneumonia. Ventilator-associated pneumonia has significant morbidity and mortality, prolongs mechanical ventilation, and extends length of hospitalization. Despite its prevalence and impact, uniform diagnostic standards are lacking. The Centers for Disease Control, American Thoracic Society, and Infectious Diseases Society of America have recommended focus on improving preventive measures, establishing widely available and accurate diagnostic tools, and improving ventilator-associated pneumonia management with length of therapy guidelines. The purpose of this article is to review the evidence supporting the clinical pulmonary infection score as an adjunct to distinguish and detect clinically relevant ventilator-associated pneumonia and its use to guide length of therapy. This score combines clinical diagnostic criteria (tracheal secretion quantification and body temperature) with routinely obtained laboratory data (white blood cell count and oxygenation parameters), radiographic data, and bacteriological culture results. Limitations of clinical pulmonary infection score will be discussed.

An Analysis: Hyperglycemic Intensive Care Patients Need Continuous Glucose Monitoring—Easier Said Than Done

Experts and agencies increasingly advocate tight glycemic control (TGC) using intensive intravenous insulin therapy in critically ill patients. Questions remain about the “best” glucose goal, the universal benefit of TGC in the heterogeneous adult intensive care unit (ICU) population, and concerns about the underrecognized incidence of hypoglycemia and its neuropsychological sequelae. TGC is time-consuming for ICU staff, and pathophysiologic, technical, and personnel factors impact the accuracy of point-of-care glucose monitoring. TGC in the ICU requires safe, accurate, robust, rapid, and continuous glucose measurements (CGM) that lack interference from drugs or other substances. Establishment of reliable CGM may provide the foundation for a closed loop, microprocessed system resulting in an artificial islet cell. This commentary focuses on reports from two respected groups on the potential use of CGM devices in the critically ill. It emphasizes the challenges of applying this technology in the ICU and looks to future refinements to address them.

Pregnancy tests with end-stage renal disease

Tests to ascertain pregnancy status are often obtained during preoperative evaluation, especially when there is a history of uncertain pregnancy or suggestion of current pregnancy. A serum pregnancy test, a beta-human chorionic gonadotropin (beta-HCG) level, was preoperatively obtained from a woman of childbearing age with end-stage renal disease (ESRD) with an unreliable history of irregular menstruation coupled with unprotected sexual activity. The beta-HCG was elevated in the range indicating pregnancy. Further work-up showed that this hormonal elevation was secondary to ESRD without pregnancy.

Integrating evidence-based medicine into the perioperative care of cardiac surgery patients.

a r t m p d w c v p THE BEST PRACTICE PATTERNS in modern medical care aim to integrate the evidence from the medical literature with the clinician’s personal and institutional expertise (including cumulative clinical experience, education, and skills) and the individual patient’s preferences and values. The integration of evidence-based medicine (EBM) into perioperative care is an important component of modern anesthesiology, surgery, pharmacy, and nursing practice, particularly in the arena of cardiac surgery (CS). Because the evidence in this area continually is evolving, the landscape of EBM for the perioperative care of CS patients is ever-changing, with optimized, patient-centered care as the impetus for progress. Additionally, various external funding and oversight organizations as well as accreditation agencies, including the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission, have begun to affect physician and hospital reimbursement and accreditation by tracking hospital and physician performance on certain “core measures” and their reported incidence of so-called “never-events” (conditions or complications that should occur with a very low incidence) when providing ideal or perfect clinical care. In this review, the authors describe the application of the most current literature to 4 important perioperative problems including glycemic control, hospital-associated infections, coagulopathies, and postoperative delirium and cognitive decline. Each of these topics relates to the perioperative care of patients undergoing CS, and each of these topics already is or eventually may be integrated into a public reporting scorecard and individual practitioners and hospitals may, therefore, have a vested interest in improving the care of patients with regard to each of these issues. Although a complete review of the literature for each of these problems is far beyond the scope of this review, the authors attempt to draw a few conclusions from the best available information in each section, recognizing that there may be significant limitations to the integration of these recommendations within some health care systems.

Perioperative Antibiotic Process Improvement Reaps Rewards

Recent health care improvement initiatives have linked financial payments to compliance with predetermined performance measures. This article reports the effect of a unique prophylactic antibiotic use program on compliance rates and costs. The Departments of Surgery, Infection Control, and Anesthesiology collaborated on a prophylactic preoperative antibiotic protocol, whereby Anesthesiology assumed responsibility for timely antibiotic prophylaxis (TAP) before surgical incision. Data from January 1, 2008, to December 31, 2008, were compared (z test) with the 12-month period before this change. χ2 Analysis identified factors associated with TAP. Return on investment (ROI) was calculated. TAP compliance rates increased from 75.1% to 89.3% (P < .001) following program implementation. Factors associated with TAP failure included >60 minutes from anesthesia induction to surgical incision (P < .001), surgical procedure (P < .001), specific antibiotic administered (P < .001), and individual anesthesia provider (P < .001). The ROI was 2.2. TAP compliance rates increased after Anesthesiology assumed responsibility, with anesthesia providers being a significant factor.

Implementation of a handheld electronic point-of-care billing system improved efficiency in the critical care unit.

Coding and billing are time consuming and important considerations for critical care practitioners. A 1-year prospective, observational study incorporated the use of a personal digital assistant and MDeverywhere software (Hauppauge, New York) for patient coding and billing. Twelve months of data were examined before electronic implementation (pre-elec) and compared with a 12-month period after implementation (post-elec) by using an unpaired t test or z test with P < .05 considered significant. The total number of charges was 2479 pre-elec and 2243 post-elec. The days from date of service to billing for services significantly decreased from 37.8 pre-elec to 12.4 post-elec (P < .001); days in accounts receivable significantly decreased from 92.0 to 73.0 (P < .001). The net collection rate increased from 44.7% pre-elec to 49.3% post-elec (P < .001). Duplicate charges significantly decreased from 5.0% pre-elec to 1.4% post-elec ( P < .001). The return on investment was 1.97-fold (197%). The initiation of personal digital assistant technology to facilitate billing and coding resulted in significant improvements.