Monday October 31, 2005
IHI's 5 essentials to prevent central line infections
Who will disagree with following 5 essentials to prevent central line infections from IHI (Institute for Healthcare Improvement).
1. Washing Hands: Before and after palpating the insertion site. (Good to avoid palpation once field is ready).
2. Maximal barrier precautions: yes !! - complete application of sterile drape from head to toe and those “four magic words” - cap, mask, gown and gloves.
3. Use of Chlohexidine as an anti-septic: Proven to be superior than Povidone-iodine(Betadine).
4. Sub-clavian as prefferd site: (may be controversial if operator is not experienced).
5. Daily evaluation of necessity of line: So true !
See IHI’s Central line complete guide .
Please register free at ihi.org for immense other resources.
Sunday, October 30, 2005
Sunday October 30, 2005
Back to Basics - essential trace elements
Importance of seven essential trace elements is relatively way higher in ICUs due to hypermetabolic state of patients. Being an intensivist it is important to have some know how of them. Except for iron and iodine all others need to be provided with enteral and parentral formulae to satisfy atleast their RDA.
1. Iron: in ICU merely checking Fe level may not give real answer of its deficiency. Always check Ferritin level (below 18 indicates deficiency).
2. Selenium: important anti-oxidant and unfortunately many times not included in available enteral/parentral formulae.
3. Chromium: necessary for normal glucose utilization.
4. Copper: essential for formation of hemoglobin.
5. Iodine: needed for proper thyroid metabolism.
6. Manganese: part of Ca+/phos+ metabolism.
7. Zinc: needed for proper wound healing.
Refrences: Click to get abstract/article.
1. Trace minerals in ICU patients: a forgotten cause of delayed recovery? - Critical Care 2004, 8(Suppl 1):P264
2. Trace element supplementation modulates pulmonary infection rates after major burns: American Journal of Clinical Nutrition, Vol 68, 365-371
3. Levels of oligo-elements and trace elements in patients at the time of admission in intensive care units - Nutr Hosp. 1990 Sep-Oct;5(5):338-44.
4.Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients - Journal of Parenteral and Enteral Nutrition, Vol 27, Issue 5, 355-373
5. EARLY ENTERAL SUPPLEMENTATION WITH PHARMACONUTRIENTS IN CRITICALLY ILL PATIENTS - Critical Care Medicine: Volume 32(12) Supplement December 2004 p A4
Back to Basics - essential trace elements
Importance of seven essential trace elements is relatively way higher in ICUs due to hypermetabolic state of patients. Being an intensivist it is important to have some know how of them. Except for iron and iodine all others need to be provided with enteral and parentral formulae to satisfy atleast their RDA.
1. Iron: in ICU merely checking Fe level may not give real answer of its deficiency. Always check Ferritin level (below 18 indicates deficiency).
2. Selenium: important anti-oxidant and unfortunately many times not included in available enteral/parentral formulae.
3. Chromium: necessary for normal glucose utilization.
4. Copper: essential for formation of hemoglobin.
5. Iodine: needed for proper thyroid metabolism.
6. Manganese: part of Ca+/phos+ metabolism.
7. Zinc: needed for proper wound healing.
Refrences: Click to get abstract/article.
1. Trace minerals in ICU patients: a forgotten cause of delayed recovery? - Critical Care 2004, 8(Suppl 1):P264
2. Trace element supplementation modulates pulmonary infection rates after major burns: American Journal of Clinical Nutrition, Vol 68, 365-371
3. Levels of oligo-elements and trace elements in patients at the time of admission in intensive care units - Nutr Hosp. 1990 Sep-Oct;5(5):338-44.
4.Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients - Journal of Parenteral and Enteral Nutrition, Vol 27, Issue 5, 355-373
5. EARLY ENTERAL SUPPLEMENTATION WITH PHARMACONUTRIENTS IN CRITICALLY ILL PATIENTS - Critical Care Medicine: Volume 32(12) Supplement December 2004 p A4
Saturday, October 29, 2005
Saturday October 29, 2005
Venous Air Embolism - VAE - immediate maneuvers
If Venous Air Embolism is suspected during line procedure with symptoms of sudden occurrence of cardiopulmonary dysfunction like hypotension, hypoxia or churning murmur over left sternal border ( "millwheel murmur" ) - following 7 steps are essential:
1. Clamp the line (do not withdraw) - to prevent further air.
2. Rotate patient to left lateral decubitus position - to decrease air leaving through RV outflow tract.
3. Place patient in Trendelenburg position - to help air trap in the apex of the ventricle.
4. Increase oxygen to 100% - Supplemental oxygen reduces the size of embolus. (Avoid High PEEP as it may increase the risk of paradoxical emboli).
5. Advance the catheter little, unclamp the line and aspirate from the 'distal port' to attempt to remove air. (PA-catheter is not as effective as triple lumen catheter in aspirating air).
6. If hypotension occurs - start IVF wide open and add pressor if needed (catecholamines are prefered).
7. Continue supportive treatment till air is absorbed or further management for complications like paradoxical emboli or hyperbaric oxygen therapy is planned.
Refrences: Click to get abstract/article.
1. Venous Air Embolism - emedicine.com
2. Gas Embolism - NEJM, feb. 2000, Volume 342:476-482
3. Venous air embolism: a review. J Clin Anesth 1997;9:251-257
4. Venous Air embolism - Rashad Net University
Venous Air Embolism - VAE - immediate maneuvers
If Venous Air Embolism is suspected during line procedure with symptoms of sudden occurrence of cardiopulmonary dysfunction like hypotension, hypoxia or churning murmur over left sternal border ( "millwheel murmur" ) - following 7 steps are essential:
1. Clamp the line (do not withdraw) - to prevent further air.
2. Rotate patient to left lateral decubitus position - to decrease air leaving through RV outflow tract.
3. Place patient in Trendelenburg position - to help air trap in the apex of the ventricle.
4. Increase oxygen to 100% - Supplemental oxygen reduces the size of embolus. (Avoid High PEEP as it may increase the risk of paradoxical emboli).
5. Advance the catheter little, unclamp the line and aspirate from the 'distal port' to attempt to remove air. (PA-catheter is not as effective as triple lumen catheter in aspirating air).
6. If hypotension occurs - start IVF wide open and add pressor if needed (catecholamines are prefered).
7. Continue supportive treatment till air is absorbed or further management for complications like paradoxical emboli or hyperbaric oxygen therapy is planned.
Refrences: Click to get abstract/article.
1. Venous Air Embolism - emedicine.com
2. Gas Embolism - NEJM, feb. 2000, Volume 342:476-482
3. Venous air embolism: a review. J Clin Anesth 1997;9:251-257
4. Venous Air embolism - Rashad Net University
Friday, October 28, 2005
Friday October 28, 2005
3 new antibiotics
Recently atleast 3 new antibiotics have been introduced in market. No doubt, these are big guns but it is important to know their drawbacks.
1. INVANZ (Ertapenem): Unlike other carbapenems this antibiotic has limited role in nosocomial infections due to negligible activity against Pseudomonas aeruginosa and Acinetobacter baumanni !!
2. CUBICIN (Daptomycin): Cubicin is indicated only for complicated skin and skin structure infections caused by Gram-positive organisms including MRSA (no gram-negative coverage). It has been used as off label for VRE and endocarditis but not approved by FDA. Dose dependent myopathy is a concern, and CPK monitoring is required.
3. TYGACIL (Tigecycline): has been approved for complicated skin (including MRSA) and intra-abdominal (MRSA not included) infections. It has very broad spectrum coverage. It is a distinct class similar to tetracycline. Though nick-named as "Superbug Antibiotic", experts warn against use as a first line or mono-therapy. Side effect profile is long including increase liver enzymes, azotemia, acidosis, hypophosphatemia, hyperglycemia, hypokalemia etc.
Readings: Click to get abstract/article.
1. Carbapenems - Dept of Anaesth. & Int. Care, The Chinese Univ. of HK
2. Cubicin: cleveland clinic - pharmacotherapy update
3. FDA warning letter for cubicin - pharmcast.com
3 new antibiotics
Recently atleast 3 new antibiotics have been introduced in market. No doubt, these are big guns but it is important to know their drawbacks.
1. INVANZ (Ertapenem): Unlike other carbapenems this antibiotic has limited role in nosocomial infections due to negligible activity against Pseudomonas aeruginosa and Acinetobacter baumanni !!
2. CUBICIN (Daptomycin): Cubicin is indicated only for complicated skin and skin structure infections caused by Gram-positive organisms including MRSA (no gram-negative coverage). It has been used as off label for VRE and endocarditis but not approved by FDA. Dose dependent myopathy is a concern, and CPK monitoring is required.
3. TYGACIL (Tigecycline): has been approved for complicated skin (including MRSA) and intra-abdominal (MRSA not included) infections. It has very broad spectrum coverage. It is a distinct class similar to tetracycline. Though nick-named as "Superbug Antibiotic", experts warn against use as a first line or mono-therapy. Side effect profile is long including increase liver enzymes, azotemia, acidosis, hypophosphatemia, hyperglycemia, hypokalemia etc.
Readings: Click to get abstract/article.
1. Carbapenems - Dept of Anaesth. & Int. Care, The Chinese Univ. of HK
2. Cubicin: cleveland clinic - pharmacotherapy update
3. FDA warning letter for cubicin - pharmcast.com
Thursday, October 27, 2005
Thursday October 27, 2005
Propofol Infusion Syndrome (PRIS)
Propofol Infusion Syndrome is a serious threat when propofol is continued for more than 48 hours particularly if dose goes beyond 5mg/kg/hr. Propofol Infusion Syndrome is hallmark by unexplained metabolic acidosis, rhabdomyolysis, cardiac events, arrthymias, hepatomegaly, lipemia, renal failure and hyperkalemia. Unexplained lactic acidosis is suggested as an early marker of "PRIS". Acquired carnitine deficiency has been postulated as a cause, atleast in one article.
Reference: Click to get abstract/article.
1. Cremer and coll.: Long-term propofol infusion and cardiac failure in adult head-injured patients. The Lancet 2001;357:117-118 (Article available at www.thelancet.com with free registration)
2. The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome. - Intensive Care Med. 2003 Sep;29(9):1417-25.
3. Acquired Carnitine Deficiency: A Clinical Model for Propofol Infusion Syndrome? - Anesthesiology: Volume 103(4) October 2005 p 909
Propofol Infusion Syndrome (PRIS)
Propofol Infusion Syndrome is a serious threat when propofol is continued for more than 48 hours particularly if dose goes beyond 5mg/kg/hr. Propofol Infusion Syndrome is hallmark by unexplained metabolic acidosis, rhabdomyolysis, cardiac events, arrthymias, hepatomegaly, lipemia, renal failure and hyperkalemia. Unexplained lactic acidosis is suggested as an early marker of "PRIS". Acquired carnitine deficiency has been postulated as a cause, atleast in one article.
Reference: Click to get abstract/article.
1. Cremer and coll.: Long-term propofol infusion and cardiac failure in adult head-injured patients. The Lancet 2001;357:117-118 (Article available at www.thelancet.com with free registration)
2. The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome. - Intensive Care Med. 2003 Sep;29(9):1417-25.
3. Acquired Carnitine Deficiency: A Clinical Model for Propofol Infusion Syndrome? - Anesthesiology: Volume 103(4) October 2005 p 909
Tuesday, October 25, 2005
Tuesday October 25, 2005
STOP Sepsis bundle - another step forward
After instituting Dr. Rivers' Early Goal Directed Therapy (EGDT) in septic patients - it is imperative to implement Dr. Nguyen's "yes/NO" STOP sepsis bundle as a second step - including
1. Hemodynamic monitoring (CVP/ScvO2 ) within 2 hours
2. Broad spectrum antibiotics administered within 4 hours
3. EGDT achieved at 6 hours (CVP of 8 mm Hg or higher, MAP of 65 mm Hg or higher, ScvO2 of 70% or higher)
4. Monitor for decreasing lactate, and
5. Administer steroid if the patient is on a vasopressor.
See Dr. Nguyen's - Loma Linda University's STOP sepsis bundle at Ref. # 1
References:
1. About the STOP Sepsis Bundle Toolkit - H. Bryant Nguyen, MD, MS
2. IMPROVING THE UNIFORMITY OF CARE WITH THE STOP SEPSIS BUNDLE - Critical Care Medicine: Volume 32(12) Supplement December 2004 p A11
STOP Sepsis bundle - another step forward
After instituting Dr. Rivers' Early Goal Directed Therapy (EGDT) in septic patients - it is imperative to implement Dr. Nguyen's "yes/NO" STOP sepsis bundle as a second step - including
1. Hemodynamic monitoring (CVP/ScvO2 ) within 2 hours
2. Broad spectrum antibiotics administered within 4 hours
3. EGDT achieved at 6 hours (CVP of 8 mm Hg or higher, MAP of 65 mm Hg or higher, ScvO2 of 70% or higher)
4. Monitor for decreasing lactate, and
5. Administer steroid if the patient is on a vasopressor.
See Dr. Nguyen's - Loma Linda University's STOP sepsis bundle at Ref. # 1
References:
1. About the STOP Sepsis Bundle Toolkit - H. Bryant Nguyen, MD, MS
2. IMPROVING THE UNIFORMITY OF CARE WITH THE STOP SEPSIS BUNDLE - Critical Care Medicine: Volume 32(12) Supplement December 2004 p A11
Sunday, October 23, 2005
Sunday October 23, 2005
Visiting Basics - age adjustment for A-a Gradient
As we are encountering more and more geriatric population with pulmonary symptoms, it is advisible to remind house staff to first adjust normal A-a Gradient value per age before jumping to calculate PAO2. Normal Gradient of 80 years old patient may not be consider acceptable for 20 years old.
Two quick formulae for age adjustment are:
1. Normal A-a Gradient = Age/4 + 4
(For 80 years old is 24 but for 20 years old is 9)
2. Normal A-a gradient = (Age+10) / 4
(For 80 years old is 22.5 but for 20 years old is 7.5)
Visiting Basics - age adjustment for A-a Gradient
As we are encountering more and more geriatric population with pulmonary symptoms, it is advisible to remind house staff to first adjust normal A-a Gradient value per age before jumping to calculate PAO2. Normal Gradient of 80 years old patient may not be consider acceptable for 20 years old.
Two quick formulae for age adjustment are:
1. Normal A-a Gradient = Age/4 + 4
(For 80 years old is 24 but for 20 years old is 9)
2. Normal A-a gradient = (Age+10) / 4
(For 80 years old is 22.5 but for 20 years old is 7.5)
(A-a Gradient = Alveolar-arterial Gradient)
See Nice Review on A-a Gradient - Dr. Lawrence Martin.
Saturday, October 22, 2005
Saturday October 22, 2005
Hypothermic Shivering
As induction of hypothermia is gaining more ground in our ICUs for acute stroke patients - associated shivering remains a major issue. One trick of the trade is to add oral Buspirone (15-60 mg in 2-3 divided doses) with traditional IV Meperidine. The combination of buspirone and meperidine has been found to act synergistically to reduce the shivering (and dose of meperidine) while causing little sedation or respiratory toxicity.
(Re-warming should be slow and controlled to avoid complications. For rewarming tips see related MGH's Hypothermia Protocol after Cardiac Arrest in our protocol section).
References: Click to get abstract
1. Buspirone and Meperidine Synergistically Reduce the Shivering Threshold - Anesth Analg 2001;93:1233-1239
2. Controlled trials of hypothermia in stroke - strokecenter.org
Hypothermic Shivering
As induction of hypothermia is gaining more ground in our ICUs for acute stroke patients - associated shivering remains a major issue. One trick of the trade is to add oral Buspirone (15-60 mg in 2-3 divided doses) with traditional IV Meperidine. The combination of buspirone and meperidine has been found to act synergistically to reduce the shivering (and dose of meperidine) while causing little sedation or respiratory toxicity.
(Re-warming should be slow and controlled to avoid complications. For rewarming tips see related MGH's Hypothermia Protocol after Cardiac Arrest in our protocol section).
References: Click to get abstract
1. Buspirone and Meperidine Synergistically Reduce the Shivering Threshold - Anesth Analg 2001;93:1233-1239
2. Controlled trials of hypothermia in stroke - strokecenter.org
Friday, October 21, 2005
Friday October 21, 2005
Call for dialysis in Lithium overdose
Call for Hemodialysis in Lithium toxicity is "clinical" depending on symptoms particularly neurological symptoms such as myoclonus, seizure, confusion or coma. There is no laboratory cutoff value as patient with chronic exposure to lithium may show clinical signs at much lower value. Also some recent data favors CVVHD (or HD followed by CVVHD) as it showed to prevent rebound of lithium serum concentration.
See complete Toxicology manual.
References: click on link to get article:
1. To dialyse or not to dialyse… - pwr point presentation - S. Gosselin, MD
2. HD followed by continuous hemofiltration..: Am J Kidney Dis. 2001 May;37(5):1044-7
Call for dialysis in Lithium overdose
Call for Hemodialysis in Lithium toxicity is "clinical" depending on symptoms particularly neurological symptoms such as myoclonus, seizure, confusion or coma. There is no laboratory cutoff value as patient with chronic exposure to lithium may show clinical signs at much lower value. Also some recent data favors CVVHD (or HD followed by CVVHD) as it showed to prevent rebound of lithium serum concentration.
See complete Toxicology manual.
References: click on link to get article:
1. To dialyse or not to dialyse… - pwr point presentation - S. Gosselin, MD
2. HD followed by continuous hemofiltration..: Am J Kidney Dis. 2001 May;37(5):1044-7
Thursday, October 20, 2005
Thursday October 20, 2005
Free cotisol - not 'ripe' yet !
April 15, 2004 NEJM article advocates using "free" cortisol level before initiating steroid therapy in critically ill patients but "free" cortisol is not part of the game yet ! Evidence (and guidelines) is still in favor of use of low dose steroid (+/- florinef) in septic shock. We need to wait for the result of substudy of CORTICUS trial (steroid therapy of septic shock) which will compare total and free cortisol levels in septic shock patients.
References: click on link to get article:
1. Serum Free Cortisol in Critically Ill Patients - NEJM
2. CORTICUS TRIAL - clinicaltrials.gov
3. Free cortisol levels should not be used to determine adrenal responsiveness - ccforum.com
Free cotisol - not 'ripe' yet !
April 15, 2004 NEJM article advocates using "free" cortisol level before initiating steroid therapy in critically ill patients but "free" cortisol is not part of the game yet ! Evidence (and guidelines) is still in favor of use of low dose steroid (+/- florinef) in septic shock. We need to wait for the result of substudy of CORTICUS trial (steroid therapy of septic shock) which will compare total and free cortisol levels in septic shock patients.
References: click on link to get article:
1. Serum Free Cortisol in Critically Ill Patients - NEJM
2. CORTICUS TRIAL - clinicaltrials.gov
3. Free cortisol levels should not be used to determine adrenal responsiveness - ccforum.com
Tuesday, October 18, 2005
Wednesday October 19, 2005
Hypocalcemia in massive transfusion
Ideally you should not "reflexly" replace low calcium after massive transfusion as hypocalcemia is usually transient (citrate get metabolize through liver very quickly). Replacement required only if there are clinical signs of hypocalcemia particularly prolong QT interval. It is advisible to follow "ionized calcium" if replacement desired. Another electrolyte to keep eye on is Magnesium as citrate has an equal binding affinity for ionized magnesium.
See manual Massive transfusion in our "M" search at www.icuroom.net
References: click on link to get article:
1. Transfusion for Massive Blood Loss - Trauma.org
2. Management of prolonged QT interval during a massive transfusion: calcium, magnesium or both? - Canadian Journal of Anesthesia 47:792-795 (2000)
Hypocalcemia in massive transfusion
Ideally you should not "reflexly" replace low calcium after massive transfusion as hypocalcemia is usually transient (citrate get metabolize through liver very quickly). Replacement required only if there are clinical signs of hypocalcemia particularly prolong QT interval. It is advisible to follow "ionized calcium" if replacement desired. Another electrolyte to keep eye on is Magnesium as citrate has an equal binding affinity for ionized magnesium.
See manual Massive transfusion in our "M" search at www.icuroom.net
References: click on link to get article:
1. Transfusion for Massive Blood Loss - Trauma.org
2. Management of prolonged QT interval during a massive transfusion: calcium, magnesium or both? - Canadian Journal of Anesthesia 47:792-795 (2000)
Novo-seven
Tuesday October 18, 2005
Off label use of Novoseven and cost concern
A growing literature suggests that there may be indications for the off label use of NovoSeven (rFVIIa) like critical coagulopathy; intracerebral hemorrhage; severe liver disease; to achieve hemostasis in acute variceal bleed; high-risk surgeries; blood loss from trauma; platelet disorders etc.
It is important to develop official policy / protocol due to high cost. Cost of single 4.8 mg vial (4800 ug) is about 4-5,000 US dollars. Usual dose is about 90 ug/kg (every 2 hours till hemostasis achieved) !! - Go figure out !!
Click to view FDA Warning letter re. NovoSeven
References: click on link to get article:
1. Off-Label Use of rFVIIa - P & T Community
2. NovoSeven for Traumatic Coagulopathy - Dr. Karim Brohi at trauma.org
3. Novoseven for Acute Intracerebral Hemorrhage - NEJM
4. Efficacy of Novoseven in cirrhotic patients with upper gastrointestinal bleeding: A randomised double-blind trial. J Hepatol. 2003;38 (Suppl 2):13
Off label use of Novoseven and cost concern
A growing literature suggests that there may be indications for the off label use of NovoSeven (rFVIIa) like critical coagulopathy; intracerebral hemorrhage; severe liver disease; to achieve hemostasis in acute variceal bleed; high-risk surgeries; blood loss from trauma; platelet disorders etc.
It is important to develop official policy / protocol due to high cost. Cost of single 4.8 mg vial (4800 ug) is about 4-5,000 US dollars. Usual dose is about 90 ug/kg (every 2 hours till hemostasis achieved) !! - Go figure out !!
Click to view FDA Warning letter re. NovoSeven
References: click on link to get article:
1. Off-Label Use of rFVIIa - P & T Community
2. NovoSeven for Traumatic Coagulopathy - Dr. Karim Brohi at trauma.org
3. Novoseven for Acute Intracerebral Hemorrhage - NEJM
4. Efficacy of Novoseven in cirrhotic patients with upper gastrointestinal bleeding: A randomised double-blind trial. J Hepatol. 2003;38 (Suppl 2):13
Sunday, October 16, 2005
DIC score
Monday October 17, 2005
DIC Scoring
The Subcommittee on DIC of the International Society on Thrombosis and Haemostasis (ISTH) has developed a scoring card for disseminated intravascular coagulation (DIC) - each for "overt" and "non-overt" DIC. Following is the scoring for "overt" DIC.
1. platelet count (more than 100 = 0; less than 100 = 1; less than 50 = 2)
2. elevated fibrin degradation products (no increase = 0; moderate increase= 2; strong increase= 3)
3. PT upper limit of ref. range ( less than 3 secs = 0; more than 3 secs = 1; more than 6 sec. = 2)
4. fibrinogen level ( more than 100 mg/dl = 0; less than 100 mg/dl = 1)
Score of 5: compatible with overt DIC
References: click on link to get article:
Towards Definition, Clinical and Laboratory Criteria, and scoring system for DIC - ISTH
DIC Scoring
The Subcommittee on DIC of the International Society on Thrombosis and Haemostasis (ISTH) has developed a scoring card for disseminated intravascular coagulation (DIC) - each for "overt" and "non-overt" DIC. Following is the scoring for "overt" DIC.
1. platelet count (more than 100 = 0; less than 100 = 1; less than 50 = 2)
2. elevated fibrin degradation products (no increase = 0; moderate increase= 2; strong increase= 3)
3. PT upper limit of ref. range ( less than 3 secs = 0; more than 3 secs = 1; more than 6 sec. = 2)
4. fibrinogen level ( more than 100 mg/dl = 0; less than 100 mg/dl = 1)
Score of 5: compatible with overt DIC
References: click on link to get article:
Towards Definition, Clinical and Laboratory Criteria, and scoring system for DIC - ISTH
Saturday, October 15, 2005
Sunday October 16, 2005
Proton Pump Inhibitors (PPIs) and C.diff.
It is interesting to note few recent reports showing that: "Patients in hospital who received proton pump inhibitors may be at increased risk of C. difficile diarrhea".
References: get full text by clicking link
1. Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors - CMAJ • July 6, 2004; 171 (1).
Proton Pump Inhibitors (PPIs) and C.diff.
It is interesting to note few recent reports showing that: "Patients in hospital who received proton pump inhibitors may be at increased risk of C. difficile diarrhea".
References: get full text by clicking link
1. Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors - CMAJ • July 6, 2004; 171 (1).
Friday, October 14, 2005
qaegr
Saturday October 15, 2005
Quinolones and errant glycemic reaction.
Contributed by: Drs. Badar and Tuazon: Pulmonary, Critical Care and Sleep medicine services, MH Southwest Hospital, Houston, TX
As use of quinolones is on rise in our ICUs, this is important to know a reported adverse reaction associated with Gatifloxacin (Tequin) - hypoglycemia and in some cases as 'resistant hypoglycemia'. Patients with history of diabetes and with concomitant use of hypoglycemic agents seems more prone to hypoglycemia. The exact mechanism of hypoglycemia is unknown, but increase in serum insulin level after quinolone administration is suspected. Some cases of hyperglycemia reported too. We also found atleast one case report of fatal hypoglycemia associated with levofloxacin (levaquin). 4
Interesting Site: Fluoroquinolone Toxicity Research Foundation
References:
1. Canadian Adverse Reaction Newsletter - Volume 13, Number 3, July 2003
2. Gatifloxacin as a Possible Cause of Serious Postoperative Hypoglycemia - Anesth Analg.2005; 101: 635-636.
3. Severe Hyperglycemia During Renally Adjusted Gatifloxacin Therapy - Ann. Pharmacother., July 1, 2005; 39(7): 1349 - 1352.
4. Fatal hypoglycemia associated with levofloxacin. Pharmacoepidemiol Drug Saf. 2005 Jan;14(1):31-40.
Quinolones and errant glycemic reaction.
Contributed by: Drs. Badar and Tuazon: Pulmonary, Critical Care and Sleep medicine services, MH Southwest Hospital, Houston, TX
As use of quinolones is on rise in our ICUs, this is important to know a reported adverse reaction associated with Gatifloxacin (Tequin) - hypoglycemia and in some cases as 'resistant hypoglycemia'. Patients with history of diabetes and with concomitant use of hypoglycemic agents seems more prone to hypoglycemia. The exact mechanism of hypoglycemia is unknown, but increase in serum insulin level after quinolone administration is suspected. Some cases of hyperglycemia reported too. We also found atleast one case report of fatal hypoglycemia associated with levofloxacin (levaquin). 4
Interesting Site: Fluoroquinolone Toxicity Research Foundation
References:
1. Canadian Adverse Reaction Newsletter - Volume 13, Number 3, July 2003
2. Gatifloxacin as a Possible Cause of Serious Postoperative Hypoglycemia - Anesth Analg.2005; 101: 635-636.
3. Severe Hyperglycemia During Renally Adjusted Gatifloxacin Therapy - Ann. Pharmacother., July 1, 2005; 39(7): 1349 - 1352.
4. Fatal hypoglycemia associated with levofloxacin. Pharmacoepidemiol Drug Saf. 2005 Jan;14(1):31-40.
roundingupardsnettrials
Friday October 14, 2005
Rounding up ARDSNET TRIALS
1. ARMA study: In patients with ALI / ARDS, lower TV (6 ml/kg of ideal body weight) results in decreased mortality and increases days without ventilator.1
2. ALVEOLI Study: In patients with ALI / ARDS, clinical outcomes are same whether lower or higher PEEP levels are used (with low TV and limited PlPr). 2
3. KARMA Study: In patients with ALI / ARDS, ketoconazole did not reduce mortality or duration of mechanical ventilation or improve lung function. 3
4. LARMA Study: lisofylline had no beneficial effects in ALI / ARDS. 4
5. LATE STERIOD RESCUE STUDY (LaSRS): The Efficacy of steroids as Rescue Therapy for the Late Phase of ARDS - Publication pending.
6. FACTT Study - 2 parts : - Ongoing Trial
1) Swan(PAC) vs Central Venous Catheter for Management of ALI / ARDS.
2) "Fluid Conservative" vs "Fluid Liberal" Management of ALI / ARDS) 5
References:
1. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome - N Engl J Med. 2000;342:1301-1308
2. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome - N Engl J Med 2004;351:327-336
3. Ketoconazole for Early Treatment of Acute Lung Injury and Acute Respiratory Distress Syndrome - JAMA, 2000;283:1995-2002
4. Randomized, placebo-controlled trial of lisofylline for early treatment of acute lung injury and ARDS - Crit Care Med. 2002; 30(1):1-6
5. Protocol details - FACTT Trial - ARDSnet
Rounding up ARDSNET TRIALS
1. ARMA study: In patients with ALI / ARDS, lower TV (6 ml/kg of ideal body weight) results in decreased mortality and increases days without ventilator.1
2. ALVEOLI Study: In patients with ALI / ARDS, clinical outcomes are same whether lower or higher PEEP levels are used (with low TV and limited PlPr). 2
3. KARMA Study: In patients with ALI / ARDS, ketoconazole did not reduce mortality or duration of mechanical ventilation or improve lung function. 3
4. LARMA Study: lisofylline had no beneficial effects in ALI / ARDS. 4
5. LATE STERIOD RESCUE STUDY (LaSRS): The Efficacy of steroids as Rescue Therapy for the Late Phase of ARDS - Publication pending.
6. FACTT Study - 2 parts : - Ongoing Trial
1) Swan(PAC) vs Central Venous Catheter for Management of ALI / ARDS.
2) "Fluid Conservative" vs "Fluid Liberal" Management of ALI / ARDS) 5
References:
1. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome - N Engl J Med. 2000;342:1301-1308
2. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome - N Engl J Med 2004;351:327-336
3. Ketoconazole for Early Treatment of Acute Lung Injury and Acute Respiratory Distress Syndrome - JAMA, 2000;283:1995-2002
4. Randomized, placebo-controlled trial of lisofylline for early treatment of acute lung injury and ARDS - Crit Care Med. 2002; 30(1):1-6
5. Protocol details - FACTT Trial - ARDSnet
Thursday, October 13, 2005
sucralfateandhypophosphatemia
Thursday October 13, 2005
Sucralfate and Hypophosphatemia
If you decide (and very well rightly) to choose sucralfate as your choice of stress ulcer prophylaxis - just make sure you keep eye on phosphate level as it tends to cause hypophosphatemia. (But in no way it should stop you from using it). Many drugs if deliver via enteral route may see decrease bioavailability with sucralfate as Warfarin, Dilantin, Cipro., Digoxin etc. So as a precaution administer sucralfate about 2 hours before enteral admininstration of medicines.
Sucralfate and Hypophosphatemia
If you decide (and very well rightly) to choose sucralfate as your choice of stress ulcer prophylaxis - just make sure you keep eye on phosphate level as it tends to cause hypophosphatemia. (But in no way it should stop you from using it). Many drugs if deliver via enteral route may see decrease bioavailability with sucralfate as Warfarin, Dilantin, Cipro., Digoxin etc. So as a precaution administer sucralfate about 2 hours before enteral admininstration of medicines.
Wednesday, October 12, 2005
argatrobanandinr
Wednesday October 12, 2005
Argatroban and INR
Please note that you do not follow regular INR level to monitor Coumadin while overlapping with Argtroban. You may have to perform Special Coagulation Study - Chromogenic Xa level. General recommendation is to overlap argatroban and coumadin for no less than 5 days after starting coumadin at 5 mg/day and on day 3-4, obtain a Chromogenic Xa level.
Chromogenic Xa level of 40% corresponds to an INR of 2
Chromogenic Xa level of 20% corresponds to an INR of 3
Chromogenic Xa should be therapeutic for 24 hours before discontinuing argatroban.
And if above study is not available in your lab, general rule of thumb is to have INR atleast above 4.
Recommended Readings: Click on link to go to reference.
1. Argatroban - Massachusetts General Hospital
2. The International Normalized Ratio during Concurrent Warfarin and Argatroban Anticoagulation -Clinical Chemistry. 1999;45:409-412
Argatroban and INR
Please note that you do not follow regular INR level to monitor Coumadin while overlapping with Argtroban. You may have to perform Special Coagulation Study - Chromogenic Xa level. General recommendation is to overlap argatroban and coumadin for no less than 5 days after starting coumadin at 5 mg/day and on day 3-4, obtain a Chromogenic Xa level.
Chromogenic Xa level of 40% corresponds to an INR of 2
Chromogenic Xa level of 20% corresponds to an INR of 3
Chromogenic Xa should be therapeutic for 24 hours before discontinuing argatroban.
And if above study is not available in your lab, general rule of thumb is to have INR atleast above 4.
Recommended Readings: Click on link to go to reference.
1. Argatroban - Massachusetts General Hospital
2. The International Normalized Ratio during Concurrent Warfarin and Argatroban Anticoagulation -Clinical Chemistry. 1999;45:409-412
Tuesday, October 11, 2005
vaphapandhcap
Tuesday October 11, 2005
VAP, HAP and HCAP
Beside VAP (Ventilator-associated Pneumonia) - it is important to know 2 other terms HAP (Hospital-acquired Pneumonia) and HCAP (Healthcare-associated Pneumonia) as it may influence choice of antibiotics in early management as risk factors for MDR pathogens may be high.
HAP is pneumonia either 1) early onset that occurs within 4 days (Anbx sensitive) or 2) late onset that occurs after 4 days of hospitalization (risk for MDR pathogens).
HCAP is pneumonia that occurs 1) hospitalization for 2 days or more in the preceding 90 days or 2) residence in Nursing home or any extended care facility or 3) Home infusion therapy or 4) long term dialysis within 30 days or 5) Home wound care or 6) Family member with MDR pathogen or 7) Antibiotics in last 90 days or 8) immunosuppressive disease / therapy.
Reference.
Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia: Am. J. Respir. Crit. Care Med. 2005; 171: 388-416
VAP, HAP and HCAP
Beside VAP (Ventilator-associated Pneumonia) - it is important to know 2 other terms HAP (Hospital-acquired Pneumonia) and HCAP (Healthcare-associated Pneumonia) as it may influence choice of antibiotics in early management as risk factors for MDR pathogens may be high.
HAP is pneumonia either 1) early onset that occurs within 4 days (Anbx sensitive) or 2) late onset that occurs after 4 days of hospitalization (risk for MDR pathogens).
HCAP is pneumonia that occurs 1) hospitalization for 2 days or more in the preceding 90 days or 2) residence in Nursing home or any extended care facility or 3) Home infusion therapy or 4) long term dialysis within 30 days or 5) Home wound care or 6) Family member with MDR pathogen or 7) Antibiotics in last 90 days or 8) immunosuppressive disease / therapy.
Reference.
Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia: Am. J. Respir. Crit. Care Med. 2005; 171: 388-416
Monday, October 10, 2005
intensiviststaffedhospitalsimproveoutcome
Monday October 10, 2005
Intensivist staffed hospitals improve outcome
Studies after studies have proved that intensivist driven ICUs improve outcome in hospitals.
Picture contributed by:
Jeff Scott
Director of Intensive Care
SWFRMC, Fort Myers, Florida
Recommended reading: Click on link to go to reference.
1. "Closed" ICUs and Other Models of Care for Critically Ill Patients - Agency for Healthcare Research and Quality.
2. Implement an Intensivist Model in the Intensive Care Unit (ICU) - IHI
3. Captaining the Ship During a Storm - Chest
Saturday, October 08, 2005
mf95icus
aSunday October 9, 2005
M-F 9-5 ICUs ?
contributed by: Wanda Lewis - Critical Care Nurse at Memorial Hermann Healthcare System, Houston - Texas
4 years ago one of the largest study in history looking into 3.8 millions lives over 10 years done in Toronto, Canada - clearly showed that: "...the relative increase in mortality associated with weekend admission appeared to be greatest for the conditions that were especially lethal". (PE was in top 3). Isn't many many ICUs in our country are in reality still functioning as M-F 9-5 ?
Recommended reading: Click on link to go to reference.
1. Mortality among Patients Admitted to Hospitals on Weekends - NEJM 08/30/2001
M-F 9-5 ICUs ?
contributed by: Wanda Lewis - Critical Care Nurse at Memorial Hermann Healthcare System, Houston - Texas
4 years ago one of the largest study in history looking into 3.8 millions lives over 10 years done in Toronto, Canada - clearly showed that: "...the relative increase in mortality associated with weekend admission appeared to be greatest for the conditions that were especially lethal". (PE was in top 3). Isn't many many ICUs in our country are in reality still functioning as M-F 9-5 ?
Recommended reading: Click on link to go to reference.
1. Mortality among Patients Admitted to Hospitals on Weekends - NEJM 08/30/2001
preventingcontrastinducednephropathy
Saturday October 8, 2005
Preventing contrast-Induced Nephropathy
Except for IV hydration so far no strategy has proved of clear cut benefit in preventing Radiocontrast-Induced Nephropathy including famous Mucomyst (N-Acetylcysteine). But it is interesting to know that a recent randomized controlled trial has shown that: "Hydration with sodium bicarbonate before contrast exposure is more effective than only hydration with saline in prophylaxis of contrast-induced renal failure"1.
All patients undergoing contrasted studies should be volume replete with saline 1 mL/kg/h for at least 12 hours before and after the procedure - warranting clinical judgment.
Recommended reading: Click on link to go to reference.
1. Prevention of Contrast-Induced Nephropathy With Sodium Bicarbonate - JAMA 2004;292:1428-1428. (full text available with free reg.)
2. N-Acetylcysteine and Radiocontrast-Induced Nephropathy - Jeff S. Rose, MD
Preventing contrast-Induced Nephropathy
Except for IV hydration so far no strategy has proved of clear cut benefit in preventing Radiocontrast-Induced Nephropathy including famous Mucomyst (N-Acetylcysteine). But it is interesting to know that a recent randomized controlled trial has shown that: "Hydration with sodium bicarbonate before contrast exposure is more effective than only hydration with saline in prophylaxis of contrast-induced renal failure"1.
All patients undergoing contrasted studies should be volume replete with saline 1 mL/kg/h for at least 12 hours before and after the procedure - warranting clinical judgment.
Recommended reading: Click on link to go to reference.
1. Prevention of Contrast-Induced Nephropathy With Sodium Bicarbonate - JAMA 2004;292:1428-1428. (full text available with free reg.)
2. N-Acetylcysteine and Radiocontrast-Induced Nephropathy - Jeff S. Rose, MD
Thursday, October 06, 2005
7pearlsonfeveranddrawingbloodcultures
Friday October 7, 2005
7 pearls on Fever and drawing blood cultures
1. Ideally all ICUs should have "Fever Protocol".
2. All fevers don't require treatment in ICUs as there are atleast 25 non-infectious reasons of fever in ICUs.
3. Generally, experts agree on non-axillary 101 F (38.3 C) level as defining point of Fever.
4. Atleast 2 blood cultures (preferably 10 minutes apart) from different peripheral venipunture sites are required.
5. Atleast 10 (preferably 20) ml of blood should be collected per bottle as sensitivity is highly related to blood volume.
6. Central catheters to collect culture should be use only if venipuntures are difficult and if use, most recently placed catheter should be utilize.
7. Use of hypothermia blankets should be discouraged and in fact even antipyretics should not be use routinely for symptomatic treatment.
Recommended reading: Click on link to go to reference.
1. Fever in ICU - Chest 2000 2.
PRACTICE PARAMETERS FOR NEW FEVER - SCCM / IDSA 1998
7 pearls on Fever and drawing blood cultures
1. Ideally all ICUs should have "Fever Protocol".
2. All fevers don't require treatment in ICUs as there are atleast 25 non-infectious reasons of fever in ICUs.
3. Generally, experts agree on non-axillary 101 F (38.3 C) level as defining point of Fever.
4. Atleast 2 blood cultures (preferably 10 minutes apart) from different peripheral venipunture sites are required.
5. Atleast 10 (preferably 20) ml of blood should be collected per bottle as sensitivity is highly related to blood volume.
6. Central catheters to collect culture should be use only if venipuntures are difficult and if use, most recently placed catheter should be utilize.
7. Use of hypothermia blankets should be discouraged and in fact even antipyretics should not be use routinely for symptomatic treatment.
Recommended reading: Click on link to go to reference.
1. Fever in ICU - Chest 2000 2.
PRACTICE PARAMETERS FOR NEW FEVER - SCCM / IDSA 1998
Wednesday, October 05, 2005
vapbundle
Thursday October 6, 2005
VAP bundle
Experts have included many maneuvers to decrease Vantilator-associated pneumonia including continuous subglottic secretion removal, OG tubes instead of NG tubes, use of oral hygiene with chlorhexidine gluconate and selective digestive tract decontamination but IHI recommends atleast following 4 key components in daily goal checklist.
1. Elevation of the Head of the Bed
2. Daily "Sedation Vacations"
3. Peptic Ulcer Disease Prophylaxis
4. Deep Venous Thrombosis Prophylaxis
Recommended Readings: Click on links to go to reference
1. VAP bundle - IHI
2. Seven strategies to prevent VAP - Hospitalist Today 05/2005
VAP bundle
Experts have included many maneuvers to decrease Vantilator-associated pneumonia including continuous subglottic secretion removal, OG tubes instead of NG tubes, use of oral hygiene with chlorhexidine gluconate and selective digestive tract decontamination but IHI recommends atleast following 4 key components in daily goal checklist.
1. Elevation of the Head of the Bed
2. Daily "Sedation Vacations"
3. Peptic Ulcer Disease Prophylaxis
4. Deep Venous Thrombosis Prophylaxis
Recommended Readings: Click on links to go to reference
1. VAP bundle - IHI
2. Seven strategies to prevent VAP - Hospitalist Today 05/2005
candidiasischangingspectrumofspecies
Tuesday October 5, 2005
Candidiasis - changing spectrum of species
Prophylactic coverage with Diflucan (fluconazole) is still very valid for fungal infections but note that spectrum of candidal infection is progressively showing change from albicans to non-albicans (C. Krusei and C. glabrata) species. It reminds us that Amphotericin B (though we call it Amphoterrible) is still a major player. Also, availability of Caspofungin (Cancidas) is a big relief with better side effect profile.
Recommended Readings: Click on links to go to reference
1. Increase in prevalence of nosocomial non-Candida albicans candidaemia and the association of Candida krusei with fluconazole use. J Hosp Infect. 2002 Jan;50(1):56-65
2. The changing face of nosocomial candidemia: epidemiology, resistance, and drug therapy. - Am J Health Syst Pharm. 1999 Mar 15;56(6):525-33
3. Comparison of Caspofungin and Amphotericin B for Invasive Candidiasis - NEJM - 12/2002
4. Caspofungin versus Liposomal Amphotericin B for Empirical Antifungal Therapy in Patients with Persistent Fever and Neutropenia - NEJM 09/2004
Candidiasis - changing spectrum of species
Prophylactic coverage with Diflucan (fluconazole) is still very valid for fungal infections but note that spectrum of candidal infection is progressively showing change from albicans to non-albicans (C. Krusei and C. glabrata) species. It reminds us that Amphotericin B (though we call it Amphoterrible) is still a major player. Also, availability of Caspofungin (Cancidas) is a big relief with better side effect profile.
Recommended Readings: Click on links to go to reference
1. Increase in prevalence of nosocomial non-Candida albicans candidaemia and the association of Candida krusei with fluconazole use. J Hosp Infect. 2002 Jan;50(1):56-65
2. The changing face of nosocomial candidemia: epidemiology, resistance, and drug therapy. - Am J Health Syst Pharm. 1999 Mar 15;56(6):525-33
3. Comparison of Caspofungin and Amphotericin B for Invasive Candidiasis - NEJM - 12/2002
4. Caspofungin versus Liposomal Amphotericin B for Empirical Antifungal Therapy in Patients with Persistent Fever and Neutropenia - NEJM 09/2004
Tuesday, October 04, 2005
flushingoflines
Tuesday October 4, 2005
Flushing of lines
As we are diagnosing more and more HIT (Heaprin induced Thrombocytopenia) in our ICUs - it is important to know:
1. Saline flush is as effective as heparin flush for venous catheters.
2. Heparin flush is still preferable for A-lines but if contra-indicated or concern of HIT - 1.4% Na-citrate solution is an effective alternative.
Recommended Readings:
http://bmj.bmjjournals.com/cgi/content/full/316/7136/969 - BMJ
http://www.chestjournal.org/cgi/content/abstract/103/3/882 - Chest
Flushing of lines
As we are diagnosing more and more HIT (Heaprin induced Thrombocytopenia) in our ICUs - it is important to know:
1. Saline flush is as effective as heparin flush for venous catheters.
2. Heparin flush is still preferable for A-lines but if contra-indicated or concern of HIT - 1.4% Na-citrate solution is an effective alternative.
Recommended Readings:
http://bmj.bmjjournals.com/cgi/content/full/316/7136/969 - BMJ
http://www.chestjournal.org/cgi/content/abstract/103/3/882 - Chest
Monday, October 03, 2005
calciumchannelblokadeoverdoseandglucagon
Monday October 3, 2005
Calcium channel blokade overdose and Glucagon
Glucagon is a very viable option in Calcium channel blokade (Cardizem, Verapamil, adalat etc) overdose treatment. But if it is consider in management plan - its advisible to administer before Calcium infusion as erratic blood calcium level may mask full effect of glucagon.
Recommended Readings:
Toxicity, Calcium Channel Blocker - Dr. B.Z. Horowitz - - posted on emedicine.com
Calcium channel blokade overdose and Glucagon
Glucagon is a very viable option in Calcium channel blokade (Cardizem, Verapamil, adalat etc) overdose treatment. But if it is consider in management plan - its advisible to administer before Calcium infusion as erratic blood calcium level may mask full effect of glucagon.
Recommended Readings:
Toxicity, Calcium Channel Blocker - Dr. B.Z. Horowitz - - posted on emedicine.com
Sunday, October 02, 2005
centralcathetersointmentandcare
Sunday October 2, 2005
Central catheters, ointment and care
As against common belief, application of ointment at catheter insertion site does not decrease the infection rate. Actually application of antibiotic ointments (e.g., bacitracin) to catheter-insertion sites increases the rate of catheter colonization by fungi and promotes the emergence of antibiotic-resistant bacteria. Also, after insertion of central venous catheter - simple dressing with gauze and tape is enough (change on average 24-48 hours). Occlusive dressings may increase colonizations at site. Water impermeable dressings like Tegaderm or Duoderm may infact increase chances of catheter related septicemia.
Recommended Readings:
1. Preventing Complications of Central Venous Catheterization, David C. McGee, M.D.,, NEJM, March 03, Volume 348:1123-1133.
2. Marshall DA and coll. Occlusive dressings, Arch Surg 1990;125:1136-1139.
3. Hoffman and coll. Meta-analysis on dressings, JAMA 1992; 267:2072-2076.
Central catheters, ointment and care
As against common belief, application of ointment at catheter insertion site does not decrease the infection rate. Actually application of antibiotic ointments (e.g., bacitracin) to catheter-insertion sites increases the rate of catheter colonization by fungi and promotes the emergence of antibiotic-resistant bacteria. Also, after insertion of central venous catheter - simple dressing with gauze and tape is enough (change on average 24-48 hours). Occlusive dressings may increase colonizations at site. Water impermeable dressings like Tegaderm or Duoderm may infact increase chances of catheter related septicemia.
Recommended Readings:
1. Preventing Complications of Central Venous Catheterization, David C. McGee, M.D.,, NEJM, March 03, Volume 348:1123-1133.
2. Marshall DA and coll. Occlusive dressings, Arch Surg 1990;125:1136-1139.
3. Hoffman and coll. Meta-analysis on dressings, JAMA 1992; 267:2072-2076.
Saturday, October 01, 2005
deficienciesofscoringsystem
Saturday, 1 October 2005
Deficiencies of Scoring system?
Interestingly neither blood glucose nor lactic acid level is part of any famous ICU scoring system including SOFA, SAPS or APACHE II - which have independently shown direct proportionality with mortality in recent literature and are part of latest guidelines.
(Find complete adult and pediatrics medical, surgical and trauma Scoring guide here - courtesy of Society Francaise d’Anesthesie et de Reanimation)
Deficiencies of Scoring system?
Interestingly neither blood glucose nor lactic acid level is part of any famous ICU scoring system including SOFA, SAPS or APACHE II - which have independently shown direct proportionality with mortality in recent literature and are part of latest guidelines.
(Find complete adult and pediatrics medical, surgical and trauma Scoring guide here - courtesy of Society Francaise d’Anesthesie et de Reanimation)
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