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ABSTRACT: Recent data have shown a link between normal blood glucose levels and improved outcomes in intensive care patients. We wished to develop an insulin adjustment protocol for an adult intensive care unit to maintain blood glucose concentrations safely within a narrow range.
After a 6 month introductory period, an observational study was conducted during a 10 month period in an Australian level III intensive care unit to assess the safety and feasibility of an insulin adjustment protocol to maintain blood glucose concentrations safely within a narrow range. The protocol included a variable insulin infusion, a constant caloric source and frequent blood glucose level monitoring to detect and prevent hypoglycaemia.
Over the 10 month period a total of 148 patients were studied using the protocol and represented 13 % of all intensive care unit admissions during this period. In total, there were 12,623 patient hours 'on protocol', with 5,603 blood glucose levels performed. The mean morning blood glucose level was 6.5 mmol/L and 49% of blood glucose levels were within the target range of 4.1 - 7.0 mmol/L. There were four recorded incidents of hypoglycaemia, defined as a blood glucose level of less than 2.2 mmol/L, the lowest at 1.5 mmol/L being the only symptomatic episode. The incidence of hyperglycaemia (blood glucose level > 10 mmol/L) was 13 % of all blood glucose level measurements.
The insulin adjustment protocol with a constant caloric source and frequent blood glucose level monitoring was found to be safe and feasible in maintaining blood glucose concentrations within a narrow range in a mixed adult intensive care unit population.
Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine 06/2004; 6(2):92-8. · 1.67 Impact Factor
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ABSTRACT: Glove contamination at the time a central venous catheter is handled is highly undesirable and likely to increase the risk of subsequent line infection. This study was designed to determine how frequently gloves become contaminated during central venous line insertion and to demonstrate the value of glove decontamination immediately prior to handling of the central venous catheter During twenty routine internal jugular catheter insertions the sterility of the operator's gloved fingertips (just prior to handling the intravenous catheter) was assessed by touching the fingertips onto blood agar plates. The gloved hands were then rinsed in chlorhexidine/alcohol and after drying were placed onto a further plate. Contamination was detected in 55% of the prewash plates but in none of the postwash plates. Procedures performed by less experienced resident staff had a higher contamination rate despite there being no evident breach of sterile technique. It is likely that glove contamination results from the persistance of bacteria within the deeper layers of the skin, despite surface disinfection. These bacteria may be released by manipulation of the skin when identifying landmarks. This hypothesis was supported by a subsequent observation that gloves were more highly contaminated after firm touching of the skin rather than light touching. Glove contamination during central line insertion is frequent. Catheter contamination rates could be reduced (without risk or additional cost) by rinsing gloved hands in a solution of chlorhexidine (0.5%) in alcohol (70%) prior to handling the catheter.
Anaesthesia and intensive care 07/2002; 30(3):338-40. · 1.28 Impact Factor
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ABSTRACT: To review the role of secretory phospholipase A2 in the pathogenesis of multiple organ failure in the critically ill patient.
Relevant articles and published reviews on secretory phospholipase A2 in critical illness.
Secretory phospholipase A2 (sPLA2) has an important role in inflammation and in antimicrobial defence. However, excessive activity of sPLA2 has been shown to result in tissue damage and has been implicated as a mediator of organ failure associated with critical illness. Gastrointestinal release of secretory phospholipase A2 from Paneth cells increases during intestinal ischaemia and may be an important factor in the pathogenesis of the multiple organ dysfunction syndrome. In experimental models, specific PLA2 inhibitors reduce organ failure associated with sPLA infusion and may play an important role in reducing organ failure in the management of the critically ill patient.
Intestinal ischaemia may play an important role in the pathogenesis of the multiple organ dysfunction syndrome in the critically ill patient. In patients with sepsis, specific PLA2 inhibitors have the potential to reduce organ failure and improve morbidity and mortality.
Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine 01/2002; 3(4):244-9. · 1.67 Impact Factor
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C Corke
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ABSTRACT: In this article are salutory and awful stories, all based on true cases. They serve to illustrate how terrible the problems can be when travel insurance is not appropriately secured before a traveller becomes sick, or where the patient assumes the risk himself, without insurance, in the absence of a proper understanding of the consequences.
Australian family physician 12/2001; 30(11):1057-60. · 0.73 Impact Factor
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ABSTRACT: To review the clinical and experimental methods of detecting intestinal ischaemia and to assess their value in current clinical practice.
Relevant articles and published reviews on intestinal ischaemia and/or infarction.
The incidence of acute mesenteric ischaemia has increased substantially over the last few decades. Death rates of 70% to 90% have been reported for this condition. Improved management depends upon prompt diagnosis and early aggressive management. Despite mounting evidence that ischaemic intestinal injury may be frequent and may be a cause of multi-organ failure, accurate monitor-ing of the intestinal circulation in critically ill patients continues to be a distant goal. The need for a reliable, specific test of intestinal ischaemia has been recognised for many years. Numerous potential monitors have been evaluated including intraluminal pCO2, abdominal CT, abdominal MRI and specific plasma enzymes, but few have shown potential to be clinically useful. At present no specific test for intestinal ischaemia and/or infarction is in routine clinical use. Development of a specific test to monitor for intestinal injury would be of great clinical value. Further work will inevitably lead to the development of useful markers.
Accurate detection of intestinal ischaemia in the critically ill patient is often difficult. While numerous tests have been examined to diagnose and monitor intestinal ischaemia and/or infarction most exhibit an unacceptably low specificity and sensitivity.
Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine 10/2001; 3(3):176-80. · 1.67 Impact Factor
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C Corke
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ABSTRACT: To review the pathophysiology of gastroparesis and present a practical approach to the management of this disorder in the critically ill patient.
Articles and published abstracts on the mechanisms and management gastroparesis relevant to the critically ill patient.
The importance of early enteral nutrition in the critically ill patient has been recognised for many years. However, while nasogastric tubes are easy to insert, gastric dysmotility is common, and often hinders the introduction of effective enteral nutrition. Small bowel motility problems are uncommon in the intensive care patient, and direct instillation of nutrients into the jejunum will allow enteral nutrition to begin without delay. However compared with gastric tubes, jejunal tubes are often difficult to insert, often requiring endoscopic or surgical techniques. The cause of gastric dysmotility is multifactorial. Treatment of underlying sepsis, pain, hypotension, dehydration and hyperglycaemia should occur, and opiates and dopamine should be avoided before commencing prokinetic agents. The patient's head should remain elevated, and oral or nasogastric cisapride (10 mg 6-hourly) administered. If this is not effective then erythromycin (e.g. 250 mg i.v. 8-hourly) may be included.
Gastric dysmotility is common in the critically ill patient. However, treatment of the underlying conditions leading to gastroparesis and the introduction of prokinetic agents will allow the majority of patients to be successfully fed enterally.
Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine 04/1999; 1(1):39-44. · 1.67 Impact Factor
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ABSTRACT: Minitracheostomy is a valuable technique in patients with sputum retention. However, insertion of a minitracheostomy tube over a dilator passed through an incision through the cricothyroid membrane (the suggested method of insertion of the 'Mini-trach II', [Portex]), can prove difficult. A Seldinger method is described which results in easier and more reliable placement in difficult cases.
Anaesthesia and intensive care 06/1988; 16(2):206-7. · 1.28 Impact Factor
