OBJECTIVE -In a recent randomized controlled trial, lowering blood glucose levels to 80 -110 mg/dl improved clinical outcomes in critically ill patients. In that study, the insulin infusion protocol (IIP) used to normalize blood glucose levels provided valuable guidelines for adjusting insulin therapy. In our hands, however, ongoing expert supervision was required to effectively manage the insulin infusions. This work describes our early experience with a safe, effective, nurse-implemented IIP that provides detailed insulin dosing instructions and requires minimal physician input.RESEARCH DESIGN AND METHODS -We collected data from 52 medical intensive care unit (MICU) patients who were placed on the IIP. Blood glucose levels were the primary outcome measurement. Relevant clinical variables and insulin requirements were also recorded. MICU nurses were surveyed regarding their experience with the IIP.RESULTS -To date, our IIP has been employed 69 times in 52 patients admitted to an MICU. Using the IIP, the median time to reach target blood glucose levels (100 -139 mg/dl) was 9 h. Once blood glucose levels fell below 140 mg/dl, 52% of 5,808 subsequent hourly blood glucose values fell within our narrow target range; 66% within a "clinically desirable" range of 80 -139 mg/dl; and 93% within a "clinically acceptable" range of 80 -199 mg/dl. Only 20 (0.3%) blood glucose values were Ͻ60 mg/dl, none of which resulted in clinically significant adverse events. In general, the IIP was readily accepted by our MICU nursing staff, most of whom rated the protocol as both clinically effective and easy to use. CONCLUSIONS -Our nurse-implemented IIP is safe and effective in improving glycemic control in critically ill patients. Diabetes Care 27:461-467, 2004I n 2001, a large randomized controlled trial from Leuven, Belgium, demonstrated that normalization of blood glucose levels using an intensive insulin infusion protocol (IIP) improved clinical outcomes in patients admitted to a surgical intensive care unit (ICU) (1). In the Leuven study, intensive insulin therapy (to maintain blood glucose levels between 80 and 110 mg/dl) reduced ICU mortality by 42% and also reduced the incidence of bloodstream infections, the incidence of acute renal failure, the need for prolonged ventilatory support, and the duration of ICU stay. Strict glycemic control appears to be beneficial in other intensive care settings as well. In the DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) study (2,3), an intravenous insulin-glucose infusion (followed by an outpatient multidose subcutaneous insulin regimen) improved long-term prognosis in diabetic patients following acute myocardial infarction. In patients undergoing open heart surgery, the use of a perioperative IIP dramatically reduced the incidence of deep sternal wound infections (4).Based on this emerging clinical evidence, there are increasing efforts worldwide to maintain strict glycemic control in critically ill patients. However, achieving this goal requires exte...

Delirium is a frequent complication in older ICU patients and often persists beyond their ICU stay. Delirium in older ICU persons is a dynamic and complex process. Dementia is an important predisposing risk factor for the development of delirium in this population during and after the ICU stay.

In a cohort of bereaved next of kin of patients who died in the intensive care unit, we identified a high prevalence of psychiatric illness, particularly major depressive disorder. More work is needed to identify those at risk for psychiatric illness so that appropriate interventions may be targeted.

Rationale: Microvascular injury, inflammation, and coagulation play critical roles in the pathogenesis of acute lung injury (ALI). Plasma protein C levels are decreased in patients with acute lung injury and are associated with higher mortality and fewer ventilator-free days. Objectives: To test the efficacy of activated protein C (APC) as a therapy for patients with ALI. Methods: Eligible subjects were critically ill patients who met the American/European consensus criteria for ALI. Patients with severe sepsis and an APACHE II score of 25 or more were excluded. Participants were randomized to receive APC (24 mg/kg/h for 96 h) or placebo in a double-blind fashion within 72 hours of the onset of ALI. The primary endpoint was ventilator-free days. Measurements and Main Results: APC increased plasma protein C levels (P 5 0.002) and decreased pulmonary dead space fraction (P 5 0.02). However, there was no statistically significant difference between patients receiving placebo (n 5 38) or APC (n 5 37) in the number of ventilator-free days (median [25-75% interquartile range]: 19 [0-24] vs. 19 [14-22], respectively; P 5 0.78) or in 60-day mortality (5/38 vs. 5/37 patients, respectively; P 5 1.0). There were no differences in the number of bleeding events between the two groups. Conclusions: APC did not improve outcomes from ALI. The results of this trial do not support a large clinical trial of APC for ALI in the absence of severe sepsis and high disease severity. Clinical trial registered with www.clinicaltrials.gov (NCT 00112164).