No abstract

Background The optimal target range for blood glucose in critically ill patients remains unclear. Methods Within 24 hours after admission to an intensive care unit(ICU), adults who were expected to require treatment in the ICU on 3 or more consecutive days were randomly assigned to undergo either intensive glucose control, with a target blood glucose range of 81 to 108 mg per deciliter(4.5 to 6.0 mmol per liter), or conventional glucose control, with a target of 180 mg or less per deciliter(10.0 mmol or less per liter). We defined the primary end point as death from any cause within 90 days after randomization. Results Of the 6104 patients who underwent randomization, 3054 were assigned to undergo intensive control and 3050 to undergo conventional control; data with regard to the primary outcome at day 90 were available for 3010 and 3012 patients, respectively. The two groups had similar characteristics at baseline. A total of 829 patients(27.5%) in the intensive-control group and 751(24.9%) in the conventional-control group died(odds ratio for intensive control, 1.14; 95% confidence interval, 1.02 to 1.28; P=0.02). The treatment effect did not differ significantly between operative(surgical) patients and nonoperative(medical) patients(odds ratio for death in the intensive-control group, 1.31 and 1.07, respectively; P = 0.10). Severe hypoglycemia(blood glucose level, <40 mg per deciliter>[2.2 mmol per liter]) was reported in 206 of 3016 patients(6.8%) in the intensive-control group and 15 of 3014(0.5%) in the conventional-control group(P<0.001). There was no significant difference between the two treatment groups in the median number of days in the ICU(P = 0.84) or hospital(P = 0.86) or the median number of days of mechanical ventilation(P = 0.56) or renal-replacement therapy(P=0.39). Conclusions In this large, international, randomized trial, we found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg per deciliter.(ClinicalTrials.gov number, NCT00220987.)

This guideline is a joint venture of the Canadian Critical Care Society, the Canadian Critical Trials Group, the Canadian Society for Clinical Nutrition, and Dietitians of Canada. The Canadian Critical Care Society and the Institute of Nutrition, Metabolism, and Diabetes of the Canadian Institutes of Health Research provided funding for development of this guideline.

No abstract

Research O ver the past decade, several initiatives have been established to attempt to improve end-of-life care. 1-3Quality of life for terminally ill patients, 4,5 quality of death and dying 6,7 and quality care at the end of life 8 are related concepts that have been evaluated in these efforts to improve end-of-life care. Quality of care at the end of life is distinguished from quality of life and of death by its focus on the optimization of care and satisfaction with care, clearly linking quality measurement and quality improvement. 6,9Unfortunately, initiatives to improve satisfaction with endof-life care remain hampered by our nascent understanding of what quality care means to patients and their families, and how it is best measured.9-11 Several experts and professional societies have attempted to define the specific components and related areas (domains) involved in quality end-of-life care;12-16 in contrast, patient and family perspectives are surprisingly lacking.Most previous studies of quality have focused on outpatients and people with cancer.17-21 We recently documented that most Canadians (> 70%) die in hospitals, and the majority of decedents are elderly patients who died from causes unrelated to cancer.22,23 The trajectory of a patient dying from cancer differs from one dying from other, chronic, end-stage medical conditions.24 Thus, issues deemed important to quality end-of-life care that were identified by previous investigators may not be generalizable to seriously ill patients with advanced disease other than cancer, who have a more uncertain prognosis.The primary purpose of this study was to describe what seriously ill patients admitted to hospital and their family members consider the key elements of quality end-of-life care. Our secondary objectives included exploring whether differences in ratings of importance exist between patient and caregiver subgroups and between patients and family members. MethodsWe designed a cross-sectional survey to be conducted at 5 tertiary care teaching hospitals across Canada. From west to east, they were St. Paul's Hospital, Vancouver, BC; Royal Alexandra Hospital, Edmonton, Alta.; Toronto General Hospital, Toronto, and Kingston General Hospital, Kingston, Ont.; and Queen Elizabeth II Health Sciences Centre, Halifax, NS.

Most family members were highly satisfied with the care provided to them and their critically ill relative in the intensive care unit. Efforts to improve the nature of interactions and communication with families are likely to lead to improvements in satisfaction.

Early AKI is common in septic shock. Delays to appropriate antimicrobial therapy may contribute to significant increases in the incidence of AKI. Survival was considerably lower for septic shock associated with early AKI, with increasing severity of AKI, and with increasing delays to appropriate antimicrobial therapy.

If effectively implemented, this guideline may decrease the morbidity, mortality, and costs of VAP in mechanically ventilated patients.