Strict glycemic control improves clinical outcomes in critically ill patients. However, practical tools for frequent monitoring of blood glucose (BG) levels in the intensive care unit (ICU) are limited. The Continuous Glucose Monitoring System (CGMS, Medtronic MiniMed, Northridge, CA) is currently approved for detecting glycemic excursions in outpatients with diabetes mellitus. The use of this device has never been carefully examined in the inpatient setting. This preliminary study was designed to investigate the accuracy of the CGMS in critically ill patients admitted to a medical ICU (MICU). Subjects at risk for hyperglycemia were recruited from among all patients admitted to our MICU. CGMS sensors were implanted for up to 72 h. Study subjects wore between one and five consecutive sensors. Four or more standard capillary BG readings were recorded per 24 h. All paired meter-sensor (M-S) readings were used both for CGMS calibration and for data analysis. Twenty-two MICU patients wore 41 CGMS sensors, yielding 546 M-S BG pairs. Overall, the Pearson correlation coefficient ( r ) was 0.88, with a mean M-S difference of 3.3 +/- 26.7 mg/dL (0.6 +/- 17.4%) and a mean absolute M-S difference of 19.7 +/- 18.3 mg/dL (12.8 +/- 11.9%). Clarke Error Grid analysis categorized 98.7% of the M-S pairs within "clinically acceptable" zones A and B. The CGMS is promising for potential use in critically ill patients. If validated in larger studies, the device could serve as a useful research tool for investigating the role of hyperglycemia (and strict glycemic control) in ICU patients. If further developed as a "real-time" glucose sensor, CGMS technology could ultimately prove clinically useful in the ICU, by decreasing nursing workload and/or by providing alarm signals for impending glycemic excursions.

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BackgroundClinicians in intensive care units experience alarm fatigue related to frequent false and non-actionable alarms produced by physiologic monitors. To reduce non-actionable alarms, alarm settings may need to be customized for individual patients; however, nurses may not customize alarms because of competing demands and alarm fatigue.ObjectiveTo examine the effectiveness and acceptance of physiologic monitor software to support customization of alarms.MethodsThis pre/post intervention study was conducted in a 56-bed medical intensive care unit. IntelliVue® Alarm Advisor customization support software for alarm limit violations was installed on all monitors and education on its use provided. For 2 months before and after implementation of the software, data were collected on patient characteristics from the electronic health record, alarm counts and duration from the monitoring system, and nurses’ experience of alarms from a survey.ResultsMedium-priority heart rate, respiratory rate, and arterial pressure alarms were significantly reduced after software implementation (9.3%, 11.8%, and 15.9% reduction respectively; p<0.001 for all). The duration of these alarms was also significantly shorter (7.8%, 13.3%, and 9.3% reduction respectively; p<0.05 for all). The number and duration of SpO2 alarms did not decrease (p>0.05 for both). Patients post-intervention had worse Glasgow Coma Scale scores (p = 0.014), but otherwise were comparable to those pre-intervention. Nurses reported less time spent on non-actionable alarms post-intervention than pre-intervention (p = 0.026). Also lower post-intervention were the proportions of nurses who reported that alarms disturbed their workflow (p = 0.027) and who encountered a situation where an important alarm was ignored (p = 0.043). The majority (>50%) agreed that the software supported setting appropriate alarm limits and was easy to use.ConclusionAlarm customization software was associated with a reduction in alarms. Use of software to support nurses’ recognition of trends in patients’ alarms and facilitate changes to alarm settings may add value to alarm reduction initiatives.

The correlation between the CIWA-Ar and mMINDS tools is strong and appears to be most robust in patients with CIWA-Ar scores of 10 or less.

Mechanical ventilation is a life-sustaining technology used with increasing frequency in the elderly population. Prolonged mechanical ventilation is associated with high morbidity, mortality, and poor functional status. Care of these complex patients requires a coordinated multidisciplinary approach to optimize outcome. To minimize mortality and morbidity and contain health care costs, it is essential to identify patients at high risk for prolonged ventilation and to implement early interventions to curtail functional decline. In this article, the incidence and outcome of prolonged mechanical ventilation is reviewed, along with interventions to promote recovery. In particular, the role of tracheostomy timing and placement is discussed.