Introduction
Materials and methods
Statistics
Results
Patient characteristics
Total population n = 620 | Surgical intensive care unit n = 476 | Medical intensive care unit n = 144 | |||||||
---|---|---|---|---|---|---|---|---|---|
Before IIT n = 168 | After IIT n = 452 | p-value | Before IIT n = 62 | After IIT n = 414 | p-value | Before IIT n = 106 | After IIT n = 38 | p-value | |
Male/female sex, n (%) | 105/168 (62.5) | 305/452 (67.5) | 0.2 | 41/62 (66.1) | 285/414 (68.8) | 0.7 | 64/106 (60.4) | 20/38 (52.6) | 0.4 |
Age, years (mean ± SD) | 61 ± 15 | 62 ± 14 | 0.4 | 64 ± 13 | 63 ± 14 | 0.6 | 60 ± 15 | 61 ± 17 | 0.9 |
ICU type/MICU total n (%) | 106/168 (63.1) | 38/452 (8.4) |
< 0.0001
| ||||||
Diagnostic group, total n (%) of the category |
< 0.0001
| 0.1 | |||||||
Abdominal/gastro- intestinal/liver | 19/71 (26.8) | 52/71 (73.2) | 6/55 (10.9) | 49/55 (89.1) | 13/16 (81.3) | 3/16 (18.7) | |||
Cardiovascular | 24/171 (14.0) | 147/171 (86.0) | 21/167 (12.6) | 146/167 (87.4) | 3/4 (75.0) | 1/4 (25.0) | |||
Cerebral/neurological | 6/60 (10.0) | 54/60 (90.0) | 2/52 (3.8) | 50/52 (96.2) | 4/8 (50.0) | 4/8(50.0) | |||
Haematological/oncol ogy/transplant | 3/31 (9.7) | 28/31 (90.3) | 2/29 (6.9) | 27/29 (93.1) | 1/2 (50.0) | 1/2 (50.0) | |||
Other | 32/73 (43.8) | 41/73 (56.2) | 10/43 (23.3) | 33/43 (76.7) | 22/30 (73.3) | 8/30 (26.7) | |||
Polytrauma | 6/37 (16.2) | 31/37 (83.8) | 6/37 (16.2) | 31/37 (83.8) | 0/0 | 0/0 | |||
Respiratory/thoracic | 61/136 (44.9) | 75/136 (55.1) | 8/64 (12.5) | 56/64 (87.5) | 53/72 (73.6) | 19/72 (26.4) | |||
History of diabetes, total n (%) | 0.2 | 0.9 | 0.07 | ||||||
Insulin treated | 11/151 (7.3) | 26/420 (6.2) | 3/55 (5.5) | 23/384 (6.0) | 8/96(8.3) | 3/36 (8.3) | |||
Oral antidiabetic treatment and/or diet | 16/151 (10.6) | 26/420 (6.2) | 3/55 (5.5) | 26/384 (6.8) | 13/96 (13.5) | 0/36 (0) | |||
Baseline APACHE II, (mean ± SD) | 19.0 ± 8.3 | 16.2 ± 7.1 |
< 0.0001
| 14.6 ± 6.7 | 15.7 ± 6.9 | 0.3 | 21.7 ± 8.1 | 21.5 ± 7.5 | 0.9 |
On admission blood glucose, mg/dl median (IQR) | 157 (126 to 202) | 134 (107 to 172) |
< 0.0001
| 163 (126 to 199) | 135 (109 to 173) |
0.007
| 151 (126 to 202) | 124 (96 to 156) |
0.008
|
On admission mechanical ventilation, total n (%) | 133/140 (95.0) | 402/413 (97.3) | 0.2 | 55/55 (100) | 375/381 (98.4) | 0.3 | 78/85 (91.8) | 27/32 (84.4) | 0.2 |
Total population n = 620 | Surgical ICU n = 476 | Medical ICU n = 144 | |||||||
---|---|---|---|---|---|---|---|---|---|
Before IIT n = 168 | After IIT n = 452 | p- value | Before IIT n = 62 | After IIT n = 414 | p-value | Before IIT n = 106 | After IIT n = 38 | p-value | |
Treatment with noradrenaline | |||||||||
Treated patients, total n (%) | 84/142 (59.2) | 345/399 (86.5) |
< 0.0001
| 37/53 (69.8) | 319/366 (87.2) |
< 0.0001
| 47/89 (52.8) | 26/33 (78.8) |
0.007
|
Number of days treatment, median (IQR) | 2(0 to 9) | 8 (3 to 16) |
< 0.0001
| 6(0 to 15) | 9(4 to 17) |
0.03
| 1(0 to 6) | 9(4 to 17) |
0.03
|
Treatment with aminoglycosides | |||||||||
Treated patients, total n (%) | 45/142 (31.7) | 82/399 (20.6) |
0.007
| 14/53 (26.4) | 76/366 (20.8) | 0.3 | 31/89 (34.8) | 6/33 (18.2) | 0.08 |
Number of days treatment, median (IQR) | 0 (0 to 1) | 0 (0 to 0) | 0.08 | 0 (0 to 1) | 0 (0 to 0) | 0.5 | 0 (0 to 1) | 0 (0 to 0) | 0.2 |
Treatment with glucocorticoids | |||||||||
Treated patients, total n (%) | 93/142 (65.5) | 201/399 (50.4) |
0.002
| 30/53 (56.6) | 177/366 (48.4) | 0.3 | 63/89 (70.8) | 24/33 (72.7) |
0.04
|
Number of days treatment, median (IQR) | 4.5 (0 to 12) | 1 (0 to 11) |
0.02
| 1(0 to 12) | 0(0 to 11) | 0.6 | 6(0 to 12) | 5(0 to 11) | 0.6 |
Cumulative dose hydrocortisone equivalent mg (IQR) | 945 (0 to 4350) | 50 (0 to 2100) |
0.001
| 300 (0 to 3009) | 0 (0 to 1725) | 0.3 | 1125 (0 to 5181) | 833 (0 to 2695) | 0.3 |
Treatment with NMBA | |||||||||
Treated patients prolonged (min 3d bolus or drip) total n (%) | 37/142 (26.1) | 129/399 (32.3) | 0.2 | 15/53 (28.3) | 121/366 (33.1) | 0.5 | 22/89 (24.7) | 8/33 (24.2) | 0.9 |
Number of days treatment at least 1 bolus or drip, median (IQR) | 1 (0 to 3) | 2 (1 to 4) |
0.006
| 2 (0 to 4) | 2 (1 to 4) | 0.6 | 1 (0 to 3) | 1 (0 to 2) | 0.8 |
Dialysis, | |||||||||
Yes | 41/142 (28.9) | 149/399 (37.3) | 0.07 | 18/53 (34.0) | 142/366 (38.8) | 0.5 | 23/89 (25.8) | 7/33 (21.2) | 0.6 |
d, median (IQR) | 0 (0 to 3) | 0 (0 to 9) | 0.06 | 0 (0 to 9) | 0 (0 to 11) | 0.6 | 0 (0 to 1) | 0 (0 to 0) | 0.7 |
Bacteraemia, yes, total n (%) | 54/142 (38.0) | 135/399 (33.8) | 0.4 | 24/53 (45.3) | 119/366 (32.5) | 0.07 | 30/89 (33.7) | 16/33 (48.5) | 0.1 |
Time to diagnosis, days median (IQR) | 18 (12 to 28) | 21 (13 to 32) |
0.01
| 21 (15 to 34) | 22 (14 to 32) | 0.7 | 15 (9 to 25) | 12 (8 to 18) | 0.2 |
Glycaemia control and general outcome
Total population n = 620 | Surgical ICU n = 476 | Medical ICU n = 144 | |||||||
---|---|---|---|---|---|---|---|---|---|
Outcome before and after IIT | Before IIT n = 168 | After IIT n = 452 | p- value | Before IIT n = 62 | After IIT n = 414 | p- value | Before IIT n = 106 | After IIT n = 38 | p- value |
General outcome
| |||||||||
Mean glyc mg/dl, (mean ± SD) | 144 ± 20 | 107 ± 10 |
< 0.0001
| 142 ± 18 | 107 ± 10 |
< 0.0001
| 145 ± 21 | 111 ± 15 |
< 0.0001
|
ICU stay, days, median (IQR) | 37 (22 to 54) | 41 (25 to 61) | 0.07 | 45 (27 to 77) | 41 (27 to 61) | 0.4 | 32 (20 to 50) | 24 (16 to 52) | 0.3 |
Hospital stay, days, median (IQR) | 61 (33 to 106) | 60 (42 to 98) | 0.4 | 74 (38 to 130) | 61 (43 to 100) | 0.3 | 50 (32 to 95) | 47 (27 to 78) | 0.4 |
Hospital mortality, total n (%) | 66/152 (43.4) | 170/425 (40.0) | 0.5 | 23/54 (42.6) | 154/389 (39.6) | 0.7 | 43/98 (43.9) | 16/36 (44.4) | 0.9 |
Mechanical ventilation ≥ 14 days, total n (%) | 84/142 (59.2) | 259/399 (64.9) | 0.2 | 38/53 (71.7) | 248/366 (67.8) | 0.6 | 46/89 (51.7) | 11/33 (33.3) | 0.07 |
Electrophysiological data
| |||||||||
Spontaneous electrical activity present, total n (%) | 125/168 (74.4) | 220/452 (48.7) |
< 0.0001
| 49/62 (79.0) | 209/414 (50.5) |
< 0.0001
| 76/106 (71.7) | 11/38 (28.9) |
< 0.0001
|
SNAP UL | |||||||||
absolute value (uV), median (IQR) | 6 (0 to 10) | 8 (4–13) |
0.0002
| 6 (3–9) | 8 (4–13) |
0.02
| 6 (0–10) | 6 (4–13) | 0.08 |
percentage of normal median (IQR) | 75 (0 to 125) | 100 (50 to 162) |
0.0002
| 75 (34 to 113) | 100 (50 to 163) |
0.02
| 75 (0 to 125) | 80 (50 to 163) | 0.08 |
SNAP LL | |||||||||
absolute value (uV), median (IQR) | 4 (0 to 8) | 5 (0 to 8) | 0.3 | 5 (0 to 8) | 5 (0 to 8) | 0.3 | 2 (0 to 6) | 5 (0 to 8) | 0.1 |
percentage of normal median (IQR) | 83 (0 to 200) | 100 (0 to 200) | 0.5 | 133 (0 to 250) | 100 (0 to 200) | 0.09 | 27 (0 to 163) | 102 (0 to 197) | 0.1 |
Voluntary motor unit potential recruitment obtained, total n (%) | 90/168 (53.6) | 247/452 (54.6) | 0.8 | 36/62 (58.1) | 221/414 (53.4) | 0.5 | 54/106 (50.9) | 26/38 (68.4) | 0.06 |
myogenic component present, total n (% of all patients) | 27/168 (16.1) | 45/452 (10.0) |
0.04
| 12/62 (19.4) | 39/414 (9.4) |
0.02
| 15/106 (14.1) | 6/38 (15.8) | 0.8 |
myogenic component, total n (% of patients in whom contraction achieved) | 27/90 (30.0) | 45/202 (18.2) |
0.02
| 12/36 (33.3) | 39/221 (17.6) |
0.03
| 15/54 (27.8) | 6/26 (23.1) | 0.6 |
Electrophysiological data
CIP/CIM Total population, n = 620 | Prolonged mechanical ventilation Total population, n = 541 | |||||
---|---|---|---|---|---|---|
CIP/CIM n = 345 | No CIP/CIM n = 275 | p- value | Prolonged mechanical ventilation | No prolonged mechanical ventilation | p- value | |
Therapy
| ||||||
IIT total n (%) | 220/345 (63.8) | 232/275 (84.4) |
< 0.0001
| 259/343 (75.5) | 140/198 (70.7) | 0.2 |
Baseline
| ||||||
Male/female sex, n (%) | 239/345 (69.3) | 171/275 (62.2) | 0.06 | 242/343 (70.6) | 118/198 (59.6) |
0.009
|
Age, years (mean ± SD) | 62 ± 14 | 63 ± 15 | 0.4 | 62 ± 14 | 64 ± 15 | 0.2 |
ICU type (MICU, %) | 87/345 (25.2) | 57/275 (20.7) | 0.2 | 57/343 (16.6) | 65/198 (32.8) |
< 0.0001
|
Baseline APACHE II, median (IQR) | 15 (11 to 22) | 15 (11 to 22) | 0.4 | 15 (12 to 22) | 16 (11 to 23) | 0.7 |
On admission blood glucose, mg/dl median (IQR) | 137 (109 to 174) | 139 (112 to 181) | 0.5 | 139 (111 to 175) | 139 (113 to 183) | 0.6 |
On admission mechanical ventilation, total n (%) | 298/306 (97.4) | 237/247 (96.0) | 0.3 | 332/341 (97.4) | 185/194 (95.4) | 0.2 |
Diagnostic group, total n (%) of the category | 0.3 | 0.4 | ||||
Abdominal/gastrointestinal/liver | 39/71 (54.9) | 32/71 (45.1) | 45/67 (67.2) | 22/67 (32.8) | ||
Cardiovascular | 91/171 (53.2) | 80/171 (46.8) | 111/165(67.3) | 54/165 (32.7) | ||
Cerebral/neurological | 26/60 (43.3) | 34/60 (56.7) | 34/53 (64.2) | 19/53 (35.8) | ||
Haematological/oncologic/transplant | 15/31 (48.4) | 16/31 (51.6) | 19/27 (70.4) | 8/27 (29.6) | ||
Other | 42/73 (57.5) | 31/173 (42.5) | 38/70 (54.3) | 32/70 (45.7) | ||
Polytrauma | 221/37 (59.5) | 15/37 (40.5) | 22/32 (68.8) | 10/32 (31.2) | ||
Respiratory/thoracic | 85/136 (62.5) | 51/136 (37.5) | 74/127 (58.3) | 53/127 (41.7) | ||
History of diabetes, total n (%) | 0.2 | 0.7 | ||||
Insulin treated | 21/317 (6.6) | 16/254 (6.3) | 25/343 (7.3) | 11/198 (5.6) | ||
Oral antidiabetic treatment and/or diet | 22/317 (6.9) | 20/254 (7.9) | 24/343 (7.0) | 15/198 (7.6) | ||
Known risk factors
| ||||||
Treatment with noradrenaline | ||||||
Treated patients, total n (%) | 232/301 (77.1) | 197/240 (82.1) | 0.2 | 289/343 (84.3) | 129/198 (65.2) |
< 0.0001
|
Number of days treatment, median (IQR) | 7(1 to 15) | 6(2 to 13) | 0.4 | 8 (3 to 13) | 3 (0 to 6) |
< 0.0001
|
Treatment with aminoglycosides | ||||||
Treated patients, total n (%) | 76/301 (25.2) | 51/240 (21.3) | 0.3 | 77/343 (22.4) | 29/198 (14.6) |
0.03
|
Number of days treatment, median (IQR) | 0 (0 to 1) | 0 (0 to 0) | 0.5 | 0 (0 to 0) | 0 (0 to 0) | 0.1 |
Treatment with glucocorticoids | ||||||
Treated patients, total n (%) | 165/301 (54.8) | 129/240(53.8) | 0.8 | 163/343 (47.5) | 100/198 (50.5) | 0.5 |
Number of days treatment, median (IQR) | 1 (0 to 12) | 1 (0 to 10) | 0.4 | 0 (0 to 8) | 1 (0 to 7) | 0.9 |
Cumulative dose up to time t | 250 (0 to 2500) | 300(0 to 2500) | 0.8 | 0 (0 to 1398) | 31 (0 to 1140) | 0.9 |
Treatment with NMBA | ||||||
Number of days treatment (≥ 1 bolus or drip), median (IQR) | 2 (1 to 4) | 1 (0 to 4) | 0.06 | 2 (1 to 3) | 1 (0 to 2) |
< 0.0001
|
Patients treated prolonged (≥ 3d bolus or drip) total n (%) | 95/301 (31.6) | 71/240(29.6) | 0.6 | 262/343 (76.4)) | 107/198 (54.0) |
< 0.0001
|
Dialysis | ||||||
yes | 118/301 (39.2) | 72/240 (30.0) |
0.03
| 126/343 (36.7) | 37/198 (18.7) |
< 0.0001
|
n days, median (IQR) | 0 (0 to 10) | 0 (0 to 5) |
0.05
| 0 (0 to 6) | 0 (0 to 0) |
0.0001
|
Bacteraemia, yes, total n (%) | 113/301 (37.5) | 76/240 (31.7) | 0.2 | 92/343 (26.8) | 32/198 (16.2) |
0.004
|
Time to diagnosis, d median (IQR) | 22 (14 to 33) | 18 (11 to 27) |
0.000 7
| - | - | - |
Diagnosis of CIP/CIM during ICU stay, total n (%) | - | - |
-
| 207/343 (60.4) | 94/198 (47.5) |
0.004
|
Risk for development of CIP/CIMa | Risk for prolonged mechanical ventilationb | |||
---|---|---|---|---|
OR (95% CI) | p-value | OR (95% CI) | p-value | |
A. Uncorrected.
| ||||
Glycaemic control, IIT | 0.33 (0.22 to 0.48) |
< 0.0001
| 1.28 (0.86 to 1.89) | 0.2 |
B. Corrected for baseline risk factors.
| ||||
Glycaemic control, IIT | 0.24 (0.14 to 0.42) |
< 0.0001
| 0.56 (0.32 to 0.96) |
0.04
|
ICU type, medical | 0.49 (0.27 to 0.90) |
0.02
| 0.29 (0.16 to 0.53) |
< 0.0001
|
Diagnostic category | ||||
Cardiovascular | 1.005 (0.55 to 1.82) | 0.9 | 0.78 (0.41 to 1.47) | 0.4 |
Cerebral/neurological | 0.77 (0.37 to 1.63) | 0.5 | 0.79 (0.36 to 1.72) | 0.5 |
Haematological/oncological/transplant | 1.04 (0.41 to 2.60) | 0.9 | 0.96 (0.35 to 2.63) | 0.9 |
Other | 1.02 (0.50 to 20.7) | 0.9 | 0.60 (0.29 to 1.26) | 0.2 |
Polytrauma | 1.03 (0.43 to 2.49) | 0.9 | 0.75 (0.29 to 1.90) | 0.5 |
Respiratory/thoracic | 1.43 (0.75 to 2.71) | 0.3 | 0.85 (0.44 to 1.64) | 0.6 |
On admission blood glucose | 0.99 (0.99 to 1.001) | 0.1 | 0.99 (0.99 to 1.002) | 0.7 |
Gender, female | 0.68 (0.47 to 1.000) |
0.05
| 0.63 (0.43 to 0.93) |
0.02
|
C. Corrected for baseline risk factors and known risk factors occurring during ICU stay.
| ||||
Glycaemic control, IIT | 0.25 (0.14 to 0.43) |
< 0.0001
| 0.40 (0.22 to 0.72) |
0.002
|
ICU type, medical | 0.62 (0.33 to 1.16) | 0.1 | 0.35 (0.18 to 0.67) |
0.002
|
Diagnostic category | ||||
Cardiovascular | 0.99 (0.54 to 1.83) | 0.9 | 0.64 (0.31 to 1.29) | 0.2 |
Cerebral/neurological | 0.83 (0.39 to 1.80) | 0.6 | 0.87 (0.36 to 2.11) | 0.8 |
Haematological/ | 1.18 (0.45 to 3.12) | 0.7 | 0.60 (0.19 to 1.93) | 0.4 |
oncological/transplant | 1.002 (0.49 to 2.07) | 0.9 | 0.58 (0.26 to 1.27) | 0.2 |
Other | 1.09 (0.43 to 2.73) | 0.9 | 0.88 (0.30 to 2.57) | 0.8 |
Polytrauma | 1.38 (0.72 to 2.66) | 0.3 | 089 (0.43 to 1.86) | 0.8 |
Respiratory/thoracic | ||||
On admission blood glucose | 0.99 (0.99 to 1.001) | 0.1 | 0.99 (0.99 to 1.002) | 0.4 |
Gender, female | 0.74 (0.50 to 1.09) | 0.1 | 0.74 (0.48 to 1.12) | 0.2 |
Number of days treatment with noradrenaline, per day added | 1.002 (0.98 to 1.03) | 0.8 | 1.16 (1.11 to 1.22) |
< 0.0001
|
Cumulative dose hydrocortisone equivalent, per mg added | 1.000 (1.000 to 1.000) | 0.3 | 1.00 (1.00 to 1.00) | 0.9 |
Treatment with aminoglycosides, yes | 1.073 (0.69 to 1.68) | 0.8 | 1.72 (1.003 to 2.96) |
0.05
|
Number of days treatment with NMBAs (min 1 bolus or drip), per day added | 1.04 (0.98 to 1.10) | 0.2 | 1.15 (1.04 to 1.27) |
0.007
|
Number of days treatment with dialysis, per day added | 1.004 (0.98 to 1.02) | 0.7 | 1.09 (1.03 to 1.15) |
0.004
|
Time t, per day added | 1.01 (0.99 to 1.03) | 0.2 | - |
-
|
Bacteraemia, yes | - | - | 2.11 (1.26 to 3.55) |
0.005
|
Prolonged mechanical ventilation
Discussion
Conclusion
Key messages
-
Implementing IIT in daily care of critically ill medical and surgical patients is feasible.
-
IIT reduced electrophysiological incidence of CIP/CIM in daily clinical practice in critically ill medical and surgical patients, outside the controlled setting of a study protocol.