Patients requiring mechanical ventilation require sedation and analgesia. Appropriate levels of sedation are difficult to obtain without the use of a sedation assessment tool. Clinical practice guidelines recommend using a sedation scale to monitor patients to optimize sedation. Although there is no gold standard for sedation assessment, there are numerous scales available that are accurate and reliable. The Ramsay Sedation Scale is a widely utilized method for evaluating sedation in mechanically ventilated patients. The Ramsay Sedation Scale was designed in 1974 as a way to monitor sedation levels in patients receiving continuous sedation (1). It has since been utilized in numerous studies and is one of the recommended sedation assessment scales defined by the practice guidelines for sustained sedation in the critically ill (2). 1. Determine the appropriateness of ICU sedation among ventilated patients in the absence of a standard assessment tool 2. Implement a standard ICU sedation assessment tool (Ramsay Sedation Scale) 3. Compare the appropriateness of sedation before and after standardization Implementing the Ramsay Sedation Scale for use in mechanically ventilated ICU patients will lead to more optimized levels of sedation. Sedation Assessment Optimized sedation = 3,4. Inappropriate sedation = 1,2,5,6. G Power Sample Size Calculator for  = 0.05 and  = Sample size = 64 patients. Enrolling 32 patients in each study group. Wilcoxon-Mann Whitney test used to compare pre and post Ramsay Scale. 1. Ramsay MA, Savege TM, Simpson BR, et al: Controlled sedation with alphaxalone –alphadolone. Br Med J 1974; 2:656– Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30(1):119–41. Initial Observation Period A daily sedation assessment will be done every morning on all patients receiving mechanical ventilation and continuous sedation. At each daily assessment, the primary investigator will assign a sedation score based on the Ramsay Sedation Scale. Nurses will be blinded to the sedation assessment. Implementation of Ramsay Sedation Scale All ICU nurses will be trained to assess and document sedation using the Ramsay Sedation Scale. The primary investigator will continue assessing the appropriateness of sedation after the implementation. Nurses will continue to be blinded to the sedation assessment. Inclusion/Exclusion Criteria Inclusion criteria: patients > 18 years old, must be ventilated and on continuous sedation. Exclusion criteria : patients <18 years old or require neuromuscular blockers. Ramsay Sedation Scale ScoreLevel of Activity 1AwakePatient anxious and agitated or restless, or both 2Patient co-operative, orientated, and tranquil 3Patient responds to commands only 4AsleepBrisk response to a light glabellar tap or auditory stimulus 5Sluggish response to a light glabellar tap or auditory stimulus 6No response to light glabellar tap or loud auditory stimulus Hospital NumberRamsay ScoreDate-TimeAppropriate (Y/N) EX: SM / N AgeDateDiagnosis Day of Mechanical Ventilation Vent Mode Sedative or Analgesic Drug Used 579/10/10 Respiratory failure 3A/C Fentanyl Ativan Drug DoseBUN Serum Creatinine (mg/dl) AstAlt T.Bili 75mcg/hr 4mg/hr Authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation - Geoff Lockwood: Nothing to disclose - Christopher Miller: Nothing to disclose - Mauricio Rodriguez: Speaker with Ortho-McNeil-Janssen Pharmaceuticals Introduction Disclosures Data Collection Objectives Hypothesis Statistics Methods Evaluation and Standardization of Sedation inIntensive Care Unit Patients CHRISTUS Spohn Health System Geoff Lockwood, PharmD Mauricio Rodriguez, PharmD, BCPS Christopher Miller, PharmD, BCPP

Objectives Preliminary Results References Objectives Methods Background The primary research question is to observe the rates of DKA in patients with type 1 and type 2 diabetes mellitus that are admitted to the CHRISTUS Spohn Health System in Corpus Christi, TX and describe their clinical and metabolic features. Diabetic ketoacidosis is a serious acute complication of diabetes which continues to be a significant cause of morbidity and mortality in spite of major advances in the understanding of it’s pathogenesis 1. DKA was once thought to occur in patients with type 1 diabetes and rarely in patients with type 2 diabetes. Recently there have been reports of DKA occurring in patients with type 2 diabetes mellitus 2,3. The frequency and patient characteristics of these patients have yet to be fully determined. The population of South Texas is ethnically diverse with a large Hispanic community contributing to the increased incidence of type 2 diabetes mellitus. This results in a unique setting to study DKA in patients with type 2 diabetes mellitus and its treatment. Additionally, there have been reports of a mixed type of diabetes that share features of type 1 and type 2 diabetes. This has been referred to as: type 1B, idiopathic type 1 diabetes, atypical diabetes, type 1.5 diabetes, and more recently ketosis-prone type 2 diabetes. This population of patients are characterized by severely impaired insulin secretion and action with significant improvement in beta cell function within a few months. 4,5 Design: This study is a retrospective analysis of charted data on patients that were admitted to CHRISTUS Spohn hospitals in Corpus Christi for DKA between June 1, 2009 and June 30, Inclusion Criteria: ICD-9 code : diabetes mellitus with ketoacidosis, type two or unspecified type, or ICD-9 code : diabetes mellitus with ketoacidosis, type one, 18 years or older, anion gap of 10 mEq/L or more, arterial pH less than 7.35, plasma glucose greater than 250 mg/dL, documented presence of serum ketones and urine ketones, absence of concomitant conditions that might result in anion gap acidosis or ketosis, such as pregnancy, renal insufficiency (other than mild, reversible prerenal state), lactic acidosis, or organic poison ingestion. Exclusion criteria: Patients less than 18 years old, pregnant, severe renal insufficiency, lactic acidosis, or organic poison ingestion. Statistical Analysis: Patient demographics, clinical and metabolic characteristics for type 1 and type 2 patients will be compared using χ2 tests for categorical data and student's t-test or analysis of variance for continuous variables. Comparisons of patient characteristics will be made using initial admission data. The sample size will be a representation of the population of patients in the area and should be comparable to the number of patients that are documented in similar studies. 2,4,5  After IRB approval this study commenced and is currently ongoing in the data collection(Fig. 2) and data analysis phase  There are a total of 200 patients that potentially fit the inclusion criteria. Shown in Figure 1 is the proportion of ICD-9 coded admissions for patients that present to CHRISTUS Spohn hospitals in Corpus Christi with either type 1 or type 2 diabetes.  Preliminary data shows that the triggering factor for DKA is either non compliance with insulin therapy or an infection 1.Kitabchi A, Umpirrez G, Murphy M, Barrett E, Kreisberg R, Malone J, Wall B. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001;24: Balasubramanyam A, Zern J, Hyman D, Pavlik V. New profiles of diabetic ketoacidosis: type 1 vs. type 2 diabetes and the effect of ethnicity. Arch Intern Med. 1999;159: Pinero-Pilona A, Litonjua P, Aviles-Santa L, Raskin P. Idiopathic type 1 diabetes in Dallas, Texas. Diabetes Care. 2001;24: Newton C, Raskin P. Diabetic ketoacidosis in type 1 and type 2 diabetes mellitus: clinical and biochemical differences. Arch Intern Med. 2004;164: Umpierrez GE, Smiley D, Kitabchi AE. Narrative review: ketosis-prone type 2 diabetes mellitus. Ann Intern Med. 2006;144: Preliminary findings show that there is a higher proportion of patients with type 2 diabetes mellitus that are admitted to the hospital for DKA than what is published in the current literature. 2.One of the limitations in data collection is the lack of information that describes the clinical picture, including the pertinent history leading up to admission. 3.A second limitation would be the possibility of incorrect coding of the type of diabetes mellitus. 4.Once complete, this data could be useful as a pilot for another study, possibly prospective, that looks at the treatment of patients with type 2 diabetes and DKA and their long term management. DISCLOSURE: Authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation: Beau Baker: Nothing to disclose Lisa Prather: Nothing to disclose Christopher Miller: Nothing to disclose Diabetic ketoacidosis (DKA) in type 1 and type 2 diabetes mellitus: a population study in South Texas CHRISTUS Spohn Health System Beau Baker, Pharm.D. Lisa Prather, Pharm.D. BCPS, BC-ADM Christopher Miller, Pharm.D. BCPP Evaluation I estimate that a large number of patients that present with DKA in South Texas are not patients with type 1 diabetes. The results gathered from this study may help evaluate prospectively the impact of diagnostic and therapeutic strategies in the management of DKA. Hypothesis