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Sun L, Bing H, Zhang C, Lin L, Lian H, Chu Q, Jin X. Short-Term Preconditioning with Insulin and Glucose Efficiently Protected the Kidney Against Ischemia-Reperfusion Injury via the P-AKT-Bax-Caspase-3 Signaling Pathway in Mice. Drug Des Devel Ther 2024; 18:2461-2474. [PMID: 38915866 PMCID: PMC11195683 DOI: 10.2147/dddt.s465836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/13/2024] [Indexed: 06/26/2024] Open
Abstract
Objective Insulin attaches insulin receptor to activate the PI3-kinase/Akt signaling to maintain glucose homeostasis and inhibit apoptosis. This study determined whether preconditioning with insulin and glucose protects the kidney against ischemia-reperfusion injury (IRI). Methods Kidney IRI was performed in C57BL/6 mice by clamping the renal vessels for 30 min, followed by reperfusion for 24 h. A total subcutaneous 0.1 unit of insulin along with 10% glucose in drinking water was treated on the mice for 24 h before kidney IRI. The kidney function and injuries were investigated through the determination of BUN and Cr in blood plasma, as well as the apoptosis and the expression of P-AKT, BAX, and caspase-3 in the kidneys. The role of P-AKT in insulin-treated IRI kidneys was tested using an AKT inhibitor. The effects of the preconditional duration of insulin and glucose on IRI kidneys were investigated by expanding the treatment duration to 1, 3, and 6 days. Results Preconditioning with insulin and glucose protected the kidney against IRI as manifested by a decrease in creatinine and BUN and a reduction of kidney tubular injury. The protection effect was mediated by P-AKT-BAX-caspase-3 signaling pathway resulting in suppression of apoptotic cell death. An AKT inhibitor partially reversed the protective effects of preconditional insulin. The preconditional duration for 1, 3, and 6 days had no differences in improving kidney functions and pathology. Conclusion A short-term preconditioning with insulin and glucose protected the kidney from IRI through the activation of p-AKT and subsequent reduction of BAX-caspase-3-induced apoptosis. The short-term precondition provides a practicable strategy for protecting the kidney against predictable IRI, such as kidney transplant and major surgical operations with high risk of hypotension.
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Affiliation(s)
- Liwei Sun
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Hailong Bing
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Chenxi Zhang
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Lin Lin
- Research of Trauma Center, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, 450007, People’s Republic of China
| | - Hongkai Lian
- Research of Trauma Center, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, 450007, People’s Republic of China
| | - Qinjun Chu
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Xiaogao Jin
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, People’s Republic of China
- Department of Anesthesiology, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, People’s Republic of China
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Defante MLR, Mendes BX, de Souza MDM, De Hollanda Morais BADA, Martins OC, Prizão VM, Parolin SAEC. Tight Versus Liberal Blood Glucose Control in Patients With Diabetes in the ICU: A Meta-Analysis of Randomized Controlled Trials. J Intensive Care Med 2024:8850666241255671. [PMID: 38751353 DOI: 10.1177/08850666241255671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
Introduction: Glycemia is an important factor among critically ill patients in the intensive care unit (ICU). There is conflicting evidence on the preferred strategy of blood glucose control among patients with diabetes in the ICU. We aimed to conduct a meta-analysis comparing tight with liberal blood glucose in critically ill patients with diabetes in the ICU. Methods: We systematically searched PubMed, Embase, and Cochrane Central for randomized controlled trials (RCTs) comparing tight versus liberal blood glucose control in critically ill patients with diabetes from inception to December 2023. We pooled odds-ratios (OR) and 95% confidence intervals (CI) with a random-effects model for binary endpoints. We used the Review Manager 5.17 and R version 4.3.2 for statistical analyses. Risk of bias assessment was performed with the Cochrane tool for randomized trials (RoB2). Results: Eight RCTs with 4474 patients were included. There was no statistically significant difference in all-cause mortality (OR 1.11; 95% CI 0.95-1.28; P = .18; I² = 0%) between a tight and liberal blood glucose control. RoB2 identified all studies at low risk of bias and funnel plot suggested no evidence of publication bias. Conclusion: In patients with diabetes in the ICU, there was no statistically significant difference in all-cause mortality between a tight and liberal blood glucose control. PROSPERO registration: CRD42023485032.
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Affiliation(s)
- Maria L R Defante
- Department of Medicine, Redentor University Center, Itaperuna, Brazil
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3
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Kapellen T, Agwu JC, Martin L, Kumar S, Rachmiel M, Cody D, Nirmala SVSG, Marcovecchio ML. ISPAD clinical practice consensus guidelines 2022: Management of children and adolescents with diabetes requiring surgery. Pediatr Diabetes 2022; 23:1468-1477. [PMID: 36537521 DOI: 10.1111/pedi.13446] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Thomas Kapellen
- Department for Women and Child Health, Hospital for Children and Adolescents, Liebigstrasse 20 Leipzig; Children's Hospital Am Nicolausholz, Bad Kösen, University of Leipzig, Leipzig, Germany
| | - Juliana Chizo Agwu
- Department of Paediatrics, Sandwell and West Birmingham, NHS Trust, Birmingham, UK
| | - Lizabeth Martin
- University of Washington Department of Anesthesiology, Division of Pediatric Anesthesia, Seattle Children's Hospital, Seattle, Washington, USA
| | - Seema Kumar
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Marianna Rachmiel
- Pediatric Endocrinology and Diabetes Institute, Shamir (Assaf Haroffeh) Medical Center, Zerifin, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Declan Cody
- Children's Hospital Ireland Crumlin Dublin, University College Dublin, Dublin, Ireland
| | - Sunkara V S G Nirmala
- Department of Pediatric and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
| | - M Loredana Marcovecchio
- Department of Paediatrics, University of Cambridge and Cambridge University Hospitals, NHS Foundation Trust, Cambridge, UK
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Xie J, Kittur FS, Li PA, Hung CY. Rethinking the necessity of low glucose intervention for cerebral ischemia/reperfusion injury. Neural Regen Res 2021; 17:1397-1403. [PMID: 34916409 PMCID: PMC8771096 DOI: 10.4103/1673-5374.330592] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Glucose is the essential and almost exclusive metabolic fuel for the brain. Ischemic stroke caused by a blockage in one or more cerebral arteries quickly leads to a lack of regional cerebral blood supply resulting in severe glucose deprivation with subsequent induction of cellular homeostasis disturbance and eventual neuronal death. To make up ischemia-mediated adenosine 5′-triphosphate depletion, glucose in the ischemic penumbra area rapidly enters anaerobic metabolism to produce glycolytic adenosine 5′-triphosphate for cell survival. It appears that an increase in glucose in the ischemic brain would exert favorable effects. This notion is supported by in vitro studies, but generally denied by most in vivo studies. Clinical studies to manage increased blood glucose levels after stroke also failed to show any benefits or even brought out harmful effects while elevated admission blood glucose concentrations frequently correlated with poor outcomes. Surprisingly, strict glycaemic control in clinical practice also failed to yield any beneficial outcome. These controversial results from glucose management studies during the past three decades remain a challenging question of whether glucose intervention is needed for ischemic stroke care. This review provides a brief overview of the roles of cerebral glucose under normal and ischemic conditions and the results of managing glucose levels in non-diabetic patients. Moreover, the relationship between blood glucose and cerebral glucose during the ischemia/reperfusion processes and the potential benefits of low glucose supplements for non-diabetic patients are discussed.
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Affiliation(s)
- Jiahua Xie
- Department of Pharmaceutical Sciences, Biomanufacturing Research Institute & Technology Enterprise, North Carolina Central University, Durham, NC, USA
| | - Farooqahmed S Kittur
- Department of Pharmaceutical Sciences, Biomanufacturing Research Institute & Technology Enterprise, North Carolina Central University, Durham, NC, USA
| | - P Andy Li
- Department of Pharmaceutical Sciences, Biomanufacturing Research Institute & Technology Enterprise, North Carolina Central University, Durham, NC, USA
| | - Chiu-Yueh Hung
- Department of Pharmaceutical Sciences, Biomanufacturing Research Institute & Technology Enterprise, North Carolina Central University, Durham, NC, USA
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5
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Metabolic Alterations in Sepsis. J Clin Med 2021; 10:jcm10112412. [PMID: 34072402 PMCID: PMC8197843 DOI: 10.3390/jcm10112412] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/19/2021] [Accepted: 05/27/2021] [Indexed: 12/20/2022] Open
Abstract
Sepsis is defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection”. Contrary to the older definitions, the current one not only focuses on inflammation, but points to systemic disturbances in homeostasis, including metabolism. Sepsis leads to sepsis-induced dysfunction and mitochondrial damage, which is suggested as a major cause of cell metabolism disorders in these patients. The changes affect the metabolism of all macronutrients. The metabolism of all macronutrients is altered. A characteristic change in carbohydrate metabolism is the intensification of glycolysis, which in combination with the failure of entering pyruvate to the tricarboxylic acid cycle increases the formation of lactate. Sepsis also affects lipid metabolism—lipolysis in adipose tissue is upregulated, which leads to an increase in the level of fatty acids and triglycerides in the blood. At the same time, their use is disturbed, which may result in the accumulation of lipids and their toxic metabolites. Changes in the metabolism of ketone bodies and amino acids have also been described. Metabolic disorders in sepsis are an important area of research, both for their potential role as a target for future therapies (metabolic resuscitation) and for optimizing the current treatment, such as clinical nutrition.
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Jamme M, Legrand M, Geri G. Outcome of acute kidney injury: how to make a difference? Ann Intensive Care 2021; 11:60. [PMID: 33856581 PMCID: PMC8050180 DOI: 10.1186/s13613-021-00849-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 04/03/2021] [Indexed: 12/16/2022] Open
Abstract
Background Acute kidney injury (AKI) is one of the most frequent organ failure encountered among intensive care unit patients. In addition to the well-known immediate complications (hydroelectrolytic disorders, hypervolemia, drug overdose), the occurrence of long-term complications and/or chronic comorbidities related to AKI has long been underestimated. The aim of this manuscript is to briefly review the short- and long-term consequences of AKI and discuss strategies likely to improve outcome of AKI. Main body We reviewed the literature, focusing on the consequences of AKI in all its aspects and the management of AKI. We addressed the importance of clinical management for improving outcomes AKI. Finally, we have also proposed candidate future strategies and management perspectives. Conclusion AKI must be considered as a systemic disease. Due to its short- and long-term impact, measures to prevent AKI and limit the consequences of AKI are expected to improve global outcomes of patients suffering from critical illnesses.
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Affiliation(s)
- Matthieu Jamme
- Service de Réanimation, Hôpital de Poissy, CHI Poissy Saint Germain, 10 rue du champ Gaillard, 78300, Poissy, France. .,INSERM UMR 1018, Equipe Epidémiologie clinique, CESP, Villejuif, France. .,Université Paris Saclay, UFR Simone Veil - Santé, Montigny-Le-Bretonneux, France.
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA
| | - Guillaume Geri
- INSERM UMR 1018, Equipe Epidémiologie clinique, CESP, Villejuif, France.,Université Paris Saclay, UFR Simone Veil - Santé, Montigny-Le-Bretonneux, France.,Service de Médecine Intensive Réanimation, Hôpital Ambroise Paré, AP-HP, Boulogne Billancourt, France
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7
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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8
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Ambrose T, De Silva A, Naghibi M, Saunders J, Smith TR, Coleman RL, Stroud M. Refeeding risks in patients requiring intravenous nutrition support: Results of a two-centre, prospective, double-blind, randomised controlled trial. Clin Nutr ESPEN 2021; 41:143-152. [PMID: 33487258 DOI: 10.1016/j.clnesp.2020.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND/AIMS Refeeding syndrome can result following excessive feeding of malnourished patients. The syndrome remains poorly defined but encompasses a range of adverse effects including electrolyte shifts, hyperglycaemia and other less well-defined phenomena. There are additional risks of underfeeding malnourished individuals. Studies of refeeding syndrome have generally focussed on critical care environments or patients with anorexia nervosa. Here we have conducted a two-centre, prospective, double-blind, randomised controlled trial amongst all patients referred to hospital nutrition support teams for intravenous nutrition support. We sought to determine whether electrolyte and other abnormalities suggestive of refeeding syndrome risk varied depending on initial rate of intravenous feeding. METHODS Patients at moderate or high risk of refeeding syndrome, as defined by United Kingdom National Institute of Health and Care Excellence guidelines, were screened for inclusion. Patients were randomised to receive either high (30 kcal/kg/day, 0.25 gN/kg/day) or low (15 kcal/day, 0.125 gN/kg/day) rate feeding for the first 48 h prior to escalation to standard parenteral nutrition regimens. The primary outcome was rates of potential refeeding risks within the first 7 days as defined by electrolyte imbalance or hyperglycaemia requiring insulin. Secondary outcomes included effects on QTc interval, infections and length of hospital stay. Statistical analysis was performed with χ2 or Wilcoxon rank sum tests and all analysis was intention-to-treat. Problems with study recruitment led to premature termination of the trial. Registered on the EU Clinical Trials Register (EudraCT number 2007-005547-17). RESULTS 534 patients were screened and 104 randomised to either high or low rate feeding based on risk of refeeding syndrome. Seven patients were withdrawn prior to collection of baseline demographics and were excluded from analysis. 48 patients were analysed for the primary outcome with potential refeeding risks identified in 46%. No differences in risks were seen between high and low rate feeding (p > 0.99) or high and moderate risk feeding (p = 0.68). There were no differences in QTc abnormalities, infection rates, or hospital length of stay between groups. CONCLUSIONS In this randomised trial of rates of refeeding risk, in patients pre-stratified as being at high or moderate risk, we found no evidence of increased refeeding related disturbances in those commenced on high rate feeding compared to low rate. No differences were seen in secondary endpoints including cardiac rhythm analysis, infections or length of stay. Our study reflects real world experience of patients referred for nutrition support and highlights challenges encountered when conducting clinical nutrition research.
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Affiliation(s)
- Tim Ambrose
- Department of Gastroenterology, Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, United Kingdom
| | - Aminda De Silva
- Department of Gastroenterology, Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, United Kingdom
| | - Mani Naghibi
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD, United Kingdom
| | - John Saunders
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD, United Kingdom
| | - Trevor R Smith
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD, United Kingdom
| | - Ruth L Coleman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Oxford, OX3 7LJ, United Kingdom
| | - Mike Stroud
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD, United Kingdom.
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9
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Lin S, He W, Zeng M. Association of Diabetes and Admission Blood Glucose Levels with Short-Term Outcomes in Patients with Critical Illnesses. J Inflamm Res 2020; 13:1151-1166. [PMID: 33376380 PMCID: PMC7764887 DOI: 10.2147/jir.s287510] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/04/2020] [Indexed: 12/16/2022] Open
Abstract
Background Association of diabetes and admission glucose on the short-term prognosis in patients with critical illnesses are currently ambiguous. We aimed to determine whether diabetes and admission glucose affects short-term prognosis of critically ill patients. Methods We performed a retrospective analysis of data on 46,476 critically ill patients from the critical care database. Association of diabetes with 28-day mortality was assessed by inverse probability weighting based on the propensity score. Smoothing splines and threshold effect analysis were applied to explore the relationship between admission glucose and clinical outcomes. Results Of the 33,680 patients enrolled in the study, 8,701 (25.83%) had diabetes. In the main analysis, the 28-day mortality was reduced by 29% (hazard ratio (HR)=0.71, 95% confidence interval (CI) 0.67–0.76) in patients with diabetes compared to those without diabetes. The E-value of 2.17 indicated robustness to unmeasured confounders. Significant interactions were observed for glucose at ICU admission, admission type, and insulin use (Interaction P <0.05). A V-shaped relationship was observed between admission glucose and 28-day mortality in non-diabetic patients, with the lowest 28-day mortality corresponding to a glucose level of 101.75 mg/dl (95% CI 94.64–105.80 mg/dl), and admission hypoglycemia or hyperglycemia should be avoided, especially in patients admitted to the surgical intensive care unit (SICU), cardiac surgery recovery unit (CSRU), and coronary care unit (CCU); for diabetic patients, elevated admission glucose does not appear to be associated with a poor prognosis and perhaps may be beneficial except for CCU and CSRU. Conclusion The non-detrimental effect of diabetes on the short-term prognosis of critically ill patients was further confirmed, which would reduce 28-day mortality by approximately 29%. For non-diabetic patients, the admission glucose level corresponding to the lowest 28-day mortality was 101.75 mg/dl (95% CI 94.64–105.80 mg/dl); however, for diabetics, the appropriate admission glucose threshold remains unresolved.
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Affiliation(s)
- Shan Lin
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Wanmei He
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Mian Zeng
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
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Herrera-Perez D, Fox-Lee R, Bien J, Prasad V. Frequency of Medical Reversal Among Published Randomized Controlled Trials Assessing Cardiopulmonary Resuscitation (CPR). Mayo Clin Proc 2020; 95:889-910. [PMID: 32370852 DOI: 10.1016/j.mayocp.2020.01.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/31/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To characterize what proportion of all randomized controlled trials (RCTs) among patients experiencing cardiac arrest find that an established practice is ineffective or harmful, that is, a medical reversal. METHODS We reviewed a database of all published RCTs of cardiac arrest patient populations between 1995 and 2014. Articles were classified on the basis of whether they tested a new or existing therapy and whether results were positive or negative. A reversal was defined as a negative RCT of an established practice. Further review and categorization were performed to confirm that reversals were supported by subsequent systematic review, as well as to identify the type of medical practice studied in each reversal. This study was conducted from October 2017 to June 17, 2019. RESULTS We reviewed 92 original articles, 76 of which could be conclusively categorized. Of these, 18 (24%) articles examined a new medical practice, whereas 58 (76%) tested an established practice. A total of 18 (24%) studies had positive findings, whereas 58 (76%) reached a negative conclusion. Of the 58 articles testing existing standard of care, 44 (76%) reversed that practice, whereas 14 (24%) reaffirmed it. CONCLUSION Reversal of cardiopulmonary resuscitation practices is widespread. This investigation sheds new light on low-value practices and patterns of medical research and suggests that novel resuscitation practices have low pretest probability and should be empirically tested with rigorous trials before implementation.
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Affiliation(s)
- Diana Herrera-Perez
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland
| | - Ryan Fox-Lee
- School of Medicine, Oregon Health and Science University, Portland
| | - Jeffrey Bien
- School of Medicine, Oregon Health and Science University, Portland
| | - Vinay Prasad
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland; Center for Health Care Ethics, Oregon Health and Science University, Portland.
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Yao RQ, Ren C, Wu GS, Zhu YB, Xia ZF, Yao YM. Is intensive glucose control bad for critically ill patients? A systematic review and meta-analysis. Int J Biol Sci 2020; 16:1658-1675. [PMID: 32226310 PMCID: PMC7097913 DOI: 10.7150/ijbs.43447] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/27/2020] [Indexed: 02/07/2023] Open
Abstract
Background: The monitoring and management of blood glucose concentration are standard practices in critical settings as hyperglycaemia has been shown close association with poorer outcomes. Several meta-analyses have revealed that intensive glucose control has no benefit in decreasing short-term mortality among critically ill patients, while the studies these meta-analyses have incorporated have been largely divergent. We aim to perform a more comprehensive meta-analysis addressing this problem to provide stronger evidence. Methods: We conducted comprehensive searches for relevant randomized controlled studies in online databases, including the Cochrane Library, EMBASE, and PubMed databases, up to September 1, 2018. The clinical data, which included all-cause mortality, severe hypoglycemia, need for RRT, infection resulting in sepsis, ICU mortality, 90-day mortality, 180-day mortality, and hospital and ICU lengths of stay, were screened and analyzed after data extraction. We applied odds ratios (ORs) to analyze dichotomous outcomes and mean differences for continuous outcomes with a random effects model. Results: A total of 57 RCTs involving a total of 21840 patients were finally included. Patients admitted to the ICU who underwent intensive glucose control showed significantly reduced all-cause mortality (OR: 0.89; 95% CI: 0.80-1.00; P=0.04; I2=32%), reduced infection rate (OR: 0.65, 95% CI: 0.51-0.82, P=0.0002; I2=47%), a lower occurrence of acquired sepsis (OR: 0.80, 95% CI: 0.65-0.99, P=0.04; I2=0%) and shortened length of ICU stay (MD: -0.70, 95% CI: -1.21--0.19, P=0.007, I2=70%) when compared to the same parameters as those treated with the usual care strategy. However, patients in the intensive glucose control group presented with a significantly higher risk of severe hypoglycemia (OR: 5.63, 95% CI: 4.02-7.87, P<0.00001; I2=67%). Conclusions: Critically ill patients undergoing intensive glucose control showed significantly reduced all-cause mortality, length of ICU stay and incidence of acquired infection and sepsis compared to the same parameters in patients treated with the usual care strategy, while the intensive glucose control strategy was associated with higher occurrence of severe hypoglycemic events.
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Affiliation(s)
- Ren-qi Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai 200433, People's Republic of China
| | - Chao Ren
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
| | - Guo-sheng Wu
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai 200433, People's Republic of China
| | - Yi-bing Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing 100038, People's Republic of China
| | - Zhao-fan Xia
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai 200433, People's Republic of China
| | - Yong-ming Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
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12
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Conway J, Friedman B. Intensive Glucose Control for Critically Ill Patients. Acad Emerg Med 2019; 26:1391-1392. [PMID: 31074175 DOI: 10.1111/acem.13777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/05/2019] [Accepted: 05/07/2019] [Indexed: 11/28/2022]
Affiliation(s)
- John Conway
- Albert Einstein College of Medicine, Bronx, NY
| | - Benjamin Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY
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13
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Fu Y, Sun Y, Zhang J, Cheng Y. Intensive glucose control for critically ill patients: an updated meta-analysis. Endocr Connect 2018; 7:1288-1298. [PMID: 30352416 PMCID: PMC6240146 DOI: 10.1530/ec-18-0393] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 10/10/2018] [Indexed: 01/01/2023]
Abstract
This meta-analysis aims to update the evidence for the effects of intensive glucose control (IGC) on the outcomes among critically ill patients. We performed a systematic literature review from inception through December, 2017 by two independent authors by searching PubMed, EMBASE and Cochrane Library. Randomized clinical trials of the effects of IGC compared with conventional glucose control were selected. Random-effect models were applied to calculate summary relative risks (RRs) for the related outcomes. Of 4247 records identified, we abstracted data from 27 relevant trials for meta-analysis. Compared with patients receiving conventional glucose control (controls), patients with IGC did not have significantly decreased risk of short-term mortality (in-hospital mortality or intensive care unit (ICU) mortality) (RR 0.99, 95% CI 0.92-1.06) or 3- to 6-month mortality (RR 1.02, 95% CI 0.97-1.08). These results remained constant among different study settings including surgical ICUs, medical ICUs or mixed ICUs. Similarly, we also found that patients with IGC did not have significantly lower risk of sepsis (RR 1.00, 95% CI 0.89-1.11) or new need for dialysis (RR 0.97, 95% CI 0.84-1.11). However, patients with IGC had almost 4-fold increase in risk of hypoglycemia (RR 4.86, 95% CI 3.16-7.46). In conclusion, in this updated meta-analysis of published trials, critically ill patients receiving IGC were found to be at neutral risk for short-term or 3- 6-month mortality, risk of sepsis or new need for dialysis, but at higher risk of hypoglycemia.
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Affiliation(s)
- Yongli Fu
- Department of Endocrinology, The Second Affiliated Hospital of Qiqihar Medical College, Qiqihar, Heilongjiang Province, People’s Republic of China
| | - Yaowu Sun
- Higher Education Research and Teaching Quality Assessment Center, Qiqihar Medical College, Qiqihar, Heilongjiang Province, People’s Republic of China
| | - Jiankun Zhang
- Department of Clinical Laboratory, The Second Affiliated Hospital of Qiqihar Medical College, Qiqihar, Heilongjiang Province, People’s Republic of China
| | - Yu Cheng
- Department of Nutrition and Food Hygiene, School of Public Health, Qiqihar Medical College, Qiqihar, Heilongjiang Province, People’s Republic of China
- Correspondence should be addressed to Y Cheng:
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14
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Highest In-Hospital Glucose Measurements are Associated With Neurological Outcomes After Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2018; 27:2662-2668. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/17/2018] [Accepted: 05/22/2018] [Indexed: 12/31/2022] Open
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15
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Jefferies C, Rhodes E, Rachmiel M, Agwu JC, Kapellen T, Abdulla MA, Hofer SE. ISPAD Clinical Practice Consensus Guidelines 2018: Management of children and adolescents with diabetes requiring surgery. Pediatr Diabetes 2018; 19 Suppl 27:227-236. [PMID: 30039617 DOI: 10.1111/pedi.12733] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/10/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Craig Jefferies
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Erinn Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Marianna Rachmiel
- Assaf Haroffeh Medical Center, Zerifin, Sackler School of Medicine, Tel Aviv University, Israel
| | - Juliana C Agwu
- Department of Paediatrics, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Thomas Kapellen
- Department for Women and Child Health, Hospital for Children and Adolescents, University of Leipzig, Leipzig, Germany
| | | | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
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16
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Shah FA, Singamsetty S, Guo L, Chuan BW, McDonald S, Cooper BA, O'Donnell BJ, Stefanovski D, Wice B, Zhang Y, O'Donnell CP, McVerry BJ. Stimulation of the endogenous incretin glucose-dependent insulinotropic peptide by enteral dextrose improves glucose homeostasis and inflammation in murine endotoxemia. Transl Res 2018; 193:1-12. [PMID: 29222967 PMCID: PMC5826869 DOI: 10.1016/j.trsl.2017.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/20/2017] [Accepted: 11/08/2017] [Indexed: 12/11/2022]
Abstract
Loss of glucose homeostasis during sepsis is associated with increased organ dysfunction and higher mortality. Novel therapeutic strategies to promote euglycemia in sepsis are needed. We have previously shown that early low-level intravenous (IV) dextrose suppresses pancreatic insulin secretion and induces insulin resistance in septic mice, resulting in profound hyperglycemia and worsened systemic inflammation. In this study, we hypothesized that administration of low-level dextrose via the enteral route would stimulate intestinal incretin hormone production, potentiate insulin secretion in a glucose-dependent manner, and thereby improve glycemic control in the acute phase of sepsis. We administered IV or enteral dextrose to 10-week-old male C57BL/6J mice exposed to bacterial endotoxin and measured incretin hormone release, glucose disposal, and proinflammatory cytokine production. Compared with IV administration, enteral dextrose increased circulating levels of the incretin hormone glucose-dependent insulinotropic peptide (GIP) associated with increased insulin release and insulin sensitivity, improved mean arterial pressure, and decreased proinflammatory cytokines in endotoxemic mice. Exogenous GIP rescued glucose metabolism, improved blood pressure, and increased insulin release in endotoxemic mice receiving IV dextrose, whereas pharmacologic inhibition of GIP signaling abrogated the beneficial effects of enteral dextrose. Thus, stimulation of endogenous GIP secretion by early enteral dextrose maintains glucose homeostasis and attenuates the systemic inflammatory response in endotoxemic mice and may provide a therapeutic target for improving glycemic control and clinical outcomes in patients with sepsis.
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Affiliation(s)
- Faraaz Ali Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa.
| | - Srikanth Singamsetty
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Lanping Guo
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Byron W Chuan
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | | | - Bryce A Cooper
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Brett J O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Darko Stefanovski
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Burton Wice
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University, St. Louis, Mo
| | - Yingze Zhang
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Christopher P O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
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17
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Paliosa AK, Teixeira C, Rosa RG, Blatt CR. Hyperglycemia in critical patients: Determinants of insulin dose choice. Rev Assoc Med Bras (1992) 2017; 63:441-446. [PMID: 28724042 DOI: 10.1590/1806-9282.63.05.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 11/20/2016] [Indexed: 12/15/2022] Open
Abstract
Objective: To identify factors that can determine the choice of intermittent subcutaneous regular insulin dose in critically ill patients with hyperglycemia. Method: Cross-sectional study in a general adult ICU with 26 beds, data collected between September and October 2014. The variables analyzed were: sex, age, previous diagnosis of diabetes mellitus, use of corticosteroids, use of lactulose, sepsis, fasting, enteral nutrition, use of dextrose 5% in water, NPH insulin prescription and blood glucose level. Patients with one or more episodes of hyperglycemia (blood glucose greater than 180 mg/dL) were included as a convenience sample, not consecutively. Those with continuous insulin prescription were excluded from analysis. Results: We included 64 records of hyperglycemia observed in 22 patients who had at least one episode of hyperglycemia. The median administered subcutaneous regular human insulin was 6 IU and among the factors evaluated only blood glucose levels were associated with the choice of insulin dose administered. Conclusion: Clinical characteristics such as diet, medications and diagnosis of diabetes mellitus are clearly ignored in the decision-making regarding insulin dose to be administered for glucose control in critically ill patients with hyperglycemia.
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Affiliation(s)
- Aline Klitzke Paliosa
- Pharmacy Resident, Integrated Multiprofessional Health Residency (REMIS), Irmandade Santa Casa de Misericórdia de Porto Alegre (ISCMPA) and Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Cassiano Teixeira
- MD, Intensivist, ISCMPA's Central ICU and Hospital Moinhos de Vento. Adjunct Professor of Internal Medicine, UFSCPA, Porto Alegre, RS, Brazil
| | | | - Carine Raquel Blatt
- Pharmacist. Adjunct Professor, Department of Pharmaceutical Sciences, UFCSPA. Lecturer of Pharmacy, REMIS, ISCMPA/UFCSPA, Porto Alegre, RS, Brazil
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18
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Current status of perioperative management for elderly patients. Nihon Ronen Igakkai Zasshi 2017; 54:299-313. [PMID: 28855453 DOI: 10.3143/geriatrics.54.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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19
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Keeley A, Hine P, Nsutebu E. The recognition and management of sepsis and septic shock: a guide for non-intensivists. Postgrad Med J 2017; 93:626-634. [PMID: 28756405 DOI: 10.1136/postgradmedj-2016-134519] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 04/28/2017] [Accepted: 04/30/2017] [Indexed: 12/13/2022]
Abstract
Sepsis is common, often fatal and requires rapid interventions to improve outcomes. While the optimal management of sepsis in the intensive care setting is the focus of extensive research interest, the mainstay of the recognition and initial management of sepsis will occur outside the intensive care setting. Therefore, it is key that institutions and clinicians remain well informed of the current updates in sepsis management and continue to use them to deliver appropriate and timely interventions to enhance patient survival. This review discusses the latest updates in sepsis care including the new consensus definition of sepsis, the outcome of the proCESS, ProMISe and ARISE trials of early goal directed therapy (EGDT), and the most recent guidelines from the Surviving Sepsis Campaign.
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Affiliation(s)
- Alexander Keeley
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Paul Hine
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Emmanuel Nsutebu
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
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20
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Joannidis M, Druml W, Forni LG, Groeneveld ABJ, Honore PM, Hoste E, Ostermann M, Oudemans-van Straaten HM, Schetz M. Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017 : Expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive Care Med 2017; 43:730-749. [PMID: 28577069 PMCID: PMC5487598 DOI: 10.1007/s00134-017-4832-y] [Citation(s) in RCA: 193] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/02/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) in the intensive care unit is associated with significant mortality and morbidity. OBJECTIVES To determine and update previous recommendations for the prevention of AKI, specifically the role of fluids, diuretics, inotropes, vasopressors/vasodilators, hormonal and nutritional interventions, sedatives, statins, remote ischaemic preconditioning and care bundles. METHOD A systematic search of the literature was performed for studies published between 1966 and March 2017 using these potential protective strategies in adult patients at risk of AKI. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, exposure to potentially nephrotoxic drugs and radiocontrast. Clinical endpoints included incidence or grade of AKI, the need for renal replacement therapy and mortality. Studies were graded according to the international GRADE system. RESULTS We formulated 12 recommendations, 13 suggestions and seven best practice statements. The few strong recommendations with high-level evidence are mostly against the intervention in question (starches, low-dose dopamine, statins in cardiac surgery). Strong recommendations with lower-level evidence include controlled fluid resuscitation with crystalloids, avoiding fluid overload, titration of norepinephrine to a target MAP of 65-70 mmHg (unless chronic hypertension) and not using diuretics or levosimendan for kidney protection solely. CONCLUSION The results of recent randomised controlled trials have allowed the formulation of new recommendations and/or increase the strength of previous recommendations. On the other hand, in many domains the available evidence remains insufficient, resulting from the limited quality of the clinical trials and the poor reporting of kidney outcomes.
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Affiliation(s)
- M Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstasse 35, 6020, Innsbruck, Austria.
| | - W Druml
- Department of Internal Medicine III, University Hospital Vienna, Vienna, Austria
| | - L G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey and Surrey Perioperative Anaesthesia and Critical Care Collaborative Research Group (SPACeR), Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, United Kingdom
| | | | - P M Honore
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - E Hoste
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
| | - M Ostermann
- Department of Critical Care and Nephrology, Guy's and St Thomas' Hospital, London, United Kingdom
| | - H M Oudemans-van Straaten
- Department of Adult Intensive Care, VU University Medical Centre, De Boelelaan 1118, 1081 HZ, Amsterdam, The Netherlands
| | - M Schetz
- Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
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21
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45:486-552. [PMID: 28098591 DOI: 10.1097/ccm.0000000000002255] [Citation(s) in RCA: 1889] [Impact Index Per Article: 269.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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22
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304-377. [PMID: 28101605 DOI: 10.1007/s00134-017-4683-6] [Citation(s) in RCA: 3702] [Impact Index Per Article: 528.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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23
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Associations between blood glucose level and outcomes of adult in-hospital cardiac arrest: a retrospective cohort study. Cardiovasc Diabetol 2016; 15:118. [PMID: 27557653 PMCID: PMC4997657 DOI: 10.1186/s12933-016-0445-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/19/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND We intended to analyse the associations between blood glucose (BG) level and clinical outcomes of in-hospital cardiac arrest (IHCA). METHODS We conducted a retrospective observational study in a single medical centre and evaluated patients who experienced IHCA between 2006 and 2014. We used multivariable logistic regression analysis to study associations between independent variables and outcomes. We calculated the mean BG level for each patient by averaging the maximum and minimum BG levels in the first 24 h after arrest, and we used mean BG level for our final analysis. RESULTS We included a total of 402 patients. Of these, 157 patients (39.1 %) had diabetes mellitus (DM). The average mean BG level was 209.9 mg/dL (11.7 mmol/L). For DM patients, a mean BG level between 183 and 307 mg/dL (10.2-17.1 mmol/L) was significantly associated with favourable neurological outcome (odds ratio [OR] 2.71, 95 % confidence interval [CI] 1.18-6.20; p value = 0.02); a mean BG level between 147 and 317 mg/dL (8.2-17.6 mmol/L) was significantly associated with survival to hospital discharge (OR 2.38, 95 % CI 1.26-4.53; p value = 0.008). For non-DM patients, a mean BG level between 143 and 268 mg/dL (7.9-14.9 mmol/L) was significantly associated with survival to hospital discharge (OR 2.93, 95 % CI 1.62-5.40; p value < 0.001). CONCLUSIONS Mean BG level in the first 24 h after cardiac arrest was associated with neurological outcome for IHCA patients with DM. For neurological and survival outcomes, the optimal BG range may be higher for patients with DM than for patients without DM.
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24
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Zhang S, Song XY, Xia CY, Ai QD, Chen J, Chu SF, He WB, Chen NH. Effects of cerebral glucose levels in infarct areas on stroke injury mediated by blood glucose changes. RSC Adv 2016. [DOI: 10.1039/c6ra19715a] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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25
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Viana MV, Moraes RB, Fabbrin AR, Santos MF, Gerchman F. [Assessment and treatment of hyperglycemia in critically ill patients]. Rev Bras Ter Intensiva 2015; 26:71-6. [PMID: 24770692 PMCID: PMC4031893 DOI: 10.5935/0103-507x.20140011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Accepted: 02/11/2014] [Indexed: 12/24/2022] Open
Abstract
Hyperglycemia is a commonly encountered issue in critically ill patients in the
intensive care setting. The presence of hyperglycemia is associated with increased
morbidity and mortality, regardless of the reason for admission (e.g., acute
myocardial infarction, status post-cardiovascular surgery, stroke, sepsis). However,
the pathophysiology and, in particular, the treatment of hyperglycemia in the
critically ill patient remain controversial. In clinical practice, several aspects
must be taken into account in the management of these patients, including blood
glucose targets, history of diabetes mellitus, the route of nutrition (enteral or
parenteral), and available monitoring equipment, which substantially increases the
workload of providers involved in the patients' care. This review describes the
epidemiology, pathophysiology, management, and monitoring of hyperglycemia in the
critically ill adult patient.
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Affiliation(s)
- Marina Verçoza Viana
- Serviço de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brasil
| | | | | | | | - Fernando Gerchman
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
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Abstract
Ascorbic acid (vitamin C) decreases systemic inflammation and lowers fluid requirements after thermal injury; therefore it has been adopted in many burn centers as an adjunct to resuscitation. However, recent concerns have been expressed over clinically significant hypoglycemic events caused by vitamin C interference with the point-of-care (POC) glucose measurements. This case series presents a direct comparison of POC and laboratory reference glucose values in the patients receiving vitamin C infusion. Vitamin C was administered at 66 mg/kg/hour in seven patients with burns >30% TBSA. The baseline characteristics and burn characteristics were recorded. POC glucose measurements were made with a commonly used hand-held device, and the laboratory values were obtained using standard spectrophotometric methods. POC and laboratory glucose values drawn within the same hour were compared. Hemoglobin, which is known to cause interference in POC testing, was also recorded. All the patients demonstrated falsely elevated POC glucose values during and/or immediately after the infusion period, with discrepancies ranging from 10 to 200 mg/dl. These findings were irregular, unpredictable and unrelated to hemoglobin levels. The findings suggest an idiosyncratic reaction that cannot be easily corrected at the bedside using mathematical equations. POC glucose monitoring should be avoided during and after vitamin C therapy.
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27
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Singamsetty S, Shah FA, Guo L, Watanabe Y, McDonald S, Sharma R, Zhang Y, Alonso LC, O'Donnell CP, McVerry BJ. Early initiation of low-level parenteral dextrose induces an accelerated diabetic phenotype in septic C57BL/6J mice. Appl Physiol Nutr Metab 2015; 41:12-9. [PMID: 26624964 DOI: 10.1139/apnm-2015-0213] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Development of hyperglycemia during sepsis is associated with increased morbidity and mortality. Nutritional support is common practice in the intensive care unit, but the metabolic effects are not well understood. The purpose of this study is to determine the effect of early low-level calorie provision on the development of hyperglycemia in a clinically relevant murine model of sepsis. C57BL/6J mice underwent femoral arterial and venous catheterization followed by cecal ligation and puncture (CLP) or sham surgery and low-dose intravenous dextrose or saline infusion. Blood glucose, plasma insulin, and cytokines were measured after 24 h. Additional septic mice underwent hyperinsulinemic-euglycemic clamps or received intravenous insulin concurrent with dextrose to determine whole-body insulin sensitivity and test the efficacy of insulin to reverse hyperglycemia. Neither dextrose infusion nor CLP alone induced hyperglycemia. Early initiation of low-level dextrose in septic mice produced a variable glycemic response: 49% maintained euglycemia (blood glucose < 200) and 27% developed severe hyperglycemia (blood glucose ≥ 600). Hyperglycemia was associated with increased inflammation and reduced insulin secretion and sensitivity compared with control mice or CLP mice maintaining euglycemia. Insulin prevented the progression to severe hyperglycemia but was ineffective in reestablishing glycemic control once hyperglycemia had developed. In conclusion, early initiation of clinically relevant low-level dextrose (∼ 20% daily caloric requirements) precipitated hyperglycemia akin to an acute diabetic phenotype in septic mice characterized by decreased insulin sensitivity, decreased insulin secretion, and an increased inflammatory response.
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Affiliation(s)
- Srikanth Singamsetty
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Faraaz Ali Shah
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Lanping Guo
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Yoshio Watanabe
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Sherie McDonald
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Rohit Sharma
- b Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Yingze Zhang
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Laura C Alonso
- b Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Christopher P O'Donnell
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Bryan J McVerry
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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28
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Davidson P, Kwiatkowski CA, Wien M. Management of Hyperglycemia and Enteral Nutrition in the Hospitalized Patient. Nutr Clin Pract 2015; 30:652-9. [PMID: 26084507 DOI: 10.1177/0884533615591057] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
There has been increased attention on the importance of identifying and distinguishing the differences between stress-induced hyperglycemia (SH), newly diagnosed hyperglycemia (NDH), and hyperglycemia in persons with established diabetes mellitus (DM). Inpatient blood glucose control is now being recognized as not only a cost issue for hospitals but also a concern for patient safety and care. The reasons for the increased incidence of hyperglycemia in hospitalized patients include preexisting DM, undiagnosed DM or prediabetes, SH, and medication-induced hyperglycemia with resulting transient blood glucose variability. It is clear that identifying and documenting hyperglycemia in hospitalized patients with and without a previous diagnosis of DM and initiating prompt insulin treatment are important. Agreement on the optimum treatment goals for hyperglycemia remains quite controversial, and the benefits of intensive glucose management may be lost at the cost of hypoglycemia in intensive care unit patients. Nutrition support in the form of enteral nutrition (EN) increases the risk of hyperglycemia in both critical and non-critically ill hospitalized patients. Reasons for beginning a tube feeding are the same whether a person has NDH or DM. What differs is how to incorporate EN into the established insulin management protocols. The risk for hyperglycemia with the addition of EN is even higher in those without a previous diagnosis of DM. This review discusses the incidence of hyperglycemia, the pathogenesis of hyperglycemia, factors contributing to hyperglycemia in the hospitalized patient, glycemic management goals, current glycemic management recommendations, and considerations for EN formula selection, administration, and treatment.
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Affiliation(s)
| | - Cynthia Ann Kwiatkowski
- Monmouth Medical Center, Long Branch, New Jersey Rutgers University, School of Health Related Professions, Scotch Plains, New Jersey
| | - Michelle Wien
- Human Nutrition and Food Science Department, California State Polytechnic University, Pomona, California
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29
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Boutin JM, Gauthier L. Insulin infusion therapy in critically ill patients. Can J Diabetes 2015; 38:144-50. [PMID: 24690510 DOI: 10.1016/j.jcjd.2014.01.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/28/2014] [Accepted: 01/29/2014] [Indexed: 12/20/2022]
Abstract
While dysglycemia (hyperglycemia, hypoglycemia and glucose variability) is clearly associated with increased mortality in critically ill patients, target range of blood glucose control remains controversial. Standardized insulin infusion protocols constitute the basis of treatment of these patients. The choice of protocol and its implementation is a great challenge. In this article, we review the published data to help define the essential elements that compose a good protocol and apply the right conditions to make it safe and effective.
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Affiliation(s)
- Jean-Marie Boutin
- Département de Médecine, Service d'endocrinologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
| | - Lyne Gauthier
- Département de Pharmacie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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30
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Kahles F, Meyer C, Möllmann J, Diebold S, Findeisen HM, Lebherz C, Trautwein C, Koch A, Tacke F, Marx N, Lehrke M. GLP-1 secretion is increased by inflammatory stimuli in an IL-6-dependent manner, leading to hyperinsulinemia and blood glucose lowering. Diabetes 2014; 63:3221-9. [PMID: 24947356 DOI: 10.2337/db14-0100] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hypoglycemia and hyperglycemia are both predictors for adverse outcome in critically ill patients. Hyperinsulinemia is induced by inflammatory stimuli as a relevant mechanism for glucose lowering in the critically ill. The incretine hormone GLP-1 was currently found to be induced by endotoxin, leading to insulin secretion and glucose lowering under inflammatory conditions in mice. Here, we describe GLP-1 secretion to be increased by a variety of inflammatory stimuli, including endotoxin, interleukin-1β (IL-1β), and IL-6. Although abrogation of IL-1 signaling proved insufficient to prevent endotoxin-dependent GLP-1 induction, this was abolished in the absence of IL-6 in respective knockout animals. Hence, we found endotoxin-dependent GLP-1 secretion to be mediated by an inflammatory cascade, with IL-6 being necessary and sufficient for GLP-1 induction. Functionally, augmentation of the GLP-1 system by pharmacological inhibition of DPP-4 caused hyperinsulinemia, suppression of glucagon release, and glucose lowering under endotoxic conditions, whereas inhibition of the GLP-1 receptor led to the opposite effect. Furthermore, total GLP-1 plasma levels were profoundly increased in 155 critically ill patients presenting to the intensive care unit (ICU) in comparison with 134 healthy control subjects. In the ICU cohort, GLP-1 plasma levels correlated with markers of inflammation and disease severity. Consequently, GLP-1 provides a novel link between the immune system and the gut with strong relevance for metabolic regulation in context of inflammation.
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Affiliation(s)
- Florian Kahles
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Christina Meyer
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Julia Möllmann
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Sebastian Diebold
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Hannes M Findeisen
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Corinna Lebherz
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Christian Trautwein
- Department of Internal Medicine III, University Hospital Aachen, Aachen, Germany
| | - Alexander Koch
- Department of Internal Medicine III, University Hospital Aachen, Aachen, Germany
| | - Frank Tacke
- Department of Internal Medicine III, University Hospital Aachen, Aachen, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Michael Lehrke
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
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Erejuwa OO. Effect of honey in diabetes mellitus: matters arising. J Diabetes Metab Disord 2014; 13:23. [PMID: 24476150 PMCID: PMC3909917 DOI: 10.1186/2251-6581-13-23] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 01/19/2014] [Indexed: 12/22/2022]
Abstract
Diabetes mellitus remains an incurable disorder in spite of intense research. As result of limitations and unmet goals associated with the use of anti-diabetic drugs, an increased number of diabetic populations globally now resort to complementary and alternative medicine (CAM) such as herbs and other natural products. There has been a renewed interest in the use of honey in the treatment of diabetes mellitus, partly due to an increase in the availability of evidence-based data demonstrating its benefits in diabetic rodents and patients. This commentary aims to underscore some of the research implications, issues and questions raised from these studies which show the beneficial effects of honey in the treatment of diabetes mellitus. Some of the issues highlighted in this article include: considering honey is sweet and rich in sugars, how could it be beneficial in the management of diabetes mellitus? Are the observed effects of honey or combined with anti-diabetic drugs exclusive to certain honey such as tualang honey? Could these beneficial effects be reproduced with other honey samples? Anti-diabetic drugs in combination with honey improve glycemic control, enhance antioxidant defenses and reduce oxidative damage. These effects are believed to be mediated partly via antioxidant mechanism of honey. This raises another question. Could similar data be obtained if anti-diabetic drugs are co-administered with other potent antioxidants such as vitamin C or E? As the evidence has revealed, the prospect of managing diabetes mellitus with honey or antioxidants (such as vitamin C or E) as an adjunct to conventional diabetes therapy is vast. However, more well-designed, rigorously conducted randomized controlled studies are necessary to further validate these findings.
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Affiliation(s)
- Omotayo O Erejuwa
- Department of Pharmacology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
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Wagstaff AE, Cheung NW. Diabetes and hyperglycemia in the critical care setting: has the evidence for glycemic control vanished? (Or … is going away?). Curr Diab Rep 2014; 14:444. [PMID: 24277672 DOI: 10.1007/s11892-013-0444-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Hyperglycemia is associated with increased mortality and other complications amongst hospitalized patients. However, the studies of tight glycemic control in a range of critical illness settings, including intensive care, acute myocardial infarction, and stroke, have produced inconsistent and divergent results. We examine some of the factors that may have contributed to the differing results, and their implications for targeting tight glucose control in critical illness. With these in mind, most clinical guidelines now recommend moderate glucose control with an upper glucose target of <10 mmol/L (180 mg/dL) in critical illness while avoiding hypoglycemia.
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Affiliation(s)
- Amy E Wagstaff
- Dubbo Specialist Medical Centre, Dubbo Base Hospital, Suite 1/77, Myall St, Dubbo, NSW, 2830, Australia
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Pathophysiologic mechanisms in septic shock. J Transl Med 2014; 94:4-12. [PMID: 24061288 PMCID: PMC5656285 DOI: 10.1038/labinvest.2013.110] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 08/16/2013] [Accepted: 08/17/2013] [Indexed: 12/16/2022] Open
Abstract
The systemic inflammatory response that occurs in the septic patient as a result of an infectious insult affects multiple organs and systems, causing numerous physiological derangements. Alterations in phagocytic, lymphocytic and endothelial cell function and immune regulation are evident, leading to heterogeneity in a host's response to a septic challenge. In addition, the normal hemostatic balance shifts toward a procoagulant state through alterations in tissue factor, antithrombin, protein C and the inhibition of fibinolysis, which can result in thrombus formation and paradoxical hemostatic failure. In an effort to diagnose sepsis and predict outcomes, biomarkers such as C-reactive protein, pro-calcitonin, pro- and anti-inflammatory cytokines have been investigated with varying results. Targeted therapies for sepsis, most notably Xigris (recombinant human activated protein C), have proven unsuccessful and treatment continues to remain reliant on source control, antibiotics and supportive interventions, specifically early goal-directed therapy. This brief review gives an overview of the immunopathologic and coagulopathic alterations that occur in sepsis, soluble inflammatory mediators as potential diagnostic and prognostic biomarkers, and the clinical management of the septic patient.
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Kaukonen KM, Bailey M, Pilcher D, Orford N, Finfer S, Bellomo R. Glycaemic control in Australia and New Zealand before and after the NICE-SUGAR trial: a translational study. Crit Care 2013; 17:R215. [PMID: 24088368 PMCID: PMC4056083 DOI: 10.1186/cc13030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 07/30/2013] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION There is no information on the uptake of Intensive Insulin Therapy (IIT) before the Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR) trial in Australia and New Zealand (ANZ) and on the bi-national response to the trial, yet such data would provide important information on the evolution of ANZ practice in this field. We aimed to study ANZ glycaemic control before and after the publication of the results of the NICE-SUGAR trial. METHODS We analysed glucose control in critically ill patients across Australia and New Zealand during a two-year period before and after the publication of the NICE-SUGAR study. We used the mean first day glucose (Glu1) (a validated surrogate of ICU glucose control) to define practice. The implementation of an IIT protocol was presumed if the median of Glu₁ measurements was <6.44 mmol/L for a given ICU. Hypoglycaemia was categorised as severe (glucose ≤2.2 mmol/L) or moderate (glucose ≤3.9 mmol/L). RESULTS We studied 49 ICUs and 176,505 patients. No ICU practiced IIT before or after NICE-SUGAR. Overall, Glu1 increased from 7.96 (2.95) mmol/L to 8.03 (2.92) mmol/L (P <0.0001) after NICE-SUGAR. Similar increases were noted in all patient subgroups studied (surgical, medical, insulin dependent diabetes mellitus, ICU stay >48/<48 hours). The rate of severe and moderate hypoglycaemia before and after NICE-SUGAR study were 0.59% vs. 0.55% (P =0.33) and 6.62% vs. 5.68% (P <0.0001), respectively. Both crude and adjusted mortalities declined over the study period. CONCLUSIONS IIT had not been adopted in ANZ before the NICE-SUGAR study and glycaemic control corresponded to that delivered in the control arm of NICE-SUGAR trial. There were only minor changes in practice after the trial toward looser glycaemic control. The rate of moderate hypoglycaemia and mortality decreased along with such changes.
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Affiliation(s)
- Kirsi-Maija Kaukonen
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- Australian & New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS CORE), Ievers Terrace, Melbourne, VIC, Australia
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Melbourne, VIC, Australia
| | - Neil Orford
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Geelong Hospital, Barwon Health, Geelong, VIC, Australia
| | - Simon Finfer
- The George Institute for Global health, University of Sydney, Sydney, NSW, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
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