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S Y, S V, A T J, T S K, S SP, S SP, R SK, N S, S N, Prasad R. Understanding the Complexity of Hyperglycemic Emergencies: Exploring the Influence of the Type and Duration of Diabetes Mellitus and Its Impact on Mortality. Cureus 2024; 16:e58916. [PMID: 38800154 PMCID: PMC11120012 DOI: 10.7759/cureus.58916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
Background Diabetes mellitus remains a pressing global health issue, characterized by chronic metabolic dysfunction and the potential for life-threatening acute hyperglycemic emergencies. These emergencies, known as diabetic ketoacidosis and hyperosmolar hyperglycemic states, trigger a series of physiological disruptions. This article delves deeply into how the type and duration of diabetes mellitus affect the occurrence of hyperglycemic emergencies and mortality rates. Methods The study was conducted at the Institute of Internal Medicine, Rajiv Gandhi General Hospital, affiliated with Madras Medical College, spanning from July 2021 to December 2021. It encompassed both individuals newly diagnosed with diabetic ketoacidosis and patients already undergoing diabetic treatment who developed diabetic ketoacidosis and hyperosmolar hyperglycemic states. Results Within the study cohort of 110 patients, 37.27% were diagnosed with Type 1 diabetes mellitus, while 62.73% were classified as Type 2 diabetes mellitus patients. Among these individuals, 23.60% were newly diagnosed with diabetes, 22.70% had been diabetic for less than one year, 47.30% had a diabetic history of two to five years, and 6.40% had been diabetic for over six years. However, upon investigating the relationship between diabetes duration and mortality rate, no statistically significant findings were observed. Conclusion Hyperglycemic emergencies represent multifaceted clinical challenges influenced by the interplay of various factors, including the type and duration of the disease. By maintaining effective management of hyperglycemia from the outset and sustaining it throughout their lives, people with diabetes can improve their physical and mental health and reduce the likelihood of developing long-term complications that may negatively impact their overall well-being.
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Affiliation(s)
- Yogesh S
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
| | - Venkatesan S
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
| | - Jayaraj A T
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
| | - Karthigeyan T S
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
| | - Siva Prasath S
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
| | - Suriya Prakash S
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
| | - Selva Krishna R
- Internal medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
| | - Sandhiya N
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
| | - Navvin S
- Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, IND
| | - Roshan Prasad
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Hori S, Imamura Y, Kanie Y, Okamura A, Kanamori J, Watanabe M. Early postoperative hyperglycemia as a predictor of postoperative infectious complications and overall survival in non-diabetic patients with esophageal cancer. J Gastrointest Surg 2023; 27:2743-2751. [PMID: 37940808 DOI: 10.1007/s11605-023-05869-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/14/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) is known to be a risk factor for postoperative infectious complications (PICs). However, the significance of postoperative hyperglycemia in non-DM cases has not been well investigated. We sought to establish whether postoperative hyperglycemia is associated with PICs and survival among patients with esophageal cancer, with a focus on non-DM cases. METHODS A total of 430 patients who underwent subtotal esophagectomy for esophageal cancer between 2014 and 2018 were enrolled. Postoperative blood glucose was measured by arterial blood gas test every 8 h from postoperative day (POD) 1 to POD4. The association between hyperglycemia (mean ≥ 200 mg/dl) and PICs or long-term outcomes on each POD was investigated. RESULTS There were 53 DM and 377 non-DM cases. PICs occurred in 127 patients. In the multivariate analysis of all cases, PICs were associated with hyperglycemia on POD1 or -2 (odds ratio [OR] = 1.69, 95% CI, 1.05-2.73, P = 0.031 for POD1; OR = 2.55, 95% CI, 1.10-5.93, P = 0.029 for POD 2). Among non-DM cases, the association was more evident, and persisted until POD4 (OR = 1.94, 95% CI, 1.16-3.24, P = 0.012 for POD1; OR = 3.68, 95% CI, 1.28-10.6, P = 0.016 for POD2; OR = 3.07, 95% CI, 1.11-8.51, P = 0.031 for POD4). Survival analyses limited to R0 cases revealed hyperglycemia on POD2 as an independent prognostic factor in all cases (N = 412) [hazard ratio (HR) = 2.61, 95%CI, 1.21-5.63, P = 0.014], with the prognostic impact more evident among non-DM cases (N = 360) (HR = 4.38, 95% CI, 1.82-10.57, P = 0.0010). CONCLUSION Postoperative hyperglycemia is associated with PICs and worse survival after esophagectomy, particularly in patients without DM.
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Affiliation(s)
- Soshi Hori
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-Ku, Tokyo, 135-8550, Japan.
| | - Yasukazu Kanie
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Akihiko Okamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Jun Kanamori
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-Ku, Tokyo, 135-8550, Japan
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Sreedharan R, Khanna S, Shaw A. Perioperative glycemic management in adults presenting for elective cardiac and non-cardiac surgery. Perioper Med (Lond) 2023; 12:13. [PMID: 37120562 PMCID: PMC10149003 DOI: 10.1186/s13741-023-00302-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/19/2023] [Indexed: 05/01/2023] Open
Abstract
Perioperative dysglycemia is associated with adverse outcomes in both cardiac and non-cardiac surgical patients. Hyperglycemia in the perioperative period is associated with an increased risk of postoperative infections, length of stay, and mortality. Hypoglycemia can induce neuronal damage, leading to significant cognitive deficits, as well as death. This review endeavors to summarize existing literature on perioperative dysglycemia and provides updates on pharmacotherapy and management of perioperative hyperglycemia and hypoglycemia in surgical patients.
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Affiliation(s)
- Roshni Sreedharan
- Department of Intensive Care & Resuscitation, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of General Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sandeep Khanna
- Department of General Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Department of Outcomes Research, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Andrew Shaw
- Department of Intensive Care & Resuscitation, Cleveland Clinic Foundation, Cleveland, OH, USA
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Evaluating the Impact of Inadequate Meal Consumption on Insulin-Related Hypoglycemia in Hospitalized Patients. Endocr Pract 2020; 27:443-448. [PMID: 33934753 DOI: 10.1016/j.eprac.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/09/2020] [Accepted: 11/06/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Meal intake is sometimes reduced in hospitalized patients. Meal-time insulin administration can cause hypoglycemia when a meal is not consumed. Inpatient providers may avoid ordering meal-time insulin due to hypoglycemia concerns, which can result in hyperglycemia. The frequency of reduced meal intake in hospitalized patients remains inadequately determined. This quality improvement project evaluates the percentage of meals consumed by hospitalized patients with insulin orders and the resulting risk of postmeal hypoglycemia (blood glucose [BG] <70 mg/dL, <3.9 mmol/L). METHODS This was a retrospective quality improvement project evaluating patients with any subcutaneous insulin orders hospitalized at a regional academic medical center between 2015 and 2017. BG, laboratory values, point of care, insulin administration, diet orders, and percentage of meal consumed documented by registered nurses were abstracted from electronic health records. RESULTS Meal consumption ≥50% was observed for 85% of meals with insulin orders, and bedside registered nurses were accurate at estimating this percentage. Age ≥65 years was a risk factor for reduced meal consumption (21% of meals 0%-49% consumed, P < .05 vs age < 65 years [12%]). Receiving meal-time insulin and then consuming only 0% to 49% of a meal (defined here as a mismatch) was not rare (6% of meals) and increased postmeal hypoglycemia risk. However, the attributable risk of postmeal hypoglycemia due to this mismatch was low (4 events per 1000) in patients with premeal BG between 70 and 180 mg/dL. CONCLUSION This project demonstrates that hospitalized patients treated with subcutaneous insulin have a low attributable risk of postmeal hypoglycemia related to inadequate meal intake.
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Fiorillo C, Quero G, Laterza V, Mascagni P, Longo F, Menghi R, Razionale F, Rosa F, Mezza T, Boskoski I, Giaccari A, Alfieri S. Postoperative hyperglycemia affects survival after gastrectomy for cancer: A single-center analysis using propensity score matching. Surgery 2019; 167:815-820. [PMID: 31810521 DOI: 10.1016/j.surg.2019.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/31/2019] [Accepted: 11/03/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND No data are present currently on the potential correlation between postoperative hyperglycemia and long-term outcomes after gastric surgery for cancer. The aim of this study was to investigate the effects of postoperative hyperglycemia on survival after curative gastrectomy for cancer. METHODS All patients who underwent gastric surgery for cancer with curative intent were reviewed retrospectively. Diabetic patients and patients who needed pancreatic resection were excluded. In all patients, a prepared intravenous infusion of NaCl and carbohydrates (Isolyte Baxter 2,000 mL/day; glucose 50.0 g/L;Ringers lactate 1,000 mL/day) was used, and the patients were kept nil by mouth until the fourth postoperative day. The glucose levels were monitored during the first 72 hours. The study population was divided into normoglycemic and hyperglycemic patients according to the blood glucose level (<140 mg/dL and ≥140 mg/dL, respectively). The 2 groups were matched for age, sex, type of operative procedure, TNM status, and lymph node status. RESULTS After matching, 104 patients were included for the analysis. Perioperative morbidity accounted for 18.3% with a greater rate for hyperglycemic patients (12% vs 31%; P = .018). When compared with normoglycemic patients, hyperglycemic patients had worse overall survival (45% vs 57%; P = .05) and worse disease-free survival (46% vs 68%; P = .02). On the multivariate analysis, hyperglycemia was an independent risk factor for a worse overall and disease-free survival. CONCLUSION Postoperative hyperglycemia owing to surgical stress conditions can affect postoperative outcomes. Additionally, hyperglycemia may be a factor that promotes gastric cancer progression.
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Affiliation(s)
- Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Vito Laterza
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Fabio Longo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Roberta Menghi
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Razionale
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Fausto Rosa
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Teresa Mezza
- Università Cattolica del Sacro Cuore, Rome, Italy; Endocrinology and Metabolic Diasease Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ivo Boskoski
- Università Cattolica del Sacro Cuore, Rome, Italy; Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea Giaccari
- Università Cattolica del Sacro Cuore, Rome, Italy; Endocrinology and Metabolic Diasease Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
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Steinberg A, Van Cleave JH, Parikh AB, Moshier E, Ru M, Lawson M, Marks D, Montelibano A, Philpott A, Garner K, Hammer MJ. The Effect of Glucose Levels Prior to Hematopoietic Cell Transplantation on Post-Transplant Complications and Health Resource Utilization. Int J Hematol Oncol Stem Cell Res 2019; 13:122-131. [PMID: 31649802 PMCID: PMC6801324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: Abnormal blood glucose (BG) levels during hematopoietic cell transplantation (HCT) are associated with increased infections, delayed engraftment, and prolonged hospitalization, though little is known about these associations. Materials and Methods: We retrospectively evaluated mean BG levels in the week prior to HCT and subsequent outcomes for 852 HCTs at our hospital from 1/2009 - 12/2013 pertaining to 745 patients. Outcomes included infections (pneumonia, C. difficile, positive cultures, administration of antimicrobials, or neutropenic fever), time-to-engraftment (TTE), and quality indicators (30- and 90-day readmission rates [RR] and median length-of-stay [LOS]). Results: 404 patients met the criteria for involvement in this study. The population was 55% male and was racially and ethnically mixed (White 38%, African American 23%, Hispanic 6%, Asian 7%, Other 21%). Mean age was 57+14 years. Significantly more patients in Group 2 were diagnosed with pneumonia (19%) compared with the Group 1 (7%) and Group 3 (10%) [p=.0054]. Patients in Group 2 also had significantly longer median LOS: Group 1-23 days, Group 2-26 days, Group 3-22 days [p = .0157]. No significant differences were noted in terms of the other infectious complications or in time-to-engraftment or readmissions. Conclusion: Pre-HCT BG trends may be a prognostic biomarker for adverse outcomes, and thus can help improve quality of care for HCT patients.
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Affiliation(s)
- Amir Steinberg
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - Janet H. Van Cleave
- Department of Nursing, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA,New York University Rory Meyers College of Nursing, New York, NY, USA
| | - Anish B. Parikh
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - Erin Moshier
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Meng Ru
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Molly Lawson
- Department of Nursing, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Douglas Marks
- Division of Hematology/Oncology, Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | - Antoinette Montelibano
- Department of Nursing, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amanda Philpott
- Department of Nursing, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kourtney Garner
- Department of Nursing, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marilyn J. Hammer
- Department of Nursing, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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López-Simarro F, Redondo Margüello E, Mediavilla Bravo JJ, Soriano Llora T, Iturralde Iriso J, Hormigo Pozo A. [Prevention and treatment of infectious diseases in diabetic patients]. Semergen 2018; 45:117-127. [PMID: 30580897 DOI: 10.1016/j.semerg.2018.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 01/13/2023]
Abstract
The bidirectional relationship between infectious diseases and diabetes is well-known. On the one hand, diabetes patients are at a higher risk of presenting with infectious diseases, possibly with more severity, and on the other hand, infectious diseases impair metabolic control in patients with diabetes. Population ageing arises partly due to an increased survival rate in chronic diseases, of which diabetes is amongst them. Improving infectious disease prevention could reduce complications arising from the former diseases, consequences of decompensated diabetes condition (morbidity, incapacity, hospital admissions, healthcare costs, and mortality rates) and result in improved quality of life in patients with diabetes. The current review presents the treatment of infectious diseases in patients with diabetes and the dealing with immuno-preventable diseases with the currently advised vaccinations.
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Affiliation(s)
- F López-Simarro
- Área Básica de Salud Martorell Urbano, Institut Català de la Salut, Martorell, Barcelona, España; Grupo de Trabajo Diabetes de SEMERGEN, España.
| | - E Redondo Margüello
- Centro de Salud Internacional Madrid Salud, Ayuntamiento de Madrid, Madrid, España; Grupo de Actividades Preventivas y Salud Pública de SEMERGEN, España
| | - J J Mediavilla Bravo
- Grupo de Trabajo Diabetes de SEMERGEN, España; Centro de Salud Burgos Rural, Burgos, España
| | - T Soriano Llora
- Grupo de Trabajo Diabetes de SEMERGEN, España; Centro de Salud Canal de Panamá, Madrid, España
| | - J Iturralde Iriso
- Grupo de Trabajo Diabetes de SEMERGEN, España; Centro de Salud La Habana, Vitoria-Gasteiz, España
| | - A Hormigo Pozo
- Grupo de Trabajo Diabetes de SEMERGEN, España; Unidad de Gestión Clínica Puerta Blanca, Málaga, España
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8
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Helmle KE, Edwards AL, Kushniruk AW, Borycki EM. Qualitative Evaluation of the Barriers and Facilitators Influencing the Use of an Electronic Basal Bolus Insulin Therapy Protocol to Improve the Care of Adult Inpatients With Diabetes. Can J Diabetes 2018; 42:459-464.e1. [PMID: 29395845 DOI: 10.1016/j.jcjd.2017.10.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/26/2017] [Accepted: 10/26/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVES A qualitative evaluation of the perceived impact of a new evidence-informed electronic basal bolus insulin therapy order set on clinical workflow and practice, and exploration of potential barriers and facilitators to electronic basal bolus insulin order set uptake and use in acute care facilities for various acute care team members. METHODS We conducted 9 semistructured focus groups with multidisciplinary nursing staff (n=22), resident trainees (n=24) and attending physicians (n=23) involved in the delivery of inpatient diabetes care at 3 adult acute care facilities. The domains of inquiry included impact on workload, perceived impact on patient care and discipline-specific barriers and facilitators to use, including care-providers' needs, comfort and competencies, contributions from the clinical environment and efficacy of communication. The interviews were transcribed and analyzed using a content analysis approach. RESULTS Several major themes emerged from the focus group discussions, including impact of education, information technology/user interface, workflow, organizational issues and practices, and perceived outcomes. Barriers and facilitators were identified relating to each theme. CONCLUSIONS The outcomes highlight the complex interplay between educational, organizational and technical themes and the significance of employing a systemic approach to support the implementation of electronic inpatient glycemic-management protocols within complex social organizations.
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Affiliation(s)
- Karmon E Helmle
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Alun L Edwards
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andre W Kushniruk
- School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada
| | - Elizabeth M Borycki
- School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada
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9
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Helmle KE, Chacko S, Chan T, Drake A, Edwards AL, Moore GE, Philp LC, Popeski N, Roedler RL, Rogers EJR, Zimmermann GL, McKeen J. Knowledge Translation to Optimize Adult Inpatient Glycemic Management With Basal Bolus Insulin Therapy and Improve Patient Outcomes. Can J Diabetes 2017; 42:505-513.e1. [PMID: 29555341 DOI: 10.1016/j.jcjd.2017.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/19/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To develop and evaluate a Basal Bolus Insulin Therapy (BBIT) Knowledge Translation toolkit to address barriers to adoption of established best practice with BBIT in the care of adult inpatients. METHODS This study was conducted in 2 phases and focused on the hospitalist provider group across 4 acute care facilities in Calgary. Phase 1 involved a qualitative evaluation of provider and site specific barriers and facilitators, which were mapped to validated interventions using behaviour change theory. This informed the co-development and optimization of the BBIT Knowledge Translation toolkit, with each tool targeting a specific barrier to improved diabetes care practice, including BBIT ordering. In Phase 2, the BBIT Knowledge Translation toolkit was implemented and evaluated, focusing on BBIT ordering frequency, as well as secondary outcomes of hyperglycemia (patient-days with BG >14.0 mmol/L), hypoglycemia (patient-days with BG <4.0 mmol/L), and acute length of stay. RESULTS Implementation of the BBIT Knowledge Translation toolkit resulted in a significant 13% absolute increase in BBIT ordering. Hyperglycemic patient-days were significantly reduced, with no increase in hypoglycemia. There was a significant, absolute 14% reduction in length of stay. CONCLUSIONS The implementation of an evidence-informed, multifaceted BBIT Knowledge Translation toolkit effectively reduced a deeply entrenched in-patient diabetes care gap. The resulting sustained practice change improved patient clinical and system resource utilization outcomes. This systemic approach to implementation will guide further scale and spread of glycemic optimization initiatives.
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Affiliation(s)
- Karmon E Helmle
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Sunita Chacko
- Hospitalist Program, Department of Family Medicine, Alberta Health Services-Calgary Zone, Calgary, Alberta, Canada
| | - Trevor Chan
- Hospitalist Program, Department of Family Medicine, Alberta Health Services-Calgary Zone, Calgary, Alberta, Canada
| | - Alison Drake
- Hospitalist Program, Department of Family Medicine, Alberta Health Services-Calgary Zone, Calgary, Alberta, Canada
| | - Alun L Edwards
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Glenda E Moore
- Diabetes, Obesity, and Nutrition Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Leta C Philp
- Diabetes, Obesity, and Nutrition Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Naomi Popeski
- Diabetes, Obesity, and Nutrition Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Rhonda L Roedler
- Pharmacy Services, South Health Campus, Alberta Health Services, Calgary, Alberta, Canada
| | - Edwin J R Rogers
- Clinical Analytics, Analytics, Data Integration, Measurement and Reporting (DIMR), Alberta Health Services, Calgary, Alberta, Canada
| | - Gabrielle L Zimmermann
- Knowledge Translation Platform, Alberta SPOR SUPPORT Unit, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Julie McKeen
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Diabetes, Obesity, and Nutrition Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
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10
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Hodges A, Hall J, Castellanos E, Laue E, Ellis T, Oelschlaeger L. Implementing a pharmacist consultation model for multimodal insulin therapy. Am J Health Syst Pharm 2017; 74:e224-e229. [DOI: 10.2146/ajhp150941] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Angela Hodges
- Texas Health Huguley Hospital Fort Worth South, Burleson, TX
| | - James Hall
- Texas Health Huguley Hospital Fort Worth South, Burleson, TX
| | | | - Edward Laue
- Texas Health Huguley Hospital Fort Worth South, Burleson, TX
| | - Tammy Ellis
- Texas Health Huguley Hospital Fort Worth South, Burleson, TX
| | - LaDonna Oelschlaeger
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA
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11
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Hijaze D, Szalat A. Retrospective Evaluation of Glycemic Control With Basal-Bolus or Neutral Protamine Hagedorn Insulin Regimens in Patients Receiving Continuous Enteral Nutrition Therapy in Medicine Wards. Nutr Clin Pract 2017; 32:557-562. [PMID: 28760108 DOI: 10.1177/0884533617692765] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Reasonable glycemic control is difficult to achieve in patients with diabetes mellitus (DM) receiving continuous enteral nutrition therapy (CENT). There are no solid evidence-based medicine guidelines regarding this issue in these patients. The purpose of this study was to determine if the use of a basal-bolus insulin regimen is more effective than neutral protamine Hagedorn (NPH) insulin alone in controlling blood glucose in non-critically ill patients with DM receiving CENT. We performed a retrospective, records-based review comparing basal-bolus with NPH insulin regimen in these patients, hospitalized in the internal medicine wards in our hospital. Number of hypoglycemic episodes, mean blood glucose, and time-to-target (time needed to reach 3 successive glucose readings in the appropriate target of 140-180 mg/dL) were evaluated in each regimen. Mean blood glucose was 199.22 mg/dL (95% confidence interval [CI], 179.8-218.5 mg/dL) in the basal-bolus vs 190.73 mg/dL (95% CI, 172.1-209.2 mg/dL) in the NPH insulin regimen ( P = .538). Time-to-target was an average of 3.65 ± 1.75 days in the basal-bolus group and 4.33 ± 2.42 days in the NPH group ( P = .364). There were no statistically significant differences in frequency of hypoglycemia ( P = .364). Rate of death was high (around 40%) in both groups. We conclude that hospitalized hyperglycemic patients receiving CENT can be treated by either basal-bolus or NPH insulin regimens. However, the overall glucose levels remain elevated during hospitalization irrespective of the insulin therapy. There is an urgent need to define glucose targets in this population of patients and to evaluate prospectively head-to-head different insulin protocols.
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Affiliation(s)
- Dema Hijaze
- 1 Internal Medicine Department, Hadassah-Mount Scopus, Hebrew-University Medical Center, Jerusalem, Israel
| | - Auryan Szalat
- 1 Internal Medicine Department, Hadassah-Mount Scopus, Hebrew-University Medical Center, Jerusalem, Israel
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Abstract
An association between perioperative hyperglycemia and adverse outcomes has been established in surgical patients, 1 -3 with morbidity being reduced in those treated with insulin.5 -6 A practical treatment algorithm and literature summary is provided for surgical patients with diabetes and hyperglycemia.
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Affiliation(s)
- Elizabeth W Duggan
- From the Departments of Anesthesiology (E.W.D., K.C.) and Medicine (G.E.U.), Emory University School of Medicine, Atlanta, Georgia
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Bissell LA, Hensor EMA, Kozera L, Mackie SL, Burska AN, Nam JL, Keen H, Villeneuve E, Donica H, Buch MH, Conaghan PG, Andrews J, Emery P, Morgan AW. Improvement in insulin resistance is greater when infliximab is added to methotrexate during intensive treatment of early rheumatoid arthritis-results from the IDEA study. Rheumatology (Oxford) 2016; 55:2181-2190. [PMID: 27638812 DOI: 10.1093/rheumatology/kew306] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 07/15/2016] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To determine the change in established biomarkers of cardiovascular (CV) risk, namely, total cholesterol/high-density lipoprotein cholesterol ratio (TC/HDL-C), N-terminal pro-brain natriuretic peptide (NT-proBNP) and insulin resistance (IR) in patients with early RA treated with two different treat-to-target strategies. METHODS Fasting glucose, lipids, insulin and NT-proBNP were measured at baseline, weeks 26 and 78 in 79 DMARD-naïve RA patients, free of CV disease, as part of a double-blind randomized controlled trial of MTX with either infliximab (IFX) or methylprednisolone as induction therapy. Homeostasis model assessment-estimated IR (HOMA-IR) (glucose*insulin/405) was used to measure IR. Multiple imputation was employed, and linear regression analyses were adjusted for baseline values. RESULTS Changes in DAS44-CRP did not differ between the treatment arms at weeks 26 and 78. Mean TC/HDL-C, HOMA-IR and NT-proBNP improved in both groups at weeks 26 and 78, although change in NT-proBNP was not statistically significant at week 78. Changes in TC/HDL-C and NT-proBNP were similar between treatment arms, but HOMA-IR values in the IFX + MTX arm were 42% lower than those treated with MTX + methylprednisolone at week 78 (P = 0.003); the difference remained significant after adjustment for baseline BMI, ACPA positivity, smoking status and intramuscular glucocorticoid use (P = 0.007). CONCLUSION When implementing a treat-to-target approach, treatment of early RA was associated with improvement in TC/HDL-C, HOMA-IR and NT-proBNP, and a greater long-term improvement in HOMA-IR was seen in those treated with IFX. TRIAL REGISTRATION EU Clinical Trials Register, http://www.clinicaltrialsregister.eu, Eudract-2005-005013-37; ISRTCNregisrty, http://www.isrctn.com, ISRCTN48638981.
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Affiliation(s)
- Lesley-Anne Bissell
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Elizabeth M A Hensor
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Lukasz Kozera
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Faculty of Pharmacy, Wroclaw Medical University, Wroclaw
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Agata N Burska
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Helen Keen
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edith Villeneuve
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Helena Donica
- Department of Biochemical Diagnostics, Medical University of Lublin, Lublin, Poland
| | - Maya H Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline Andrews
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ann W Morgan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds & NIHR-Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK,
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Wiwanitkit V. Hyperglycemia in poor controlled diabetes from crude tamarind herbal pill: a case study. Asian Pac J Trop Biomed 2015; 1:79-80. [PMID: 23569730 DOI: 10.1016/s2221-1691(11)60073-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Revised: 12/28/2010] [Accepted: 02/28/2011] [Indexed: 11/16/2022] Open
Abstract
Hyperglycemia is an important finding in the diabetic patient with poor glycemic control. There are several possible causes of hyperglycemic. Here, the author presents an interesting case study on a female diabetic patient presenting with hyperglycemic due to intake of crude tamarind herbal pill. General practitioner should realize that the use of alternative medicine can be a cause of unexplained hyperglycemic episode in diabetic patient.
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Brady VJ, Grimes D, Armstrong T, LoBiondo-Wood G. Management of Steroid-Induced Hyperglycemia in Hospitalized Patients With Cancer: A Review. Oncol Nurs Forum 2014; 41:E355-65. [DOI: 10.1188/14.onf.e355-e365] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Tamez-Pérez HE, Quintanilla-Flores DL, Proskauer-Peña SL, González-González JG, Hernández-Coria MI, Garza-Garza LA, Tamez-Peña AL. Inpatient hyperglycemia: Clinical management needs in teaching hospital. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2014; 1:176-178. [PMID: 29159098 PMCID: PMC5685020 DOI: 10.1016/j.jcte.2014.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 09/11/2014] [Accepted: 09/16/2014] [Indexed: 12/22/2022]
Affiliation(s)
- H E Tamez-Pérez
- Subdirección de Investigación, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González" UANL, Monterrey, NL, México
| | - D L Quintanilla-Flores
- Subdirección de Investigación, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González" UANL, Monterrey, NL, México
| | - S L Proskauer-Peña
- Subdirección de Investigación, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González" UANL, Monterrey, NL, México
| | - J G González-González
- Subdirección de Investigación, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González" UANL, Monterrey, NL, México
| | - M I Hernández-Coria
- Subdirección de Investigación, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González" UANL, Monterrey, NL, México
| | - L A Garza-Garza
- Subdirección de Investigación, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González" UANL, Monterrey, NL, México
| | - A L Tamez-Peña
- Subdirección de Investigación, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González" UANL, Monterrey, NL, México
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Smiley D, Umpierrez GE, Hermayer K, Newton C, Jacobs S, Olson DE, Khan A, Rizzo M, Peng L, Reyes D, Cardona S, Fonseca V. Differences in inpatient glycemic control and response to subcutaneous insulin therapy between medicine and surgery patients with type 2 diabetes. J Diabetes Complications 2013; 27:637-41. [PMID: 23911535 PMCID: PMC4416966 DOI: 10.1016/j.jdiacomp.2013.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 05/03/2013] [Accepted: 05/30/2013] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To determine differences in inpatient glycemic control and response to two different glargine-based insulin regimens in general medicine and surgery patients with type 2 diabetes (T2D). METHODS This is a post-hoc analysis of a prospective, multicenter, randomized trial of 298 non-ICU medicine and surgery patients with T2D treated with Basal Bolus regimen with glargine once daily and glulisine before meals and with Basal Plus regimen with glargine once daily and supplemental doses of glulisine before meals for blood glucose (BG)>140mg/dl. Major study outcomes included differences in mean daily BG, frequency of treatment failures (defined as >2 consecutive BG>240mg/dl or a mean daily BG>240mg/dl), and hypoglycemia between the medicine and surgery cohorts. RESULTS Patients treated with Basal Bolus or with Basal Plus experienced similar improvement in mean daily BG after 1st day of therapy (p=0.16), number of treatment failures (p=0.11) and hypoglycemic events (p=0.50). Compared to surgery patients (n=130), medicine patients (n=168) had higher admission BG (p=0.01) and HbA1c levels (p<0.01); however, they had similar response to either treatment regimen without differences in mean daily BG after 1st day of therapy (p=0.18), number of treatment failures (p=0.58), daily insulin requirements (p=0.36), or in the frequency of hypoglycemia (p=0.79). CONCLUSION The Basal Plus regimen with glargine once daily and correction doses with glulisine before meals resulted in similar glycemic control to basal bolus regimen. We observed no differences in response to either basal insulin regimen between medicine and surgery patients with type 2 diabetes.
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Affiliation(s)
- Dawn Smiley
- Department of Medicine, Division of Endocrinology at Emory University, Atlanta, GA, USA.
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Rymaszewski HL, Breakwell S. A Retrospective Review of Sliding Scale vs. Basal/Bolus Insulin Protocols. J Nurse Pract 2013. [DOI: 10.1016/j.nurpra.2013.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Brady V. Management of hyperglycemia in the intensive care unit: when glucose reaches critical levels. Crit Care Nurs Clin North Am 2012; 25:7-13. [PMID: 23410641 DOI: 10.1016/j.ccell.2012.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Hyperglycemia among hospitalized critically ill patients has been shown to be an independent predictor of poorer outcomes. Appropriate treatment of hyperglycemia among these patients has been associated with reduced mortality and morbidity. There are risk and benefits associated with management of hyperglycemia in the critically ill patient. The ultimate goal of treatment is to obtain glycemic control without causing undue hypoglycemia. This article discusses issues related to glycemic control among critically ill patients, glucose targets in this population, and best practices in the management of hyperglycemia in patients in the intensive care unit.
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Affiliation(s)
- Veronica Brady
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX 77030-1402, USA.
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Crawford K. Guidelines for care of the hospitalized patient with hyperglycemia and diabetes. Crit Care Nurs Clin North Am 2012; 25:1-6. [PMID: 23410640 DOI: 10.1016/j.ccell.2012.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hyperglycemia and diabetes place hospitalized patients at greater risk for serious complications such as infections, diabetic ketoacidosis, hyperosmolar hyperglycemic state, dehydration, electrolyte imbalances, greater antibiotic use, and lengthened hospitalization. Identification and proper treatment of hyperglycemia and diabetes are therefore essential for prevention of significant morbidity and mortality to the patient and to conserve ever-shrinking health care resources. The author discusses standards for the identification of diabetes and hyperglycemia, provides recommendations for target blood glucose values, and discusses current consensus guidelines on inpatient glycemic management in non-critically ill hospitalized patients.
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Affiliation(s)
- Kate Crawford
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1461, Houston, TX 77030, USA.
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De Flines J, Paquot N, Preiser JC. Gestion de l’hyperglycémie au cours d’une nutrition parentérale. NUTR CLIN METAB 2012. [DOI: 10.1016/j.nupar.2012.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Farrokhi F, Klindukhova O, Chandra P, Peng L, Smiley D, Newton C, Pasquel F, Fereira ME, Umpierrez G. Risk factors for inpatient hypoglycemia during subcutaneous insulin therapy in non-critically ill patients with type 2 diabetes. J Diabetes Sci Technol 2012; 6:1022-9. [PMID: 23063027 PMCID: PMC3570835 DOI: 10.1177/193229681200600505] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We aimed to determine risk factors associated with hypoglycemia during subcutaneous insulin therapy in non-critically ill patients with type 2 diabetes. METHODS We conducted an analysis of three randomized control trials using basal/bolus regimen and regular sliding scale insulin (SSI) in patients with diabetes admitted to medical and surgical settings. RESULTS We analyzed medical records of 261 general medicine and 211 noncardiac surgery patients treated with basal/bolus regimen with glargine/glulisine (n = 169), detemir/aspart (n = 67), neutral protamine Hagedorn/regular (n = 63), or with SSI (n = 173). The overall frequency of mild and severe hypoglycemia (<70 and <40 mg/dl) was 19% and 2%, respectively. During treatment, medical patients experienced a higher number of hypoglycemia than surgical patients (23% versus 13%; p = .005), but the rate of severe hypoglycemia was similar between groups (1.9% versus 1.9%; p = not significant). Increasing age, impaired kidney function (glomerular filtration rate < 60 ml/min), total daily insulin dose, and type of insulin regimen (basal/bolus versus SSI) during hospitalization were important contributors for hypoglycemia in both medical and surgical patients. Among these variables, increasing age and type of insulin regimen (basal/bolus versus SSI) were found to be independent predictors of hypoglycemic events. CONCLUSIONS Mild hypoglycemic events are common during subcutaneous insulin therapy in medical and surgical patients with type 2 diabetes. Increasing age, impaired renal function, daily insulin dose, and insulin regimen (basal/bolus versus SSI) are important predictors of hypoglycemia during insulin therapy in patients with type 2 diabetes mellitus.
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Abstract
PURPOSE/OBJECTIVES To introduce a conceptual model detailing the physiologic contributions of malglycemia to cancer formation and increased morbidity and mortality. DATA SOURCES A literature search was conducted using the PubMed, CINAHL®, and Cochrane databases, as well as Surveillance, Epidemiology and End Results (SEER) cancer statistics. DATA SYNTHESIS Multiple complex factors are associated with malignancy formation, proliferation, and outcomes for each individual. The authors present a model, termed the Malglycemia Orbit Model, that is analogous to an atom, centered on a core of individual factors, and surrounded by "orbits" containing cancer and related factors. Highlighted in this model is the role of malglycemia. CONCLUSIONS Cancer formation and sequelae involve numerous multifaceted factors. One factor not well described or understood within the context of malignancies is glycemic status, most notably how malglycemia impacts cancer formation and risks for adverse outcomes. The atomic-structured malglycemia model describes this process. IMPLICATIONS FOR NURSING Among the many uncontrollable factors that contribute to cancer formation and adverse outcomes, malglycemia is one that is modifiable. Nurses are in a prime position to conduct research to enhance understanding and ultimately improve protocols for better glycemic control and, in effect, better outcomes for individuals with cancer.
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McGovern KF, Lascola KM, Smith SA, Clark-Price SC, McMichael M, Wilkins PA. Assessment of acute moderate hyperglycemia on traditional and thromboelastometry coagulation parameters in healthy adult horses. J Vet Emerg Crit Care (San Antonio) 2012; 22:550-7. [DOI: 10.1111/j.1476-4431.2012.00792.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 07/16/2012] [Indexed: 11/26/2022]
Affiliation(s)
| | | | - Stephanie A. Smith
- College of Medicine; University of Illinois; 1008 W Hazelwood Drive; Urbana; IL; 61802
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Chaudhuri A, Umpierrez GE. Oxidative stress and inflammation in hyperglycemic crises and resolution with insulin: implications for the acute and chronic complications of hyperglycemia. J Diabetes Complications 2012; 26:257-8. [PMID: 22658407 PMCID: PMC3718464 DOI: 10.1016/j.jdiacomp.2012.04.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 04/30/2012] [Indexed: 01/04/2023]
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Hsia E, Seggelke SA, Gibbs J, Rasouli N, Draznin B. Comparison of 70/30 biphasic insulin with glargine/lispro regimen in non-critically ill diabetic patients on continuous enteral nutrition therapy. Nutr Clin Pract 2012; 26:714-7. [PMID: 22205560 DOI: 10.1177/0884533611420727] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite significant advances in inpatient diabetes management, it is still a challenge to choose the safest and most efficacious subcutaneous insulin regimen for diabetic patients on continuous enteral nutrition (EN) therapy. The authors conducted a retrospective analysis of glycemic control in 22 non-critically ill diabetic patients, receiving at least 3 days of continuous EN. Patients received different insulin regimens while on continuous EN, including a basal/bolus glargine/lispro regimen (group 1, n = 8), 70/30 biphasic insulin twice daily (group 2, n = 8), and 70/30 biphasic insulin 3 times a day (group 3, n = 6). The glucose data from 72 hours from the initiation of EN were analyzed (12 point-of-contact glucose measurements per patient). Overall, the degree of control was comparable in all groups, with target range maintained more consistently in group 3 (70/30 insulin administered 3 times daily). In this group, 69% of values were in the target range (140-180 mg/dL) as compared with 24% in glargine/lispro group and 22% in the 70/30 insulin bid group. Eight hypoglycemic episodes occurred among the 3 groups: 5 episodes in group 1 (5.4%), 2 episodes in group 2 (2.1%), and 1 episode in group 3 (1.4%) (P = .05, groups 2 and 3 vs group 1). Administration of 70/30 biphasic insulin 3 times daily is a safe therapeutic regimen in diabetic patients on continuous EN as it maintains glycemia in the target range and might produce fewer episodes of hypoglycemia.
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Affiliation(s)
- Elisa Hsia
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Denver, 12801 E 17th Ave, Aurora, CO 80045, USA
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Abstract
PURPOSE OF REVIEW The publication of Van den Berghe's landmark study in 2001 supported the use of intensive insulin therapy (IIT) to target normoglycemia in the critically ill and triggered a new era in glycemic management in the perioperative period and in the ICU. In 2009, the normoglycemia in intensive care evaluation-survival using glucose algorithm regulation (NICE-SUGAR) trial demonstrated increased mortality and incidence of hypoglycemia in patients managed with IIT, resulting in a shift toward higher blood glucose targets in this patient population. This review distills clinically pertinent principles from the related literature published in the months since the NICE-SUGAR trial. RECENT FINDINGS A target blood glucose level in the acute care setting supported by many of the pertinent societies and frequently quoted in the literature is 140-180 mg/dl. Hyperglycemia, hypoglycemia, and glucose variability are detrimental. Accurate and efficient glucose monitoring devices are essential. Insulin infusion protocols (IIPs) employed to achieve desired blood glucose targets must be individualized and validated for the ICU and institution in which they are being implemented. SUMMARY Appropriate glycemic management in the acute care setting can be achieved by targeting a reasonable blood glucose range and employing specific and institutionally validated IIPs.
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Creating a perioperative glycemic control program. Anesthesiol Res Pract 2011; 2011:465974. [PMID: 21912542 PMCID: PMC3168770 DOI: 10.1155/2011/465974] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 06/15/2011] [Accepted: 07/06/2011] [Indexed: 01/23/2023] Open
Abstract
Hyperglycemia in the surgical population is a recognized risk factor for postoperative complications; however, there is little literature to date regarding the management of hyperglycemia in the perioperative period. Here, we detail the strategies that our institutions have employed to identify and treat hyperglycemia in patients with diabetes who present for surgery. Our approach focuses on the recognition of hyperglycemia and metabolic abnormalities, control of glucose levels via insulin infusion when needed, monitoring for hypoglycemia and a comprehensive multidisciplinary approach that provides standardized recommendations for patients at all points in care as they transition from the preoperative clinic into the operating room, and then into the hospital.
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Abstract
Automated closed-loop insulin delivery, also referred to as the 'artificial pancreas', has been an important but elusive goal of diabetes treatment for many decades. Research milestones include the conception of continuous glucose monitoring in the early 1960s, followed by the production of the first commercial hospital-based artificial pancreas in the late 1970s that combined intravenous glucose sensing and insulin delivery. In the past 10 years, research into the artificial pancreas has gained substantial momentum and focused on the subcutaneous route for glucose measurement and insulin delivery, which reflects technological advances in interstitial glucose monitoring and the increasing use of the continuous subcutaneous insulin infusion. This Review discusses the design of an artificial pancreas, its components and clinical results, as well as the advantages and disadvantages of different types of automated closed-loop systems and potential future advances. The introduction of the artificial pancreas into clinical practice will probably occur gradually, starting with simpler approaches, such as overnight control of blood glucose concentration and temporary pump shut-off, that are adapted to more complex situations, such as glycemic control during meals and exercise.
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Affiliation(s)
- Roman Hovorka
- Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, UK.
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