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Blonde L, Umpierrez GE, Reddy SS, McGill JB, Berga SL, Bush M, Chandrasekaran S, DeFronzo RA, Einhorn D, Galindo RJ, Gardner TW, Garg R, Garvey WT, Hirsch IB, Hurley DL, Izuora K, Kosiborod M, Olson D, Patel SB, Pop-Busui R, Sadhu AR, Samson SL, Stec C, Tamborlane WV, Tuttle KR, Twining C, Vella A, Vellanki P, Weber SL. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract 2022; 28:923-1049. [PMID: 35963508 PMCID: PMC10200071 DOI: 10.1016/j.eprac.2022.08.002] [Citation(s) in RCA: 187] [Impact Index Per Article: 93.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. METHODS The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. RESULTS This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes. CONCLUSIONS This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
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Affiliation(s)
| | | | - S Sethu Reddy
- Central Michigan University, Mount Pleasant, Michigan
| | | | | | | | | | | | - Daniel Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, California
| | | | | | - Rajesh Garg
- Lundquist Institute/Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | | | - Darin Olson
- Colorado Mountain Medical, LLC, Avon, Colorado
| | | | | | - Archana R Sadhu
- Houston Methodist; Weill Cornell Medicine; Texas A&M College of Medicine; Houston, Texas
| | | | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | | | - Katherine R Tuttle
- University of Washington and Providence Health Care, Seattle and Spokane, Washington
| | | | | | | | - Sandra L Weber
- University of South Carolina School of Medicine-Greenville, Prisma Health System, Greenville, South Carolina
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Fan R, Xie L, Peng X, Yu B, Zou H, Huang J, Yu X, Wang D, Yang Y. Preadmission Insulin-Treated Type 2 Diabetes Mellitus Patients Had Increased Mortality in Intensive Care Units. Diabetes Metab Syndr Obes 2022; 15:2135-2148. [PMID: 35911502 PMCID: PMC9325876 DOI: 10.2147/dmso.s369152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/09/2022] [Indexed: 11/23/2022] Open
Abstract
AIM To explore the clinical outcomes among preadmission insulin-treated type 2 diabetes mellitus (T2DM) in intensive care units (ICU). PATIENTS AND METHODS In this retrospective observational study, 578 T2DM patients admitted to ICU were recruited from March 2011 to February 2021, which were composed of 528 patients treated with insulin after ICU admission (including 300 preadmission non-insulin-treated and 228 preadmission insulin-treated patients) and 50 patients treated without insulin before and after ICU admission. Clinical outcomes were compared between the groups. Variables of age (± 10 years), gender, blood glucose >10 mmol/l on ICU admission, and original comorbidities were used for matching to get the 1:1 matched cohort. The Kaplan-Meier survival curves were graphed to describe the survival trend and Cox regression analysis was performed to get adjusted hazard ratio (HR). RESULTS Compared with the preadmission non-insulin-treated T2DM patients, preadmission insulin-treated T2DM patients had higher incidence of hypoglycemia [14.5% (33/228) vs 8.7% (26/300); p = 0.036]. In the 1:1 matched cohort, the preadmission insulin-treated T2DM patients had significantly increased mortality rate [30.0% (45/150) vs (16.0% (24/150)); adjusted HR, 1.68 (1.01-2.80)] than preadmission non-insulin-treated T2DM patients. Compared with T2DM patients treated without insulin before and after ICU admission, preadmission insulin-treated T2DM patients had higher mortality and longer length of ICU stay (all p < 0.05). CONCLUSION Preadmission insulin treatment was associated with increased mortality rate and longer length of ICU stay among T2DM patients in ICU. Preadmission insulin-treated T2DM patients might have worse clinical outcomes when they are critically ill.
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Affiliation(s)
- Rongping Fan
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
| | - Lei Xie
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
| | - Xuemin Peng
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
| | - Bo Yu
- Division of Cardiology, Department of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - Huajie Zou
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
- Division of Endocrinology, Department of Internal Medicine, The Affiliated Hospital of Qinghai University, Xining, Qinghai, 810001, People’s Republic of China
| | - Jiaojiao Huang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
| | - Xuefeng Yu
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
| | - Daowen Wang
- Division of Cardiology, Department of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - Yan Yang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
- Correspondence: Yan Yang; Daowen Wang, Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China, Tel +86-27-83665513, Fax +86-27-83662883, Email ;
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Grigolashvili MA, Zhuanysheva EM. [Risk factors for post stroke epilepsy]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:35-40. [PMID: 34553579 DOI: 10.17116/jnevro202112108235] [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: 11/17/2022]
Abstract
Stroke is the leading cause of death and disability in the world. The prevalence of post-stroke epilepsy increases with the increase in the number of stroke cases. Epilepsy may develop in 10% of post-stroke cases and first-diagnosed seizures may develop in 55%. Most often they occur in people who have had intracerebral or subarachnoid haemorrhage. A huge number of factors influence the development of post-stroke seizures and epilepsy. The role of some of them is not in doubt. However, in most cases, the influence of a factor remains controversial and participation in the development of post-stroke epilepsy is not fully proven. The management of post-stroke epilepsy is of great clinical importance, since patients with seizures after a stroke have a higher mortality and disability than those without seizures. Attacks worsen the quality of life of patients, can slow the recovery of functions damaged as a result of a stroke, and aggravate cognitive impairment. Social consequences of post-stroke epilepsy play an important role as well.
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Effects and mechanisms of glucose-insulin-potassium on post-procedural myocardial injury after percutaneous coronary intervention. J Geriatr Cardiol 2020; 17:554-560. [PMID: 33117419 PMCID: PMC7568045 DOI: 10.11909/j.issn.1671-5411.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To evaluate the effects and mechanisms of glucose-insulin-potassium (GIK) on post-procedural myocardial injury (PMI) after percutaneous coronary intervention (PCI). METHODS A total of 200 non-diabetic patients with documented coronary heart disease (CHD) were divided into the Group GIK and Group G, with 100 patients in each group. Patients in Group G were given intravenous infusion of glucose solution 2 hours before PCI. As compared, patients in Group GIK were given GIK. RESULTS Both post-procedural creatine phosphokinase isoenzyme MB (CK-MB; 62.1 ± 47.8 vs. 48.8 ± 52.6 U/L, P = 0.007) and cTnI (0.68 ± 0.83 vs. 0.19 ± 0.24 ng/mL, P < 0.001) in Group GIK were significantly higher than those in Group G. In Group G, 9.0% and 4.0% of patients had post-procedural increases in CK-MB 1-3 times and > 3 times, which were significantly lower than those in Group GIK (14.0% and 7.0%, respectively; all P values < 0.01); 13.0% and 7.0% of patients had post-procedural increases in cTnI 1-3 times and > 3 times, which were also significantly lower than those in Group GIK (21.0% and 13.0%, respectively; all P < 0.001). Pre-procedural (10.2 ± 4.5 vs. 5.1 ± 6.3, P < 0.001) and post-procedural rapid blood glucose (RBG) levels (8.9 ± 3.9 vs. 5.3 ± 5.6, P < 0.001) in Group G were higher than those in Group GIK. In adjusted logistic models, usage of GIK (compared with glucose solution) remained significantly and independently associated with higher risk of post-procedural increases in both CK-MB and cTnI levels > 3 times. Furthermore, pre-procedural RBG levels < 5.0mmol/L were significantly associated with higher risk of post-procedural increases in both CK-MB and cTnI levels. CONCLUSIONS In non-diabetic patients with CHD, the administration of GIK may increase the risk of PMI due to hypoglycemia induced by GIK.
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Abstract
PURPOSE OF REVIEW This review is to discuss the role of autophagy in the critically ill patient population. As the understanding of autophagy continues to expand and evolve, there are certain controversies surrounding whether intensivist should allow the benefit of autophagy to supersede gold standard of insulin therapy or early nutritional support. RECENT FINDINGS The review is relevant as the current literature seems to support under-feeding patients, and perhaps the reason these studies were positive could be prescribed to the mechanisms of autophagy. It is well understood that autophagy is a physiologic response to stress and starvation, and that the inducible form could help patients with end-organ dysfunction return to homeostasis. SUMMARY The jury is still out as to how autophagy will play into clinical practice as we review several gold standard therapies for the critically ill.
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Lheureux O, Prevedello D, Preiser JC. Update on glucose in critical care. Nutrition 2018; 59:14-20. [PMID: 30415158 DOI: 10.1016/j.nut.2018.06.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/08/2018] [Accepted: 06/10/2018] [Indexed: 01/04/2023]
Abstract
The aim of this review is to summarize recent developments on the mechanisms involved in stress hyperglycemia associated with critical illness. Different aspects of the consequences of stress hyperglycemia as well as the therapeutic approaches tested so far are discussed: the physiological regulations of blood glucose, the mechanisms underlying stress hyperglycemia, the clinical associations, and the results of the prospective trials and meta-analyses to be taken into consideration when interpreting the available data. Current recommendations, challenges, and technological hopes for the future are be discussed.
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Affiliation(s)
- Olivier Lheureux
- Department of Intensive Care, CUB-Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Danielle Prevedello
- Department of Intensive Care, CUB-Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jean-Charles Preiser
- Department of Intensive Care, CUB-Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium.
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More Harm Than Benefit of Perioperative Dexamethasone on Recovery Following Reconstructive Head and Neck Cancer Surgery: A Prospective Double-Blind Randomized Trial. J Oral Maxillofac Surg 2018; 76:2425-2432. [PMID: 29864432 DOI: 10.1016/j.joms.2018.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 05/05/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Prospective studies on the effect of dexamethasone after microvascular reconstructive head and neck surgery are sparse despite the widespread use of dexamethasone in this setting. The aim of this study was to clarify whether perioperative use of dexamethasone would improve the quality and speed of recovery. The authors hypothesized that dexamethasone would enhance recovery and diminish pain and nausea. MATERIALS AND METHODS Ninety-three patients with oropharyngeal cancer and microvascular reconstruction were included in this prospective double-blinded randomized controlled trial. Patients in the study group (n = 51) received dexamethasone 60 mg over 3 perioperative days; 42 patients did not receive dexamethasone and served as controls. Patient rehabilitation, postoperative opioid and insulin consumption, postoperative nausea and vomiting (PONV), and C-reactive protein (CRP), leukocyte, and lactate levels were recorded. RESULTS There was significantly less pain in the study group (P = .030) and the total oxycodone dose for 5 days postoperatively was lower (P = .040). Dexamethasone did not significantly lessen PONV for 5 days postoperatively (P > .05). There were no differences between groups in intensive care unit or hospital stay or in other clinical measures of recovery. Patients receiving dexamethasone required significantly more insulin compared with patients in the control group (P < .001). Lactate and leukocyte levels were significantly higher (P < .001) and CRP levels were significantly lower in the study group. CONCLUSION The only benefit of perioperative dexamethasone use was lower total oxycodone dose; however, the disadvantages were greater. Because dexamethasone can have adverse effects on the postoperative course, routine use of dexamethasone as a pain or nausea medication during reconstructive head and neck cancer surgery is not recommended.
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Sandoval-Pinto E, Padilla-Gutiérrez JR, Valdés-Alvarado E, García-González IJ, Valdez-Haro A, Muñoz-Valle JF, Flores-Salinas HE, Brennan-Bourdon LM, Valle Y. Association of the -1031T>C polymorphism and soluble TNF-α levels with Acute Coronary Syndrome. Cytokine 2015; 78:37-43. [PMID: 26618233 DOI: 10.1016/j.cyto.2015.11.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 10/10/2015] [Accepted: 11/12/2015] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Inflammation has gained a pivotal role in the pathophysiology of Acute Coronary Syndrome (ACS). TNF-α is a pro-inflammatory cytokine that could be a potential biomarker in ACS due to its multiple functions. The rs1799964 TNFA polymorphism (-1031T>C) has been associated with a decrease in gene transcription and cytokine levels. OBJECTIVE To determine the association of rs1799964 TNFA polymorphism and TNF-α soluble levels in ACS. METHODS A total of 251 patients diagnosed with ACS and 164 individuals without cardiovascular diseases classified as the reference group (RG), were included. The rs1799964 polymorphism was genotyped by PCR-RFLP. Soluble protein levels were determined by ELISA. Statistical analyses were performed using chi square and U-Mann Whitney tests. RESULTS The genotype and allele frequencies were different between ACS and RG (OR=0.317, p=0.01; OR=0.688, p=0.03 respectively). ACS patients had higher soluble TNF-α levels compared with the RG (31.08 vs 23.00pg/mL, p<0.001); according genotype significant differences were observed (T/T: 24.06 vs T/C: 34.95pg/mL, p=0.0001) in patients. In the RG, T/T carriers showed discrete lower levels than C/C genotype (22.14 vs 27.83pg/mL, p=0.04). CONCLUSIONS The -1031C allele of the TNFA polymorphism confers protection for the development of ACS. The T/C genotype carriers had higher TNF-α serum levels compared to the T/T genotype in ACS. In addition, the -1031T>C TNFA polymorphism was associated with dyslipidemia in ACS in a Western Mexican population.
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Affiliation(s)
- Elena Sandoval-Pinto
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico; Doctorado en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Jorge Ramón Padilla-Gutiérrez
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Emmanuel Valdés-Alvarado
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico; Doctorado en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Ilian Janet García-González
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico; Doctorado en Genética Humana, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Angélica Valdez-Haro
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico; Doctorado en Genética Humana, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - José Francisco Muñoz-Valle
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Hector Enrique Flores-Salinas
- Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, Mexico
| | - Lorena Michele Brennan-Bourdon
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Yeminia Valle
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico.
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Kuppinger D, Hartl WH. In search of the perfect glucose concentration for hospitalized patients: a brief review of the meta-analyses. Nutrition 2013; 29:708-12. [PMID: 23422535 DOI: 10.1016/j.nut.2012.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 10/31/2012] [Accepted: 11/23/2012] [Indexed: 11/25/2022]
Abstract
In hospitalized patients, the optimal target blood glucose concentration is controversial. Numerous studies have examined clinical use of glucose control in various patient populations. In the present review, we briefly discuss corresponding meta-analyses. We electronically searched MEDLINE, EMBASE and CINAHL for meta-analyses relevant to the subject. Fifteen meta-analyses were identified that analyzed effects of a targeted glucose control. Twelve meta-analyses examined studies performed in critically ill patients. Included studies in this review varied in terms of the type of nutritional support, the efficacy of glucose control, the kind of glucose measurement, clinical end points (hospital or intensive care unit mortality, or 28-, 90- or 180-d mortality, or mortality 30 d after discharge), and the intensity of glucose control (moderate, tight, very tight). Four meta-analyses also including studies with a less stringent glucose control (glucose target <200 mg/dL) showed a beneficial effect on mortality. This effect disappeared when analyzing studies with a tighter glucose control (glucose target <150 mg/dL or <110/120 mg/dL, n = 5), with a very tight glucose control (glucose target <110/120 mg/dL, n = 2), or with a more precise definition of clinical endpoints (28-d mortality, n = 2). Eight meta-analyses showed that, despite the intensity of glucose control, the frequency of hypoglycemic episodes increased. The residual heterogeneity of individual studies incorporated into the various meta-analyses prevents a valid conclusion regarding potential benefits of a specific glucose target. A glucose concentration <200 mg/dL appears preferable.
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Affiliation(s)
- David Kuppinger
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Munich, Germany
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Papak J, Kansagara D. Management of hyperglycemia in a hospitalized patient with diabetes mellitus and cardiovascular disease. Am J Cardiol 2012; 110:24B-31B. [PMID: 23062564 DOI: 10.1016/j.amjcard.2012.08.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Hyperglycemia in patients with and without known diabetes is a common finding in patients hospitalized with cardiovascular disease, and is associated with poor outcomes. Investigators have been examining the role of insulin to treat patients with acute myocardial infarction since the 1960's. Until the 1990's most studies evaluated fixed doses of glucose-insulin-potassium (GIK) infusions. The Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial, published in 1995, evaluated the role of adjustable-dose insulin infusion to lower blood glucose. Its promising results spurred further interest and a number of trials evaluating the use of insulin to lower blood glucose in hospitalized patients - many of which included patients with cardiovascular disease - have been conducted over the last two decades with conflicting results. This manuscript reviews the epidemiology and pathophysiology of hyperglycemia in hospitalized patients, summarizes the evidence for benefits and harms of using insulin to treat hyperglycemic patients hospitalized with cardiovascular disease, and offers some practical management considerations.
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Higher Blood Glucose within the Normal Range Is Associated with More Severe Strokes. Stroke Res Treat 2012; 2012:659610. [PMID: 22550616 PMCID: PMC3329666 DOI: 10.1155/2012/659610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 01/21/2012] [Accepted: 01/23/2012] [Indexed: 12/26/2022] Open
Abstract
Background. Higher fasting blood glucose (FBG) concentrations in the hyperglycemic range are associated with more severe strokes. Whether this association also extends into patients with FBG in the normoglycemic range is unclear. We studied the association of stroke severity and FBG in normoglycemic patients with ischemic stroke in a median of 7 days after stroke when the initial glycemic stress response has resolved. Method and Material. Included were 361 nondiabetic ischemic stroke patients with admission fasting blood glucose within 70–130 mg/dL admitted into an acute stroke rehabilitation unit in a median of 7 days after stroke. Data including neuroimaging, vital signs, cardiovascular risk factors, and admission functional independence measure (AFIM) were recorded prospectively. Results. FBG correlated with stroke severity in the normoglycemic 70–130 mg/dL range (FBG-AFIM correlation coefficient −0.17; P = 0.003). Odds ratio for more severe injury (below average AFIM score) was 2.02 for patients with FBG 110–130 mg/dL compared to FBG 70–90 mg/dL (95% confidence interval 1.10–3.73, P = 0.022). Each mg/dL increase in FBG was associated with an average decrease of 0.25 FIM points. In a multiple linear regression model, FBG was associated with more severe stroke (P = 0.002). Conclusion. One week after ischemic stroke, FBG within the normoglycemic range was associated with stroke severity.
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Hyperglycemia during chemotherapy for hematologic and solid tumors is correlated with increased toxicity. Am J Clin Oncol 2011; 34:292-6. [PMID: 20622641 DOI: 10.1097/coc.0b013e3181e1d0c0] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few data are available concerning how glycemic control can affect outcomes in cancer patients treated with chemotherapy. METHODS Charts of non-Hodgkin lymphoma (NHL) and prostate cancer (PC) patients treated at Moffitt Cancer Center between January 1999 and September 2006 were reviewed, and patients who received cyclophosphamide, doxoruicin, vincristine, prednisone, rituximab or Docetaxel plus steroids were eligible. Demographics, vitals, comorbidity, laboratory parameters including baseline and average glucose level during chemotherapy, G4 hematological toxicity (HemT), and G3-G4 non-hematological toxicity (NHemT), progression, and death dates were recorded. RESULTS A total of 349 patients were eligible (NHL/PC: 162/187). G4 HemT was experienced by 76 (47%) NHL and 9 (5%) PC patients. Seventy-nine NHL and 90 PC patients had G3-G4 NHemT. The most frequent NHemT were as follows: neuropathy (25.3%), fever (non-neutropenic, 18.9%), fatigue (15.2%), for NHL; and fatigue (22.1%), thromboembolic events (11.6%), and diarrhea (9.3%) for PC. For NHL patients, G3-G4 NHemT was associated with baseline hyperglycemia (P = 0.0384, Wilcoxon Rank-Sum test) as well as with average glycemia during chemotherapy (P = 0.0048), whereas there was no significant correlation for HemT. For PC patients, a positive correlation was found between baseline hyperglycemia and G4 HemT (P = 0.0241), while univariate correlations between average glycemia during chemotherapy and G4 HemT and between both baseline and average glycemia with NHemT were not significant, multivariate correlation between average glycemia during chemotherapy and overall severe toxicity was significant at 0.05 level. CONCLUSIONS In NHL patients, hyperglycemia correlates with NHemT, and a similar although less clear pattern is suggested in PC patients. Prospective studies are needed to assess whether a better glycemic control during chemotherapy can improve toxicity and outcomes.
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The role of hyperglycemia in acute illness: Supporting evidence and its limitations. Nutrition 2011; 27:276-81. [DOI: 10.1016/j.nut.2010.07.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Revised: 04/18/2010] [Accepted: 07/26/2010] [Indexed: 01/08/2023]
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Ichai C, Preiser JC. International recommendations for glucose control in adult non diabetic critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R166. [PMID: 20840773 PMCID: PMC3219261 DOI: 10.1186/cc9258] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 07/22/2010] [Accepted: 09/14/2010] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The purpose of this research is to provide recommendations for the management of glycemic control in critically ill patients. METHODS Twenty-one experts issued recommendations related to one of the five pre-defined categories (glucose target, hypoglycemia, carbohydrate intake, monitoring of glycemia, algorithms and protocols), that were scored on a scale to obtain a strong or weak agreement. The GRADE (Grade of Recommendation, Assessment, Development and Evaluation) system was used, with a strong recommendation indicating a clear advantage for an intervention and a weak recommendation indicating that the balance between desirable and undesirable effects of an intervention is not clearly defined. RESULTS A glucose target of less than 10 mmol/L is strongly suggested, using intravenous insulin following a standard protocol, when spontaneous food intake is not possible. Definition of the severe hypoglycemia threshold of 2.2 mmol/L is recommended, regardless of the clinical signs. A general, unique amount of glucose (enteral/parenteral) to administer for any patient cannot be suggested. Glucose measurements should be performed on arterial rather than venous or capillary samples, using central lab or blood gas analysers rather than point-of-care glucose readers. CONCLUSIONS Thirty recommendations were obtained with a strong (21) and a weak (9) agreement. Among them, only 15 were graded with a high level of quality of evidence, underlying the necessity to continue clinical studies in order to improve the risk-to-benefit ratio of glucose control.
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Affiliation(s)
- Carole Ichai
- Medical and Surgical Intensive Care Unit, Saint-Roch Hospital, University of Medicine of Nice, 06000 Nice, France.
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15
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Sritharan K, Jones C, Abu-Habsa M. Trends and controversies in the management of sepsis. Br J Hosp Med (Lond) 2010; 71:M28-31. [PMID: 20220711 DOI: 10.12968/hmed.2010.71.sup2.46508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Hiperglucemia de estrés y su control con insulina en el paciente crítico: evidencia actual. Med Intensiva 2010; 34:273-81. [DOI: 10.1016/j.medin.2009.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 10/04/2009] [Accepted: 10/06/2009] [Indexed: 01/12/2023]
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Vanhorebeek I, Langouche L. Molecular mechanisms behind clinical benefits of intensive insulin therapy during critical illness: glucose versus insulin. Best Pract Res Clin Anaesthesiol 2010; 23:449-59. [PMID: 20108584 DOI: 10.1016/j.bpa.2009.08.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
High blood glucose levels have been associated with morbidity and poor outcome in critically ill patients, irrespective of underlying pathology. In a large, randomised, controlled study the use of insulin therapy to maintain normoglycaemia for at least a few days improved survival and reduced morbidity of patients who are in a surgical intensive care unit (ICU). Since the publication of this landmark study, several other investigators have provided support for, whereas others have questioned, the beneficial effects of intensive insulin therapy. In this review, we discuss the investigated potential molecular mechanisms behind the clinical benefits of intensive insulin therapy. We first describe the molecular origin of hyperglycaemia and the impact of the therapy on insulin sensitivity. Next, the molecular basis of glucose toxicity in critical illness and the impact of intensive insulin therapy hereon are described, as well as other non-glucose-toxicity-related metabolic effects of intensive insulin therapy.
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Affiliation(s)
- Ilse Vanhorebeek
- Department of Intensive Care Medicine, Katholieke Universiteit Leuven, B-3000 Leuven, Belgium.
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Abstract
This article presents a template for judging trials of tight glucose control in critically ill patients. It reviews threats to both internal validity and generalisability using examples from the current literature. When judging internal validity, it is important to consider factors specific to trials of glucose control (particularly the methods of glucose control, measurement and reporting) in addition to factors common to all randomised controlled trials (such as treatment allocation, losses to follow-up and protocol violations). Judging generalisability requires the identification of differences between the trial population and the population for whom the intervention is being considered. These may relate to the setting, the patients or the practical delivery of tight glucose control or other interventions. Once identified, a judgement must be made for each difference of whether it is likely to modify the effect of tight glucose control.
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Affiliation(s)
- Andrew Padkin
- Royal United Hospital Bath NHS Trust, Combe Park, Bath BA1 3NG, UK.
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Increasing intravenous glucose load in the presence of normoglycemia: effect on outcome and metabolism in critically ill rabbits. Crit Care Med 2010; 38:602-11. [PMID: 19851097 DOI: 10.1097/ccm.0b013e3181c03f65] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Endocrine disturbances and a feeding-resistant wasting syndrome, characterized by a negative protein balance, promote delayed recovery and poor outcome of critical illness. Parenteral nutrition alone cannot counteract the hypercatabolic state, possibly in part as a result of aggravation of the hyperglycemic response to illness. In critically ill rabbits, we investigated the impact of varying amounts of intravenous glucose while maintaining normoglycemia on mortality, organ damage, and markers of catabolism/anabolism. DESIGN Prospective, randomized laboratory investigation. SETTING University animal and molecular laboratory. SUBJECTS Three-month-old male rabbits. INTERVENTIONS Critically ill rabbits were randomized into a fasting group, a standard parenteral nutrition group, and two groups receiving either intermediate or high additional physiological amounts of intravenous glucose while maintained normoglycemic with insulin. These groups were compared with a hyperglycemic group and healthy rabbits. Protein and lipid load was equal for all fed groups. MEASUREMENTS AND MAIN RESULTS Varying intravenous glucose load did not affect mortality or organ damage provided hyperglycemia was prevented. Fasted critically ill rabbits lost weight, which was attenuated by increasing intravenous glucose load. As compared with healthy rabbits, mRNA expression and/or activity of several ubiquitin-proteasome pathway components, cathepsin-L and calpain-1, was elevated in skeletal muscle of fasted critically ill rabbits. Intravenous feeding was able to counteract this response. Excessive glucose load and/or hyperglycemia, however, reduced the protective effect of feeding. Genes investigated in the diaphragm and myocardium revealed roughly a similar response. Except in the normoglycemic group with intermediate glucose load, circulating thyroid hormone and insulin-like growth factor-1 levels decreased, most pronounced in hyperglycemic rabbits. CONCLUSIONS Increasing intravenous glucose infusion within the physiological range, while maintaining normoglycemia, was safe for organ function and survival of critically ill rabbits. Concomitantly, it reduced the catabolic responses as compared with fasting. Whether this has a beneficial effect on muscle function and mass remains to be investigated.
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Falciglia M, Freyberg RW, Almenoff PL, D'Alessio DA, Render ML. Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med 2009; 37:3001-9. [PMID: 19661802 PMCID: PMC2905804 DOI: 10.1097/ccm.0b013e3181b083f7] [Citation(s) in RCA: 372] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Hyperglycemia during critical illness is common and is associated with increased mortality. Intensive insulin therapy has improved outcomes in some, but not all, intervention trials. It is unclear whether the benefits of treatment differ among specific patient populations. The purpose of the study was to determine the association between hyperglycemia and risk- adjusted mortality in critically ill patients and in separate groups stratified by admission diagnosis. A secondary purpose was to determine whether mortality risk from hyperglycemia varies with intensive care unit type, length of stay, or diagnosed diabetes. DESIGN Retrospective cohort study. SETTING One hundred seventy-three U.S. medical, surgical, and cardiac intensive care units. PATIENTS Two hundred fifty-nine thousand and forty admissions from October 2002 to September 2005; unadjusted mortality rate, 11.2%. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A two-level logistic regression model determined the relationship between glycemia and mortality. Age, diagnosis, comorbidities, and laboratory variables were used to calculate a predicted mortality rate, which was then analyzed with mean glucose to determine the association of hyperglycemia with hospital mortality. Hyperglycemia was associated with increased mortality independent of illness severity. Compared with normoglycemic individuals (70-110 mg/dL), adjusted odds of mortality (odds ratio, [95% confidence interval]) for mean glucose 111-145, 146-199, 200-300, and >300 mg/dL was 1.31 (1.26-1.36), 1.82 (1.74-1.90), 2.13 (2.03-2.25), and 2.85 (2.58-3.14), respectively. Furthermore, the adjusted odds of mortality related to hyperglycemia varied with admission diagnosis, demonstrating a clear association in some patients (acute myocardial infarction, arrhythmia, unstable angina, pulmonary embolism) and little or no association in others. Hyperglycemia was associated with increased mortality independent of intensive care unit type, length of stay, and diabetes. CONCLUSIONS The association between hyperglycemia and mortality implicates hyperglycemia as a potentially harmful and correctable abnormality in critically ill patients. The finding that hyperglycemia-related risk varied with admission diagnosis suggests differences in the interaction between specific medical conditions and injury from hyperglycemia. The design and interpretation of future trials should consider the primary disease states of patients and the balance of medical conditions in the intensive care unit studied.
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Affiliation(s)
- Mercedes Falciglia
- Veterans Affairs (VA) Inpatient Evaluation Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Divisions of Endocrinology, Diabetes & Metabolism, University of Cincinnati College of Medicine, Cincinnati, OH
- VA Medical Center, Cincinnati, OH
| | - Ron W. Freyberg
- Veterans Affairs (VA) Inpatient Evaluation Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Pulmonary, Critical Care & Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Peter L. Almenoff
- Veterans Affairs (VA) Inpatient Evaluation Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Pulmonary & Critical Care, University of Kansas School of Medicine, Kansas City, Kansas
| | - David A. D'Alessio
- Divisions of Endocrinology, Diabetes & Metabolism, University of Cincinnati College of Medicine, Cincinnati, OH
- VA Medical Center, Cincinnati, OH
| | - Marta L. Render
- Veterans Affairs (VA) Inpatient Evaluation Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Pulmonary, Critical Care & Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- VA Medical Center, Cincinnati, OH
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Szumita PM. The hospital pharmacist: an integral part of the hyperglycaemic management team. J Clin Pharm Ther 2009; 34:613-21. [DOI: 10.1111/j.1365-2710.2009.01040.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Recommandations francophones pour le contrôle glycémique en réanimation (patients diabétiques et pédiatrie exclus). NUTR CLIN METAB 2009. [DOI: 10.1016/j.nupar.2009.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Chaichana KL, McGirt MJ, Woodworth GF, Datoo G, Tamargo RJ, Weingart J, Olivi A, Brem H, Quinones-Hinojosa A. Persistent outpatient hyperglycemia is independently associated with survival, recurrence and malignant degeneration following surgery for hemispheric low grade gliomas. Neurol Res 2009; 32:442-8. [PMID: 19589201 DOI: 10.1179/174313209x431101] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Hyperglycemia has been shown to augment tumor growth in vitro. However, the effects of persistent hyperglycemia on survival, recurrence and malignant degeneration in patients undergoing surgery for low grade gliomas remain unknown. METHODS All patients who underwent a craniotomy for hemispheric low grade glioma (WHO grade II) from 1996 to 2006 at a single institution were retrospectively reviewed. Persistent hyperglycemia was defined as serum glucose >180 microg/dl occurring three or more times between 1 and 3 months post-operatively. The independent association of outpatient glucose levels and recorded clinical and treatment variables with overall survival, tumor recurrence and malignant degeneration was assessed via separate multivariate proportional-hazards regression analyses. RESULTS In this study, 182 patients (89 fibrillary astrocytomas, 82 oligodendrogliomas and 11 mixed gliomas) were available for analysis. Eighteen (10%) patients experienced persistent hyperglycemia. Patients experiencing persistent hyperglycemia were older (44 +/- 16 versus 34 +/- 15) and more frequently diabetic [3 (17%) versus 4 (2%)]. All other clinical and treatment variables were not significantly different between the two cohorts. After adjusting for inter-group differences including age and diabetes and variables associated with survival and recurrence, persistent hyperglycemia was independently associated with decreased survival (p=0.001), increased recurrence (p=0.0001) and increased malignant degeneration (p<0.0001). This remained true after excluding all patients with diabetes and those on continued steroid administration. Five-year overall survival, progression-free survival and malignancy-free survival for persistent hyperglycemia versus relatively euglycemic cohorts were 43% versus 84%, 16% versus 46% and 46% versus 77%, respectively. DISCUSSION These findings may provide useful insight for increasing survival, decreasing tumor recurrence and decreasing malignant degeneration in patients undergoing surgery for low grade gliomas.
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Affiliation(s)
- Kaisorn L Chaichana
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21231, USA
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Ichai C. [Control or not glycemia in intensive care unit: is it the right question?]. ACTA ACUST UNITED AC 2009; 28:626-7. [PMID: 19574021 DOI: 10.1016/j.annfar.2009.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Blood glucose is often elevated in acute stroke, and higher admission glucose levels are associated with larger lesions, greater mortality and poorer functional outcome. In patients treated with thrombolysis, hyperglycemia is associated with an increased risk of hemorrhagic transformation of infarcts. For a number of years, tight glycemic control has been regarded as beneficial in critically illness, but recent research has been unable to support this notion. The only completed randomized study on glucose-lowering therapy in stroke has failed to demonstrate effect, and concerns relating to the risk of inducing potentially harmful hypoglycemia has been raised. Still, basic and observational research is overwhelmingly in support of a causal relationship between blood glucose and stroke outcome and further research on glucose-lowering therapy in acute stroke is highly warranted.
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Affiliation(s)
- Tom Skyhøj Olsen
- Department of Neurorehabilitation, The Stroke Unit, Hvidovre University Hospital, Hvidovre, Denmark.
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26
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Paniagua P, Pérez A. [Repercussions and management of perioperative hyperglycemia in cardiac surgery]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:299-311. [PMID: 19580133 DOI: 10.1016/s0034-9356(09)70399-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Surgery produces a neuroendocrine stress response that affects resistance to insulin, reduces insulin secretion, and increases the release of glucose from the liver. This situation can trigger hyperglycemia in both diabetics and nondiabetics. Hyperglycemia has been linked to an increase in the morbidity and mortality among patients who undergo cardiac surgery, and the benefits of correcting hyperglycemia in this setting by means of intensive insulin therapy are well documented. This review discusses various aspects of hyperglycemia, particularly the evidence supporting stricter control of this condition in patients undergoing cardiac surgery. Furthermore, based on the available data and recommendations, and our clinical experience, we suggest therapeutic strategies to improve the control of hyperglycemia in these patients.
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Affiliation(s)
- P Paniagua
- Servicio de Anestesia, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona.
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Wion-Barbot N, Halimi S. [Glycemic control in the intensive care unit: specifities in diabetic patients]. ACTA ACUST UNITED AC 2009; 28:e225-9. [PMID: 19410421 DOI: 10.1016/j.annfar.2009.02.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- N Wion-Barbot
- Service d'endocrinologie, diabétologie et nutrition, CHU de Grenoble, BP 217, 38000 Grenoble, France.
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Olansky L, Sam S, Lober C, Yared JP, Hoogwerf B. Cleveland Clinic cardiovascular intensive care unit insulin conversion protocol. J Diabetes Sci Technol 2009; 3:478-86. [PMID: 20144285 PMCID: PMC2769886 DOI: 10.1177/193229680900300311] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The importance of near-normal blood glucose in the immediate postoperative period is generally accepted and is best achieved in the perioperative period with a constant intravenous (IV) infusion of insulin. This requires intensive nursing only achievable in an intensive care unit (ICU) setting. Glucose management after transfer to a regular nursing floor (RNF) has not been studied systematically. In August 2006, the Cleveland Clinic began using long-acting insulin glargine as the insulin infusion was terminated in the ICU. METHODS This prospective analysis examined all patients receiving IV insulin infusion after cardiothoracic surgery in a 1 month period. The analyses evaluated the safety and efficacy of a protocol using a transition to subcutaneous insulin glargine of 50% of the calculated 24 h requirement at the end of the ICU insulin infusion protocol in preparation for transfer to the RNF. RESULTS Only 1 patient in 99 developed hypoglycemia, and no patient suffered severe hypoglycemia (glucose < 40 mg/dl), while the majority (70%) had euglycemia (glucose between 70 and 150 mg/dl). CONCLUSIONS This approach was both safe-as there was very little hypoglycemia (1 patient in 99)-and effective, as blood sugar was well controlled in most subjects. Efficacy for achieving euglycemia was 70%. Efficacy was likely reduced because of the upper limit of insulin glargine dosage imposed by some providers as a safety consideration. Although there was a physician option to override, the maximum protocol dose of 30 U was rarely exceeded, leading to inadequate dosing in some subjects who required high insulin infusion rates in the ICU.
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Affiliation(s)
- Leann Olansky
- Department of Endocrinology, Cleveland Clinic and Outcomes Research, Cleveland, OH 44195, USA.
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Gunst J, Vanhorebeek I, Van den Berghe G. [Glycemic control in the intensive care unit]. ACTA ACUST UNITED AC 2009; 28:e209-16. [PMID: 19410417 DOI: 10.1016/j.annfar.2009.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- J Gunst
- Department of Intensive Care Medicine, Katholieke Universiteit Leuven, 3000 Leuven, Belgique
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Ellger B, Westphal M, Stubbe HD, Van den Heuvel I, Van Aken H, Van den Berghe G. [Glycemic control in sepsis and septic shock: friend or foe?]. Anaesthesist 2008; 57:43-8. [PMID: 18034219 DOI: 10.1007/s00101-007-1285-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Intensive care patients commonly suffer from hyperglycemia. Evidence is growing that strictly maintaining normoglycemia by intensive insulin therapy (IIT) ameliorates outcome in these patients. Whether or not this also holds true for patients with sepsis and septic shock is the issue of this post-hoc analysis of the database (2,748 patients) of 2 recent prospective clinical trials. MATERIAL AND METHODS A total of 950 patients suffering from sepsis were identified and of these 462 fulfilled the diagnostic criteria of septic shock upon admission to the intensive care unit (ICU). Patients were treated by either IIT [mean glycemia 5.88 mmol/l (106 mg/dl)] or conventional glucose management [mean glycemia 8.44 mmol/l (152 mg/dl)]. RESULTS Under IIT the mortality of patients treated for more than 3 days in the ICU was lowered by 7.6% (p=0.03) in septic patients and by 8.7% (p=0.08) in septic shock patients. Polyneuropathy occurred less frequently under IIT compared to conventional glucose management (sepsis -9.8%, septic shock -14%; p<0.001). The incidence of acute renal failure was not affected by either treatment regimen (sepsis -3.3%, septic shock -3.1%; p<0.25). Intensive insulin therapy was associated with an increased risk of hypoglycemia (sepsis +16.7%, septic shock +18.8; p<0.0001) which did not, however, directly affect morbidity nor mortality. CONCLUSIONS These data suggest that IIT improves outcome of patients with sepsis or septic shock. Hypoglycemia is a frequent complication, but its clinical relevance remains to be defined.
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Affiliation(s)
- B Ellger
- Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, 48149 Münster, Deutschland.
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Abstract
OBJECTIVE To determine the association between hyperglycemia and outcome in children ventilated for meningococcal sepsis. DESIGN Retrospective case notes review. SETTING Eight bedded pediatric intensive care unit in London. PATIENTS Consecutive children ventilated for meningococcal sepsis 2001-2004. INTERVENTIONS None. MEASUREMENTS Peak glucose for the entire admission was determined and mean glucose was calculated for the following three epochs: 1) first 24 hrs, 2) second 24 hrs, and 3) the entire pediatric intensive care unit admission. Patients were also grouped according to whether their blood glucose rose to >7 mmol/L (126 mg/dL), >10 mmol/L (180 mg/dL), or remained below these levels during the pediatric intensive care unit admission. Outcome measures were predicted mortality (based on pediatric risk of mortality score), ventilator free days at 30 days, nosocomial infection, use of renal replacement therapy, use of inotropes, and skin necrosis. MAIN RESULTS Ninety-seven patients were identified with a median age of 2.1 yrs and a median length of stay of 4 days. Four patients died. Peak glucose significantly correlated with predicted mortality and negatively correlated with ventilator free days at 30 days (p < 0.001 and p < 0.001, respectively). Patients who received renal replacement therapy or inotropic support, or developed a nosocomial infection or skin necrosis had significantly higher peak glucose than those who did not (p = 0.006, p < 0.0001, p = 0.022, and p < 0.0001, respectively). Patients who received renal replacement therapy or who developed skin necrosis had significantly higher mean blood glucose in the second 24 hrs of admission (p = 0.017 and p = 0.004, respectively). However, mean blood glucose in the first 24 hrs and over the entire admission did not correlate with outcome. Patients defined as hyperglycemic with blood glucose either >7 mmol/L or >10 mmol/L also had a significantly worse outcome than those who maintained blood glucose below these levels. CONCLUSIONS There was a significant association between hyperglycemia and outcome. Our results support a trial of tight glycemic control in this group of critically ill children.
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Intensive insulin therapy: enhanced Model Predictive Control algorithm versus standard care. Intensive Care Med 2008; 35:123-8. [PMID: 18661120 DOI: 10.1007/s00134-008-1236-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2007] [Accepted: 07/03/2008] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To investigate the effectiveness of an enhanced software Model Predictive Control (eMPC) algorithm for intravenous insulin infusion, targeted at tight glucose control in critically ill patients, over 72 h, in two intensive care units with different management protocols. DESIGN Comparison with standard care in a two center open randomized clinical trial. SETTING Two adult intensive care units in University Hospitals. PATIENTS AND PARTICIPANTS Thirty-four critically ill patients with hyperglycaemia (glucose >120 mg/dL) or already receiving insulin infusion. INTERVENTIONS Patients were randomized, within each ICU, to intravenous insulin infusion advised by eMPC algorithm or the ICU's standard insulin infusion administration regimen. MEASUREMENTS AND RESULTS Arterial glucose concentration was measured at study entry and when advised by eMPC or measured as part of standard care. Time-weighted average glucose concentrations in patients receiving eMPC advised insulin infusions were similar [104 mg/dL (5.8 mmol/L)] in both ICUs. eMPC advised glucose measurement interval was significantly different between ICUs (1.1 vs. 1.8 h, P < 0.01). The standard care insulin algorithms resulted in significantly different time-weighted average glucose concentrations between ICUs [128 vs. 99 mg/dL (7.1 vs. 5.5 mmol/L), P < 0.01]. CONCLUSIONS In this feasibility study the eMPC algorithm provided similar, effective and safe tight glucose control over 72 h in critically ill patients in two different ICUs. Further development is required to reduce glucose sampling interval while maintaining a low risk of hypoglycaemia.
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Elia M, De Silva A. Tight glucose control in intensive care units: an update with an emphasis on nutritional issues. Curr Opin Clin Nutr Metab Care 2008; 11:465-70. [PMID: 18542008 DOI: 10.1097/mco.0b013e3282fcea2a] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Tight glucose control in ICU patients is now regarded as a goal of successful care. Some challenge this on the basis that it produces no benefit and may cause harm. We review the recent literature with an emphasis on nutritional aspects. RECENT FINDINGS Since 2001, several randomized controlled trials have examined the effect of tight glucose control in ICU patients, but only one showed an overall survival benefit. Glucose potassium insulin infusions have also produced variable results, and sometimes cause falls in plasma phosphate with potential consequences. Several studies have shown tight glucose control is labour-intensive and increases the incidence of hypoglycaemia, which could have profound effects, especially if cerebral perfusion is poor. Nutritional intake during tight glucose control has generally been poorly defined. Unintentional cessation of nutrition has been identified as a risk factor for hypoglycaemia. No difference in glucose control has been found between parenteral and enteral feeding. SUMMARY Without knowledge of nutrition provision in terms of carbohydrate, total energy intake and route of administration, some studies are difficult to interpret. It is currently difficult to recommend routine use of tight glucose control in the ICU. Many clinicians have adopted regimes to control glucose between 5.0-9.0 mmol/l.
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Affiliation(s)
- Marinos Elia
- aInstitute of Human Nutrition, University of Southampton, Southampton, UK.
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Kalfon P, Preiser JC. Tight glucose control: should we move from intensive insulin therapy alone to modulation of insulin and nutritional inputs? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:156. [PMID: 18598381 PMCID: PMC2481468 DOI: 10.1186/cc6915] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The report by Chase and coworkers in the previous issue of Critical Care describes the implementation into clinical practice of the Specialized Relative Insulin Nutrition Table (SPRINT) for tight glycaemic control in critically ill patients. SPRINT is a simple, wheel-based system that modulates both insulin rate and nutritional inputs. It achieved a better glycaemic control in a severely ill critical cohort than their previous method for glycaemic control in a matched historical cohort. Reductions in mortality were also observed.
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Affiliation(s)
- Pierre Kalfon
- Department of General Intensive Care, Hospital of Chartres, 34, rue du Docteur Maunoury, 28000 Chartres, France.
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Honiden S, Schultz A, Im SA, Nierman DM, Gong MN. Early versus late intravenous insulin administration in critically ill patients. Intensive Care Med 2008; 34:881-7. [PMID: 18180902 PMCID: PMC2486366 DOI: 10.1007/s00134-007-0978-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Accepted: 12/06/2007] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To investigate whether timing of intensive insulin therapy (IIT) after intensive care unit (ICU) admission influences outcome. DESIGN AND SETTING Single-center prospective cohort study in the 14-bed medical ICU of a 1,171-bed tertiary teaching hospital. PATIENTS The study included 127 patients started on ITT within 48 h of ICU admission (early group) and 51 started on ITT thereafter (late group); the groups did not differ in age, gender, race, BMI, APACHE III, ICU steroid use, admission diagnosis, or underlying comorbidities. MEASUREMENTS AND RESULTS The early group had more ventilator-free days in the first 28 days after ICU admission (median 12 days, IQR 0-24, vs. 1 day, 0-11), shorter ICU stay (6 days, IQR 3-11, vs. 11 days, vs. 7-17), shorter hospital stay (15 days, IQR 9-30, vs. 25 days, 13-43), lower ICU mortality (OR 0.48), and lower hospital mortality (OR 0.27). On multivariate analysis, early therapy was still associated with decreased hospital mortality (ORadj 0.29). The strength and direction of association favoring early IIT was consistent after propensity score modeling regardless of method used for analysis. CONCLUSIONS Early IIT was associated with better outcomes. Our results raise questions about the assumption that delayed administration of IIT has the same benefit as early therapy. A randomized study is needed to determine the optimal timing of therapy.
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Affiliation(s)
- Shyoko Honiden
- Yale University School of Medicine, Section of Pulmonary and Critical Care Medicine, Department of Medicine, New Haven Conn., USA
| | - Atara Schultz
- Mount Sinai School of Medicine, Department of Medicine, New York N.Y., USA
| | - Shelly A. Im
- Mount Sinai School of Medicine, Department of Medicine, New York N.Y., USA
| | - David M. Nierman
- Mount Sinai School of Medicine, Critical Care and Sleep Medicine, Division of Pulmonary, Department of Medicine, 1 Gustave L. Levy Place, Box 1232, New York 10029, NY, USA
| | - Michelle N. Gong
- Mount Sinai School of Medicine, Critical Care and Sleep Medicine, Division of Pulmonary, Department of Medicine, 1 Gustave L. Levy Place, Box 1232, New York 10029, NY, USA, e-mail:
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Modulation of regional nitric oxide metabolism: Blood glucose control or insulin? Intensive Care Med 2008; 34:1525-33. [DOI: 10.1007/s00134-008-1118-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2007] [Accepted: 03/16/2008] [Indexed: 12/14/2022]
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Gandhi GY, Murad MH, Flynn DN, Erwin PJ, Cavalcante AB, Bay Nielsen H, Capes SE, Thorlund K, Montori VM, Devereaux PJ. Effect of perioperative insulin infusion on surgical morbidity and mortality: systematic review and meta-analysis of randomized trials.7. Mayo Clin Proc 2008; 83:418-30. [PMID: 18380987 DOI: 10.4065/83.4.418] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of perioperative insulin infusion on outcomes important to patients. PATIENTS AND METHODS We used 6 search strategies including an electronic database search of MEDLINE, EMBASE, and Cochrane CENTRAL, from their inception up to May 1, 2006, and included RCTs of perioperative insulin infusion (with or without glucose targets) measuring outcomes in patients undergoing any surgery. Pairs of reviewers working independently assessed the methodological quality and characteristics of included trials and abstracted data on perioperative outcomes (ie, outcomes that occurred during hospitalization or within 30 days of surgery). RESULTS We identified 34 eligible trials. In the 14 trials that assessed mortality, there were 68 deaths among 2192 patients randomized to insulin infusion compared with 98 deaths among 2163 patients randomized to control therapy (random-effects pooled relative risk, 0.69; 95% confidence interval [CI], 0.51-0.94; 99% CI, 0.46-1.04; I2, 0%; 95% CI, 0.0%-47.4%). Hypoglycemia increased in the intensively treated group (20 trials, 119/1470 patients in insulin infusion vs 48/1476 patients in control group; relative risk, 2.07; 95% CI, 1.29-3.32; 99% CI, 1.09-3.88; I2, 31.5%; 95% CI, 0.0%-59.0%). No significant effect was seen in any other outcomes. The available mortality data represent only 40% of the optimal information size required to reliably detect a plausible treatment effect; potential methodological and reporting biases weaken inferences. CONCLUSION Perioperative insulin infusion may reduce mortality but increases hypoglycemia in patients who are undergoing surgery; however, mortality results require confirmation in large and rigorous RCTs.
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Affiliation(s)
- Gunjan Y Gandhi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Abstract
PURPOSE OF REVIEW In a 2001 report from a surgical intensive care unit in Leuven, Belgium, intravenous insulin infusion targeting blood glucose 80-110 mg/dl reduced patient mortality and morbidities. Subsequent research has failed to define glycemic targets necessary or sufficient for attainment of desired health outcomes in other inpatient settings, but a large body of evidence suggests hospital outcomes are related to hyperglycemia. RECENT FINDINGS Recent literature describes observational evidence for hypoglycemia as an independent predictor of mortality in a general medical intensive care unit; superiority of performance of computerized intravenous insulin algorithms in comparison to earlier manual algorithms; acceptability of early transition to scheduled basal prandial correction subcutaneous insulin analog therapy for maintenance of glycemic targets after induction of euglycemia by intravenous insulin infusion, among cardiothoracic surgery patients; inferiority of sliding scale insulin compared to basal prandial correction therapy; and feasibility of diabetes patient self-management in the hospital setting. SUMMARY With development of improved insulin administration strategies problems of hypoglycemia and variability of glycemic control are reduced. Investigators and care providers need to achieve glycemic targets to optimize patient outcomes.
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Affiliation(s)
- Susan Shapiro Braithwaite
- Division of Endocrinology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina 27599-7172, USA.
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Schwinn DA, Podgoreanu M. Pharmacogenomics and end-organ susceptibility to injury in the perioperative period. Best Pract Res Clin Anaesthesiol 2008; 22:23-37. [PMID: 18494387 PMCID: PMC2603024 DOI: 10.1016/j.bpa.2007.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Genomic medicine has provided new mechanistic understanding for many complex diseases over the last 5-10 years. More recently genomic approaches have been applied to the perioperative paradigm, facilitating identification of patients at high risk for adverse events, as well as those who will respond better/worse to specific pharmacologic therapies. The consistent biological theme emerging is that while inflammation is important in healing from surgical trauma, patients who are too robustly proinflammatory appear to be at higher risk for adverse perioperative events. Precise predictors of each adverse event are being elucidated so that corrective therapeutics can be instituted to improve outcomes in high-risk patients. While the field of perioperative genomics could be considered in its infancy, such approaches are the wave of the future.
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Affiliation(s)
- Debra A. Schwinn
- Professor and Chair of Anesthesiology, Adjunct Professor of Pharmacology & Genome Sciences, Box 356540, University of Washington, 1959 NE Pacific Street, Seattle WA 98195-6540 USA, Phone: (206) 543 – 2673|Fax (206) 543 – 2958,
| | - Mihai Podgoreanu
- Assistant Professor of Anesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710 USA,
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Abstract
OBJECTIVE To report the presence of type B lactic acidosis and insulin-resistant hyperglycemia following cardiopulmonary bypass in a pediatric patient. DESIGN Case report. SETTING Tertiary referral children's hospital pediatric intensive care unit. PATIENT Fourteen-year-old child with hyperlactatemia and hyperglycemia following cardiac surgery. INTERVENTIONS AND RESULTS We report a patient who following cardiopulmonary bypass for repair of his congenital heart disease developed type B lactic acidosis and hyperglycemia resistant to insulin therapy. Resolution of his hyperlactatemia and hyperglycemia occurred approximately 24 hrs postoperatively without apparent ill effect. CONCLUSIONS Type B lactic acidosis is a phenomenon that may occur in the pediatric population in conjunction with insulin-resistant hyperglycemia. We observed that its resolution corresponded to improvement in the patient's hyperglycemia.
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Abstract
PURPOSE OF REVIEW This article reviews recent epidemiologic and intervention studies addressing the impact of hyperglycemia on morbidity and mortality in critically ill patients. It also discusses a growing body of literature examining why elevated blood glucose occurs in hospitalized patients without previously recognized diabetes. RECENT FINDINGS Hyperglycemia is highly prevalent in the intensive care unit. Numerous observational studies have demonstrated the association between hyperglycemia and adverse outcomes, independent of pre-existing diabetes. Intervention trials of insulin therapy are limited but overall demonstrate that glucose lowering significantly improves outcomes. The ideal target for blood glucose and the population that would benefit most from intervention remain controversial. Less frequently studied than the consequences, the causes of hyperglycemia occurring during critical illness remain unclear. Although glucose abnormalities in hospitalized patients have traditionally been explained by mediators of stress, a growing body of evidence has examined whether underlying defects in glucose metabolism may also be important contributors. SUMMARY In general, evidence suggests that hyperglycemia is a potentially correctable abnormality that has deleterious effects in critically ill individuals. Hyperglycemic patients without previously recognized diabetes appear to be particularly vulnerable, and thus further examination of the mechanisms underlying the development of elevated blood glucose is warranted.
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Affiliation(s)
- Mercedes Falciglia
- University of Cincinnati, Division of Endocrinology, Diabetes, and Metabolism, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio 45267-0547, USA.
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Falciglia M. Intensive insulin therapy for the critically ill hospitalized patient-do the benefits outweigh the risks? NATURE CLINICAL PRACTICE. ENDOCRINOLOGY & METABOLISM 2007; 3:386-7. [PMID: 17342063 DOI: 10.1038/ncpendmet0476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2006] [Accepted: 01/23/2007] [Indexed: 05/14/2023]
Affiliation(s)
- Mercedes Falciglia
- Division of Endocrinology, Diabetes, and Metabolism, University of Cincinnati, OH 45267-0529, USA.
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Abstract
PURPOSE OF REVIEW There is evidence that maintaining a normal glycemia level in critically ill patients has beneficial effects on outcome. Strategies aimed at lowering glycemia are based on the understanding of mechanisms regulating glucose metabolism. RECENT FINDINGS Activation of AMP protein kinase in skeletal muscle and in the liver leads to a reduction in glucose production, a stimulation of glucose uptake, and a lowering of glycemia. These mechanisms appear to be activated during exercise, or by the endogenous adipokine adiponectin. Alterations in adiponectin concentrations during critical illness may thus play a role in the metabolic stress responses. In addition, AMP-activated protein kinase is the target for drugs (metformin, thazolidinediones), which may be of interest in the intensive care unit. Besides insulin, plasma glucose concentrations may be lowered by hypocaloric feeding, or by feeding 'diabetic' formula with low glucose content and supplemented with fructose. Whether such approaches lead to beneficial effects comparable to those observed with insulin remains to be established. SUMMARY Recent findings regarding the molecular mechanisms underlying glucose transport and metabolism are summarized, and potential strategies other than insulin are outlined which may contribute to lowering glycemia in critically ill patients.
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Affiliation(s)
- Gerald Seematter
- Service of Anaesthesiology, University Hospital of Canton de Vaud (CHUV), Lausanne, Switzerland
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Boulkina LS, Braithwaite SS. Practical aspects of intensive insulinization in the intensive care unit. Curr Opin Clin Nutr Metab Care 2007; 10:197-205. [PMID: 17285010 DOI: 10.1097/mco.0b013e3280141ff4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Strategies used for intensive insulin therapy of critically ill patients and differences of approach according to medical condition are reviewed. RECENT FINDINGS Acceptance of proposed glycemic targets for critically ill patients has been tempered by uncertainties about benefit of strict glycemic control for specific target subpopulations, differences between treatment centers, optimal timing and duration of intervention, and safety. Present-day intravenous insulin infusion protocols may perform well only for restricted populations. Assessment of protocol performance requires knowledge of algorithm behavior on or near the narrow target range and, using the patient as unit of observation, examination of glycemic variability. Systems of the future will permit adjustment of algorithm parameters to meet individual- or population-specific targets and match carbohydrate exposure. SUMMARY Attainment and preservation of glycemic control among critically ill patients are best attempted with intravenous insulin infusion. Advances in the design of decision support and insulin delivery systems, and progress in the technology of continuous blood glucose monitoring, are likely to reduce the risk of hypoglycemia, without compromise of target range control, such that the patient outcomes enjoyed by experienced centers in the future will prove generalizable to others through the extension of new technologies.
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Annane D. Does intensive insulin therapy affect the cortisol response of critically ill patients? ACTA ACUST UNITED AC 2007; 3:336-7. [PMID: 17325720 DOI: 10.1038/ncpendmet0458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Accepted: 01/23/2007] [Indexed: 11/09/2022]
Affiliation(s)
- Djillali Annane
- Critical Care Unit, Raymond Poincaré University Hospital (AP-HP), Garches, France.
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Abstract
PURPOSE OF REVIEW The role of hyperglycaemia in the pathogenesis of myocardial damage during cardiac surgery or patients with acute coronary syndromes has been the subject of increasing interest over the past few years. Several further trials and meta-analyses investigating the role of insulin treatment, either aimed at tight control of blood glucose concentration or as part of a regimen including glucose and potassium, have been reported recently and are the subject of this review. RECENT FINDINGS Good control of blood glucose has been demonstrated to improve outcomes for diabetic patients undergoing cardiac surgery and following acute myocardial infarction. In surgical intensive care patients, tight glucose control improved mortality--a finding that is awaiting confirmation in multicentre studies. The use of glucose-insulin-potassium regimens does not improve outcomes in patients with acute myocardial infarction who have undergone reperfusion therapy, but may be beneficial during cardiac surgery. SUMMARY Tight control of blood glucose has been shown to be beneficial in several patient groups. The optimal target glucose concentration and glucose and insulin regimens remain to be confirmed or determined in each clinical situation.
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Affiliation(s)
- Andrew O Wade
- Unit of Critical Care, Royal Brompton Hospital, London, UK
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Kajbaf F, Mojtahedzadeh M, Abdollahi M. Mechanisms underlying stress-induced hyperglycemia in critically ill patients. ACTA ACUST UNITED AC 2007. [DOI: 10.2217/14750708.4.1.97] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Schultz MJ, Royakkers AANM, Levi M, Moeniralam HS, Spronk PE. Intensive insulin therapy in intensive care: an example of the struggle to implement evidence-based medicine. PLoS Med 2006; 3:e456. [PMID: 17147466 PMCID: PMC1762062 DOI: 10.1371/journal.pmed.0030456] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Schultz and colleagues discuss the factors hindering implementation of intensive insulin therapy.
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Affiliation(s)
- Marcus J Schultz
- Department of Intensive Care Medicine and the Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
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