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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Casillas S, Jauregui E, Surani S, Varon J. Blood glucose control in the intensive care unit: Where is the data? World J Meta-Anal 2019; 7:399-405. [DOI: 10.13105/wjma.v7.i8.399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 08/13/2019] [Accepted: 08/20/2019] [Indexed: 02/06/2023] Open
Abstract
Blood glucose control, including hyperglycemia correction, maintaining glucose at optimal level and avoiding hypoglycemia, is a challenge clinicians face every day in intensive care units (ICUs). If managed inadequately, its related mortality can increase. Prior to 2001, no relevant data from randomized, controlled studies assessing glucose control in the ICU were available. In the past 18 years, however, many clinical trials have defined criteria for managing abnormal blood glucose levels, as well as provided suggestions for glycemic monitoring. Point-of-care blood glucose monitors have become the preferred bedside technology to aid in glycemic management. In addition, in some institutions, continuous glucose monitoring is now available. Cost-effectiveness of adequate glycemic control in the ICU must be taken into consideration when addressing this complex issue. Newer types of glycemic monitoring may reduce nursing staff fatigue and shorten times for the treatment of hyperglycemia or hypoglycemia. There are a variety of glycemic care protocols available. However, not all ICU clinicians are aware of them. The following minireview describes some of these concepts.
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Affiliation(s)
- Sebastian Casillas
- Universidad Autonoma de Baja California, Campus Otay, Nueva, Mexicali 21100, Mexico
| | - Edgar Jauregui
- Universidad Autonoma de Baja California, Campus Otay, Nueva, Mexicali 21100, Mexico
| | - Salim Surani
- Department of Medicine, Pulmonary, Critical Care and Sleep Medicine, Texas A and M University, Corpus Christi, TX 78414, United States
| | - Joseph Varon
- Acute and Continuing Care, The University of Texas Health Science Center at Houston, The University of Texas, Medical Branch at Galveston, United Memorial Medical Center/United General Hospital, Houston, TX 77030, United States
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Defayette AA, Voigt LM, Zammit KT, Nadler JN, Kersten BP. Evaluation of a Computerized Insulin Dosing Tool for the Treatment of Diabetic Ketoacidosis. J Pharm Pract 2019; 33:768-773. [PMID: 30852934 DOI: 10.1177/0897190019834367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Computerized insulin dosing tools (CIDT) have been shown to improve the care of critically ill patients with hyperglycemia. Application of a CIDT in addition to a diabetic ketoacidosis (DKA) order set for the treatment of DKA has not been evaluated. Our goal was to determine the effects the CIDT would have on the treatment of a patient with DKA. METHODS In this retrospective, pre-post chart review, a provider-driven insulin dosing strategy (pregroup) was compared to the CIDT (postgroup) with 24-hour pharmacist monitoring. The CIDT utilized an equation that incorporated a patient's most recent blood glucose (BG) value and recommended a rate of insulin (units/hour) every hour. RESULTS All baseline characterizes were similar between the 2 groups. There were no significant differences in average time to anion gap closure (≤ 12 mEq/L) or intensive care unit length of stay between the pregroup and postgroup (12.5 [6] hours vs 10.5 [7] hours, P = 0.235; 40.6 [24] hours vs 40.8 [24] hours, P = 0.945). Although not statistically significant, 17 hypoglycemic events (BG < 70 mg/dL) occurred in the pregroup with 4 being severe (BG < 50 mg/dL) while 5 hypoglycemic events occurred in the postgroup, none of which were severe. CONCLUSION This study suggests, when compared to a provider-driven insulin dosing strategy, the CIDT with 24-hour pharmacist monitoring is efficacious and safe for treatment of patients with a primary diagnosis of DKA.
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Affiliation(s)
| | - Lisa M Voigt
- Kaleida Health, Buffalo General Medical Center, Buffalo, New York, USA
| | - Kimberly T Zammit
- Kaleida Health, Buffalo General Medical Center, Buffalo, New York, USA
| | - Jamie N Nadler
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Brian P Kersten
- Kaleida Health, Buffalo General Medical Center, Buffalo, New York, USA
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Braithwaite SS, Clark LP, Idrees T, Qureshi F, Soetan OT. Hypoglycemia Prevention by Algorithm Design During Intravenous Insulin Infusion. Curr Diab Rep 2018; 18:26. [PMID: 29582176 DOI: 10.1007/s11892-018-0994-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW This review examines algorithm design features that may reduce risk for hypoglycemia while preserving glycemic control during intravenous insulin infusion. We focus principally upon algorithms in which the assignment of the insulin infusion rate (IR) depends upon maintenance rate of insulin infusion (MR) or a multiplier. RECENT FINDINGS Design features that may mitigate risk for hypoglycemia include use of a mid-protocol bolus feature and establishment of a low BG threshold for temporary interruption of infusion. Computer-guided dosing may improve target attainment without exacerbating risk for hypoglycemia. Column assignment (MR) within a tabular user-interpreted algorithm or multiplier may be specified initially according to patient characteristics and medical condition with revision during treatment based on patient response. We hypothesize that a strictly increasing sigmoidal relationship between MR-dependent IR and BG may reduce risk for hypoglycemia, in comparison to a linear relationship between multiplier-dependent IR and BG. Guidelines are needed that curb excessive up-titration of MR and recommend periodic pre-emptive trials of MR reduction. Future research should foster development of recommendations for "protocol maxima" of IR appropriate to patient condition.
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Affiliation(s)
- Susan Shapiro Braithwaite
- , 1135 Ridge Road, Wilmette, IL, 60091, USA.
- Endocrinology Consults and Care, S.C, 3048 West Peterson Ave, Chicago, IL, 60659, USA.
| | - Lisa P Clark
- Presence Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Thaer Idrees
- Presence Saint Joseph Hospital, 2900 N. Lakeshore Dr, Chicago, IL, 60657, USA
| | - Faisal Qureshi
- Presence Saint Joseph Hospital, 2800 N Sheridan Road Suite 309, Chicago, IL, 60657, USA
| | - Oluwakemi T Soetan
- Presence Saint Joseph Hospital, 2900 N. Lakeshore Dr, Chicago, IL, 60657, USA
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Abstract
PURPOSE OF REVIEW We reviewed the strategies associated with hypoglycemia risk reduction among critically ill non-pregnant adult patients. RECENT FINDINGS Hypoglycemia in the ICU has been associated with increased mortality in a number of studies. Insulin dosing and glucose monitoring rules, response to impending hypoglycemia, use of computerization, and attention to modifiable factors extrinsic to insulin algorithms may affect the risk for hypoglycemia. Recurring use of intravenous (IV) bolus doses of insulin in insulin-resistant cases may reduce reliance upon higher IV infusion rates. In order to reduce the risk for hypoglycemia in the ICU, caregivers should define responses to interruption of continuous carbohydrate exposure, incorporate transitioning strategies upon initiation and interruption of IV insulin, define modifications of antihyperglycemic therapy in the presence of worsening renal function or chronic kidney disease, and anticipate the effects traceable to other medications and substances. Institutional and system-wide quality improvement efforts should assign priority to hypoglycemia prevention.
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Affiliation(s)
- Susan Shapiro Braithwaite
- , 1135 Ridge Road, Wilmette, IL, 60091, USA.
- Endocrinology Consults and Care, S.C, 3048 West Peterson Ave, Chicago, IL, 60659, USA.
| | - Dharmesh B Bavda
- Presence Saint Joseph Hospital-Chicago, 2900 N. Lake Shore Drive, Chicago, IL, 60657, USA
| | - Thaer Idrees
- Presence Saint Joseph Hospital-Chicago, 2900 N. Lake Shore Drive, Chicago, IL, 60657, USA
| | - Faisal Qureshi
- , 2800 N Sheridan Road Suite 309, Chicago, IL, 60657, USA
| | - Oluwakemi T Soetan
- Presence Saint Joseph Hospital-Chicago, 2900 N. Lake Shore Drive, Chicago, IL, 60657, USA
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Challenges of Inpatient Glycemic Control. J Nurs Care Qual 2017; 32:267-271. [PMID: 28323688 DOI: 10.1097/ncq.0000000000000257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hyperglycemia occurs in more than 30% of hospitalized patients. The condition has been associated with higher mortality and poor outcomes. Systems to effectively treat dysglycemia have been put into place, although many focus on critical care areas. The purpose of this article is to provide an overview of the challenges for glycemic control in non-critical care areas. Standardized order sets, critical pathways, professional education, and collaborative systems can support improved control.
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45:486-552. [PMID: 28098591 DOI: 10.1097/ccm.0000000000002255] [Citation(s) in RCA: 1889] [Impact Index Per Article: 269.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304-377. [PMID: 28101605 DOI: 10.1007/s00134-017-4683-6] [Citation(s) in RCA: 3714] [Impact Index Per Article: 530.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Gianchandani RY, Neupane S, Iyengar JJ, Heung M. PATHOPHYSIOLOGY AND MANAGEMENT OF HYPOGLYCEMIAIN END-STAGE RENAL DISEASE PATIENTS: A REVIEW. Endocr Pract 2016; 23:353-362. [PMID: 27967230 DOI: 10.4158/ep161471.ra] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This review focuses on hypoglycemia in patients with end-stage renal disease (ESRD). It discusses the pathophysiology of glucose metabolism in the kidney, the impact of dialysis on glucose and insulin metabolism, and the challenges of glucose monitoring in ESRD. The clinical relevance of these changes is reviewed in relation to altered blood glucose targets and modification of antidiabetes therapy to prevent hypoglycemia. Based on current data and guidelines, recommendations for the outpatient and inpatient setting are provided for diabetes management in ESRD. METHODS PubMed, OVID, and Google Scholar were searched to identify related articles through May 2016 using the following keywords: "glucose metabolism," "kidney," "diabetes," "hypoglycemia," "ESRD," and "insulin" in various combinations for this review. RESULTS In ESRD, a combination of impaired insulin clearance, changes in glucose metabolism, and the dialysis process make patients vulnerable to low blood glucose levels. Hypoglycemia accounts for up to 3.6% of all ESRD-related admissions. At admission or during hospitalization, hypoglycemia in ESRD has a poor prognosis, with mortality rates reported at 30%. Several guidelines suggest a modified hemoglobin A1c (A1c) goal of 7 to 8.5% (53 to 69 mmol/mol) and an average blood glucose goal of 150 to 200 mg/dL. Noninsulin antidiabetes agents like dipeptidyl peptidase 4 inhibitors, repaglinide, and glipizide in appropriate doses and reduction of insulin doses up to 50% may help decrease hypoglycemia. CONCLUSION Patients with ESRD are at high risk for hypoglycemia. Increased awareness by providers regarding these risks and appropriate diabetes regimen adjustments can help minimize hypoglycemic events. ABBREVIATIONS ADA = antidiabetes agent BG = blood glucose CKD = chronic kidney disease DPP-4 = dipeptidyl peptidase 4 eGFR = estimated glomerular filtration rate ESRD = end-stage renal disease GFR = glomerular filtration rate HD = hemodialysis NPH = neutral protamine Hagedorn PD = peritoneal dialysis SA = short acting SU = sulfonylurea.
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Abstract
Hyperglycemia and acute kidney injury (AKI) are frequently observed during the perioperative period. Substantial evidence indicates that hyperglycemia increases the prevalence of AKI as a surgical complication. Patients who develop hyperglycemia and AKI during the perioperative period are at significantly elevated risk for poor outcomes such as major adverse cardiac events and all-cause mortality. Early observational and interventional trials demonstrated that the use of intensive insulin therapy to achieve strict glycemic control resulted in remarkable reductions of AKI in surgical populations. However, more recent interventional trials and meta-analyses have produced contradictory evidence questioning the renal benefits of strict glycemic control. Although the exact mechanisms through which hyperglycemia increases the risk of AKI have not been elucidated, multiple pathophysiologic pathways have been proposed. Hypoglycemia and glycemic variability may also play a significant role in the development of AKI. In this literature review, the complex relationship between hyperglycemia and AKI as well as its impact on clinical outcomes during the perioperative period is explored.
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Affiliation(s)
- Carlos E Mendez
- Albany Stratton VA Medical Center, Albany Medical College, 113 Holland Avenue, Albany, NY, 12208, USA.
| | - Paul J Der Mesropian
- Albany Stratton VA Medical Center, Albany Medical College, 113 Holland Avenue, Albany, NY, 12208, USA.
| | - Roy O Mathew
- Albany Stratton VA Medical Center, Albany Medical College, 113 Holland Avenue, Albany, NY, 12208, USA.
| | - Barbara Slawski
- Department of Medicine, Froedtert and Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI, 53226, USA.
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