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Li Y, Li W, Xu B. Between blood glucose and mortality in critically ill patients: Retrospective analysis of the MIMIC-IV database. J Diabetes Investig 2024; 15:931-938. [PMID: 38470005 PMCID: PMC11215680 DOI: 10.1111/jdi.14182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/13/2024] Open
Abstract
AIMS/INTRODUCTION Mean blood glucose (MBG) level is associated with mortality among critically ill patients. We undertook a cohort study to investigate the relationship between MBG and mortality in critically ill patients. MATERIALS AND METHODS Critically ill patients were enrolled from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. MBG was calculated to represent the overall glycemic status during intensive care unit (ICU) hospitalization, and a multivariate logistic regression determined the relationship between MBG and ICU mortality in different subgroups of critically ill patients. RESULTS A total of 8,973 patients were included in the study, 1,244 of whom died within 28 days, including 5,402 men and 3,571 women. Multivariate adjusted restricted cubic spline analyses suggested that the relationship between MBG and ICU mortality was a "J" shape. Logistic regression showed 28 day mortality in group 3 (glucose ≥10 mmol/L): the adjusted odds ratio was 2.06 (95% confidence interval 1.65-2.57). The results of subgroup analysis showed that hyperglycemia had a more significant impact on ICU mortality in patients without diabetes, hypoglycemia and liver disease, and the ICU mortality risk of non-diabetes patients was always higher than that of diabetes patients with the same hyperglycemia level. CONCLUSIONS Current evidence suggested a J-shaped relationship between MBG and mortality in critically ill patients.
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Affiliation(s)
- Yuanyuan Li
- Department of ICUJining No.1 People's HospitalJiningChina
| | - Wenqiang Li
- Department of ICUJining No.1 People's HospitalJiningChina
| | - Baocai Xu
- Department of urologyJining No.1 People's HospitalJiningChina
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Hu J, Ouyang L, Li J, Li X, Zhong Y, Hou C. Mean Blood Glucose Level During ICU Hospitalization is a Strong Predictor of the Mortality of COVID-19. Diabetes Metab Syndr Obes 2024; 17:1903-1909. [PMID: 38706805 PMCID: PMC11070158 DOI: 10.2147/dmso.s450489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/16/2024] [Indexed: 05/07/2024] Open
Abstract
Objective To investigate the potential prognostic value of mean blood glucose (MBG) in hospital for prognosis of COVID-19 adult patients in the intensive unit care unit (ICU). Methods A single-site and retrospective study enrolled 107 patients diagnosed as COVID-19 from department of critical care medicine in the Second Xiangya Hospital between October 2022 and June 2023. Demographic information including glucose during ICU hospitalization, comorbidity, clinical data, types of medications and treatment, and clinical outcome were collected. The multivariate logistic and cox regression was used to explore the relationship between blood glucose changes and clinical outcomes of COVID-19 during ICU stay. Results In total, 107 adult patients confirmed with COVID-19 were included. Multivariate logistic regression results showed an increase in MBG was associated with ICU mortality rate. Compared with normal glucose group (MBG <= 7.8 mmol/L), the risk of ICU mortality, 7-day mortality and 28-day mortality from COVID-19 were significantly increased in high glucose group (MBG >7.8mmol/L). Conclusion MBG level during ICU hospitalization was strongly correlated to all-cause mortality and co-infection in COVID-19 patients. These findings further emphasize the importance of overall glucose management in severe cases of COVID-19.
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Affiliation(s)
- Jie Hu
- Critical Care Medicine Center, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology, Key Laboratory Diseases Immunology, Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, People’s Republic of China
| | - Lin Ouyang
- Department of Critical Care Medicine Center, Guilin Hospital of the Second Xiangya Hospital, The Second Xiangya Hospital of Central South University, Changsha, Hunan, People’s Republic of China
| | - Jinxiu Li
- Critical Care Medicine Center, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Xia Li
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology, Key Laboratory Diseases Immunology, Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, People’s Republic of China
| | - Yanjun Zhong
- Critical Care Medicine Center, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Can Hou
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology, Key Laboratory Diseases Immunology, Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, People’s Republic of China
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von Loeffelholz C, Birkenfeld AL. Tight versus liberal blood-glucose control in the intensive care unit: special considerations for patients with diabetes. Lancet Diabetes Endocrinol 2024; 12:277-284. [PMID: 38514241 DOI: 10.1016/s2213-8587(24)00058-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 03/23/2024]
Abstract
Stress hyperglycaemia, hypoglycaemia, and diabetes are common in critically ill patients and related to clinical endpoints. To avoid complications related to hypoglycaemia and hyperglycaemia, it is recommended to start insulin therapy for the majority of critically ill patients with persistent blood glucose concentrations higher than 10·0 mmol/L (>180 mg/dL), targeting a range of 7·8-10·0 mmol/L (140-180 mg/dL). However, management and evidence-based targets for blood glucose control are under debate, particularly for patients with diabetes. Recent randomised controlled clinical trials now challenge current recommendations. In this Personal View, we aim to highlight these developments and the important differences between critically ill patients with and without diabetes, taking into account the considerable heterogeneity in this patient group. We critically discuss evidence from prospective randomised controlled trials and observational studies on the safety and efficacy of glycaemic control, specifically in the context of patients with diabetes in intensive care units.
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Affiliation(s)
- Christian von Loeffelholz
- Department of Anaesthesiology and Intensive Care, Jena University Hospital, Friedrich Schiller University, Jena, Germany.
| | - Andreas L Birkenfeld
- Department of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany; Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich, Eberhard Karls University Tübingen, German Center for Diabetes Research (DZD), Neuherberg, Germany; Department of Diabetes, School of Cardiovascular and Metabolic Medicine & Sciences, Life Sciences & Medicine, Kings College London, London, UK
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Davidson S, Pretty C, Uyttendaele V, Knopp J, Desaive T, Chase JG. Multi-input stochastic prediction of insulin sensitivity for tight glycaemic control using insulin sensitivity and blood glucose data. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 182:105043. [PMID: 31470221 DOI: 10.1016/j.cmpb.2019.105043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 07/28/2019] [Accepted: 08/20/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Glycaemic control in the intensive care unit is dependent on effective prediction of patient insulin sensitivity (SI). The stochastic targeted (STAR) controller uses a 2D stochastic model for prediction, with current SI as an input and future SI as an output. METHODS This paper develops an extension of the STAR 2D stochastic model into 3D by adding blood glucose (G) as an input. The performance of the 2D and 3D stochastic models is compared over a retrospective cohort of 65,269 data points across 1525 patients. RESULTS Under five-fold cross-validation, the 3D model was found to better match the expected potion of data points within, above and below various credible intervals, suggesting it provided a better representation of the underlying probability field. The 3D model was also found to provide an 18.1% narrower 90% credible interval on average, and a narrower 90% credible interval in 96.4% of cases, suggesting it provided more accurate predictions of future SI. Additionally, the 3D stochastic model was found to avoid the undesirable tendency of the 2D model to overestimate SI for patients with high G, and underestimate SI for patients with low G. CONCLUSIONS Overall, the 3D stochastic model is shown to provide clear potential benefits over the 2D model for minimal clinical cost or effort, though further exploration into whether these improvements in SI prediction translate into improved clinical outcomes is required.
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Affiliation(s)
- Shaun Davidson
- Department of Mechanical Engineering, University of Canterbury, 20 Kirkwood Ave, Upper Riccarton, Christchurch 8041, New Zealand.
| | - Chris Pretty
- Department of Mechanical Engineering, University of Canterbury, 20 Kirkwood Ave, Upper Riccarton, Christchurch 8041, New Zealand
| | | | - Jennifer Knopp
- Department of Mechanical Engineering, University of Canterbury, 20 Kirkwood Ave, Upper Riccarton, Christchurch 8041, New Zealand
| | - Thomas Desaive
- GIGA-Cardiovascular Sciences, University of Liège, Liège, Belgium
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, 20 Kirkwood Ave, Upper Riccarton, Christchurch 8041, New Zealand
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3D kernel-density stochastic model for more personalized glycaemic control: development and in-silico validation. Biomed Eng Online 2019; 18:102. [PMID: 31640720 PMCID: PMC6805453 DOI: 10.1186/s12938-019-0720-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 10/09/2019] [Indexed: 01/08/2023] Open
Abstract
Background The challenges of glycaemic control in critically ill patients have been debated for 20 years. While glycaemic control shows benefits inter- and intra-patient metabolic variability results in increased hypoglycaemia and glycaemic variability, both increasing morbidity and mortality. Hence, current recommendations for glycaemic control target higher glycaemic ranges, guided by the fear of harm. Lately, studies have proven the ability to provide safe, effective control for lower, normoglycaemic, ranges, using model-based computerised methods. Such methods usually identify patient-specific physiological parameters to personalize titration of insulin and/or nutrition. The Stochastic-Targeted (STAR) glycaemic control framework uses patient-specific insulin sensitivity and a stochastic model of its future variability to directly account for both inter- and intra-patient variability in a risk-based insulin-dosing approach. Results In this study, a more personalized and specific 3D version of the stochastic model used in STAR is compared to the current 2D stochastic model, both built using kernel-density estimation methods. Fivefold cross validation on 681 retrospective patient glycaemic control episodes, totalling over 65,000 h of control, is used to determine whether the 3D model better captures metabolic variability, and the potential gain in glycaemic outcome is assessed using validated virtual trials. Results show that the 3D stochastic model has similar forward predictive power, but provides significantly tighter, more patient-specific, prediction ranges, showing the 2D model over-conservative > 70% of the time. Virtual trial results show that overall glycaemic safety and performance are similar, but the 3D stochastic model reduced median blood glucose levels (6.3 [5.7, 7.0] vs. 6.2 [5.6, 6.9]) with a higher 61% vs. 56% of blood glucose within the 4.4–6.5 mmol/L range. Conclusions This improved performance is achieved with higher insulin rates and higher carbohydrate intake, but no loss in safety from hypoglycaemia. Thus, the 3D stochastic model developed better characterises patient-specific future insulin sensitivity dynamics, resulting in improved simulated glycaemic outcomes and a greater level of personalization in control. The results justify inclusion into ongoing clinical use of STAR.
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Topjian AA, de Caen A, Wainwright MS, Abella BS, Abend NS, Atkins DL, Bembea MM, Fink EL, Guerguerian AM, Haskell SE, Kilgannon JH, Lasa JJ, Hazinski MF. Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e194-e233. [DOI: 10.1161/cir.0000000000000697] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post–cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post–cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post–cardiac arrest care.
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Shapey IM, Summers A, Yiannoullou P, Bannard-Smith J, Augustine T, Rutter MK, van Dellen D. Insulin therapy in organ donation and transplantation. Diabetes Obes Metab 2019; 21:1521-1528. [PMID: 30924574 DOI: 10.1111/dom.13728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/12/2019] [Accepted: 03/26/2019] [Indexed: 12/27/2022]
Abstract
Hyperglycaemia is common in hospitalized individuals, and is often caused by physiological stress associated with critical illness or major surgery. Insulin therapy is an established treatment for hyperglycaemia and acute hyperkalaemia, and has also been used for myocardial dysfunction resistant to inotropic support. Insulin is commonly used in both organ donors and transplant recipients for hyperglycaemia, but the underlying knowledge base supporting its use remains limited. Insulin therapy plays an important yet poorly understood role in both organ donation and transplantation. Tight glycaemic control has been extensively studied in critical care over the past 15 years; however, this has not yet translated into the field of transplantation, where patients are more unwell and where improved outcomes remain an ongoing challenge. Insulin therapy and optimization of glycaemic control represent important areas for future hypothesis-driven research into organ donation and transplantation, such as amelioration of ischaemia-reperfusion injury, rejection and infection.
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Affiliation(s)
- Iestyn M Shapey
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Angela Summers
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Petros Yiannoullou
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Jonathan Bannard-Smith
- Department of Critical Care, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Titus Augustine
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Martin K Rutter
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - David van Dellen
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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8
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Stewart KW, Chase JG, Pretty CG, Shaw GM. Nutrition delivery, workload and performance in a model-based ICU glycaemic control system. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2018; 166:9-18. [PMID: 30415721 DOI: 10.1016/j.cmpb.2018.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 08/20/2018] [Accepted: 09/10/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND OBJECTIVE Hyperglycaemia is commonplace in the adult intensive care unit (ICU), and has been associated with increased morbidity and mortality. Effective glycaemic control (GC) can reduce morbidity and mortality, but has proven difficult. STAR is a model-based GC protocol that uniquely maintains normoglycaemia by changing both insulin and nutrition interventions, and has been proven effective in controlling blood glucose (BG) in the ICU. However, most ICU GC protocols only change insulin interventions, making the variable nutrition aspect of STAR less clinically desirable. This paper compares the performance of STAR modulating only insulin, with three simpler alternative nutrition protocols in clinically evaluated virtual trials. METHODS Alternative nutrition protocols are fixed nutrition rate (100% caloric goal), CB (Cahill et al. best) stepped nutrition rate (60%, 80% and 100% caloric goal for the first 3 days of GC, and 100% thereafter) and SLQ (STAR lower quartile) stepped nutrition rate (65%, 75% and 85% caloric goal for the first 3 days of GC, and 85% thereafter). Each nutrition protocol is simulated with the STAR insulin protocol on a 221 patient virtual cohort, and GC performance, safety and total intervention workload are assessed. RESULTS All alternative nutrition protocols considerably reduced total intervention workload (14.6-19.8%) due to reduced numbers of nutrition changes. However, only the stepped nutrition protocols achieved similar GC performance to the current variable nutrition protocol. Of the two stepped nutrition protocols, the SLQ nutrition protocol also improved GC safety, almost halving the number of severe hypoglycaemic cases (5 vs. 9, P = 0.42). CONCLUSIONS Overall, the SLQ nutrition protocol was the best alternative to the current variable nutrition protocol, but either stepped nutrition protocol could be adapted by STAR to reduce workload and make it more clinically acceptable, while maintaining its proven performance and safety.
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Affiliation(s)
- Kent W Stewart
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand.
| | - J Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand.
| | - Christopher G Pretty
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand.
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand.
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Jamaludin UK, M Suhaimi F, Abdul Razak NN, Md Ralib A, Mat Nor MB, Pretty CG, Humaidi L. Performance of Stochastic Targeted Blood Glucose Control Protocol by virtual trials in the Malaysian intensive care unit. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2018; 162:149-155. [PMID: 29903481 DOI: 10.1016/j.cmpb.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 02/26/2018] [Accepted: 03/09/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Blood glucose variability is common in healthcare and it is not related or influenced by diabetes mellitus. To minimise the risk of high blood glucose in critically ill patients, Stochastic Targeted Blood Glucose Control Protocol is used in intensive care unit at hospitals worldwide. Thus, this study focuses on the performance of stochastic modelling protocol in comparison to the current blood glucose management protocols in the Malaysian intensive care unit. Also, this study is to assess the effectiveness of Stochastic Targeted Blood Glucose Control Protocol when it is applied to a cohort of diabetic patients. METHODS Retrospective data from 210 patients were obtained from a general hospital in Malaysia from May 2014 until June 2015, where 123 patients were having comorbid diabetes mellitus. The comparison of blood glucose control protocol performance between both protocol simulations was conducted through blood glucose fitted with physiological modelling on top of virtual trial simulations, mean calculation of simulation error and several graphical comparisons using stochastic modelling. RESULTS Stochastic Targeted Blood Glucose Control Protocol reduces hyperglycaemia by 16% in diabetic and 9% in nondiabetic cohorts. The protocol helps to control blood glucose level in the targeted range of 4.0-10.0 mmol/L for 71.8% in diabetic and 82.7% in nondiabetic cohorts, besides minimising the treatment hour up to 71 h for 123 diabetic patients and 39 h for 87 nondiabetic patients. CONCLUSION It is concluded that Stochastic Targeted Blood Glucose Control Protocol is good in reducing hyperglycaemia as compared to the current blood glucose management protocol in the Malaysian intensive care unit. Hence, the current Malaysian intensive care unit protocols need to be modified to enhance their performance, especially in the integration of insulin and nutrition intervention in decreasing the hyperglycaemia incidences. Improvement in Stochastic Targeted Blood Glucose Control Protocol in terms of uen model is also a must to adapt with the diabetic cohort.
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Affiliation(s)
- Ummu K Jamaludin
- Universiti Malaysia Pahang, Faculty of Mechanical Engineering, 26600 Pekan, Pahang, Malaysia.
| | - Fatanah M Suhaimi
- Universiti Sains Malaysia, Advanced Medical and Dental Institute, 13200 Bertam, Kepala Batas, Penang, Malaysia
| | - Normy Norfiza Abdul Razak
- Universiti Tenaga Nasional, College of Engineering, Putrajaya Campus, 43000 Kajang, Selangor, Malaysia
| | - Azrina Md Ralib
- International Islamic University Malaysia, Kuliyyah of Medicine, 25200 Kuantan, Pahang, Malaysia
| | - Mohd Basri Mat Nor
- International Islamic University Malaysia, Kuliyyah of Medicine, 25200 Kuantan, Pahang, Malaysia
| | - Christopher G Pretty
- University of Canterbury, Department of Mechanical Engineering, Private Bag 4800, Christchurch 8041, New Zealand
| | - Luqman Humaidi
- Universiti Malaysia Pahang, Faculty of Mechanical Engineering, 26600 Pekan, Pahang, Malaysia
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Merrill A, Jones S. Effectiveness of Tight Glycemic Control in the Medical Intensive Care Unit: A Systematic Review. ACTA ACUST UNITED AC 2018; 8:1-8. [PMID: 27820349 DOI: 10.11124/01938924-201008341-00001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND: Intensive Insulin Therapy (IIT) as a means to achieve tight glycemic control (TGC) has become controversial in the medical intensive care unit (ICU) or mixed medical-surgical ICU. The question still remains as to the benefit of tight glycemic control in all patient populations and the optimal target blood glucose range.
REVIEW QUESTIONS/OBJECTIVES: INCLUSION CRITERIA: This review included studies with patients 18 years of age and older, females and males, all types of conditions or diseases, and all stages of severity admitted to a critical care or intensive care unit that required hyperglycemia management and had not had a surgical procedure. This review included studies that evaluated the effectiveness of tight glycemic control or intensive insulin therapy as compared to conventional, moderate or liberal insulin therapy. This review considered studies that included the following outcome measures: frequency and severity of hypoglycemia, and any type of reported mortality. This review included only randomized controlled trials which met all of the inclusion criteria.
SEARCH STRATEGY: A three-step search strategy was utilized find both published and unpublished studies in English language only. An initial limited search of MEDLINE and CINAHL was completed followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies.
METHODOLOGICAL QUALITY: The reviewers used the JBI Critical Appraisal Checklist for Randomised Controlled Trials to assess methodological quality.
DATA COLLECTION: Data was extracted using The JBI Data Extraction Form for Experimental/Observational studies.
DATA SYNTHESIS: Due to the heterogeneous nature of the study methods, the findings of this systematic review are presented in a narrative summary. Meta-analysis was unable to be performed.
RESULTS: The four studies in this systematic review include patients with a multitude of diagnoses and comorbidities which further complicates treatment and outcomes assessment. Until further studies prove otherwise, nonsurgical patients requiring glycemic management are best served with less intensive regimens than their surgical counterparts.
CONCLUSIONS: Further research is needed to establish clear, evidence-based guidelines for the management of hyperglycemia in all ICU patient populations.Based on the results of this review and data from the four included studies, glycemic management for medical patients in the intensive care unit should differ from that of surgical patients. Blood glucoses should be kept between 110-180mg/dL in order to prevent the unwarranted effects of hypoglycemic episodes. Published studies compare outcomes for patients with dissimilar medical conditions and current protocols for glycemic management are still based on the results of surgical patient trials. Measurements for interventions and outcomes need to be standardized in order to ensure proper comparison and application of results.
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Affiliation(s)
- April Merrill
- 1. The Joanna Briggs Institute of Oklahoma (JBIO): a collaborating centre of the Joanna Briggs Institute, University of Adelaide, Australia
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Zhu C, Chen J, Pan J, Qiu Z, Xu T. Therapeutic effect of intensive glycemic control therapy in patients with traumatic brain injury: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97:e11671. [PMID: 30045323 PMCID: PMC6078679 DOI: 10.1097/md.0000000000011671] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hyperglycemia is associated with dismal outcomes in patients with traumatic brain injury (TBI), which is frequently treated with insulin therapy. In this study, a systematic review and meta-analysis of the published randomized controlled trials (RCTs) was performed to assess the safety and efficacy of intensive glycemic control (IGC) versus conventional glycemic control (CGC) for patients following TBI. METHODS Databases, including PubMed, Embase, and the Cochran database, were retrieved up to January 2018. The outcomes evaluated in this study included mortality, neurological outcome, infection rate, hypoglycemia episode, and length of stay (LOS) in intensive care unit (ICU). The enrolled trials were analyzed using the Review Manager 5.3 software. RESULTS A total of 7 randomized controlled trials (RCTs) involving 1013 cases were enrolled in this study, and the results indicated no significant difference in 6-month mortality (risk ratio [RR], 0.92; 95% confidence interval [CI] 0.76-1.10; P = .34). Subsequently, IGC was associated with a better neurological outcome (RR, 1.22; 95% CI 1.05-1.43; P = .01), lower infection rate (RR, 0.65; 95% CI 0.51-0.82; P = .0003) and shorter LOS in ICU (mean difference [MD] = -1.37; 95%CI = -2.11, -0.63; P = .0003). In addition, IGC would also increase the risk of hypoglycemia episode (RR, 4.53; 95% CI 2.18-9.42; P < .001). CONCLUSIONS IGC plays a protective role in improving neurological outcome, decreasing infection rate and reducing the LOS in ICU. However, IGC therapy can also remarkably increase the risk of hypoglycemia, but it will not affect the mortality in TBI patients.
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Affiliation(s)
- Chunran Zhu
- Department of Neurosurgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine
| | - Jinjing Chen
- Department of Neurosurgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine
| | - Junchen Pan
- Department of Neurosurgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhichao Qiu
- Department of Neurosurgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Tao Xu
- Department of Neurosurgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Stewart KW, Chase JG, Pretty CG, Shaw GM. Nutrition delivery of a model-based ICU glycaemic control system. Ann Intensive Care 2018; 8:4. [PMID: 29330610 PMCID: PMC5768573 DOI: 10.1186/s13613-017-0351-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 12/29/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Hyperglycaemia is commonplace in the adult intensive care unit (ICU), associated with increased morbidity and mortality. Effective glycaemic control (GC) can reduce morbidity and mortality, but has proven difficult. STAR is a proven, effective model-based ICU GC protocol that uniquely maintains normo-glycaemia by changing both insulin and nutrition interventions to maximise nutrition in the context of GC in the 4.4-8.0 mmol/L range. Hence, the level of nutrition it provides is a time-varying estimate of the patient-specific ability to take up glucose. METHODS First, the clinical provision of nutrition by STAR in Christchurch Hospital, New Zealand (N = 221 Patients) is evaluated versus other ICUs, based on the Cahill et al. survey of 158 ICUs. Second, the inter- and intra- patient variation of nutrition delivery with STAR is analysed. Nutrition rates are in terms of percentage of caloric goal achieved. RESULTS Mean nutrition rates clinically achieved by STAR were significantly higher than the mean and best ICU surveyed, for the first 3 days of ICU stay. There was large inter-patient variation in nutrition rates achieved per day, which reduced overtime as patient-specific metabolic state stabilised. Median intra-patient variation was 12.9%; however, the interquartile range of the mean per-patient nutrition rates achieved was 74.3-98.2%, suggesting patients do not deviate much from their mean patient-specific nutrition rate. Thus, the ability to tolerate glucose intake varies significantly between, rather than within, patients. CONCLUSIONS Overall, STAR's protocol-driven changes in nutrition rate provide higher nutrition rates to hyperglycaemic patients than those of 158 ICUs from 20 countries. There is significant inter-patient variability between patients to tolerate and uptake glucose, where intra-patient variability over stay is much lower. Thus, a best nutrition rate is likely patient specific for patients requiring GC. More importantly, these overall outcomes show high nutrition delivery and safe, effective GC are not exclusive and that restricting nutrition for GC does not limit overall nutritional intake compared to other ICUs.
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Affiliation(s)
- Kent W. Stewart
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8140 New Zealand
| | - J. Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8140 New Zealand
| | - Christopher G. Pretty
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8140 New Zealand
| | - Geoffrey M. Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
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Paliosa AK, Teixeira C, Rosa RG, Blatt CR. Hyperglycemia in critical patients: Determinants of insulin dose choice. Rev Assoc Med Bras (1992) 2017; 63:441-446. [PMID: 28724042 DOI: 10.1590/1806-9282.63.05.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 11/20/2016] [Indexed: 12/15/2022] Open
Abstract
Objective: To identify factors that can determine the choice of intermittent subcutaneous regular insulin dose in critically ill patients with hyperglycemia. Method: Cross-sectional study in a general adult ICU with 26 beds, data collected between September and October 2014. The variables analyzed were: sex, age, previous diagnosis of diabetes mellitus, use of corticosteroids, use of lactulose, sepsis, fasting, enteral nutrition, use of dextrose 5% in water, NPH insulin prescription and blood glucose level. Patients with one or more episodes of hyperglycemia (blood glucose greater than 180 mg/dL) were included as a convenience sample, not consecutively. Those with continuous insulin prescription were excluded from analysis. Results: We included 64 records of hyperglycemia observed in 22 patients who had at least one episode of hyperglycemia. The median administered subcutaneous regular human insulin was 6 IU and among the factors evaluated only blood glucose levels were associated with the choice of insulin dose administered. Conclusion: Clinical characteristics such as diet, medications and diagnosis of diabetes mellitus are clearly ignored in the decision-making regarding insulin dose to be administered for glucose control in critically ill patients with hyperglycemia.
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Affiliation(s)
- Aline Klitzke Paliosa
- Pharmacy Resident, Integrated Multiprofessional Health Residency (REMIS), Irmandade Santa Casa de Misericórdia de Porto Alegre (ISCMPA) and Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Cassiano Teixeira
- MD, Intensivist, ISCMPA's Central ICU and Hospital Moinhos de Vento. Adjunct Professor of Internal Medicine, UFSCPA, Porto Alegre, RS, Brazil
| | | | - Carine Raquel Blatt
- Pharmacist. Adjunct Professor, Department of Pharmaceutical Sciences, UFCSPA. Lecturer of Pharmacy, REMIS, ISCMPA/UFCSPA, Porto Alegre, RS, Brazil
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Patkova A, Joskova V, Havel E, Kovarik M, Kucharova M, Zadak Z, Hronek M. Energy, Protein, Carbohydrate, and Lipid Intakes and Their Effects on Morbidity and Mortality in Critically Ill Adult Patients: A Systematic Review. Adv Nutr 2017; 8:624-634. [PMID: 28710148 PMCID: PMC5502871 DOI: 10.3945/an.117.015172] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The guidelines for nutritional support in critically ill adult patients differ in various aspects. The optimal amount of energy and nutritional substrates supplied is important for reducing morbidity and mortality, but unfortunately this is not well known, because the topic is complex and every patient is individual. The aim of this review was to gather recent pertinent information concerning the nutritional support of critically ill patients in the intensive care unit (ICU) with respect to the energy, protein, carbohydrate, and lipid intakes and the effect of their specific utilization on morbidity and mortality. Enteral nutrition (EN) is generally recommended over parenteral nutrition (PN) and is beneficial when administered within 24-48 h after ICU admission. In contrast, early PN does not provide substantial advantages in terms of morbidity and mortality, and the time when it is safe and beneficial remains unclear. The most advantageous recommendation seems to be administration of a hypocaloric (<20 kcal · kg-1 · d-1), high-protein diet (amino acids at doses of ≥2 g · kg-1 · d-1), at least during the first week of critical illness. Another important factor for reducing morbidity is the maintenance of blood glucose concentrations at 120-150 mg/dL, which is accomplished with the use of insulin and lower doses of glucose of 1-2 g · kg-1 · d-1, because this prevents the risk of hypoglycemia and is associated with a better prognosis according to recent studies. A fat emulsion is used as a source of required calories because of insulin resistance in the majority of patients. In addition, lipid oxidation in these patients is ∼25% higher than in healthy subjects.
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Affiliation(s)
- Anna Patkova
- Departments of Biological and Medical Sciences and,Departments of Research and Development and
| | - Vera Joskova
- Departments of Biological and Medical Sciences and,Departments of Research and Development and
| | - Eduard Havel
- Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Miroslav Kovarik
- Departments of Biological and Medical Sciences and,Departments of Research and Development and
| | - Monika Kucharova
- Biophysics and Physical Chemistry, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic; and,Departments of Research and Development and
| | | | - Miloslav Hronek
- Departments of Biological and Medical Sciences and .,Departments of Research and Development and
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Uyttendaele V, Dickson JL, Shaw GM, Desaive T, Chase JG. Untangling glycaemia and mortality in critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017. [PMID: 28645302 PMCID: PMC5482947 DOI: 10.1186/s13054-017-1725-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Hyperglycaemia is associated with adverse outcomes in the intensive care unit, and initial studies suggested outcome benefits of glycaemic control (GC). However, subsequent studies often failed to replicate these results, and they were often unable to achieve consistent, safe control, raising questions about the benefit or harm of GC as well as the nature of the association of glycaemia with mortality and clinical outcomes. In this study, we evaluated if non-survivors are harder to control than survivors and determined if glycaemic outcome is a function of patient condition and eventual outcome or of the glycaemic control provided. Methods Clinically validated, model-based, hour-to-hour insulin sensitivity (SI) and its hour-to-hour variability (%ΔSI) were identified over the first 72 h of therapy in 145 patients (119 survivors, 26 non-survivors). In hypothesis testing, we compared distributions of SI and %ΔSI in 6-hourly blocks for survivors and non-survivors. In equivalence testing, we assessed if differences in these distributions, based on blood glucose measurement error, were clinically significant. Results SI level was never equivalent between survivors and non-survivors (95% CI of percentage difference in medians outside ±12%). Non-survivors had higher SI, ranging from 9% to 47% higher overall in 6-h blocks, and this difference became statistically significant as glycaemic control progressed. %ΔSI was equivalent between survivors and non-survivors for all 6-hourly blocks (95% CI of difference in medians within ±12%) and decreased in general over time as glycaemic control progressed. Conclusions Whereas non-survivors had higher SI levels, variability was equivalent to that of survivors over the first 72 h. These results indicate survivors and non-survivors are equally controllable, given an effective glycaemic control protocol, suggesting that glycaemia level and variability, and thus the association between glycaemia and outcome, are essentially determined by the control provided rather than by underlying patient or metabolic condition. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1725-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vincent Uyttendaele
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand. .,GIGA - In Silico Medicine, University of Liège, Allée du 6 Août 19, bâtiment B5a, 4000, Liège, Belgium.
| | - Jennifer L Dickson
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA - In Silico Medicine, University of Liège, Allée du 6 Août 19, bâtiment B5a, 4000, Liège, Belgium
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand
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Takesue Y, Tsuchida T. Strict glycemic control to prevent surgical site infections in gastroenterological surgery. Ann Gastroenterol Surg 2017; 1:52-59. [PMID: 29863158 PMCID: PMC5881357 DOI: 10.1002/ags3.12006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/18/2017] [Indexed: 12/21/2022] Open
Abstract
Perioperative hyperglycemia is a risk factor for surgical site infections (SSI). Although the recommended target blood glucose level (BG) is 140–180 mg/dL for critically ill patients, recent studies conducted in patients undergoing surgery showed a significant benefit of intensive insulin therapy for the management of perioperative hyperglycemia. The aim of the present review is to evaluate the benefits of strict glycemic control for reducing SSI in gastroenterological surgery. We carried out a post‐hoc analysis of the previously published data from research on the risk factors for SSI. The highest BG within 24 hours after surgery was evaluated. A total of 1555 patients were enrolled in the study. In multivariate analysis, a dose–response relationship between the level of hyperglycemia and the odds of SSI was demonstrated when compared with the reference group (≤150 mg/dL) (odds ratio [OR] = 1.68, 95% confidence interval [CI] 1.14–2.49 for 150–200 mg/dL; and OR = 2.15, 95% CI 1.40–3.29 for >200 mg/dL). Unexpectedly, hyperglycemia was not a significant risk factor for SSI among diabetes patients. By contrast, non‐diabetes patients with a BG of >150 mg/dL were found to have increased odds of SSI. In conclusion, a target BG of ≤150 mg/dL is recommended in patients without diabetes who undergo gastroenterological surgery. Additional study is required to determine an optimal target BG in diabetes patients. Because of the risk of hypoglycemia, a conventional protocol is indicated for patients admitted to the general ward where frequent glucose measurement is not assured.
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Affiliation(s)
- Yoshio Takesue
- Department of Infection Prevention and Control Hyogo College of Medicine Hyogo Japan
| | - Toshie Tsuchida
- Department of Nursing Hyogo University of Health Sciences Hyogo Japan
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Cioară AP, Flonta M, Binder A, Pop A, Siladi V, Todor N, Cristea V, Lupse M. Can we find accessible and relevant markers for sepsis outcome? REV ROMANA MED LAB 2017. [DOI: 10.1515/rrlm-2017-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Background and Aim: Sepsis is a life-threatening disease with high mortality, therefore establishing early diagnostic and finding reliable prognostic biomarkers is vital. We aimed to investigate the prognostic role, as a single value, of serum procalcitonin, C-reactive protein, serum lactate, platelets number and serum glucose level in septic patients, all measured in the first 24 hours after hospital admittance.
Materials and methods: This retrospective study included 241 adult patients with sepsis, severe sepsis or septic shock. We use data from patients observation sheets. Data that were collected include: demographic parameters, comorbidities, necessity of mechanical ventilation and laboratory variables. We performed the statistical analysis with the chi square test for nonparametric data and to analyse the accuracy of prediction we used the receiver - operator curves with the level of significance set at p < 0.05.
Results: From 241 patients with a median age of 68 years, 127 (52.69%) were male.113 patients had severe sepsis. 89 patients (36.9%) died and male had an increase mortality rate. Most cases were respiratory sepsis (45.20%). The highest mortality rate was in septic shock (51.2%). Procalcitonin, C-reactive protein and glucose serum level at admittance were not correlated with mortality. The serum levels of creatinine >1.67 mg/dL and serum lactate >1.9 mmol/L at admittance were correlated with mortality (p < 0.01). The cutoff value of 121×103/uL platelets number was also correlated with mortality (p < 0.01).
Conclusions: Our findings suggest that serum creatinine, serum lactate and the platelets number could be used as prognostic markers in septic patients at admittance.
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Affiliation(s)
| | - Mirela Flonta
- Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania
| | - Astrid Binder
- Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania
| | - Andreea Pop
- Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania
| | - Violeta Siladi
- Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania
| | - Nicolae Todor
- ”Prof. Dr. Ion Chiricuța” Institute of Oncology, Cluj-Napoca, Romania
| | - Victor Cristea
- University of Medicine and Pharmacy „Iuliu Hațieganu”, Cluj-Napoca, Romania
| | - Mihaela Lupse
- University of Medicine and Pharmacy „Iuliu Hațieganu”, Cluj-Napoca, Romania
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Distinguishing Between Efficacy and Real-World Effectiveness: The Case for Thinking Beyond Classic Randomized Controlled Trial Design. Reg Anesth Pain Med 2017; 42:131-132. [PMID: 28207640 DOI: 10.1097/aap.0000000000000563] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Stewart KW, Pretty CG, Tomlinson H, Thomas FL, Homlok J, Noémi SN, Illyés A, Shaw GM, Benyó B, Chase JG. Safety, efficacy and clinical generalization of the STAR protocol: a retrospective analysis. Ann Intensive Care 2016; 6:24. [PMID: 27025951 PMCID: PMC4811843 DOI: 10.1186/s13613-016-0125-9] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 03/08/2016] [Indexed: 02/06/2023] Open
Abstract
Background The changes in metabolic pathways and metabolites due to critical illness result in a highly complex and dynamic metabolic state, making safe, effective management of hyperglycemia and hypoglycemia difficult. In addition, clinical practices can vary significantly, thus making GC protocols difficult to generalize across units.The aim of this study was to provide a retrospective analysis of the safety, performance and workload of the stochastic targeted (STAR) glycemic control (GC) protocol to demonstrate that patient-specific, safe, effective GC is possible with the STAR protocol and that it is also generalizable across/over different units and clinical practices. Methods Retrospective analysis of STAR GC in the Christchurch Hospital Intensive Care Unit (ICU), New Zealand (267 patients), and the Gyula Hospital, Hungary (47 patients), is analyzed (2011–2015). STAR Christchurch (BG target 4.4–8.0 mmol/L) is also compared to the Specialized Relative Insulin and Nutrition Tables (SPRINT) protocol (BG target 4.4–6.1 mmol/L) implemented in the Christchurch Hospital ICU, New Zealand (292 patients, 2005–2007). Cohort mortality, effectiveness and safety of glycemic control and nutrition delivered are compared using nonparametric statistics. Results Both STAR implementations and SPRINT resulted in over 86 % of time per episode in the blood glucose (BG) band of 4.4–8.0 mmol/L. Patients treated using STAR in Christchurch ICU spent 36.7 % less time on protocol and were fed significantly more than those treated with SPRINT (73 vs. 86 % of caloric target). The results from STAR in both Christchurch and Gyula were very similar, with the BG distributions being almost identical. STAR provided safe GC with very few patients experiencing severe hypoglycemia (BG < 2.2 mmol/L, <5 patients, 1.5 %). Conclusions STAR outperformed its predecessor, SPRINT, by providing higher nutrition and equally safe, effective control for all the days of patient stay, while lowering the number of measurements and interventions required. The STAR protocol has the ability to deliver high performance and high safety across patient types, time, clinical practice culture (Christchurch and Gyula) and clinical resources.
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Affiliation(s)
- Kent W Stewart
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8140, New Zealand.
| | - Christopher G Pretty
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8140, New Zealand
| | - Hamish Tomlinson
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8140, New Zealand
| | - Felicity L Thomas
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8140, New Zealand
| | - József Homlok
- Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
| | | | - Attila Illyés
- Department of Intensive Care, Kálmán Pándy Hospital, Gyula, Hungary
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
| | - Balázs Benyó
- Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
| | - J Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8140, New Zealand
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Mahmoodpoor A, Hamishehkar H, Beigmohammadi M, Sanaie S, Shadvar K, Soleimanpour H, Rahimi A, Safari S. Predisposing Factors for Hypoglycemia and Its Relation With Mortality in Critically Ill Patients Undergoing Insulin Therapy in an Intensive Care Unit. Anesth Pain Med 2016; 6:e33849. [PMID: 27110538 PMCID: PMC4835586 DOI: 10.5812/aapm.33849] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 11/22/2015] [Accepted: 11/29/2015] [Indexed: 12/30/2022] Open
Abstract
Background: Hypoglycemia is a common and the most important complication of intensive insulin therapy in critically ill patients. Because of hypoglycemia’s impact on the cardinal organs as a fuel, if untreated it could results in permanent brain damage and increased mortality. Objectives: In this study, we aim to evaluate the incidence of hypoglycemia, its risk factors, and its relationship with mortality in critically ill patients. Patients and Methods: Five hundred adult patients who admitted to an intensive care unit (ICU) were enrolled in this study. A program of glycemic control with a target of 100 - 140 mg/dL was instituted. We used the threshold of 150 mg/dL for septic patients, which were monitored by point of care devices for capillary blood measurement. We detected hypoglycemia with a blood sugar of less than 50 mg/dL and with the detection of each episode of hypoglycemia, blood glucose measurement was performed every 30 minutes. Results: Five hundred patients experienced at least one episode of hypoglycemia, almost always on the third day. Of 15 expired patients who had one hypoglycemia episode, the most common causes were multiple trauma and sepsis. Increases in the sequential organ failure assessment (SOFA) number augmented the hypoglycemia risk to 52% (P < 0.001). Moreover, in patients with acute kidney injury (AKI), the risk of hypoglycemia is 10 times greater than in those without AKI (RR: 10.3, CI: 3.16 - 33.6, P < 0.001). ICU admission blood sugar has a significant relationship with mortality (RR: 1.01, CI: 1.004 - 1.02, P < 0.006). Hypoglycemia increased the mortality rate twofold, but it was not significant (RR: 1.2, CI: 0.927 - 1.58, P = 0.221). Conclusions: Our results showed that the SOFA score, AKI, and hemoglobin A1c are the independent risk factors for the development of hypoglycemia and demonstrated that ICU admission blood glucose, Hba1c, and hypoglycemia increased the risk of death, but only ICU admission blood glucose is significantly related to increased mortality.
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Affiliation(s)
- Ata Mahmoodpoor
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hadi Hamishehkar
- Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Sarvin Sanaie
- Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kamran Shadvar
- Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Soleimanpour
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding author: Hassan Soleimanpour, Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. Tel: +98-9141164134, Fax: +98-4133341994, E-mail:
| | - Ahsan Rahimi
- Students Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saeid Safari
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
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Monsieurs K, Nolan J, Bossaert L, Greif R, Maconochie I, Nikolaou N, Perkins G, Soar J, Truhlář A, Wyllie J, Zideman D. Kurzdarstellung. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, Perkins GD, Soar J, Truhlář A, Wyllie J, Zideman DA, Alfonzo A, Arntz HR, Askitopoulou H, Bellou A, Beygui F, Biarent D, Bingham R, Bierens JJ, Böttiger BW, Bossaert LL, Brattebø G, Brugger H, Bruinenberg J, Cariou A, Carli P, Cassan P, Castrén M, Chalkias AF, Conaghan P, Deakin CD, De Buck ED, Dunning J, De Vries W, Evans TR, Eich C, Gräsner JT, Greif R, Hafner CM, Handley AJ, Haywood KL, Hunyadi-Antičević S, Koster RW, Lippert A, Lockey DJ, Lockey AS, López-Herce J, Lott C, Maconochie IK, Mentzelopoulos SD, Meyran D, Monsieurs KG, Nikolaou NI, Nolan JP, Olasveengen T, Paal P, Pellis T, Perkins GD, Rajka T, Raffay VI, Ristagno G, Rodríguez-Núñez A, Roehr CC, Rüdiger M, Sandroni C, Schunder-Tatzber S, Singletary EM, Skrifvars MB, Smith GB, Smyth MA, Soar J, Thies KC, Trevisanuto D, Truhlář A, Vandekerckhove PG, de Voorde PV, Sunde K, Urlesberger B, Wenzel V, Wyllie J, Xanthos TT, Zideman DA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015; 95:1-80. [PMID: 26477410 DOI: 10.1016/j.resuscitation.2015.07.038] [Citation(s) in RCA: 568] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Koenraad G Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern, Bern, Switzerland; University of Bern, Bern, Switzerland
| | - Ian K Maconochie
- Paediatric Emergency Medicine Department, Imperial College Healthcare NHS Trust and BRC Imperial NIHR, Imperial College, London, UK
| | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jonathan Wyllie
- Department of Neonatology, The James Cook University Hospital, Middlesbrough, UK
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Maconochie IK, Bingham R, Eich C, López-Herce J, Rodríguez-Núñez A, Rajka T, Van de Voorde P, Zideman DA, Biarent D, Monsieurs KG, Nolan JP. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2015; 95:223-48. [DOI: 10.1016/j.resuscitation.2015.07.028] [Citation(s) in RCA: 217] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Huang PY, Lin MZ, Wen JP, Li XJ, Shi XL, Zhang HJ, Chen N, Li XY, Yang SY, Chen G. Correlation of early postoperative blood glucose levels with postoperative complications, hospital costs, and length of hospital stay in patients with gastrointestinal malignancies. Endocrine 2015; 48:187-94. [PMID: 24853883 DOI: 10.1007/s12020-014-0291-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 05/06/2014] [Indexed: 12/20/2022]
Abstract
Early postoperative hyperglycemia in non-diabetic patients is an important risk factor affecting postoperative complications and mortality. This study aimed at investigating the effects of early postoperative hyperglycemia on postoperative complications, hospital costs, and length of hospital stay in non-diabetic patients with gastrointestinal malignancies; data of 1,015 non-diabetic patients with gastrointestinal malignancies, who underwent surgical intervention between January 2010 and January 2012, were retrospectively evaluated. Records on fasting plasma glucose (FPG), liver function, and kidney function were collected before and one day after surgery. Correlation of early postoperative FPG levels with postoperative complications, hospital costs, and length of hospital stay was further assessed in non-diabetic patients with gastrointestinal malignancies. One day after surgery, FPG results were significantly increased compared to preoperative values. FPG levels greater than or equal to 9.13 mmol/L (or 164.34 mg/dL) were associated with significant increases in the incidence of postoperative complications, length of hospital stay, and hospital costs. An association is shown between FPG and postoperative hyperglycemia in non-diabetic patients undergoing surgery for gastrointestinal malignancies. Significant increases in postoperative complications among these patients suggest that measurement of early postoperative FPG levels is critical to identify patients with postoperative hyperglycemia.
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Affiliation(s)
- Pei-ying Huang
- Department of Endocrinology, The First Affiliated Hospital of Xiamen University, Xiamen, 361001, China
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Stochastic Model Predictive (STOMP) glycaemic control for the intensive care unit: Development and virtual trial validation. Biomed Signal Process Control 2015. [DOI: 10.1016/j.bspc.2014.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Sin HY. Hyperglycemia and survival rate in Asian patients with acute coronary syndrome. Arch Pharm Res 2014; 37:738-45. [PMID: 24687257 DOI: 10.1007/s12272-014-0354-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 02/03/2014] [Indexed: 01/04/2023]
Abstract
Current studies are debating on the association of higher admission blood glucose (BG) and increased mortality of acute coronary syndrome (ACS). This study evaluated association of mortality between admission BG and BG control in 222 patients with ACS who received coronary intervention in the intensive care unit. This study observed medical records through electronic medical record retrospectively and evaluated all patients who were admitted for the first attack of ST-segment elevation MI (STEMI), non-STEMI, and unstable angina pectoris. Admission BG higher than 220 mg/dl was statistically significantly associated with lower survival in patients; the association was stronger than in patients with admission BG higher than 140 mg/dl to less than 220 mg/dl and patients with admission BG less than 140 mg/dl (Wilcoxon test, p = 0.002). Survival time after admission was also associated with the history of diabetes mellitus (DM). Patients with diabetes had significantly lower survival than those without diabetes (Wilcoxon test, p = 0.028). Survival after ACS was not consistent with each insulin intervention of on admission to 6, 24, and 48 h after admission. There is a statistically significant association between admission BG higher than 220 mg/dl and low survival but each intervention of post admission BG levels were not consistently associated with the mortality. Additionally, history of DM is associated with lower survival in patients with ACS on admission.
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Affiliation(s)
- Hye Yeon Sin
- College of Pharmacy, Duksung Women's University, Seoul, 132-714, Korea,
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Ballestero Y, López-Herce J, González R, Solana MJ, del Castillo J, Urbano J, Botran M, García A, López N, Bellón JM. Relationship between hyperglycemia, hormone disturbances, and clinical evolution in severely hyperglycemic post surgery critically ill children: an observational study. BMC Endocr Disord 2014; 14:25. [PMID: 24628829 PMCID: PMC3995587 DOI: 10.1186/1472-6823-14-25] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 03/11/2014] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To study hormonal changes associated with severe hyperglycemia in critically ill children and the relationship with prognosis and length of stay in intensive care. METHODS Observational study in twenty-nine critically ill children with severe hyperglycemia defined as 2 blood glucose measurements greater than 180 mg/dL. Severity of illness was assessed using pediatric index of mortality (PIM2), pediatric risk of mortality (PRISM) score, and pediatric logistic organ dysfunction (PELOD) scales. Blood glucose, glycosuria, insulin, C-peptide, cortisol, corticotropin, insulinlike growth factor-1, growth hormone, thyrotropin, thyroxine, and treatment with insulin were recorded. β-cell function and insulin sensitivity and resistance were determined on the basis of the homeostatic model assessment (HOMA), using blood glucose and C-peptide levels. RESULTS The initial blood glucose level was 249 mg/dL and fell gradually to 125 mg/dL at 72 hours. Initial β-cell function (49.2%) and insulin sensitivity (13.2%) were low. At the time of diagnosis of hyperglycemia, 50% of the patients presented insulin resistance and β-cell dysfunction, 46% presented isolated insulin resistance, and 4% isolated β-cell dysfunction. β-cell function improved rapidly but insulin resistance persisted. Initial glycemia did not correlate with any other factor, and there was no relationship between glycemia and mortality. Patients who died had higher cortisol and growth hormone levels at diagnosis. Length of stay was correlated by univariate analysis, but not by multivariate analysis, with C-peptide and glycemic control at 24 hours, insulin resistance, and severity of illness scores. CONCLUSIONS Critically ill children with severe hyperglycemia initially present decreased β-cell function and insulin sensitivity. Nonsurvivors had higher cortisol and growth hormone levels and developed hyperglycemia later than survivors.
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Affiliation(s)
- Yolanda Ballestero
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón Complutense University of Madrid, Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón Complutense University of Madrid, Madrid, Spain
- Instituto de Investigación biomédica del Hospital Gregorio Marañón, Madrid, Spain
- Red de Salud Materno Infantil y del Desarrollo, Red SAMID II, Madrid, Spain
| | - Rafael González
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón Complutense University of Madrid, Madrid, Spain
- Instituto de Investigación biomédica del Hospital Gregorio Marañón, Madrid, Spain
- Red de Salud Materno Infantil y del Desarrollo, Red SAMID II, Madrid, Spain
| | - Maria José Solana
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón Complutense University of Madrid, Madrid, Spain
- Instituto de Investigación biomédica del Hospital Gregorio Marañón, Madrid, Spain
- Red de Salud Materno Infantil y del Desarrollo, Red SAMID II, Madrid, Spain
| | - Jimena del Castillo
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón Complutense University of Madrid, Madrid, Spain
- Instituto de Investigación biomédica del Hospital Gregorio Marañón, Madrid, Spain
- Red de Salud Materno Infantil y del Desarrollo, Red SAMID II, Madrid, Spain
| | - Javier Urbano
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón Complutense University of Madrid, Madrid, Spain
- Instituto de Investigación biomédica del Hospital Gregorio Marañón, Madrid, Spain
- Red de Salud Materno Infantil y del Desarrollo, Red SAMID II, Madrid, Spain
| | - Marta Botran
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón Complutense University of Madrid, Madrid, Spain
| | - Ana García
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón Complutense University of Madrid, Madrid, Spain
| | - Nieves López
- Laboratory Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jose María Bellón
- Instituto de Investigación biomédica del Hospital Gregorio Marañón, Madrid, Spain
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Penning S, Chase JG, Preiser JC, Pretty CG, Signal M, Mélot C, Desaive T. Does the achievement of an intermediate glycemic target reduce organ failure and mortality? A post hoc analysis of the Glucontrol trial. J Crit Care 2014; 29:374-9. [PMID: 24679489 DOI: 10.1016/j.jcrc.2014.01.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 12/16/2013] [Accepted: 01/17/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE This research evaluates the impact of the achievement of an intermediate target glycemic band on the severity of organ failure and mortality. METHODS Daily Sequential Organ Failure Assessment (SOFA) score and the cumulative time in a 4.0 to 7.0 mmol/L band (cTIB) were evaluated daily up to 14 days in 704 participants of the multicentre Glucontrol trial (16 centers) that randomized patients to intensive group A (blood glucose [BG] target: 4.4-6.1 mmol/L) or conventional group B (BG target: 7.8-10.0 mmol/L). Sequential Organ Failure Assessment evolution was measured by percentage of patients with SOFA less than or equal to 5 on each day, percentage of individual organ failures, and percentage of organ failure-free days. Conditional and joint probability analysis of SOFA and cTIB 0.5 or more assessed the impact of achieving 4.0 to 7.0 mmol/L target glycemic range on organ failure. Odds ratios (OR) compare the odds risk of death for cTIB 0.5 or more vs cTIB less than 0.5, where a ratio greater than 1.0 indicates an improvement for achieving cTIB 0.5 or more independent of SOFA or glycemic target. RESULTS Groups A and B were matched for demographic and severity of illness data. Blood glucose differed between groups A and B (P<.05), as expected. There was no difference in the percentage of patients with SOFA less than or equal to 5, individual organ failures, and organ failure-free days between groups A and B over days 1 to 14. However, 20% to 30% of group A patients failed to achieve cTIB 0.5 or more for all days, and significant crossover confounds interpretation. Mortality OR was greater than 1.0 for patients with cTIB 0.5 or more in both groups but much higher for group A on all days. CONCLUSIONS There was no difference in organ failure in the Glucontrol study based on intention to treat to different glycemic targets. Actual outcomes and significant crossover indicate that this result may not be due to the difference in target or treatment. Odds ratios-associated achieving an intermediate 4.0 to 7.0 mmol/L range improved outcome.
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Affiliation(s)
- Sophie Penning
- GIGA-Cardiovascular Sciences, Institut de Physique, Université de Liege, Institut de Physics, Allée du 6 Août, 17 (Bât B5), B4000 Liege, Liege, Belgium.
| | - J Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, Private Bag 4800, 8054, New Zealand.
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, 808 route de Lennik, B1070 Brussels, Belgium.
| | - Christopher G Pretty
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, Private Bag 4800, 8054, New Zealand.
| | - Matthew Signal
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, Private Bag 4800, 8054, New Zealand.
| | - Christian Mélot
- Department of Emergency Medicine, Erasme University Hospital, Brussels, Belgium.
| | - Thomas Desaive
- GIGA-Cardiovascular Sciences, Institut de Physique, Université de Liege, Institut de Physics, Allée du 6 Août, 17 (Bât B5), B4000 Liege, Liege, Belgium.
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Marics G, Koncz L, Körner A, Mikos B, Tóth-Heyn P. [Role of continuous subcutaneous glucose monitoring in intensive care]. Orv Hetil 2013; 154:1043-8. [PMID: 23816891 DOI: 10.1556/oh.2013.29662] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Critical care associated with stress hyperglycaemia has gained a new view in the last decade since the demonstration of the beneficial effects of strong glycaemic control on the mortality in intensive care units. Strong glycaemic control may, however, induce hypoglycaemia, resulting in increased mortality, too. Pediatric population has an increased risk of hypoglycaemia because of the developing central nervous system. In this view there is a strong need for close monitoring of glucose levels in intensive care units. The subcutaneous continuous glucose monitoring developed for diabetes care is an alternative for this purpose instead of regular blood glucose measurements. It is important to know the limitations of subcutaneous continuous glucose monitoring in intensive care. Decreased tissue perfusion may disturb the results of subcutaneous continuous glucose monitoring, because the measurement occurs in interstitial fluid. The routine use of subcutaneous continuous glucose monitoring in intensive care units is not recommended yet until sufficient data on the reliability of the system are available. The Medtronic subcutaneous continuous glucose monitoring system is evaluated in the review partly based on the authors own results.
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Affiliation(s)
- Gábor Marics
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Gyermekgyógyászati Klinika Budapest.
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Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med 2013; 40:3251-76. [PMID: 23164767 DOI: 10.1097/ccm.0b013e3182653269] [Citation(s) in RCA: 372] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point. METHODS Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear. RECOMMENDATIONS The article is focused on a suggested glycemic control end point such that a blood glucose ≥ 150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤ 70 mg/dL) and to minimize glycemic variability.Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate monitoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients. CONCLUSIONS While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infusion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy.
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Solheim O, Losvik OK. Tight glycemic control in the neuro-intensive care unit? Neurosurgery 2012; 72:E694-6. [PMID: 23266864 DOI: 10.1227/neu.0b013e318282d804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Benyo B, Illyés A, Némedi NS, Le Compte AJ, Havas A, Kovacs L, Fisk L, Shaw GM, Chase JG. Pilot study of the SPRINT glycemic control protocol in a Hungarian medical intensive care unit. J Diabetes Sci Technol 2012; 6:1464-77. [PMID: 23294794 PMCID: PMC3570889 DOI: 10.1177/193229681200600628] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Stress-induced hyperglycemia increases morbidity and mortality. Tight control can reduce mortality but has proven difficult to achieve. The SPRINT (Specialized Relative Insulin and Nutrition Tables) protocol is the only protocol that reduced both mortality and hypoglycemia by modulating both insulin and nutrition, but it has not been tested in independent hospitals. METHODS SPRINT was used for 12 adult intensive care unit patients (949 h) at Kálmán Pándy Hospital (Gyula, Hungary) as a clinical practice assessment. Insulin recommendations (0-6 U/h) were administered via constant infusion rather than bolus delivery. Nutrition was administered per local standard protocol, weaning parenteral to enteral nutrition, but was modulated per SPRINT recommendations. Measurement was every 1 to 2 h, per protocol. Glycemic performance is assessed by percentage of blood glucose (BG) measurements in glycemic bands for the cohort and per patient. Safety from hypoglycemia is assessed by numbers of patients with BG < 2.2 (severe) and %BG < 3.0 and < 4.0 mmol/liter (moderate and light). Clinical effort is assessed by measurements per day. Results are median (interquartile range). RESULTS There were 742 measurements over 1088 h of control (16.4 measurements/day), which is similar to clinical SPRINT results (16.2/day). Per-patient hours of control were 65 (50-95) h. Initial per-patient BG was 10.5 (7.9-11.2) mmol/liter. All patients (100%) reached 6.1 mmol/liter. Cohort BG was 6.3 (5.5-7.5) mmol/liter, with 42.2%, 65.1% and 77.6% of BG in the 4.0-6.1, 4.0-7.0, and 4.0-8.0 mmol/liter bands. Per-patient, median percentage time in these bands was 40.2 (26.7-51.5)%, 62.5 (46.0-75.7)%, and 74.7 (61.6.8-87.8)%, respectively. No patients had BG < 2.2 mmol/liter, and the %BG < 4.0 mmol/liter was 1.9%. These results were achieved using 3.0 (3.0-5.0) U/h of insulin with 7.4 (4.4-10.2) g/h of dextrose administration (all sources) for the cohort. Per-patient median insulin administration was 3.0 (3.0-3.0) U/h and 7.1 (3.4-9.6) g/h dextrose. Higher carbohydrate nutrition formulas than were used in SPRINT are offset by slightly higher insulin administration in this study. CONCLUSIONS The glycemic performance shows that using the SPRINT protocol to guide insulin infusions and nutrition administration provided very good glycemic control in initial pilot testing, with no severe hypoglycemia. The overall design of the protocol was able to be generalized with good compliance and outcomes across geographically distinct clinical units, patients, and clinical practice.
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Affiliation(s)
- Balazs Benyo
- Medical Informatics, Budapest University of Technology and Economics, Budapest, Hungary
| | - Attila Illyés
- Department of Anesthesiology and Intensive Care, Kálmán Pándy Hospital, Gyula, Hungary
| | - Noémi Szabó Némedi
- Department of Anesthesiology and Intensive Care, Kálmán Pándy Hospital, Gyula, Hungary
| | - Aaron J. Le Compte
- University of Canterbury, Department of Mechanical Engineering, Centre for Bio-Engineering, Christchurch, New Zealand
| | - Attila Havas
- Department of Anesthesiology and Intensive Care, Kálmán Pándy Hospital, Gyula, Hungary
| | - Levente Kovacs
- Medical Informatics, Budapest University of Technology and Economics, Budapest, Hungary
| | - Liam Fisk
- University of Canterbury, Department of Mechanical Engineering, Centre for Bio-Engineering, Christchurch, New Zealand
| | - Geoffrey M. Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
| | - J. Geoffrey Chase
- University of Canterbury, Department of Mechanical Engineering, Centre for Bio-Engineering, Christchurch, New Zealand
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Lee LJ, Emons MF, Martin SA, Faries D, Bae J, Nathanson BH, Yu HT, Haidar T, Bode BW. Association of blood glucose levels with in-hospital mortality and 30-day readmission in patients undergoing invasive cardiovascular surgery. Curr Med Res Opin 2012; 28:1657-65. [PMID: 22867281 DOI: 10.1185/03007995.2012.718268] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study aimed to evaluate the association of mean and maximum blood glucose (BG) levels with in-hospital mortality and 30-day hospital readmission among patients in the intensive care unit (ICU) undergoing invasive cardiovascular (CV) surgery. RESEARCH DESIGN AND METHODS The retrospective database analysis consisted of data from 3132 patients from 17 hospitals who underwent an invasive CV surgery during 1/2000-12/2006. Patients with hyperglycemia were identified based on serum BG levels recorded from 12 hours prior to and 24 hours after ICU admission. Separate logistic regression models were used to examine the association of mean and maximum BG levels to in-hospital mortality and 30-day readmission, adjusting for patient demographics, comorbidities and laboratory values. RESULTS The adjusted odds ratio (OR) for in-hospital mortality was 1.07 (95% CI: 1.01-1.12; p < .001) for every 0.56-mmol/L increase in mean BG, and OR = 1.06 (95% CI: 1.03-1.08, p < .001) for every 0.56-mmol/L increase in maximum BG. Mean BG was not associated with 30-day readmission while maximum BG had a borderline association: OR = 1.02 (95% CI: 1.00-1.03, p = .06). LIMITATION The results are not generalizable to all cardiovascular surgical patients since only those undergoing invasive procedures were included in the study. CONCLUSIONS Higher mean and maximum BG levels were associated with increased risk of in-hospital mortality but not with 30-day readmission. Further research is needed to identify optimal BG targets and the effects of avoiding extreme hyperglycemia on patient outcomes.
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Liu HC, Zhou YB, Chen D, Niu ZJ, Yu Y. Effect of intensive vs conventional insulin therapy on perioperative nutritional substrates metabolism in patients undergoing gastrectomy. World J Gastroenterol 2012; 18:2695-703. [PMID: 22690080 PMCID: PMC3370008 DOI: 10.3748/wjg.v18.i21.2695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Revised: 07/06/2011] [Accepted: 07/13/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of intensive vs conventional insulin therapy on perioperative nutritional substrates metabolism in patients undergoing radical distal gastrectomy.
METHODS: Within 24 h of intensive care unit management, patients with gastric cancer were enrolled after written informed consent and randomized to the intensive insulin therapy (IIT) group to keep glucose levels from 4.4 to 6.1 mmol/L or the conventional insulin therapy (CIT) group to keep levels less than 10 mmol/L. Resting energy expenditure (REE), respiratory quotient (RQ), resting energy expenditure per kilogram (REE/kg), and the lipid oxidation rate were monitored by the indirect calorimeter of calcium citrate malate nutrition metabolism investigation system. The changes in body composition were analyzed by multi-frequency bioimpedance analysis. Blood fasting glucose and insulin concentration were measured for assessment of Homeostasis model assessment of insulin resistance.
RESULTS: Sixty patients were enrolled. Compared with preoperative baseline, postoperative REE increased by over 22.15% and 11.07%; REE/kg rose up to 27.22 ± 1.33 kcal/kg and 24.72 ± 1.43 kcal/kg; RQ decreased to 0.759 ± 0.034 and 0.791 ± 0.037; the lipid oxidation ratio was up to 78.25% ± 17.74% and 67.13% ± 12.76% supported by parenteral nutrition solutions from 37.56% ± 11.64% at the baseline; the level of Ln-HOMA-IR went up dramatically (P < 0.05, respectively) on postoperative days 1 and 3 in the IIT group. Meanwhile the concentration of total protein, albumin and triglyceride declined significantly on postoperative days 1 and 3 compared with pre-operative levels (P < 0.05, respectively). Compared with the CIT group, IIT reduced the REE/kg level (27.22 ± 1.33 kcal/kg vs 29.97 ± 1.47 kcal/kg, P = 0.008; 24.72 ± 1.43 kcal/kg vs 25.66 ± 1.63 kcal/kg, P = 0.013); and decreased the Ln-HOMA-IR score (P = 0.019, 0.028) on postoperative days 1 and 3; IIT decreased the level of CRP on postoperative days 1 and 3 (P = 0.017, 0.006); the total protein and albumin concentrations in the IIT group were greater than those in the CIT group (P = 0.023, 0.009). Postoperative values of internal cell fluid (ICF), fat mass, protein mass (PM), muscle mass, free fat mass and body weight decreased obviously on postoperative 7th day compared with the preoperative baseline in the CIT group (P < 0.05, respectively). IIT reduced markedly consumption of fat mass, PM and ICF compared with CIT (P = 0.009 to 0.026).
CONCLUSION: There were some benefits of IIT in decreasing the perioperative insulin resistance state, reducing energy expenditure and consumption of proteins and lipids tissue in patients undergoing gastrectomy.
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Abstract
UNLABELLED NEED AND PURPOSE OF REVIEW: Hyperglycemia is prevalent among critically ill pediatric patients. Previously thought to be an adaptive response to stress, hyperglycemia is now recognized to be associated with an adverse outcome. Correction of such hyperglycemia with insulin infusion has been shown to improve outcome but carries risk of hypoglycemia. This review addresses these issues related to treatment of hyperglycemia. METHODS A Pubmed search was performed using the search strategy: (hyperglycemia OR blood glucose OR insulin therapy) AND (critical illness OR critical care OR intensive care unit). Randomized controlled trials, clinical trials, meta-analysis and observational studies (adult and pediatric) published in the last 10 years were included. CONCLUSION Blood sugar monitoring and correction of hyperglycemia while caring for critically ill children is crucial. A modest blood glucose target of <150 mg/dL is appropriate. Providing adequate nutrition along with training of the nursing personnel would prevent any adverse effect such as hypoglycemia.
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Schroeder JE, Liebergall M, Raz I, Egleston R, Ben Sussan G, Peyser A, Eldor R. Benefits of a simple glycaemic protocol in an orthopaedic surgery ward: a randomized prospective study. Diabetes Metab Res Rev 2012; 28:71-5. [PMID: 21584922 DOI: 10.1002/dmrr.1217] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hyperglycaemia and diabetes mellitus are common in patients hospitalized in the orthopaedic surgery ward. However, glycaemic control obtained during hospitalization is often suboptimal. No method for achieving adequate glycaemic control in this population has been validated in an in-hospital setting. INTERVENTION An intervention including an intensive subcutaneous insulin protocol in the orthopaedic department. METHODS All diabetic patients admitted to the Department of Orthopaedic Surgery were prospectively randomized during a 6-month period. One group (n = 30) received standard care with sliding scale insulin and the other group (n = 35) received the intervention protocol. During the intervention period, the staff was briefed on the importance of glucose monitoring and control. An intensive multiple-injection protocol consisting of four daily regular/neutral protamine hagedorn (NPH) insulin injections was initiated in diabetic patients. The programme was followed up by a consulting diabetologist. RESULTS Mean blood glucose levels throughout the hospitalization were 161.48 ± 3.8 mg/dL in the intervention group versus 175.29 ± 2.3 mg/dL in the control group (p < 0.0005). Hospitalization was shorter by 2 days in the intervention group (p < 0.05). The number of severe hyperglycaemic events (blood glucose level above 400 mg%) was significantly lower (p < 0.05) in the intervention group. There was no significant difference in the number of hypoglycaemic events. CONCLUSIONS The suggested four-step intervention regimen improved glycaemic control of hospitalized patients in the orthopaedic department and simplified the 'in-house' treatment of the diabetic patient. Hospital stays were reduced on average by two days (p < 0.05).
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Affiliation(s)
- Josh E Schroeder
- The Orthopedic Surgery Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
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Abstract
PURPOSE OF REVIEW The publication of Van den Berghe's landmark study in 2001 supported the use of intensive insulin therapy (IIT) to target normoglycemia in the critically ill and triggered a new era in glycemic management in the perioperative period and in the ICU. In 2009, the normoglycemia in intensive care evaluation-survival using glucose algorithm regulation (NICE-SUGAR) trial demonstrated increased mortality and incidence of hypoglycemia in patients managed with IIT, resulting in a shift toward higher blood glucose targets in this patient population. This review distills clinically pertinent principles from the related literature published in the months since the NICE-SUGAR trial. RECENT FINDINGS A target blood glucose level in the acute care setting supported by many of the pertinent societies and frequently quoted in the literature is 140-180 mg/dl. Hyperglycemia, hypoglycemia, and glucose variability are detrimental. Accurate and efficient glucose monitoring devices are essential. Insulin infusion protocols (IIPs) employed to achieve desired blood glucose targets must be individualized and validated for the ICU and institution in which they are being implemented. SUMMARY Appropriate glycemic management in the acute care setting can be achieved by targeting a reasonable blood glucose range and employing specific and institutionally validated IIPs.
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Pecha T, Sharma D, Hoffman NG, Sookplung P, Curry P, Vavilala MS. Hyperglycemia During Craniotomy for Adult Traumatic Brain Injury. Anesth Analg 2011; 113:336-42. [DOI: 10.1213/ane.0b013e31821d3dde] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Griesdale DEG, Tremblay MH, McEwen J, Chittock DR. Glucose control and mortality in patients with severe traumatic brain injury. Neurocrit Care 2011; 11:311-6. [PMID: 19636972 DOI: 10.1007/s12028-009-9249-1] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The optimal glucose range in patients with severe traumatic brain injury (TBI) remains unclear. The goal of this study was to examine the association of serum glucose levels on mortality in patients with severe TBI. As a secondary endpoint, we determined the risk of hyperglycemic and hypoglycemic events, and their association with mortality. METHODS We conducted a retrospective cohort study of patients admitted to the ICU between May 2000 and March 2006 with severe TBI (Glasgow Coma Scale ≤ 8) who survived at least 12 h. Average daily morning glucose levels for the first 10 days of admission were calculated and divided into quintiles. RESULTS A total of 170 patients were included in the analysis. We found no association between quintiles of mean daily morning glucose and hospital mortality. Episodes of hyperglycemia ( ≥ 11.1 mmol/l or 200 mg/dl) during the first 10 days occurred in 65% of patients (5.4% of all glucose measurements). Using multivariable regression, a single episode of hyperglycemia was associated with 3.6-fold increased risk of hospital mortality (95%CI: 1.2-11.2, P = 0.02). Hypoglycemia ( ≤ 4.4 mmol/l or 80 mg/dl) was present in 48% of patients (4.3% of all glucose measurements), and was not associated with mortality. CONCLUSION Any episode of hyperglycemia ( ≥ 11.1 mmol/l or 200 mg/dl) was associated with 3.6-fold increased risk of hospital mortality in patients with severe TBI and thus, should be avoided. Maintaining serum glucose ≤ 10 mmol/l appears to be a reasonable balance to avoid extremes of glucose control, but further studies are needed to determine the optimal glucose range.
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Affiliation(s)
- Donald E G Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.
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Chase JG, Le Compte AJ, Suhaimi F, Shaw GM, Lynn A, Lin J, Pretty CG, Razak N, Parente JD, Hann CE, Preiser JC, Desaive T. Tight glycemic control in critical care--the leading role of insulin sensitivity and patient variability: a review and model-based analysis. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2011; 102:156-171. [PMID: 21145614 DOI: 10.1016/j.cmpb.2010.11.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Revised: 10/27/2010] [Accepted: 11/15/2010] [Indexed: 05/30/2023]
Abstract
Tight glycemic control (TGC) has emerged as a major research focus in critical care due to its potential to simultaneously reduce both mortality and costs. However, repeating initial successful TGC trials that reduced mortality and other outcomes has proven difficult with more failures than successes. Hence, there has been growing debate over the necessity of TGC, its goals, the risk of severe hypoglycemia, and target cohorts. This paper provides a review of TGC via new analyses of data from several clinical trials, including SPRINT, Glucontrol and a recent NICU study. It thus provides both a review of the problem and major background factors driving it, as well as a novel model-based analysis designed to examine these dynamics from a new perspective. Using these clinical results and analysis, the goal is to develop new insights that shed greater light on the leading factors that make TGC difficult and inconsistent, as well as the requirements they thus impose on the design and implementation of TGC protocols. A model-based analysis of insulin sensitivity using data from three different critical care units, comprising over 75,000h of clinical data, is used to analyse variability in metabolic dynamics using a clinically validated model-based insulin sensitivity metric (S(I)). Variation in S(I) provides a new interpretation and explanation for the variable results seen (across cohorts and studies) in applying TGC. In particular, significant intra- and inter-patient variability in insulin resistance (1/S(I)) is seen be a major confounder that makes TGC difficult over diverse cohorts, yielding variable results over many published studies and protocols. Further factors that exacerbate this variability in glycemic outcome are found to include measurement frequency and whether a protocol is blind to carbohydrate administration.
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Affiliation(s)
- J Geoffrey Chase
- University of Canterbury, Dept of Mechanical Engineering, Centre for Bio-Engineering, Private Bag 4800, Christchurch, New Zealand.
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Lin J, Razak NN, Pretty CG, Le Compte A, Docherty P, Parente JD, Shaw GM, Hann CE, Geoffrey Chase J. A physiological Intensive Control Insulin-Nutrition-Glucose (ICING) model validated in critically ill patients. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2011; 102:192-205. [PMID: 21288592 DOI: 10.1016/j.cmpb.2010.12.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Revised: 09/30/2010] [Accepted: 12/08/2010] [Indexed: 05/30/2023]
Abstract
Intensive insulin therapy (IIT) and tight glycaemic control (TGC), particularly in intensive care unit (ICU), are the subjects of increasing and controversial debate in recent years. Model-based TGC has shown potential in delivering safe and tight glycaemic management, all the while limiting hypoglycaemia. A comprehensive, more physiologically relevant Intensive Control Insulin-Nutrition-Glucose (ICING) model is presented and validated using data from critically ill patients. Two existing glucose-insulin models are reviewed and formed the basis for the ICING model. Model limitations are discussed with respect to relevant physiology, pharmacodynamics and TGC practicality. Model identifiability issues are carefully considered for clinical settings. This article also contains significant reference to relevant physiology and clinical literature, as well as some references to the modeling efforts in this field. Identification of critical constant population parameters was performed in two stages, thus addressing model identifiability issues. Model predictive performance is the primary factor for optimizing population parameter values. The use of population values are necessary due to the limited clinical data available at the bedside in the clinical control scenario. Insulin sensitivity, S(I), the only dynamic, time-varying parameter, is identified hourly for each individual. All population parameters are justified physiologically and with respect to values reported in the clinical literature. A parameter sensitivity study confirms the validity of limiting time-varying parameters to S(I) only, as well as the choices for the population parameters. The ICING model achieves median fitting error of <1% over data from 173 patients (N=42,941 h in total) who received insulin while in the ICU and stayed for ≥ 72 h. Most importantly, the median per-patient 1-h ahead prediction error is a very low 2.80% [IQR 1.18, 6.41%]. It is significant that the 75th percentile prediction error is within the lower bound of typical glucometer measurement errors of 7-12%. These results confirm that the ICING model is suitable for developing model-based insulin therapies, and capable of delivering real-time model-based TGC with a very tight prediction error range. Finally, the detailed examination and discussion of issues surrounding model-based TGC and existing glucose-insulin models render this article a mini-review of the state of model-based TGC in critical care.
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Affiliation(s)
- Jessica Lin
- Department of Medicine, University of Otago Christchurch, New Zealand.
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Du J, Liu H, Liu R, Yao Y, Jiao H, Zhao X, Yin H, Li Z. Clinical effects of intensive insulin therapy treating traumatic shock combined with multiple organ dysfunction syndrome. ACTA ACUST UNITED AC 2011; 31:194-198. [PMID: 21505984 DOI: 10.1007/s11596-011-0251-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Indexed: 01/04/2023]
Abstract
The therapeutic effects of intensive insulin therapy in treatment of traumatic shock combined with multiple organ dysfunction syndrome (MODS) were investigated. A total of 114 patients with traumatic shock combined with MODS were randomly divided into two groups: control group (n=56) treated with conventional therapy, and intensive insulin therapy group (n=58) treated with conventional therapy plus continuous insulin pumping to control the blood glucose level at range of 4.4-6.1 mmol/L. White blood cells (WBC) counts, prothrombin time (PT), serum creatinine (SCr), alanine aminotransferase (ALT), serum albumin and PaO(2) were measured before and at the day 1, 3, 5, 7 and 14 after treatment. The incidence of gastrointestinal dysfunction, the incidence of MODS, hospital stay and the mortality were also observed and compared. After intensive insulin therapy, the WBC counts, SCr, ALT and PT were significantly reduced (P<0.05), but the level of serum albumin was significantly increased (P<0.05) at the day 3, 5, 7 and 14. In the meantime, the PaO2 was significantly elevated at the day 3, 5 and 7 (P<0.01) after intensive insulin therapy. The incidence of gastrointestinal dysfunction, the incidence of MODS, the length of hospital stay and the mortality were markedly decreased (P<0.01). The results suggest early treatment with intensive insulin therapy is effective for traumatic shock combined with MODS and can decrease the length of hospital stay and the mortality.
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Affiliation(s)
- Jundong Du
- Department of Hepatobiliary Surgery, First Affiliated Hospital to General Hospital of PLA, Beijing, 100037, China
| | - Hongming Liu
- Department of Hepatobiliary Surgery, Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042, China
| | - Rong Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital to General Hospital of PLA, Beijing, 100037, China.
| | - Yongming Yao
- Department of Hepatobiliary Surgery, First Affiliated Hospital to General Hospital of PLA, Beijing, 100037, China
| | - Huabo Jiao
- Department of Hepatobiliary Surgery, First Affiliated Hospital to General Hospital of PLA, Beijing, 100037, China
| | - Xiaodong Zhao
- Department of Hepatobiliary Surgery, First Affiliated Hospital to General Hospital of PLA, Beijing, 100037, China
| | - Huinan Yin
- Department of Hepatobiliary Surgery, First Affiliated Hospital to General Hospital of PLA, Beijing, 100037, China
| | - Zhanliang Li
- Department of Hepatobiliary Surgery, First Affiliated Hospital to General Hospital of PLA, Beijing, 100037, China
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Biarent D, Bingham R, Eich C, López-Herce J, Maconochie I, Rodríguez-Núñez A, Rajka T, Zideman D. European Resuscitation Council Guidelines for Resuscitation 2010 Section 6. Paediatric life support. Resuscitation 2011; 81:1364-88. [PMID: 20956047 DOI: 10.1016/j.resuscitation.2010.08.012] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Dominique Biarent
- Paediatric Intensive Care, Hôpital Universitaire des Enfants, 15 av JJ Crocq, Brussels, Belgium.
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Accuracy and reliability of a subcutaneous continuous glucose-monitoring system in critically ill patients*. Crit Care Med 2011; 39:659-64. [DOI: 10.1097/ccm.0b013e318206bf2e] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Godoy DA, Di Napoli M, Rabinstein AA. Treating hyperglycemia in neurocritical patients: benefits and perils. Neurocrit Care 2011; 13:425-38. [PMID: 20652767 DOI: 10.1007/s12028-010-9404-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
There is growing debate over the value of intensive insulin therapy (IIT) in critically ill patients. Available trials have been performed in general medical or surgical intensive care units, and the results may not be directly applicable to patients with severe acute brain disease because these patients may have heightened susceptibility to hyperglycemia (HyperG) and hypoglycemia. Our objective was to review the pathophysiology and effects of HyperG and hypoglycemia in neurocritical patients and to analyze the potential role of IIT in this population. Source data were obtained from a PubMed search of the medical literature combining the terms HyperG, hypoglycemia, insulin, stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), spinal cord injury (SCI), and related diagnoses. Brain metabolism is highly dependent on constant supply of glucose. As a consequence, the acutely injured brain is particularly sensitive to hypoglycemia, which can induce a state of energy failure (metabolic crisis). Meanwhile, neurocritical patients have a high prevalence of HyperG, and its occurrence is associated with poor outcome after acute ischemic stroke, ICH, SAH, and TBI. It is unclear whether this association is due to direct detrimental effects exerted by HyperG or simply represents a marker of severe brain injury. Insulin has been shown to have various potentially pleiotropic neuroprotective properties in experimental models. However, the safety and efficacy of IIT in patients with critical brain disease have not been well studied. Available results do not support the use of IIT to maintain strict normoglycemia in this population. Patients with critical brain disease should have frequent glucose monitoring because severe HyperG and even modest hypoglycemia may be detrimental. Careful use of insulin infusion protocols appears advisable, but maintenance of strict normoglycemia cannot be recommended. Rigorous studies must be conducted to assess the value of insulin therapy and to determine the optimal blood glucose targets in patients with the most common acute vascular and traumatic brain insults.
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Affiliation(s)
- Daniel A Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina
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de Caen AR, Kleinman ME, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D. Part 10: Paediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e213-59. [PMID: 20956041 DOI: 10.1016/j.resuscitation.2010.08.028] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Allan R de Caen
- Stollery Children's Hospital, University of Alberta, Canada.
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Compliance with a sepsis bundle and its effect on intensive care unit mortality in surgical septic shock patients. ACTA ACUST UNITED AC 2011; 69:1282-7. [PMID: 20134352 DOI: 10.1097/ta.0b013e3181c4539f] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Surviving Sepsis Campaign was launched in 2002, aiming at a 25% reduction in mortality in sepsis during a 5-year period. We hypothesized that the compliance with an adapted sepsis bundle would improve intensive care unit (ICU) survival in a cohort of surgical septic shock patients. METHODS A retrospective, observational study was performed in surgical ICUs from two University hospitals. Seven quality indicators were considered to study the compliance with the sepsis bundle in 182 patients: (1) administration of antibiotics within 6 hours from diagnosis of septic shock, (2) initial effective antibiotic treatment, (3) adequate resuscitation within 6 hours after the diagnosis of septic shock, (4) administration of steroids, (5) use of activated protein C, (6) glucose control, and (7) protective ventilation. Univariate and multivariate logistic regression analyses were performed to make a predictive model to study the probability of survival according to the number of therapeutic guidelines fulfilled and to adjust for other predictive factors. RESULTS Compliance with individual guidelines was considered adequate in more than 60% of the cases, except in the case of glucose control. For all quality indicators, ICU survival was higher in the bundle-compliant patients. Survival (61%) was associated with the fulfilment of increasing number of therapeutic guidelines (odds ratio, 1.64; 95% confidence interval, 1.28-2.1; p < 0.001). CONCLUSIONS In surgical septic shock patients, the outcome was significantly related to the number of fulfilled therapeutic guidelines included in a sepsis bundle.
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Affiliation(s)
- Brian P Kavanagh
- Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada.
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