Clinical potential of insulin therapy in critically ill patients

The Ameliorative Effect of Pectin-Insulin Patch On Renal Injury in Streptozotocin-Induced Diabetic Rats

BACKGROUND/AIMS

Renal damage and dysfunction is attributed to sustained hyperglycaemia in overt diabetes. Subcutaneous insulin injections are beneficial in delaying the progression of renal dysfunction and damage in diabetics. However, the current mode of administration is associated with severe undesirable effects. In this study, we evaluated the ameliorative effects of pectin-insulin dermal patches on renal dysfunction in diabetes.

METHODS

Pectin-insulin patches (20.0, 40.8 and 82.9 µg/kg) were applied on the skin of streptozotocin-induced diabetic rats, thrice daily for 5 weeks. Blood glucose concentration, blood pressure and urine output volume were recorded on week 5 after which the animals were sacrificed after which the kidneys and plasma were collected. Kidney nephrin expression and urinary nephrin concentration, albumin excretion rate (AER), creatinine clearance (CC) and albumin creatinine ratio (ACR) were assessed.

RESULTS

Patch application resulted in reduced blood glucose concentration and blood pressure. Furthermore, pectin-insulin patch treatment resulted in increased kidney nephrin expression and reduced urinary nephrin concentration. AER, CC ACR were also reduced post patch application.

CONCLUSIONS

The application of pectin-insulin patch limited diabetes associated kidney damaged and improved kidney function. These observations suggest that pectin-insulin patches may ameliorate kidney dysfunction that is associated with chronic subcutaneous insulin administration.

Prognostic Impact of Combined Dysglycemia and Hypoxic Liver Injury on Admission in Patients With ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention (from the INTERSTELLAR Cohort)

Dysglycemia on admission is known to predict the prognosis of ST-segment elevation myocardial infarction (STEMI). Recently, hypoxic liver injury (HLI) has been proposed as a novel prognosticator for STEMI. We evaluated the prognostic impact of combined dysglycemia and HLI at the time of presentation in patients with STEMI who underwent primary percutaneous coronary intervention. From 2007 to 2014, 1,525 consecutive patients (79% men, mean age 61 years) who underwent primary percutaneous coronary intervention for STEMI in the INTERSTELLAR (Incheon-Bucheon Cohort of Patients Undergoing Primary PCI for Acute ST-Elevation Myocardial Infarction) cohort were analyzed retrospectively. Dysglycemia was defined as either hypoglycemia (serum glucose <90 mg/dl) or hyperglycemia (serum glucose >250 mg/dl). HLI was defined as more than twofold increase of any serum aminotransferases above the upper normal limit. Patients were divided into 4 groups according to their dysglycemia and HLI status on admission: group 1, normoglycemia without HLI; group 2, dysglycemia without HLI; group 3, normoglycemia with HLI; and group 4, dysglycemia with HLI. Primary end point was inhospital death and secondary end point was all-cause mortality at 12 months after the index procedure. Of the 1,525 patients, there were 87 inhospital deaths (5.7%) and 113 all-cause deaths (7.4%) at 12 months after the index procedure. Both dysglycemia and HLI on admission were independent predictors of inhospital death. Inhospital mortality rate was the highest in group 4 (32.1%), followed by groups 2 and 3. Kaplan-Meier survival analysis at 12 months showed similar trends among the 4 groups. In conclusion, combined dysglycemia and HLI on admission predicts early prognosis for STEMI.

The association between blood glucose levels and matrix-metalloproteinase-9 in early severe sepsis and septic shock

Background

Hyperglycemia is a frequent and important metabolic derangement that accompanies severe sepsis and septic shock. Matrix-Metalloproteinase 9 (MMP-9) has been shown to be elevated in acute stress hyperglycemia, chronic hyperglycemia, and in patient with sepsis. The objective of this study was to examine the clinical and pathogenic link between MMP-9 and blood glucose (BG) levels in patients with early severe sepsis and septic shock.

Methods

We prospectively examined 230 patients with severe sepsis and septic shock immediately upon hospital presentation and before any treatment including insulin administration. Clinical and laboratory data were obtained along with blood samples for the purpose of this study. Univariate tests for mean and median distribution using Spearman correlation and analysis of variance (ANOVA) were performed. A p value ≤ 0.05 was considered statistically significant.

Results

Patients were grouped based on their presenting BG level (mg/dL): BG <80 (n = 32), 80–120 (n = 53), 121–150 (n = 38), 151–200 (n = 23), and > 201 (n = 84). Rising MMP-9 levels were significantly associated with rising BG levels (p = 0.043). A corresponding increase in the prevalence of diabetes for each glucose grouping from 6.3 to 54.1 % (p = 0.0001) was also found. As MMP-9 levels increased a significantly (p < 0.001) decreases in IL-8 (pg/mL) and ICAM-1 (ng/mL) were noted.

Conclusion

This is the first study in humans demonstrating a significant and early association between MMP-9 and BG levels in in patients with severe sepsis and septic shock. Neutrophil affecting biomarkers such as IL-8 and ICAM-1 are noted to decrease as MMP-9 levels increase. Clinical risk stratification using MMP-9 levels could potentially help determine which patients would benefit from intensive versus conventional insulin therapy. In addition, antagonizing the up-regulation of MMP-9 could serve as a potential treatment option in severe sepsis or septic shock patients.

Guidelines for Perioperative Management of the Diabetic Patient

Management of glycemic levels in the perioperative setting is critical, especially in diabetic patients. The effects of surgical stress and anesthesia have unique effects on blood glucose levels, which should be taken into consideration to maintain optimum glycemic control. Each stage of surgery presents unique challenges in keeping glucose levels within target range. Additionally, there are special operative conditions that require distinctive glucose management protocols. Interestingly, the literature still does not report a consensus perioperative glucose management strategy for diabetic patients. We hope to outline the most important factors required in formulating a perioperative diabetic regimen, while still allowing for specific adjustments using prudent clinical judgment. Overall, through careful glycemic management in perioperative patients, we may reduce morbidity and mortality and improve surgical outcomes.

Glucose and lipid assessment in patients with acute stroke

Background

Stroke is a major health issue in Nigeria and it is also a common cause of emergency admissions. Stroke often results in increased morbidity, mortality and reduced quality of life in people thus affected. The risk factors for stroke include metabolic abnormalities such as dyslipidaemia and diabetes mellitus (DM). The stress of an acute stroke may present with hyperglycaemia and in persons without a prior history of DM, may be a pointer to stress hyperglycaemia or undiagnosed DM.

Methodology

This was a cross sectional study carried out over a period of one year in a teaching hospital in Lagos, Nigeria. Patients with acute stroke admitted to the hospital within three days of the episode of stroke and who met other inclusion criteria for the Study were consecutively recruited. Clinically relevant data was documented and biochemical assessments were carried out within three days of hospitalization. Tests for lipid profile, glycosylated haemoglobin(HbA1c), and blood glucose at presentation were carried out. The presence of past history of DM, undiagnosed DM, stress hyperglycaemia and abnormal lipid profile were noted. Students t test and Chi square were the statistical tests employed.

Results

A total of 137 persons with stroke were recruited of which 107 (76%) met the defining criteria for ischaemic stroke. The mean age and age range of the Study subjects were 62.2 (11.7) and 26–89 years respectively. The Study subjects were classified according to their glycaemic status into the following categories viz; stress hyperglycaemia, euglycaemia, DM and previously undiagnosed DM. Stress hyperglycaemia occurred commonly in the fifth decade of life and its incidence was comparable between those with cerebral and haemorrhagic stroke. The commonly occurring lipid abnormalities were elevated LDL-C and low HDL.

Conclusions

The detection of abnormal metabolic milieu is a window of opportunity for aggressive management in persons with stroke as this will improve outcome. Routine screening for hyperglycaemia in persons with stroke using glycosylated haemoglobin tests and blood glucose may uncover previously undiagnosed DM.

Hyperglycemia in critical illness

Evidence that acute injury and critical illness can result in an elevation of blood glucose levels is not a new concept. However, the last decade has seen a rise in publications describing the potential harm of this unique form of hyperglycemia and the subsequent benefits of glucose control. More recently, the untoward effects of tightly controlling glucose concentrations in this setting have been more thoroughly elucidated. This has lead to a challenging clinical conundrum for practitioners both inside and outside of the intensive care unit. The latest guidelines attempt to shed light on this dilemma and provide guidance for practitioners. This article reviews the progression of the research, the multiple guidelines that have been published, and the clinical implications on the treatment of critical illness hyperglycemia, with particular focus on the emergency department.

Hyperglycemia in critically ill children

OBJECTIVES

To determine the incidence and study association of hyperglycemia with outcome of critically ill children.

SETTING AND DESIGN

This was a prospective observational study conducted in eight bedded pediatric intensive care unit (PICU) of a tertiary care hospital.

MATERIALS AND METHODS

One hundred and one critically ill non-diabetic children between ages of 1 month to 16 years were studied from the day of admission till discharge or death. Serial blood sugars were determined first at admission, thereafter every 12 hourly in all children. Blood glucose level above 126 mg/dl (>7 mmol/dl) was considered as hyperglycemia. Children with hyperglycemia were followed 6 hourly till blood glucose fell below 126 mg/dl. Hyper and non-hyperglycemic children were compared with respect to length of stay, mechanical ventilation, use of inotrops and final outcome. Survivors and non-survivors were compared in relation to admission blood glucose, peak blood glucose level and duration of hyperglycemia.

RESULTS

Seventy (69.3%) children had hyperglycemia. Requirement of ventilation [(23) 32.9% vs.(3) 9.7%], requirement of inotropic support [(27) 38.6% vs.(5) 16.1%], Mean length of stay in PICU (7.91 ± 5.01 vs. 5.58 ± 1.95 days) and mortality (28.6% vs. 3.2%) among hyperglycemic children was significantly higher (P < 0.05) than that of non-hyperglycemic. Logistic regression analysis showed Peak blood glucose level and duration of hyperglycemia has independent association with increased risk of death.

CONCLUSION

Incidence of hyperglycemia is high in critically ill children and it is associated with high morbidity and mortality.

Continuous glucose monitoring: current use and future directions

Continuous glucose monitoring (CGM) is an emerging technology that provides a continuous measure of interstitial glucose levels. In addition to providing a more complete pattern of glucose excursions, CGMs utilize real-time alarms for thresholds and predictions of hypo- and hyperglycemia, as well as rate of change alarms for rapid glycemic excursions. CGM users have been able to improve glycemic control without increasing their risk of hypoglycemia. Sensor accuracy, reliability, and wearability are important challenges to CGM success and are critical to the development of an artificial pancreas (or closed-loop system).

Hyperglycemia is associated with poor outcomes in surgical critically ill patients receiving parenteral nutrition

BACKGROUND AND AIMS

Hyperglycemia, a major side effect of patients receiving total parenteral nutrition (PN), is associated with higher mortality in critically ill patients. The aim of this study was to determine whether elevated blood glucose levels would be associated with worse outcomes in patients receiving PN.

METHODS

This retrospective study included postoperative patients admitted to our surgical intensive care unit (SICU) from July 2008 to June 2009. Data collected included blood glucose levels, length of stay, and outcome measures. Correlations among daily average, maximum, and minimum blood glucose levels and outcome measures were calculated.

RESULTS

Sixty-nine patients were enrolled and divided into PN (n = 40) and non-PN (n = 29) groups. The initial mean blood glucose levels were 138.4 ± 63.1 mg/dL and 123.2 ± 41.8 mg/dL for the PN and non-PN groups, respectively. The mean blood glucose concentration was significantly increased (ΔBS = 44.8 ± 57.3 mg/dL; p < 0.001) in the PN group compared with the non-PN group (ΔBS = 39.4 ± 67.0 mg/dL; p = 0.004). The blood glucose concentration was significantly increased and consequently, consumption of insulin was increased on the 2(nd) day of ICU admission. The risk of mortality increased by a factor of 1.3 (OR = 1.30, 95% CI = 1.07-1.59, p = 0.010) for each 10 mg/dL increase in blood glucose level, when the daily maximum blood glucose level was >250 mg/dL. There were no cases of mortality in the current study when the blood glucose levels were controlled below 180 mg/dL. The mean blood glucose level in patients receiving PN was higher in those with diabetes than in those without diabetes (215.5 ± 42.8 vs. 165.8 ± 42.0 mg/dL, respectively, p = 0.001).

CONCLUSION

The blood glucose level was associated with patient outcome and should be intensively monitored in critically ill surgical patients. We suggest that blood glucose levels should be controlled below 180 mg/dL in postoperative critically ill patients.

Nutrition of the critically ill &#8212; a 21st-century perspective

Health care-induced diseases constitute a fast-increasing problem. Just one type of these health care-associated infections (HCAI) constitutes the fourth leading cause of death in Western countries. About 25 million individuals worldwide are estimated each year to undergo major surgery, of which approximately 3 million will never return home from the hospital. Furthermore, the quality of life is reported to be significantly impaired for the rest of the lives of those who, during their hospital stay, suffered life-threatening infections/sepsis. Severe infections are strongly associated with a high degree of systemic inflammation in the body, and intimately associated with significantly reduced and malfunctioning GI microbiota, a condition called dysbiosis. Deranged composition and function of the gastrointestinal microbiota, occurring from the mouth to the anus, has been found to cause impaired ability to maintain intact mucosal membrane functions and prevent leakage of toxins - bacterial endotoxins, as well as whole bacteria or debris of bacteria, the DNA of which are commonly found in most cells of the body, often in adipocytes of obese individuals or in arteriosclerotic plaques. Foods rich in proteotoxins such as gluten, casein and zein, and proteins, have been observed to have endotoxin-like effects that can contribute to dysbiosis. About 75% of the food in the Western diet is of limited or no benefit to the microbiota in the lower gut. Most of it, comprised specifically of refined carbohydrates, is already absorbed in the upper part of the GI tract, and what eventually reaches the large intestine is of limited value, as it contains only small amounts of the minerals, vitamins and other nutrients necessary for maintenance of the microbiota. The consequence is that the microbiota of modern humans is greatly reduced, both in terms of numbers and diversity when compared to the diets of our paleolithic forebears and the individuals living a rural lifestyle today. It is the artificial treatment provided in modern medical care - unfortunately often the only alternative provided - which constitute the main contributors to a poor outcome. These treatments include artificial ventilation, artificial nutrition, hygienic measures, use of skin-penetrating devices, tubes and catheters, frequent use of pharmaceuticals; they are all known to severely impair the microbiomes in various locations of the body, which, to a large extent, are ultimately responsible for a poor outcome. Attempts to reconstitute a normal microbiome by supply of probiotics have often failed as they are almost always undertaken as a complement to - and not as an alternative to - existing treatment schemes, especially those based on antibiotics, but also other pharmaceuticals.

Nutrition of the critically ill - emphasis on liver and pancreas

About 25 million individuals undergo high risk surgery each year. Of these about 3 million will never return home from hospital, and the quality of life for many of those who return is often significantly impaired. Furthermore, many of those who manage to leave hospital have undergone severe life-threatening complications, mostly infections/sepsis. The development is strongly associated with the level of systemic inflammation in the body, which again is entirely a result of malfunctioning GI microbiota, a condition called dysbiosis, with deranged composition and function of the gastrointestinal microbiota from the mouth to the anus and impaired ability to maintain intact mucosal membrane functions and prevent leakage of toxins-bacterial endotoxins and whole or debris of bacteria, but also foods containing proteotoxins gluten, casein and zein and heat-induced molecules such as advanced glycation end products (AGEs) and advanced lipoxidation end products (ALEs). Markedly lower total anaerobic bacterial counts, particularly of the beneficial Bifidobacterium and Lactobacillus and higher counts of total facultative anaerobes such as Staphylococcus and Pseudomonas are often observed when analyzing the colonic microbiota. In addition Gram-negative facultative anaerobes are commonly identified microbial organisms in mesenteric lymph nodes and at serosal "scrapings" at laparotomy in patients suffering what is called "Systemic inflammation response system" (SIRS). Clearly the outcome is influenced by preexisting conditions in those undergoing surgery, but not to the extent as one could expect. Several studies have for example been unable to find significant influence of pre-existing obesity. The outcome seems much more to be related to the life-style of the individual and her/his "maintenance" of the microbiota e.g., size and diversity of microbiota, normal microbiota, eubiosis, being highly preventive. About 75% of the food Westerners consume does not benefit microbiota in the lower gut. Most of it, refined carbohydrates, is already absorbed in the upper part of the GI tract, and of what reaches the large intestine is of limited value containing less minerals, less vitamins and other nutrients important for maintenance of the microbiota. The consequence is that the microbiota of modern man has a much reduced size and diversity in comparison to what our Palelithic forefathers had, and individuals living a rural life have today. It is the artificial treatment provided by modern care, unfortunately often the only alternative, which belongs to the main contributor to poor outcome, among them; artificial ventilation, artificial nutrition, hygienic measures, use of skin penetrating devices, tubes and catheters, frequent use of pharmaceuticals, all known to significantly impair the total microbiome of the body and dramatically contribute to poor outcome. Attempts to reconstitute a normal microbiome have often failed as they have always been undertaken as a complement to and not an alternative to existing treatment schemes, especially treatments with antibiotics. Modern nutrition formulas are clearly too artificial as they are based on mixture of a variety of chemicals, which alone or together induce inflammation. Alternative formulas, based on regular food ingredients, especially rich in raw fresh greens, vegetables and fruits and with them healthy bacteria are suggested to be developed and tried.

Prevention of cardiovascular complications of the metabolic syndrome: focus on pharmacotherapy

The metabolic syndrome increases the risk of atherothrombotic cardiovascular disease (CVD) and diabetes. In turn, diabetes promotes the development of atheroma and is regarded as a coronary heart disease risk equivalent. A multifactorial therapeutic strategy is advocated for patients with the metabolic syndrome to improve cardiovascular risk factor profiles and to reduce the chances of developing type 2 diabetes. Individual components of the syndrome must be addressed using safe, efficacious, and cost-effective measures. There is general agreement that lifestyle modifications, including control of body weight, avoidance of central adiposity, adoption of an antiatherogenic diet, and regular physical activity, are crucial. However, as the magnitude of the individual components of the metabolic syndrome increases with time, lifestyle measures are often insufficient. An individual with metabolic syndrome will often require drug treatment for hyperglycemia, atherogenic dyslipidemia, and high blood pressure, together with antiplatelet therapy. Reducing the need for polypharmacy is an increasingly important consideration for clinicians and the pharmaceutical industry; to date, no single therapy has emerged that targets the root cause(s) of the syndrome. HMG-CoA reductase inhibitors are important agents that reduce CVD morbidity and mortality, in people with impaired fasting glucose or metabolic syndrome. Selective cannabinoid receptor antagonists appear promising because they improve or attenuate several key defects of the syndrome. Thiazolidinediones and metformin are presently licensed for treatment of type 2 diabetes but may prove to have a broader role in future. Novel insulin-sensitizing drugs are under investigation. Drugs that act to prevent or reverse endothelial dysfunction may be of particular utility in preventing cardiovascular disease, especially if initiated before tissue damage has become irreversible. Insulin therapy, which has antiinflammatory and endothelial protective properties, has been shown to reduce morbidity and mortality in high-risk nondiabetic patients during critical illness. Potential synergy between different classes of drugs with metabolic and/or cardiovascular protective properties merits further investigation.

Preoperative evaluation of hospitalized patients

Carefully managing patients undergoing elective surgeries is difficult in the perioperative setting. However, this becomes increasingly complex in patients hospitalized for acute conditions that may or may not be related to the pending surgery. Not only must the consulting physician take into consideration any complications inherent to the surgical procedure, but must also consider all related comorbidities of the acute condition for which the patient was initially hospitalized plus any existing chronic conditions. A careful systematic approach should be undertaken in these circumstances, which consists of (1) perioperative risk stratification, (2) medical optimization, and (3) perioperative risk reduction. Risk stratification is determined by the patient's inherent perioperative cardiac risk factors, whereas medical optimization and risk reduction are actively determined during the hospital course. For perioperative risk stratification, the Revised Cardiac Risk Index is the simplest tool for accurately identifying those patients at increased perioperative risk for cardiac mortality and morbidity. Medical optimization involves performing any necessary preoperative testing that would help identify concurrent undiagnosed medical conditions that might require preoperative intervention or the initiation of certain medication regimens to optimize disease treatment. Lastly, perioperative risk reduction includes any modalities that would be started to decrease the risk of potential perioperative cardiac, pulmonary, or other surgery-related comorbidities.

Acute, muscle-type specific insulin resistance following injury

Acute insulin resistance can develop following critical illness and severe injury, and the mortality of critically ill patients can be reduced by intensive insulin therapy. Thus, compensating for the insulin resistance in the clinical care setting is important. However, the molecular mechanisms that lead to the development of acute injury/infection-associated insulin resistance are unknown, and the development of acute insulin resistance is much less studied than chronic disease-associated insulin resistance. An animal model of injury and blood loss was utilized to determine whether acute skeletal muscle insulin resistance develops following injury, and surgical trauma in the absence of hemorrhage had little effect on insulin-mediated signaling. However, following hemorrhage, there was an almost complete loss of insulin-induced Akt phosphorylation in triceps, and severely decreased tyrosine phosphorylation of the insulin receptor and insulin receptor substrate-1. The severity of insulin resistance was similar in triceps and extensor digitorum longus muscles, but was more modest in diaphragm, and there was little change in insulin signaling in cardiac muscle following hemorrhage. Since skeletal muscle is an important insulin target tissue and accounts for much of insulin-induced glucose disposal, it is important to determine its role in injury/infection-induced hyperglycemia. This is the first report of an acute development of skeletal muscle insulin signaling defects. The presented data indicates that the defects in insulin signaling occurred rapidly, were reversible and more severe in some skeletal muscles, and did not occur in cardiac muscle.

Alterations in glucose homeostasis in the pediatric intensive care unit: Hyperglycemia and glucose variability are associated with increased mortality and morbidity

OBJECTIVES

Critically ill patients with alterations in glucose equilibrium may experience adverse outcomes. We sought to describe the distribution of blood glucose values in the absence of insulin therapy and to evaluate the association of hyperglycemia, hypoglycemia, and glucose variability with mortality and morbidity of critically ill children.

DESIGN

Retrospective cohort analysis.

SETTING

University-affiliated children's hospital pediatric intensive care unit (PICU).

PATIENTS

All children admitted to the PICU for >24 hrs with at least one blood glucose level recorded from a 1-yr period. Patients were excluded if >18 yrs of age, if insulin was administered during their PICU stay, and if the PICU admitting diagnosis included diabetes mellitus or hypoglycemia.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were categorized with isolated hyperglycemia (blood glucose >or=150 mg/dL, [>or=8.3 mmol/L]), isolated hypoglycemia (blood glucose <or=60 mg/dL, [<or=3.3 mmol/L]), and glucose variability (both hyper- and hypoglycemia), and the associations with mortality, hospital length of stay, and nosocomial infections were assessed. Fisher's exact test, Kruskal-Wallis test, and logistic and linear regression were used to test for associations. Hyperglycemic and hypoglycemic measurements occurred in 56.1% and 9.7% of all patients, respectively. Glucose variability occurred in 6.8% of all patients. Glucose variability (odds ratio 63.6; 95% confidence interval, 7.8-512) and hyperglycemia (odds ratio 11.1; 95% confidence interval, 1.5-85.6) in the univariate analysis were associated with increased mortality. There were no deaths among patients with isolated hypoglycemia. Hyperglycemia and glucose variability were also associated with nosocomial infections (p = .01) and increased hospital length of stay (p < .001). Hypoglycemia and glucose variability occurred more commonly in younger patients (p < .001).

CONCLUSIONS

We found a relationship between blood glucose level and PICU patient outcomes. The relationship is similar to that found in adults and raises the question whether attention to control of blood glucose will improve outcomes in critically ill children.

Blood glucose control in critical care patients - a review of the literature

The role of hyperglycaemia in critical illness, and its corresponding treatment, has been an area of controversy, fuelled by conflicting research findings. The aims of this study were to critically evaluate the literature and present an historical review of the sequence of published papers relating to blood glucose control in critical care. Their subsequent impact together with the implications for patient care is discussed. This article is based on a systematic review of papers relating to glycaemic control in critical care patients. The review was conducted using the MedLine, CINAHL and EMBASE databases using key search terms (details of the search terms can be found after the conclusion of the paper) for the period 1950-2006. The searches resulted in 4863 papers being screened for relevance to the historic progression of glycaemic management in critical care patients, by title and then abstract. Of these, 209 were accessed, and their reference lists were snowballed for further papers. Papers that were repeatedly quoted throughout the literature and were therefore considered important in the historical development of accepted critical care practice were finally subjected to rigorous appraisal. These totalled 91 papers and included 18 randomized controlled trials, an additional 28 research papers, 25 editorials and 20 reviews. This critical evaluation of published work indicates that the evidence for the benefit of this therapy may not be as compelling as previously indicated, and its widespread use may have been premature. From a nursing perspective, this demonstrates the importance of maintaining a questioning attitude to new therapies and reviewing best practice in the light of evolving evidence.

Acute pancreatitis: practical considerations in nutrition support

Acute pancreatitis is a clinical syndrome defined by a discrete episode of abdominal pain and elevations in serum enzyme levels. Seventy-five percent to 85% of all pancreatic episodes are considered mild and self-limiting and do not require intervention with nutrition support. Considering the significant risk of malnutrition in moderate to severe forms of pancreatic injury, enteral nutrition has more recently been documented in its benefit as an adjunct to management. In addition, it may play a role in obviating the systemic inflammatory response syndrome and in modifying the course of the disease. This paper reviews practical considerations in feeding patients with severe acute pancreatitis, including discussion of gastric versus post-pyloric feeding, choice of enteral product, and relative role and optimization of parenteral nutrition support.

Financial implications of glycemic control: results of an inpatient diabetes management program

OBJECTIVE

(1) To determine the financial implications associated with changes in clinical outcomes resulting from implementation of an inpatient diabetes management program and (2) to describe the strategies involved in the formation of this program.

METHODS

The various factors that influence financial outcomes are examined, and previous and current outcomes are compared.

RESULTS

Associations exist between hyperglycemia, length of stay, and hospital costs. Implementation of an inpatient diabetes management program, based on published guidelines, has been shown to increase the use of scheduled medications to treat hyperglycemia and increase the frequency of physician intervention for glucose readings outside desired ranges. Results from implementing this program have included a reduction in the average glucose level in the medical intensive care unit through use of protocols driven to initiate intravenous insulin once the glucose level exceeds 140 mg/dL. Additionally, glucose levels have been reduced throughout the hospital, primarily because of interactions between diabetes nurse care managers and the primary care team. Associated with these lower glucose levels are a decreased prevalence of central line infections and shorter lengths of stay. The reduction in the length of stay for patients with diabetes has resulted in a savings of more than 2 million dollars for the year and has yielded a 467% return on investment for the hospital.

CONCLUSION

Improved blood glucose control during the hospitalization of patients with known hyperglycemia is associated with reduced morbidity, reduced hospital length of stay, and cost savings. The implementation of an inpatient diabetes management program can provide better glycemic control, thereby improving outcomes for hyperglycemic patients while saving the hospital money.

Modulation of the glycemic response using insulin attenuates the pulmonary response in an animal trauma model

BACKGROUND

Hyperglycemia has been shown to be an independent prognostic indicator of poor outcome in the traumatized patient. The role of insulin and the prevention of hyperglycemia in the trauma patient have as yet not been fully explored. We hypothesized that the systemic inflammatory response to trauma could be modified by modulating the glycemic response to trauma using insulin.

METHODS

A rodent model of end- organ (lung) injury in trauma was chosen. Two groups underwent bilateral femur fracture and 15% blood loss. The third group was anesthetized only. The treatment group immediately received subcutaneous insulin according to a sliding scale. The control groups received normal saline subcutaneously. The animals were maintained under anesthesia for 4 hours from injury. Blood samples were then taken. Bronchoalveolar lavage was performed for neutrophil content and total protein estimation. The left lower lobe was harvested for wet:dry lung weight ratios as a measure of end-organ tissue edema.

RESULTS

Measures of end-organ injury, wet:dry lung weight ratios, and bronchoalveolar lavage neutrophil content were significantly reduced in the insulin-treated animals compared with in the controls (p < 0.05). Neutrophil respiratory burst activity was increased in insulin-treated animals compared with in controls (p < 0.05).

CONCLUSIONS

Insulin reduces leukocyte lung sequestration and end-organ (lung) edema, indicating an endothelial protective effect in this injured-animal model without attenuating neutrophil function. This work confirms that modifying the glycemic response to trauma using insulin may have a role in reducing adult respiratory distress syndrome rates in injured patients and thereby lead to improved outcomes.

A review of the use of insulin protocols to maintain normoglycaemia in high dependency patients

AIM

This paper critically examines the evidence base for and issues involved in the introduction of an insulin protocol to maintain normoglycaemia in patients within a medical/surgical high dependency ward.

BACKGROUND

A growing body of evidence has linked hyperglycaemia to worsened clinical outcomes. This has led to intravenous insulin protocols becoming a new standard of care in intensive care units. However, the use and benefits of insulin protocols within high dependency units have not yet been addressed in the literature.

METHODS

The literature was examined for the 10-year period up to January 2005. The databases searched were MEDLINE, OVID, CINHAL, the British Nursing Index, the EBSCO collection, the COCHRANE library, the Department of Health, and guidelines within the Scottish Intercollegiate Guidelines Network and National Institute for Clinical Excellence using the key words insulin, protocol, hyperglycaemia, critical care, intensive care and high dependency.

RESULTS

The literature reports that both medical and surgical intensive care patients treated with intravenous insulin protocols to maintain normoglycaemia experienced significantly reduced mortality and morbidity. Resulting hypoglycaemic episodes were limited with no incidence of patient deterioration. A review of published intravenous insulin protocols used in intensive care settings revealed their safe and effective use in nurse to patient ratios similar to those present in high dependency units.

CONCLUSIONS

In the light of this evidence, it would seem safe and ethically correct to enable high dependency patients to benefit from this cheap intervention. An insulin protocol tailored for the glycaemic control of high dependency patients has been suggested, although it may have to be commenced in conjunction with other fluid and nutrition protocols to safeguard the risk of hypoglycaemic events. Further research into the safety and benefit of insulin protocols in high dependency populations is required.

RELEVANCE TO CLINICAL PRACTICE

The stress of critical illness often leads to hyperglycaemia, which is linked to worsened clinical outcomes. Both medical and surgical intensive care patients treated with intravenous insulin protocols to maintain normoglycaemia experienced significantly reduced mortality and morbidity. This paper identifies that, to date, no research into the benefits of glycaemic control in high dependency populations has been published. The case for the introduction of insulin protocols into high dependency units is therefore examined and an insulin protocol suggested.

Hypoglycemia in the intensive care unit

PURPOSE OF REVIEW

To review recent articles and evaluate hypoglycemia as a major complication of intensive insulin therapy in anticipation of emerging data from current clinical studies.

RECENT FINDINGS

Following the 2001 landmark Leuven study demonstrating that intensive insulin therapy in the surgical intensive care unit reduces mortality, many studies have evaluated aspects of intensive insulin therapy with respect to improved clinical outcome and the impact of hypoglycemia. Specific risk factors for hypoglycemia in the intensive care unit with intensive insulin therapy are diabetes, octreotide therapy, nutrition support, continuous venovenous hemofiltration with bicarbonate replacement fluid, sepsis and need for inotropic support. In prospective studies with a comparator group, the incidence of hypoglycemia in intensive care unit patients treated with intensive insulin therapy is up to 25%, corresponding to a relative risk of 5.0. In studies without a comparator group, however, the incidence is less than 7%.

SUMMARY

Hypoglycemia is associated with adverse outcome in intensive care unit patients. It remains unclear whether intensive insulin therapy-induced hypoglycemia per se is responsible for this adverse outcome. The threat of hypoglycemia is a barrier to intensive insulin therapy in critical care, supporting the need for frequent glucose monitoring, readily available concentrated intravenous dextrose infusions, better training of nurses and technological advances in glucose-sensing and insulin-dosing algorithms.

An adaptive input-output modeling approach for predicting the glycemia of critically ill patients

In this paper we apply system identification techniques in order to build a model suitable for the prediction of glycemia levels of critically ill patients admitted to the intensive care unit. These patients typically show increased glycemia levels, and it has been shown that glycemia control by means of insulin therapy significantly reduces morbidity and mortality. Based on a real-life dataset from 15 critically ill patients, an initial input-output model is estimated which captures the insulin effect on glycemia under different settings. To incorporate patient-specific features, an adaptive modeling strategy is also proposed in which the model is re-estimated at each time step (i.e., every hour). Both one-hour-ahead predictions and four-hours-ahead simulations are executed. The optimized adaptive modeling technique outperforms the general initial model. To avoid data selection bias, 500 permutations, in which the patients are randomly selected, are considered. The results are satisfactory both in terms of forecasting ability and in the clinical interpretation of the estimated coefficients.

Risk Factors for Short-Term Mortality in Older Subjects with Acute Ischemic Stroke

BACKGROUND

Stroke is the third cause of death in older individuals living in Western Countries. The identification of predictors for mortality after stroke has a major importance for clinicians in order to allow the implementation of therapeutic and preventive strategies.

OBJECTIVE

To evaluate the association between clinical and laboratory parameters and 30-days total mortality in a large sample of older patients with stroke.

METHODS

469 older patients (median age: 80.0 years) consecutively hospitalized for acute ischemic stroke were enrolled. The data recorded included: (1) clinical features of stroke; (2) routine clinical chemistry analyses; (3) medical history, and (4) 12-lead ECG. All patients underwent computed tomography scan of the brain. Stroke type was classified by the Oxfordshire Community Stroke Project system.

RESULTS

130 subjects died within 30 days after stroke, with an overall mortality of 27.7%. At univariate analysis, altered levels of consciousness (ALC), congestive heart failure, atrial fibrillation, previous stroke, high blood glucose, fibrinogen and blood sedimentation rate levels, higher white blood cell count, lower serum albumin and iron levels were associated with mortality. Multivariate logistic regression analysis indicated that short-term mortality was associated with ALC (OR: 11.80; CI 95%: 5.50-24.00), congestive heart failure (OR: 3.06; CI 95%: 1.04-8.80), and age (OR: 1.04; CI 95%: 1.002-1.09) independent of gender, previous stroke, AF, fasting blood glucose, serum albumin, serum iron, and white blood cell count. In patients with ALC (high-mortality rate: 63.6%), only hyperglycemia (III vs. I tertile, OR: 9.60; CI 95%: 1.65-52.50) was associated with mortality after multivariate adjustment.

CONCLUSION

Our study highlights the role of ALC and congestive heart failure in the short-term prognostic stratification of older patients with acute ischemic stroke. Furthermore, our results support the value of post-stroke hyperglycemia as a marker for short-term mortality also in advanced age, and particularly in the presence of ALC and in nondiabetic individuals.

Bioecologic Control of Inflammation and Infection in Critical Illness

Surgical and medical emergencies and treatments are still affected by an unacceptably high rate of morbidity and mortality. Sepsis is the most common medical and surgical complication and the tenth most common cause of death. Antibiotics and antagonists and inhibitors of proinflammatory cytokines have not met expectations. Selective bowel decontamination is no longer a treatment option. After more than 30 randomized clinical trials and 30 years of dedicated efforts to combat sepsis by the use of various combinations of antibiotics, we seem ready to conclude that the vigorous use of antibiotics does not significantly reduce mortality in critically ill patients. Side effects and price constitute important obstacles, especially when it comes to use of cytokine antagonists and inhibitors.

Barriers to Glucose Control in the Intensive Care Unit

Despite published evidence supporting glycemic control in critically ill patients, achieving euglycemia remains a problem in the intensive care units (ICUs) of many institutions. Clinicians seeking to implement the findings of published evidence in their practice face many potential barriers that make euglycemia difficult to achieve in patients in the ICU. Developing a comprehensive understanding of the many barriers to ICU glucose control can aide clinicians in attempting to change practice and improve patient outcomes. Barriers to ICU glucose control include the role of different health professionals in glucose management, communication among health care professionals, guidelines, protocols, ICU culture, fear of hypoglycemia, glucose monitoring, education, systems analysis, health care resources, nutritional needs, and drug utilization. By ensuring compliance, changing ICU culture, developing guidelines and protocols, and incorporating a multidisciplinary approach, clinicians can achieve glycemic control in the critically ill population and improve patient outcomes.

Insulin infusion protocol for critical care units

PURPOSE

An insulin infusion protocol for critical care units is described.

SUMMARY

Evidence that aggressive glycemic control improves outcomes led physicians, nurses, dietitians, and pharmacists at a trauma center to develop an insulin infusion protocol. Before the protocol, elevated blood glucose concentrations were often not treated until they reached 200 mg/dL or higher. Insulin infusions were underutilized and were often not started until capillary blood glucose concentrations were greater than 350 mg/dL for 12 or more hours. When orders for an insulin infusion were written, they did not include directions for dosage adjustment, and the goal blood glucose range varied. A preliminary protocol was drafted allowing adjustments in insulin administration to be based on changes in capillary blood glucose values since the previous blood glucose measurement. The protocol was presented to a multidisciplinary team and further refined. The targeted blood glucose concentration range was 80-130 mg/dL. After the targeted range was achieved for a patient, if the blood glucose level continued to decrease over three consecutive measurements, the infusion rate was decreased by 0.5 or 1 unit/hr, depending on the capillary blood glucose level. Data for the first 30 patients were collected from September 2003 to August 2004. It took 2-36 hours (mean, 12.6 hours) to bring the capillary blood glucose concentration to less than 130 mg/dL. Among 2,845 capillary blood glucose measurements, there were 15 cases of hypoglycemia (0.4%) requiring treatment with 50% dextrose injection.

CONCLUSION

A multidisciplinary effort resulted in the development of an insulin infusion protocol for use in critical care units.

Relationship Between Hyperglycemia and Infection in Critically Ill Patients

Hyperglycemia is a common problem encountered in hospitalized patients, especially in critically ill patients and those with diabetes mellitus. Uncontrolled hyperglycemia may be associated with complications such as fluid and electrolyte disturbances and increased infection risk. Studies have demonstrated impairment of host defenses, including decreased polymorphonuclear leukocyte mobilization, chemotaxis, and phagocytic activity related to hyperglycemia. Until 2001, hyperglycemia (blood glucose concentrations up to 220 mg/dl) had been tolerated in critically ill patients not only because high blood glucose concentrations were believed to be a normal physiologic reaction in stressed patients and excess glucose is necessary to support the energy needs of glucose-dependent organs, but also because the true significance of short-term hyperglycemia was not known. Recent clinical data show that the use of intensive insulin therapy to maintain tight blood glucose concentrations between 80 and 110 mg/dl decreases morbidity and mortality in critically ill surgical patients. Intensive insulin therapy minimizes derangements in normal host defense mechanisms and modulates release of inflammatory mediators. The principal benefit of intensive insulin therapy is a decrease in infection-related complications and mortality. Further research will define which patient populations will benefit most from intensive insulin therapy and firmly establish the blood glucose concentration at which benefits will be realized.

Persistent hyperglycemia in critically ill children

OBJECTIVES

To determine the prevalence and prognostic significance of hyperglycemia among critically ill nondiabetic children.

STUDY DESIGN

We performed a retrospective cohort study using point-of-care blood glucose measurements, hospital administrative databases, and a computerized information system; 942 nondiabetic patients admitted to our Pediatric Intensive Care Unit (PICU) from October 2000 to September 2003 were included. The prevalence of hyperglycemia was based on initial PICU glucose measurement, highest value within 24 hours, and highest value measured during PICU stay up to 10 days after the first measurement. Primary outcome was in-hospital death with PICU lengths of stay (LOS) as secondary outcome.

RESULTS

Through the use of three cutoff values (120 mg/dL, 150 mg/dL, and 200 mg/dL), the prevalence of hyperglycemia was 16.7% to 75.0%. The relative risk (RR) for dying increased for maximum glucose within 24 hours >150 mg/dL (RR, 2.50; 95% confidence interval (CI), 1.26 to 4.93) and highest glucose within 10 days >120 mg/dL (RR, 5.68; 95% CI, 1.38 to 23.47). LOS was decreased for admission glucose >120 mg/dL and 150 mg/dL but increased for all threshold values for maximum glucose within 10 days.

CONCLUSIONS

Hyperglycemia occurs frequently among critically ill nondiabetic children and is correlated with a greater in-hospital mortality rate and longer LOS.

Excess hospitalizations, hospital days, and inpatient costs among people with diabetes in Andalusia, Spain

OBJECTIVE

The goal of this study was to estimate the excess hospitalizations, hospital days, and inpatient costs attributable to diabetes in Andalusia, Spain (37 hospitals, 7,236,459 inhabitants), during 1999 compared with those without diabetes.

RESEARCH DESIGN AND METHODS

This study was an analysis of all hospital discharges. Those with an ICD-9-CM code of 250 as either the main or secondary diagnosis were considered to have been admissions of individuals with diabetes. An estimate of costs was applied to each inpatient admission by assigning a cost weight based on the diagnostic-related group (DRG) related to each admission.

RESULTS

A total of 538,580 admissions generated 4,310,654 hospital bed-days and total costs of 940,026,949 euro. People with diabetes accounted for 9.7% of all hospital discharges, 13.8% of total stays, and 14.1% of the total cost. Of the total cost for individuals with diabetes (132,509,217 euro), 58.3% were excess costs, of which 47% was attributable to cardiovascular complications and 43% to admissions for comorbid diseases. Individuals 45-75 years of age accounted for 75% of the excess costs. The rate of admissions during the study year was 145 per 1,000 inhabitants for individuals with diabetes compared with 70 admissions per 1,000 inhabitants for individuals without diabetes.

CONCLUSIONS

The costs arising from hospitalization of individuals with diabetes are disproportionate in relation to their prevalence. For those aged >or=45 years, cardiovascular complications were clearly the most important factor determining increased costs from diabetes.

Regulation of the somatotropic axis by intensive insulin therapy during protracted critical illness

The catabolic state of critical illness has been linked to the suppressed somatotropic GH-IGF-binding protein (IGFBP) axis. In critically ill patients it has been demonstrated that, compared with the conventional approach, which only recommended insulin therapy when blood glucose levels exceeded 12 mmol/liter, strict maintenance of blood glucose levels below 6.1 mmol/liter with intensive insulin therapy almost halved intensive care mortality, acute renal failure, critical illness polyneuropathy, and bloodstream infections. Poor blood glucose control in diabetes mellitus has also been associated with low serum IGF-I levels, which can be increased by insulin therapy. We hypothesized that intensive insulin therapy would improve the IGF-I axis, possibly contributing to the clinical correlates of anabolism. Therefore, this study of 363 patients, requiring intensive care for more than 7 d and randomly assigned to either conventional or intensive insulin therapy, examines the effects of intensive insulin therapy on the somatotropic axis. Contrary to expectation, intensive insulin therapy suppressed serum IGF-I, IGFBP-3, and acid-labile subunit concentrations. This effect was independent of survival of the critically ill patient. Concomitantly, serum GH levels were increased by intensive insulin therapy. The suppression of IGF-I in association with the increased GH levels suggests GH resistance induced by intensive insulin therapy, which was reflected by the decreased serum GH-binding protein levels. Intensive insulin therapy did not affect IGFBP-3 proteolysis, which was markedly higher in protracted critically ill patients compared with healthy controls. Also, intensive insulin therapy did not suppress the urea/creatinine ratio, a clinical correlate of catabolism. In conclusion, our data suggest that intensive insulin therapy surprisingly suppressed the somatotropic axis despite its beneficial effects on patient outcome. GH resistance accompanied this suppression of the IGF-I axis. To what extent and through which mechanisms the changes in the GH-IGF-IGFBP axis contributed to the survival benefit under intensive insulin therapy remain elusive.

Inpatient diabetology. The new frontier

Tight glycemic control is now an imperative of outpatient diabetes care. The inpatient arena remains under the influence of an ineffective paradigm characterized by tolerance for hyperglycemia and a reluctance to use insulin intensively. This article is a call to action against the lip service paid to inpatient diabetes care. The compelling in vitro and in vivo evidence for the benefit of intensive insulin-mediated glycemic control is summarized. The linchpin of current inpatient care is a commonly used insulin sliding scale. This autopilot approach as the sole mode of treatment for inpatient hyperglycemia has been strongly condemned. Nevertheless, it continues to survive. The evidence supports the compelling argument that the adverse effect of hyperglycemia on hospital length of stay, morbidity, and mortality is substantial. Clinicians, nurses, administrators, and insurers ought to look critically at the prevailing paradigm and spearhead the much-needed revolution in inpatient diabetology. The issue of glycemic targets, the need for noninvasive blood glucose monitoring, and the role of nursing staff in this revolution are raised. We call for the banning of the insulin sliding scale use as the sole diabetes order. Also, the use of basal insulin via continuous intravenous insulin infusion or subcutaneous insulin analogs should be embraced. Educating nurses, house staff, and other frontline professionals in the adverse consequences of the current paradigm is essential. Inpatient glycemic control matters; clinical and financial outcomes are at stake. It behooves the health care system and the diabetic public to address the contemporary state of inpatient diabetology as soon as possible.

Critical care management of acute ischemic stroke

PURPOSE OF REVIEW

To review and examine the efficacy of recently described medical and surgical interventions after acute ischaemic stroke using data from well conducted, clinical trials and systematic reviews. This review will consider recently published or updated articles.

RECENT FINDINGS

As therapeutic options evolve, including thrombolysis and anti-platelet therapy, prevention of secondary insults, becomes increasingly important during periods of acute cerebral ischaemia in order to prevent worsening of the neurological injury. As in other acute medical conditions, urgent management of patients with acute ischaemic stroke should begin with the assessment and treatment of the airway, breathing, circulation, temperature, and blood glucose control.

SUMMARY

It is estimated that there will be 8.5 million patients with acute ischaemic stroke in the European Union and the USA over the next decade, and of these, about one and a half million will die within six months of stroke onset. Of those who survive, about one third will depend on other people for help with their activities of daily living. Future treatment strategies are likely to involve agents that re-canalise vessels and minimise further neuronal damage.

Standardization of intravenous insulin therapy improves the efficiency and safety of blood glucose control in critically ill adults

OBJECTIVE

Aggressive glycemic control improves mortality and morbidity in critically ill adults, however implementation of such a strategy can be logistically difficult. This study evaluates the efficiency and safety of a nurse-managed insulin protocol in critically ill adults.

DESIGN

Combined retrospective-prospective before-after cohort study.

SETTING

Twenty-one bed, medical/surgical ICU in a tertiary care hospital.

PATIENTS

Two cohorts of 50 consecutive ICU patients requiring insulin infusions.

INTERVENTION

Patients in the control cohort received insulin infusions titrated according to target blood glucose ranges and sliding scales at the physician's discretion. Patients in the interventional cohort received an insulin infusion adjusted using a standardized protocol targeting a blood glucose of 4.5-6.1 mmol/l (81-110 mg/dl).

MEASUREMENTS AND MAIN RESULTS

Efficiency was measured by comparing the time to reach, and the time spent within, the target range between cohorts. Safety was assessed by comparing the incidence of severe hypoglycemia, the frequency of rescue dextrose administration and the cumulative time that the infusion was held for hypoglycemia between cohorts. Patients in the interventional cohort reached their target more rapidly (11.3+/-7.9 vs 16.4+/-12.6 h; p=0.028) and maintained their blood glucose within the target range longer (11.5+/-3.7 vs 7.1+/-5.0 h/day; p<0.001) than controls. The standardized protocol yielded a four-fold reduction in the incidence of severe hypoglycemia (4 vs 16%; p=0.046) and reduced the median frequency of dextrose rescue therapy (0 [0-0.91] vs 0.17 [0-1.2] episodes/patient per day; p=0.01) as compared to controls.

CONCLUSION

Standardization of intensive insulin therapy improves the efficiency and safety of glycemic control in critically ill adults.

Bio-ecological control of perioperative and ITU morbidity

BACKGROUND

Perioperative and intensive therapy unit (ITU) morbidity and mortality has remained unchanged during the past several decades, and this at an unacceptably high level. It is most likely, in the EU countries annually, that more than 1 million people suffer severe sepsis and some 300,000 die. Pharmaceutical attempts at prevention and treatment have, despite extensive efforts, hitherto failed to improve outcome more significantly. Much supports the fact that sepsis and its severe consequences are results of a malfunctioning innate immune system, impaired by both lifestyle and disease. A series of mostly simple measures to prevent further deterioration of the immune system, and to boost it, is recommended. Among the measures recommended are some modifications of surgical and postoperative management: restricted use of antibiotics, attempts made to maintain salivation and GI secretions, omission of prophylactic gastric decompression, postoperative drainage and preoperative bowel preparation, restricted use of stored blood, avoidance of overload with nutrients, uninterrupted enteral nutrition but also tight blood glucose control, supply of antioxidants, administration of prebiotic fibre and probiotic lactic acid bacteria. Nutritional control of postoperative morbidity includes use of so-called synbiotics, e.g. a combination of bioactive lactic acid bacteria (LAB) and bioactive plant fibres.

RESULTS

Dramatic reduction in (in reality, almost abolishment of) septic morbidity is reported following supplementation of specific bioactive lactic bacteria in combination with prebiotic plant fibres, as tried in controlled studies in connection with extensive abdominal operations, liver transplantation and severe acute pancreatitis.

Using insulin as a drug rather than as a replacement hormone during acute illness: a new paradigm

The direct correlation between glucose levels and cardiovascular disease in individuals with type 2 diabetes can now be applied to individuals that share an abnormal metabolic milieu similar to that found in central obesity, the metabolic syndrome, and type 2 diabetes. Premature macrovascular complications with a very high morbidity and mortality rate can be found in these nondiabetic populations. The typical phenotype has visceral or central obesity, excess of free fatty acids, insulin resistance, increased insulin secretion, and hypertension. A more complex metabolic-cardiovascular syndrome develops that includes dyslipidemia, abnormal production of cytokines, chronic inflammatory state, and abnormal coagulation. The interplay of all these cardiovascular risk factors is responsible for the accelerated atherosclerotic process. The different terminologies used for populations sharing this common ground for premature cardiovascular disease now generally accepted as the metabolic syndrome, are also discussed. Aggressive insulin treatment during acute illness in individuals with the abnormal metabolic milieu is beneficial. Insulin treatment is changing from using insulin as a hormone to treat only severe hyperglycemia, to a new paradigm using insulin in high doses as a drug. Aggressive insulin regimens should be used to treat only minimal elevations of blood glucose or to prevent hyperglycemia. The newly observed properties of insulin are reviewed which include suppression of inflammatory cytokines and adhesion molecules, improved hemostasis, and other cardiac beneficial effects. The concomitant administration of intravenous glucose and insulin permits the administration of higher insulin doses that can result in improved outcome due to its nonglycemic-related benefits. The use of aggressive insulin therapy requires both better and more cost-effective algorithms to successfully treat this high-risk population during acute illness.

Influence of acute hyperglycemia in human sepsis on inflammatory cytokine and counterregulatory hormone concentrations

AIM: In human sepsis, a prominent component of the hypermetabolite is impaired glucose tolerance (IGT) and hyperglycemia. Elevations in plasma glucose concentration impair immune function by altering cytokine production from macrophages. We assessed the role of glucose in the regulation of circulating levels of insulin, glucagon, cortisol, IL-6 and TNF-α in human sepsis with normal or impaired glucose tolerance.

METHODS: According to the results of intravenous glucose tolerance test, forty patients were classified into two groups: control group (n = 20) and IGT group (n = 20). Plasma glucose levels were acutely raised in two groups and maintained at 15 mmol/L for 3 hours. Plasma insulin, glucagon and cortisol levels were measured by radioimmunoassay, the levels of TNF-α and IL-6 were detected by ELISA.

RESULTS: In IGT group, the fasting concentrations of plasma glucose, insulin, glucagon, cortisol, IL-6 and TNF-α levels were significantly higher than those in control group (P < 0.05). During clamp, the control group had a higher average amount of dextrose infusion than the IGT group (P < 0.01). In control group, plasma insulin levels rose from a basal value to a peak at an hour (P < 0.05) and maintained at high levels. Plasma glucagon levels descended from a basal value to the lowest level within an hour (P < 0.01) and low levels were maintained throughout the clamp. In IGT group, plasma insulin was more significantly elevated (P < 0.01), and plasma glucagon levels were not significantly declined. Plasma cortisol levels were not significantly changed in two groups. In control group, plasma IL-6 and TNF-α levels rose (P < 0.01) within 2 hours of the clamp and returned to basal values at 3 hours. In IGT group, increased levels of plasma cytokine lasted longer than in control group (3 hours vs. 2 hours, P < 0.05), and the cytokine peaks of IGT group were higher (P < 0.05) than those of control group.

CONCLUSION: Acute hyperglycemia pricks up hyperinsulinemia and increases circulating cytokine concentrations and these effects are more pronounced in sepsis with IGT. This suggests a potential modulation of immunoinflammatory responses in human sepsis by hyperglycemia.