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Honarmand K, Sirimaturos M, Hirshberg EL, Bircher NG, Agus MSD, Carpenter DL, Downs CR, Farrington EA, Freire AX, Grow A, Irving SY, Krinsley JS, Lanspa MJ, Long MT, Nagpal D, Preiser JC, Srinivasan V, Umpierrez GE, Jacobi J. Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024: Executive Summary. Crit Care Med 2024; 52:649-655. [PMID: 38240482 DOI: 10.1097/ccm.0000000000006173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- GUIDE Canada, McMaster University, Hamilton, ON, Canada
| | - Michael Sirimaturos
- System Critical Care Pharmacy Services Leader, Houston Methodist Hospital, Houston, TX
| | - Eliotte L Hirshberg
- Adult and Pediatric Critical Care Specialist, University of Utah School of Medicine, Salt Lake City, UT
| | - Nicholas G Bircher
- Department of Nurse Anesthesia, School of Nursing, University of Pittsburgh, Pittsburgh, PA
| | - Michael S D Agus
- Harvard Medical School and Division Chief, Medical Critical Care, Boston Children's Hospital, Boston, MA
| | | | | | | | - Amado X Freire
- Pulmonary Critical Care and Sleep Medicine at the University of Tennessee Health Science Center, Memphis, TN
| | | | - Sharon Y Irving
- Department of Nursing and Clinical Care Services-Critical Care, University of Pennsylvania School of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA
| | - James S Krinsley
- Director of Critical Care, Emeritus, Vagelos Columbia University College of Physicians and Surgeons, Stamford Hospital, Stamford, CT
| | - Michael J Lanspa
- Division of Critical Care, Intermountain Medical Center, Salt Lake City, UT
| | - Micah T Long
- Department of Anesthesiology, Division of Critical Care, University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - David Nagpal
- Division of Cardiac Surgery, Critical Care Western, London Health Sciences Centre, London, ON, Canada
| | - Jean-Charles Preiser
- Medical Director for Research and Teaching, Erasme Hospital, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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Honarmand K, Sirimaturos M, Hirshberg EL, Bircher NG, Agus MSD, Carpenter DL, Downs CR, Farrington EA, Freire AX, Grow A, Irving SY, Krinsley JS, Lanspa MJ, Long MT, Nagpal D, Preiser JC, Srinivasan V, Umpierrez GE, Jacobi J. Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024. Crit Care Med 2024; 52:e161-e181. [PMID: 38240484 DOI: 10.1097/ccm.0000000000006174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Abstract
RATIONALE Maintaining glycemic control of critically ill patients may impact outcomes such as survival, infection, and neuromuscular recovery, but there is equipoise on the target blood levels, monitoring frequency, and methods. OBJECTIVES The purpose was to update the 2012 Society of Critical Care Medicine and American College of Critical Care Medicine (ACCM) guidelines with a new systematic review of the literature and provide actionable guidance for clinicians. PANEL DESIGN The total multiprofessional task force of 22, consisting of clinicians and patient/family advocates, and a methodologist applied the processes described in the ACCM guidelines standard operating procedure manual to develop evidence-based recommendations in alignment with the Grading of Recommendations Assessment, Development, and Evaluation Approach (GRADE) methodology. Conflict of interest policies were strictly followed in all phases of the guidelines, including panel selection and voting. METHODS We conducted a systematic review for each Population, Intervention, Comparator, and Outcomes question related to glycemic management in critically ill children (≥ 42 wk old adjusted gestational age to 18 yr old) and adults, including triggers for initiation of insulin therapy, route of administration, monitoring frequency, role of an explicit decision support tool for protocol maintenance, and methodology for glucose testing. We identified the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as a good practice statement. In addition, "In our practice" statements were included when the available evidence was insufficient to support a recommendation, but the panel felt that describing their practice patterns may be appropriate. Additional topics were identified for future research. RESULTS This guideline is an update of the guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. It is intended for adult and pediatric practitioners to reassess current practices and direct research into areas with inadequate literature. The panel issued seven statements related to glycemic control in unselected adults (two good practice statements, four conditional recommendations, one research statement) and seven statements for pediatric patients (two good practice statements, one strong recommendation, one conditional recommendation, two "In our practice" statements, and one research statement), with additional detail on specific subset populations where available. CONCLUSIONS The guidelines panel achieved consensus for adults and children regarding a preference for an insulin infusion for the acute management of hyperglycemia with titration guided by an explicit clinical decision support tool and frequent (≤ 1 hr) monitoring intervals during glycemic instability to minimize hypoglycemia and against targeting intensive glucose levels. These recommendations are intended for consideration within the framework of the patient's existing clinical status. Further research is required to evaluate the role of individualized glycemic targets, continuous glucose monitoring systems, explicit decision support tools, and standardized glycemic control metrics.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- GUIDE Canada, McMaster University, Hamilton, ON, Canada
| | - Michael Sirimaturos
- System Critical Care Pharmacy Services Leader, Houston Methodist Hospital, Houston, TX
| | - Eliotte L Hirshberg
- Adult and Pediatric Critical Care Specialist, University of Utah School of Medicine, Salt Lake City, UT
| | - Nicholas G Bircher
- Department of Nurse Anesthesia, School of Nursing, University of Pittsburgh, Pittsburgh, PA
| | - Michael S D Agus
- Harvard Medical School and Division Chief, Medical Critical Care, Boston Children's Hospital, Boston, MA
| | | | | | | | - Amado X Freire
- Pulmonary Critical Care and Sleep Medicine at the University of Tennessee Health Science Center, Memphis, TN
| | | | - Sharon Y Irving
- Department of Nursing and Clinical Care Services-Critical Care, University of Pennsylvania School of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA
| | - James S Krinsley
- Director of Critical Care, Emeritus, Vagelos Columbia University College of Physicians and Surgeons, Stamford Hospital, Stamford, CT
| | - Michael J Lanspa
- Division of Critical Care, Intermountain Medical Center, Salt Lake City, UT
| | - Micah T Long
- Department of Anesthesiology, Division of Critical Care, University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - David Nagpal
- Division of Cardiac Surgery, Critical Care Western, London Health Sciences Centre, London, ON, Canada
| | - Jean-Charles Preiser
- Medical Director for Research and Teaching, Erasme Hospital, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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Thompson C, Mebrahtu T, Skyrme S, Bloor K, Andre D, Keenan AM, Ledward A, Yang H, Randell R. The effects of computerised decision support systems on nursing and allied health professional performance and patient outcomes: a systematic review and user contextualisation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023:1-85. [PMID: 37470324 DOI: 10.3310/grnm5147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Background Computerised decision support systems (CDSS) are widely used by nurses and allied health professionals but their effect on clinical performance and patient outcomes is uncertain. Objectives Evaluate the effects of clinical decision support systems use on nurses', midwives' and allied health professionals' performance and patient outcomes and sense-check the results with developers and users. Eligibility criteria Comparative studies (randomised controlled trials (RCTs), non-randomised trials, controlled before-and-after (CBA) studies, interrupted time series (ITS) and repeated measures studies comparing) of CDSS versus usual care from nurses, midwives or other allied health professionals. Information sources Nineteen bibliographic databases searched October 2019 and February 2021. Risk of bias Assessed using structured risk of bias guidelines; almost all included studies were at high risk of bias. Synthesis of results Heterogeneity between interventions and outcomes necessitated narrative synthesis and grouping by: similarity in focus or CDSS-type, targeted health professionals, patient group, outcomes reported and study design. Included studies Of 36,106 initial records, 262 studies were assessed for eligibility, with 35 included: 28 RCTs (80%), 3 CBA studies (8.6%), 3 ITS (8.6%) and 1 non-randomised trial, a total of 1318 health professionals and 67,595 patient participants. Few studies were multi-site and most focused on decision-making by nurses (71%) or paramedics (5.7%). Standalone, computer-based CDSS featured in 88.7% of the studies; only 8.6% of the studies involved 'smart' mobile or handheld technology. Care processes - including adherence to guidance - were positively influenced in 47% of the measures adopted. For example, nurses' adherence to hand disinfection guidance, insulin dosing, on-time blood sampling, and documenting care were improved if they used CDSS. Patient care outcomes were statistically - if not always clinically - significantly improved in 40.7% of indicators. For example, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity, and accurate triaging were features of professionals using CDSS compared to those who were not. Evidence limitations Allied health professionals (AHPs) were underrepresented compared to nurses; systems, studies and outcomes were heterogeneous, preventing statistical aggregation; very wide confidence intervals around effects meant clinical significance was questionable; decision and implementation theory that would have helped interpret effects - including null effects - was largely absent; economic data were scant and diverse, preventing estimation of overall cost-effectiveness. Interpretation CDSS can positively influence selected aspects of nurses', midwives' and AHPs' performance and care outcomes. Comparative research is generally of low quality and outcomes wide ranging and heterogeneous. After more than a decade of synthesised research into CDSS in healthcare professions other than medicine, the effect on processes and outcomes remains uncertain. Higher-quality, theoretically informed, evaluative research that addresses the economics of CDSS development and implementation is still required. Future work Developing nursing CDSS and primary research evaluation. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in Health and Social Care Delivery Research; 2023. See the NIHR Journals Library website for further project information. Registration PROSPERO [number: CRD42019147773].
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Affiliation(s)
- Carl Thompson
- School of Healthcare, University of Leeds, Leeds, UK
| | | | - Sarah Skyrme
- School of Healthcare, University of Leeds, Leeds, UK
| | - Karen Bloor
- Department of Health Sciences, University of York, York, UK
| | - Deidre Andre
- Library Services, University of Leeds, Leeds, UK
| | | | | | - Huiqin Yang
- School of Healthcare, University of Leeds, Leeds, UK
| | - Rebecca Randell
- Faculty of Health Studies, University of Bradford, Bradford, UK
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Saseedharan S, Udhoji P, Kadam V, Chiluka A, Mathew E, Talwalkar P, Argikar A, Boraskar A, Phatak R, Kulkarni N, Baghel P, Patil A, Gadgil Y, Patil K, Jain S. Observational study on SavenG protocol of glucose control in intensive care unit. JOURNAL OF DIABETOLOGY 2022. [DOI: 10.4103/jod.jod_112_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Mebrahtu TF, Skyrme S, Randell R, Keenan AM, Bloor K, Yang H, Andre D, Ledward A, King H, Thompson C. Effects of computerised clinical decision support systems (CDSS) on nursing and allied health professional performance and patient outcomes: a systematic review of experimental and observational studies. BMJ Open 2021; 11:e053886. [PMID: 34911719 PMCID: PMC8679061 DOI: 10.1136/bmjopen-2021-053886] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 11/22/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Computerised clinical decision support systems (CDSS) are an increasingly important part of nurse and allied health professional (AHP) roles in delivering healthcare. The impact of these technologies on these health professionals' performance and patient outcomes has not been systematically reviewed. We aimed to conduct a systematic review to investigate this. MATERIALS AND METHODS The following bibliographic databases and grey literature sources were searched by an experienced Information Professional for published and unpublished research from inception to February 2021 without language restrictions: MEDLINE (Ovid), Embase Classic+Embase (Ovid), PsycINFO (Ovid), HMIC (Ovid), AMED (Allied and Complementary Medicine) (Ovid), CINAHL (EBSCO), Cochrane Central Register of Controlled Trials (Wiley), Cochrane Database of Systematic Reviews (Wiley), Social Sciences Citation Index Expanded (Clarivate), ProQuest Dissertations & Theses Abstracts & Index, ProQuest ASSIA (Applied Social Science Index and Abstract), Clinical Trials.gov, WHO International Clinical Trials Registry (ICTRP), Health Services Research Projects in Progress (HSRProj), OpenClinical(www.OpenClinical.org), OpenGrey (www.opengrey.eu), Health.IT.gov, Agency for Healthcare Research and Quality (www.ahrq.gov). Any comparative research studies comparing CDSS with usual care were eligible for inclusion. RESULTS A total of 36 106 non-duplicate records were identified. Of 35 included studies: 28 were randomised trials, three controlled-before-and-after studies, three interrupted-time-series and one non-randomised trial. There were ~1318 health professionals and ~67 595 patient participants in the studies. Most studies focused on nurse decision-makers (71%) or paramedics (5.7%). CDSS as a standalone Personal Computer/LAPTOP-technology was a feature of 88.7% of the studies; only 8.6% of the studies involved 'smart' mobile/handheld-technology. DISCUSSION CDSS impacted 38% of the outcome measures used positively. Care processes were better in 47% of the measures adopted; examples included, nurses' adherence to hand disinfection guidance, insulin dosing, on-time blood sampling and documenting care. Patient care outcomes in 40.7% of indicators were better; examples included, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity and triaging appropriateness. CONCLUSION CDSS may have a positive impact on selected aspects of nurses' and AHPs' performance and care outcomes. However, comparative research is generally low quality, with a wide range of heterogeneous outcomes. After more than 13 years of synthesised research into CDSS in healthcare professions other than medicine, the need for better quality evaluative research remains as pressing.
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Affiliation(s)
| | - Sarah Skyrme
- School of Healthcare, University of Leeds, Leeds, UK
| | - Rebecca Randell
- Faculty of Health Studies, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | | | - Karen Bloor
- Department of Health Sciences, University of York, York, UK
| | - Huiqin Yang
- School of Healthcare, University of Leeds, Leeds, UK
| | | | | | - Henry King
- School of Healthcare, University of Leeds, Leeds, UK
| | - Carl Thompson
- School of Healthcare, University of Leeds, Leeds, UK
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Effectiveness and safety of the Space GlucoseControl system for glycaemia control in caring for postoperative cardiac surgical patients. Aust Crit Care 2021; 35:136-142. [PMID: 33962858 DOI: 10.1016/j.aucc.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/25/2021] [Accepted: 03/08/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hyperglycaemia is a very common complication in post-cardiac surgical patients, and as such, it must be properly managed. For this purpose, the enhanced Model Predictive Control algorithm for glycaemia control has been implemented into a nurse-led device called Space GlucoseControl (SGC) that aims to achieve a safe and effective blood glucose control in a better way than the traditional "paper-based" protocols. PURPOSE The aim of the study was to know the effectiveness and safety of the SGC in glycaemia control in cardiosurgical adult patients in the immediate postoperative period in the intensive care unit. METHODS A prospective before-and-after intervention study was conducted. One hundred sixty cardiosurgical adult patients with hyperglycaemia were selected: 80 in the control group from May to November 2018 and 80 in the intervention group (use of the SGC device) from January to December 2019. The primary outcome was the percentage of time within the target range (140-180 mg/dL in the control group and 100-160 mg/dL in the intervention group). RESULTS The percentage of time within the target range was significantly higher in the SGC group than in the control group (70.5% [58.25-80] vs 54.83% [36.09-75], p < 0.001). The range was also achieved earlier with the SGC (5 [3-6.875] hours vs 7 [4-11] hours; p < 0.05). The first blood glucose value after reaching the target range was higher in the control group, with statistical significance (p < 0.05). There were no hypoglycaemia episodes in the control group. However, during SGC treatment, six episodes of hypoglycaemia occurred, and all of them were nonsevere (mean value = 61 mg/dL). CONCLUSION The SGC is useful to achieve a faster tight glycaemic control, with a higher percentage of time within the target range, although episodes of nonsevere hypoglycaemia could be observed.
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Chase JG, Shaw GM, Preiser JC, Knopp JL, Desaive T. Risk-Based Care: Let's Think Outside the Box. Front Med (Lausanne) 2021; 8:535244. [PMID: 33718394 PMCID: PMC7947294 DOI: 10.3389/fmed.2021.535244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 01/22/2021] [Indexed: 12/19/2022] Open
Affiliation(s)
- James Geoffrey Chase
- Centre for Bioengineering, Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, University of Otago Christchurch School of Medicine, Christchurch, New Zealand
| | | | - Jennifer L Knopp
- Centre for Bioengineering, Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA In Silico Medicine, University of Liege, Liege, Belgium
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Chancellor WZ, Mehaffey JH, Hawkins RB, Charles EJ, Tribble C, Yarboro LT, Ailawadi G, Kirby JL. Electronic Glycemic Management System and Endocrinology Service Improve Value in Cardiac Surgery. Am Surg 2020; 87:568-575. [PMID: 33118411 DOI: 10.1177/0003134820950685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Postoperative glycemic control improves cardiac surgery outcomes but insulin protocols are limited by complexity and inflexibility. We sought to evaluate the effect of implementing an electronic glycemic management system (eGMS) in conjunction with a cardiac surgery endocrinology consult service on glycemic control and outcomes after cardiac surgery. METHODS All patients with a calculated preoperative risk of mortality who underwent cardiac surgery before and after implementation of an eGMS and an endocrinology consult service were identified. Glycemic control and surgical outcomes were compared using univariate analysis, and multivariate regression was used to model the risk-adjusted effects of the interventions on glycemic control, surgical outcomes, and resource utilization. The health care-related value added by the interventions was calculated by dividing risk-adjusted outcomes by total hospital costs. RESULTS A total of 2612 patients were identified, with 1263 patients in the preimplementation cohort and 1349 in the postimplementation cohort. Multivariate regression demonstrated fewer postoperative hyperglycemic events (odds ratio [OR] 0.8, 95% CI, 0.65-0.99) after protocol implementation without an increase in hypoglycemic events (OR 0.96, 95% CI, 0.71-1.3). Average day-weighted mean glucose decreased from 144 to 138 mg/dL (P < .001). The improved glycemic control correlated with a risk-adjusted decrease in composite morbidity or mortality (OR 0.61, 95% CI, 0.47-0.79). Although hospital costs increased after implementation, the protocol increased health care-related value by 38%. CONCLUSION Implementation of a protocol consisting of an eGMS paired with a cardiac surgery-specific endocrinology consult service was associated with improved glycemic control and reduced morbidity. Despite higher costs health care-related value increased as a result of eGMS implementation.
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Affiliation(s)
- William Z Chancellor
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - James H Mehaffey
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Robert B Hawkins
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Eric J Charles
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Curt Tribble
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Leora T Yarboro
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Gorav Ailawadi
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Jennifer L Kirby
- 2358 Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Virginia, USA
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Roumeliotis N, Sniderman J, Adams-Webber T, Addo N, Anand V, Rochon P, Taddio A, Parshuram C. Effect of Electronic Prescribing Strategies on Medication Error and Harm in Hospital: a Systematic Review and Meta-analysis. J Gen Intern Med 2019; 34:2210-2223. [PMID: 31396810 PMCID: PMC6816608 DOI: 10.1007/s11606-019-05236-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/02/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Computerized physician order entry and clinical decision support systems are electronic prescribing strategies that are increasingly used to improve patient safety. Previous reviews show limited effect on patient outcomes. Our objective was to assess the impact of electronic prescribing strategies on medication errors and patient harm in hospitalized patients. METHODS MEDLINE, EMBASE, CENTRAL, and CINAHL were searched from January 2007 to January 2018. We included prospective studies that compared hospital-based electronic prescribing strategies with control, and reported on medication error or patient harm. Data were abstracted by two reviewers and pooled using random effects model. Study quality was assessed using the Effective Practice and Organisation of Care and evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS Thirty-eight studies were included; comprised of 11 randomized control trials and 27 non-randomized interventional studies. Electronic prescribing strategies reduced medication errors (RR 0.24 (95% CI 0.13, 0.46), I2 98%, n = 11) and dosing errors (RR 0.17 (95% CI 0.08, 0.38), I2 96%, n = 9), with both risk ratios significantly affected by advancing year of publication. There was a significant effect of electronic prescribing strategies on adverse drug events (ADEs) (RR 0.52 (95% CI 0.40, 0.68), I2 0%, n = 2), but not on preventable ADEs (RR 0.55 (95% CI 0.30, 1.01), I2 78%, n = 3), hypoglycemia (RR 1.03 (95% CI 0.62-1.70), I2 28%, n = 7), length of stay (MD - 0.18 (95% - 1.42, 1.05), I2 94%, n = 7), or mortality (RR 0.97 (95% CI 0.79, 1.19), I2 74%, n = 9). The quality of evidence was rated very low. DISCUSSION Electronic prescribing strategies decrease medication errors and adverse drug events, but had no effect on other patient outcomes. Conservative interpretations of these findings are supported by significant heterogeneity and the preponderance of low-quality studies.
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Affiliation(s)
- Nadia Roumeliotis
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada. .,Child Health Evaluative Sciences, and Center for Safety Research, SickKids Research Institute, Toronto, ON, Canada.
| | - Jonathan Sniderman
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Newton Addo
- Division of Clinical Pharmacology, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Vijay Anand
- Department of Pediatrics, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Paula Rochon
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Anna Taddio
- Child Health Evaluative Sciences, and Center for Safety Research, SickKids Research Institute, Toronto, ON, Canada
| | - Christopher Parshuram
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Child Health Evaluative Sciences, and Center for Safety Research, SickKids Research Institute, Toronto, ON, Canada
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Arthur CPDS, Mejía OAV, Lapenna GA, Brandão CMDA, Lisboa LAF, Dias RR, Dallan LAO, Pomerantzeff PMA, Jatene FB. Perioperative Management of the Diabetic Patient Referred to Cardiac Surgery. Braz J Cardiovasc Surg 2019; 33:618-625. [PMID: 30652752 PMCID: PMC6326452 DOI: 10.21470/1678-9741-2018-0147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 07/31/2018] [Indexed: 01/04/2023] Open
Abstract
Currently there is a progressive increase in the prevalence of diabetes in a referred for cardiovascular surgery. Benefits of glycemic management (< 180 mg/dL) in diabetic patients compared to patients without diabetes in perioperative cardiac surgery. The purpose of this study is to present recommendations based on international evidence and adapted to our clinical practice for the perioperative management of hyperglycemia in adult patients with and without diabetes undergoing cardiovascular surgery. This update is based on the latest current literature derived from articles and guidelines regarding perioperative management of diabetic patients to cardiovascular surgery.
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Affiliation(s)
- Camila Perez de Souza Arthur
- Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Omar Asdrúbal Vilca Mejía
- Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Gisele Aparecida Lapenna
- Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Carlos Manuel de Almeida Brandão
- Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Luiz Augusto Ferreira Lisboa
- Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Ricardo Ribeiro Dias
- Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Luís Alberto Oliveira Dallan
- Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Pablo Maria Alberto Pomerantzeff
- Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Fabio B Jatene
- Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
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Gupta D, Prasad A, Siddiqui F, Sitaula S, Albert SG. Insulin infusion responses in diabetic ketoacidosis alone and with a mixed hypochloremic alkalosis. Diabetes Metab Syndr 2019; 13:216-221. [PMID: 30641700 DOI: 10.1016/j.dsx.2018.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 08/21/2018] [Indexed: 11/21/2022]
Abstract
AIMS Although diabetic ketoacidosis (DKA) commonly presents as a pure diabetic ketoacidosis (PDKA), up to 30% of cases may be associated with a mixed hypochloremic metabolic alkalosis (HMA). It is unknown whether there is a difference in treatment outcomes between these two entities. We evaluated an insulin infusion protocol (IIP), previously validated for hyperglycemia management in ICU's, for the management of PDKA and HMA. MATERIALS AND METHODS A retrospective case series/cohort study of 41 DKA admissions was further characterized as having PDKA or HMA. HMA was defined in those having an elevated delta-delta gradient (ΔAG-ΔHCO3) ≥ 5 mmol/L and base excess chloride (BECl) > 2.7 mmol/L. The main outcome measures were times to recovery of glucose levels to ≤250 mg/dL and of anion gap to ≤12 mmol/L. RESULTS The initial serum glucose was 553 ± 265 mg/dL, serum bicarbonate of 8.8 ± 5.1 mmol/L, and venous pH 7.13 ± 0.2). Recovery of glucose occurred in 5 h: 25 min (±3 h:39min), and for anion gap in 11 h:25 min (±6 h:56min). HMA compared with PDKA had a delayed recovery of serum glucose (7 h: 23min ± 3 h: 35min vs. 4 h: 31min ± 3:h:21min, p = 0.017), which was due to the higher initial level of glucose (p = 0.02) rather than level of BECl (p = 0.17). There was no difference in time to anion gap closure between the PDKA and HMA. CONCLUSIONS Correction of hyperglycemia and acidosis in PDKA as well as in HMA was managed through the IIP. The simultaneous fluid and electrolyte management corrected the hypochloremic alkalosis.
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Affiliation(s)
- Deepashree Gupta
- Division of Endocrinology, University of California, Los Angeles, United States
| | - Anju Prasad
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States
| | - Faisal Siddiqui
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States
| | - Sujata Sitaula
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States
| | - Stewart G Albert
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States.
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Chase JG, Desaive T, Bohe J, Cnop M, De Block C, Gunst J, Hovorka R, Kalfon P, Krinsley J, Renard E, Preiser JC. Improving glycemic control in critically ill patients: personalized care to mimic the endocrine pancreas. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:182. [PMID: 30071851 PMCID: PMC6091026 DOI: 10.1186/s13054-018-2110-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/29/2018] [Indexed: 02/06/2023]
Abstract
There is considerable physiological and clinical evidence of harm and increased risk of death associated with dysglycemia in critical care. However, glycemic control (GC) currently leads to increased hypoglycemia, independently associated with a greater risk of death. Indeed, recent evidence suggests GC is difficult to safely and effectively achieve for all patients. In this review, leading experts in the field discuss this evidence and relevant data in diabetology, including the artificial pancreas, and suggest how safe, effective GC can be achieved in critically ill patients in ways seeking to mimic normal islet cell function. The review is structured around the specific clinical hurdles of: understanding the patient’s metabolic state; designing GC to fit clinical practice, safety, efficacy, and workload; and the need for standardized metrics. These aspects are addressed by reviewing relevant recent advances in science and technology. Finally, we provide a set of concise recommendations to advance the safety, quality, consistency, and clinical uptake of GC in critical care. This review thus presents a roadmap toward better, more personalized metabolic care and improved patient outcomes.
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Affiliation(s)
- J Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA In-Silico Medicine, University of Liège, Liège, Belgium
| | - Julien Bohe
- Medical Intensive Care Unit, Lyon-Sud University Hospital, Pierre-Bénite, France
| | - Miriam Cnop
- ULB Center for Diabetes Research, and Division of Endocrinology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Edegem, Belgium
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Roman Hovorka
- University of Cambridge Metabolic Research Laboratories, Level 4, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
| | - Pierre Kalfon
- Service de Réanimation polyvalente, Hôpital Louis Pasteur, CH de Chartres, Chartres, France
| | - James Krinsley
- Division of Critical Care, Department of Medicine, Stamford Hospital, Columbia University College of Physicians and Surgeons, Stamford, CT, USA
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, and Institute of Functional Genomics, CNRS, INSERM, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, route de Lennik 808, 1070, Brussels, Belgium.
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Xu B, Jiang W, Wang CY, Weng L, Hu XY, Peng JM, Du B. Comparison of Space Glucose Control and Routine Glucose Management Protocol for Glycemic Control in Critically Ill Patients: A Prospective, Randomized Clinical Study. Chin Med J (Engl) 2018; 130:2041-2049. [PMID: 28836546 PMCID: PMC5586171 DOI: 10.4103/0366-6999.213422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: The Space Glucose Control (SGC) system is a computer-assisted device combining infusion pumps with the enhanced Model Predictive Control algorithm to achieve the target blood glucose (BG) level safely. The objective of this study was to evaluate the efficacy and safety of glycemic control by SGC with customized BG target range of 5.8–8.9 mmol/L in the critically ill patients. Methods: It is a randomized controlled trial of seventy critically ill patients with mechanical ventilation and hyperglycemia (BG ≥ 9.0 mmol/L). Thirty-six patients in the SGC group and 34 in the routine glucose management group were observed for three consecutive days. Target BG for both groups was 5.8–8.9 mmol/L. The primary outcome was the percentage time in the target range. Results: The percentage time within BG target range in the SGC group (69 ± 15%) was significantly higher than in the routine management group (52 ± 24%; P < 0.01). No measurement was ≤2.2 mmol/L, and there was only one episode of hypoglycemia (2.3–3.3 mmol/L) in each group. The average BG was significantly lower in the SGC group (7.8 ± 0.7 mmol/L) than in the routine management group (9.1 ± 1.6 mmol/L, P < 0.001). Target BG level was reached earlier in the SGC group than routine management group (2.5 ± 2.9 vs. 12.1 ± 15.3 h, P = 0.001). However, the SGC group performed worse for daily insulin requirement (59.8 ± 39.3 vs. 28.4 ± 36.7 U, P = 0.001) and sampling interval (2.0 ± 0.5 vs. 3.7 ± 0.5 h, P < 0.001) than the routine management group did. Multiple linear regression showed that the intervention group remained a significant individual predictor (P < 0.001) of the percentage time in target range. Conclusions: The SGC system, with a BG target of 5.8–8.9 mmol/L, resulted in effective and reliable glycemic control with few hypoglycemic episodes in critically ill patients with mechanical ventilation and hyperglycemia. However, the workload was increased. Trial Registration: http://www.clinicaltrials.gov, NCT 02491346; https://www.clinicaltrials.gov/ct2/show/NCT02491346?term=NCT02491346&cond=Hyperglycemia&cntry1=ES%3ACN&rank=1.
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Affiliation(s)
- Biao Xu
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730; Critical Care Center, 302 Military Hospital of China, Beijing 100039, China
| | - Wei Jiang
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Chun-Yao Wang
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Li Weng
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xiao-Yun Hu
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jin-Min Peng
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
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Braithwaite SS, Clark LP, Idrees T, Qureshi F, Soetan OT. Hypoglycemia Prevention by Algorithm Design During Intravenous Insulin Infusion. Curr Diab Rep 2018; 18:26. [PMID: 29582176 DOI: 10.1007/s11892-018-0994-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW This review examines algorithm design features that may reduce risk for hypoglycemia while preserving glycemic control during intravenous insulin infusion. We focus principally upon algorithms in which the assignment of the insulin infusion rate (IR) depends upon maintenance rate of insulin infusion (MR) or a multiplier. RECENT FINDINGS Design features that may mitigate risk for hypoglycemia include use of a mid-protocol bolus feature and establishment of a low BG threshold for temporary interruption of infusion. Computer-guided dosing may improve target attainment without exacerbating risk for hypoglycemia. Column assignment (MR) within a tabular user-interpreted algorithm or multiplier may be specified initially according to patient characteristics and medical condition with revision during treatment based on patient response. We hypothesize that a strictly increasing sigmoidal relationship between MR-dependent IR and BG may reduce risk for hypoglycemia, in comparison to a linear relationship between multiplier-dependent IR and BG. Guidelines are needed that curb excessive up-titration of MR and recommend periodic pre-emptive trials of MR reduction. Future research should foster development of recommendations for "protocol maxima" of IR appropriate to patient condition.
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Affiliation(s)
- Susan Shapiro Braithwaite
- , 1135 Ridge Road, Wilmette, IL, 60091, USA.
- Endocrinology Consults and Care, S.C, 3048 West Peterson Ave, Chicago, IL, 60659, USA.
| | - Lisa P Clark
- Presence Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Thaer Idrees
- Presence Saint Joseph Hospital, 2900 N. Lakeshore Dr, Chicago, IL, 60657, USA
| | - Faisal Qureshi
- Presence Saint Joseph Hospital, 2800 N Sheridan Road Suite 309, Chicago, IL, 60657, USA
| | - Oluwakemi T Soetan
- Presence Saint Joseph Hospital, 2900 N. Lakeshore Dr, Chicago, IL, 60657, USA
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15
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Chase JG, Preiser JC, Dickson JL, Pironet A, Chiew YS, Pretty CG, Shaw GM, Benyo B, Moeller K, Safaei S, Tawhai M, Hunter P, Desaive T. Next-generation, personalised, model-based critical care medicine: a state-of-the art review of in silico virtual patient models, methods, and cohorts, and how to validation them. Biomed Eng Online 2018; 17:24. [PMID: 29463246 PMCID: PMC5819676 DOI: 10.1186/s12938-018-0455-y] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 02/12/2018] [Indexed: 01/17/2023] Open
Abstract
Critical care, like many healthcare areas, is under a dual assault from significantly increasing demographic and economic pressures. Intensive care unit (ICU) patients are highly variable in response to treatment, and increasingly aging populations mean ICUs are under increasing demand and their cohorts are increasingly ill. Equally, patient expectations are growing, while the economic ability to deliver care to all is declining. Better, more productive care is thus the big challenge. One means to that end is personalised care designed to manage the significant inter- and intra-patient variability that makes the ICU patient difficult. Thus, moving from current "one size fits all" protocolised care to adaptive, model-based "one method fits all" personalised care could deliver the required step change in the quality, and simultaneously the productivity and cost, of care. Computer models of human physiology are a unique tool to personalise care, as they can couple clinical data with mathematical methods to create subject-specific models and virtual patients to design new, personalised and more optimal protocols, as well as to guide care in real-time. They rely on identifying time varying patient-specific parameters in the model that capture inter- and intra-patient variability, the difference between patients and the evolution of patient condition. Properly validated, virtual patients represent the real patients, and can be used in silico to test different protocols or interventions, or in real-time to guide care. Hence, the underlying models and methods create the foundation for next generation care, as well as a tool for safely and rapidly developing personalised treatment protocols over large virtual cohorts using virtual trials. This review examines the models and methods used to create virtual patients. Specifically, it presents the models types and structures used and the data required. It then covers how to validate the resulting virtual patients and trials, and how these virtual trials can help design and optimise clinical trial. Links between these models and higher order, more complex physiome models are also discussed. In each section, it explores the progress reported up to date, especially on core ICU therapies in glycemic, circulatory and mechanical ventilation management, where high cost and frequency of occurrence provide a significant opportunity for model-based methods to have measurable clinical and economic impact. The outcomes are readily generalised to other areas of medical care.
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Affiliation(s)
- J. Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University of Hospital, 1070 Brussels, Belgium
| | - Jennifer L. Dickson
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand
| | - Antoine Pironet
- GIGA In Silico Medicine, University of Liege, 4000 Liege, Belgium
| | - Yeong Shiong Chiew
- Department of Mechanical Engineering, School of Engineering, Monash University Malaysia, 47500 Selangor, Malaysia
| | - Christopher G. Pretty
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand
| | - Geoffrey M. Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
| | - Balazs Benyo
- Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
| | - Knut Moeller
- Department of Biomedical Engineering, Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Soroush Safaei
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Merryn Tawhai
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Peter Hunter
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Thomas Desaive
- GIGA In Silico Medicine, University of Liege, 4000 Liege, Belgium
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Lipš M, Mráz M, Kloučková J, Kopecký P, Dobiáš M, Křížová J, Lindner J, Diamant M, Haluzík M. Effect of continuous exenatide infusion on cardiac function and peri-operative glucose control in patients undergoing cardiac surgery: A single-blind, randomized controlled trial. Diabetes Obes Metab 2017; 19:1818-1822. [PMID: 28581209 DOI: 10.1111/dom.13029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/30/2017] [Accepted: 05/30/2017] [Indexed: 01/24/2023]
Abstract
We performed a randomized controlled trial with the glucagon-like peptide-1 (GLP-1) receptor agonist exenatide as add-on to standard peri-operative insulin therapy in patients undergoing elective cardiac surgery. The aims of the study were to intensify peri-operative glucose control while minimizing the risk of hypoglycaemia and to evaluate the suggested cardioprotective effects of GLP-1-based treatments. A total of 38 patients with decreased left ventricular systolic function (ejection fraction ≤50%) scheduled for elective coronary artery bypass grafting (CABG) were randomized to receive either exenatide or placebo in a continuous 72-hour intravenous (i.v.) infusion on top of standard peri-operative insulin therapy. While no significant difference in postoperative echocardiographic variables was found between the groups, participants receiving exenatide showed improved peri-operative glucose control as compared with the placebo group (average glycaemia 6.4 ± 0.5 vs 7.3 ± 0.8 mmol/L; P < .001; percentage of time in target range of 4.5-6.5 mmol/L 54.8% ± 14.5% vs 38.6% ± 14.4%; P = .001; percentage of time above target range 39.7% ± 13.9% vs 52.8% ± 15.2%; P = .009) without an increased risk of hypoglycaemia (glycaemia <3.3 mmol/L: 0.10 ± 0.32 vs 0.21 ± 0.42 episodes per participant; P = .586). Continuous administration of i.v. exenatide in patients undergoing elective CABG could provide a safe option for intensifying the peri-operative glucose management of such patients.
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Affiliation(s)
- Michal Lipš
- Department of Anaesthesiology, Resuscitation and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Miloš Mráz
- Department of Diabetes, Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jana Kloučková
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Experimental Diabetology, Centre for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petr Kopecký
- Department of Anaesthesiology, Resuscitation and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Miloš Dobiáš
- Department of Anaesthesiology, Resuscitation and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jarmila Křížová
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jaroslav Lindner
- 2nd Department of Surgery - Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | | | - Martin Haluzík
- Department of Diabetes, Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Experimental Diabetology, Centre for Experimental Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Department of Obesitology, Institute of Endocrinology, Prague, Czech Republic
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Ramadan M, Abdelgawad A, Elshemy A, Sarawy E, Emad A, Mazen M, Abdel Aziz A. Impact of elevated glycosylated hemoglobin on hospital outcome and 1 year survival of primary isolated coronary artery bypass grafting patients. Egypt Heart J 2017; 70:113-118. [PMID: 30166892 PMCID: PMC6112333 DOI: 10.1016/j.ehj.2017.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 09/26/2017] [Indexed: 01/04/2023] Open
Abstract
Objective It is unknown whether adequacy of diabetic control, measured by hemoglobin A1c, is a predictor of adverse outcomes after coronary artery bypass grafting. Methods From December 2013 to November 2015, 80 consecutive patients underwent primary isolated CABG surgery at national heart institute, their data were prospectively collected and they were classified according to their HbA1c level into two groups, Group (A): Forty patients with fair glycemic control (HbA1c below or equal to 7%), Group (B): Forty patients with poor glycemic control (HbA1c above 7%). Hospital morbidity, mortality and one year survival were examined in both groups. Telephone conversation was used to call patients or their relatives to determine the one year survival and it was 100% complete. This study had gained the ethical approval from national heart institute ethical committee. Results In-hospital mortality for group A was 2.5% (one patient) and 7.5% (3 patients) for group B with no statistical significance. One year mortality was (5.13%) (2 patients for group A) and (8.11%) (3 patients) for group B with no statistical significance. As regard the morbidity there was no statistical significance between the two groups in the incidence of neurological complications whether stroke or coma, atrial fibrillation, postoperative myocardial infarction, low cardiac output syndrome, heart failure, renal failure, need for dialysis, deep sternal wound infection, and readmission. However, group B had lengthy hospital stay, lengthy ventilation hours, more respiratory complications, and more superficial wound infection with a statistical significance when compared to group A, P values were 0.003, 0.003, 0.038, 0.044 respectively. Conclusions This study showed that HbA1c is a good predictor of in-hospital morbidity. It worth devoting time and effort to decrease HbA1c level below 7% to decrease possible postoperative complications.
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Affiliation(s)
- Mona Ramadan
- Anesthesia Department, National Heart Institute, Egypt
| | | | - Ahmed Elshemy
- Cardiac Surgery Department, National Heart Institute, Egypt
| | - Emad Sarawy
- Cardiac Surgery Department, National Heart Institute, Egypt
| | - Aly Emad
- Cardiac Surgery Department, National Heart Institute, Egypt
| | - Mahmoud Mazen
- Cardiac Surgery Department, National Heart Institute, Egypt
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Dickson JL, Stewart KW, Pretty CG, Flechet M, Desaive T, Penning S, Lambermont BC, Benyo B, Shaw GM, Chase JG. Generalisability of a Virtual Trials Method for Glycaemic Control in Intensive Care. IEEE Trans Biomed Eng 2017; 65:1543-1553. [PMID: 28358672 DOI: 10.1109/tbme.2017.2686432] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Elevated blood glucose (BG) concentrations (Hyperglycaemia) are a common complication in critically ill patients. Insulin therapy is commonly used to treat hyperglycaemia, but metabolic variability often results in poor BG control and low BG (hypoglycaemia). OBJECTIVE This paper presents a model-based virtual trial method for glycaemic control protocol design, and evaluates its generalisability across different populations. METHODS Model-based insulin sensitivity (SI) was used to create virtual patients from clinical data from three different ICUs in New Zealand, Hungary, and Belgium. Glycaemic results from simulation of virtual patients under their original protocol (self-simulation) and protocols from other units (cross simulation) were compared. RESULTS Differences were found between the three cohorts in median SI and inter-patient variability in SI. However, hour-to-hour intra-patient variability in SI was found to be consistent between cohorts. Self and cross-simulation results were found to have overall similarity and consistency, though results may differ in the first 24-48 h due to different cohort starting BG and underlying SI. CONCLUSIONS AND SIGNIFICANCE Virtual patients and the virtual trial method were found to be generalisable across different ICUs. This virtual trial method is useful for in silico protocol design and testing, given an understanding of the underlying assumptions and limitations of this method.
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Clergeau A, Parienti JJ, Reznik Y, Clergeau D, Seguin A, Valette X, du Cheyron D, Joubert M. Impact of a Paper-Based Dynamic Insulin Infusion Protocol on Glycemic Variability, Time in Target, and Hypoglycemic Risk: A Stepped Wedge Trial in Medical Intensive Care Unit Patients. Diabetes Technol Ther 2017; 19:115-123. [PMID: 28118045 DOI: 10.1089/dia.2016.0314] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Stress-induced hyperglycemia is a common feature of intensive care unit (ICU) patients. Besides mean blood glucose (BG) level, glucose variability and hypoglycemia have been highlighted as independent predictors of ICU and hospital mortality. Recent ICU recommendations suggest using insulin infusion protocols that can minimize glucose variability and hypoglycemic risk. Our aim was to assess the efficacy, safety, and acceptance by nurses of a paper-based simple dynamic insulin protocol compared with those by nurses of a paper-based static protocol. METHODS This is a 1 year stepped-wedge study that compared a static sliding scale protocol (SP - static protocol) with a validated dynamic paper-based intravenous insulin infusion protocol (DP - dynamic protocol) in medical ICU patients of a single university hospital. Patients with stress-induced hyperglycemia >9.9 mmol/L and ≥48 h intravenous insulin infusion were included in this trial. RESULTS One hundred thirty-one patients were included and received continuous intravenous insulin infusion managed with SP (n = 65) or DP (n = 66). Glucose variability was significantly higher in the SP group than in the DP group (mean average glucose excursion index: 0.90 [0.00-1.91] mmol/L vs. 0.00 [0.00-0.90] mmol/L, respectively; P = 0.001). The percentage of time spent in the target range (7.7-9.9 mmol/L) was lower in the SP group than in the DP group (42.5% [28.8%-54.2%] vs. 47.5% [36.6%-57.1%]; P = 0.037). Low BG (<4.4 mmol/L) and hypoglycemia (<3.3 mmol/L) were more frequent in the SP group than in the DP group. According to a satisfaction survey, this protocol was well accepted by nurses. CONCLUSIONS Our simple and feasible paper-based, dynamic insulin infusion protocol reduced glycemic variability and hypoglycemic risk in a medical ICU.
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Affiliation(s)
- Antoine Clergeau
- 1 Diabetes Care Unit, University Hospital of Caen , Caen, France
| | | | - Yves Reznik
- 1 Diabetes Care Unit, University Hospital of Caen , Caen, France
| | - Deborah Clergeau
- 3 Intensive Care Unit, University Hospital of Caen , Caen, France
| | - Amelie Seguin
- 3 Intensive Care Unit, University Hospital of Caen , Caen, France
| | - Xavier Valette
- 3 Intensive Care Unit, University Hospital of Caen , Caen, France
| | | | - Michael Joubert
- 1 Diabetes Care Unit, University Hospital of Caen , Caen, France
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21
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Higgs MH, Fernandez RS. Computerised insulin dosing calculators for the management of continuous insulin infusions after cardiac surgery: A systematic review and meta-analysis. Intensive Crit Care Nurs 2016; 39:37-44. [PMID: 27956247 DOI: 10.1016/j.iccn.2016.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 08/18/2016] [Accepted: 08/21/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To investigate the effectiveness of computerised insulin dosing calculators for the management of continuous insulin infusions in adult patients who underwent cardiac surgery. METHOD A systematic review was conducted. The CINAHL, MEDLINE and Cochrane databases were searched for primary studies that compared a computerised insulin dosing calculator to a paper protocol. The main outcome measures were mean Blood Glucose Level (BGL), time to achieve BGL target range, time spent within BGL target range, the incidence of hyperglycaemia and the incidence of hypoglycaemia. RESULTS Five studies were included in the final review. Pooled data demonstrated significant improvements in mean BGL (MD -14.24, 95% CI -26.93 to -1.55), p=0.03 and significantly lower rates of hypoglycaemia (OR 0.038, 95% CI: 0.16-0.90), p=0.03 amongst the computer calculator groups in comparison to the paper protocol groups. No significant difference in the incidence of severe hypoglycaemia was demonstrated (OR 0.21, 95% CI 0.02-1.79), p=0.15. No difference was found in time (hours) to reach target blood glucose range (MD -1.47, 95% CI -3.75 to 0.81), p=0.21. CONCLUSION There is some evidence to support the use of computerised insulin dosing calculators for insulin infusion management within critical care environments.
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Affiliation(s)
- Megan H Higgs
- Centre for Research in Nursing and Health, St. George Hospital, Kogarah, Sydney, Australia; Centre for Evidence Based Initiatives in Health Care, A Collaborating Centre of The Joanna Briggs Institute, Australia.
| | - Ritin S Fernandez
- Centre for Research in Nursing and Health, St. George Hospital, Kogarah, Sydney, Australia; Centre for Evidence Based Initiatives in Health Care, A Collaborating Centre of The Joanna Briggs Institute, Australia; School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Australia.
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De Block CEM, Rogiers P, Jorens PG, Schepens T, Scuffi C, Van Gaal LF. A comparison of two insulin infusion protocols in the medical intensive care unit by continuous glucose monitoring. Ann Intensive Care 2016; 6:115. [PMID: 27878572 PMCID: PMC5120161 DOI: 10.1186/s13613-016-0214-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 11/05/2016] [Indexed: 12/12/2022] Open
Abstract
Background Achieving good glycemic control in intensive care units (ICU) requires a safe and efficient insulin infusion protocol (IIP). We aimed to compare the clinical performance of two IIPs (Leuven versus modified Yale protocol) in patients admitted to medical ICU, by using continuous glucose monitoring (CGM). This is a pooled data analysis of two published prospective randomized controlled trials. CGM monitoring was performed in 57 MICU patients (age 64 ± 12 years, APACHE-II score 28 ± 7, non-diabetic/diabetic: 36/21). The main outcome measures were percentage of time in normoglycemia (80–110 mg/dl) and in hypoglycemia (<60 mg/dl), and glycemic variability (standard deviation, coefficient of variation, mean amplitude of glucose excursions, mean of daily differences). Results Twenty-two subjects were treated using the Leuven protocol and 35 by the Yale protocol; >63,000 CGM measurements were available. The percentage of time in normoglycemia (80–110 mg/dl) was higher (37 ± 15 vs. 26 ± 11%, p = 0.001) and percentage of time spent in hypoglycemia was lower (0[0–2] vs. 5[1–8]%, p = 0.001) in the Yale group. Median glycemia did not differ between groups (118[108–128] vs. 128[106–154] mg/dl). Glycemic variability was less pronounced in the Yale group (median SD 28[21–37] vs. 47[31–71] mg/dl, p = 0.001; CV 23[19–31] vs. 36[26–50]%, p = 0.001; MODD 35[26–41] vs. 60[33–94] mg/dl, p = 0.001). However, logistic regression could not identify type of IIP, diabetes status, age, BMI, or APACHE-II score as independent parameters for strict glucose control. Conclusions The Yale protocol provided better average glycemia, more time spent in normoglycemia, less time in hypoglycemia, and less glycemic variability than the Leuven protocol, but was not independently associated with strict glycemic control. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0214-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christophe E M De Block
- Department of Endocrinology, Diabetology and Metabolism, Faculty of Medicine, Antwerp University Hospital and University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium.
| | - Peter Rogiers
- Intensive Care Unit, ZNA, General Hospital Middelheim, Antwerp, Belgium
| | - Philippe G Jorens
- Intensive Care Unit, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Tom Schepens
- Intensive Care Unit, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Cosimo Scuffi
- A. Menarini Diagnostics, Scientific and Technology Affairs, Florence, Italy
| | - Luc F Van Gaal
- Department of Endocrinology, Diabetology and Metabolism, Faculty of Medicine, Antwerp University Hospital and University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium
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Bilal M, Haseeb A, Khan MH, Khetpal A, Saad M, Arshad MH, Dar MI, Hasan N, Rafiq R, Sherwani M, Abbas H, Sultan A, Inam M. Assessment of Blood Glucose and Electrolytes during Cardiopulmonary Bypass in Diabetic and Non-Diabetic Patients of Pakistan. Glob J Health Sci 2016; 8:54312. [PMID: 27157174 PMCID: PMC5064073 DOI: 10.5539/gjhs.v8n9p159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 12/21/2015] [Accepted: 12/10/2015] [Indexed: 01/04/2023] Open
Abstract
Introduction: Perioperative hyperglycemia has been shown to be related to higher levels of morbidity and mortality in patients on cardiopulmonary bypass (CPB) undergoing coronary artery bypass grafting (CABG), both diabetic and non-diabetic. Blood electrolytes, like sodium, potassium, calcium, and chloride play a very important role in the normal functioning of the body and can lead to a variety of clinical disorders if they become deficient. A minimal number of studies have been conducted on the simultaneous perioperative changes in both blood glucose and electrolyte levels during CPB in Pakistan. Therefore, our aim is to record and compare the changes in blood glucose and electrolyte levels during CPB in diabetic and non-diabetic patients. Materials and Methods: This was a prospective, observational study conducted on 200 patients who underwent CABG with CPB, from October 2014 to March 2015. The patients were recruited from the Cardiac Surgery Ward, Civil Hospital Karachi after they complied with the inclusion criteria. Repeated-measures analysis of variance (ANOVA) was used to compare the trend of the changes perioperatively for the two groups. Results: There was no significant difference in changes in blood glucose between the two groups (P = 0.62). The only significant difference detected between the two groups was for PaCO2 (P = 0.001). Besides, further analysis revealed insignificant group differences for the trend changes in other blood electrolytes (P > 0.05). Conclusion: Our findings highlighted that there is no significant difference in blood electrolytes changes and the increase in blood glucose levels between diabetic and non-diabetic patients.
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Abdelmalak BB, Duncan AE, Bonilla A, Yang D, Parra-Sanchez I, Fergany A, Irefin SA, Sessler DI. The intraoperative glycemic response to intravenous insulin during noncardiac surgery: a subanalysis of the DeLiT randomized trial. J Clin Anesth 2016; 29:19-29. [PMID: 26897443 DOI: 10.1016/j.jclinane.2015.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 09/02/2015] [Accepted: 10/12/2015] [Indexed: 01/22/2023]
Abstract
Patient characteristics may affect patients' response to insulin. We examined the impact of body weight and presence of diabetes on the response to insulin during noncardiac surgery. We studied 202 patients who were enrolled in the DeLiT Trial and received intraoperative intravenous insulin. Univariable and multivariable analyses (Bonferroni corrected) assessed the relationship between patient's response to the initial intraoperative I.V. bolus of regular insulin and the factors of interest. Blood glucose concentrations decreased 8.3 ± 10mg/dL (0.46 ± 0.56mmol/L) per unit of I.V. insulin in 30minutes. The response to insulin was similar in patients with or without diabetes (adjusted mean difference [97.5% confidence interval], 0.2 [-3.9, 4.2] mg/dL, 0.01 [-0.22, 0.24] mmol/L; P = .93). No relationship was found between insulin response and body weight (P=0.38). Our results suggest that adjustment for body weight and the presence of diabetes may not improve intraoperative insulin treatment algorithms.
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Affiliation(s)
- Basem B Abdelmalak
- Associate Professor, Department of General Anesthesiology, Cleveland Clinic.
| | - Andra E Duncan
- Assistant Professor, Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH, USA.
| | - Angela Bonilla
- Clinical Research Fellow, Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Dongsheng Yang
- System Analyst, Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Ivan Parra-Sanchez
- Clinical Research Fellow, Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Amr Fergany
- Staff Urologist, Department of Urology, Cleveland Clinic, Cleveland, OH, USA.
| | - Samuel A Irefin
- Associate Professor, Department of General Anesthesiology, Cleveland Clinic.
| | - Daniel I Sessler
- Michael Cudahy Professor, Chair, Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
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Passarelli AJ, Gibbs H, Rowden AM, Efird L, Zink E, Mathioudakis N. Evaluation of a Nurse-Managed Insulin Infusion Protocol. Diabetes Technol Ther 2016; 18:93-9. [PMID: 26583890 PMCID: PMC4808278 DOI: 10.1089/dia.2015.0046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the performance of an insulin infusion protocol targeting a blood glucose (BG) level of 140-180 mg/dL and to characterize protocol adherence. MATERIALS AND METHODS This was a retrospective observational cohort study including patients for whom the protocol was ordered from January 2012 to May 2013. Performance metrics were assessed in all patients and in patients with an initial BG level of ≥200 mg/dL. Protocol adherence was assessed in a random subset of 50 patients without hypoglycemia and in all hypoglycemic patients. RESULTS In patients with an initial BG level of ≥200 mg/dL, the mean time to goal was 7.1 h. The rate of decline of BG level in the first 6 h was 16.4 mg/dL/h. Mean BG level was 167 mg/dL, with 43.9% of BG values within goal and 80.3% between 80 and 199 mg/dL. The rate of hypoglycemic events was 0.14 per 100 h. The mean protocol violation rate was higher in patients with hypoglycemia compared with those without (39.8 vs. 23.5 per 100 h, P = 0.002), and 60.7% of hypoglycemic events were attributable to protocol violations. The protocol violation rate (42.8 vs. 17.6 per 100 h; P < 0.001) and the odds of hypoglycemia (odds ratio = 5.2; 95% confidence interval, 1.6, 16.5) were higher in the cardiac surgery patients compared with other patients. CONCLUSIONS This protocol provides adequate BG control within the clinically acceptable range of 80-199 mg/dL but not within the narrower range of 140-180 mg/dL, with a low incidence of hypoglycemia. Risk factors for hypoglycemia and barriers to protocol adherence in the cardiac surgery population should be elucidated.
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Affiliation(s)
- Andrea J. Passarelli
- Department of Clinical Pharmacy Services, Christiana Care Health System, Newark, Delaware
| | - Haley Gibbs
- Department of Pharmacy, Wake Forest Baptist Medical Center, Winston Salem, North Carolina
| | - Annette M. Rowden
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Leigh Efird
- Department of Pharmacy, New York-Presbyterian Hospital Weill Cornell Medical Center, New York, New York
| | - Elizabeth Zink
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Blaha J, Barteczko-Grajek B, Berezowicz P, Charvat J, Chvojka J, Grau T, Holmgren J, Jaschinski U, Kopecky P, Manak J, Moehl M, Paddle J, Pasculli M, Petersson J, Petros S, Radrizzani D, Singh V, Starkopf J. Space GlucoseControl system for blood glucose control in intensive care patients--a European multicentre observational study. BMC Anesthesiol 2016; 16:8. [PMID: 26801983 PMCID: PMC4722682 DOI: 10.1186/s12871-016-0175-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 01/20/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Glycaemia control (GC) remains an important therapeutic goal in critically ill patients. The enhanced Model Predictive Control (eMPC) algorithm, which models the behaviour of blood glucose (BG) and insulin sensitivity in individual ICU patients with variable blood samples, is an effective, clinically proven computer based protocol successfully tested at multiple institutions on medical and surgical patients with different nutritional protocols. eMPC has been integrated into the B.Braun Space GlucoseControl system (SGC), which allows direct data communication between pumps and microprocessor. The present study was undertaken to assess the clinical performance and safety of the SGC for glycaemia control in critically ill patients under routine conditions in different ICU settings and with various nutritional protocols. METHODS The study endpoints were the percentage of time the BG was within the target range 4.4 - 8.3 mmol.l(-1), the frequency of hypoglycaemic episodes, adherence to the advice of the SGC and BG measurement intervals. BG was monitored, and insulin was given as a continuous infusion according to the advice of the SGC. Nutritional management (enteral, parenteral or both) was carried out at the discretion of each centre. RESULTS 17 centres from 9 European countries included a total of 508 patients, the median study time was 2.9 (1.9-6.1) days. The median (IQR) time-in-target was 83.0 (68.7-93.1) % of time with the mean proposed measurement interval 2.0 ± 0.5 hours. 99.6% of the SGC advices on insulin infusion rate were accepted by the user. Only 4 episodes (0.01% of all BG measurements) of severe hypoglycaemia <2.2 mmol.l(-1) in 4 patients occurred (0.8%; 95% CI 0.02-1.6%). CONCLUSION Under routine conditions and under different nutritional protocols the Space GlucoseControl system with integrated eMPC algorithm has exhibited its suitability for glycaemia control in critically ill patients. TRIAL REGISTRATION ClinicalTrials.gov NCT01523665.
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Affiliation(s)
- Jan Blaha
- Department of Anaesthesiology and Intensive Medicine, 1st Faculty of Medicine, Charles University and General University Hospital Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
| | - Barbara Barteczko-Grajek
- Department of Anaesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland.
| | - Pawel Berezowicz
- Department of Anaesthesiology and Intensive Care Medicine, Vejle Hospital, Vejle, Denmark.
| | - Jiri Charvat
- Internal Medicine Clinic, University Hospital in Motol, Prague, Czech Republic.
| | - Jiri Chvojka
- Medical Department I, Faculty of Medicine in Pilsen, Charles University in Prague and University Hospital in Pilsen, Pilsen, Czech Republic.
| | - Teodoro Grau
- Department of Anaesthesiology and Intensive Care Medicine, Capio Hospital Sur, Madrid, Spain.
| | - Jonathan Holmgren
- Department of Anaesthesiology and Intensive Care Medicine, County Hospital Ryhov, Jönköping, Sweden.
| | - Ulrich Jaschinski
- Department of Anaesthesiology and Surgical Intensive Care Medicine, Klinikum Augsburg, Augsburg, Germany.
| | - Petr Kopecky
- Department of Anaesthesiology and Intensive Medicine, 1st Faculty of Medicine, Charles University and General University Hospital Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
| | - Jan Manak
- Department of Internal Medicine III - Metabolism and Gerontology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Mette Moehl
- Department of Cardiothoracic Anaesthesia and Intensive Care Unit, University Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Jonathan Paddle
- Intensive Care Department, Royal Cornwall Hospital, Truro, UK.
| | - Marcello Pasculli
- Department of Surgical and Intensive Medicine, Siena University Hospital, Siena, Italy.
| | - Johan Petersson
- Department of Anesthesiology and Intensive Care, Karolinska University Hospital Solna, Stockholm, Sweden.
| | - Sirak Petros
- Medical ICU, University Hospital Leipzig, Leipzig, Germany.
| | - Danilo Radrizzani
- Department of Anesthesiology and Intensive Care, Legnano Hospital, Legnano, Italy.
| | - Vinodkumar Singh
- Critical Care Services, Department of Anaesthetics, West Suffollk Hospital NHS Trust, Bury St Edmunds, UK.
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.
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Abstract
PURPOSE The purpose of this evidence-based practice improvement project was to improve patients' blood glucose control after cardiac surgery, specifically aiming to keep blood glucose levels less than 200 mg/dL. BACKGROUND/RATIONALE Glycemic control is essential for wound healing and infection prevention. Multiple factors including the use of corticosteroids and the stress of critical illness put cardiac surgery patients at greater risk for elevated blood glucose levels postoperatively. A Surgical Care Improvement Project measure related to infection prevention calls for the morning blood glucose level (closest to 6:00 AM) to be less than 200 mg/dL on postoperative days 0 to 2. Patients on our cardiothoracic surgery unit were experiencing blood glucose levels greater than benchmark goals. DESCRIPTION A practice improvement effort was designed to decrease the number of blood glucose results greater than 200 mg/dL after cardiac surgery. The clinical nurse specialists for diabetes and cardiac surgery worked with nursing staff and the interdisciplinary team to implement a 4-pronged approach to improve efficiency in care processes: (1) increase frequency of glucose monitoring, (2) improve accessibility of insulin orders, (3) develop delegation protocol to facilitate nurse-initiated insulin infusion, and (4) implement revised insulin infusion protocol. OUTCOMES Hyperglycemia was identified more quickly, and a nurse-initiated protocol prompted more timely use of revised insulin infusion orders and involvement of the diabetes specialty team. Clinically significant improvement in postoperative glycemic control was achieved. CONCLUSIONS Empowering nurses to initiate hyperglycemia treatment and consultation by diabetes specialists may greatly improve efficiency in care processes and clinical outcomes for cardiac surgery patients. IMPLICATIONS Clinical nurse specialists are well positioned to plan and implement interventions that facilitate an evidence-based approach to glycemic management after cardiac surgery.
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Hemmingsen B, Lund SS, Gluud C, Vaag A, Almdal TP, Wetterslev J. WITHDRAWN: Targeting intensive glycaemic control versus targeting conventional glycaemic control for type 2 diabetes mellitus. Cochrane Database Syst Rev 2015; 2015:CD008143. [PMID: 26222248 PMCID: PMC10637254 DOI: 10.1002/14651858.cd008143.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Cochrane Metabolic and Endocrine Disorders Group withdrew this review as of Issue 7, 2015 because the involvement of two authors (C Hemmingsen and SS Lund) being employed in pharmaceutical companies. The authors of the review and the Cochrane Metabolic and Endocrine Disorders Group did not find that this was a breach of the rules of the Cochrane Collaboration at the time when it was published. However, after the publication of the review, the Cochrane Collaboration requested withdrawal of the review due to the employment of the two authors. A new protocol for a review to cover this topic will be published. This will have a new title and a markedly improved protocol fulfilling new and important developments and standards within the Cochrane Collaboration as well as an improved inclusion and search strategy making it necessary to embark on a completely new review project. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Bianca Hemmingsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Søren S Lund
- Boehringer Ingelheim Pharma GmbH & Co. KGIngelheimGermany
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Allan Vaag
- Rigshospitalet and Copenhagen UniversityDepartment of Endocrinology, Diabetes and MetabolismAfsnit 7652København NDenmark2200
| | - Thomas P Almdal
- Copenhagen University Hospital GentofteDepartment of Medicine FHellerupDenmark2900
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
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Patek SD, Ortiz EA, Farhy LS, Lobo JM, Isbell J, Kirby JL, McCall A. Population-Specific Models of Glycemic Control in Intensive Care: Towards a Simulation-Based Methodology for Protocol Optimization. PROCEEDINGS OF THE ... AMERICAN CONTROL CONFERENCE. AMERICAN CONTROL CONFERENCE 2015; 2015:5084-5090. [PMID: 31787804 DOI: 10.1109/acc.2015.7172132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Stress-induced hyperglycemia is common in critically ill patients, where elevated blood glucose and glycemic variability have been found to contribute to infection, slow wound healing, and short-term mortality. Early clinical studies demonstrated improvement in mortality and morbidity resulting from intensive insulin therapy targeting euglycemia. Follow-up clinical studies have shown mixed results suggesting that the risk of hypoglycemia may outweigh the benefits of aggressive glycemic control. None of the prior studies clarify whether euglycemic targets are in themselves harmful, or if the danger lies in the inadequacy of the available methods for achieving desired glycemic outcomes. In this paper, we use a recently developed simulation model of stress hyperglycemia to demonstrate that given an insulin protocol glycemic outcomes are specific to the patient population under consideration, and that there is a need to optimize insulin therapy at the population level. Next, we use the simulator to demonstrate that the performance of Adaptive Proportional Feedback (APF), a popular format for computerized insulin therapy, is sensitive to its parameters, especially to the parameters that govern the aggressiveness of adaptation. Finally, we propose a framework for simulation-based protocol optimization using an objective function that penalizes below-range deviations more heavily than comparable deviations above.
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Affiliation(s)
- Stephen D Patek
- S. D. Patek and E. A. Ortiz are with the Department of Systems and Information Engineering and the University of Virginia Center for Diabetes Technology, University of Virginia, Charlottesville, VA, 22904
| | - E Andy Ortiz
- S. D. Patek and E. A. Ortiz are with the Department of Systems and Information Engineering and the University of Virginia Center for Diabetes Technology, University of Virginia, Charlottesville, VA, 22904
| | - Leon S Farhy
- L. S. Farhy, J. L. Kirby, and A. McCall are with the Department of Medicine in the School of Medicine of the University of Virginia; L. S. Farhy and A. McCall are also affiliated with the University of Virginia Center for Diabetes Technology, University of Virginia, Charlottesville, VA, 22904
| | - Jennifer Mason Lobo
- J. M. Lobo is with the Department of Public Health Sciences in the School of Medicine of the University of Virginia, Charlottesville, VA, 22904
| | - James Isbell
- J. Isbell is with the Department of Surgery in the School of Medicine of the University of Virginia, Charlottesville, VA, 22904
| | - Jennifer L Kirby
- L. S. Farhy, J. L. Kirby, and A. McCall are with the Department of Medicine in the School of Medicine of the University of Virginia; L. S. Farhy and A. McCall are also affiliated with the University of Virginia Center for Diabetes Technology, University of Virginia, Charlottesville, VA, 22904
| | - Anthony McCall
- L. S. Farhy, J. L. Kirby, and A. McCall are with the Department of Medicine in the School of Medicine of the University of Virginia; L. S. Farhy and A. McCall are also affiliated with the University of Virginia Center for Diabetes Technology, University of Virginia, Charlottesville, VA, 22904
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30
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Higgs M, Fernandez R. The effect of insulin therapy algorithms on blood glucose levels in patients following cardiac surgery: a systematic review. ACTA ACUST UNITED AC 2015. [DOI: 10.11124/01938924-201513050-00013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Wilinska ME, Hovorka R. Glucose control in the intensive care unit by use of continuous glucose monitoring: what level of measurement error is acceptable? Clin Chem 2014; 60:1500-9. [PMID: 25294923 DOI: 10.1373/clinchem.2014.225326] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Accuracy and frequency of glucose measurement is essential to achieve safe and efficacious glucose control in the intensive care unit. Emerging continuous glucose monitors provide frequent measurements, trending information, and alarms. The objective of this study was to establish the level of accuracy of continuous glucose monitoring (CGM) associated with safe and efficacious glucose control in the intensive care unit. METHODS We evaluated 3 established glucose control protocols [Yale, University of Washington, and Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR)] by use of computer simulations. Insulin delivery was informed by intermittent blood glucose (BG) measurements or CGM levels with an increasing level of measurement error. Measures of glucose control included mean glucose, glucose variability, proportion of time glucose was in target range, and hypoglycemia episodes. RESULTS Apart from the Washington protocol, CGM with mean absolute relative deviation (MARD) ≤ 15% resulted in similar mean glucose as with the use of intermittent BG measurements. Glucose variability was also similar between CGM and BG-informed protocols. Frequency and duration of hypoglycemia were not worse by use of CGM with MARD ≤ 10%. Measures of glucose control varied more between protocols than at different levels of the CGM error. CONCLUSIONS The efficacy of CGM-informed and BG-informed commonly used glucose protocols is similar, but the risk of hypoglycemia may be reduced by use of CGM with MARD ≤ 10%. Protocol choice has greater influence on glucose control measures than the glucose measurement method.
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Affiliation(s)
- Malgorzata E Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science and Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science and Department of Paediatrics, University of Cambridge, Cambridge, UK.
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Amrein K, Kachel N, Fries H, Hovorka R, Pieber TR, Plank J, Wenger U, Lienhardt B, Maggiorini M. Glucose control in intensive care: usability, efficacy and safety of Space GlucoseControl in two medical European intensive care units. BMC Endocr Disord 2014; 14:62. [PMID: 25074071 PMCID: PMC4118658 DOI: 10.1186/1472-6823-14-62] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/15/2014] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The Space GlucoseControl system (SGC) is a nurse-driven, computer-assisted device for glycemic control combining infusion pumps with the enhanced Model Predictive Control algorithm (B. Braun, Melsungen, Germany). We aimed to investigate the performance of the SGC in medical critically ill patients. METHODS Two open clinical investigations in tertiary centers in Graz, Austria and Zurich, Switzerland were performed. Efficacy was assessed by percentage of time within the target range (4.4-8.3 mmol/L; primary end point), mean blood glucose, and sampling interval. Safety was assessed by the number of hypoglycemic episodes (≤2.2 mmol/L) and the percentage of time spent below this cutoff level. Usability was analyzed with a standardized questionnaire given to involved nursing staff after the trial. RESULTS Forty medical critically ill patients (age, 62 ± 15 years; body mass index, 30.0 ± 8.9 kg/m2; APACHE II score, 24.8 ± 5.4; 27 males; 8 with diabetes) were included for a period of 6.5 ± 3.7 days (n = 20 in each center). The primary endpoint (time in target range 4.4 to 8.3 mmol/l) was reached in 88.3% ± 9.3 of the time and mean arterial blood glucose was 6.7 ± 0.4 mmol/l. The sampling interval was 2.2 ± 0.4 hours. The mean daily insulin dose was 87.2 ± 64.6 IU. The adherence to the given insulin dose advice was high (98.2%). While the percentage of time spent in a moderately hypoglycemic range (2.2 to 3.3 mmol/L) was low (0.07 ± 0.26% of the time), one severe hypoglycemic episode (<2.2 mmol/L) occurred (2.5% of patients or 0.03% of glucose readings). CONCLUSIONS SGC is a safe and efficient method to control blood glucose in critically ill patients as assessed in two European medical intensive care units.
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Affiliation(s)
- Karin Amrein
- Medical University of Graz, Austria, Department of Internal Medicine, Division of Endocrinology and Metabolism, Auenbruggerplatz 15, 8036 Graz, Austria
| | | | | | - Roman Hovorka
- Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Thomas R Pieber
- Medical University of Graz, Austria, Department of Internal Medicine, Division of Endocrinology and Metabolism, Auenbruggerplatz 15, 8036 Graz, Austria
- Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
| | - Johannes Plank
- Medical University of Graz, Austria, Department of Internal Medicine, Division of Endocrinology and Metabolism, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Urs Wenger
- Medical University of Zurich, Department of Internal Medicine, Medical Intensive Care Unit, Zurich, Switzerland
| | - Barbara Lienhardt
- Medical University of Zurich, Department of Internal Medicine, Medical Intensive Care Unit, Zurich, Switzerland
| | - Marco Maggiorini
- Medical University of Zurich, Department of Internal Medicine, Medical Intensive Care Unit, Zurich, Switzerland
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Haluzik M, Mraz M, Kopecky P, Lips M, Svacina S. Glucose control in the ICU: is there a time for more ambitious targets again? J Diabetes Sci Technol 2014; 8:652-7. [PMID: 24876440 PMCID: PMC4764214 DOI: 10.1177/1932296814533847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
During the last 2 decades, the treatment of hyperglycemia in critically ill patients has become one of the most discussed topics in the intensive medicine field. The initial data suggesting significant benefit of normalization of blood glucose levels in critically ill patients using intensive intravenous insulin therapy have been challenged or even neglected by some later studies. At the moment, the need for glucose control in critically ill patients is generally accepted yet the target glucose values are still the subject of ongoing debates. In this review, we summarize the current data on the benefits and risks of tight glucose control in critically ill patients focusing on the novel technological approaches including continuous glucose monitoring and its combination with computer-based algorithms that might help to overcome some of the hurdles of tight glucose control. Since increased risk of hypoglycemia appears to be the major obstacle of tight glucose control, we try to put forward novel approaches that may help to achieve optimal glucose control with low risk of hypoglycemia. If such approaches can be implemented in real-world practice the entire concept of tight glucose control may need to be revisited.
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Affiliation(s)
- Martin Haluzik
- 3rd Department of Medicine, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Milos Mraz
- 3rd Department of Medicine, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Petr Kopecky
- Department of Anaesthesia, Resuscitation and Intensive Medicine, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Michal Lips
- Department of Anaesthesia, Resuscitation and Intensive Medicine, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Stepan Svacina
- 3rd Department of Medicine, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
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Bayoumi I, Al Balas M, Handler SM, Dolovich L, Hutchison B, Holbrook A. The effectiveness of computerized drug-lab alerts: a systematic review and meta-analysis. Int J Med Inform 2014; 83:406-15. [PMID: 24793784 DOI: 10.1016/j.ijmedinf.2014.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 03/17/2014] [Accepted: 03/19/2014] [Indexed: 01/18/2023]
Abstract
BACKGROUND Inadequate lab monitoring of drugs is a potential cause of ADEs (adverse drug events) which is remediable. OBJECTIVES To determine the effectiveness of computerized drug-lab alerts to improve medication-related outcomes. DATA SOURCES Citations from the Computerized Clinical Decision Support System Systematic Review (CCDSSR) and MMIT (Medications Management through Health Information Technology) databases, which had searched MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts from 1974 to March 27, 2013. STUDY SELECTION Randomized controlled trials (RCTs) of clinician-targeted computerized drug lab alerts conducted in any healthcare setting. Two reviewers performed full text review to determine study eligibility. DATA ABSTRACTION A single reviewer abstracted data and evaluated validity of included studies using Cochrane handbook domains. DATA SYNTHESIS Thirty-six studies met the inclusion criteria (25 single drug studies with 22,504 participants, 14 targeting anticoagulation; 11 multi-drug studies with 56,769 participants). ADEs were reported as an outcome in only four trials, all targeting anticoagulants. Computerized drug-lab alerts did not reduce ADEs (OR 0.89, 95% CI 0.79-1.00, p=0.05), length of hospital stay (SMD 0.00, 95%CI -0.93 to 0.93, p=0.055, 1 study), likelihood of hypoglycemia (OR 1.29, 95% CI 0.31-5.37) or likelihood of bleeding, but were associated with increased likelihood of prescribing changes (OR 1.73, 95% CI 1.21-2.47) or lab monitoring (OR 1.47, 95% confidence interval 1.12-1.94) in accordance with the alert. CONCLUSIONS There is no evidence that computerized drug-lab alerts are associated with important clinical benefits, but there is evidence of improvement in selected clinical surrogate outcomes (time in therapeutic range for vitamin K antagonists), and changes in process outcomes (lab monitoring and prescribing decisions).
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Affiliation(s)
- Imaan Bayoumi
- Department of Family Medicine, McMaster University, Canada; Kingston Community Health Centres, Canada; Department of Family Medicine, Queen's University, Canada.
| | - Mosab Al Balas
- Department of Pharmacy, St. Joseph's Health Care Hamilton, Hamilton, Canada
| | - Steven M Handler
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System (VAPHS), Pittsburgh, PA, United States; Center for Health Equity Research and Promotion (CHERP), VAPHS, Pittsburgh, PA, United States
| | - Lisa Dolovich
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Canada; Department of Family Medicine, McMaster University, Canada; Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton, Canada
| | - Brian Hutchison
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Canada; Department of Family Medicine, McMaster University, Canada
| | - Anne Holbrook
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Canada; Division of Clinical Pharmacology & Therapeutics, Department of Medicine, McMaster University, Canada; Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton, Canada
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KOTULAK T, DRAPALOVA J, LIPS M, LACINOVA Z, KRAMAR P, RIHA H, NETUKA I, MALY J, BLAHA J, LINDNER J, SVACINA S, MRAZ M, HALUZIK M. Cardiac Surgery Increases Serum Concentrations of Adipocyte Fatty Acid-Binding Protein and Its mRNA Expression in Circulating Monocytes but Not in Adipose Tissue. Physiol Res 2014; 63:83-94. [DOI: 10.33549/physiolres.932574] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Adipocyte fatty acid binding protein (A-FABP) is a novel adipokine involved in the regulation of lipid and glucose metabolism and inflammation. To evaluate its potential role in the development of postoperative hyperglycemia and insulin resistance we assessed A-FABP serum concentrations and mRNA expression in skeletal and myocardial muscle, subcutaneous and epicardial adipose tissue and peripheral monocytes in 11 diabetic and 20 age- and sex-matched non-diabetic patients undergoing elective cardiac surgery. Baseline serum A-FABP did not differ between the groups (31.1±5.1 vs. 25.9±4.6 ng/ml, p=0.175). Cardiac surgery markedly increased serum A-FABP in both groups with a rapid peak at the end of surgery followed by a gradual decrease to baseline values during the next 48 h with no significant difference between the groups at any timepoint. These trends were analogous to postoperative excursions of plasma glucose, insulin and selected proinflammatory markers. Cardiac surgery increased A-FABP mRNA expression in peripheral monocytes, while no effect was observed in adipose tissue or muscle. Our data suggest that circulating A-FABP might be involved in the development of acute perioperative stress response, insulin resistance and hyperglycemia of critically ill irrespectively of the presence of diabetes mellitus.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - M. HALUZIK
- Third Department of Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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Bothe MK, Dickens L, Reichel K, Tellmann A, Ellger B, Westphal M, Faisal AA. The use of reinforcement learning algorithms to meet the challenges of an artificial pancreas. Expert Rev Med Devices 2014; 10:661-73. [PMID: 23972072 DOI: 10.1586/17434440.2013.827515] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Melanie K Bothe
- Fresenius Kabi Deutschland GmbH, Else-Kröner-Strasse 1, 61352 Bad Homburg, Germany
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Blaha J. Evaluation of blood glucose control in ICU patients with Space GlucoseControl: a European study. Crit Care 2014. [PMCID: PMC4069371 DOI: 10.1186/cc13628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Gillaizeau F, Chan E, Trinquart L, Colombet I, Walton RT, Rège-Walther M, Burnand B, Durieux P. Computerized advice on drug dosage to improve prescribing practice. Cochrane Database Syst Rev 2013:CD002894. [PMID: 24218045 DOI: 10.1002/14651858.cd002894.pub3] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Maintaining therapeutic concentrations of drugs with a narrow therapeutic window is a complex task. Several computer systems have been designed to help doctors determine optimum drug dosage. Significant improvements in health care could be achieved if computer advice improved health outcomes and could be implemented in routine practice in a cost-effective fashion. This is an updated version of an earlier Cochrane systematic review, first published in 2001 and updated in 2008. OBJECTIVES To assess whether computerized advice on drug dosage has beneficial effects on patient outcomes compared with routine care (empiric dosing without computer assistance). SEARCH METHODS The following databases were searched from 1996 to January 2012: EPOC Group Specialized Register, Reference Manager; Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Ovid; EMBASE, Ovid; and CINAHL, EbscoHost. A "top up" search was conducted for the period January 2012 to January 2013; these results were screened by the authors and potentially relevant studies are listed in Studies Awaiting Classification. The review authors also searched reference lists of relevant studies and related reviews. SELECTION CRITERIA We included randomized controlled trials, non-randomized controlled trials, controlled before-and-after studies and interrupted time series analyses of computerized advice on drug dosage. The participants were healthcare professionals responsible for patient care. The outcomes were any objectively measured change in the health of patients resulting from computerized advice (such as therapeutic drug control, clinical improvement, adverse reactions). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality. We grouped the results from the included studies by drug used and the effect aimed at for aminoglycoside antibiotics, amitriptyline, anaesthetics, insulin, anticoagulants, ovarian stimulation, anti-rejection drugs and theophylline. We combined the effect sizes to give an overall effect for each subgroup of studies, using a random-effects model. We further grouped studies by type of outcome when appropriate (i.e. no evidence of heterogeneity). MAIN RESULTS Forty-six comparisons (from 42 trials) were included (as compared with 26 comparisons in the last update) including a wide range of drugs in inpatient and outpatient settings. All were randomized controlled trials except two studies. Interventions usually targeted doctors, although some studies attempted to influence prescriptions by pharmacists and nurses. Drugs evaluated were anticoagulants, insulin, aminoglycoside antibiotics, theophylline, anti-rejection drugs, anaesthetic agents, antidepressants and gonadotropins. Although all studies used reliable outcome measures, their quality was generally low.This update found similar results to the previous update and managed to identify specific therapeutic areas where the computerized advice on drug dosage was beneficial compared with routine care:1. it increased target peak serum concentrations (standardized mean difference (SMD) 0.79, 95% CI 0.46 to 1.13) and the proportion of people with plasma drug concentrations within the therapeutic range after two days (pooled risk ratio (RR) 4.44, 95% CI 1.94 to 10.13) for aminoglycoside antibiotics;2. it led to a physiological parameter more often within the desired range for oral anticoagulants (SMD for percentage of time spent in target international normalized ratio +0.19, 95% CI 0.06 to 0.33) and insulin (SMD for percentage of time in target glucose range: +1.27, 95% CI 0.56 to 1.98);3. it decreased the time to achieve stabilization for oral anticoagulants (SMD -0.56, 95% CI -1.07 to -0.04);4. it decreased the thromboembolism events (rate ratio 0.68, 95% CI 0.49 to 0.94) and tended to decrease bleeding events for anticoagulants although the difference was not significant (rate ratio 0.81, 95% CI 0.60 to 1.08). It tended to decrease unwanted effects for aminoglycoside antibiotics (nephrotoxicity: RR 0.67, 95% CI 0.42 to 1.06) and anti-rejection drugs (cytomegalovirus infections: RR 0.90, 95% CI 0.58 to 1.40);5. it tended to reduce the length of time spent in the hospital although the difference was not significant (SMD -0.15, 95% CI -0.33 to 0.02) and to achieve comparable or better cost-effectiveness ratios than usual care;6. there was no evidence of differences in mortality or other clinical adverse events for insulin (hypoglycaemia), anaesthetic agents, anti-rejection drugs and antidepressants.For all outcomes, statistical heterogeneity quantified by I(2) statistics was moderate to high. AUTHORS' CONCLUSIONS This review update suggests that computerized advice for drug dosage has some benefits: it increases the serum concentrations for aminoglycoside antibiotics and improves the proportion of people for which the plasma drug is within the therapeutic range for aminoglycoside antibiotics.It leads to a physiological parameter more often within the desired range for oral anticoagulants and insulin. It decreases the time to achieve stabilization for oral anticoagulants. It tends to decrease unwanted effects for aminoglycoside antibiotics and anti-rejection drugs, and it significantly decreases thromboembolism events for anticoagulants. It tends to reduce the length of hospital stay compared with routine care while comparable or better cost-effectiveness ratios were achieved.However, there was no evidence that decision support had an effect on mortality or other clinical adverse events for insulin (hypoglycaemia), anaesthetic agents, anti-rejection drugs and antidepressants. In addition, there was no evidence to suggest that some decision support technical features (such as its integration into a computer physician order entry system) or aspects of organization of care (such as the setting) could optimize the effect of computerized advice.Taking into account the high risk of bias of, and high heterogeneity between, studies, these results must be interpreted with caution.
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Affiliation(s)
- Florence Gillaizeau
- French Cochrane Center, Hôpital Hôtel-Dieu, 1 place du Parvis Notre-Dame, Paris, France, 75004
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Hemmingsen B, Lund SS, Gluud C, Vaag A, Almdal TP, Hemmingsen C, Wetterslev J. Targeting intensive glycaemic control versus targeting conventional glycaemic control for type 2 diabetes mellitus. Cochrane Database Syst Rev 2013:CD008143. [PMID: 24214280 DOI: 10.1002/14651858.cd008143.pub3] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with type 2 diabetes mellitus (T2D) have an increased risk of cardiovascular disease and mortality compared to the background population. Observational studies report an association between reduced blood glucose and reduced risk of both micro- and macrovascular complications in patients with T2D. Our previous systematic review of intensive glycaemic control versus conventional glycaemic control was based on 20 randomised clinical trials that randomised 29 ,986 participants with T2D. We now report our updated review. OBJECTIVES To assess the effects of targeted intensive glycaemic control compared with conventional glycaemic control in patients with T2D. SEARCH METHODS Trials were obtained from searches of The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS, and CINAHL (all until December 2012). SELECTION CRITERIA We included randomised clinical trials that prespecified targets of intensive glycaemic control versus conventional glycaemic control targets in adults with T2D. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias and extracted data. Dichotomous outcomes were assessed by risk ratios (RR) and 95% confidence intervals (CI). Health-related quality of life and costs of intervention were assessed with standardized mean differences (SMD) and 95% Cl. MAIN RESULTS Twenty-eight trials with 34,912 T2D participants randomised 18,717 participants to intensive glycaemic control versus 16,195 participants to conventional glycaemic control. Only two trials had low risk of bias on all risk of bias domains assessed. The duration of the intervention ranged from three days to 12.5 years. The number of participants in the included trials ranged from 20 to 11,140. There were no statistically significant differences between targeting intensive versus conventional glycaemic control for all-cause mortality (RR 1.00, 95% CI 0.92 to 1.08; 34,325 participants, 24 trials) or cardiovascular mortality (RR 1.06, 95% CI 0.94 to 1.21; 34,177 participants, 22 trials). Trial sequential analysis showed that a 10% relative risk reduction could be refuted for all-cause mortality. Targeting intensive glycaemic control did not show a statistically significant effect on the risks of macrovascular complications as a composite outcome in the random-effects model, but decreased the risks in the fixed-effect model (random RR 0.91, 95% CI 0.82 to 1.02; and fixed RR 0.93, 95% CI 0.87 to 0.99; P = 0.02; 32,846 participants, 14 trials). Targeting intensive versus conventional glycaemic control seemed to reduce the risks of non-fatal myocardial infarction (RR 0.87, 95% CI 0.77 to 0.98; P = 0.02; 30,417 participants, 14 trials), amputation of a lower extremity (RR 0.65, 95% CI 0.45 to 0.94; P = 0.02; 11,200 participants, 11 trials), as well as the risk of developing a composite outcome of microvascular diseases (RR 0.88, 95% CI 0.82 to 0.95; P = 0.0008; 25,927 participants, 6 trials), nephropathy (RR 0.75, 95% CI 0.59 to 0.95; P = 0.02; 28,096 participants, 11 trials), retinopathy (RR 0.79, 95% CI 0.68 to 0.92; P = 0.002; 10,300 participants, 9 trials), and the risk of retinal photocoagulation (RR 0.77, 95% CI 0.61 to 0.97; P = 0.03; 11,212 participants, 8 trials). No statistically significant effect of targeting intensive glucose control could be shown on non-fatal stroke, cardiac revascularization, or peripheral revascularization. Trial sequential analyses did not confirm a reduction of the risk of non-fatal myocardial infarction but confirmed a 10% relative risk reduction in favour of intensive glycaemic control on the composite outcome of microvascular diseases. For the remaining microvascular outcomes, trial sequential analyses could not establish firm evidence for a 10% relative risk reduction. Targeting intensive glycaemic control significantly increased the risk of mild hypoglycaemia, but substantial heterogeneity was present; severe hypoglycaemia (RR 2.18, 95% CI 1.53 to 3.11; 28,794 participants, 12 trials); and serious adverse events (RR 1.06, 95% CI 1.02 to 1.10; P = 0.007; 24,280 participants, 11 trials). Trial sequential analysis for a 10% relative risk increase showed firm evidence for mild hypoglycaemia and serious adverse events and a 30% relative risk increase for severe hypoglycaemia when targeting intensive versus conventional glycaemic control. Overall health-related quality of life, as well as the mental and the physical components of health-related quality of life did not show any statistical significant differences. AUTHORS' CONCLUSIONS Although we have been able to expand the number of participants by 16% in this update, we still find paucity of data on outcomes and the bias risk of the trials was mostly considered high. Targeting intensive glycaemic control compared with conventional glycaemic control did not show significant differences for all-cause mortality and cardiovascular mortality. Targeting intensive glycaemic control seemed to reduce the risk of microvascular complications, if we disregard the risks of bias, but increases the risk of hypoglycaemia and serious adverse events.
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Affiliation(s)
- Bianca Hemmingsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen, Denmark, DK-2100
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Maasoumi G, Saberi K. Comparison of blood electrolytes and glucose during cardiopulmonary bypass in diabetic and non-diabetic patients. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2013; 18:322-5. [PMID: 24124430 PMCID: PMC3793378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 01/25/2013] [Accepted: 02/26/2013] [Indexed: 12/04/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) during coronary artery bypass grafting is thought to contribute significantly to increased blood glucose level and altered blood electrolytes balance during the operation. In this (CABG) study, blood electrolytes and glucose during CPB in insulin-dependent diabetic and non-diabetic patients were assessed with special emphasis on the trend of the changes. MATERIALS AND METHODS Blood glucose and electrolytes were assessed in 30 insulin-dependent diabetic and 30 non-diabetic patients, classified as class II and III American Society of Anesthesiologist, before, during, and after CPB. Repeated-measures analysis of variance (ANOVA) was used to compare the trend of the changes during CPB for the two groups. RESULTS The trend in blood glucose level did not show any significant difference between two groups (P = 0.59). For other blood factors, no significant between-group difference was detected except for PaCO2 (P = 0.002). CONCLUSION The study suggested that the changes in blood electrolytes and the increase in blood glucose level do not differ between insulin dependent diabetic and non-diabetic patients.
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Affiliation(s)
- Golamreza Maasoumi
- Department of Cardiac Anesthesiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Kianoush Saberi
- Department of Cardiac Anesthesiology, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Cardiac Anesthesiology, Tehran University of Medical Science, Isfahan, Iran
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Marvin MR, Inzucchi SE, Besterman BJ. Computerization of the Yale insulin infusion protocol and potential insights into causes of hypoglycemia with intravenous insulin. Diabetes Technol Ther 2013; 15:246-52. [PMID: 23289409 PMCID: PMC3696925 DOI: 10.1089/dia.2012.0277] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The management of critically ill hyperglycemic patients in the intensive care unit (ICU) has been fraught with recent controversy. Only one randomized trial has demonstrated a mortality benefit to intensive glycemic control, with all subsequent studies failing to confirm this benefit and revealing a markedly increased risk of severe hypoglycemia (SH) in intensively treated patients. In most of these trials, adherence to the protocols were neither tracked nor reported. METHODS A retrospective analysis of all patients admitted to an ICU who were treated with an insulin infusion directed by the GlucoCare™ IGC System, an FDA-cleared insulin-dosing calculator (Yale 100-140 mg/dL protocol). Mean blood glucose (BG) levels, time to target range and incidence of SH (<40 mg/dL) and moderate hypoglycemia (MH) (40-69 mg/dL) were determined, and potential causes of hypoglycemic episodes were assessed. RESULTS Mean post-target BG was approximately 123 mg/dL. Of >55,000 readings in 1,657 patients, overall incidence of SH was 0.01% of readings and 0.3% of patients. MH occurred in 1.1% of readings and 17.6% of patients. The top potential causes of MH were: (1) Protocol-directed recommendations including continuation of insulin with BG <100 mg/dL and decreases in the frequency of BG checks (63.7%), and (2) Staff non-adherence to protocol directives (15.3%). CONCLUSIONS The results of the GlucoCare-directed Yale 100-140 mg/dL protocol experience revealed an extremely low incidence of SH and an incidence of MH of 1.1%. The incidence of SH in this study was lower than the control group of the NICE-SUGAR study and are supportive of the new Society of Critical Care guidelines to target BG levels of 100-150 mg/dL in critically ill patients. Further refinements to the original protocol and emphasis on staff adherence to protocol directives could potentially further reduce these very low hypoglycemia rates.
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Affiliation(s)
- Michael R Marvin
- Hiram C. Polk Department of Surgery, University of Louisville, Louisville, KY 40202, USA.
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The use of continuous glucose monitoring combined with computer-based eMPC algorithm for tight glucose control in cardiosurgical ICU. BIOMED RESEARCH INTERNATIONAL 2013; 2013:186439. [PMID: 23555075 PMCID: PMC3595106 DOI: 10.1155/2013/186439] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 12/19/2012] [Accepted: 12/20/2012] [Indexed: 12/27/2022]
Abstract
AIM In postcardiac surgery patients, we assessed the performance of a system for intensive intravenous insulin therapy using continuous glucose monitoring (CGM) and enhanced model predictive control (eMPC) algorithm. METHODS Glucose control in eMPC-CGM group (n = 12) was compared with a control (C) group (n = 12) treated by intravenous insulin infusion adjusted according to eMPC protocol with a variable sampling interval alone. In the eMPC-CGM group glucose measured with a REAL-Time CGM system (Guardian RT) served as input for the eMPC adjusting insulin infusion every 15 minutes. The accuracy of CGM was evaluated hourly using reference arterial glucose and Clarke error-grid analysis (C-EGA). Target glucose range was 4.4-6.1 mmol/L. RESULTS Of the 277 paired CGM-reference glycemic values, 270 (97.5%) were in clinically acceptable zones of C-EGA and only 7 (2.5%) were in unacceptable D zone. Glucose control in eMPC-CGM group was comparable to C group in all measured values (average glycemia, percentage of time above, within, and below target range,). No episode of hypoglycemia (<2.9 mmol) occurred in eMPC-CGM group compared to 2 in C group. CONCLUSION Our data show that the combination of eMPC algorithm with CGM is reliable and accurate enough to test this approach in a larger study population.
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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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Leelarathna L, English SW, Thabit H, Caldwell K, Allen JM, Kumareswaran K, Wilinska ME, Nodale M, Mangat J, Evans ML, Burnstein R, Hovorka R. Feasibility of fully automated closed-loop glucose control using continuous subcutaneous glucose measurements in critical illness: a randomized controlled trial. Crit Care 2013; 17:R159. [PMID: 23883613 PMCID: PMC4056260 DOI: 10.1186/cc12838] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 07/24/2013] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Closed-loop (CL) systems modulate insulin delivery according to glucose levels without nurse input. In a prospective randomized controlled trial, we evaluated the feasibility of an automated closed-loop approach based on subcutaneous glucose measurements in comparison with a local sliding-scale insulin-therapy protocol. METHODS Twenty-four critically ill adults (predominantly trauma and neuroscience patients) with hyperglycemia (glucose, ≥10 mM) or already receiving insulin therapy, were randomized to receive either fully automated closed-loop therapy (model predictive control algorithm directing insulin and 20% dextrose infusion based on FreeStyle Navigator continuous subcutaneous glucose values, n = 12) or a local protocol (n = 12) with intravenous sliding-scale insulin, over a 48-hour period. The primary end point was percentage of time when arterial blood glucose was between 6.0 and 8.0 mM. RESULTS The time when glucose was in the target range was significantly increased during closed-loop therapy (54.3% (44.1 to 72.8) versus 18.5% (0.1 to 39.9), P = 0.001; median (interquartile range)), and so was time in wider targets, 5.6 to 10.0 mM and 4.0 to 10.0 mM (P ≤ 0.002), reflecting a reduced glucose exposure >8 and >10 mM (P ≤ 0.002). Mean glucose was significantly lower during CL (7.8 (7.4 to 8.2) versus 9.1 (8.3 to 13.0] mM; P = 0.001) without hypoglycemia (<4 mM) during either therapy. CONCLUSIONS Fully automated closed-loop control based on subcutaneous glucose measurements is feasible and may provide efficacious and hypoglycemia-free glucose control in critically ill adults. TRIAL REGISTRATION ClinicalTrials.gov Identifier, NCT01440842.
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Affiliation(s)
- Lalantha Leelarathna
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Shane W English
- Neurosciences Critical Care Unit, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Hood Thabit
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Karen Caldwell
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Janet M Allen
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Kavita Kumareswaran
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Malgorzata E Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Marianna Nodale
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Jasdip Mangat
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Mark L Evans
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Rowan Burnstein
- Neurosciences Critical Care Unit, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
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Buchleitner AM, Martínez-Alonso M, Hernández M, Solà I, Mauricio D. Perioperative glycaemic control for diabetic patients undergoing surgery. Cochrane Database Syst Rev 2012:CD007315. [PMID: 22972106 DOI: 10.1002/14651858.cd007315.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with diabetes mellitus are at increased risk of postoperative complications. Data from randomised clinical trials and meta-analyses point to a potential benefit of intensive glycaemic control, targeting near-normal blood glucose, in patients with hyperglycaemia (with and without diabetes mellitus) being submitted to surgical procedures. However, there is limited evidence concerning this question in patients with diabetes mellitus undergoing surgery. OBJECTIVES To assess the effects of perioperative glycaemic control for diabetic patients undergoing surgery. SEARCH METHODS Trials were obtained from searches of The Cochrane Library, MEDLINE, EMBASE, LILACS, CINAHL and ISIS (all up to February 2012). SELECTION CRITERIA We included randomised controlled clinical trials that prespecified different targets of perioperative glycaemic control (intensive versus conventional or standard care) DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. We summarised studies using meta-analysis or descriptive methods. MAIN RESULTS Twelve trials randomised 694 diabetic participants to intensive control and 709 diabetic participants to conventional glycaemic control. The duration of the intervention ranged from just the duration of the surgical procedure up to 90 days. The number of participants ranged from 13 to 421, and the mean age was 64 years. Comparison of intensive with conventional glycaemic control demonstrated the following results for our predefined primary outcomes: analysis restricted to studies with low or unclear detection or attrition bias for infectious complications showed a risk ratio (RR) of 0.46 (95% confidence interval (CI) 0.18 to 1.18), P = 0.11, 627 participants, eight trials, moderate quality of the evidence (grading of recommendations assessment, development and evaluation - (GRADE)). Evaluation of death from any cause revealed a RR of 1.19 (95% CI 0.89 to 1.59), P = 0.24, 1365 participants, 11 trials, high quality of the evidence (GRADE).On the basis of a posthoc analysis, there is the hypothesis that intensive glycaemic control may increase the risk of hypoglycaemic episodes if longer-term outcome measures are analysed (RR 6.92, 95% CI 2.04 to 23.41), P = 0.002, 724 patients, three trials, low quality of the evidence (GRADE). Analysis of our predefined secondary outcomes revealed the following findings: cardiovascular events had a RR of 1.03 (95% CI 0.21 to 5.13), P = 0.97, 682 participants, six trials, moderate quality of the evidence (GRADE) when comparing the two treatment modalities; and renal failure also did not show significant differences between intensive and regular glucose control (RR 0.61, 95% CI 0.34 to 1.08), P = 0.09, 434 participants, two trials, moderate quality of the evidence (GRADE). We did not meta-analyse length of hospital stay and intensive care unit (ICU) stay due to substantial unexplained heterogeneity. Mean differences between intensive and regular glucose control groups ranged from -1.7 days to 2.1 days for ICU stay and between -8 days to 3.7 days for hospital stay (moderate quality of the evidence (GRADE)). One trial assessed health-related quality of life in 12/37 (32.4%) of participants in the intervention group and 13/44 (29.5%) of participants in the control group, and did not show an important difference (low quality of the evidence (GRADE)) in the measured physical health composite score of the short-form 12-item health survey (SF-12). None of the trials examined the effects of the interventions in terms of costs. AUTHORS' CONCLUSIONS The included trials did not demonstrate significant differences for most of the outcomes when targeting intensive perioperative glycaemic control compared with conventional glycaemic control in patients with diabetes mellitus. However, posthoc analysis indicated that intensive glycaemic control was associated with an increased number of patients experiencing hypoglycaemic episodes. Intensive glycaemic control protocols with near-normal blood glucose targets for patients with diabetes mellitus undergoing surgical procedures are currently not supported by an adequate scientific basis. We suggest that insulin treatment regimens, patient- and health-system relevant outcomes, and time points for outcome measures should be defined in a thorough and uniform way in future studies.
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Affiliation(s)
- Ana Maria Buchleitner
- Department of Endocrinology and Nutrition, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida(IRBLLEIDA), Lleida, Spain
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Abstract
The mechanisms for hyperglycemia-mediated harm in the hospitalized cardiac patient are poorly understood. Potential obstacles in the inpatient management of hyperglycemia in cardiac patients include rapidly changing clinical status, frequent procedures and interruptions in carbohydrate exposure, and short hospital length of stay. A patient's preadmission regimen is rarely suitable for inpatient glycemic control. Instead, an approach to a flexible, physiologic insulin regimen is described, which is intended to minimize glycemic excursions. When diabetes or hyperglycemia is addressed early and consistently, the hospital stay can serve as a potential window of opportunity for reinforcing self-care behaviors that reduce long-term complications.
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Affiliation(s)
- Jared Moore
- Department of Internal Medicine, The Ohio State University, 2050 Kenny Road, Columbus, OH 43221-3502, USA
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Amrein K, Ellmerer M, Hovorka R, Kachel N, Fries H, von Lewinski D, Smolle K, Pieber TR, Plank J. Efficacy and safety of glucose control with Space GlucoseControl in the medical intensive care unit--an open clinical investigation. Diabetes Technol Ther 2012; 14:690-5. [PMID: 22694176 DOI: 10.1089/dia.2012.0021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND We aimed to investigate the performance of the Space GlucoseControl system (SGC) (B. Braun, Melsungen, Germany) in medical critically ill patients. The SGC is a nurse-driven, computer-assisted device for glycemic control combining infusion pumps with the enhanced Model Predictive Control algorithm. SUBJECTS AND METHODS The trial was designed as a single-center, open clinical investigation in a nine-bed medical intensive care unit in a tertiary center in Graz, Austria. Efficacy was assessed by percentage of time within the target range (4.4-8.3 mmol/L; primary end point), mean blood glucose, and sampling interval. Safety was assessed by the number of hypoglycemic episodes (≤2.2 mmol/L). RESULTS Twenty mechanically ventilated patients (age, 63±16 years; body mass index, 31.0±10.7 kg/m(2); Acute Physiology and Chronic Health Evaluation II score, 25.4±6.3; 14 males; six with diabetes) were included for a period of 7.0±3.6 days. Time within target range was 83.4±8.9% (mean±SD), and mean arterial blood glucose was 6.8±0.4 mmol/L. No severe hypoglycemic episodes (<2.2 mmol/L) occurred, and the percentage of time within 2.2 and 3.3 mmol/L was low (0.03±0.07%). The sampling interval was 2.0±0.4 h. The mean insulin dose was 93.5±80.1 IU/day, and the adherence to the given insulin dose advice was high (98.3%). A total of 11 unintended therapy interruptions (0.08 events/treatment day) caused by software problems occurred in four patients. CONCLUSIONS SGC is a safe and efficient method to control blood glucose in critically ill patients in the medical intensive care unit.
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Affiliation(s)
- Karin Amrein
- Division of Endocrinology and Metabolism, Medical University of Graz, Auenbruggerplatz 15, Graz, Austria.
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Dumont C, Bourguignon C. Effect of a computerized insulin dose calculator on the process of glycemic control. Am J Crit Care 2012; 21:106-15. [PMID: 22381987 DOI: 10.4037/ajcc2012956] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Glycemic control is important to patients' outcomes. However, the process of maintaining glycemic control is risk laden and labor intensive for nurses. OBJECTIVES To examine the effects of using a computerized insulin dose calculator to facilitate management of glycemic control for critically ill cardiac patients. METHODS A prospective randomized controlled trial was conducted with a sample of 300 intensive care patients, 141 randomized to the calculator group and 159 in the control (paper protocol) group. A convenience sample of 44 intensive care nurses responded to a nurse satisfaction survey. RESULTS A significantly higher percentage of glucose measurements were in the target range in the calculator group than in the control group (70.4% [SD, 15.2%] vs 61.6% [SD, 17.9%], Z = -4.423, P < .001), and glucose variance was significantly less in the calculator group (35.5 [SD, 18.3] mg/dL vs 42.3 [SD, 21.2] mg/dL, Z = -3.845, P < .001). Fewer hypoglycemic events occurred in the calculator group (7 vs 18), although this difference was not statistically significant. Nurse satisfaction was higher for the calculator group than for the control group (8.4 [SD, 1.4] vs 4.8 [SD, 2.4], Z = -5.055, P < .001). Nurses' deviation from the protocol was also less in the calculator group than in the control group. CONCLUSIONS Management of glycemic control and nurse satisfaction were improved with use of the dose calculator. Improving nurses' processes of care may improve nurses' use of time and patient care overall. Studies with larger sample sizes over time are needed to determine these relationships.
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Affiliation(s)
- Cheryl Dumont
- Cheryl Dumont is director of nursing research and vascular access at Winchester Medical Center in Winchester, Virginia. Cheryl Bourguignon is a statistician and a faculty member in the Center for the Study of Complementary and Alternative Therapies at the University of Virginia School of Nursing in Charlottesville
| | - Cheryl Bourguignon
- Cheryl Dumont is director of nursing research and vascular access at Winchester Medical Center in Winchester, Virginia. Cheryl Bourguignon is a statistician and a faculty member in the Center for the Study of Complementary and Alternative Therapies at the University of Virginia School of Nursing in Charlottesville
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Abstract
BACKGROUND The practice of glycemic control with intravenous insulin in critically ill patients has brought clinical focus on understanding the effects of hypoglycemia, especially in children. Very little is published on the impact of hypoglycemia in this population. We aimed to review the existing literature on hypoglycemia in critically ill neonates and children. METHODS We performed a systematic review of the literature up to August 2011 using PubMed, Ovid MEDLINE and ISI Web of Science using the search terms "hypoglycemia or hypoglyc*" and "critical care or intensive care or critical illness". Articles were limited to "all child (0-18 years old)" and "English". RESULTS A total of 513 articles were identified and 132 were included for review. Hypoglycemia is a significant concern among pediatric and neonatal intensivists. Its definition is complicated by the use of a biochemical measure (i.e., blood glucose) for a pathophysiologic problem (i.e., neuroglycopenia). Based on associated outcomes, we suggest defining hypoglycemia as <40-45 mg/dl in neonates and <60-65 mg/dl in children. Below the suggested threshold values, hypoglycemia is associated with worse neurological outcomes, increased intensive care unit stay, and increased mortality. Disruptions in carbohydrate metabolism increase the risk of hypoglycemia incritically ill children. Prevention of hypoglycemia, especially in the setting of intravenous insulin use, will be best accomplished by the combination of accurate measuring techniques, frequent or continuous glucose monitoring, and computerized insulin titration protocols. CONCLUSION Studies on hypoglycemia in critically ill children have focused on spontaneous hypoglycemia. With the current practice of maintaining blood glucose within a narrow range with intravenous insulin, the risk factors and outcomes associated with insulin-induced hypoglycemia should be rigorously studied to prevent hypoglycemia and potentially improve outcomes of critically ill children.
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Hemmingsen B, Lund SS, Gluud C, Vaag A, Almdal T, Hemmingsen C, Wetterslev J. Intensive glycaemic control for patients with type 2 diabetes: systematic review with meta-analysis and trial sequential analysis of randomised clinical trials. BMJ 2011; 343:d6898. [PMID: 22115901 PMCID: PMC3223424 DOI: 10.1136/bmj.d6898] [Citation(s) in RCA: 246] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2011] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the effect of targeting intensive glycaemic control versus conventional glycaemic control on all cause mortality and cardiovascular mortality, non-fatal myocardial infarction, microvascular complications, and severe hypoglycaemia in patients with type 2 diabetes. DESIGN Systematic review with meta-analyses and trial sequential analyses of randomised trials. DATA SOURCES Cochrane Library, Medline, Embase, Science Citation Index Expanded, LILACS, and CINAHL to December 2010; hand search of reference lists and conference proceedings; contacts with authors, relevant pharmaceutical companies, and the US Food and Drug Administration. STUDY SELECTION Randomised clinical trials comparing targeted intensive glycaemic control with conventional glycaemic control in patients with type 2 diabetes. Published and unpublished trials in all languages were included, irrespective of predefined outcomes. DATA EXTRACTION Two reviewers independently assessed studies for inclusion and extracted data related to study methods, interventions, outcomes, risk of bias, and adverse events. Risk ratios with 95% confidence intervals were estimated with fixed and random effects models. RESULTS Fourteen clinical trials that randomised 28,614 participants with type 2 diabetes (15,269 to intensive control and 13,345 to conventional control) were included. Intensive glycaemic control did not significantly affect the relative risks of all cause (1.02, 95% confidence interval 0.91 to 1.13; 28,359 participants, 12 trials) or cardiovascular mortality (1.11, 0.92 to 1.35; 28,359 participants, 12 trials). Trial sequential analyses rejected a relative risk reduction above 10% for all cause mortality and showed insufficient data on cardiovascular mortality. The risk of non-fatal myocardial infarction may be reduced (relative risk 0.85, 0.76 to 0.95; P=0.004; 28,111 participants, 8 trials), but this finding was not confirmed in trial sequential analysis. Intensive glycaemic control showed a reduction of the relative risks for the composite microvascular outcome (0.88, 0.79 to 0.97; P=0.01; 25,600 participants, 3 trials) and retinopathy (0.80, 0.67 to 0.94; P=0.009; 10,793 participants, 7 trials), but trial sequential analyses showed that sufficient evidence had not yet been reached. The estimate of an effect on the risk of nephropathy (relative risk 0.83, 0.64 to 1.06; 27,769 participants, 8 trials) was not statistically significant. The risk of severe hypoglycaemia was significantly increased when intensive glycaemic control was targeted (relative risk 2.39, 1.71 to 3.34; 27,844 participants, 9 trials); trial sequential analysis supported a 30% increased relative risk of severe hypoglycaemia. CONCLUSION Intensive glycaemic control does not seem to reduce all cause mortality in patients with type 2 diabetes. Data available from randomised clinical trials remain insufficient to prove or refute a relative risk reduction for cardiovascular mortality, non-fatal myocardial infarction, composite microvascular complications, or retinopathy at a magnitude of 10%. Intensive glycaemic control increases the relative risk of severe hypoglycaemia by 30%.
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Affiliation(s)
- Bianca Hemmingsen
- Copenhagen Trial Unit, Center for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Denmark.
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