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Chu C, Li J, Yang X, Zhao H, Wu Z, Xu R, Gao J. Continuous glucose monitoring versus conventional glucose monitoring in the ICU: A randomized controlled trial. J Crit Care 2024; 84:154894. [PMID: 39106581 DOI: 10.1016/j.jcrc.2024.154894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 07/20/2024] [Accepted: 07/29/2024] [Indexed: 08/09/2024]
Abstract
PURPOSE This study evaluated the clinical utility of continuous glucose monitoring system (CGMS) in critically ill patients. METHODS In this randomized controlled trial, we randomly assigned critically ill participants with diabetes or stress-induced hyperglycemia to the CGMS group (n = 48) or to the conventional point-of-care monitoring (POCM) group (n = 48). The glucose values and clinical outcome were compared between the two group. The primary endpoint was 28-day mortality after intensive care unit admission. RESULTS The 28-day mortality was not significantly different between the CGMS and POCM group (20.8% vs 31.3%, P = 0.25). The mean glucose, time-weighted average glucose, glucose standard deviation and time in range (3.9-10.0) were significantly improved in the CGMS group (all P < 0.05). CONCLUSION Compared with conventional POCM, CGMS did not decrease the 28-day mortality in critically ill participants with diabetes or stress-induced hyperglycemia. But CGMS may improve the glycemic control and may be increasingly used in critically ill patients.
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Affiliation(s)
- Chen Chu
- Department of Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jian Li
- Department of Anesthesiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - XiaoDong Yang
- Department of Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - HuiJing Zhao
- Department of Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - ZaiXian Wu
- Department of Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - RuoXin Xu
- Department of Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - JianLing Gao
- Department of Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; Department of Intensive Care Unit of Anesthesia, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.
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Huang M, Yang R, Zhang C, Gan X. Staff knowledge, attitudes and practices regarding glycaemic management in adult intensive care units: A national survey. Nurs Crit Care 2023; 28:931-939. [PMID: 37902982 DOI: 10.1111/nicc.12838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hyperglycaemia is common in critically ill adult patients. Many studies have identified the content, methods, and effects of glycaemic control but have not explored the effects of knowledge, attitudes, and practices (KAP) on glycaemic control in critically ill adults. Various factors also influence the KAP of intensive care unit (ICU) staff. AIMS To assess KAP regarding glucose management for critically ill adults among nurses and medical professionals and identify the factors that influence their KAP in ICUs. METHODS A multicentre cross-sectional survey. RESULTS In total, 403/459 (response rate: 87.8%) participants from ICUs in nine tertiary hospitals in China participated in this study, 82.4% of whom were female and 93.4% of whom were nurses. The mean work experience was 8.88 years, and the mean critical care experience was 6.59 years. The scoring rate for the three dimensions of knowledge, attitudes, and practices were 82.35%, 87.69%, and 76%, respectively. We did not find any other factors affecting the KAP scores except for the level of knowledge awareness (p < 0.001), awareness of the importance (p < 0.001), and training for glucose control (p = 0.004). CONCLUSION ICU staff KAP regarding glycaemic control in critically ill adults among ICU professionals were acceptable in China. However, ICU professionals' current knowledge regarding nutrition, glucose variability, and skills related to glucose management could be improved. RELEVANCE TO CLINICAL PRACTICE ICU educators should provide more skills-related training for healthcare professionals in the glycaemic management of critically ill adults. Moreover, the process of managing blood glucose in adult ICU patients is a collaborative, multidisciplinary team effort, with monitoring and feedback required during implementation.
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Affiliation(s)
- Miao Huang
- School of Nursing, Chongqing Medical University, Chongqing, China
- Department of Nursing, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ruiqi Yang
- Department of Nursing, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chuanlai Zhang
- Gneral ICU, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiuni Gan
- Department of Nursing, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Albert SG, Shrestha E, Wood EM. Euglycemic diabetic ketoacidosis: The paradox of delayed correction of acidosis. Diabetes Metab Syndr 2023; 17:102848. [PMID: 37651890 DOI: 10.1016/j.dsx.2023.102848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE The effectiveness of standard treatment for diabetic ketoacidosis (DKA) in "euglycemic DKA" (EuDKA, blood glucose (BG) ≤ 250 mg/dL) was evaluated with respect to the time to correction of BG ≤ 200 mg/dL, anion gap (AG)≤12 mmol/L, and serum bicarbonate [HCO3] ≥18 mmol/L. METHODS Data were retrieved from an electronic health record (EPIC) for "diabetic ketoacidosis." Patients were categorized by initial BG as EuDKA, middle range DKA (MrDKA, >250 < 600 mg/dL) and hyperosmolar DKA (HyperDKA ≥600 mg/dL). RESULTS There were 56 patients (27men, 29women; age 45.8 ± 15.6 (SD) years. The initial 8-h insulin infusion rate (0.05 ± 0.02, 0.09 ± 0.03, 0.14 ± 0.05units/kg/h, p < 0.001) and the time to correction of BG (3.4 ± 1.9, 6.1 ± 2.9 and 9.6 ± 3.9 h, p < 0.001), differed for EuDKA, MrDKA and HyperDKA. There were no differences in the time to correction of AG or [HCO3]. The earlier time to correction of BG in EuDKA resulted in paradoxical longer lag times for correction of [HCO3] (p = 0.003) and AG (p = 0.048). Changes in BG, AG and [HCO3] correlated with insulin infusion rates of 0.08-0.1units/kg/h whereas in EuDKA the insulin infusion rate was 0.05 ± 0.02 units/kg/h. CONCLUSION In EuDKA, correlation analyses suggest that higher glucose and insulin infusion rates than what would be projected for the level of blood glucose are required to reverse ketoacidosis. Prospective trials are required to optimize the levels of glucose and insulin infusions in EuDKA.
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Affiliation(s)
- Stewart G Albert
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States.
| | - Ekta Shrestha
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States
| | - Emily M Wood
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States
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Sundarsingh V, Poddar B, Saran S, Jena SK, Azim A, Gurjar M, Singh RK, Baronia AK. Glucometrics in the first week of critical illness and its association with mortality. Med Intensiva 2023; 47:326-337. [PMID: 36344343 DOI: 10.1016/j.medine.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/05/2022] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Evaluation of glucometrics in the first week of ICU stay and its association with outcomes. DESIGN Prospective observational study. SETTING Mixed ICU of teaching hospital. PATIENTS Adults initiated on insulin infusion for 2 consecutive blood glucose (BG) readings ≥180mg/dL. MAIN VARIABLES OF INTEREST Glucometrics calculated from the BG of first week of admission: hyperglycemia (BG>180mg/dL) and hypoglycemia (BG<70mg/dL) episodes; median, standard deviation (SD) and coefficient of variation (CV) of BG, glycemic lability index (GLI), time in target BG range (TIR). Factors influencing glucometrics and the association of glucometrics to patient outcomes analyzed. RESULTS A total of 5762 BG measurements in 100 patients of median age 55 years included. Glucometrics: hyperglycemia: 2253 (39%), hypoglycemia: 28 (0.48%), median BG: 169mg/dL (162-178.75), SD 31mg/dL (26-38.75), CV 18.6% (17.1-22.5), GLI: 718.5 [(mg/dL)2/h]/week (540.5-1131.5) and TIR 57% (50-67). Diabetes and higher APACHE II score were associated with higher SD and CV, and lower TIR. On multivariate regression, diabetes (p=0.009) and APACHE II score (p=0.016) were independently associated with higher SD. Higher SD and CV were associated with less vasopressor-free days; lower TIR with more blood-stream infections (BSI). Patients with higher SD, CV and GLI had a higher 28-day mortality. On multivariate analysis, GLI alone was associated with a higher mortality (OR 2.99, p=0.04). CONCLUSIONS Glycemic lability in the first week in ICU patients receiving insulin infusion is associated with higher mortality. Lower TIR is associated with more blood stream infections.
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Affiliation(s)
- V Sundarsingh
- Department of Critical Care Medicine, Father Muller Medical College Hospital, Mangalore, India
| | - B Poddar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| | - S Saran
- Department of Critical Care Medicine, King George Medical University, Lucknow, India
| | - S K Jena
- Department of Critical Care Medicine, Kalinga Institute of Medical Sciences, Bhuvaneswar, India
| | - A Azim
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - M Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - R K Singh
- Department of Emergency Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - A K Baronia
- Government Medical College, Pithoragarh, India
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Mader JK, Brix JM, Aberer F, Vonbank A, Resl M, Hochfellner DA, Ress C, Pieber TR, Stechemesser L, Sourij H. [Hospital diabetes management (Update 2023)]. Wien Klin Wochenschr 2023; 135:242-255. [PMID: 37101046 PMCID: PMC10133359 DOI: 10.1007/s00508-023-02177-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/28/2023]
Abstract
This position statement presents the recommendations of the Austrian Diabetes Association for diabetes management of adult patients during inpatient stay. It is based on the current evidence with respect to blood glucose targets, insulin therapy and treatment with oral/injectable antidiabetic drugs during inpatient hospitalization. Additionally, special circumstances such as intravenous insulin therapy, concomitant therapy with glucocorticoids and use of diabetes technology during hospitalization are discussed.
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Affiliation(s)
- Julia K Mader
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich.
| | - Johanna M Brix
- Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
| | - Felix Aberer
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Alexander Vonbank
- Innere Medizin I mit Kardiologie, Angiologie, Endokrinologie, Diabetologie und Intensivmedizin, Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Michael Resl
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
| | - Daniel A Hochfellner
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Claudia Ress
- Innere Medizin, Department I, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Thomas R Pieber
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Lars Stechemesser
- Universitätsklinik für Innere Medizin I, Paracelsus Medizinische Privatuniversität - Landeskrankenhaus, Salzburg, Österreich
| | - Harald Sourij
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
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Chazal E, Parmentier AL, Pili-Floury S, Bouhaddi M, Borot S, Perrotti A, Vettoretti L, Trajkovski J, Ferreira D, Zanoni C, Samain E, Besch G, Salomon du Mont L. Perioperative blood glucose variability and autonomic nervous system activity in on-pump cardiac surgery patients: Study protocol of a single-center observational study. Medicine (Baltimore) 2022; 101:e31821. [PMID: 36451410 PMCID: PMC9704965 DOI: 10.1097/md.0000000000031821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION On-pump coronary artery bypass graft (CABG) and surgical valve replacement (SVR) are high-risk procedures. Several studies reported that perioperative blood glucose (BG) variability was independently associated with impaired postoperative outcome. However, the underlying mechanisms contributing to increased perioperative BG variability and to its deleterious impact remain unknown. The hypothesis of the study is that perioperative BG variability could be related to perioperative alteration of the autonomic nervous system (ANS) activity and to preoperative BG variability. METHODS AND ANALYSIS We designed a prospective observational single-center study. Four groups of 30 patients will be studied: group 1, including insulin-requiring type 2 diabetic patients undergoing on-pump CABG; group 2, including non-insulin-requiring type 2 diabetic patients undergoing on-pump CABG; group 3, including non-diabetic patients undergoing aortic SVR; and group 4, including non-diabetic patient undergoing on-pump CABG. Preoperative (baseline) and postoperative BG variability will be quantified using the Abbott's Freestyle Libre Pro sensor allowing for continuous subcutaneous BG monitoring. Preoperative (baseline) and postoperative ANS activity will be measured using noninvasive continuous heart rate monitoring (Mooky HR memory®). Blood level and urinary concentration of inflammatory and endothelial dysfunction biomarkers will be measured from blood and urinary samples at the end of the surgery and on postoperative day 1 and 2. The primary objective is to describe the relationship between baseline BG variability and postoperative BG variability. The secondary objectives are to describe the relationship: between baseline and postoperative BG variability according to the diabetes phenotype and to the type of surgery; between the ANS activity and the BG variability; and between postoperative BG variability and, urinary and blood biomarkers.
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Affiliation(s)
- Etienne Chazal
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, and EA 3920, University of Franche-Comte, Besancon, France
| | - Anne-Laure Parmentier
- Clinical Methodology Center, INSERM CIC 1431, University Hospital of Besancon, and UMR 6249 Chrono Environment, University of Franche-Comte, Besancon, France
| | - Sebastien Pili-Floury
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, and EA 3920, University of Franche-Comte, Besancon, France
| | - Malika Bouhaddi
- Department of Physiology, Functional Investigations, University Hospital of Besancon, and EA 3920, University of Franche-Comte, Besancon, France
| | - Sophie Borot
- Department of Endocrinology, Metabolism, Diabetes and Nutrition, University Hospital of Besancon, Besancon, France
| | - Andrea Perrotti
- Department of Cardiac Surgery, University Hospital of Besancon, and EA 3920, University of Franche-Comte, Besancon, France
| | - Lucie Vettoretti
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France
| | - Julian Trajkovski
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France
| | - David Ferreira
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, and EA 481 Neuroscience, University of Bourgogne Franche-Comte, Besancon, France
| | - Chloe Zanoni
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, and EA 481 Neuroscience, University of Bourgogne Franche-Comte, Besancon, France
| | - Emmanuel Samain
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, and EA 3920, University of Franche-Comte, Besancon, France
| | - Guillaume Besch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, and EA 3920, University of Franche-Comte, Besancon, France
| | - Lucie Salomon du Mont
- Department of Vascular Surgery University Hospital of Besancon, and EA 3920, University of Franche-Comte, Besancon, France
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Blonde L, Umpierrez GE, Reddy SS, McGill JB, Berga SL, Bush M, Chandrasekaran S, DeFronzo RA, Einhorn D, Galindo RJ, Gardner TW, Garg R, Garvey WT, Hirsch IB, Hurley DL, Izuora K, Kosiborod M, Olson D, Patel SB, Pop-Busui R, Sadhu AR, Samson SL, Stec C, Tamborlane WV, Tuttle KR, Twining C, Vella A, Vellanki P, Weber SL. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract 2022; 28:923-1049. [PMID: 35963508 PMCID: PMC10200071 DOI: 10.1016/j.eprac.2022.08.002] [Citation(s) in RCA: 154] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. METHODS The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. RESULTS This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes. CONCLUSIONS This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
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Affiliation(s)
| | | | - S Sethu Reddy
- Central Michigan University, Mount Pleasant, Michigan
| | | | | | | | | | | | - Daniel Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, California
| | | | | | - Rajesh Garg
- Lundquist Institute/Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | | | - Darin Olson
- Colorado Mountain Medical, LLC, Avon, Colorado
| | | | | | - Archana R Sadhu
- Houston Methodist; Weill Cornell Medicine; Texas A&M College of Medicine; Houston, Texas
| | | | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | | | - Katherine R Tuttle
- University of Washington and Providence Health Care, Seattle and Spokane, Washington
| | | | | | | | - Sandra L Weber
- University of South Carolina School of Medicine-Greenville, Prisma Health System, Greenville, South Carolina
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Rovida S, Bruni A, Pelaia C, Bosco V, Saraco G, Galluzzo E, Froio A, Auletta G, Garofalo E, Longhini F. Nurse led protocols for control of glycaemia in critically ill patients: A systematic review. Intensive Crit Care Nurs 2022; 71:103247. [PMID: 35437186 DOI: 10.1016/j.iccn.2022.103247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Blood glucose control in critically ill patients is challenging and can affect clinical outcomes. Several manual as well as automated approaches have been proposed over the time, however nursing staff still covers the key-role for optimization of glycemia throughout adjustment of insulin infusion and administration. AIM Systematic review to compare the efficacy/the effects of nurse led insulin infusion protocols versus standard approaches in patients admitted in the intensive care unit. METHODS All relevant studies evaluating nurse directed protocols for insulin administration in critically ill adults. Data was independently extracted and collected through a dedicated electronic form. The following outcomes have been recorded: the number (or percentage) of glycaemia measurements within the target range; the number of hypo- and hyper-glycaemic events, separately; the mean glycaemia; the lowest and highest glycemia values recorded; the time to reach the glycaemia target; the ICU length of stay and the ICU and the long-term (>30 days) mortality. Statistical analysis was conducted on the summary statistics of the selected articles (eg, means, medians, proportions). Unpaired nonparametric continuous data were compared through the Mann-Whitney U-test. RESULTS Glycaemic control as well as ICU length of stay and mortality are similar in both patients' groups. Specifically, the group of patients treated with standard modalities include those treated with doctors led protocols, paper charts or software-based approaches. CONCLUSION Overall, nurse led insulin protocols can effectively control blood glucose level among critically ill patients.
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Affiliation(s)
- Serena Rovida
- Department of Emergency Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Andrea Bruni
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Corrado Pelaia
- Department of Health Sciences, Magna Graecia University, Catanzaro, Italy
| | - Vincenzo Bosco
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Giuseppe Saraco
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Erika Galluzzo
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Annamaria Froio
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Gaetano Auletta
- School of Nursing, Department of Translational Medicine, Eastern Piedmont University, Novara, Italy
| | - Eugenio Garofalo
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.
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Sundarsingh V, Poddar B, Saran S, Jena S, Azim A, Gurjar M, Singh R, Baronia A. Glucometrics in the first week of critical illness and its association with mortality. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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10
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Chatley MM, Thuyns MR. Safety and Efficacy of an Intensive Care Insulin Infusion Protocol Targeting a Blood Glucose of 140 to 180 mg/dL. Ann Pharmacother 2022; 56:10600280221074683. [PMID: 35168404 DOI: 10.1177/10600280221074683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite multiple guideline recommendations of a goal blood glucose of 140 to 180 mg/dL in critically ill patients, no insulin infusion protocols (IIPs) targeting this range have been validated and published in the literature. OBJECTIVE The purpose of this study is to determine the safety and efficacy of an IIP targeting a blood glucose of 140 to 180 mg/dL in critically ill patients, with the ultimate goal of validating such a protocol. METHODS This retrospective chart review uses data of critically ill patients admitted from August 2018 to December 2018. Patient data from August 2017 to December 2017 served as a historical comparator to further assess safety outcomes. Percent of blood glucose readings within goal was the primary outcome measurement. Relevant clinical variables, insulin requirements, hypoglycemic events, and protocol adherence were also recorded. RESULTS A total of 88 insulin infusions were included in analysis, 34 of which served as a historical comparator. In the IIP targeting a blood glucose 140 to 180 mg/dL, once blood glucose levels decreased below 180 mg/dL, 54% of blood glucose readings were within goal (140-180 mg/dL) and 73% of blood glucose readings were within a "clinically acceptable" range (110-180 mg/dL). The number of hypoglycemic events decreased from 70 in the historical comparator group to 4 in the current IIP (P < .0001). CONCLUSION AND RELEVANCE This IIP is both safe and effective at targeting a blood glucose of 140 to 180 mg/dL and could be used at other institutions to achieve satisfactory glycemic control.
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Bogun M, Beier MA, Singh SK, McLaughlin D, Ning Y, Kurlansky P, Raza ST. Diabetes workshops for providers improve glucose control in coronary artery bypass grafting patients. J Card Surg 2022; 37:930-936. [DOI: 10.1111/jocs.16282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 11/22/2021] [Accepted: 01/07/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Magdalena Bogun
- Division of Endocrinology, Department of Medicine Columbia University Irving Medical Center New York City New York USA
| | - Mathew A. Beier
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery Columbia University Irving Medical Center New York City New York USA
| | - Sameer K. Singh
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery Columbia University Irving Medical Center New York City New York USA
| | - Denise McLaughlin
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery Columbia University Irving Medical Center New York City New York USA
| | - Yuming Ning
- Department of Surgery Center for Innovation and Outcomes Research, Columbia University Irving Medical Center New York City New York USA
| | - Paul Kurlansky
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery Columbia University Irving Medical Center New York City New York USA
| | - Syed T. Raza
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery Columbia University Irving Medical Center New York City New York USA
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Johansson I, Dicembrini I, Mannucci E, Cosentino F. Glucose-lowering therapy in patients undergoing percutaneous coronary intervention. EUROINTERVENTION 2021; 17:e618-e630. [PMID: 34596567 PMCID: PMC9724943 DOI: 10.4244/eij-d-20-01250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 01/08/2023]
Abstract
The number of individuals with diabetes and pre-diabetes is constantly increasing. These conditions are overrepresented in patients undergoing percutaneous coronary intervention and are associated with adverse prognosis. Optimal glycaemic control during an acute coronary syndrome is a relevant factor for the improvement of longer-term outcomes. In addition, the implementation of newer glucose-lowering drugs with proven cardiovascular benefits has a remarkable impact on recurrence of events, hospitalisations for heart failure and mortality. In this narrative review, we outline the current state-of-the art recommendations for glucose-lowering therapy in patients with diabetes undergoing coronary intervention. In addition, we discuss the most recent evidence-based indications for revascularisation in patients with diabetes as well as the targets for glycaemic control post revascularisation. Current treatment goals for concomitant risk factor control are also addressed. Lastly, we acknowledge the presence of knowledge gaps in need of future research.
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Affiliation(s)
- Isabelle Johansson
- Cardiology Unit, Department of Medicine Solna, Karolinska Institute Heart & Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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Goyal A, Mathew UE, Golla KK, Mannar V, Kubihal S, Gupta Y, Tandon N. A practical guidance on the use of intravenous insulin infusion for management of inpatient hyperglycemia: Intravenous Insulin Infusion for Management of Inpatient Hyperglycemia. Diabetes Metab Syndr 2021; 15:102244. [PMID: 34425556 DOI: 10.1016/j.dsx.2021.102244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/05/2021] [Accepted: 08/07/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND We aim to provide a practical guidance on the use of intravenous insulin infusion for managing inpatient hyperglycemia. METHODS AND RESULTS This document was formulated based on the review of available literature and personal experience of authors. We have used various case scenarios to illustrate variables which should be taken into account when deciding adjustments in infusion rate, including but not restricted to ambient blood glucose level and magnitude of blood glucose change in the previous hour. CONCLUSION The guidance can be generalized to any situation where dedicated protocols are lacking, trained manpower is not available and resource constraints are present.
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Affiliation(s)
- Alpesh Goyal
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Uthara Elsa Mathew
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Kiran Kumar Golla
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Velmurugan Mannar
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Suraj Kubihal
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Yashdeep Gupta
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India.
| | - Nikhil Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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Efficacy and safety of a new insulin infusion protocol adapted for the target glycemic range of 140–180 mg/dl in adult critical care units: a tertiary care centre experience. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-020-00915-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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15
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Suggested Canadian Standards for Perioperative/Periprocedure Glycemic Management in Patients With Type 1 and Type 2 Diabetes. Can J Diabetes 2021; 46:99-107.e5. [PMID: 34210609 DOI: 10.1016/j.jcjd.2021.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 03/25/2021] [Accepted: 04/26/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVES The goal of this quality initiative was to develop consensus standards for glycemic management of patients with diabetes who undergo surgical procedures in Canada. METHODS A modified Delphi method was used to gather broad stakeholder input and arrive at a consensus for perioperative/periprocedure diabetes management. RESULTS Glycemic management standards were developed for the following categories: Organization of Care; Preoperative Assessment; Immediate Preoperative and Intraoperative; Postanesthesia Care Unit or Recovery Room; Postoperative Period; and Transition to Outpatient Care. CONCLUSIONS It is anticipated these standards will serve as a basis to develop clinical tools to support the recommendations.
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Emidio AC, Faria R, Bispo B, Vaz-Pinto V, Messias A, Meneses-Oliveira C. GlucoSTRESS - A project to optimize glycemic control in a level C (III) Portuguese intensive care unit. Rev Bras Ter Intensiva 2021; 33:138-145. [PMID: 33886863 PMCID: PMC8075347 DOI: 10.5935/0103-507x.20210015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 06/17/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To double the percentage of time within the 100 - 180mg/dL blood glucose range in the first three months following a phased implementation of a formal education program, and then, of an insulin therapy protocol, without entailing an increased incidence of hypoglycemia. Methods The pre-intervention glycemic control was assessed retrospectively. Next, were carried out the implementation of a formal education program, distribution of manual algorithms for intravenous insulin therapy - optimized by the users, based on the modified Yale protocol - and informal training of the nursing staff. The use of electronic blood glucose control systems was supported, and the results were recorded prospectively. Results The first phase of the program (formal education) lead to improvement of the time within the euglycemic interval (28% to 37%). In the second phase, euglycemia was achieved 66% of the time, and the incidence of hypoglycemia was decreased. The percentage of patients on intravenous insulin infusion at 48 hours from admission increased from 6% to 35%. Conclusion The phased implementation of a formal education program, fostering the use of electronic insulin therapy protocols and dynamic manuals, received good adherence and has shown to be safe and effective for blood glucose control in critically ill patients, with a concomitant decrease in hypoglycemia.
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Affiliation(s)
- Ana Catarina Emidio
- Serviço de Medicina Interna, Centro Hospitalar de Setúbal - Setúbal, Portugal
| | - Rita Faria
- Serviço de Medicina Intensiva, Hospital Beatriz Ângelo - Loures, Lisboa, Portugal
| | - Bruno Bispo
- Serviço de Medicina Intensiva, Hospital Beatriz Ângelo - Loures, Lisboa, Portugal
| | - Vítor Vaz-Pinto
- Serviço de Medicina Intensiva, Hospital Beatriz Ângelo - Loures, Lisboa, Portugal
| | - António Messias
- Serviço de Medicina Intensiva, Hospital Beatriz Ângelo - Loures, Lisboa, Portugal
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Rao RH, Perreiah PL, Cunningham CA. Monitoring the Impact of Aggressive Glycemic Intervention during Critical Care after Cardiac Surgery with a Glycemic Expert System for Nurse-Implemented Euglycemia: The MAGIC GENIE Project. J Diabetes Sci Technol 2021; 15:251-264. [PMID: 33650454 PMCID: PMC8256075 DOI: 10.1177/1932296821995568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A novel, multi-dimensional protocol named GENIE has been in use for intensive insulin therapy (IIT, target glucose <140 mg/dL) in the surgical intensive care unit (SICU) after open heart surgery (OHS) at VA Pittsburgh since 2005. Despite concerns over increased mortality from IIT after the publication of the NICE-SUGAR Trial, it remains in use, with ongoing monitoring under the MAGIC GENIE Project showing that GENIE performance over 12 years (2005-2016) aligns with the current consensus that IIT with target blood glucose (BG) <140 mg/dL is advisable only if it does not provoke severe hypoglycemia (SH). Two studies have been conducted to monitor glucometrics and outcomes during GENIE use in the SICU. One compares GENIE (n = 382) with a traditional IIT protocol (FORMULA, n = 289) during four years of contemporaneous use (2005-2008). The other compares GENIE's impact overall (n = 1404) with a cohort of patients who maintained euglycemia after OHS (euglycemic no-insulin [ENo-I], n = 111) extending across 12 years (2005-2016). GENIE performed significantly better than FORMULA during contemporaneous use, maintaining lower time-averaged glucose, provoking less frequent, severe, prolonged, or repetitive hypoglycemia, and achieving 50% lower one-year mortality, with no deaths from mediastinitis (0 of 8 cases vs 4 of 9 on FORMULA). Those benefits were sustained over the subsequent eight years of exclusive use in OHS patients, with an overall one-year mortality rate (4.2%) equivalent to the ENo-I cohort (4.5%). The results of the MAGIC GENIE Project show that GENIE can maintain tight glycemic control without provoking SH in patients undergoing OHS, and may be associated with a durable survival benefit. The results, however, await confirmation in a randomized control trial.
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Affiliation(s)
- R. Harsha Rao
- Division of Endocrinology, Medicine
Service Line, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- R. Harsha Rao, MD, FRCP, Professor of
Medicine and Chief of Endocrinology, VA Pittsburgh Healthcare System, Room
7W-109 VAPHS, University Drive Division, Pittsburgh, PA 15240, USA. Emails:
;
| | - Peter L. Perreiah
- Division of Endocrinology, Medicine
Service Line, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Candace A. Cunningham
- Division of Endocrinology, Medicine
Service Line, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Adlar F, Anthony W. Spontaneous Pneumothorax as a Complication in Concomitant Diabetic Ketoacidosis and Pulmonary Tuberculosis: A Case Report. CASE REPORTS IN ACUTE MEDICINE 2021. [DOI: 10.1159/000513324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Secondary spontaneous pneumothorax (SSP) can occur as a complication of several underlying diseases such as pulmonary tuberculosis (TB) or, rarely, diabetic ketoacidosis (DKA). As diabetes mellitus (DM) is significantly prevalent in tuberculosis patients, it is possible to have both TB and DKA concurrently. However, there has not been any documentation of SSP as a complication in concomitant DKA and pulmonary TB. In this report, we described a 30-year-old female who presented to the emergency department with a chief complaint of shortness of breath that had intensified since a day before. She was diagnosed with pulmonary TB 1 week before and had started on her anti-tuberculosis drugs regimen. Prior history of DM was not known. Physical examination showed a slight decrease in consciousness, tachycardia, tachypnea, Kussmaul breathing, decreased lung sounds in the right hemithorax and hyperresonant on percussion. Laboratory results showed leukocytosis and hyperglycemia, ketones were positive on urinalysis and arterial blood gas analysis indicated metabolic acidosis. Chest X-ray revealed pneumothorax in the right hemithorax. She was diagnosed with pneumothorax of the right hemithorax, DKA, sepsis and pulmonary TB. Treatment involved prompt placement of chest tube drainage, fluid rehydration, intravenous insulin, antibiotic, sodium bicarbonate and anti-tuberculosis drugs. Her condition improved after 9 days of uneventful hospitalization. We discussed how concomitant presence of both DKA and pulmonary TB can increase the likelihood of developing secondary spontaneous pneumothorax.
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Lal A, Haque N, Lee J, Katta SR, Maranda L, George S, Trivedi N. Optimal Blood Glucose Monitoring Interval for Insulin Infusion in Critically Ill Non-Cardiothoracic Patients: A Pilot Study. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021036. [PMID: 33682835 PMCID: PMC7975947 DOI: 10.23750/abm.v92i1.9083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 01/05/2020] [Indexed: 11/29/2022]
Abstract
Objective: The American Diabetes Association and the Society of Critical Care Medicine recommend monitoring blood glucose (BG) every 1-2 hours in patients receiving insulin infusion to guide titration of insulin infusion to maintain serum glucose in the target range; however, this is based on weak evidence. We evaluated the compliance of hourly BG monitoring and relation of less frequent BG monitoring to glycemic status. Materials and Methods: Retrospective chart review performed on 56 consecutive adult patients who received intravenous insulin infusion for persistent hyperglycemia in the ICU at Saint Vincent Hospital, a tertiary care community hospital an urban setting in Northeast region of USA. The frequency of fingerstick blood glucose (FSBG) readings was reviewed for compliance with hourly FSBG monitoring per protocol and the impact of FSBG testing at different time intervals on the glycemic status. Depending on time interval of FSBG monitoring, the data was divided into three groups: Group A (<90 min), Group B (91-179 min) and Group C (≥180 min). Results: The mean age was 69 years (48% were males), 77% patients had preexisting type 2 diabetes mellitus (T2DM). The mean MPM II score was 41. Of the 1411 readings for BG monitoring on insulin infusion, 467 (33%) were in group A, 806 (57%) in group B and 138 (10%) in group C; hourly BG monitoring compliance was 12.6%. The overall glycemic status was similar among all groups. There were 14 (0.99%) hypoglycemic episodes observed. The rate of hypoglycemic episodes was similar in all three groups (p=0.55). Conclusion: In patients requiring insulin infusion for sustained hyperglycemia in ICU, the risk of hypoglycemic episodes was not significantly different with less frequent BG monitoring. The compliance to hourly blood glucose monitoring and ICU was variable, and hypoglycemic episodes were similar across the groups despite the variation in monitoring. Significance of the Study: The importance of glycemic control in ICU has been well established and it is a resource intensive venture. However, there are no major studies highlighting the most optimal time interval for blood glucose checks in critically ill patients on insulin infusion. With this study we hypothesize that time duration between blood glucose checks can be increased safely without any untoward effects. Our study provides evidence for effective resource management with reducing the time spent with every glucose check and directly translating into high value care.
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Affiliation(s)
| | - Nurul Haque
- Department of Medicine Merit Health River Region Hospital 2100 US-61, Vicksburg, MS 39183.
| | - Jennifer Lee
- Clinical Pharmacy Coordinator, Critical Care Department of Pharmacy 123 Summer Street Saint Vincent Hospital, Worcester, Massachusetts. USA 01608.
| | - Sai Ramya Katta
- Clinical Pharmacy Coordinator, Critical Care Department of Pharmacy 123 Summer Street Saint Vincent Hospital, Worcester, Massachusetts. USA 01608.
| | - Louise Maranda
- Department of Biostatistics University of Massachusetts Medical School.
| | - Susan George
- Clinical Associate Professor of Medicine University of Massachusetts Medical School Program Director, Internal Medicine Residency Chair, Department of Medicine Performance Improvement Committee 123 Summer Street Saint Vincent Hospital, Worcester, Massachusetts..
| | - Nitin Trivedi
- Director, Division of Endocrinology Associate Program Director, Internal Medicine Residency Department of Medicine, Saint Vincent Hospital Associate Professor of Medicine University of Massachusetts Medical School 123 Summer Street Saint Vincent Hospital, Worcester, Massachusetts.
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McNett M, O'Mathúna D, Tucker S, Roberts H, Mion LC, Balas MC. A Scoping Review of Implementation Science in Adult Critical Care Settings. Crit Care Explor 2020; 2:e0301. [PMID: 33354675 PMCID: PMC7746210 DOI: 10.1097/cce.0000000000000301] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The purpose of this scoping review is to provide a synthesis of the available literature on implementation science in critical care settings. Specifically, we aimed to identify the evidence-based practices selected for implementation, the frequency and type of implementation strategies used to foster change, and the process and clinical outcomes associated with implementation. DATA SOURCES A librarian-assisted search was performed using three electronic databases. STUDY SELECTION Articles that reported outcomes aimed at disseminating, implementing, or sustaining an evidence-based intervention or practice, used established implementation strategies, and were conducted in a critical care unit were included. DATA EXTRACTION Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. DATA SYNTHESIS Of 1,707 citations, 82 met eligibility criteria. Studies included prospective research investigations, quality improvement projects, and implementation science trials. The most common practices investigated were use of a ventilator-associated pneumonia bundle, nutritional support protocols, and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility bundle. A variety of implementation strategies were used to facilitate evidence adoption, most commonly educational meetings, auditing and feedback, developing tools, and use of local opinion leaders. The majority of studies (76/82, 93%) reported using more than one implementation strategy. Few studies specifically used implementation science designs and frameworks to systematically evaluate both implementation and clinical outcomes. CONCLUSIONS The field of critical care has experienced slow but steady gains in the number of investigations specifically guided by implementation science. However, given the exponential growth of evidence-based practices and guidelines in this same period, much work remains to critically evaluate the most effective mechanisms to integrate and sustain these practices across diverse critical care settings and teams.
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Affiliation(s)
- Molly McNett
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Dónal O'Mathúna
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Sharon Tucker
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Haley Roberts
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
| | - Lorraine C Mion
- College of Nursing, The Ohio State University, Columbus, OH
- Center for Healthy Aging, Self Management, and Complex Care, The Ohio State University, Columbus, OH
| | - Michele C Balas
- College of Nursing, The Ohio State University, Columbus, OH
- Center for Healthy Aging, Self Management, and Complex Care, The Ohio State University, Columbus, OH
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Ekanayake PS, Juang PS, Kulasa K. Review of Intravenous and Subcutaneous Electronic Glucose Management Systems for Inpatient Glycemic Control. Curr Diab Rep 2020; 20:68. [PMID: 33165676 DOI: 10.1007/s11892-020-01364-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to summarize current literature on electronic glucose management systems (eGMS) and discuss their benefits and disadvantages in the inpatient setting. RECENT FINDINGS We review different versions of commercially available eGMS: Glucommander™ (Glytec, Greenville, SC), EndoToolR (MD Scientific LLC, Charlotte, NC), GlucoStabilizer™ (Medical Decision Network, Charlottesville, VA), GlucoCare™ (Pronia Medical Systems, KY), and discuss advantages such as reducing rates of hypoglycemia, hyperglycemia, and glycemic variability. In addition, eCGMs offer a uniform standard of care and may improve workflows across institutions as well reduce barriers. Despite ample literature on intravenous (IV) versions of eGMS, there is little published research on subcutaneous (SQ) insulin guidance. Although use of eGMS requires extensive training and institution-wide adoption, time spent on diabetes management is better facilitated by their use.
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Affiliation(s)
- Preethika S Ekanayake
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, San Diego, CA, USA.
| | - Patricia S Juang
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, San Diego, CA, USA
| | - Kristen Kulasa
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, San Diego, CA, USA
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Hasan SS, Kow CS, Bain A, Kavanagh S, Merchant HA, Hadi MA. Pharmacotherapeutic considerations for the management of diabetes mellitus among hospitalized COVID-19 patients. Expert Opin Pharmacother 2020; 22:229-240. [PMID: 33054481 DOI: 10.1080/14656566.2020.1837114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Diabetes mellitus is one of the most prevalent comorbidities identified in patients with coronavirus disease 2019 (COVID-19). This article aims to discuss the pharmacotherapeutic considerations for the management of diabetes in hospitalized patients with COVID-19. AREAS COVERED We discussed various aspects of pharmacotherapeutic management in hospitalized patients with COVID-19: (i) susceptibility and severity of COVID-19 among individuals with diabetes, (ii) glycemic goals for hospitalized patients with COVID-19 and concurrent diabetes, (iii) pharmacological treatment considerations for hospitalized patients with COVID-19 and concurrent diabetes. EXPERT OPINION The glycemic goals in patients with COVID-19 and concurrent type 1 (T1DM) or type 2 diabetes (T2DM) are to avoid disruption of stable metabolic state, maintain optimal glycemic control, and prevent adverse glycemic events. Patients with T1DM require insulin therapy at all times to prevent ketosis. The management strategies for patients with T2DM include temporary discontinuation of certain oral antidiabetic agents and consideration for insulin therapy. Patients with T2DM who are relatively stable and able to eat regularly may continue with oral antidiabetic agents if glycemic control is satisfactory. Hyperglycemia may develop in patients with systemic corticosteroid treatment and should be managed upon accordingly.
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Affiliation(s)
| | - Chia Siang Kow
- School of Postgraduate Studies, International Medical University , Kuala Lumpur, Malaysia
| | - Amie Bain
- Department of Pharmacy, University of Huddersfield , Huddersfield, UK.,Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK
| | - Sallianne Kavanagh
- Department of Pharmacy, University of Huddersfield , Huddersfield, UK.,Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK
| | - Hamid A Merchant
- Department of Pharmacy, University of Huddersfield , Huddersfield, UK
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Lopes RW, Hohl A. After a STEMI, is Less Sugar more Protective to Myocardium? INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2020. [DOI: 10.36660/ijcs.20200173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Gulsen K, Ayca B, Baskurt M, Okcun B, Ersanli MK. Does Tight Glucose Control During the First 24 hours of Hospitalization Reduce Scintigraphic Infarct Size in STEMI Patients? INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2020. [DOI: 10.36660/ijcs.20200020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
BACKGROUND Hyperglycemia is prevalent and is associated with an increase in morbidity and mortality in hospitalized patients. Insulin therapy is the most appropriate method for controlling glycemia in hospital, but is associated with increased risk of hypoglycemia, which is a barrier to achieving glycemic goals. AREAS OF UNCERTAINTY Optimal glycemic targets have not been established in the critical and noncritical hospitalized patients, and there are different modalities of insulin therapy. The primary purpose of this review is to discuss controversy regarding appropriate glycemic targets and summarize the evidence about the safety and efficacy of insulin therapy in critical and noncritical care settings. DATA SOURCES A literature search was conducted through PubMed with the following key words (inpatient hyperglycemia, inpatient diabetes, glycemic control AND critically or non-critically ill patient, Insulin therapy in hospital). RESULTS In critically ill patient, blood glucose levels >180 mg/dL may increase the risk of hospital complications, and blood glucose levels <110 mg/dL have been associated with an increased risk of hypoglycemia. Continuous intravenous insulin infusion is the best method for achieving glycemic targets in the critically ill patient. The ideal glucose goals for noncritically ill patients remain undefined and must be individualized according to the characteristics of the patients. A basal-bolus insulin strategy resulted in better glycemic control than sliding scale insulin and lower risk of hypoglycemia than premixed insulin regimen. CONCLUSIONS Extremes of blood glucose lead to poor outcomes, and target glucose range of 110-180 mg/dL may be appropriate for most critically ill patients and noncritically ill patients. Insulin is the most appropriate pharmacologic agent for effectively controlling glycemia in hospital. A continuous intravenous insulin infusion and scheduled basal-bolus-correction insulin are the preferred modalities for glycemic control in critically and noncritically ill hospitalized patients, respectively.
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Yi D. Letter: An Electronic Health Record-Integrated Computerized Intravenous Insulin Infusion Protocol: Clinical Outcomes and in Silico Adjustment ( Diabetes Metab J 2020;44:56-66). Diabetes Metab J 2020; 44:354-355. [PMID: 32347028 PMCID: PMC7188977 DOI: 10.4093/dmj.2020.0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Dongwon Yi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.
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Canbolat O, Kapucu S, Kilickaya O. Comparison of Routine and Computer-Guided Glucose Management for Glycemic Control in Critically Ill Patients. Crit Care Nurse 2020; 39:20-27. [PMID: 31371364 DOI: 10.4037/ccn2019431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Glycemic control is crucial for reducing morbidity and mortality in critically ill patients. A standardized approach to glycemic control using a computer-guided protocol may help maintain blood glucose level within a target range and prevent human-induced medical errors. OBJECTIVE To determine the effectiveness of a computer-guided glucose management protocol for glycemic control in intensive care patients. METHODS This controlled, open-label implementation study involved 66 intensive care patients: 33 in the intervention group and 33 in the control group. The blood glucose level target range was established as 120 to 180 mg/dL. The control group received the clinic's routine glycemic monitoring approach, and the intervention group received monitoring using newly developed glycemic control software. At the end of the study, nurse perceptions and satisfaction were determined using a questionnaire. RESULTS The rates of hyperglycemia and hypoglycemia were lower and the blood glucose level was more successfully maintained in the target range in the intervention group than in the control group (P < .001). The time to achieve the target range was shorter and less insulin was used in the intervention group than in the control group (P < .05). Nurses reported higher levels of satisfaction with the computerized protocol, which they found to be more effective and reliable than routine clinical practice. CONCLUSIONS The computerized protocol was more effective than routine clinical practice in achieving glycemic control. It was also associated with higher nurse satisfaction levels.
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Affiliation(s)
- Ozlem Canbolat
- Ozlem Canbolat is an assistant professor, Faculty of Nursing, Necmettin Erbakan University, Selçuklu, Konya, Turkey. Sevgisun Kapucu is a professor, Faculty of Nursing, Hacettepe University, Ankara, Turkey. Oguz Kilickaya is an associate professor, Bahcelievler Medical Park Hospital, Istanbul, Turkey.
| | - Sevgisun Kapucu
- Ozlem Canbolat is an assistant professor, Faculty of Nursing, Necmettin Erbakan University, Selçuklu, Konya, Turkey. Sevgisun Kapucu is a professor, Faculty of Nursing, Hacettepe University, Ankara, Turkey. Oguz Kilickaya is an associate professor, Bahcelievler Medical Park Hospital, Istanbul, Turkey
| | - Oguz Kilickaya
- Ozlem Canbolat is an assistant professor, Faculty of Nursing, Necmettin Erbakan University, Selçuklu, Konya, Turkey. Sevgisun Kapucu is a professor, Faculty of Nursing, Hacettepe University, Ankara, Turkey. Oguz Kilickaya is an associate professor, Bahcelievler Medical Park Hospital, Istanbul, Turkey
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Wu S, Furutani E, Sugawara T, Asaga T, Shirakami G. Glycemic Control for Critically Ill Patients with Online Identification of Insulin Sensitivity. ADVANCED BIOMEDICAL ENGINEERING 2020. [DOI: 10.14326/abe.9.43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Sha Wu
- Department of Electrical Engineering, Kyoto University
| | - Eiko Furutani
- Department of Electrical Materials and Engineering, University of Hyogo
- Department of Anesthesiology, Kagawa University
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Barasch N, Romig MC, Demko ZO, Dwyer C, Dietz A, Rosen M, Griffiths SM, Ravitz AD, Pronovost PJ, Sapirstein A. Automation and interoperability of a nurse-managed insulin infusion protocol as a model to improve safety and efficiency in the delivery of high-alert medications. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2019. [DOI: 10.1177/2516043519893228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Noah Barasch
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Mark C Romig
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Zoe O Demko
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Cindy Dwyer
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Aaron Dietz
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Michael Rosen
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Steven M Griffiths
- Applied Physics Laboratory, The Johns Hopkins University, Baltimore, MD, USA
| | - Alan D Ravitz
- Applied Physics Laboratory, The Johns Hopkins University, Baltimore, MD, USA
| | - Peter J Pronovost
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Adam Sapirstein
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA
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Abstract
BACKGROUND Deviations in glucose control in critical care have been shown to increase mortality and morbidity. However, optimal glucose control through present technologies has shown to be a challenge. The insulin balanced infusion system (IBIS) is a new and emerging technology. METHODS The closed loop system was tested in a stress trial to evaluate glucose stability in response to various conditions in nonrandomized people with type 1 diabetes mellitus (n=12). The prototype used in this trial was based on intermittent capillary measurements. RESULTS Induced stresses in the study using unpredicted stimuli of intravenous or oral glucose and intravenous insulin boluses, was contained with glucose remaining in target 43.8% of the time. Mean increase in glucose concentration after glucose load was 17.4 mg/dl; after insulin bolus, no hypoglycemia (blood glucose less than 70 mg/dl) occurred. CONCLUSION The use of IBIS proved safe and feasible under a wide range of conditions. The sensing and stress response of the IBIS demonstrated noticeable features.
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Affiliation(s)
- Nasseh Hashemi
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
- Nasseh Hashemi, BSc, School of Medicine and Health, Aalborg University, Hobrovej 18-22, Aalborg 9100, Denmark.
| | - Tim Valk
- Admetsys Research Center, Orlando, FL, USA
| | - Kim Houlind
- Department of Vascular Surgery, Kolding Hospital, Kolding, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Jutland, Aalborg, Denmark
- Department of Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark
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31
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Breuer TGK, Kampmann K, Wutzler A, Steinfort C, Uhl W, Schmidt WE, Meier JJ. [Severe atypical ketoacidosis due to SGLT2-inhibitor therapy : Two case reports]. Internist (Berl) 2019; 59:282-287. [PMID: 28864828 DOI: 10.1007/s00108-017-0316-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Two female patients were admitted due to ketoacidosis. Serum glucose was moderately elevated. The patients exhibited abdominal and neurologic symptoms. Treatment consisted of metformin, insulin glargin and empagliflozin, as well as glimepiride, insulin detemir and empagliflozin, respectively. Treatment with intravenous fluid replacement, insulin, glucose, potassium and buffer solution led to a normalisation of pH and serum glucose levels. Our report describes two cases of atypical ketoacidosis with moderately elevated serum glucose during sodium-glucose co-transporter-2 (SGLT2) inhibitor therapy.
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Affiliation(s)
- T G K Breuer
- Diabetes-Zentrum Bochum/Hattingen, Katholisches Klinikum Bochum, Klinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
| | - K Kampmann
- Diabetes-Zentrum Bochum/Hattingen, Katholisches Klinikum Bochum, Klinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
| | - A Wutzler
- Abteilung für Elektrophysiologie, St. Josef-Hospital, Ruhr-Universität Bochum, Bochum, Deutschland
| | - C Steinfort
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital, Ruhr-Universität Bochum, Bochum, Deutschland
| | - W Uhl
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital, Ruhr-Universität Bochum, Bochum, Deutschland
| | - W E Schmidt
- Diabetes-Zentrum Bochum/Hattingen, Katholisches Klinikum Bochum, Klinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
| | - J J Meier
- Diabetes-Zentrum Bochum/Hattingen, Katholisches Klinikum Bochum, Klinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland.
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The Efficacy and Safety of an Insulin Infusion Protocol in a Medical Intensive Care Unit at a Tertiary Care Hospital: a Prospective Study. Int J Diabetes Dev Ctries 2019. [DOI: 10.1007/s13410-019-00731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Mader JK, Brix J, Aberer F, Vonbank A, Resl M, Pieber TR, Stechemesser L, Sourij H. [Hospital diabetes management (Update 2019)]. Wien Klin Wochenschr 2019; 131:200-211. [PMID: 30980162 DOI: 10.1007/s00508-019-1447-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This position statement presents the recommendations of the Austrian Diabetes Association for diabetes management of adult patients during inpatient stay. It is based on the current evidence with respect to blood glucose targets, insulin therapy and treatment with oral antidiabetic drugs during inpatient hospitalization. Additionally, special circumstances such as intravenous insulin therapy, concomitant therapy with glucocorticoids and use of diabetes technology during hospitalization are discussed.
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Affiliation(s)
- Julia K Mader
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich.
| | - Johanna Brix
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Krankenanstalt Rudolfstiftung, Wien, Österreich
| | - Felix Aberer
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Alexander Vonbank
- Innere Medizin I mit Kardiologie, Angiologie, Endokrinologie, Diabetologie und Intensivmedizin, Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Michael Resl
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
| | - Thomas R Pieber
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Lars Stechemesser
- Universitätsklinik für Innere Medizin I, Paracelsus Medizinische Privatuniversität - Landeskrankenhaus, Salzburg, Österreich
| | - Harald Sourij
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
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Griffiths SM, Sapirstein A, Guzman JC, Soriano Z, Ravitz AD. Automated, Web-Based Solution for Bidirectional EHR-Infusion Pump Communication. Biomed Instrum Technol 2019; 53:30-37. [PMID: 30702922 DOI: 10.2345/0899-8205-53.1.30] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Smart Agent is a web-based solution for establishing bidirectional communication between an infusion pump and an electronic health record (EHR). It eliminates the need for clinician double check of medication administration using an infusion pump. Because the clinician already is using the EHR to review patient health information and update status, the addition of the web service would help eliminate the potential for human error when using a manual system. The Smart Agent process encompasses the reading of pertinent patient data from the EHR, determination of a new medication dosage based on an internal protocol, input of the dosage into an infusion pump, confirmation of the medication dosage acceptance at the infusion pump, and recording the medication change back into the EHR. The widespread use of Smart Agent-type algorithms with bidirectional communication capabilities would result in safer, more efficient provision of care, as well as better value.
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Besch G, Pili-Floury S, Morel C, Gilard M, Flicoteaux G, Salomon du Mont L, Perrotti A, Meneveau N, Chocron S, Schiele F, Le Breton H, Samain E, Chopard R. Impact of post-procedural glycemic variability on cardiovascular morbidity and mortality after transcatheter aortic valve implantation: a post hoc cohort analysis. Cardiovasc Diabetol 2019; 18:27. [PMID: 30857532 PMCID: PMC6410509 DOI: 10.1186/s12933-019-0831-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 02/19/2019] [Indexed: 12/28/2022] Open
Abstract
Background Glycemic variability is associated with worse outcomes after cardiac surgery, but the prognosis value of early glycemic variability after transcatheter aortic valve implantation is not known. This study was therefore designed to analyze the prognosis significance of post-procedural glycemic variability within 30 days after transcatheter aortic valve implantation. Methods A post hoc analysis of patients from our center included in the FRANCE and FRANCE-2 registries was conducted. Post-procedural glycemic variability was assessed by calculating the mean daily δ blood glucose during the first 2 days after transcatheter aortic valve implantation. Major complications within 30 days were death, stroke, myocardial infarction, acute heart failure, and life-threatening cardiac arrhythmias. Results We analyzed 160 patients (age (median [interquartile] = 84 [80–88] years; diabetes mellitus (n) = 41 (26%) patients; logistic Euroscore = 20 [12–32]). The median value of mean daily δ blood glucose was 4.3 mmol l−1. The rate of major complications within 30 days after procedure among patients with the lowest quartile of glycemic variability was 12%, increasing from 12 to 26%, and 39% in the second, third, and fourth quartiles, respectively. In multivariate analysis, glycemic variability was independently associated with an increased risk of major complications within 30 days after the procedure (odds ratio [95% CI] = 1.83 [1.19–2.83]; p = 0.006). Conclusions This study showed that post-procedural glycemic variability was associated with an increased risk of major complications within 30 days after transcatheter aortic valve implantation. Trial registration Clinical trial registration number https://www.clinicaltrials.gov/; identifier: NCT02726958; date: April 4th, 2016
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Affiliation(s)
- Guillaume Besch
- Department of Anesthesiology and Intensive Care, University Hospital of Besancon, 3 Boulevard Alexander Fleming, 25000, Besancon, France. .,EA3920, University of Franche-Comte, 25000, Besancon, France.
| | - Sebastien Pili-Floury
- Department of Anesthesiology and Intensive Care, University Hospital of Besancon, 3 Boulevard Alexander Fleming, 25000, Besancon, France.,EA3920, University of Franche-Comte, 25000, Besancon, France
| | - Caroline Morel
- Department of Anesthesiology and Intensive Care, University Hospital of Besancon, 3 Boulevard Alexander Fleming, 25000, Besancon, France
| | - Martine Gilard
- Department of Cardiology, University Hospital of Brest, 29609, Brest, France
| | - Guillaume Flicoteaux
- Department of Anesthesiology and Intensive Care, University Hospital of Besancon, 3 Boulevard Alexander Fleming, 25000, Besancon, France
| | - Lucie Salomon du Mont
- Department of Vascular Surgery, University Hospital of Besancon, 25000, Besancon, France
| | - Andrea Perrotti
- EA3920, University of Franche-Comte, 25000, Besancon, France.,Department of Cardiothoracic Surgery, University Hospital of Besancon, 25000, Besancon, France
| | - Nicolas Meneveau
- EA3920, University of Franche-Comte, 25000, Besancon, France.,Department of Cardiology, University Hospital of Besancon, 25000, Besancon, France
| | - Sidney Chocron
- EA3920, University of Franche-Comte, 25000, Besancon, France.,Department of Cardiothoracic Surgery, University Hospital of Besancon, 25000, Besancon, France
| | - Francois Schiele
- EA3920, University of Franche-Comte, 25000, Besancon, France.,Department of Cardiology, University Hospital of Besancon, 25000, Besancon, France
| | - Herve Le Breton
- Department of Cardiology and Vascular Diseases, University Hospital of Rennes, Rennes-1 University, LTSI, INSERM U1099, 35000, Rennes, France
| | - Emmanuel Samain
- Department of Anesthesiology and Intensive Care, University Hospital of Besancon, 3 Boulevard Alexander Fleming, 25000, Besancon, France.,EA3920, University of Franche-Comte, 25000, Besancon, France
| | - Romain Chopard
- EA3920, University of Franche-Comte, 25000, Besancon, France.,Department of Cardiology, University Hospital of Besancon, 25000, Besancon, France
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Ogiso K, Koriyama N, Obo T, Tokito A, Ueno T, Nishio Y. Performance of a 2-step insulin infusion protocol with adjustment of insulin doses for Asians in the medical intensive care unit following cardiothoracic surgery. Diabetol Int 2019; 10:12-23. [PMID: 30800560 DOI: 10.1007/s13340-018-0358-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 06/07/2018] [Indexed: 10/28/2022]
Abstract
Background Most previous insulin infusion protocols are titrated for Westerners and are not simple to follow. In this study, we tested the efficacy and safety of our simple insulin infusion protocol utilizing lower insulin doses for Asians. Methods A total of 152 patients with type 2 diabetes undergoing cardiothoracic surgery were included. After surgery, blood glucose (BG) was initially managed according to our algorithm protocol, and subsequently by the post-algorithm protocol. Insulin infusion rates in the algorithm protocol were titrated in two steps according to (1) current BG levels and (2) the difference between current and previous BG levels. In the post-algorithm protocol, insulin lispro was injected subcutaneously in addition to intravenous insulin infusion according to BG levels. The efficacy was assessed as achievement rates of two target BG ranges (140-199 and 80-199 mg/dL), and safety was assessed as hypoglycemia (< 70 mg/dL) and protocol error rates. Results With the use of the algorithm protocol, 58.7% of 1749 BG measurements achieved a range of 140-199 mg/dL, and 95.9% achieved levels within the 80-199 mg/dL range. Hypoglycemia and protocol error rates were 0.47 and 0.51%, respectively. With the post-algorithm protocol, 48.7 and 98.3% of 898 BG measurements achieved each target range. Hypoglycemia and protocol error rates were 0.78 and 0.22%, respectively. Severe hypoglycemia (< 40 mg/dL) was not observed. Conclusions Our insulin infusion protocol seems to be efficacious, safe, and widely feasible for Asian patients because of its simplicity and lower insulin dose.
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Affiliation(s)
- Kazuma Ogiso
- 1Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853 Japan.,2Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medical and Dental Science, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| | - Nobuyuki Koriyama
- 1Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853 Japan
| | - Takahiko Obo
- 1Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853 Japan.,2Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medical and Dental Science, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| | - Akinori Tokito
- 1Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853 Japan
| | - Takayuki Ueno
- 3Department of Cardiovascular Surgery, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853 Japan
| | - Yoshihiko Nishio
- 2Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medical and Dental Science, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
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Montanier N, Bernard L, Lambert C, Pereira B, Desbiez F, Terral D, Abergel A, Bohatier J, Rosset E, Schmidt J, Sautou V, Hadjadj S, Batisse-Lignier M, Tauveron I, Maqdasy S, Roche B. Prospective evaluation of a dynamic insulin infusion algorithm for non critically-ill diabetic patients: A before-after study. PLoS One 2019; 14:e0211425. [PMID: 30689675 PMCID: PMC6349328 DOI: 10.1371/journal.pone.0211425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/14/2019] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Insulin infusion is recommended during management of diabetic patients in critical care units to rapidly achieve glycaemic stability and reduce the mortality. The application of an easy-to-use standardized protocol, compatible with the workload is preferred. Glycaemic target must quickly be reached, therefore static algorithms should be replaced by dynamic ones. The dynamic algorithm seems closer to the physiological situation and appreciates insulin sensitivity. However, the protocol must meet both safety and efficiency requirements. Indeed, apprehension from hypoglycaemia is the main deadlock with the dynamic algorithms, thus their application remains limited. In contrary to the critical care units, to date, no prospective study evaluated a dynamic algorithm of insulin infusion in non-critically ill patients. AIM This study primarily aimed to evaluate the efficacy of a dynamic algorithm of intravenous insulin therapy in non-critically-ill patients, and addressed its safety and feasibility in different departments of our university hospital. METHODS A "before-after" study was conducted in five hospital departments (endocrinology and four "non-expert" units) comparing a dynamic algorithm (during the "after" period-P2) to the static protocol (the "before" period-P1). Static protocol is based on determining insulin infusion according to an instant blood glycaemia (BG) level at a given time. In the dynamic algorithm, insulin infusion rate is determined according to the rate of change of the BG (the previous and actual BG under a specific insulin infusion rate). Additionally, two distinct glycaemic targets were defined according to the patients' profile: 100-180 mg/dl (5.5-10 mmol/l) for vigorous patients and 140-220 mg/dl (7.8-12.2 mmol/l) for frail ones. Different BG measurements for each patient were collected and recorded in a specific database (e-CRF) in order to analyse the rates of hypo- and hyperglycaemia. A satisfaction survey was also performed. A study approval was obtained from the institutional revision board before starting the study. RESULTS Over 8 months, 72 and 66 patients during P1 and P2 were respectively included. The dynamic algorithm was more efficient, with reduced time to control hyperglycaemia (P1 vs P2:8.3 vs 5.3 hours; HR: 2.02 [1.27; 3.21]; p<0.01), increased the number of in-target BG measurements (P1 vs P2: 37.0% vs 41.8%; p<0.05), and reduced the glycaemic variability related to each patient (P1 vs P2, %CV: 40.9 vs 38.2;p<0.05, Index Correlation Class:0.30 vs 0.14; p<0.05). In patients after the first event of hypoglycemia after having started the infusion, new events were lower (P1 vs P2: 19.4 vs 11.4; p<0.001) thanks to an earlier reaction to hypoglycaemia (8.3% during P1 vs 44.3% during P2; p = 0.004). With the dynamic algorithm, the percentage of recurrence of mild hypoglycaemia was significantly lower in frail patients (20.5% vs 10.2%; p<0.001), and in patients managed in the non-expert units (18 vs 7.1%, p<0.001). The %CV was significantly improved in frail patients (36.9%). Mean BG measurements for each patient/day were 5.5±1.1 during P1 and 6.0±1.6 during P2 (p = 0.6). The threat from hypoglycaemia and the difficulty in using dynamic algorithm are barriers for nurses' adherence. CONCLUSIONS This dynamic algorithm for non-critically-ill patients is more efficient and safe than the static protocol, and adapted for frail patients and non-expert units.
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Affiliation(s)
- Nathanaëlle Montanier
- CHU Clermont-Ferrand, Service d’endocrinologie, diabétologie et maladies métaboliques, Clermont-Ferrand, France
| | - Lise Bernard
- Pôle Pharmacie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Céline Lambert
- Délégation à la Recherche Clinique et à l'Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Délégation à la Recherche Clinique et à l'Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Françoise Desbiez
- CHU Clermont-Ferrand, Service d’endocrinologie, diabétologie et maladies métaboliques, Clermont-Ferrand, France
| | - Daniel Terral
- CHU Clermont-Ferrand, Service de Pédiatrie Générale, Clermont-Ferrand, France
| | - Armand Abergel
- CHU Clermont-Ferrand, Service de Médecine Digestive, Clermont-Ferrand, France
| | - Jérôme Bohatier
- CHU Clermont-Ferrand, Service de Court séjour Gériatrique, Riom, France
| | - Eugenio Rosset
- CHU Clermont-Ferrand, Service de Chirurgie vasculaire, Clermont-Ferrand, France
| | - Jeannot Schmidt
- CHU Clermont-Ferrand, Pôle Urgences, Clermont-Ferrand, France
| | - Valérie Sautou
- Pôle Pharmacie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Samy Hadjadj
- CHU Poitiers, Service de Médecine interne, endocrinologie et maladies métaboliques, Poitiers, France
| | - Marie Batisse-Lignier
- CHU Clermont-Ferrand, Service d’endocrinologie, diabétologie et maladies métaboliques, Clermont-Ferrand, France
- Laboratoire GReD: UMR Université Clermont Auvergne-CNRS 6293, INSERM U1103, Clermont-Ferrand, France
| | - Igor Tauveron
- CHU Clermont-Ferrand, Service d’endocrinologie, diabétologie et maladies métaboliques, Clermont-Ferrand, France
- Laboratoire GReD: UMR Université Clermont Auvergne-CNRS 6293, INSERM U1103, Clermont-Ferrand, France
| | - Salwan Maqdasy
- CHU Clermont-Ferrand, Service d’endocrinologie, diabétologie et maladies métaboliques, Clermont-Ferrand, France
- Laboratoire GReD: UMR Université Clermont Auvergne-CNRS 6293, INSERM U1103, Clermont-Ferrand, France
- * E-mail:
| | - Béatrice Roche
- CHU Clermont-Ferrand, Service d’endocrinologie, diabétologie et maladies métaboliques, Clermont-Ferrand, France
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Grancini V, Resi V, Palmieri E, Pugliese G, Orsi E. Management of diabetes mellitus in patients undergoing liver transplantation. Pharmacol Res 2019; 141:556-573. [PMID: 30690071 DOI: 10.1016/j.phrs.2019.01.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 02/07/2023]
Abstract
Diabetes is a common feature in cirrhotic individuals both before and after liver transplantation and negatively affects prognosis. Certain aetiological agents of chronic liver disease and loss of liver function per se favour the occurrence of pre-transplant diabetes in susceptible individuals, whereas immunosuppressant treatment, changes in lifestyle habits, and donor- and procedure-related factors contribute to diabetes development/persistence after transplantation. Challenges in the management of pre-transplant diabetes include the profound nutritional alterations characterizing cirrhotic individuals and the limitations to the use of drugs with liver metabolism. Special issues in the management of post-transplant diabetes include the diabetogenic potential of immunosuppressant drugs and the increased cardiovascular risk characterizing solid organ transplant survivors. Overall, the pharmacological management of cirrhotic patients undergoing liver transplantation is complicated by the lack of specific guidelines reflecting the paucity of data on the impact of glycaemic control and the safety and efficacy of anti-hyperglycaemic agents in these individuals.
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Affiliation(s)
- Valeria Grancini
- Diabetes Service, Endocrinology and Metabolic Diseases Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, and Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Veronica Resi
- Diabetes Service, Endocrinology and Metabolic Diseases Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, and Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Eva Palmieri
- Diabetes Service, Endocrinology and Metabolic Diseases Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, and Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, and Diabetes Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Emanuela Orsi
- Diabetes Service, Endocrinology and Metabolic Diseases Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, and Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
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Rhee SY. Glucose Control in Intensive Care Unit Patients: Recent Updates. JOURNAL OF NEUROCRITICAL CARE 2018. [DOI: 10.18700/jnc.180067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Lu M, Zuo Y, Guo J, Wen X, Kang Y. Continuous glucose monitoring system can improve the quality of glucose control and glucose variability compared with point-of-care measurement in critically ill patients: A randomized controlled trial. Medicine (Baltimore) 2018; 97:e12138. [PMID: 30200106 PMCID: PMC6133393 DOI: 10.1097/md.0000000000012138] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The purpose of this study was to determine whether subcutaneous continuous glucose monitoring systems (CGMS) could improve glucose management in critically ill patients compared with frequent and conventional point-of-care (POC) glucose measurements. METHODS A total of 144 patients with an expected length of stay in the ICU of at least 72 hours and with an admission glucose or two random glucose values of >10.0 mmol/L within 24 hours after admission, were randomly assigned to the CGMS group (n = 74) or the conventional group (C group, n = 70). Both groups used the same insulin algorithm to reach the same glucose target range (8.0-10.0 mmol/L). RESULTS Time in range (TIR, 8.0-10.0 mmol/L), which is our primary outcome measure, was higher in the CGMS group than in the C group (51.5% vs. 29.0%, P < .001). Glucose variability (coefficient of variation, CV; standard deviation, SD; glucose lability index, and GLI) was improved by CGMS (all P < .05). Mean glucose level (MGL) (9.6 vs. 10.3 mmol/L, P = .156) and the proportion of patients with hypoglycemia did not differ between CGMS (5.4%) and C (5.7%) (P = 1.000). However, duration of hypoglycemia was reduced in the CGMS group (15 vs. 28 minutes, P = .032). Clinical outcomes were similar between groups except for the fewer usage of CRRT and lower peak plasma urea nitrogen level in the CGMS group. CONCLUSION The use of CGMS, compared with POC glucose measurement, could improve the TIR, GV and duration of hypoglycemia.
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Hosseini Dehkordi SH, Albu J, Aziz EF, Herzog E. Pathway for the Management of Hyperglycemia in the Cardiac Care Unit. Crit Pathw Cardiol 2018; 16:119-125. [PMID: 29135618 DOI: 10.1097/hpc.0000000000000112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Inpatient hyperglycemia has been associated with increased morbidity and mortality in critically ill patients. Optimal control of blood glucose (BG) levels using insulin infusion protocols has been shown to improve clinical outcomes. Protocols have been developed to prescribe a safe and effective rate of insulin infusion for optimal control of BG levels; however, a major obstacle in their implementation is their complexity. We have revised and updated our previously published pathway for the management of hyperglycemia, which introduces the "wheel" concept for insulin dosing. The "wheel" serves as a treatment guide. It is made up of 6 concentric circles. The core circle represents the goal of BG in critically ill patients, with inner circle showing the actual BG range of the patient. The 4 outer circles correspond to increasing rates of insulin infusion from tier 1 to tier 4. Simple guidelines are provided to facilitate conversion from insulin infusion to a subcutaneous insulin-delivery regimen in preparation for transfer from the cardiac care unit (CCU) setting. Our protocols also provide guidelines for management of diabetic ketoacidosis and hyperosmolar hyperglycemic states while at the same time creates a flowchart for activation of diabetes care team and their involvement in the multidisciplinary care of a patient in CCU with hyperglycemia and/or diabetes mellitus. This pathway provides a comprehensive and detailed, yet simple and practical algorithm for management of hyperglycemia in the CCU.
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Affiliation(s)
- Seyed Hamed Hosseini Dehkordi
- From the *Division of Internal Medicine, Icahn School of Medicine at Mount Sinai St. Luke's-West Hospital Center, New York, NY; †Division of Endocrinology, Icahn School of Medicine at Mount Sinai St. Luke's-West Hospital Center, New York, NY; ‡Division of Electrophysiology, Icahn School of Medicine at Mount Sinai St. Luke's-West Hospital Center, New York, NY; and §Cardiac Care Unit, Icahn School of Medicine at Mount Sinai St. Luke's Hospital. New York, NY
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Besch G, Perrotti A, Salomon du Mont L, Tucella R, Flicoteaux G, Bondy A, Samain E, Chocron S, Pili-Floury S. Long-term compliance with a validated intravenous insulin therapy protocol in cardiac surgery patients: a quality improvement project. Int J Qual Health Care 2018; 30:817-822. [DOI: 10.1093/intqhc/mzy112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 04/30/2018] [Indexed: 01/04/2023] Open
Affiliation(s)
- Guillaume Besch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, Besancon, France
- EA 3920, Bourgogne Franche-Comte University, Besancon, France
| | - Andrea Perrotti
- EA 3920, Bourgogne Franche-Comte University, Besancon, France
- Department of Cardiothoracic Surgery, University Hospital of Besancon, 3 bvd Alexander Fleming, Besancon, France
| | - Lucie Salomon du Mont
- EA 3920, Bourgogne Franche-Comte University, Besancon, France
- Department of Vascular Surgery, University Hospital of Besancon, 3 bvd Alexander Fleming, Besancon, France
| | - Raphaelle Tucella
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, Besancon, France
| | - Guillaume Flicoteaux
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, Besancon, France
| | - Aline Bondy
- Department of Cardiothoracic Surgery, University Hospital of Besancon, 3 bvd Alexander Fleming, Besancon, France
| | - Emmanuel Samain
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, Besancon, France
- EA 3920, Bourgogne Franche-Comte University, Besancon, France
| | - Sidney Chocron
- EA 3920, Bourgogne Franche-Comte University, Besancon, France
- Department of Cardiothoracic Surgery, University Hospital of Besancon, 3 bvd Alexander Fleming, Besancon, France
| | - Sebastien Pili-Floury
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, Besancon, France
- EA 3920, Bourgogne Franche-Comte University, Besancon, France
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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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46
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Galindo RJ, Fayfman M, Umpierrez GE. Perioperative Management of Hyperglycemia and Diabetes in Cardiac Surgery Patients. Endocrinol Metab Clin North Am 2018; 47:203-222. [PMID: 29407052 PMCID: PMC5805476 DOI: 10.1016/j.ecl.2017.10.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Perioperative hyperglycemia is common after cardiac surgery, reported in 60% to 90% of patients with diabetes and in approximately 60% of patients without history of diabetes. Many observational and prospective randomized trials in critically-ill cardiac surgery patients support a strong association between hyperglycemia and poor clinical outcome. Despite ongoing debate about the optimal glucose target, there is strong agreement that improved glycemic control reduces perioperative complications.
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Affiliation(s)
- Rodolfo J Galindo
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Drive, Glenn Building, Suite 202, Atlanta, GA 30303, USA
| | - Maya Fayfman
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Drive, Glenn Building, Suite 202, Atlanta, GA 30303, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Drive, Glenn Building, Suite 202, Atlanta, GA 30303, USA.
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47
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Rabinovich M, Grahl J, Durr E, Gayed R, Chester K, McFarland R, McLean B. Risk of Hypoglycemia During Insulin Infusion Directed by Paper Protocol Versus Electronic Glycemic Management System in Critically Ill Patients at a Large Academic Medical Center. J Diabetes Sci Technol 2018; 12:47-52. [PMID: 29251064 PMCID: PMC5761992 DOI: 10.1177/1932296817747617] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Insulin infusions are commonly utilized to control hyperglycemia in critically ill patients and decrease hyperglycemia associated complications. Safety concerns have been raised in trials evaluating methods of glycemic control regarding the incidence of hypoglycemia and its relationship to increased mortality. Electronic glycemic management systems (eGMS) may result in less variable blood glucose (BG) control and less hypoglycemia. This study aimed to compare BG control, time in target BG range, and the rate of hypoglycemia when critically ill patients were managed with an insulin infusion guided by paper-based protocol (PBP) versus eGMS. METHODS This retrospective review compared critically ill patients ≥ 18 years old that received insulin infusion from March to May 2015 (PBP group) and October to January 2017 (eGMS group). The primary outcome was the incidence of hypoglycemia. Secondary outcomes included frequency and severity of hypoglycemia, duration in glycemic target, length of insulin therapy, as well as ICU and hospital length of stay. RESULTS Fifty-four patients were evaluated, 27 in each group. Percentage of days with BG <70 mg/dL was significantly reduced after eGMS implementation (21.5% v 1.3%, P < .0001) including the frequency of severe hypoglycemia (BG < 40 mg/dL) (5.4% v 0.01%, P < .0001). Patients in the eGMS group spent a greater amount of time in target BG range (31.5% v 63.7%, P < .0001). CONCLUSIONS An eGMS has the potential to address many of the unmet needs of an optimal glycemic control strategy, minimizing hypoglycemia, and glycemic variability in a heterogeneous critically ill population.
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Affiliation(s)
- Marina Rabinovich
- Grady Health System, Atlanta, GA, USA
- Marina Rabinovich, PharmD, Grady Health System, 80 Jesse Hill Jr. Dr SE, Atlanta, GA 30303, USA.
| | - Jessica Grahl
- Vanderbilt University Medical Center, Nashville, TN, USA
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Zhou T, Dickson JL, Shaw GM, Chase JG. Continuous Glucose Monitoring Measures Can Be Used for Glycemic Control in the ICU: An In-Silico Study. J Diabetes Sci Technol 2018; 12:7-19. [PMID: 29103302 PMCID: PMC5761989 DOI: 10.1177/1932296817738791] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Continuous glucose monitoring (CGM) technology has become more prevalent in the intensive care unit (ICU), offering potential benefits of increased safety and reduced workload in glycemic control (GC). The drift and higher point accuracy errors of CGM devices over traditional intermittent blood glucose (BG) measures have so far limited their application in the ICU. This study delineates the trade-offs of performance, safety and workload that CGM sensors provide in GC protocols. METHODS Clinical data from 236 patients were used for clinically validated virtual trials. A CGM-enabled version of the STAR GC protocol was used to evaluate the use of guard rails and rolling windows. Safety was assessed through percentage of patients who had a severe hypoglycemic episode (BG < 40 mg/dl) as well as percentage of resampled BG < 72 mg/dl. Performance was assessed as percentage of resampled measurements in the 80-126 mg/dl and the 80-144 mg/dl target bands. Workload was measured by number of manual BG measures per day. RESULTS CGM-enabled versions of STAR decreased the number of required blood draws by up to 74%, while maintaining performance (76.6% BG measurements in the 80-126 mg/dl range vs 62.8% clinically, 87.9% in the 80-144 mg/dl range vs 83.7% clinically) and maintaining patient safety (1.13% of patients experienced a severe hypoglycemic event vs 0.85% clinically, 1.37% of BG measurements were less than 72 mg/dl vs 0.51% clinically). CONCLUSION CGM sensor traces were reproduced in virtual trials to guide GC. Existing GC protocols such as STAR may need to be adjusted only slightly to gain the benefits of the increased temporal measurements of CGM sensors, through which workload may be significantly decreased while maintaining GC performance and safety.
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Affiliation(s)
- Tony Zhou
- Department of Mechanical Engineering, University of Canterbury, Christchurch, Canterbury, New Zealand
- Tony Zhou, BE, Department of Mechanical Engineering, University of Canterbury, 20 Kirkwood Ave, Riccarton, Christchurch, Canterbury 8041, New Zealand.
| | - Jennifer L. Dickson
- Department of Mechanical Engineering, University of Canterbury, Christchurch, Canterbury, New Zealand
| | - Geoffrey M. Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch School of Medicine and Health Science, University of Otago, New Zealand
| | - J. Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, Canterbury, New Zealand
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Clinical Effectiveness of Intravenous Exenatide Infusion in Perioperative Glycemic Control after Coronary Artery Bypass Graft Surgery. Anesthesiology 2017; 127:775-787. [DOI: 10.1097/aln.0000000000001838] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Abstract
Background
We aimed to assess the clinical effectiveness of intravenous exenatide compared to insulin in perioperative blood glucose control in coronary artery bypass grafting surgery patients.
Methods
Patients more than 18 yr old admitted for elective coronary artery bypass grafting were included in a phase II/III nonblinded randomized superiority trial. Current insulin use and creatinine clearance of less than 60 ml/min were exclusion criteria. Two groups were compared: the exenatide group, receiving exenatide (1-h bolus of 0.05 µg/min followed by a constant infusion of 0.025 µg/min), and the control group, receiving insulin therapy. The blood glucose target range was 100 to 139 mg/dl. The primary outcome was the proportion of patients who spent at least 50% of the study period within the target range. The consumption of insulin (Cinsulin) and the time to start insulin (Tinsulin) were compared between the two groups.
Results
In total, 53 and 51 patients were included and analyzed in the exenatide and control groups, respectively (age: 70 ± 9 vs. 68 ± 11 yr; diabetes mellitus: 12 [23%] vs. 10 [20%]). The primary outcome was observed in 38 (72%) patients in the exenatide group and in 41 (80%) patients in the control group (odds ratio [95% CI] = 0.85 [0.34 to 2.11]; P = 0.30). Cinsulin was significantly lower (60 [40 to 80] vs. 92 [63 to 121] U, P < 0.001), and Tinsulin was significantly longer (12 [7 to 16] vs. 7 [5 to 10] h, P = 0.02) in the exenatide group.
Conclusions
Exenatide alone at the dose used was not enough to achieve adequate blood glucose control in coronary artery bypass grafting patients, but it reduces overall consumption of insulin and increases the time to initiation of insulin.
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Gupta D, Kirn M, Jamkhana ZA, Lee R, Albert SG, Rollins KM. A unified Hyperglycemia and Diabetic ketoacidosis (DKA) insulin infusion protocol based on an Excel algorithm and implemented via Electronic Medical Record (EMR) in Intensive Care Units. Diabetes Metab Syndr 2017; 11:265-271. [PMID: 27658894 DOI: 10.1016/j.dsx.2016.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 09/03/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND To assess the efficacy of a unified hyperglycemia and diabetic ketoacidosis (DKA) insulin infusion protocol (IIP), based on an Excel algorithm and implemented as an electronic order set, in achieving glycemic targets and minimizing hypoglycemia. METHODS An IIP was instituted in medical and surgical intensive care units for post-cardiac surgery (PCS) and other stress hyperglycemia (SH), diabetes hyperglycemia (DH), and DKA. The IIP initiated therapeutic insulin rates at elevated blood glucose (BG), and decreased insulin when target range was achieved. A convenience sample (n=62) was studied; 20 PCS, 15 with DH, 9 with SH, 8 with diabetes on vasopressors, 7 with diabetes on glucocorticoids and 3 with DKA were assessed. RESULTS The protocol maintained BG at 144±24.7mg/dL for PCS and 167±36mg/dL for patients with diabetes mellitus. It maintained acceptable target range (ATR) (100mg/dL-180mg/dL) 89% of the time for PCS and 67% of the time for patients with diabetes mellitus. There were no measurements of BG<70mg/dL. The protocol lowered the BG at a similar rate and time period in those with diabetes, DKA and those with or without vasopressors or glucocorticoids. To determine long-term efficacy, a retrospective review of Point of Care (POC) RALS (Remote Automated Data System) BG data 2 years post implementation demonstrated fewer episodes of hypoglycemia<70mg/dL and hyperglycemia>240mg/dL and more BG values within ATR. CONCLUSIONS This IIP maintained ATR without hypoglycemia for patients in the ICU setting without requiring complex nursing calculations.
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Affiliation(s)
- Deepashree Gupta
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States.
| | - Meredith Kirn
- Department of Pharmacy, St. Luke's Hospital, St. Louis, MO, United States
| | - Zafar A Jamkhana
- Division of Pulmonary, Critical Care and Sleep Medicine, Saint Louis University School of Medicine, United States
| | - Richard Lee
- Department of Cardiovascular Medicine, Division of Comprehensive Cardiovascular Care, 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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