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Insler SR, Wakefield B, Debs A, Brake K, Nwosu I, Isaacs D, Bena J, Lansang MC. Continuous Glucose Monitoring Using the Dexcom G6 in Cardiac Surgery During the Postoperative Period. Endocr Pract 2024:S1530-891X(24)00505-6. [PMID: 38692488 DOI: 10.1016/j.eprac.2024.04.015] [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: 11/20/2023] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE Cardiac surgery is associated with hyperglycemia, which in turn is associated with adverse postsurgical outcomes such as wound infections, acute renal failure, and mortality. This pilot study seeks to determine if Dexcom G6Pro continuous glucose monitor (Dexcom G6Pro CGM) is accurate during the postoperative cardiac surgery period when fluid shifts, systemic inflammatory response syndrome, and vasoactive medications are frequently encountered, compared to standard glucose monitoring techniques. METHODS This study received institutional review board approval. In this prospective study, correlation between clinical and Dexcom glucose readings was evaluated. Clinical glucose (blood gas, metabolic panel, and point of care) data set included 1428 readings from 29 patients, while the Dexcom G6Pro CGM data included 45 645 data points following placement to upper arm. Additionally, average clinical measurements of day and overnight temperatures and hemodynamics were evaluated. Clinical and Dexcom data were restricted to being at least 1 hour after prior clinical reading Matching Dexcom G6Pro CGM data were required within 5 minutes of clinical measure. Data included only if taken at least 2 hours after Dexcom G6Pro CGM insertion (warm-up time) and analyzed only following intensive care unit (ICU) admission. Finally, a data set excluding the first 24 hours after ICU admission was created to explore stability of the device. Patients remained on Dexcom G6Pro CGM until discharge or 10 days postoperatively. RESULTS The population was 71% male, 14% with known diabetes; 66% required intravenous insulin infusion. The Clarke error grid plot of all measures post-ICU admission showed 53.5% in zone A, 45.9% in zone B, and 0.6% (n = 5) in zones D or E. The restricted dataset that excluded the first 24 hours post-ICU admission showed 55.9% in zone A, 43.9% in zone B, and 0.2% in zone D. Mean absolute relative difference between clinical and Dexcom G6Pro CGM measures was 20.6% and 21.6% in the entire post-ICU admission data set, and the data set excluding the first 24 hours after ICU admission, respectively. In the subanalysis of the 12 patients who did not have more than a 5-minute tap in the operating room, a consensus error grid, demonstrated that after ICU admission, percentage in zone A was 53.9%, zone B 45.4%, and zone C 0.7%. Similar percentages were obtained removing the first 24 hours post-ICU admission. These numbers are very similar to the entire cohort. A consensus error grid created post-ICU admission demonstrated: (zone A) 54%, (zone B) 45%, (zone C) 0.9%, and the following for the dataset created excluding the first 24 hours: (zone A) 56%, (zone B) 44%, (zone C) 0.4%, which demonstrated very close agreement with the original Clarke error grid. No adverse events were reported. CONCLUSIONS Almost 100% of Dexcom G6Pro CGM and clinical data matching points fell within areas considered as giving clinically correct decisions (zone A) and clinically uncritical decisions (zone B). However, the relatively high mean absolute relative difference precludes its use for both monitoring and treatment in the clinical context. As technology evolves, interstitial glucose monitoring may become an important tool to limit iatrogenic anemia and mitigate glycemic fluctuations.
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Affiliation(s)
- Steven R Insler
- Departments of Intensive Care and Resuscitation and Cardiothoracic Anesthesiology, The Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Brett Wakefield
- Departments of Intensive Care and Resuscitation and Cardiothoracic Anesthesiology, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Andrea Debs
- Department of Endocrinology, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Kelly Brake
- Department of Endocrinology, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ikenna Nwosu
- Department of Endocrinology, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Diana Isaacs
- Department of Endocrinology, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - James Bena
- Department of Quantitative Health Sciences, Cleveland Clinic, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - M Cecilia Lansang
- Department of Endocrinology, The Cleveland Clinic Foundation, Cleveland, Ohio
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Bihari I, Guex JJ, Jawien A, Szolnoky G. Clinical Perspectives and Management of Edema in Chronic Venous Disease—What about Ruscus? MEDICINES 2022; 9:medicines9080041. [PMID: 35893088 PMCID: PMC9331752 DOI: 10.3390/medicines9080041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022]
Abstract
Background: Edema is highly prevalent in patients with cardiovascular disease and is associated with various underlying pathologic conditions, making it challenging for physicians to diagnose and manage. Methods: We report on presentations from a virtual symposium at the Annual Meeting of the European Venous Forum (25 June 2021), which examined edema classification within clinical practice, provided guidance on making differential diagnoses and reviewed evidence for the use of the treatment combination of Ruscus extract, hesperidin methyl chalcone and vitamin C. Results: The understanding of the pathophysiologic mechanisms underlying fluid build-up in chronic venous disease (CVD) is limited. Despite amendments to the classic Starling Principle, discrepancies exist between the theories proposed and real-world evidence. Given the varied disease presentations seen in edema patients, thorough clinical examinations are recommended in order to make a differential diagnosis. The recent CEAP classification update states that edema should be considered a sign of CVD. The combination of Ruscus extract, hesperidin methyl chalcone and vitamin C improves venous tone and lymph contractility and reduces macromolecule permeability and inflammation. Conclusions: Data from randomized controlled trials support guideline recommendations for the use of Ruscus extract, hesperidin methyl chalcone and vitamin C to relieve major CVD-related symptoms and edema.
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Affiliation(s)
- Imre Bihari
- Vascular Surgery Department, St Rokus Clinical Block, Semmelweis University, 1085 Budapest, Hungary
- Correspondence:
| | | | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, University Hospital No. 1, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, 85-094 Tourn, Poland;
| | - Gyozo Szolnoky
- Department of Dermatology and Allergology, Albert Szent-Györgyi Medical School, University of Szeged, 6720 Szeged, Hungary;
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Hahn RG, Dull RO, Zdolsek J. The Extended Starling principle needs clinical validation. Acta Anaesthesiol Scand 2020; 64:884-887. [PMID: 32270471 DOI: 10.1111/aas.13593] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 12/11/2022]
Abstract
The Revised (or "Extended") Starling principle is based on highly controlled laboratory-based frog and rodent experiments and remains a hypothesis awaiting clinical validation. A key point is that the endothelial glycocalyx layer moves the oncotic gradient from being between the plasma and the interstitium to between the plasma and a virtually protein-free space between the glycocalyx and the endothelial cell membrane, which dramatically changes the prerequisites for fluid absorption from tissue to plasma. However, many experimental and clinical observations in humans agree poorly with the new microcirculatory proposals. The most troubling aspect of the explanation regarding the role of the glycocalyx in the Revised Starling principle is the effective reabsorption of fluid by skeletal muscle when the capillary filtration pressure is acutely reduced. Other issues include the plasma volume effects of hypertonic saline, iso-oncotic and hyper-oncotic albumin, fluid distribution during cardio-pulmonary bypass, and the virtually identical capillary leakage of plasma and albumin despite marked inflammation found in our fluid therapy studies. The Revised Starling principle deals mainly with steady-state conditions, but the circulatory system is highly dynamic. Second to second vasomotion is always operational and must be considered to understand what we observe in humans.
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Affiliation(s)
- Robert G. Hahn
- Research Unit Södertälje Hospital Södertälje Sweden
- Karolinska Institutet at Danderyds Hospital (KIDS) Stockholm Sweden
| | - Randal O. Dull
- Departments of Anesthesiology, Pathology, Physiology College of Medicine University of Arizona Tucson AZ USA
| | - Joachim Zdolsek
- Department of Anesthesiology and Intensive Care Department of Medical and Health Sciences Linköping University Linköping Sweden
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Lee JY, Ryu HS, Yoon SS, Kim EH, Yoon SW. Extracellular-to-Intracellular Fluid Volume Ratio as a Prognostic Factor for Survival in Patients With Metastatic Cancer. Integr Cancer Ther 2019; 18:1534735419847285. [PMID: 31043080 PMCID: PMC6498769 DOI: 10.1177/1534735419847285] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Purpose: This study aimed to investigate whether the
extracellular-to-intracellular fluid volume (E/I) ratio can predict survival in
patients with metastatic cancer. Methods: Clinical data were
collected from April 2016 to March 2018. Patients aged ≥19 years with metastatic
solid tumor were eligible. Bioimpedance analysis was used to assess body fluid
distribution and the E/I ratio. Clinical characteristics, including laboratory
test results and nutrition status according to the E/I ratio, were analyzed. Cox
proportional hazards models and Kaplan-Meier analysis were used to identify risk
factors for mortality. Results: In total, 87 patients were included
in the study. The 87 patients were divided into 2 groups according to the median
E/I ratio: a high E/I group (E/I ratio ≥1.0, n = 43) and a low E/I group (E/I
ratio <1.0, n = 44). Poor performance status, fluid retention, malnutrition,
elevation of C-reactive protein levels, and decreases in hemoglobin, albumin,
and protein levels were significantly associated with the high E/I group. The
median overall survival time was 1.6 and 12.5 months in the high E/I and low E/I
groups, respectively (P < .001). In the multivariate
analysis, poor performance status, leukocytosis, fluid retention, and E/I ratio
were independent prognostic factors, and the E/I ratio was the strongest
prognostic factor predicting overall survival (hazard ratio = 3.49, 95%
confidence interval = 1.75-6.96, P < .001).
Conclusions: The E/I ratio can predict survival time in
patients with metastatic cancer. More rigorous research is required to confirm
this result.
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Affiliation(s)
- Jee Young Lee
- Kyung Hee University Hospital at
Gangdong, Gangdonggu, Seoul, Republic of Korea
| | - Han Sung Ryu
- Kyung Hee University Hospital at
Gangdong, Gangdonggu, Seoul, Republic of Korea
| | - Sung Soo Yoon
- Kyung Hee University Hospital at
Gangdong, Gangdonggu, Seoul, Republic of Korea
| | - Eun Hye Kim
- Kyung Hee University Hospital at
Gangdong, Gangdonggu, Seoul, Republic of Korea
| | - Seong Woo Yoon
- Kyung Hee University Hospital at
Gangdong, Gangdonggu, Seoul, Republic of Korea
- Seong Woo Yoon, Department of Internal
Medicine, Korean Medicine Cancer Center, Kyung Hee University Hospital at
Gangdong, Dongnamro 892, Gangdonggu, Seoul 134-727, Republic of Korea.
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Zdolsek M, Hahn RG, Zdolsek JH. Recruitment of extravascular fluid by hyperoncotic albumin. Acta Anaesthesiol Scand 2018; 62:1255-1260. [PMID: 29845612 DOI: 10.1111/aas.13150] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 03/12/2018] [Accepted: 04/10/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although hyperoncotic albumin may be used to recruit oedema, its effectiveness remains unclear. Therefore, this issue was studied during infusion experiments in healthy volunteers. METHOD Fifteen healthy volunteers (mean age 31 years) received an infusion of 3 mL/kg of 20% albumin over 30 minutes. Their urinary excretion was recorded, and venous blood samples were taken to measure blood haemoglobin (Hb), haematocrit, colloid osmotic pressure as well as plasma albumin and sodium concentrations on 15 occasions over a period of 300 minutes. Plasma volume expansion was taken as the inverse of the fluid-induced dilution of venous plasma, as given by the blood Hb concentration. Mass balance calculations were used to estimate the mobilisation of fluid from the tissues. RESULTS Maximum plasma volume expansion was reached 20 minutes after completing an infusion of 20% albumin. Urinary excretion was effectively increased, and the mobilised fluid from the tissues at 300 minutes amounted to 3.4 ± 1.2 mL for each infused mL of 20% albumin, of which 19% was of intracellular origin. The urinary excretion correlated strongly with the amount of recruited fluid (R2 = 0.87) and inversely with the plasma volume expansion (R2 = 0.53). CONCLUSION The infusion of 20% albumin significantly increases the plasma volume by recruiting interstitial fluid. After completing the infusion, there is a delay of 20 minutes until maximum plasma dilution is reached, and the duration of the plasma volume expansion lasts far beyond 5 hours.
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Affiliation(s)
- M. Zdolsek
- Department of Clinical and Experimental Medicine; Linköping University; Linköping Sweden
- Vrinnevihospital; Norrköping Sweden
| | - R. G. Hahn
- Research Unit; Södertälje Hospital; Södertälje Sweden
- Department of Clinical Sciences at Danderyd Hospital (KIDS); Karolinska Institutet; Stockholm Sweden
| | - J. H. Zdolsek
- Department of Anaesthesiology and Intensive Care and Department of Medical and Health Sciences; Linköping University; Linköping Sweden
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Mongero L, Stammers A, Tesdahl E, Stasko A, Weinstein S. The effect of ultrafiltration on end-cardiopulmonary bypass hematocrit during cardiac surgery. Perfusion 2018; 33:367-374. [PMID: 29301459 DOI: 10.1177/0267659117747046] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Ultrafiltration (UF) during cardiopulmonary bypass (CPB) is a well-accepted method for hemoconcentration to reduce excess fluid and increase hematocrit, platelet count and plasma constituents. The efficacy of this technique may confer specific benefit to certain patients presenting with acquired cardiac defects. The purpose of this study was to retrospectively evaluate the effect of UF on end-CPB hematocrit by cardiac surgical procedure type. METHODS A review of 73,506 cardiac procedures from a national registry (SCOPE) was conducted between April 2012 and October 2016 at 197 institutions. Cases included in this analysis were those completed without intraoperative red blood cell transfusion and where zero-balance UF was not used. The primary end point was the last hematocrit reading taken before the end of CPB, with a secondary end point of urine output during CPB. In order to isolate the effect of the UF volume removed, we controlled for a number of confounding factors, including: first hematocrit on CPB, total asanguineous volume, estimated circulating blood volume, CPB urine output, total volume of crystalloid cardioplegia, total volume of other asanguineous fluids administered by both perfusion and anesthesia, type of cardiac procedure, acuity, gender, age and total time on CPB. Descriptive statistics were calculated among five subgroups according to the UF volume removed: no volume removed and quartiles across the range of UF volume removed. The effect of UF volume on primary and secondary end points was modeled using ordinary least squares and restricted cubic splines in order to assess possible non-linearity in the effect of the UF volume while controlling for the above-named confounding factors. An interaction term was included in each model to account for possible differences by procedure type. RESULTS The study found a statistically significant non-linear pattern in the relationship between the UF volume removed and the last hematocrit on bypass (X2 = 172.5, df=24, p<0.001). For most procedure types, UF was most effective at increasing the last hematocrit on CPB, from 1 mL to approximately 2.5 L, with continued improvements in hematocrit coming more slowly as the UF volume was increased above 2.5 L. There were statistically significant interactions between UF and procedure type (X2 = 78.5, df=24, p<0.0001) as well as UF and starting hematocrit on CPB (X2 = 234.0, df=4, p<0.0001). In a secondary end-point model, there was a statistically significant relationship between the ultrafiltration volume removed and urine output on bypass (X2 = 598.9, df=28, p<0.001). CONCLUSION The use of UF during CPB resulted in significant increases in end-hematocrit, with the greatest benefit shown when volumes were under 2.5 L. We saw a positive linear benefit up to 2.5 L removed and, thereafter, in most procedures, the benefit leveled off. However, of note is markedly decreased urine output on bypass as the ultrafiltration volumes increase.
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Hahn RG. In response: fluids in neurosurgery. Acta Anaesthesiol Scand 2018; 62:140-141. [PMID: 29143305 DOI: 10.1111/aas.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 10/18/2017] [Accepted: 10/21/2017] [Indexed: 11/29/2022]
Affiliation(s)
- R. G. Hahn
- Research Unit; Södertälje Hospital; Södertälje Sweden
- Department of Clinical Sciences (KIDS); Karolinska Institutet; Stockholm Sweden
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