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Al Duhailib Z, Hakeam H, Almossalem A, Alrashidi A, Al Zhrani A, Al Salman H, Alenizy K, Alqafashat S, Alshalawi M, Mohamed G, Slessarev M, Rochwerg B. Insulin Degludec in Critically Ill Patients With Type 2 Diabetes Mellitus: A Prospective Interventional Study. Endocr Pract 2025; 31:503-510. [PMID: 39725356 DOI: 10.1016/j.eprac.2024.12.014] [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: 10/22/2024] [Revised: 12/03/2024] [Accepted: 12/13/2024] [Indexed: 12/28/2024]
Abstract
OBJECTIVE Dysglycemia has deleterious outcomes on critically ill patients with diabetes mellitus (DM). Insulin degludec, an ultralong-acting insulin, is associated with lower rates of hypoglycemia and blood glucose (BG) variability in non-critically ill patients. The experience with insulin degludec in the intensive care units is lacking. This study aimed to assess the effect of insulin degludec on glycemic control in critically ill patients with type 2 DM. METHODS A prospective, interventional study enrolled critically ill patients with type 2 DM. Subjects were started on insulin degludec plus insulin regular correctional doses. BG levels were assessed every 6 hours. The primary outcome was the percentage of BG levels within a target of 140 to 180 mg/dL. The secondary outcomes included the median BG levels, severe hypoglycemia rate, and BG variability. RESULTS In total, 155 patients were enrolled. The percentage of BG levels within the target was 28.5%. The first day that the median of BG levels within target was on day 2 of insulin degludec therapy, which continued to be within the target for 1 week. Severe hypoglycemia developed in 5 patients (3.2%). The BG variability in the study was 26% using the coefficient of variation. CONCLUSION In critically ill patients with type 2 DM, one-fourth of BG levels were within the glycemic target (140-180 mg/dL) with insulin degludec plus insulin regular correctional doses. The median BG levels were in target starting the second day of insulin degludec therapy. The favorable BG variability using insulin degludec merits further investigation for effect on clinical outcomes.
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Affiliation(s)
- Zainab Al Duhailib
- Critical Care Medicine Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Hakeam Hakeam
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Pharmaceutical Care Division, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Ammar Almossalem
- Critical Care Medicine Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Ahood Alrashidi
- Critical Care Medicine Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Abdulrahman Al Zhrani
- Critical Care Medicine Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Hassan Al Salman
- Critical Care Medicine Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Khalid Alenizy
- Critical Care Department, King Fahad Specialist Hospital, Al Qassim, Saudi Arabia
| | - Sukaina Alqafashat
- Critical Care Medicine Department, Qatif Central Hospital. Qatif, Saudi Arabia
| | - Munirah Alshalawi
- Critical Care Medicine Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Gamal Mohamed
- Biostatistics Epidemiology & Scientific Computing Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Marat Slessarev
- Division of Critical Care, Department of Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Nielsen CG, Grigonyte-Daraskeviciene M, Olsen MT, Møller MH, Nørgaard K, Perner A, Mårtensson J, Pedersen-Bjergaard U, Kristensen PL, Bestle MH. Accuracy of continuous glucose monitoring systems in intensive care unit patients: a scoping review. Intensive Care Med 2024; 50:2005-2018. [PMID: 39417874 DOI: 10.1007/s00134-024-07663-6] [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: 05/31/2024] [Accepted: 09/14/2024] [Indexed: 10/19/2024]
Abstract
PURPOSE Glycemic control poses a challenge in intensive care unit (ICU) patients and dysglycemia is associated with poor outcomes. Continuous glucose monitoring (CGM) has been successfully implemented in the type 1 diabetes out-patient setting and renewed interest has been directed into the transition of CGM into the ICU. This scoping review aimed to provide an overview of CGM accuracy in ICU patients to inform future research and CGM implementation. METHODS We systematically searched PubMed and EMBASE between 5th of December 2023 and 21st of May 2024 and reported findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline for scoping reviews (PRISMA-ScR). We assessed studies reporting the accuracy of CGM in the ICU and report study characteristics and accuracy outcomes. RESULTS We identified 2133 studies, of which 96 were included. Most studies were observational (91.7%), conducted in adult patients (74%), in mixed ICUs (47.9%), from 2014 and onward, and assessed subcutaneous CGM systems (80%) using arterial blood samples as reference test (40.6%). Half of the studies (56.3%) mention the use of a prespecified reference test protocol. The mean absolute relative difference (MARD) ranged from 6.6 to 30.5% for all subcutaneous CGM studies. For newer factory calibrated CGM, MARD ranged from 9.7 to 20.6%. MARD for intravenous CGM was 5-14.2% and 6.4-13% for intraarterial CGM. CONCLUSIONS In this scoping review of CGM accuracy in the ICU, we found great diversity in accuracy reporting. Accuracy varied depending on CGM and comparator, and may be better for intravascular CGM and potentially lower during hypoglycemia.
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Affiliation(s)
- Christian G Nielsen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital-North Zealand, Hilleroed, Denmark.
| | | | - Mikkel T Olsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-North Zealand, Hilleroed, Denmark
| | - Morten H Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Nørgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Clinical Translational Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Johan Mårtensson
- Department of Physiology and Pharmacology, Section of Anesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-North Zealand, Hilleroed, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter L Kristensen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-North Zealand, Hilleroed, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital-North Zealand, Hilleroed, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Shi J, Weng J, Ding Y, Xia Y, Zhou Y, Wang X, Zhang F, Zhang P, Luo S, Zheng X, Liu X, Wang C, Sun W, Weng J. Performance of Continuous Glucose Monitoring System Among Patients With Acute Ischaemic Stroke Treated With Mechanical Thrombectomy. Diabetes Metab Res Rev 2024; 40:e70001. [PMID: 39545344 DOI: 10.1002/dmrr.70001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 07/14/2024] [Accepted: 08/26/2024] [Indexed: 11/17/2024]
Abstract
AIMS Glucose metabolism abnormalities are prevalent in acute ischaemic stroke (AIS) patients and are associated with poor prognosis. The continuous glucose monitoring (CGM) system can provide detailed information on glucose levels and glycaemic excursions. This study aimed to evaluate the feasibility and accuracy of CGM application in the acute phase of AIS patients. METHODS This single-centre, prospective, and observational study consecutively enrolled patients with AIS with anterior circulation large vessel occlusion (AC-LVO) and received mechanical thrombectomy (MT) within 24 h of symptom onset. A user-retrospectively calibrated iPro2 CGM system was implanted right before the MT procedure started and removed on the fifth day after MT or at discharge. Fingertip glucose was measured as a reference. Accuracy evaluation included the Bland-Altman plot (with a proportion of CGM values within 15/15, 20/20 and 30/30), the absolute relative difference (ARD) and error grid analysis (EGA). The safety and glucose profiles were also evaluated. RESULTS Of the 183 patients screened, 141 were included, with a median monitoring duration of 4.49 days. Compared to reference measurements, 3097 CGM readings were matched with a mean bias of -4.16 mg/dL. The proportions of sensor readings meeting the 15/15, 20/20 and 30/30 criteria were 64.55%, 76.07% and 87.21%, respectively. The overall mean and median ARD were 14.60% ± 14.62% and 9.77% (4.15, 20.00). EGA showed that 98.97%, 99.42% and 99.06% values fall within clinically accurate zones in Clarke, Parkes and continuous glucose EGA, respectively. CONCLUSION The CGM system was feasible, safe and accurate for in-hospital use among AIS patients who received MT.
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Affiliation(s)
- Jie Shi
- Department of Endocrinology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, China
| | - Jiahao Weng
- Department of Endocrinology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, China
| | - Yu Ding
- Department of Endocrinology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, China
| | - Yue Xia
- Department of Neurology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yongwen Zhou
- Department of Endocrinology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, China
| | - Xulin Wang
- Department of Endocrinology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, China
| | - Feng Zhang
- Department of Neurology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Pan Zhang
- Department of Neurology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Sihui Luo
- Department of Endocrinology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, China
| | - Xueying Zheng
- Department of Endocrinology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, China
| | - Xinfeng Liu
- Department of Neurology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Chaofan Wang
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Diabetes Prevention and Control Research Center, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Wen Sun
- Department of Neurology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Jianping Weng
- Department of Endocrinology, Centre for Leading Medicine and Advanced Technologies of IHM, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Clinical Research Hospital of Chinese Academy of Sciences (Hefei), University of Science and Technology of China, Hefei, China
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Bann SA, Hercus JC, Atkins P, Alkhairy A, Loyal JP, Sekhon M, Thompson DJ. Accuracy of a Continuous Glucose Monitor in the Intensive Care Unit: A Proposed Accuracy Standard and Calibration Protocol for Inpatient Use. Diabetes Technol Ther 2024; 26:797-805. [PMID: 38913325 DOI: 10.1089/dia.2024.0074] [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] [Indexed: 06/25/2024]
Abstract
Background and Aims: Guidelines now recommend inpatient continuous glucose monitor (CGM) use with confirmatory blood glucose measurements. However, the Food and Drug Administration has not yet officially approved CGM for inpatient use in large part because its accuracy has not been established in this setting. We tested the accuracy of the Dexcom G6 (G6) in 28 adults on an insulin infusion in a medical-surgical intensive care unit with 1064 matched CGM and arterial point-of-care pairs. Methods: The participants were on average 57.29 (SD 2.39) years, of whom 13 had a prior diagnosis of diabetes and 14 were admitted for a surgical diagnosis. The first 19 participants received the G6 without calibration and had a mean absolute relative difference (MARD) of 13.19% (IQR 5.11, 19.03) across 659 matched pairs, which just meets the critical care expert recommendation of MARD <14%. We then aimed to improve accuracy for the subsequent 9 participants using a calibration protocol. Results: The MARD for calibrated participants was 9.65% (3.03, 13.33), significantly lower than for uncalibrated participants (P < 0.001). Calibration also demonstrated excellent safety with 100% of values within the Clarke Error Grid zones A and B compared with 99.07% without calibration. Our protocol achieved the lowest MARD and safest CEG profile in the critical care setting and well exceeds the critical care expert recommendations. Our large sample of heterogenous critically ill patients also reached comparable accuracy to the MARD of 9% for G6 in outpatients. We believe our calibration protocol will allow G6 to be used with sufficient accuracy in inpatients.
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Affiliation(s)
- Sewon A Bann
- Division of Endocrinology, University of British Columbia, Vancouver, Canada
| | - Jess C Hercus
- Department of Biological Sciences, Simon Fraser University, Burnaby, Canada
| | - Paul Atkins
- Division of Endocrinology, University of British Columbia, Vancouver, Canada
| | - Areej Alkhairy
- Division of Endocrinology, University of British Columbia, Vancouver, Canada
| | - Jackson P Loyal
- Deanery of Molecular, Genetic and Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Mypinder Sekhon
- Division of Critical Care, University of British Columbia, Vancouver, Canada
| | - David J Thompson
- Division of Endocrinology, University of British Columbia, Vancouver, Canada
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Hervás C, Peirotén I, González L, Alonso de Leciñana M, Alonso-López E, Casado L, De Celis-Ruíz E, Fernández Prieto AF, Frutos R, Gallego-Ruiz R, González Pérez de Villar N, Gutiérrez-Fernández M, Navia P, Otero-Ortega L, Pozo-Novoa J, Rigual R, Rodríguez-Pardo J, Ruiz G, Fuentes B. Glycaemia and ischaemia-reperfusion brain injury in patients with ischaemic stroke treated with mechanical thrombectomy (GLIAS-MT): an observational, unicentric, prospective study protocol. BMJ Open 2024; 14:e086745. [PMID: 39117402 PMCID: PMC11404171 DOI: 10.1136/bmjopen-2024-086745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/22/2024] [Indexed: 08/10/2024] Open
Abstract
INTRODUCTION Poststroke hyperglycaemia is an independent risk factor for poorer outcomes in patients treated with mechanical thrombectomy (MT) and is associated with a lower probability of functional recovery and higher mortality at 3 months. This study aims to evaluate the association between glucose levels during cerebral reperfusion with MT and functional recovery at 3 months, measured by subcutaneous continuous glucose monitoring (CGM) devices. METHODS This prospective observational study aims to recruit 100 patients with ischaemic stroke and large anterior circulation vessel occlusion, in whom MT is indicated. CGM will be performed using a Freestyle Libre ProIQ device (FSL-CGM, Abbott Diabetes Care, Alameda, California, USA), which will be implanted on admission to the emergency department, to monitor glucose levels before, during and after reperfusion. The study's primary endpoint will be the functional status at 3 months, as measured by the dichotomised modified Rankin Scale (0-2 indicating good recovery and 3-6 indicating dependency or death). We will analyse expression profiles of microRNA (miRNA) at the time of reperfusion and 24 hours later, as potential biomarkers of ischaemic-reperfusion injury. The most promising miRNAs include miR-100, miR-29b, miR-339, miR-15a and miR-424. All patients will undergo treatment according to current international recommendations and local protocols for the treatment of stroke, including intravenous thrombolysis if indicated. ETHICS AND DISSEMINATION This study (protocol V.1.1, dated 29 October 2021, code 6017) has been approved by the Clinical Research Ethics Committee of La Paz University Hospital (Madrid, Spain) and has been registered in ClinicalTrials.gov (NCT05871502). Study results will be disseminated through peer-reviewed publications in Open Access format and at conference presentations. TRIAL REGISTRATION NUMBER NCT05871502.
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Affiliation(s)
- Carlos Hervás
- Department of Neurology and Stroke Centre, La Paz University Hospital and Department of Medicine, Universidad Autónoma de Madrid, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Irene Peirotén
- Department of Neurology and Stroke Centre, La Paz University Hospital and Department of Medicine, Universidad Autónoma de Madrid, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Laura González
- Department of Neurology and Stroke Centre, La Paz University Hospital and Department of Medicine, Universidad Autónoma de Madrid, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - María Alonso de Leciñana
- Department of Neurology and Stroke Centre, La Paz University Hospital and Department of Medicine, Universidad Autónoma de Madrid, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Elisa Alonso-López
- Department of Neurology and Stroke Centre, La Paz University Hospital and Department of Medicine, Universidad Autónoma de Madrid, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Laura Casado
- Department of Neurology and Stroke Centre, La Paz University Hospital and Department of Medicine, Universidad Autónoma de Madrid, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Elena De Celis-Ruíz
- Department of Neurology and Stroke Centre, La Paz University Hospital and Department of Medicine, Universidad Autónoma de Madrid, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Andrés Francisco Fernández Prieto
- Department of Radiology (Neurointerventional Radiology), La Paz University Hospital, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Remedios Frutos
- Department of Radiology (Neurointerventional Radiology), La Paz University Hospital, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Rebeca Gallego-Ruiz
- Neurological Sciences and Cerebrovascular Research Laboratory, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Noemí González Pérez de Villar
- Diabetes Unit, Department of Endocrinology, La Paz University Hospital, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - María Gutiérrez-Fernández
- Neurological Sciences and Cerebrovascular Research Laboratory, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Pedro Navia
- Department of Radiology (Neurointerventional Radiology), La Paz University Hospital, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Laura Otero-Ortega
- Neurological Sciences and Cerebrovascular Research Laboratory, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Javier Pozo-Novoa
- Neurological Sciences and Cerebrovascular Research Laboratory, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Ricardo Rigual
- Department of Neurology and Stroke Centre, La Paz University Hospital and Department of Medicine, Universidad Autónoma de Madrid, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Jorge Rodríguez-Pardo
- Department of Neurology and Stroke Centre, La Paz University Hospital and Department of Medicine, Universidad Autónoma de Madrid, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Gerardo Ruiz
- Department of Neurology and Stroke Centre, La Paz University Hospital and Department of Medicine, Universidad Autónoma de Madrid, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
| | - Blanca Fuentes
- Department of Neurology and Stroke Centre, La Paz University Hospital and Department of Medicine, Universidad Autónoma de Madrid, La Paz University Hospital Research Institute (IdiPAZ), Madrid, Spain
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Chen J, Ye B, Lin F, Cai W, Chen R, Ruan Z. An effective insulin infusion protocol for severe traumatic brain injury patients: A retrospective observational study. ENDOCRINOL DIAB NUTR 2024; 71:103-109. [PMID: 38555106 DOI: 10.1016/j.endien.2024.03.014] [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: 10/25/2023] [Accepted: 01/09/2024] [Indexed: 04/02/2024]
Abstract
PURPOSE Severe traumatic brain injury (sTBI) patients often experience stress hyperglycaemia, which can lead to negative outcomes. This study aims to introduce an effective insulin infusion protocol specifically designed for sTBI patients. METHODS Data was collected from all sTBI patients during two periods: 1 October 2019 to 30 April 2020, and 1 June 2020 to 31 December 2020. In May 2020, a new insulin infusion protocol was implemented. Blood glucose management, infection, coagulation, and prognosis were compared in these two periods. RESULT 195 patients were included, with 106 using the new protocol. The proportion of hyperglycaemia decreased from 40.04% to 26.91% (P<0.05), and the proportion of on-target blood glucose levels increased from 35.69% to 38.98% (P<0.05). Average blood glucose levels decreased from 9.98±2.79mmol/L to 8.96±2.82mmol/L (P<0.05). There was no substantial increase in hypoglycaemia, which remained controlled below 1%. The new protocol positively influenced glucose concentration and dispersion trends. There were no significant differences in catheter-related infections, antibiotic use, mechanical ventilation (MV) duration, length of stay in ICU, Glasgow Outcome Scale (GOS), or mortality. However, the conventional protocol group had a higher coagulation tendency (R-value of thromboelastography 4.80±1.35min vs. 5.52±1.87min, P<0.05), with no difference in deep vein thrombosis (DVT) incidence. CONCLUSION Our findings suggest that a customized insulin infusion process for sTBI patients can effectively manage blood glucose. While there is no significant improvement in infection control or prognosis, it may have a positive impact on coagulation without affecting the occurrence of DVT.
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Affiliation(s)
- Jie Chen
- Department of Emergency, Third Affiliated Hospital, Wenzhou Medical University, 108 Wansong Road, Zhejiang 325200, China
| | - Bingbing Ye
- Department of Emergency, Third Affiliated Hospital, Wenzhou Medical University, 108 Wansong Road, Zhejiang 325200, China
| | - Feng Lin
- Department of Emergency, Third Affiliated Hospital, Wenzhou Medical University, 108 Wansong Road, Zhejiang 325200, China
| | - Wenchao Cai
- Department of Emergency, Third Affiliated Hospital, Wenzhou Medical University, 108 Wansong Road, Zhejiang 325200, China
| | - Rui Chen
- Department of Emergency, Third Affiliated Hospital, Wenzhou Medical University, 108 Wansong Road, Zhejiang 325200, China.
| | - Zhanwei Ruan
- Department of Emergency, Third Affiliated Hospital, Wenzhou Medical University, 108 Wansong Road, Zhejiang 325200, China.
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Arias-Rivera S, Raurell-Torredà M, Fernández-Castillo RJ, Campos-Asensio C, Thuissard-Vasallo IJ, Andreu-Vázquez C, Rodríguez-Delgado ME. Blood glucose monitoring in critically ill adult patients: type of sample and method of analysis. Systematic review and meta-analysis. ENFERMERIA INTENSIVA 2024; 35:45-72. [PMID: 37474427 DOI: 10.1016/j.enfie.2023.02.002] [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: 01/18/2023] [Accepted: 02/15/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION The clinical guideline for the management of sepsis, recommends using arterial blood samples for glycaemic control. A multicentre study in 86 Spanish intensive care units (ICU) revealed that 85.4% of ICUs used capillary puncture. OBJECTIVE To analyse the reliability of glycaemia by comparing different blood samples (arterial, venous, capillary) and instruments (glucometers, gasometers, central laboratory). Secondarily, to estimate the effect of confounding variables and the performance of measuring instruments as determined by different quality standards. METHODOLOGY Systematic review and meta-analysis with search in PubMed, CINAHL and Embase databases in September-2021 and September-2022, with no time or language limits. Grey literature sources: DART-Europe, OpenGrey and Google Scholar. Results summarised by qualitative (description of results, study characteristics) and quantitative (meta-analysis to assess standardised mean difference) synthesis. Methodological quality of articles assessed with Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). PROTOCOL https://osf.io/ DOI 10.17605/OSF.IO/T8KYP. RESULTS A total of 32 articles and 5451 patients were included. No discrepancies were obtained between arterial glucometer vs laboratory samples [bias (95%CI): 0.01 (-0.12 to 0.14) mg/dL]. In contrast, arterial samples with a gasometer did significantly overestimate [bias (95%CI): 0.12 (0.01 to 0.24) mg/dL]. The same trend is seen in capillaries with a glucometer, although not significantly [bias (95%CI): 0.07 (--0.02 to 0.15) mg/dL]. There is discrepancy between studies on the effect of haematocrit and acid-base balance. The greatest consensus is on the poor agreement of glucometer with capillary vs laboratory samples in the presence of shock and vasopressor support, renal failure or during vitamin C treatment. CONCLUSIONS The evidence to date recommends the use of arterial blood with a blood glucose meter for better reliability of glycaemic analysis and less effect of possible confounding variables, frequently present in the critically ill adult patient.
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Affiliation(s)
- S Arias-Rivera
- Enfermera Investigación, Hospital Universitario de Getafe, Madrid, Spain
| | - M Raurell-Torredà
- Departamento Enfermería, Fundamental y Médico Quirúrgica, Universitat de Barcelona, Barcelona, Spain.
| | - R-J Fernández-Castillo
- Unidad de Cuidados Críticos Hospital Universitario Virgen Macarena, Departamento de Enfermería, Facultad de Enfermería, Sevilla, Spain
| | - C Campos-Asensio
- Bibliotecaria Médica, Hospital Universitario de Getafe, Madrid, Spain
| | - I-J Thuissard-Vasallo
- Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | - C Andreu-Vázquez
- Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | - M E Rodríguez-Delgado
- Unidad de Cuidados Intensivos, Hospital Universitario Clínico San Cecilio, Granada, Spain
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Spanakis EK, Cook CB, Kulasa K, Aloi JA, Bally L, Davis G, Dungan KM, Galindo RJ, Mendez CE, Pasquel FJ, Shah VN, Umpierrez GE, Aaron RE, Tian T, Yeung AM, Huang J, Klonoff DC. A Consensus Statement for Continuous Glucose Monitoring Metrics for Inpatient Clinical Trials. J Diabetes Sci Technol 2023; 17:1527-1552. [PMID: 37592726 PMCID: PMC10658683 DOI: 10.1177/19322968231191104] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Diabetes Technology Society organized an expert consensus panel to develop metrics for research in the use of continuous glucose monitors (CGMs) in a hospital setting. The experts met virtually in small groups both before and after an April 13, 2023 virtual meeting of the entire panel. The goal of the panel was to develop consensus definitions in anticipation of greater use of CGMs in hospital settings in the future. Establishment of consensus definitions of inpatient analytical metrics will be easier to compare outcomes between studies. Panelists defined terms related to 10 dimensions of measurements related to the use of CGMs including (1) hospital hypoglycemia, (2) hospital hyperglycemia, (3) hospital time in range, (4) hospital glycemic variability, (5) hospital glycemia risk index, (6) accuracy of CGM devices and reference methods for CGMs in the hospital, (7) meaningful time blocks for hospital glycemic goals, (8) hospital CGM data sufficiency, (9) using CGM data for insulin dosing, and (10) miscellaneous factors. The panelists voted on 51 proposed recommendations. Based on the panel vote, 51 recommendations were classified as either strong (43) or mild (8). Additional research is needed on CGM performance in the hospital. This consensus report is intended to support that type of research intended to improve outcomes for hospitalized people with diabetes.
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Affiliation(s)
- Elias K. Spanakis
- Baltimore VA Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Curtiss B. Cook
- Division of Endocrinology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Kristen Kulasa
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Joseph A. Aloi
- Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Georgia Davis
- Emory University School of Medicine, Atlanta, GA, USA
| | - Kathleen M. Dungan
- Division of Endocrinology, Diabetes & Metabolism, The Ohio State University, Columbus, OH, USA
| | | | | | | | - Viral N. Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Tiffany Tian
- Diabetes Technology Society, Burlingame, CA, USA
| | | | | | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
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9
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Bellido V, Freckman G, Pérez A, Galindo RJ. Accuracy and Potential Interferences of Continuous Glucose Monitoring Sensors in the Hospital. Endocr Pract 2023; 29:919-927. [PMID: 37369291 DOI: 10.1016/j.eprac.2023.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023]
Abstract
For years, the standard of care for monitoring dysglycemia in hospitalized patients was capillary blood glucose (CBG) testing with point-of-care glucose meters. Recently, there has been a revolution in novel factory-calibrated continuous glucose monitoring (CGM) systems. Newer CGMs are smaller and less expensive, have improved accuracy and longer wear time, and do not require fingerstick CBG for calibration, resulting in increased utilization in ambulatory settings. Consequently, hospitals have noticed increased usability of CGMs among hospitalized patients and expect a progressive continued increase. During the COVID-19 pandemic, there was a critical need for innovative approaches to glycemic monitoring, with several pilot implementation projects using CGM in the intensive care unit and non-intensive care unit settings, further boosting the evidence in this area. Hence, recent guidelines have provided recommendations for the use of CGM in specific hospital scenarios and highlighted the potential of CGM to overcome CBG limitations for glucose monitoring in the inpatient setting. In this review, we provide the following: 1) an up-to-date review of the accuracy of the newer CGMs in hospitalized patients, 2) a discussion of standards for CGM accuracy metrics, 3) a contemporary overview of potential interferences that may cause inaccuracies or poor CGM performance, and 4) required steps for full regulatory approval of CGMs in the hospital and future research steps to advance the field forward.
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Affiliation(s)
- Virginia Bellido
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Guido Freckman
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | - Antonio Pérez
- Servicio de Endocrinología y Nutrición. Hospital de la Santa Creu i Sant Pau, IIB Sant Pau, Universitat Autònoma de Barcelona. CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, España
| | - Rodolfo J Galindo
- University of Miami Miller School of Medicine, Division of Endocrinology, Diabetes and Metabolism, Miami, Florida.
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10
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Benyó B, Paláncz B, Szlávecz Á, Szabó B, Kovács K, Chase JG. Classification-based deep neural network vs mixture density network models for insulin sensitivity prediction problem. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 240:107633. [PMID: 37343375 DOI: 10.1016/j.cmpb.2023.107633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/21/2023] [Accepted: 05/29/2023] [Indexed: 06/23/2023]
Abstract
Model-based glycemic control (GC) protocols are used to treat stress-induced hyperglycaemia in intensive care units (ICUs). The STAR (Stochastic-TARgeted) glycemic control protocol - used in clinical practice in several ICUs in New Zealand, Hungary, Belgium, and Malaysia - is a model-based GC protocol using a patient-specific, model-based insulin sensitivity to describe the patient's actual state. Two neural network based methods are defined in this study to predict the patient's insulin sensitivity parameter: a classification deep neural network and a Mixture Density Network based method. Treatment data from three different patient cohorts are used to train the network models. Accuracy of neural network predictions are compared with the current model- based predictions used to guide care. The prediction accuracy was found to be the same or better than the reference. The authors suggest that these methods may be a promising alternative in model-based clinical treatment for patient state prediction. Still, more research is needed to validate these findings, including in-silico simulations and clinical validation trials.
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Affiliation(s)
- Balázs Benyó
- Department of Control Engineering and Information Technology, Faculty of Electrical Engineering and Informatics, Budapest University of Technology and Economics, Budapest, Hungary.
| | - Béla Paláncz
- Department of Control Engineering and Information Technology, Faculty of Electrical Engineering and Informatics, Budapest University of Technology and Economics, Budapest, Hungary
| | - Ákos Szlávecz
- Department of Control Engineering and Information Technology, Faculty of Electrical Engineering and Informatics, Budapest University of Technology and Economics, Budapest, Hungary
| | - Bálint Szabó
- Department of Control Engineering and Information Technology, Faculty of Electrical Engineering and Informatics, Budapest University of Technology and Economics, Budapest, Hungary
| | - Katalin Kovács
- Department of Informatics, Széchenyi István University, Győr, Hungary
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
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11
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Plummer MP, Rait L, Finnis ME, French CJ, Bates S, Douglas J, Bhurani M, Broadley T, Trapani T, Deane AM, Udy AA, Burrell AJC. Diabetes mellitus, glycaemic control, and severe COVID-19 in the Australian critical care setting: A nested cohort study. Aust Crit Care 2023; 36:579-585. [PMID: 35820985 PMCID: PMC9125138 DOI: 10.1016/j.aucc.2022.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Internationally, diabetes mellitus is recognised as a risk factor for severe COVID-19. The relationship between diabetes mellitus and severe COVID-19 has not been reported in the Australian population. OBJECTIVE The objective of this study was to determine the prevalence of and outcomes for patients with diabetes admitted to Australian intensive care units (ICUs) with COVID-19. METHODS This is a nested cohort study of four ICUs in Melbourne participating in the Short Period Incidence Study of Severe Acute Respiratory Infection (SPRINT-SARI) Australia project. All adult patients admitted to the ICU with COVID-19 from 20 February 2020 to 27 February 2021 were included. Blood glucose and glycated haemoglobin (HbA1c) data were retrospectively collected. Diabetes was diagnosed from medical history or an HbA1c ≥6.5% (48 mmol/mol). Hospital mortality was assessed using logistic regression. RESULTS There were 136 patients with median age 58 years [48-68] and median Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 14 [11-19]. Fifty-eight patients had diabetes (43%), 46 patients had stress-induced hyperglycaemia (34%), and 32 patients had normoglycaemia (23%). Patients with diabetes were older, were with higher APACHE II scores, had greater glycaemic variability than patients with normoglycaemia, and had longer hospital length of stay. Overall hospital mortality was 16% (22/136), including nine patients with diabetes, nine patients with stress-induced hyperglycaemia, and two patients with normoglycaemia. CONCLUSION Diabetes is prevalent in patients admitted to Australian ICUs with severe COVID-19, highlighting the need for prevention strategies in this vulnerable population.
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Affiliation(s)
- Mark P Plummer
- Department of Critical Care, Melbourne Medical School, Melbourne, Victoria, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia.
| | - Louise Rait
- Department of Critical Care, Melbourne Medical School, Melbourne, Victoria, Australia
| | - Mark E Finnis
- Department of Critical Care, Melbourne Medical School, Melbourne, Victoria, Australia
| | - Craig J French
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Samantha Bates
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - James Douglas
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Mansi Bhurani
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Tessa Broadley
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, Melbourne, Victoria, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Aidan J C Burrell
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
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12
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Sreedharan R, Khanna S, Shaw A. Perioperative glycemic management in adults presenting for elective cardiac and non-cardiac surgery. Perioper Med (Lond) 2023; 12:13. [PMID: 37120562 PMCID: PMC10149003 DOI: 10.1186/s13741-023-00302-6] [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: 11/30/2021] [Accepted: 04/19/2023] [Indexed: 05/01/2023] Open
Abstract
Perioperative dysglycemia is associated with adverse outcomes in both cardiac and non-cardiac surgical patients. Hyperglycemia in the perioperative period is associated with an increased risk of postoperative infections, length of stay, and mortality. Hypoglycemia can induce neuronal damage, leading to significant cognitive deficits, as well as death. This review endeavors to summarize existing literature on perioperative dysglycemia and provides updates on pharmacotherapy and management of perioperative hyperglycemia and hypoglycemia in surgical patients.
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Affiliation(s)
- Roshni Sreedharan
- Department of Intensive Care & Resuscitation, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of General Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sandeep Khanna
- Department of General Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Department of Outcomes Research, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Andrew Shaw
- Department of Intensive Care & Resuscitation, Cleveland Clinic Foundation, Cleveland, OH, USA
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13
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Effect of Time-Restricted Eating and Resistance Training on High-Speed Strength and Body Composition. Nutrients 2023; 15:nu15020285. [PMID: 36678156 PMCID: PMC9863948 DOI: 10.3390/nu15020285] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/09/2023] Open
Abstract
This study examined the effects of four weeks of resistance training combined with time-restricted eating (TRE) vs. habitual diet on fat and fat-free mass as well as maximum and explosive force production in healthy, trained participants (18 males, aged 23.7 ± 2.6 years). The order of dieting was randomized and counterbalanced, and the participants served as their own controls. TRE involved an 8-h eating window and non-TRE involved a habitual meal pattern. Participants completed performance strength tests and body composition scans at baseline and post-intervention. The participants followed a structured training routine during each dietary intervention (four sets of maximum repetitions at 85% 1RM in five dynamic exercises, three times/week). Both interventions elicited deceases in fat mass (p < 0.05) but not in fat-free mass. After training (controlling for baseline values as covariates), non-TRE was compatible with better lower body jump performance than TRE (p < 0.05). Conversely, training with TRE elicited higher values in terms of peak force and dynamic strength index at the level of the upper body (p < 0.05). Thus, it can be concluded that there were no differences in fat mass and fat-free mass changes between interventions in already trained young males. Additionally, while the combination of TRE and resistance training might be beneficial for individuals focusing on developing high-speed strength performance at the upper body level, this is not applicable to those focusing on training the lower body.
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14
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Sreedharan R, Martini A, Das G, Aftab N, Khanna S, Ruetzler K. Clinical challenges of glycemic control in the intensive care unit: A narrative review. World J Clin Cases 2022; 10:11260-11272. [PMID: 36387820 PMCID: PMC9649548 DOI: 10.12998/wjcc.v10.i31.11260] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/15/2022] [Accepted: 09/27/2022] [Indexed: 02/05/2023] Open
Abstract
Glucose control in patient admitted to the intensive care unit has been a topic of much debate over the past 20 years. The harmful effects of uncontrolled hyperglycemia and hypoglycemia in critically ill patients is well established. Although a large clinical trial in 2001 demonstrated significant mortality and morbidity benefits with tight glucose control in this patient population, the results could not be replicated by other investigators. The “Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation” trial in 2009 established that tight glucose control was not only of no benefit, but in fact harmful due to the significant risk of hypoglycemia. The current guidelines suggest a moderate approach with the initiation of intravenous insulin therapy in critically ill patients when the blood glucose level is above 180 mg/dL. The most important factor that underpins glycemic management in intensive care unit patients is the consequent prevention of hypoglycemia. Robust glucose monitoring strategies and insulin protocols need to be implemented in order to achieve this goal.
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Affiliation(s)
- Roshni Sreedharan
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Adriana Martini
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Gyan Das
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Nida Aftab
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Sandeep Khanna
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Kurt Ruetzler
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
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15
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Glycemic control in critically ill patients with or without diabetes. BMC Anesthesiol 2022; 22:227. [PMID: 35842591 PMCID: PMC9288031 DOI: 10.1186/s12871-022-01769-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/08/2022] [Indexed: 11/22/2022] Open
Abstract
Background Early randomized controlled trials have demonstrated the benefits of tight glucose control. Subsequent NICE-SUGAR study found that tight glucose control increased mortality. The optimal glucose target in diabetic and nondiabetic patients remains unclear. This study aimed to evaluate the relationship between blood glucose levels and outcomes in critically ill patients with or without diabetes. Methods This was a retrospective analysis of the eICU database. Repeat ICU stays, ICU stays of less than 2 days, patients transferred from other ICUs, those with less than 2 blood glucose measurements, and those with missing data on hospital mortality were excluded. The primary outcome was hospital mortality. Generalised additive models were used to model relationship between glycemic control and mortality. Models were adjusted for age, APACHE IV scores, body mass index, admission diagnosis, mechanical ventilation, and use of vasopressor or inotropic agents. Results There were 52,107 patients in the analysis. Nondiabetes patients exhibited a J-shaped association between time-weighted average glucose and hospital mortality, while this association in diabetes patients was right-shifted and flattened. Using a TWA glucose of 100 mg/dL as the reference value, the adjusted odds ratio (OR) of TWA glucose of 140 mg/dL was 3.05 (95% confidence interval (CI) 3.03–3.08) in nondiabetes and 1.14 (95% CI 1.08–1.20) in diabetes patients. The adjusted OR of TWA glucose of 180 mg/dL were 4.20 (95% CI 4.07–4.33) and 1.49 (1.41–1.57) in patients with no diabetes and patients with diabetes, respectively. The adjusted ORs of TWA glucose of 80 mg/dL compared with 100 mg/dL were 1.74 (95% CI 1.57–1.92) in nondiabetes and 1.36 (95% CI 1.12–1.66) in patients with diabetes. The glucose ranges associated with a below-average risk of mortality were 80–120 mg/dL and 90–150 mg/dL for nondiabetes and diabetes patients, respectively. Hypoglycemia was associated with increased hospital mortality in both groups but to a lesser extent in diabetic patients. Glucose variability was positively associated with hospital mortality in nondiabetics. Conclusions Time-weighted average glucose, hypoglycemia, and glucose variability had different impacts on clinical outcomes in patients with and without diabetes. Compared with nondiabetic patients, diabetic patients showed a more blunted response to hypo- and hyperglycemia and glucose variability. Glycemic control strategies should be reconsidered to avoid both hypoglycemia and hyperglycemia. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01769-4.
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16
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Pavese F. A testing/metrological look at the accuracy of glucose strip measurements in home care for marginal diabetes, for mitigating diabetic kidney disease. J Nephrol 2022; 35:1565-1569. [PMID: 35023077 DOI: 10.1007/s40620-021-01224-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/17/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Franco Pavese
- Istituto Nazionale di Ricerca Metrologica, Turin, Italy.
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17
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Raurell-Torredà M, Arias-Rivera S. Blood glucose monitoring. Nationwide multicentre study. Med Intensiva 2021; 46:164-165. [PMID: 34961689 DOI: 10.1016/j.medine.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/16/2020] [Accepted: 12/20/2020] [Indexed: 10/19/2022]
Affiliation(s)
- M Raurell-Torredà
- Facultad de Medicina y Ciencias de la Salud. Universidad de Barcelona, Barcelona, Spain.
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18
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Nedel W, Lisboa T, Salluh JIF. What Is the Role of Steroids for Septic Shock in 2021? Semin Respir Crit Care Med 2021; 42:726-734. [PMID: 34544190 DOI: 10.1055/s-0041-1733900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Corticosteroids have been used for decades in the adjunctive treatment of severe infections in intensive care. The most frequent scenario in intensive care is in septic shock, where low doses of glucocorticoids appear to restore vascular responsiveness to norepinephrine. There is a strong body of evidence suggesting that hydrocortisone reduces time on vasopressor, and may modulate the immune response. In this review, we explore the current evidence supporting the use of corticosteroids in septic shock, its benefits, and potential harms. In addition to landmark clinical trials, we will also describe new frontiers for the use of corticosteroids in septic shock which should be explored in future studies.
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Affiliation(s)
- Wagner Nedel
- Programa de Pós-Graduação em Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Intensive Care Unit, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Thiago Lisboa
- Critical Care Department, Programa de Pós-Graduação em Ciencias Pneumologicas, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Universidade Unilasalle, Canoas, Brazil
- Instituto de Pesquisa, HCOR, São Paulo, Brazil
| | - Jorge I F Salluh
- Department of Critical Care and Postgraduate Program in Translational Medicine, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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19
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Another Stepping Stone Toward Personalized Glycemic Control. Crit Care Med 2021; 48:1893-1896. [PMID: 33255106 DOI: 10.1097/ccm.0000000000004657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Eckert I, Kumbier MCC, Silva FM, Franzosi OS, de Almeida JC. Association of specialized enteral nutrition with glycemic control and clinical outcomes in critically ill patients: A meta-analysis of randomized controlled trials. Clin Nutr 2021; 40:3940-3949. [PMID: 34139467 DOI: 10.1016/j.clnu.2021.04.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/06/2021] [Accepted: 04/19/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the association of glycemic-control formulae (GCF) with measurements of glycemic control and clinical outcomes compared to standard enteral formulae (SF) in critically ill patients. DATA SOURCES MEDLINE, EMBASE, Scopus and the Cochrane Central Register of Controlled Trials were searched from inception up to January, 2021. STUDY SELECTION RCTs that assessed the effects of GCF relative to SF in adult critically ill patients. DATA EXTRACTION Measurements of glycemic control were the primary outcomes. Secondary outcomes included insulin requirements, mechanical ventilation (MV), length of intensive care unit (ICU) stay and mortality. Two authors independently extracted data and assessed risk of bias using the Cochrane's RoB 2 tool and the GRADE approach was used to assess the quality of evidence. DATA SYNTHESIS Ten studies (12 reports, 685 patients) were included. The use of GCFs was associated with lower blood glucose (WMD, -16.06 mg/dL; 95% CI -23.48 to -8.63; I2 = 47%) and lower daily administered insulin (WMD, -7.20 IU; 95% CI -13.92 to -0.48; I2 = 53%). Glycemic variability, measured by the coefficient of variation, was also associated with the use of GCFs (WMD, -6.84%; 95% CI, -13.57 to -0.11; I2 = 95%). In contrast, analyses for length of ICU stay (WMD, -0.12, 95% CI -1.77 to 1.52; I2 = 0%), duration of MV (WMD, -0.34 days; 95% CI, -1.72 to 1.04; I2 = 0%) and mortality (RR, 1.13; 95% CI 0.82 to 1.56; I2 = 0%) were not statistically significant. Quality of evidence ranged from low to very low, and only one study was judged as at low risk of bias. CONCLUSIONS In this meta-analysis, GCFs were significantly associated with lower insulin requirements and improved glycemic control. Although results for clinical outcomes were not statistically significant, there is insufficient evidence to confirm or exclude important differences due to serious imprecision in the effect estimates and overall low quality of evidence. The effects of GCFs on clinical outcomes require confirmation in larger randomized trials.
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Affiliation(s)
- Igor Eckert
- Nutrition Undergraduate Program, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil
| | - Magali C C Kumbier
- Graduate Program on Medical Sciences: Endocrinology, Faculdade de Medicina, Universidade Federal Do Rio Grande Do Sul (UFRGS), Rio Grande do Sul, Brazil
| | - Flávia M Silva
- Department of Nutrition and Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil.
| | - Oellen S Franzosi
- Nutrition and Dietetic Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jussara C de Almeida
- Graduate Program on Medical Sciences: Endocrinology, Faculdade de Medicina, Universidade Federal Do Rio Grande Do Sul (UFRGS), Rio Grande do Sul, Brazil; Division of Nutrition and Dietetics, Hospital de Clínicas de Porto Alegre (HCPA), Rio Grande do Sul, Brazil; Department of Nutrition, Faculdade de Medicina, Universidade Federal Do Rio Grande Do Sul, Rio Grande do Sul (UFRGS), Brazil
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21
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Clarke Error Grid Analysis for Performance Evaluation of Glucometers in a Tertiary Care Referral Hospital. Indian J Clin Biochem 2021; 37:199-205. [PMID: 35463101 PMCID: PMC8993970 DOI: 10.1007/s12291-021-00971-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
Glucometer is the most commonly used POCT device and guides monitoring of blood glucose level in both clinical settings and outside. Inaccurate glucometer readings resulting in erroneous therapeutic intervention has critical consequences on patient care. Regulatory guidelines for performance evaluation of glucometers are not available in many countries. A robust program implemented by the hospital is essential to ensure accuracy and precision of glucometers to produce optimal results. The objective of this study was to design a quality assurance program for the evaluation of glucometers in a high volume tertiary care referral hospital and evaluate the results from July'18 to July'19. Seventy three glucometers used across the hospital were subjected to Internal Quality Control checks and Proficiency Testing performed once a month and every 3 months respectively. The results were reviewed and plotted on a Bland Altman Graph. Clarke Error Grid Analysis was done to evaluate the clinical significance of inaccuracies in the measurement of blood glucose concentration as per ISO 15197: 2013. Eight devices were identified as unacceptable by ISO standards and replaced subsequently. 96.83% and 3.17% of the values were in Zone A and B of Clarke Error Grid Analysis. The study complied with the standard which requires that 99% of the values fall within zones A and B. The review of the program after one year and its ability to identify defective glucometers has validated the efficacy of the model. The method used may be suggested as a prototype for quality management of glucometers in a clinical setting.
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22
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Hypoglycemic episodes predict length of stay in patients with acute burns. J Crit Care 2021; 64:68-73. [PMID: 33794469 DOI: 10.1016/j.jcrc.2021.03.005] [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: 08/10/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 11/23/2022]
Abstract
Hypoglycemic episodes are associated with worse hospital outcomes. All adult patients admitted to our burn center from 2015 to 2019 were retrospectively reviewed. Patient demographics and burn characteristics were recorded. The primary outcome was mortality, and secondary outcomes were total length-of-stay and intensive care unit length-of-stay. All patients experiencing at least one hypoglycemic episode were compared to patients who did not experience hypoglycemia. There were 914 patients with acute burns admitted during the study period, 33 of which (4%) experienced hypoglycemic episodes. Of these, 17 patients (52%) experienced a single hypoglycemic episode, while the remainder experienced multiple hypoglycemic episodes. Patients with one or more hypoglycemic events were matched to non-hypoglycemic controls using propensity matching. Patients that experienced hypoglycemia had significantly less TBSA involvement (5% vs. 13%,median, p < 0.0002), higher prevalence of diabetes (48% vs. 18%, p < 0.0001), higher mortality (18% vs. 7%, p = 0.01), longer total length-of-stay (22 vs. 8 days, median, p < 0.0001), and longer ICU length-of-stay (12 vs. 0 days, median, p < 0.0001). A single hypoglycemic episode was associated with prolonged total (IRR = 1.91, p < 0.0001) and ICU length-of-stay (IRR = 3.86, p < 0.0001). Hypoglycemia was not associated with higher mortality in the survival analysis (p = 0.46).
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23
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Burslem R, Rigassio Radler D, Parker A, Zelig R. Low-carbohydrate, high-fat enteral formulas for managing glycemic control in patients who are critically ill: A review of the evidence. Nutr Clin Pract 2021; 37:68-80. [PMID: 33734480 DOI: 10.1002/ncp.10652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Hyperglycemia is associated with increased morbidity and mortality. Low-carbohydrate, high-fat (LCHF) enteral formulas are marketed to improve glycemic control; however, given the multifactorial mechanisms contributing to hyperglycemia in patients who are critically ill, the effect that LCHF formulas may have on improving glycemic control in this patient population is unclear. Current guidelines for the use of LCHF formulas among patients who are critically ill are limited by a lack of evidence. This review explores recent research published in the past 7 years to determine whether LCHF enteral formulas improve glycemic control compared with standard enteral formulas in patients who are critically ill. Four randomized controlled trials met the inclusion criteria for this review. Their results suggest that LCHF formulas may improve glycemic control in patients who are critically ill with diabetes mellitus and/or who are hyperglycemic. Further large-scale randomized controlled trials are warranted to validate these findings among different subgroups of patients with critical illness. The potential benefits of LCHF formulas need to be weighed against specific limitations, including that LCHF formulas typically do not contain sufficient protein to meet the recommended needs of patients who are critically ill.
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Affiliation(s)
- Ryan Burslem
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers University, Newark, New Jersey, USA
| | - Diane Rigassio Radler
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers University, Newark, New Jersey, USA
| | - Anna Parker
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers University, Newark, New Jersey, USA
| | - Rena Zelig
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Rutgers University, Newark, New Jersey, USA
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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: 2] [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: 12/14/2022]
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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25
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Bochicchio GV, Nasraway SA, Moore LJ, Furnary AP, Nohra EA, Bochicchio KM, Boyd JC, Bruns DI, Hirsch IB, Preiser JC, Krinsley JS. Fifteen-minute Frequency of Glucose Measurements and the Use of Threshold Alarms: Impact on Mitigating Dysglycemia in Critically Ill Patients. J Diabetes Sci Technol 2021; 15:279-286. [PMID: 31744315 PMCID: PMC8256060 DOI: 10.1177/1932296819886917] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The use of near-continuous blood glucose (BG) monitoring has the potential to improve glycemic control in critically ill patients. The MANAGE IDE trial evaluated the performance of the OptiScanner (OS) 5000 in a multicenter cohort of 200 critically ill patients. METHODS An Independent Group reviewed the BG run charts of all 200 patients and voted whether unblinded use of the OS, with alarms set at 90 and 130 to 150 mg/dL to alert the clinical team to impending hypoglycemia and hyperglycemia, respectively, would have eliminated episodes of dysglycemia: hypoglycemia, defined as a single BG <70 mg/dL; hyperglycemia, defined as >4 hours of BG >150 mg/dL; severe hyperglycemia, defined as >4 hours of BG >200 mg/dL and increased glucose variability (GV), defined as coefficient of variation (CV) >20%. RESULTS At least one episode of dysglycemia occurred in 103 (51.5%) of the patients, including 6 (3.0%) with hypoglycemia, 83 (41.5%) with hyperglycemia, 18 (9.0%) with severe hyperglycemia, and 40 (20.0%) with increased GV. Unblinded use of the OS with appropriate alarms would likely have averted 97.1% of the episodes of dysglycemia: hypoglycemia (100.0%), hyperglycemia (96.4%), severe hyperglycemia (100.0%), and increased GV (97.5%). Point accuracy of the OS was very similar to that of the point of care BG monitoring devices used in the trial. CONCLUSION Unblinded use of the OS would have eliminated nearly every episode of dysglycemia in this cohort of critically ill patients, thereby markedly improving the quality and safety of glucose control.
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Affiliation(s)
| | | | - Laura J. Moore
- Department of Surgery, University of
Texas, McGovern Medical School, Houston, TX, USA
- Memorial Hermann Hospital, Houston, TX,
USA
| | - Anthony P. Furnary
- Providence St Vincent Medical Center,
Portland, OR, USA
- Oregon Med Laser Center, Portland, OR,
USA
- Portland Diabetes Project, OR, USA
| | - Eden A. Nohra
- Washington University, St. Louis School
of Medicine, MO, USA
| | | | - James C. Boyd
- University of Virginia Health System,
Charlottesville, VA, USA
| | - David I. Bruns
- University of Virginia Health System,
Charlottesville, VA, USA
| | - Irl B. Hirsch
- University of Washington School of
Medicine, Seattle, WA, USA
| | | | - James S. Krinsley
- Division of Critical Care, Stamford
Hospital and Columbia Vagelos College of Physicians and Surgeons, CT, USA
- James S. Krinsley, MD, FCCM, FCCP, Columbia
Vagelos College of Physicians and Surgeons, Division of Critical Care,
Department of Medicine, Stamford Hospital, 1 Hospital Plaza, Stamford, CT 06902,
USA.
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26
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Raurell-Torredà M, Arias-Rivera S. Blood glucose monitoring. Nationwide multicentre study. Med Intensiva 2021; 46:S0210-5691(21)00004-8. [PMID: 33551111 DOI: 10.1016/j.medin.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/16/2020] [Accepted: 12/20/2020] [Indexed: 12/20/2022]
Affiliation(s)
- M Raurell-Torredà
- Facultad de Medicina y Ciencias de la Salud. Universidad de Barcelona, Barcelona, España.
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27
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Mörgeli R, Wollersheim T, Engelhardt LJ, Grunow JJ, Lachmann G, Carbon NM, Koch S, Spies C, Weber-Carstens S. Critical illness myopathy precedes hyperglycaemia and high glucose variability. J Crit Care 2021; 63:32-39. [PMID: 33592497 DOI: 10.1016/j.jcrc.2021.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Critical Illness Myopathy (CIM) is a serious ICU complication, and dysglycaemia is widely regarded as a risk factor. Although glucose variability (GV) has been independently linked to ICU mortality, an association with CIM has not been investigated. This study examines the relationship between CIM and GV. METHODS Retrospective investigation including ICU patients with SOFA ≥8, mechanical ventilation, and CIM diagnostics. Glucose readings were collected every 6 h throughout the first week of treatment, when CIM is thought to develop. GV was measured using standard deviation (SD), coefficient of variability (CV), mean absolute glucose (MAG), mean amplitude of glycaemic excursions (MAGE), and mean of daily difference (MODD). RESULTS 74 patients were included, and 50 (67.6%) developed CIM. Time on glycaemic target (70-179 mg/dL), caloric and insulin intakes, mean, maximum and minimum blood glucose values were similar for all patients until the 5th day, after which CIM patients exhibited higher mean and maximum glucose levels. Significantly higher GV in CIM patients were observed on day 5 (SD, CV, MAG, MAGE), day 6 (MODD), and day 7 (SD, CV, MAG). CONCLUSIONS CIM patients developed transient increases in GV and hyperglycaemia only late in the first week, suggesting that myopathy precedes dysglycaemia.
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Affiliation(s)
- Rudolf Mörgeli
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany.
| | - Tobias Wollersheim
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, D-10178 Berlin, Germany.
| | - Lilian Jo Engelhardt
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany.
| | - Julius J Grunow
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, D-10178 Berlin, Germany.
| | - Gunnar Lachmann
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, D-10178 Berlin, Germany.
| | - Niklas M Carbon
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany.
| | - Susanne Koch
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany.
| | - Claudia Spies
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany.
| | - Steffen Weber-Carstens
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, D-10178 Berlin, Germany.
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Fuentes B, Pastor-Yborra S, Gutiérrez-Zúñiga R, González-Pérez de Villar N, de Celis E, Rodríguez-Pardo J, Gómez-de Frutos MC, Laso-García F, Gutiérrez-Fernández M, Ortega-Casarrubios MÁ, Soto A, López-Fernández M, Santamaría M, Díez-González N, Freijo MM, Zandio B, Delgado-Mederos R, Calleja A, Portilla-Cuenca JC, Lisbona A, Otero-Ortega L, Díez-Tejedor E. Glycemic variability: prognostic impact on acute ischemic stroke and the impact of corrective treatment for hyperglycemia. The GLIAS-III translational study. J Transl Med 2020; 18:414. [PMID: 33148277 PMCID: PMC7610240 DOI: 10.1186/s12967-020-02586-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/24/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction Glycemic variability (GV) represents the amplitude of oscillations in glucose levels over time and is associated with higher mortality in critically ill patients. Our aim is to evaluate the impact of GV on acute ischemic stroke (IS) outcomes in humans and explore the impact of two different insulin administration routes on GV in an animal model. Methods This translational study consists of two studies conducted in parallel: The first study is an observational, multicenter, prospective clinical study in which 340 patients with acute IS will be subcutaneously implanted a sensor to continuously monitor blood glucose levels for 96 h. The second study is a basic experimental study using an animal model (rats) with permanent occlusion of the middle cerebral artery and induced hyperglycemia (through an intraperitoneal injection of nicotinamide and streptozotocin). The animal study will include the following 6 groups (10 animals per group): sham; hyperglycemia without IS; IS without hyperglycemia; IS and hyperglycemia without treatment; IS and hyperglycemia and intravenous insulin; and IS and hyperglycemia and subcutaneous insulin. The endpoint for the first study is mortality at 3 months, while the endpoints for the animal model study are GV, functional recovery and biomarkers. Discussion The GLIAS-III study will be the first translational approach analyzing the prognostic influence of GV, evaluated by the use of subcutaneous glucose monitors, in acute stroke. Trial registrationhttps://www.clinicaltrials.gov (NCT04001049)
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Affiliation(s)
- Blanca Fuentes
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain.
| | - Silvia Pastor-Yborra
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Raquel Gutiérrez-Zúñiga
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Noemí González-Pérez de Villar
- Department of Endocrinology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Elena de Celis
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Jorge Rodríguez-Pardo
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Mari Carmen Gómez-de Frutos
- Neurological Sciences and Cerebrovascular Research Laboratory, Department of Neurology and Stroke Centre, Neuroscience Area, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Fernando Laso-García
- Neurological Sciences and Cerebrovascular Research Laboratory, Department of Neurology and Stroke Centre, Neuroscience Area, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain
| | - María Gutiérrez-Fernández
- Neurological Sciences and Cerebrovascular Research Laboratory, Department of Neurology and Stroke Centre, Neuroscience Area, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain
| | - MÁngeles Ortega-Casarrubios
- Department of Neurology, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Alfonso Soto
- Department of Endocrinology, Hospital Universitario A Coruña, A Coruña, Spain
| | | | - María Santamaría
- Department of Neurology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Santiago de Compostela, Spain
| | | | - Mar M Freijo
- Biocruces Bizkaia Health Research Institute, Department of Neurology, Hospital Universitario Cruces, Bizkaia, Spain
| | - Beatriz Zandio
- Department of Neurology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | | | - Ana Calleja
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Arturo Lisbona
- Department of Endocrinology, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Laura Otero-Ortega
- Neurological Sciences and Cerebrovascular Research Laboratory, Department of Neurology and Stroke Centre, Neuroscience Area, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain.
| | - Exuperio Díez-Tejedor
- Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid), Paseo de la Castellana 261, 28046, Madrid, Spain
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Sadhu AR, Serrano IA, Xu J, Nisar T, Lucier J, Pandya AR, Patham B. Continuous Glucose Monitoring in Critically Ill Patients With COVID-19: Results of an Emergent Pilot Study. J Diabetes Sci Technol 2020; 14:1065-1073. [PMID: 33063556 PMCID: PMC7645121 DOI: 10.1177/1932296820964264] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [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 Amidst the coronavirus disease 2019 (COVID-19) pandemic, continuous glucose monitoring (CGM) has emerged as an alternative for inpatient point-of-care blood glucose (POC-BG) monitoring. We performed a feasibility pilot study using CGM in critically ill patients with COVID-19 in the intensive care unit (ICU). METHODS Single-center, retrospective study of glucose monitoring in critically ill patients with COVID-19 on insulin therapy using Medtronic Guardian Connect and Dexcom G6 CGM systems. Primary outcomes were feasibility and accuracy for trending POC-BG. Secondary outcomes included reliability and nurse acceptance. Sensor glucose (SG) was used for trends between POC-BG with nursing guidance to reduce POC-BG frequency from one to two hours to four hours when the SG was in the target range. Mean absolute relative difference (MARD), Clarke error grids analysis (EGA), and Bland-Altman (B&A) plots were calculated for accuracy of paired SG and POC-BG measurements. RESULTS CGM devices were placed on 11 patients: Medtronic (n = 6) and Dexcom G6 (n = 5). Both systems were feasible and reliable with good nurse acceptance. To determine accuracy, 437 paired SG and POC-BG readings were analyzed. For Medtronic, the MARD was 13.1% with 100% of readings in zones A and B on Clarke EGA. For Dexcom, MARD was 11.1% with 98% of readings in zones A and B. B&A plots had a mean bias of -17.76 mg/dL (Medtronic) and -1.94 mg/dL (Dexcom), with wide 95% limits of agreement. CONCLUSIONS During the COVID-19 pandemic, CGM is feasible in critically ill patients and has acceptable accuracy to identify trends and guide intermittent blood glucose monitoring with insulin therapy.
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Affiliation(s)
- Archana R. Sadhu
- Division of Endocrinology, Diabetes and Metabolism, Houston Methodist, Weill Cornell Medical College, Texas A&M Health Sciences Center, Houston, TX, USA
- Archana R. Sadhu, MD, FACE, Division of Endocrinology, Diabetes and Metabolism, Houston Methodist, 6550 Fannin Street, Suite SM-1001, Houston, TX 77030, USA.
| | | | - Jiaqiong Xu
- Center for Outcomes Research, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Research Institute, Weill Cornell Medical College, Houston, TX, USA
| | - Tariq Nisar
- Houston Methodist Research Institute, Houston, TX, USA
| | - Jessica Lucier
- Division of Endocrinology, Diabetes and Metabolism, Houston Methodist, Houston, TX, USA
| | - Anjani R. Pandya
- Division of Endocrinology, Diabetes and Metabolism, Houston Methodist, Houston, TX, USA
| | - Bhargavi Patham
- Division of Endocrinology, Diabetes and Metabolism, Houston Methodist, Weill Cornell Medical College, Texas A&M Health Sciences Center, Houston, TX, USA
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30
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Lim HJ, Park CM, Gil E, Yoo K, Choi KJ, Jin SM. Efficiency of Computerized Insulin Infusion Glucose Control in Critically Ill Patients. JOURNAL OF ACUTE CARE SURGERY 2020. [DOI: 10.17479/jacs.2020.10.2.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Abstract
BACKGROUND To summarize new evidence regarding the methodological aspects of blood glucose control in the intensive care unit (ICU). METHODS We reviewed the literature on blood glucose control in the ICU up to August 2019 through Ovid Medline and Pubmed. RESULTS Since the publication of the Leuven studies, the benefits of glycemic control have been recognized. However, the methodology of blood glucose control, notably the blood glucose measurement accuracy and the insulin titration protocol, plays an important but underestimated role. This may partially explain the negative results of the large, pragmatic multicenter trials and made everyone realize that tight glycemic control with less-frequent glucose measurements on less accurate blood glucose meters is neither feasible nor advisable in daily practice. Blood gas analyzers remain the gold standard. New generation point-of-care blood glucose meters may be an alternative when using whole blood of critically ill patients in combination with a clinically validated insulin dosing algorithm. CONCLUSION When implementing blood glucose management in an ICU one needs to take into account the interaction between aimed glycemic target and blood glucose measurement methodology.
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Affiliation(s)
- Gert-Jan Eerdekens
- Department of Anesthesiology, University Hospitals Leuven, Belgium
- Department of Anesthesia and Intensive Care Medicine, ZOL-Genk, Belgium
- Gert-Jan Eerdekens, MD, Department of Anesthesia UZ Leuven, Herestraat 49, Leuven 3000, Belgium.
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - Dieter Mesotten
- Department of Anesthesia and Intensive Care Medicine, ZOL-Genk, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Belgium
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Uyttendaele V, Knopp JL, Shaw GM, Desaive T, Chase JG. Risk and reward: extending stochastic glycaemic control intervals to reduce workload. Biomed Eng Online 2020; 19:26. [PMID: 32349750 PMCID: PMC7191799 DOI: 10.1186/s12938-020-00771-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/17/2020] [Indexed: 01/08/2023] Open
Abstract
Background STAR is a model-based, personalised, risk-based dosing approach for glycaemic control (GC) in critically ill patients. STAR provides safe, effective control to nearly all patients, using 1–3 hourly measurement and intervention intervals. However, the average 11–12 measurements per day required can be a clinical burden in many intensive care units. This study aims to significantly reduce workload by extending STAR 1–3 hourly intervals to 1 to 4-, 5-, and 6-hourly intervals, and evaluate the impact of these longer intervals on GC safety and efficacy, using validated in silico virtual patients and trials methods. A Standard STAR approach was used which allowed more hyperglycaemia over extended intervals, and a STAR Upper Limit Controlled approach limited nutrition to mitigate hyperglycaemia over longer intervention intervals. Results Extending STAR from 1–3 hourly to 1–6 hourly provided high safety and efficacy for nearly all patients in both approaches. For STAR Standard, virtual trial results showed lower % blood glucose (BG) in the safe 4.4–8.0 mmol/L target band (from 83 to 80%) as treatment intervals increased. Longer intervals resulted in increased risks of hyper- (15% to 18% BG > 8.0 mmol/L) and hypo- (2.1% to 2.8% of patients with min. BG < 2.2 mmol/L) glycaemia. These results were achieved with slightly reduced insulin (3.2 [2.0 5.0] to 2.5 [1.5 3.0] U/h) and nutrition (100 [85 100] to 90 [75 100] % goal feed) rates, but most importantly, with significantly reduced workload (12 to 8 measurements per day). The STAR Upper Limit Controlled approach mitigated hyperglycaemia and had lower insulin and significantly lower nutrition administration rates. Conclusions The modest increased risk of hyper- and hypo-glycaemia, and the reduction in nutrition delivery associated with longer treatment intervals represent a significant risk and reward trade-off in GC. However, STAR still provided highly safe, effective control for nearly all patients regardless of treatment intervals and approach, showing this unique risk-based dosing approach, modulating both insulin and nutrition, to be robust in its design. Clinical pilot trials using STAR with different measurement timeframes should be undertaken to confirm these results clinically.
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Affiliation(s)
- Vincent Uyttendaele
- GIGA-In Silico Medicine, University of Liège, Allée Du 6 Août 19, Bât. B5a, 4000, Liège, Belgium. .,Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand.
| | - Jennifer L Knopp
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand
| | - Geoffrey M Shaw
- Dept of Intensive Care, Christchurch Hospital, Christchurch, New Zealand.,School of Medicine, University of Otago, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA-In Silico Medicine, University of Liège, Allée Du 6 Août 19, Bât. B5a, 4000, Liège, Belgium
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand
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Dynamic properties of glucose complexity during the course of critical illness: a pilot study. J Clin Monit Comput 2020; 34:361-370. [PMID: 30888595 DOI: 10.1007/s10877-019-00299-8] [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: 06/15/2018] [Accepted: 03/13/2019] [Indexed: 10/27/2022]
Abstract
Methods to control the blood glucose (BG) levels of patients in intensive care units (ICU) improve the outcomes. The development of continuous BG levels monitoring devices has also permitted to optimize these processes. Recently it was shown that a complexity loss of the BG signal is linked to poor clinical outcomes. Thus, it becomes essential to decipher this relation to design efficient BG level control methods. In previous studies the BG signal complexity was calculated as a single index for the whole ICU stay. Although, these approaches did not grasp the potential variability of the BG signal complexity. Therefore, we setup this pilot study using a continuous monitoring of central venous BG levels in ten critically ill patients (EIRUS platform, Maquet Critical CARE AB, Solna, Sweden). Data were processed and the complexity was assessed by the detrended fluctuation analysis and multiscale entropy (MSE) methods. Finally, recordings were split into 24 h overlapping intervals and a MSE analysis was applied to each of them. The MSE analysis on time intervals revealed an entropy variation and allowed periodic BG signal complexity assessments. To highlight differences of MSE between each time interval we calculated the MSE complexity index defined as the area under the curve. This new approach could pave the way to future studies exploring new strategies aimed at restoring blood glucose complexity during the ICU stay.
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Wang W, Chen W, Liu Y, Li L, Li S, Tan J, Sun X. Blood Glucose Levels and Mortality in Patients With Sepsis: Dose-Response Analysis of Observational Studies. J Intensive Care Med 2019; 36:182-190. [PMID: 31746263 DOI: 10.1177/0885066619889322] [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: 02/05/2023]
Abstract
BACKGROUND We undertook a systematic review and meta-analysis to investigate the relationship between blood glucose levels and mortality in patients with sepsis. METHODS Medline and EMBASE were searched from inception to April 8, 2018. Cohort studies or case-control studies reported the association between blood glucose and mortality in patients with sepsis were selected. Study characteristics, baseline characteristics, definition of hyperglycemia, and outcomes of interest were extracted. We performed a dose-response meta-analysis to assess the effect of blood glucose level on mortality. We also conducted meta-analysis for patients with or without diabetes separately. RESULTS Ten cohort studies involving 26 429 patients were included, of which 5 were prospective studies and 5 retrospective studies. Dose-response analysis showed that the effect of blood glucose on mortality may differ in patients with versus without diabetes. There was a U-shaped relationship for patients with diabetes and a J-shaped relationship for patients without diabetes, with blood glucose at 145 to 155 mg/dL corresponding to lowest mortality both in patients with and without diabetes. CONCLUSIONS Current evidence suggested U-shaped relationship between blood glucose and mortality in all patients irrespective of their diabetes status. Diabetic patients with blood glucose below 145 mg/dL may have poorer prognosis compared to patients without established diabetes.
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Affiliation(s)
- Wen Wang
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Wenwen Chen
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Yanmei Liu
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Ling Li
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Jing Tan
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Xin Sun
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
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Malerba E, Cattani C, Del Baldo F, Carotenuto G, Corradini S, Golinelli S, Drudi I, Fracassi F. Accuracy of a flash glucose monitoring system in dogs with diabetic ketoacidosis. J Vet Intern Med 2019; 34:83-91. [PMID: 31725202 PMCID: PMC6979271 DOI: 10.1111/jvim.15657] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 10/23/2019] [Indexed: 01/01/2023] Open
Abstract
Background A factory‐calibrated flash glucose monitoring system (FGMS; FreeStyle Libre) recently was evaluated in dogs with uncomplicated diabetes mellitus. It is not known if this system is reliable during diabetic ketoacidosis (DKA). Objectives To assess the performance of the FGMS in dogs with DKA and to determine the effect of severity of ketosis and acidosis, lactate concentration, body condition score (BCS), and time wearing the sensor on the accuracy of the device. Animals Fourteen client‐owned dogs with DKA. Methods The interstitial glucose (IG) measurements were compared with blood glucose (BG) measurements obtained using a validated portable glucometer. The influence of changes in metabolic variables (β‐hydroxybutyrate, pH, bicarbonate, and lactate) and the effect of BCS and time wearing on sensor performance were evaluated. Accuracy was determined by fulfillment of ISO15197:2013 criteria. Results Metabolic variables, BCS, and time wearing were not associated with the accuracy of the sensor. Good agreement between IG measurements and BG was obtained both before and after DKA resolution (r = .88 and r = .93, respectively). Analytical accuracy was not achieved, whereas clinical accuracy was demonstrated with 100% and 99.6% of results in zones A + B of the Parkes consensus error grid analysis before and after DKA resolution, respectively. Conclusions and Clinical Importance Changes in metabolic variables, BCS, and time wearing do not seem to affect agreement between IG and BG. Despite not fulfilling the ISO requirements, the FGMS provides clinically accurate estimates of BG in dogs with DKA.
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Affiliation(s)
- Eleonora Malerba
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
| | - Chiara Cattani
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
| | - Francesca Del Baldo
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
| | - Gaia Carotenuto
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
| | - Sara Corradini
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
| | - Stefania Golinelli
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
| | - Ignazio Drudi
- Department of Statistical Sciences, University of Bologna, Bologna, Italy
| | - Federico Fracassi
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
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Sun Q, Welsh KJ, Bruns DE, Sacks DB, Zhao Z. Inadequate Reporting of Analytical Characteristics of Biomarkers Used in Clinical Research: A Threat to Interpretation and Replication of Study Findings. Clin Chem 2019; 65:1554-1562. [PMID: 31672858 DOI: 10.1373/clinchem.2019.309575] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/15/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Analytical characteristics of methods to measure biomarkers determine how well the methods measure what they claim to measure. Transparent reporting of analytical characteristics allows readers to assess the validity and generalizability of clinical studies in which biomarkers are used. Our aims were to assess the reporting of analytical characteristics of biomarkers used in clinical research and to evaluate the extent of reported characterization procedures for assay precision. METHODS We searched 5 medical journals (Annals of Internal Medicine, JAMA: The Journal of the American Medical Association, The Lancet, The New England Journal of Medicine, and PLOS Medicine) over a 10-year period for the term "biomarker" in the full-text field. We included studies in which biomarkers were used for inclusion/exclusion of study participants, for patient classification, or as a study outcome. We tabulated the frequencies of reporting of 11 key analytical characteristics (such as analytical accuracy of test results) in the included studies. RESULTS A total of 544 studies and 1299 biomarker uses met the inclusion criteria. No information on analytical characteristics was reported for 67% of the biomarkers. For 65 biomarkers (3%), ≥4 characteristics were reported (range, 4-8). The manufacturer of the measurement procedure could not be determined for 688 (53%) of the 1299 biomarkers. The extent of assessments of assay imprecision, when reported, did not meet expectations for clinical use of biomarkers. CONCLUSIONS Reporting of the analytical performance of biomarker measurements is variable and often absent from published clinical studies. We suggest that readers need fuller reporting of analytical characteristics to interpret study results, assess generalizability of conclusions, and compare results among clinical studies.
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Affiliation(s)
- Qian Sun
- Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD
| | - Kerry J Welsh
- Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD
| | - David E Bruns
- Department of Pathology, University of Virginia, Charlottesville, VA
| | - David B Sacks
- Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD;
| | - Zhen Zhao
- Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD; .,Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
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Abstract
OBJECTIVES Tight glycemic control using intermittent blood glucose measurements is associated with a risk of hypoglycemia. Glucose concentrations can now be measured near continuously (every 5-15 min). We assessed the quality and safety of glycemic control guided by a near-continuous glucose monitoring system in ICU patients. DESIGN Prospective, cluster-randomized, crossover study. SETTING Thirty-five-bed medico-surgical department of intensive care with four separate ICUs. PATIENTS Adult patients admitted to the department and expected to stay for at least 3 days were considered for inclusion if they had persistent hyperglycemia (blood glucose > 150 mg/dL) up to 6 hours after admission and/or were receiving insulin therapy. INTERVENTIONS A peripheral venous catheter was inserted in all patients and connected to a continuous glucose monitoring sensor (GlucoClear; Edwards Lifesciences, Irvine, CA). The four ICUs were randomized in pairs in a crossover design to glycemic control using unblinded or blinded continuous glucose monitoring monitors. The insulin infusion rate was adjusted to keep blood glucose between 90 and 150 mg/dL using the blood glucose values displayed on the continuous glucose monitor (continuous glucose monitoring group-unblinded units) or according to intermittent blood glucose readings (intermittent glucose monitoring group-blinded units). MEASUREMENTS AND MAIN RESULTS The quality and safety of glycemic control were assessed using the proportion of time in range, the frequency of blood glucose less than 70 mg/dL, and the time spent with blood glucose less than 70 mg/dL (TB70), using blood glucose values measured by the continuous glucose monitoring device. Seventy-seven patients were enrolled: 39 in the continuous glucose monitoring group and 38 in the intermittent glucose monitoring group. A total of 43,107 blood glucose values were recorded. The time in range was similar in the two groups. The incidence of hypoglycemia (8/39 [20.5%] vs 15/38 [39.5%]) and the TB70 (0.4% ± 0.9% vs 1.6% ± 3.4%; p < 0.05) was lower in the continuous glucose monitoring than in the intermittent glucose monitoring group. CONCLUSIONS Use of a continuous glucose monitoring-based strategy decreased the incidence and severity of hypoglycemia, thus improving the safety of glycemic control.
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Cernat E, Puntis J. Paediatric parenteral nutrition: current issues. Frontline Gastroenterol 2019; 11:148-154. [PMID: 32133114 PMCID: PMC7043071 DOI: 10.1136/flgastro-2018-101127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 02/04/2023] Open
Abstract
Parenteral nutrition transformed the prognosis for infants and children with intestinal failure. Soon after its introduction into clinical care 50 years ago, parenteral nutrition was also rapidly adopted for use in the preterm infant, where immaturity of gastrointestinal motor function precluded enteral feeding. Preterm infants subsequently became the single largest group of patients to be fed in this way. Although the development of scientific knowledge and the lessons of clinical experience have reduced the risk of complications, some of the problems and difficulties associated with this form of nutritional support remain challenging. These include central venous catheter-related sepsis, thrombosis, liver disease, bone disease and metabolic disturbance. In an initiative to promote best practice, guidelines on parenteral nutrition were first published by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition and collaborating organisations in 2005. These were constructed following a thorough review of the scientific literature, allowing a series of evidence-based recommendations to be made. The exercise was repeated just over 10 years later and updated guidelines published in 2018. This review summarises key elements from the new guideline, with a focus on what has changed since 2005.
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Affiliation(s)
- Elena Cernat
- Department of Paediatric Gastroenterology and Nutrition, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - John Puntis
- Department of Paediatric Gastroenterology and Nutrition, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Abstract
Hyperglycemia is common in the intensive care unit (ICU) both in patients with and without a previous diagnosis of diabetes. The optimal glucose range in the ICU population is still a matter of debate. Given the risk of hypoglycemia associated with intensive insulin therapy, current recommendations include treating hyperglycemia after two consecutive glucose >180 mg/dL with target levels of 140-180 mg/dL for most patients. The optimal method of sampling glucose and delivery of insulin in critically ill patients remains elusive. While point of care glucose meters are not consistently accurate and have to be used with caution, continuous glucose monitoring (CGM) is not standard of care, nor is it generally recommended for inpatient use. Intravenous insulin therapy using paper or electronic protocols remains the preferred approach for critically ill patients. The advent of new technologies, such as electronic glucose management, CGM, and closed-loop systems, promises to improve inpatient glycemic control in the critically ill with lower rates of hypoglycemia.
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Affiliation(s)
- Pedro D. Salinas
- Aurora Critical Care Services,
University of Wisconsin School of Medicine and Public Health, Milwaukee, WI,
USA
| | - Carlos E. Mendez
- Froedtert and Medical College of
Wisconsin, Division of Diabetes and Endocrinology, Zablocki Veteran Affairs Medical
Center, Milwaukee, WI, USA
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Abu-Samah A, Knopp JL, Abdul Razak NN, Razak AA, Jamaludin UK, Mohamad Suhaimi F, Md Ralib A, Mat Nor MB, Chase JG, Pretty CG. Model-based glycemic control in a Malaysian intensive care unit: performance and safety study. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2019; 12:215-226. [PMID: 31239792 PMCID: PMC6551612 DOI: 10.2147/mder.s187840] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/30/2019] [Indexed: 01/08/2023] Open
Abstract
Background: Stress-induced hyperglycemia is common in critically ill patients. A few forms of model-based glycemic control have been introduced to reduce this phenomena and among them is the automated STAR protocol which has been used in the Christchurch and Gyulá hospitals' intensive care units (ICUs) since 2010. Methods: This article presents the pilot trial assessment of STAR protocol which has been implemented in the International Islamic University Malaysia Medical Centre (IIUMMC) Hospital ICU since December 2017. One hundred and forty-two patients who received STAR treatment for more than 20 hours were used in the assessment. The initial results are presented to discuss the ability to adopt and adapt the model-based control framework in a Malaysian environment by analyzing its performance and safety. Results: Overall, 60.7% of blood glucose measurements were in the target band. Only 0.78% and 0.02% of cohort measurements were below 4.0 mmol/L and 2.2 mmol/L (the limitsfor mild and severe hypoglycemia, respectively). Treatment preference-wise, the clinical staff were favorable of longer intervention options when available. However, 1 hourly treatments were still used in 73.7% of cases. Conclusion: The protocol succeeded in achieving patient-specific glycemic control while maintaining safety and was trusted by nurses to reduce workload. Its lower performance results, however, give the indication for modification in some of the control settings to better fit the Malaysian environment.
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Affiliation(s)
- Asma Abu-Samah
- Institute of Energy Infrastructure, Universiti Tenaga Nasional, Kajang, 43000, Malaysia
| | - Jennifer Launa Knopp
- Department of Mechanical Engineering, University of Canterbury, Christchurch, 8041, New Zealand
| | | | | | | | | | - Azrina Md Ralib
- Advanced Medical and Dental Institute, Universiti Sains Islam Malaysia, Kepala Batas, 13200, Malaysia
| | - Mohd Basri Mat Nor
- Kulliyah of Medicine, International Islamic University Malaysia, Kuantan, 25200, Malaysia
| | - James Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, 8041, New Zealand
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Abstract
PURPOSE OF REVIEW Critically ill patients usually develop hyperglycemia, which is associated with adverse outcome. Controversy exists whether the relationship is causal or not. This review summarizes recent evidence regarding glucose control in the ICU. RECENT FINDINGS Despite promising effects of tight glucose control in pioneer randomized controlled trials, the benefit has not been confirmed in subsequent multicenter studies and one trial found potential harm. This discrepancy could be explained by methodological differences between the trials rather than by a different case mix. Strategies to improve the efficacy and safety of tight glucose control have been developed, including the use of computerized treatment algorithms. SUMMARY The ideal blood glucose target remains unclear and may depend on the context. As compared with tolerating severe hyperglycemia, tight glucose control is well tolerated and effective in patients receiving early parenteral nutrition when provided with a protocol that includes frequent, accurate glucose measurements and avoids large glucose fluctuations. All patient subgroups potentially benefit, with the possible exception of patients with poorly controlled diabetes, who may need less aggressive glucose control. It remains unclear whether tight glucose control is beneficial or not in the absence of early parenteral nutrition.
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Does Regulatory Really Intersect Reality in Glucose Measurement in the ICU? Is the Issue Testing Method Accuracy or Specimen Type? Crit Care Med 2019; 45:e1186-e1188. [PMID: 29028711 DOI: 10.1097/ccm.0000000000002596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rice TW, Files DC, Morris PE, Bernard AC, Ziegler TR, Drover JW, Kress JP, Ham KR, Grathwohl DJ, Huhmann MB, Gautier JBO. Dietary Management of Blood Glucose in Medical Critically Ill Overweight and Obese Patients: An Open-Label Randomized Trial. JPEN J Parenter Enteral Nutr 2019; 43:471-480. [PMID: 30260488 PMCID: PMC7379263 DOI: 10.1002/jpen.1447] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/03/2018] [Accepted: 08/16/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Enteral nutrition (EN) increases hyperglycemia due to high carbohydrate concentrations while providing insufficient protein. The study tested whether an EN formula with very high-protein- and low-carbohydrate-facilitated glucose control delivered higher protein concentrations within a hypocaloric protocol. METHODS This was a multicenter, randomized, open-label clinical trial with parallel design in overweight/obese mechanically ventilated critically ill patients prescribed 1.5 g protein/kg ideal body weight/day. Patients received either an experimental very high-protein (37%) and low-carbohydrate (29%) or control high-protein (25%) and conventional-carbohydrate (45%) EN formula. RESULTS A prespecified interim analysis was performed after enrollment of 105 patients (52 experimental, 53 control). Protein and energy delivery for controls and experimental groups on days 1-5 were 1.2 ± 0.4 and 1.1 ± 0.3 g/kg ideal body weight/day (P = .83), and 18.2 ± 6.0 and 12.5 ± 3.7 kcals/kg ideal body weight/day (P < .0001), respectively. The combined rate of glucose events outside the range of >110 and ≤150 mg/dL were not different (P = .54, primary endpoint); thereby the trial was terminated. The mean blood glucose for the control and the experimental groups were 138 (-SD 108, +SD 177) and 126 (-SD 99, +SD 160) mg/dL (P = .004), respectively. Mean rate of glucose events >150 mg/dL decreased (Δ = -13%, P = .015), whereas that of 80-110 mg/dL increased (Δ = 14%, P = .0007). Insulin administration decreased 10.9% (95% CI, -22% to 0.1%; P = .048) in the experimental group relative to the controls. Glycemic events ≤80 mg/dL and rescue dextrose use were not different (P = .23 and P = .53). CONCLUSIONS A very high-protein and low-carbohydrate EN formula in a hypocaloric protocol reduces hyperglycemic events and insulin requirements while increasing glycemic events between 80-110 mg/dL.
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Affiliation(s)
- Todd W. Rice
- Division of AllergyPulmonaryand Critical Care MedicineDepartment of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - D. Clark Files
- Department of Internal Medicine—PulmonaryCritical CareAllergy and Immunologic DiseasesWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | | | | | - Thomas R. Ziegler
- Division of Endocrinology, Metabolism and LipidsEmory UniversityAtlantaGeorgiaUSA
| | - John W. Drover
- Department of Critical Care MedicineQueen's University and Kingston Health Science CenterKingstonOntarioCanada
| | - John P. Kress
- The University of Chicago MedicineChicagoIllinoisUSA
| | - Kealy R. Ham
- Department of Critical Care MedicineRegions HospitalUniversity of MinnesotaSt. PaulMinnesotaUSA
| | | | | | - Juan B. Ochoa Gautier
- Nestlé Health ScienceBridgewaterNew JerseyUSA
- Geisinger Medical CenterDanvillePennsylvaniaUSA
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Alkozai EM, Mahmoodi BK, Decruyenaere J, Porte RJ, Oude Lansink-Hartgring A, Lisman T, Nijsten MW. Systematic comparison of routine laboratory measurements with in-hospital mortality: ICU-Labome, a large cohort study of critically ill patients. Clin Chem Lab Med 2019; 56:1140-1151. [PMID: 29306908 DOI: 10.1515/cclm-2016-1028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 11/23/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND In intensive care unit (ICU) patients, many laboratory measurements can be deranged when compared with the standard reference interval (RI). The assumption that larger derangements are associated with worse outcome may not always be correct. The ICU-Labome study systematically evaluated the univariate association of routine laboratory measurements with outcome. METHODS We studied the 35 most frequent blood-based measurements in adults admitted ≥6 h to our ICU between 1992 and 2013. Measurements were from the first 14 ICU days and before ICU admission. Various metrics, including variability, were related with hospital survival. ICU- based RIs were derived from measurements obtained at ICU discharge in patients who were not readmitted to the ICU and survived for >1 year. RESULTS In 49,464 patients (cardiothoracic surgery 43%), we assessed >20·106 measurements. ICU readmissions, in-hospital and 1-year mortality were 13%, 14% and 19%, respectively. On ICU admission, lactate had the strongest relation with hospital mortality. Variability was independently related with hospital mortality in 30 of 35 measurements, and 16 of 35 measurements displayed a U-shaped outcome-relation. Medians of 14 of 35 ICU-based ranges were outside the standard RI. Remarkably, γ-glutamyltransferase (GGT) had a paradoxical relation with hospital mortality in the second ICU week because more abnormal GGT-levels were observed in hospital survivors. CONCLUSIONS ICU-based RIs for may be more useful than standard RIs in identifying ICU patients at risk. The association of variability with outcome for most of the measurements suggests this is a consequence and not a cause of a worse ICU outcome. Late elevation of GGT may confer protection to ICU patients.
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Affiliation(s)
- Edris M Alkozai
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, TheNetherlands.,Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, TheNetherlands
| | | | - Johan Decruyenaere
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Robert J Porte
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, TheNetherlands
| | | | - Ton Lisman
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, TheNetherlands
| | - Maarten W Nijsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands, Phone: 00-31-50-3616161, Fax: 0031-50-3615644
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Degree of implementation of preventive strategies for post-ICU syndrome: Multi-centre, observational study in Spain. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.enfie.2019.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Raurell-Torredà M, Arias-Rivera S, Martí J, Frade-Mera M, Zaragoza-García I, Gallart E, Velasco-Sanz T, San José-Arribas A, Blázquez-Martínez E, Rodríguez Delgado ME, Contreras Rodríguez AM, Oreña Cimiano E, Ortega Guerrero Á, Martínez del Aguila MDC, Rodríguez Monsalve V, Cano Herrera CL, Masegosa Pérez JM, González de la Cuesta DM, Pardo Artero MI, Palacios Laseca M, Cabello Casao AI, Vera Bellostas MBVD, Pérez Martínez C, Escuder González S, Lezcano Cisneros A, Miguel Romeo A, López Alegre I, San Pío ERD, Fernández Alonso H, Rodríguez Villanueva LM, Riaño Suárez R, Sánchez Cerviñio B, Carrasco Santos S, José Arribas AS, González García M, Linares Tavio A, Álvarez García P, Polo Hernández N, Gómez Cosío L, Pérez Loza I, Suárez Pérez Á, Crespo Rebollo S, Muñoz Camargo JC, García García J, Rojo Aguado C, Gómez López J, Sonseca Bartolomé L, José Arribas AS, Olmo Nuñez SD, García Mazo P, Siguero Torres E, Muñoz Díez I, Delgado Hito P, Garrido Martín MO, Marín Vivó G, Eseverri Rovira MDM, Guillen Dobon M, Aran Esteve M, Mirabete Rodríguez M, Mariné Méndez A, Rodríguez Fernández S, Rosselló Sancho J, Zafra Lamas V, Carmona Delgado I, Navarro Arilla À, Zariquiey Esteva G, Bueno Luna ÁL, Lerma Brianso C, Gómez García R, Planas Pascual B, Sabaté López M, Mayer Frutos AI, Roca Escrihuela R, Torrents Albà G, García Flores V, Melis Galmés J, Belmonte Moral S, Grau Pellicer M, Ruiz Eizmendi A, Garriga Moll C, de Jaureguízar EB, Cordovilla Guardia S, López Espuela F, Mateos Hinojal L, Redondo Cantos MI, Villar Redondo MDR, Vila Rey J, Sánchez Méndez S, García Fernández Y, Benítez Canosa MC, Díaz Álvarez M, Cordo Isorna JR, Estébez Penín Á, Güeto Rial G, Bouzas López E, Arias Rivera S, Frade Mera MJ, Luengo Alarcia MJ, Regueiro Díaz N, Carrasco Rodríguez-Rey LF, et alRaurell-Torredà M, Arias-Rivera S, Martí J, Frade-Mera M, Zaragoza-García I, Gallart E, Velasco-Sanz T, San José-Arribas A, Blázquez-Martínez E, Rodríguez Delgado ME, Contreras Rodríguez AM, Oreña Cimiano E, Ortega Guerrero Á, Martínez del Aguila MDC, Rodríguez Monsalve V, Cano Herrera CL, Masegosa Pérez JM, González de la Cuesta DM, Pardo Artero MI, Palacios Laseca M, Cabello Casao AI, Vera Bellostas MBVD, Pérez Martínez C, Escuder González S, Lezcano Cisneros A, Miguel Romeo A, López Alegre I, San Pío ERD, Fernández Alonso H, Rodríguez Villanueva LM, Riaño Suárez R, Sánchez Cerviñio B, Carrasco Santos S, José Arribas AS, González García M, Linares Tavio A, Álvarez García P, Polo Hernández N, Gómez Cosío L, Pérez Loza I, Suárez Pérez Á, Crespo Rebollo S, Muñoz Camargo JC, García García J, Rojo Aguado C, Gómez López J, Sonseca Bartolomé L, José Arribas AS, Olmo Nuñez SD, García Mazo P, Siguero Torres E, Muñoz Díez I, Delgado Hito P, Garrido Martín MO, Marín Vivó G, Eseverri Rovira MDM, Guillen Dobon M, Aran Esteve M, Mirabete Rodríguez M, Mariné Méndez A, Rodríguez Fernández S, Rosselló Sancho J, Zafra Lamas V, Carmona Delgado I, Navarro Arilla À, Zariquiey Esteva G, Bueno Luna ÁL, Lerma Brianso C, Gómez García R, Planas Pascual B, Sabaté López M, Mayer Frutos AI, Roca Escrihuela R, Torrents Albà G, García Flores V, Melis Galmés J, Belmonte Moral S, Grau Pellicer M, Ruiz Eizmendi A, Garriga Moll C, de Jaureguízar EB, Cordovilla Guardia S, López Espuela F, Mateos Hinojal L, Redondo Cantos MI, Villar Redondo MDR, Vila Rey J, Sánchez Méndez S, García Fernández Y, Benítez Canosa MC, Díaz Álvarez M, Cordo Isorna JR, Estébez Penín Á, Güeto Rial G, Bouzas López E, Arias Rivera S, Frade Mera MJ, Luengo Alarcia MJ, Regueiro Díaz N, Carrasco Rodríguez-Rey LF, Hernández García MDR, Sala Gómez G, Vecino Rubio J, García González S, Sánchez Sánchez MDM, Cruzado Franco C, Martín Rivera B, González Blanco R, Sánchez de la Ventana AB, Bravo Arcas ML, Escobar Lavela J, Domingo Moreno MDP, García Arias M, Collado Saiz IC, Acevedo Nuevo M, Barrios Suárez A, Zarza Bejarano FJ, Pérez Muñoz MC, Toribio Rubio V, Martínez Chicharro P, Pascual Martínez A, López Pozo S, Sánchez Infante L, Ocaña García V, Menes Medina D, Vadillo Cortázar A, Lendínez Burgos G, Díaz Juntanez J, Godino Olivares MT, Rodríguez Mondéjar JJ, Martínez Rojo FJ, Ruiz Martínez MV, Linares Celdrán D, Ros Molina A, Sáez Sánchez J, Martínez Oliva JM, Bernal Gilar A, Hernández García MB, Ríos Cortés AT, Navarro Méndez R, Gil García S, Sánchez Garre J, Barrio Linares MD, Goñi Viguria R, Aguirre Santano R, García Díez MR, Aparicio Cilla L, Delicado Domingo M, Rodríguez Núñez C, Arrasate López A, Romero Morán Á, Paños Melgoso R, Yañez Cerón M, Mercado Martínez A, Martínez Llopis B, Vayá Albelda MJ, Inat Carbonell J, Alcayne Senent MR, Giménez García F, Fernández Gonzaga EC, Febrer Puchol L, Berenguer Ortuño S, Pastor Martínez M, Valera Talavera D, Segrera Rovira MJ, Langa Revert Y, Espí Pozuelo M, Diego Miravet MÁD, Garijo Aspas B, Asensio García MDR, Sánchez Muñoz JR, Martínez Sánchez Q, López Mateu R. Grado de implementación de las estrategias preventivas del síndrome post-UCI: estudio observacional multicéntrico en España. ENFERMERIA INTENSIVA 2019; 30:59-71. [DOI: 10.1016/j.enfi.2018.04.004] [Show More Authors] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 04/05/2018] [Accepted: 04/12/2018] [Indexed: 01/28/2023]
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Monitoring nutrition in the ICU. Clin Nutr 2019; 38:584-593. [DOI: 10.1016/j.clnu.2018.07.009] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 07/02/2018] [Accepted: 07/05/2018] [Indexed: 12/21/2022]
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Fernández-Méndez R, Harvey DJR, Windle R, Adams GG. The practice of glycaemic control in intensive care units: A multicentre survey of nursing and medical professionals. J Clin Nurs 2019; 28:2088-2100. [PMID: 30653767 DOI: 10.1111/jocn.14774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 11/07/2018] [Accepted: 01/07/2019] [Indexed: 12/14/2022]
Abstract
AIMS AND OBJECTIVES To determine the views of nurses and physicians working in intensive care units (ICU) about the aims of glycaemic control and use of their protocols. BACKGROUND Evidence about the optimal aims and methods for glycaemic control in ICU is controversial, and current local protocols guiding practice differ between ICUs, both nationally and internationally. The views of professionals on glycaemic control can influence their practice. DESIGN Cross-sectional, multicentre, survey-based study. METHODS An online short survey was sent to all physicians and nurses of seven ICUs, including questions on effective glycaemic control, treatment of hypoglycaemia and deviations from protocols' instructions. STROBE reporting guidelines were followed. RESULTS Over half of the 40 respondents opined that a patient spending <75% admission time within the target glycaemic levels constituted poor glycaemic control. Professionals with more than 5 years of experience were more likely to rate a patient spending 50%-74% admission time within target glycaemic levels as poor than less experienced colleagues. Physicians were more likely to rate a patient spending <50% admission time within target as poor than nurses. There was general agreement on how professionals would rate most deviations from their protocols. Nurses were more likely to rate insulin infusions restarted late and incorrect dosage of rescue glucose as major deviations than physicians. Most professionals agreed on when they would treat hypoglycaemia. CONCLUSIONS When surveyed on various aspects of glycaemic control, ICU nurses and physicians often agreed, although there were certain areas of disagreement, in which their profession and level of experience seemed to play a role. RELEVANCE TO CLINICAL PRACTICE Differing views on glycaemic control amongst professionals may affect their practice and, thus, could lead to health inequalities. Clinical leads and the multidisciplinary ICU team should assess and, if necessary, address these differing opinions.
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Affiliation(s)
| | | | - Richard Windle
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Gary George Adams
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
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Dysglycemia and Neurologic Outcome in Mechanically Ventilated Patients With Guillain-Barré Syndrome. Crit Care Med 2019; 47:e227-e233. [DOI: 10.1097/ccm.0000000000003635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Head-to-head comparison of two continuous glucose monitoring systems on a cardio-surgical ICU. J Clin Monit Comput 2018; 33:895-901. [PMID: 30421152 DOI: 10.1007/s10877-018-0221-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 11/08/2018] [Indexed: 12/23/2022]
Abstract
In critical illness hypo-and hyperglycemia have a negative influence on patient outcome. Continuous glucose monitoring (CGM) could help in early detection of hypo-and hyperglycemia. A requirement for these new methods is an acceptable accuracy and precision in clinical practice. In this pilot study we prospectively evaluated the accuracy and precision of two CGM sensors (subcutaneous sensor: Sentrino®, Medtronic and intravasal sensor: Glucoclear®, Edwards) in 20 patients on a cardio-surgical ICU in a head to head comparison. CGM data were recorded for up to 48 h and values were compared with blood-gas-analysis (BGA) values, analysed with Bland-Altman-plots and color-coded surveillance error-grids. Shown are means ± standard deviations. In total 270/255 intravasal/subcutaneous pairs with BGA-values were analysed. The average runtime of the sensors was 28.4 ± 6.4 h. Correlation with BGA values yielded a correlation coefficient of 0.76 (subcutaneous sensor) and 0.92 (intravasal sensor). The Bland Altman Plots revealed an accuracy of 2.5 mg/dl, and a precision of + 43.0 mg/dl to - 38.0 mg/dl (subcutaneous sensor) and an accuracy of - 6.0 mg/dl, and a precision of + 12.4 mg/dl to - 24.4 mg/dl (intravasal sensor). No severe hypoglycemic event, defined as BG level below 40 mg/dl, occurred during treatment. Both sensors showed good accuracy in comparison to the BGA values, however they differ regarding precision, which in case of the subcutaneous sensor is considerable high.
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