Glucose control in the intensive care unit. Crit Care Med. 2009;37:1769-1776. [PMID: 19325461 DOI: 10.1097/ccm.0b013e3181a19ceb]

The U-shaped relationship between serum osmolality and the risk of sepsis-associated delirium development: a retrospective study

OBJECTIVE

We aim to investigate the association between serum osmolality and the risk of developing delirium in septic patients.

METHODS

Adult septic patients meeting the Sepsis-3 definition were included. Delirium was screened according to the Confusion Assessment Method for the ICU (CAM-ICU) tool. Patients lacked of serum osmolality results and those with delirium prior to sepsis occurrence were excluded. The association between osmolality and delirium was visualized using both restricted cubic splines (RCS) and local weighted scatter plot smoothing (LOWESS) methods. Logistic regression, subgroup and sensitivity analysis were performed to determine the predictive value of osmolality on delirium.

RESULTS

A total of 17,171 septic patients were included. A U-shaped pattern was observed between serum osmolality and delirium risk (P for non-linear < 0.001). Compared with intermediate range (286-301 mmol/L), patients in the low and high osmolality groups had an increased percentage of delirium. Compared with intermediate osmolality, low and high osmolality could increase the risk of delirium by 21.6-34.5% (OR 1.216-1.345) and 18.4-53.3% (OR 1.184-1.533). All subgroups analysis supported that abnormal osmolality is an independent risk factor for delirium (OR > 1), and a more significant association was found in SOFA < 6 subgroup. In sensitivity analysis, the presence of comorbidities made no influence on this U-shaped relationship. After balancing the baseline information by propensity score matching (PSM), patients in the intermediate range still had a lower incidence of delirium.

CONCLUSION

There was a U-shaped association between serum osmolality and the risk of sepsis-associated delirium. Further high-quality research is needed to verify our findings.

CLINICAL TRIAL NUMBER

Not applicable.

Exploring the impact of glycemic variability on clinical outcomes in critically ill cerebral infarction patients

BACKGROUND

Glycemic variability (GV) is a key determinant of outcomes in critically ill patients, yet its impact on cerebral infarction patients in intensive care units (ICUs) remains underexplored. This study evaluates the association between GV and clinical outcomes, including discharge outcomes, 90-day and 1-year mortality, and ICU/hospital length of stay (LOS).

METHODS

This retrospective study of 778 cerebral infarction patients from the MIMIC-IV database assessed GV, calculated as the glucose standard deviation-to-mean ratio during ICU stays. Regression models evaluated GV's impact on discharge outcomes, mortality, and ICU/hospital LOS, with adjustments for confounders. Restricted cubic spline analyses identified risk thresholds, while sensitivity and subgroup analyses validated findings. Predictive performance was assessed using AUC, NRI, and IDI, and multiple imputation methods addressed missing data.

RESULTS

Higher GV was significantly linked to adverse outcomes. Patients in the highest GV quartile had increased risks of poor discharge outcomes (adjusted OR: 1.83; 95% CI: 1.03-3.32; P = 0.042), 90-day mortality (adjusted HR: 1.51; 95% CI: 1.03-2.22; P = 0.036), and 1-year mortality (adjusted HR: 1.53; 95% CI: 1.07-2.18; P = 0.018). RCS analysis identified critical GV thresholds (≥ 11% for 90-day and ≥ 10% for 1-year mortality). Subgroup analysis revealed stronger associations between GV and poor outcomes in non-diabetic patients (adjusted OR: 1.89; 95% CI: 1.24-2.88; P = 0.003) compared to diabetic patients (adjusted OR: 0.81; 95% CI: 0.53-1.25; P = 0.337). Sensitivity analyses confirmed the robustness of findings across imputation methods.

CONCLUSIONS

GV independently predicts poor outcomes in ICU cerebral infarction patients. Integrating GV metrics into clinical workflows may improve risk stratification and guide interventions. Future research should validate these findings and explore strategies to reduce GV.

Evaluation of point-of-care capillary and venous blood glucose concentrations in hospitalized neonatal foals

OBJECTIVE

To compare glucose measurements from capillary and venous blood samples using a point-of-care (POC) glucometer with a standard laboratory (colorimetric, glucose oxidase) assay (LABGLU) in a population of hospitalized, neonatal foals.

DESIGN

Multicenter, prospective, experimental study, conducted between March 2019 and June 2020.

SETTING

Four university teaching hospitals and 1 private referral hospital.

ANIMALS

Fifty-four hospitalized neonatal (≤30 days of age) foals.

INTERVENTIONS

Simultaneous capillary (muzzle, POCMUZ) and venous (jugular, POCJUG) blood samples were obtained to determine POC glucose concentrations. Venous samples were also analyzed by LABGLU. Each foal was sampled at the time of enrollment or admission to the hospital and at 1 subsequent point during hospitalization. Indirect mean arterial pressure and hematocrit were concurrently recorded.

MEASUREMENTS AND MAIN RESULTS

Bland-Altman analysis showed a mean bias (95% limits of agreement) of -28.0 (-88.6 to 32.6) mg/dL for comparison of POCJUG with LABGLU, -8.2 (-94.3 to 78.0) mg/dL for POCMUZ and LABGLU, and 18.8 (-44.4 to 82.0) mg/dL for POCMUZ and POCJUG. A total of 63.5% of the POCJUG and 45.2% of the POCMUZ samples exceeded the reference value by ±15 mg/dL (for LABGLU samples <75 mg/dL) or ±15% (for LABGLU samples ≥75mg/dL). Concordance correlation coefficient (95% confidence interval [CI]) indicated a fair agreement between POCJUG and LABGLU (0.75, 95% CI: 0.66-0.82) and between POCMUZ and LABGLU (0.71, 95% CI: 0.58-0.80). Fifty percent (14/28) of hypoglycemic foals on the reference method were incorrectly classified as euglycemic by POCJUG, and 5 of 28 were incorrectly classified by POCMUZ.

CONCLUSIONS

In the sampled population, the chosen POC glucometer lacked agreement with the standard laboratory measurement. Limits of agreement were wide for both POCJUG and POCMUZ. Inaccuracies in POC results could impact decision-making in the clinical management of glycemic control in hospitalized neonatal foals and, importantly, increase the risk of hypoglycemic events being underdiagnosed in critical patients.

Activation of GFRAL+ neurons induces hypothermia and glucoregulatory responses associated with nausea and torpor

GFRAL-expressing neurons actuate aversion and nausea, are targets for obesity treatment, and may mediate metformin effects by long-term GDF15-GFRAL agonism. Whether GFRAL+ neurons acutely regulate glucose and energy homeostasis is, however, underexplored. Here, we report that cell-specific activation of GFRAL+ neurons using a variety of techniques causes a torpor-like state, including hypothermia, the release of stress hormones, a shift from glucose to lipid oxidation, and impaired insulin sensitivity, glucose tolerance, and skeletal muscle glucose uptake but augmented glucose uptake in visceral fat. Metabolomic analysis of blood and transcriptomics of muscle and fat indicate alterations in ketogenesis, insulin signaling, adipose tissue differentiation and mitogenesis, and energy fluxes. Our findings indicate that acute GFRAL+ neuron activation induces endocrine and gluco- and thermoregulatory responses associated with nausea and torpor. While chronic activation of GFRAL signaling promotes weight loss in obesity, these results show that acute activation of GFRAL+ neurons causes hypothermia and hyperglycemia.

Expert Recommendations for Using Time-in-Range and Other Continuous Glucose Monitoring Metrics to Achieve Patient-Centered Glycemic Control in People With Diabetes

New metrics for assessing glycemic control beyond HbA1c have recently emerged due to the increasing use of continuous glucose monitoring (CGM) in diabetes clinical practice. Among them, time in range (TIR) has appeared as a simple and intuitive metric that correlates inversely with HbA1c and has also been newly linked to the risk of long-term diabetes complications. The International Consensus on Time in Range established a series of target glucose ranges (TIR, time below range and time above range) and recommendations for time spent within these ranges for different diabetes populations. These parameters should be evaluated together with the ambulatory glucose profile (AGP). Using standardized visual reporting may help people with diabetes and healthcare professionals in the evaluation of glucose control in frequent clinical situations. The objective of the present review is to provide practical insights to quick interpretation of patient-centered metrics based on flash glucose monitoring data, as well as showing some visual examples of common clinical situations and giving practical recommendations for their management.

Parenteral Nutrition

Parenteral nutrition (PN) is a therapy to nourish patients who cannot tolerate feeding via the gut. Though a life-saving intervention, it does have risks associated. In this article, we aim to dispel myths associated with PN. Practitioners who manage critically ill patients or patients with intestinal failure should be equipped with evidence-based knowledge of PN including the indications, contraindications, feasibility, complications, and long-term management of PN.

Stress-Induced Hyperglycemia: Consequences and Management

Hyperglycemia during stress is a common occurrence seen in patients admitted to the hospital. It is defined as a blood glucose level above 180mg/dl in patients without pre-existing diabetes. Stress-induced hyperglycemia (SIH) occurs due to an illness that leads to insulin resistance and decreased insulin secretion. Such a mechanism causes elevated blood glucose and produces a complex state to manage with external insulin. This article compiles various studies to explain the development and consequences of SIH in the critically ill that ultimately lead to an increase in mortality while also discussing the dire impact of SIH on certain acute illnesses like myocardial infarction and ischemic stroke. It also evaluates multiple studies to understand the management of SIH with insulin and proper nutritional therapy in the hospitalized patients admitted to the Intensive care unit (ICU) alongside the non-critical care unit. While emphasizing the diverse effects of improper control of SIH in the hospital, this article elucidates and discusses the importance of formulating a discharge plan due to an increased risk of type 2 diabetes in the recovered.

A Systematic Review and Meta-Analysis of the effectiveness of continuous versus intermittent enteral nutrition in critically ill adults

BACKGROUND

Continuous Enteral Nutrition (CEN) remains standard practice in Intensive Care Units (ICUs) worldwide. Intermittent Enteral Nutrition (IEN) may be a suitable alternative method. This meta-analysis aims to investigate the safety, tolerance, and effectiveness of IEN compared to CEN in critically ill adults in the ICU.

METHODS

Medline, CINAHL, Scopus, Embase and Google Scholar were searched for studies published up until 30^th April 2020, along with manual searches in bibliographies. Eligible studies were trials that compared CEN versus IEN feeding in the ICU, and reported on at least one of the relevant outcomes - nutritional intake, gastric residual volume (GRV), aspiration pneumonia, vomiting, diarrhea, abdominal distension, glycemic variability. Secondary outcomes were ICU length of stay (LOS) and mortality. The Cochrane risk-of-bias tool for randomized trials was used to assess methodological quality.

RESULTS

Ten studies with 664 participants were included in the meta-analysis. The majority of studies had an overall 'High' risk of bias. Incidence of vomiting was significantly higher in CEN as compared to IEN groups (Risk Ratio 2.76; 95% CI, 1.23 - 6.23). There were no significant differences between CEN and IEN groups for nutritional intake, GRV, the incidence of aspiration pneumonia, diarrhea, abdominal distension, ICU LOS, and mortality. Definition and reporting of outcome measures were not standardized across studies, hence this heterogeneity limits generalisability of results.

CONCLUSION

Overall, the safety, tolerance, and effectiveness of CEN and IEN were found to be comparable. Future studies should explore monitoring larger sample sizes to determine best feeding practices in ICU. This article is protected by copyright. All rights reserved.

Intermittent fasting in paediatric critical illness: The properties and potential beneficial effects of an overnight fast in the PICU

Although evidence for the superiority of continuous feeding over intermittent feeding is lacking, in most paediatric intensive care units (PICU) artificial feeding is administered continuously for 24 h per day. Until now, studies in PICU on intermittent feeding have primarily focused on surrogate endpoints such as nutritional intake and gastro-intestinal complaints and none have studied the effects of an extended fasting period. Intermittent fasting has been proven to have many health benefits in both animal and human studies. The observed beneficial effects are based on multiple metabolic and endocrine changes that are presumed crucial in critical illness as well. One key element is the transition to ketone body metabolism, which, among others, contributes to the stimulation of several cellular pathways involved in stress resistance (neuro)plasticity and mitochondrial biogenesis, and might help preserve brain function. Secondly, the fasting state stimulates the activation of autophagy, a process that is crucial for cellular function and integrity. Of the different intermittent fasting strategies investigated, time-restricted feeding with a daily extended fasting period appears most feasible in the PICU. Moreover, planning the fasting period overnight could help maintain the circadian rhythm. Although not investigated, such an overnight intermittent fasting strategy might improve the metabolic profile, feeding tolerance and perhaps even have beneficial effects on tissue repair, reperfusion injury, muscle weakness, and the immune response. Future studies should investigate practical implications in critically ill children and the optimal duration of the fasting periods, which might be affected by the severity of illness and by age.

Blood glucose-related indicators are associated with in-hospital mortality in critically ill patients with acute pancreatitis

Acute pancreatitis (AP) results in potentially harmful blood glucose fluctuations, affecting patient prognosis. This study aimed to explore the relationship between blood glucose-related indicators and in-hospital mortality in critically ill patients with AP. We extracted data on AP patients from the Multiparameter Intelligent Monitoring in Intensive Care III database. Initial glucose (Glucose_initial), maximum glucose (Glucose_max), minimum glucose (Glucose_min), mean glucose (Glucose_mean), and glucose variability (glucose standard deviation [Glucose_SD] and glucose coefficient of variation [Glucose_CV]) were selected as blood glucose-related indicators. Logistic regression models and the Lowess smoothing curves were used to display the association between significant blood glucose-related indicators and in-hospital mortality. Survivors and non-survivors showed significant differences in Glucose_max, Glucose_mean, Glucose_SD, and Glucose_CV (P < 0.05). Glucose_max, Glucose_mean, Glucose_SD, and Glucose_CV were risk factors for in-hospital mortality in AP patients (OR > 1; P < 0.05). According to the Lowess smoothing curve, the overall trends of blood glucose-related indicators showed a non-linear correlation with in-hospital mortality. Glucose_max, Glucose_mean, Glucose_SD, and Glucose_CV were associated with in-hospital mortality in critically ill patients with AP.

White adipose tissue browning in critical illness: A review of the evidence, mechanisms and future perspectives

Observational studies suggest better clinical outcomes following critical illness in patients with overweight and obesity (obesity paradox). An understanding of the morphologic, physiologic and metabolic changes in adipose tissue in critical illness may provide an explanation. Recent studies have demonstrated the transformation of white to brown-like adipocytes due to the "browning process," which has been of interest as a potential novel therapy in obesity during the last decade. The characteristics of the browning of white adipose tissue (WAT) include the appearance of smaller, multilocular adipocytes, increased UCP1 mRNA expression, mitochondrial density and respiratory capacity. These changes have been identified in some critical illnesses, which specifically refers to burns, sepsis and cancer cachexia in this study. The pathophysiological nature of WAT browning, underlying mechanisms, main regulators and potential benefits and harms of this process are interesting new areas that warrants further investigations. In this review, we discuss emerging scientific discipline of adipose tissue physiology in metabolic stress, available data, gaps of knowledge and future perspectives. Future investigations in this field may provide insights into the underlying mechanisms and clinical aspects of browning that may further our understanding of the proposed obesity paradox following critical illness, which may in turn open up opportunities for novel therapies to save lives and improve recovery.

Study protocol and statistical analysis plan for the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial

BACKGROUND

Contemporary glucose management of intensive care unit (ICU) patients with type 2 diabetes is based on trial data derived predominantly from patients without type 2 diabetes. This is despite the recognition that patients with type 2 diabetes may be relatively more tolerant of hyperglycaemia and more susceptible to hypoglycaemia. It is uncertain whether glucose targets should be more liberal in patients with type 2 diabetes.

OBJECTIVE

To detail the protocol, analysis and reporting plans for a randomised clinical trial - the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial - which will evaluate the risks and benefits of targeting a higher blood glucose range in patients with type 2 diabetes.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTION

A multicentre, parallel group, open label phase 2B randomised controlled clinical trial of 450 critically ill patients with type 2 diabetes. Patients will be randomised 1:1 to liberal blood glucose (target 10.0-14.0 mmol/L) or usual care (target 6.0-10.0 mmol/L).

MAIN OUTCOME MEASURES

The primary endpoint is incident hypoglycaemia (< 4.0 mmol/L) during the study intervention. Secondary endpoints include biochemical and feasibility outcomes.

RESULTS AND CONCLUSION

The study protocol and statistical analysis plan described will delineate conduct and analysis of the trial, such that analytical and reporting bias are minimised.

TRIAL REGISTRATION

This trial has been registered on the Australian New Zealand Clinical Trials Registry (ACTRN No. 12616001135404) and has been endorsed by the Australian and New Zealand Intensive Care Society Clinical Trials Group.

Glycaemic Control in Critically Ill Adult Patients: Is intensive insulin therapy beneficial?

OBJECTIVES Glycaemic control with intensive insulin therapy and its impact on patient outcomes have always been contentious in an intensive care setting. This study aims to assess the patterns of glycaemic control in critically ill patients at a tertiary care institution in Trinidad and its relationship to outcomes. METHODS All adult patients admitted to a multidisciplinary intensive care unit (ICU) for a period of two years were enrolled for a retrospective chart review. Data collected included demographics, admission blood glucose, mean morning blood glucose (MBG), the trend of glucose control, number of hypoglycaemic episodes, admission Simplified Acute Physiology Score (SAPS) II, ICU and hospital length of stay, duration of mechanical ventilation, anaemia, renal replacement therapy and hospital outcome. RESULTS A total of 104 patients were studied. Four different patterns of insulin therapy were practised at the ICU. The median age of patients was 55.5 years, the mean SAPS II was 49.3, the mean predicted mortality was 45.5% and the overall observed mortality was 38.5%. The majority of admissions had cardiovascular illnesses (25%), followed by sepsis (20.2%). Patients with multiple hypoglycaemic episodes had an increased mortality (p<0.01). Patients had a better outcome with a higher MBG (>100 mg/dL) (p<0.05). There was a significant difference in mortality among the four patterns of glycaemic control (p<0.001). Admission blood glucose, length of time of mechanical ventilation, ICU length of stay and renal replacement therapy were not found to be associated with adverse outcomes. CONCLUSION Intensive insulin therapy (IIT) may not benefit ICU patients but can be probably associated with higher mortality. Avoidance of hypoglycaemia as well as persistent hyperglycaemia may lead to a better outcome in critically ill patients.

Association Between Blood Glucose Within 24 Hours After Intensive Care Unit Admission and Prognosis: A Retrospective Cohort Study

PURPOSE

The aim of this study was to evaluate the association between blood glucose within 24 hours after intensive care unit (ICU) admission and prognosis.

PATIENTS AND METHODS

A retrospective cohort study was conducted using data from a large critical care database. Patients who had a length of ICU stay ≥24 hours and at least two blood glucose records within 24 hours after ICU admission were included and hospital mortality was chosen as the primary outcome. The average, minimum, and maximum blood glucose within 24 hours after ICU admission were a priori selected as exposures and associations between each exposure and outcomes were assessed after adjusted for potential confounders.

RESULTS

A total of 14,237 patients were included finally with an average age of 62.9±17.7 years and a mean SAPS II on admission of 34 (26-44). Among the study population, 20.2% (2872/14,237) had uncomplicated diabetes, and 6.7% (953/14,237) had complicated diabetes. Lowest hospital mortality rate was observed in the stratum with an average blood glucose ranged 110-140 mg/dL, a minimum blood glucose ranged 80-110 mg/dL, and a maximum blood glucose ranged 110-140 mg/dL. After adjusted for confounders including age, sex, disease severity scores and comorbidities, an average blood glucose ranged 110-140 mg/dL, a minimum blood glucose ranged 80-110 mg/dL, and a maximum blood glucose ranged 110-140 mg/dL were associated with the lowest risk of hospital mortality. Consistent results were found among patients without diabetes in the subgroup analyses stratified by diabetes.

CONCLUSION

A range of 110-140 mg/dL for average and maximum blood glucose and a range of 80-110 mg/dL for minimum blood glucose within 24 hours after ICU admission predicted better prognosis especially among patients without diabetes.

A Comparison of 10% Dextrose and 50% Dextrose for the Treatment of Hypoglycemia in the Prehospital Setting

BACKGROUND

Hypoglycemia is a frequent cause of emergency medical services (EMS) activation; however, limited evidence exists to support optimal prehospital treatment.

OBJECTIVE

This study sought to compare the safety and efficacy of the administration of 10% dextrose (D10) intravenously (IV) versus 50% dextrose (D50) IV for the treatment of hypoglycemia in the prehospital setting.

METHODS

This was a retrospective cohort study of patients who received IV dextrose by EMS and were transported to an academic teaching hospital emergency department between 2014 and 2017.

RESULTS

Four hundred seventy-eight eligible patients were reviewed, with 161 patients receiving D10 and 150 patients receiving D50. There was no significant difference found regarding the need for dextrose retreatment prior to hospital arrival between the D10 and D50 groups (0.6% vs 2.0%; P = .565). The prehospital reassessment glucose in the D50 group was a significantly higher than the D10 group (151.9 vs 124.6 mg/dL, P = .001) and this difference was maintained on hospital arrival (129.5 vs 108.0 mg/dL, P = .011). No significant difference was found between groups with regard to hospital admission, length of stay, or in-hospital mortality.

CONCLUSION

When comparing D10 with D50 for the treatment of hypoglycemia by EMS, there were no significant differences in the need for dextrose retreatment prior to hospital arrival. The use of D50 resulted in a significantly higher blood glucose concentrations both in the prehospital setting and upon hospital arrival. Further study is needed in larger patient populations to evaluate the use of D10, the need for dextrose readministration, and its impact on clinical outcomes.

Early enteral nutrition (within 48 hours) versus delayed enteral nutrition (after 48 hours) with or without supplemental parenteral nutrition in critically ill adults

BACKGROUND

Early enteral nutrition support (within 48 hours of admission or injury) is frequently recommended for the management of patients in intensive care units (ICU). Early enteral nutrition is recommended in many clinical practice guidelines, although there appears to be a lack of evidence for its use and benefit.

OBJECTIVES

To evaluate the efficacy and safety of early enteral nutrition (initiated within 48 hours of initial injury or ICU admission) versus delayed enteral nutrition (initiated later than 48 hours after initial injury or ICU admission), with or without supplemental parenteral nutrition, in critically ill adults.

SEARCH METHODS

We searched CENTRAL (2019, Issue 4), MEDLINE Ovid (1946 to April 2019), Embase Ovid SP (1974 to April 2019), CINAHL EBSCO (1982 to April 2019), and ISI Web of Science (1945 to April 2019). We also searched Turning Research Into Practice (TRIP), trial registers (ClinicalTrials.gov, ISRCTN registry), and scientific conference reports, including the American Society for Parenteral and Enteral Nutrition and the European Society for Clinical Nutrition and Metabolism. We applied no restrictions by language or publication status.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared early versus delayed enteral nutrition, with or without supplemental parenteral nutrition, in adults who were in the ICU for longer than 72 hours. This included individuals admitted for medical, surgical, and trauma diagnoses, and who required any type of enteral nutrition.

DATA COLLECTION AND ANALYSIS

Two review authors extracted study data and assessed the risk of bias in the included studies. We expressed results as risk ratios (RR) for dichotomous data, and as mean differences (MD) for continuous data, both with 95% confidence intervals (CI). We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included seven RCTs with a total of 345 participants. Outcome data were limited, and we judged many trials to have an unclear risk of bias in several domains. Early versus delayed enteral nutrition Six trials (318 participants) assessed early versus delayed enteral nutrition in general, medical, and trauma ICUs in the USA, Australia, Greece, India, and Russia. Primary outcomes Five studies (259 participants) measured mortality. It is uncertain whether early enteral nutrition affects the risk of mortality within 30 days (RR 1.00, 95% CI 0.16 to 6.38; 1 study, 38 participants; very low-quality evidence). Four studies (221 participants) reported mortality without describing the timeframe; we did not pool these results. None of the studies reported a clear difference in mortality between groups. Three studies (156 participants) reported infectious complications. We were unable to pool the results due to unreported data and substantial clinical heterogeneity. The results were inconsistent across studies. One trial measured feed intolerance or gastrointestinal complications; it is uncertain whether early enteral nutrition affects this outcome (RR 0.84, 95% CI 0.35 to 2.01; 59 participants; very low-quality evidence). Secondary outcomes One trial assessed hospital length of stay and reported a longer stay in the early enteral group (median 15 days (interquartile range (IQR) 9.5 to 20) versus 12 days (IQR 7.5 to15); P = 0.05; 59 participants; very low-quality evidence). Three studies (125 participants) reported the duration of mechanical ventilation. We did not pool the results due to clinical and statistical heterogeneity. The results were inconsistent across studies. It is uncertain whether early enteral nutrition affects the risk of pneumonia (RR 0.77, 95% CI 0.55 to 1.06; 4 studies, 192 participants; very low-quality evidence). Early enteral nutrition with supplemental parenteral nutrition versus delayed enteral nutrition with supplemental parenteral nutrition We identified one trial in a burn ICU in the USA (27 participants). Primary outcomes It is uncertain whether early enteral nutrition with supplemental parenteral nutrition affects the risk of mortality (RR 0.74, 95% CI 0.25 to 2.18; very low-quality evidence), or infectious complications (MD 0.00, 95% CI -1.94 to 1.94; very low-quality evidence). There were no data available for feed intolerance or gastrointestinal complications. Secondary outcomes It is uncertain whether early enteral nutrition with supplemental parenteral nutrition reduces the duration of mechanical ventilation (MD 9.00, 95% CI -10.99 to 28.99; very low-quality evidence). There were no data available for hospital length of stay or pneumonia.

AUTHORS' CONCLUSIONS

Due to very low-quality evidence, we are uncertain whether early enteral nutrition, compared with delayed enteral nutrition, affects the risk of mortality within 30 days, feed intolerance or gastrointestinal complications, or pneumonia. Due to very low-quality evidence, we are uncertain if early enteral nutrition with supplemental parenteral nutrition compared with delayed enteral nutrition with supplemental parenteral nutrition reduces mortality, infectious complications, or duration of mechanical ventilation. There is currently insufficient evidence; there is a need for large, multicentred studies with rigorous methodology, which measure important clinical outcomes.

Blood glucose control in the intensive care unit: Where is the data?

Blood glucose control, including hyperglycemia correction, maintaining glucose at optimal level and avoiding hypoglycemia, is a challenge clinicians face every day in intensive care units (ICUs). If managed inadequately, its related mortality can increase. Prior to 2001, no relevant data from randomized, controlled studies assessing glucose control in the ICU were available. In the past 18 years, however, many clinical trials have defined criteria for managing abnormal blood glucose levels, as well as provided suggestions for glycemic monitoring. Point-of-care blood glucose monitors have become the preferred bedside technology to aid in glycemic management. In addition, in some institutions, continuous glucose monitoring is now available. Cost-effectiveness of adequate glycemic control in the ICU must be taken into consideration when addressing this complex issue. Newer types of glycemic monitoring may reduce nursing staff fatigue and shorten times for the treatment of hyperglycemia or hypoglycemia. There are a variety of glycemic care protocols available. However, not all ICU clinicians are aware of them. The following minireview describes some of these concepts.

Glycemic control outcomes of manual and computerized insulin titration protocols: a systematic review protocol

OBJECTIVE

The object of this systematic review is to determine the effectiveness of computerized insulin titration protocols compared to manual insulin titration protocols for glycemic control in hospitalized adult patients.

INTRODUCTION

Hyperglycemia is common during acute illness, and current recommendations for patients with altered glucose metabolism is the use of intravenous insulin therapy. Due to the narrow therapeutic index of insulin, euglycemia is difficult to achieve and requires frequent dose titrations and blood glucose checks. Dose titrations can be accomplished through the use of manual or computerized insulin titration protocols.

INCLUSION CRITERIA

This review will consider studies that compare manual and computerized insulin titration protocols for hospitalized adult patients requiring intravenous insulin therapy for hyperglycemia. Studies must have considered one or more glycemic control outcomes.

METHODS

This systematic review will use the JBI methodology for evidence of effectiveness. The search will be limited to studies published in English from 1984, as this was the approximate year that the first pilot study of a computerized titration protocol was implemented. The databases to be searched include: Cochrane Central Register of Controlled Trials, CINAHL, PubMed, Embase, Health Technology Assessments and Ovid Healthstar. The trial registers to be searched include: US National Library of Medicine (ClinicalTrials.gov). The search for unpublished studies will include ProQuest Dissertations and Theses, and MedNar. Retrieval of full-text studies, assessment of methodological quality and data extraction will be performed independently by two reviewers. Meta-analysis will be performed if possible, and a Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Summary of Findings presented.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019142776.

Autophagy: should it play a role in ICU management?

PURPOSE OF REVIEW

This review is to discuss the role of autophagy in the critically ill patient population. As the understanding of autophagy continues to expand and evolve, there are certain controversies surrounding whether intensivist should allow the benefit of autophagy to supersede gold standard of insulin therapy or early nutritional support.

RECENT FINDINGS

The review is relevant as the current literature seems to support under-feeding patients, and perhaps the reason these studies were positive could be prescribed to the mechanisms of autophagy. It is well understood that autophagy is a physiologic response to stress and starvation, and that the inducible form could help patients with end-organ dysfunction return to homeostasis.

SUMMARY

The jury is still out as to how autophagy will play into clinical practice as we review several gold standard therapies for the critically ill.

A nationwide survey of norovirus-associated encephalitis/encephalopathy in Japan

BACKGROUND

Norovirus is a major pathogen of gastroenteritis and is known to cause encephalitis/encephalopathy. The aim of this national survey was to clarify the clinical features of norovirus-associated encephalitis/encephalopathy (NoVE) among children in Japan.

METHODS

A nationwide survey of children with NoVE was conducted using a structured research form. The initial survey asked pediatricians about children with NoVE treated between January 2011 and March 2016. The second survey obtained patient information from two sources: hospitals that responded to the initial survey and those identified as having treated cases from a literature search.

RESULTS

Clinical information was available for 29 children. Their median age was 2 y 8 m. The outcome was good in 13 patients and poor in 15. The interval between the onset of gastrointestinal symptoms and that of encephalitis/encephalopathy was significantly shorter in those with a poor outcome. At the onset of an elevated serum creatinine level and an abnormal blood glucose level were correlated with a poor outcome. Regarding the subtypes of encephalitis/encephalopathy, acute encephalopathy with biphasic seizures and late reduced diffusion and hemorrhagic shock and encephalopathy syndrome were frequent.

CONCLUSION

The outcome of children with NoVE was poor. Early onset of neurological symptoms, an elevated serum creatinine level, and an abnormal blood glucose level were associated with a poor outcome. No effective treatment was identified and this should be the subject of future studies.

Continuous Glucose Monitoring Linked to an Artificial Intelligence Risk Index: Early Footprints of Intraventricular Hemorrhage in Preterm Neonates

OBJECTIVE

To develop and validate a new risk score for intraventricular hemorrhage (IVH) in preterm neonates based on continuous glucose monitoring (CGM).

STUDY DESIGN

We retrospectively analyzed CGM traces obtained from 50 very preterm neonates, grouped into two sub-cohorts started on CGM within 12 and 48 h of birth, respectively. A CGM linked to an Artificial Intelligence Risk (CLAIR) index was developed to quantify glucose variability during the first 72 h of life in neonates with and without IVH. Brain-US was performed at least twice a day for the first 5 days of birth. An integrated remote monitoring platform was developed to capture major clinical events in real time and gather data for the risk index. The new score performance was further compared with other measures of glucose variability (coefficient of variation [CV] and standard deviation [SD]) and with a clinical risk index for babies II (CRIB-II) as a predictor of IVH event. The two cohorts were analyzed separately for internal validation of the method.

RESULTS

The primary cohort consisted of 26 neonates (gestational age 30 [28, 31] weeks; BW1275 g[1090, 1750]). Controls (n = 23) exhibited higher CLAIR index than cases (P = 0.004). A cut-off of 0.69 for the new CLAIR index allowed a 100% sensitivity and an 83% specificity for IVH prediction. The CLAIR index was the sole significant predictor for IVH (P = 0.003) when compared with clinical variables, CV, SD, and CRIB-II. In a subgroup analysis in very low-birth-weight infants, the CLAIR index was the sole variable significantly associated with IVH (P = 0.009). Analysis on the secondary cohort (five cases and 16 controls) confirmed a higher CLAIR index in the controls (P = 0.008), in the absence of a difference for CV, SD, and CRIB-II between the two groups.

CONCLUSION

CGM, combined with the AI-algorithm, provides a high-sensitivity index for risk detection of IVH that reflects the glycemic impairment preceding IVH.

Insulin ameliorates pulmonary edema through the upregulation of epithelial sodium channel via the PI3K/SGK1 pathway in mice with lipopolysaccharide‑induced lung injury

Epithelial sodium channel (ENaC) provides the driving force for the removal of edema from the alveolar spaces in acute lung injury (ALI). Our previous study reported that insulin increased the expression of α‑ENaC, possibly via the serum/glucocorticoid‑inducible kinase‑1 (SGK1) pathway in ALI; however, the upstream regulator of SGK1 activity remains unclear. In the current study, C3H/HeN mice were subjected to lipopolysaccharide (LPS)‑induced lung injury without hyperglycemia. Exogenous insulin was administered intravenously using a micro‑osmotic pump, and intratracheal delivery of SGK1 small interfering RNA (siRNA) was performed. Furthermore, alveolar epithelial type II cells transfected with phosphatidylinositol 3‑kinase (PI3K) siRNA or SGK1 siRNA were incubated with insulin. Insulin protected the pulmonary epithelial barrier, reduced the apoptosis of alveolar epithelial cells, attenuated pulmonary edema, improved alveolar fluid clearance, and increased the expression levels of α‑, β‑ and γ‑ENaC in mice. In addition, in alveolar epithelial cells, insulin increased the expression levels of α‑, β‑ and γ‑ENaC, as well as the level of phosphorylated SGK1, which were then inhibited by the selective targeting of PI3K or SGK1 by siRNA. Taken together, the results of the present study demonstrated that insulin protected the lung epithelium and attenuated pulmonary edema through the upregulation of ENaC via the PI3K/SGK1 pathway in LPS‑induced lung injury.

Prognostic Significance of Blood Glucose Levels and Alterations Among Patients with Aluminium Phosphide Poisoning

Objectives

This study aimed to assess the prognostic significance of blood glucose levels and blood glucose alterations (i.e. hyper- or hypoglycaemia) among patients with aluminium phosphide (AlP) poisoning.

Methods

This prospective observational study was conducted at the Postgraduate Institute of Medical Education & Research, Chandigarh, India, between January 2010 and June 2011. All patients presenting to the emergency department with a definitive history of AlP ingestion or symptoms compatible with AlP poisoning were included in the study. Blood glucose levels were recorded at presentation and every six hours thereafter. Alterations in blood glucose levels and other clinical and laboratory variables were subsequently compared between survivors and non-survivors.

Results

A total of 116 patients with AlP poisoning were identified. Of these, 57 patients (49%) survived and 59 patients (51%) died. At presentation, the mean blood glucose levels of survivors and non-survivors were 119.9 ± 35.7 mg/dL and 159.7 ± 92.5 mg/dL, respectively (P <0.001). In comparison to the survivors, non-survivors had significantly higher heart rates, total leukocyte counts, blood glucose level alterations and serum creatinine levels (P <0.050). In addition, systolic blood pressure, Glasgow coma scale scores, arterial blood gas pH and bicarbonate values and duration of hospital stay was significantly lower compared to survivors (P <0.001). However, neither blood glucose levels at admission nor blood glucose alterations correlated independently with mortality in a multivariate analysis.

Conclusion

The role of blood glucose level alterations in predicting patient outcomes in AlP poisoning cases remains inconclusive. Further studies with larger sample sizes are required.

PTEN in propofol-induced insulin resistance in mouse primary hepatocytes

Propofol is the most common intravenous anesthetic agent used in clinical practice. Propofol can induce insulin resistance in mouse primary hepatocytes, however the molecular mechanism through which propofol acts remains largely unknown. Based on previous studies, it was hypothesized that phosphatase and tensin homolog (PTEN) is involved in propofol-mediated insulin resistance. The aim of the present study was to investigate the biological function of PTEN and its molecular mechanism in propofol-induced insulin resistance in mouse primary hepatocytes. Mouse primary hepatocytes were treated with propofol and transfected with small interfering RNA (siRNA)-996 to silence the endogenous expression of PTEN. The current study assessed the effects of propofol and PTEN knockdown on the expression of PTEN and several key enzymes of the phosphoinositide 3-kinase/protein kinase B/glycogen synthase kinase-3β signaling pathway, as well as the glycogen content in mouse primary hepatocytes. Treatment with propofol significantly increased protein and mRNA PTEN expression in mouse primary hepatocytes. In addition, knockdown of PTEN reversed propofol-induced insulin resistance in mouse primary hepatocytes. The present study indicated that PTEN serves a role in the physiological process of propofol-induced insulin resistance in mouse primary hepatocytes, and PTEN inhibition may be a potential target for therapeutic intervention against propofol-induced adverse effects.

Comment je prends en charge la nutrition d’un patient en état de choc

La réponse métabolique à l’agression correspond à un ensemble de réactions à la base de l’adaptation de l’organisme aux nouvelles conditions. Ces modifications concernent des aspects métaboliques spécifiques comme le maintien de la masse protéique et/ou l’état des réserves énergétiques. L’une des principales difficultés de l’optimisation du support métabolique consiste à distinguer les changements métaboliques bénéfiques de ceux qui sont délétères pour l’organisme. Dans ce contexte, les objectifs thérapeutiques peuvent se limiter à une approche nutritionnelle s’attachant à limiter le déficit énergétique et les pertes protéiques et musculaires. Ils peuvent être plus ambitieux en essayant d’adapter les apports aux différents besoins d’un point de vue quantitatif comme qualitatif. La limitation du déficit énergétique semble être un objectif raisonnable à atteindre selon les données de la littérature. Enfin, essayer d’interférer avec la réponse métabolique à l’agression (immunomodulation, manipulations pharmacologiques des voies métaboliques, etc.) représente le degré d’intervention métabolique le plus élaboré et, si quelques données ont pu être encourageantes, il n’est pas possible d’affirmer que cet objectif soit complètement réaliste, voire même bénéfique. Les apports nutritionnels doivent être intégrés à la stratégie thérapeutique globale de prise en charge. La réponse optimale du support nutritionnel a pour but « de donner les moyens métaboliques » de la guérison.

Evaluation of the effect of metformin and insulin in hyperglycemia treatment after coronary artery bypass surgery in nondiabetic patients

Introduction:

Insulin therapy is the most commonly used treatment for controlling hyperglycemia after coronary artery bypass surgery in both diabetic and nondiabetic patients. Metformin has been indicated for critically ill patients as an alternate for the treatment of hyperglycemia. This study evaluated the effect of metformin and insulin in hyperglycemia treatment after coronary artery bypass surgery in nondiabetic patients.

Settings and Design:

This study was a clinical trial comprising nondiabetic patients who had undergone coronary artery bypass surgery. Patients were randomly divided into the insulin group and the metformin group.

Methods:

Patients in the insulin group received continuous infusion of insulin while those in the metformin group received 500 mg metformin tablets twice daily. All the patients were followed up for 3 days after stabilization of blood glucose levels.

Statistical Analysis:

Data were analyzed using Chi-square test and Mann–Whitney U-test.

Results:

This study included a total of 56 patients. During the study period, the mean blood glucose levels decreased from 225.24 to 112.36 mg/dl (↓112.88 mg/dl) in the insulin group and from 221.80 to 121.92 mg/dl in the metformin group (↓99.88 mg/dl). There was no significant difference in the blood glucose levels of the patients between the two groups at any measurement times (P > 0.05).

Conclusion:

Using 500 mg metformin twice daily is similar to using insulin in nondiabetic patients undergoing coronary artery bypass graft. Therefore, the use of metformin can be considered as a treatment strategy for controlling hyperglycemia in this group of patients.

Dysglycemia in the critically ill patient: current evidence and future perspectives

Dysglycemia in critically ill patients (hyperglycemia, hypoglycemia, glycemic variability and time in range) is a biomarker of disease severity and is associated with higher mortality. However, this impact appears to be weakened in patients with previous diabetes mellitus, particularly in those with poor premorbid glycemic control; this phenomenon has been called "diabetes paradox". This phenomenon determines that glycated hemoglobin (HbA1c) values should be considered in choosing glycemic control protocols on admission to an intensive care unit and that patients' target blood glucose ranges should be adjusted according to their HbA1c values. Therefore, HbA1c emerges as a simple tool that allows information that has therapeutic utility and prognostic value to be obtained in the intensive care unit.

PTEN expression and its association with glucose control and calorie supplementation in critically ill patients

BACKGROUND & AIM

Phosphatase and tensin homologue (PTEN) reduces insulin sensitivity. Since critically ill patients present insulin resistance, we aimed at assessing the role of PTEN expression on glucose homeostasis and clinical outcome in patients admitted to an intensive care unit (ICU) and receiving artificial nutrition.

METHODS

Observational, single-center study conducted in one ICU in Rome, Italy on adult patients hospitalized for trauma. Plasma glucose levels and its variability were recorded in patients receiving artificial nutrition. PTEN expression was measured by western blotting analysis and the associations between PTEN, plasma glucose levels and variability, and calories administered were investigated. Parametric and non-parametric tests were used, as appropriate.

RESULTS

Twenty consecutive patients (13 men and 7 women, mean age of 37.3 ± 12.7 years) were studied. No correlation between plasma glucose and PTEN was documented (r = -0.15, P = 0.55), neither between glycemic variability and PTEN expression (r = -0.00, P = 0.99). However, total kcal/day administered and PTEN expression significantly correlated (r = 0.56, P = 0.01). Also, patients with PTEN levels below the median received less kcal/day than those with PTEN above the median (P = 0.048). This association was more pronounced when normalized per body weight (P = 0.03) and after adjusting for the average of insulin daily administered (P = 0.02).

CONCLUSIONS

PTEN expression might significantly contribute to glucose homeostasis and disposal in critically ill patients receiving artificial nutrition. Larger samples are necessary to confirm our observation.

CLINICAL TRIAL REGISTRY NUMBER

NCT01796847 (www.clinicaltrials.gov) submitted on February 11, 2013.

Continuous and simultaneous determination of venous blood metabolites

Metabolic syndrome is associated with cardiovascular disease, type 2 diabetes mellitus (T2DM) and prediabetes. Metabolic syndrome is a cluster of interrelated clinical disorders. Difficulties in regulating glucose levels in blood are implicated in many of these disorders. Lactate, another energy metabolite, is produced under anaerobic conditions and can be used to monitor the balance between aerobic and anaerobic metabolism. Tested together, these metabolite levels can provide pro-diagnostic information that improves patient outcomes. Glucose and lactate were determined continuously and simultaneously in whole blood using a dual-channel thermal biosensor device in which one channel employed glucose oxidase for glucose analysis in comparison with lactate oxidase for lactate analysis in the others. No detectable clogging or interference was observed using venous blood samples. The linear detection range for both the glucose and lactate assays was 0.5-45mM. The sampling rate of up to 24 samples per hour with assay cycle time of 2.5min was achieved. Comparative analysis between our device and the HemoCue method showed an excellent correlation. The device was stable for hundreds of injections over a period of 45 days. The broad linear range, fast response and detection sensitivity are satisfactory for the clinical requirements, e.g. for diabetic or cardiovascular patients in intensive care units or surgical operation, where the tight control of blood glucose can decrease morbidity or mortality.

Untangling glycaemia and mortality in critical care

Background

Hyperglycaemia is associated with adverse outcomes in the intensive care unit, and initial studies suggested outcome benefits of glycaemic control (GC). However, subsequent studies often failed to replicate these results, and they were often unable to achieve consistent, safe control, raising questions about the benefit or harm of GC as well as the nature of the association of glycaemia with mortality and clinical outcomes. In this study, we evaluated if non-survivors are harder to control than survivors and determined if glycaemic outcome is a function of patient condition and eventual outcome or of the glycaemic control provided.

Methods

Clinically validated, model-based, hour-to-hour insulin sensitivity (SI) and its hour-to-hour variability (%ΔSI) were identified over the first 72 h of therapy in 145 patients (119 survivors, 26 non-survivors). In hypothesis testing, we compared distributions of SI and %ΔSI in 6-hourly blocks for survivors and non-survivors. In equivalence testing, we assessed if differences in these distributions, based on blood glucose measurement error, were clinically significant.

Results

SI level was never equivalent between survivors and non-survivors (95% CI of percentage difference in medians outside ±12%). Non-survivors had higher SI, ranging from 9% to 47% higher overall in 6-h blocks, and this difference became statistically significant as glycaemic control progressed. %ΔSI was equivalent between survivors and non-survivors for all 6-hourly blocks (95% CI of difference in medians within ±12%) and decreased in general over time as glycaemic control progressed.

Conclusions

Whereas non-survivors had higher SI levels, variability was equivalent to that of survivors over the first 72 h. These results indicate survivors and non-survivors are equally controllable, given an effective glycaemic control protocol, suggesting that glycaemia level and variability, and thus the association between glycaemia and outcome, are essentially determined by the control provided rather than by underlying patient or metabolic condition.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1725-y) contains supplementary material, which is available to authorized users.

Association between elevated blood glucose level on admission and long-term mortality in patients with acute decompensated heart failure

BACKGROUND

The effect of elevated blood glucose (BG) levels on the long-term prognosis of acute decompensated heart failure (ADHF) patients has not been well defined. The purpose of this study is to evaluate the long-term prognosis of ADHF with elevated BG.

METHODS

A cohort of patients consecutively admitted to the cardiac intensive care unit from 2007 to 2011 was studied. Among these, 495 patients who met the criteria were divided into 4 groups based on their BG level and diabetes mellitus (DM) status. The risks for all-cause mortality in each group were assessed using the multivariate Cox proportional hazards model.

RESULTS

At a median follow-up of 1.8 years, 148 patients had died. There were 168 patients without either BG elevation or DM, 67 without BG elevation but with DM, 105 with BG elevation but not DM, and 155 with both BG elevation and DM. In a multivariate model, those with BG elevation, regardless of DM status, showed a greater risk of increased mortality when compared with patients without either BG elevation or DM [hazard ratio (HR), 1.79; p=0.042 for BG elevation without DM and HR, 1.73; p=0.048 for BG elevation with DM].

CONCLUSION

Elevated BG levels, irrespective of the DM status, at the time of admission in patients with ADHF, appear to be a prognostic marker for ADHF.

Management of critically ill patients with diabetes

Disorders of glucose homeostasis, such as stress-induced hypoglycemia and hyperglycemia, are common complications in patients in the intensive care unit. Patients with preexisting diabetes mellitus (DM) are more susceptible to hyperglycemia, as well as a higher risk from glucose overcorrection, that may results in severe hypoglycemia. In critically ill patients with DM, it is recommended to maintain a blood glucose range between 140-180 mg/dL. In neurological patients and surgical patients, tighter glycemic control (i.e., 110-140 mg/d) is recommended if hypoglycemia can be properly avoided. There is limited evidence that shows that critically ill diabetic patients with a glycosylated hemoglobin levels above 7% may benefit from looser glycemic control, in order to reduce the risk of hypoglycemia and significant glycemic variability.

D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study

INTRODUCTION

Prehospital first responders historically have used an IV bolus of 50 mL of 50% dextrose solution (D50) for the treatment of hypoglycemia in the field. A local Emergency Medical Services (EMS) system recently approved a hypoglycemia treatment protocol of IV 10% dextrose solution (D10) due to occasional shortages and higher cost of D50. We use the experience of this EMS system to report the feasibility, safety, and efficacy of this approach.

METHODS

Over the course of 104 weeks, paramedics treated 1,323 hypoglycemic patients with D10 and recorded patient demographics and clinical outcomes. Of these, 1,157 (87.5%) patients were treated with 100 mL of D10 initially upon EMS arrival, and full data on response to treatment was available on 871 (75%) of these 1,157. We captured the 871 patients' capillary glucose response to initial infusion of 100 mL of D10 and fit a linear regression line between elapsed time and difference between initial and repeat glucose values. We also explored the need for repeat glucose infusions as well as feasibility, and safety.

RESULTS

The study cohort included 469 men and 402 women with a median age of 66. The median initial field blood glucose was 37 mg/dL, while the subsequent blood glucose had a median of 91 mg/dL. The median time to second glucose testing was eight minutes after beginning the 100mL D10 infusion. Of 871 patients, 200 (23.0%) required an additional dose of IV D10 solution due to persistent or recurrent hypoglycemia and seven (0.8%) patients required a third dose. There were no reported deaths or other adverse events related to D10 administration for hypoglycemia. Linear regression analysis of elapsed time and difference between initial and repeat glucose values showed near-zero correlation.

CONCLUSIONS

The results of one local EMS system over a 104-week period demonstrate the feasibility, safety, and efficacy of using 100 mL of D10 as an alternative to D50. D50 may also have theoretical risks including extravasation injury, direct toxic effects of hypertonic dextrose, and potential neurotoxic effects of hyperglycemia. Additionally, our data suggest that there may be little or no short-term decrease in blood glucose results after D10 administration.

Blood glucose control using a computer-guided glucose management system in allogeneic hematopoietic cell transplant recipients

Allogeneic hematopoietic cell transplantation (HCT) is a potentially curative treatment for patients with hematological malignancies. However, is associated with substantial rates of morbidity and mortality. We and others have shown that malglycemia is associated with adverse transplant outcome. Therefore, improving glycemic control may improve transplant outcome. In this prospective study we evaluated the feasibility of using Glucommander (a Computer-Guided Glucose Management System; CGGM) in order to achieve improved glucose control in hospitalized HCT patients. Nineteen adult patients contributed 21 separate instances on CGGM. Patients were on CGGM for a median of 43 h. Median initial blood glucose (BG) on CGGM was 244 mg/dL, and patients on 20 study instances reached the study BG target of 100-140 mg/dL after a median of 6 h. After BG reached the target range, the median average BG level per patient was 124 mg/dL. Six patients had a total of 10 events of BG <70 mg/dL (0.9% of BG measurements), and no patients experienced BG level <40 mg/dL. The total estimated duration of BG <70 mg/dL was 3 h (0.2% of the total CGGM time). In conclusion, our study demonstrates that stringent BG control in HCT patients using CGGM is feasible.

Impact of a quality improvement project on deceased organ donor management

CONTEXT

Donors showed poor glucose control in the period between declaration of brain death and organ recovery. The level of hyperglycemia in the donors was associated with a decline in terminal renal function.

OBJECTIVE

To determine whether implementation of a quality improvement project improved glucose control and preserved renal function in deceased organ donors.

METHODS

Data collected retrospectively included demographics, medical history, mechanism of death, laboratory values, and data from the United Network for Organ Sharing.

RESULTS

After implementation of the quality improvement project, deceased donors had significantly lower mean glucose concentrations (mean [SD], 162 [44] vs 212 [42] mg/dL; P<.001) and prerecovery glucose concentration (143 [66] vs 241 [69] mg/dL; P<.001). When the donor cohorts from before and after the quality improvement project were analyzed together, mean glucose concentration remained a significant predictor of terminal creatinine level (P<.001). Multivariate analysis of delayed graft function in kidney recipients matched to donors indicated that higher terminal creatinine level was associated with delayed graft function in recipients (P<.001).

CONCLUSION

The quality improvement project improved donor glucose homeostasis, and the data confirm that poor glucose homeostasis is associated with worsening terminal renal function.

Association of the -1031T>C polymorphism and soluble TNF-α levels with Acute Coronary Syndrome

INTRODUCTION

Inflammation has gained a pivotal role in the pathophysiology of Acute Coronary Syndrome (ACS). TNF-α is a pro-inflammatory cytokine that could be a potential biomarker in ACS due to its multiple functions. The rs1799964 TNFA polymorphism (-1031T>C) has been associated with a decrease in gene transcription and cytokine levels.

OBJECTIVE

To determine the association of rs1799964 TNFA polymorphism and TNF-α soluble levels in ACS.

METHODS

A total of 251 patients diagnosed with ACS and 164 individuals without cardiovascular diseases classified as the reference group (RG), were included. The rs1799964 polymorphism was genotyped by PCR-RFLP. Soluble protein levels were determined by ELISA. Statistical analyses were performed using chi square and U-Mann Whitney tests.

RESULTS

The genotype and allele frequencies were different between ACS and RG (OR=0.317, p=0.01; OR=0.688, p=0.03 respectively). ACS patients had higher soluble TNF-α levels compared with the RG (31.08 vs 23.00pg/mL, p<0.001); according genotype significant differences were observed (T/T: 24.06 vs T/C: 34.95pg/mL, p=0.0001) in patients. In the RG, T/T carriers showed discrete lower levels than C/C genotype (22.14 vs 27.83pg/mL, p=0.04).

CONCLUSIONS

The -1031C allele of the TNFA polymorphism confers protection for the development of ACS. The T/C genotype carriers had higher TNF-α serum levels compared to the T/T genotype in ACS. In addition, the -1031T>C TNFA polymorphism was associated with dyslipidemia in ACS in a Western Mexican population.

A mathematical model for predicting glucose levels in critically-ill patients: the PIGnOLI model

Background and Objectives. Glycemic control is of paramount importance in the intensive care unit. Presently, several BG control algorithms have been developed for clinical trials, but they are mostly based on experts' opinion and consensus. There are no validated models predicting how glucose levels will change after initiating of insulin infusion in critically ill patients. The study aimed to develop an equation for initial insulin dose setting. Methods. A large critical care database was employed for the study. Linear regression model fitting was employed. Retested blood glucose was used as the independent variable. Insulin rate was forced into the model. Multivariable fractional polynomials and interaction terms were used to explore the complex relationships among covariates. The overall fit of the model was examined by using residuals and adjusted R-squared values. Regression diagnostics were used to explore the influence of outliers on the model. Main Results. A total of 6,487 ICU admissions requiring insulin pump therapy were identified. The dataset was randomly split into two subsets at 7 to 3 ratio. The initial model comprised fractional polynomials and interactions terms. However, this model was not stable by excluding several outliers. I fitted a simple linear model without interaction. The selected prediction model (Predicting Glucose Levels in ICU, PIGnOLI) included variables of initial blood glucose, insulin rate, PO volume, total parental nutrition, body mass index (BMI), lactate, congestive heart failure, renal failure, liver disease, time interval of BS recheck, dextrose rate. Insulin rate was significantly associated with blood glucose reduction (coefficient: -0.52, 95% CI [-1.03, -0.01]). The parsimonious model was well validated with the validation subset, with an adjusted R-squared value of 0.8259. Conclusion. The study developed the PIGnOLI model for the initial insulin dose setting. Furthermore, experimental study is mandatory to examine whether adjustment of the insulin infusion rate based on PIGnOLI will benefit patients' outcomes.

Protective effect of pretreatment with propofol against tumor necrosis factor-α-induced hepatic insulin resistance

Insulin resistance is common in critically ill patients and seriously affects their prognosis. The anesthetic propofol (2,6-diisopropylphenol) has been shown to cause insulin resistance in rats; however, the specific mechanism underlying this phenomenon remains unknown. Thus, the aim of the present study was to determine the molecular mechanism through which propofol influences insulin resistance in the liver. The current study assessed the effects of propofol on the phosphorylation level of key enzymes involved in the insulin signaling pathway, as well as the glycogen content in primary mouse hepatocytes. Propofol administration was demonstrated to considerably reduce the phosphorylation levels of Akt (Ser473) and glycogen synthase kinase (GSK)-3β (Ser9) in the primary mouse hepatocytes. In addition, propofol was shown to downregulate the phosphoinositide 3-kinase (PI3K)/Akt/GSK-3β signaling pathway and inhibit glycogen synthesis in hepatocytes. Thus, the present results indicated that propofol induced insulin resistance in primary mouse hepatocytes. Notably, pretreatment with propofol in tumor necrosis factor (TNF)-α-induced primary mouse hepatocytes with insulin resistance was demonstrated to alleviate the inhibitory effects of TNF-α on the PI3K/Akt/GSK-3β signaling pathway and glycogen synthesis. These results indicated that propofol exerts a protective effect against insulin resistance in primary mouse hepatocytes induced by TNF-α, indicating that propofol therapy may be clinically feasible to alleviate insulin resistance in critically ill patients.

Comparative performance assessment of point-of-care testing devices for measuring glucose and ketones at the patient bedside

Point-of-care (POC) testing devices for monitoring glucose and ketones can play a key role in the management of dysglycemia in hospitalized diabetes patients. The accuracy of glucose devices can be influenced by biochemical changes that commonly occur in critically ill hospital patients and by the medication prescribed. Little is known about the influence of these factors on ketone POC measurements. The aim of this study was to assess the analytical performance of POC hospital whole-blood glucose and ketone meters and the extent of glucose interference factors on the design and accuracy of ketone results. StatStrip glucose/ketone, Optium FreeStyle glucose/ketone, and Accu-Chek Performa glucose were also assessed and results compared to a central laboratory reference method. The analytical evaluation was performed according to Clinical and Laboratory Standards Institute (CLSI) protocols for precision, linearity, method comparison, and interference. The interferences assessed included acetoacetate, acetaminophen, ascorbic acid, galactose, maltose, uric acid, and sodium. The accuracies of both Optium ketone and glucose measurements were significantly influenced by varying levels of hematocrit and ascorbic acid. StatStrip ketone and glucose measurements were unaffected by the interferences tested with exception of ascorbic acid, which reduced the higher level ketone value. The accuracy of Accu-Chek glucose measurements was affected by hematocrit, by ascorbic acid, and significantly by galactose. The method correlation assessment indicated differences between the meters in compliance to ISO 15197 and CLSI 12-A3 performance criteria. Combined POC glucose/ketone methods are now available. The use of these devices in a hospital setting requires careful consideration with regard to the selection of instruments not sensitive to hematocrit variation and presence of interfering substances.

Relationship between Nadir Hematocrit during Cardiopulmonary Bypass and Postoperative Hyperglycemia in Nondiabetic Patients

<p><b>Background:</b> Hyperglycemia is common after cardiac surgery in both diabetic and nondiabetic patients and is associated with increased morbidity and mortality. Association between nadir hematocrit levels on cardiopulmonary bypass (CPB) and postoperative hyperglycemia is not clear. This study was carried out to determine the relationship between nadir hematocrit during CPB and postoperative hyperglycemia in nondiabetic patients.</p><p><b>Methods:</b> Records of 200 nondiabetic patients undergoing coronary artery bypass grafting operation were retrospectively reviewed. In the first analysis, patients were divided into two subgroups according to the presence or absence of hyperglycemia. Further analysis was made after dividing the patients into 3 subgroups according to nadir hematocrit levels on CPB (less than 20%; 20% to 25%; greater than or equal to 25%).</p><p><b>Results:</b> Compared to patients without hyperglycemia, patients with postoperative hyperglycemia had significantly lower preoperative hematocrit levels (p = 0.004) and were associated with lower nadir hematocrit levels during CPB (p= 0.002). Peak intensive care unit blood glucose levels and number of blood transfusions were significantly higher in patients with nadir hematocrit levels less than 20. (p<0.001 and p<0.001 respectively). Logistic regression analysis demonstrated that nadir hematocrit levels less than 20% (OR 2.9, p=0.009) and allogenic blood transfusion (OR 1.5, p=0.003) were independently associated with postoperative hyperglycemia.</p><p><b>Conclusions:</b> Nadir hematocrit levels on CPB less than 20% and allogenic blood transfusions were independently associated with postoperative hyperglycemia in nondiabetic patients. Patients with a nadir hematocrit levels less than 20 % during CPB should be closely monitored for hyperglycemia in the perioperative period.</p>

Dextrose 10% in the treatment of out-of-hospital hypoglycemia

INTRODUCTION

Prehospital first responders historically have treated hypoglycemia in the field with an IV bolus of 50 mL of 50% dextrose solution (D50). The California Contra Costa County Emergency Medical Services (EMS) system recently adopted a protocol of IV 10% dextrose solution (D10), due to frequent shortages and relatively high cost of D50. The feasibility, safety, and efficacy of this approach are reported using the experience of this EMS system.

METHODS

Over the course of 18 weeks, paramedics treated 239 hypoglycemic patients with D10 and recorded patient demographics and clinical outcomes. Of these, 203 patients were treated with 100 mL of D10 initially upon EMS arrival, and full data on response to treatment was available on 164 of the 203 patients. The 164 patients' capillary glucose response to initial infusion of 100 mL of D10 was calculated and a linear regression line fit between elapsed time and difference between initial and repeat glucose values. Feasibility, safety, and the need for repeat glucose infusions were examined.

RESULTS

The study cohort included 102 men and 62 women with a median age of 68 years. The median initial field blood glucose was 38 mg/dL, with a subsequent blood glucose median of 98 mg/dL. The median time to second glucose testing was eight minutes after beginning the 100 mL D10 infusion. Of 164 patients, 29 (18%) required an additional dose of IV D10 solution due to persistent or recurrent hypoglycemia, and one patient required a third dose. There were no reported adverse events or deaths related to D10 administration. Linear regression analysis of elapsed time and difference between initial and repeat glucose values showed near-zero correlation.

CONCLUSIONS

In addition to practical reasons of cost and availability, theoretical risks of using 50 mL of D50 in the out-of-hospital setting include extravasation injury, direct toxic effects of hypertonic dextrose, and potential neurotoxic effects of hyperglycemia. The results of one local EMS system over an 18-week period demonstrate the feasibility, safety, and efficacy of using 100 mL of D10 as an alternative. Additionally, the linear regression line of repeat glucose measurements suggests that there may be little or no short-term decay in blood glucose values after D10 administration.

[What should no longer be seen when performing a CPB]

Cardiac surgery and cardiopulmonary bypass (CPB) have made significant progress in recent years. Despite these efforts, adverse events continue to occur during surgery. From recent studies of incidents and accidents during CPB, this article focuses on critical recommendations to respect when in charge of a CPB. Some facts are based only on data unsupported by scientific research. Others have not proven their benefit in terms of postoperative morbidity or mortality. The management of anticoagulation, hematocrit, pump flow, and the temperature is discussed. Finally, the importance of teamwork especially in terms of cohesion and communication is highlighted.

Determining optimal threshold for glucose control in organ donors after neurologic determination of death: a United Network for Organ Sharing Region 5 Donor Management Goals Workgroup prospective analysis

BACKGROUND

The appropriate level of glucose control in organ donors after neurologic determination of death (DNDD) remains uncertain. We hypothesized that a glucose target of 180 mg/dL would be appropriate for optimizing organ transplantation rates and outcomes.

METHODS

Demographic, critical care, organ transplantation, and graft outcome data were prospectively collected on all DNDDs in United Network for Organ Sharing (UNOS) Region 5 from 2010 to 2012. Glucose levels were assessed at four time points in the organ donation process. The primary outcome measure was having four or more organs transplanted per donor (OTPD). Univariate analyses were conducted to determine the relationship between glucose levels and OTPD, organ transplantation rates, and graft function. Multivariate analyses were performed to determine independent predictors of four or more OTPDs. Glucose levels were analyzed at the following cutoff points: 150 or less, 180, and 200 mg/dL. Results with a p < 0.05 are listed.

RESULTS

A total of 1,611 DNDDs had a mean (SD) age of 38 (17) years and 3.4 (1.7) OTPDs. Forty-one percent had four or more OTPDs. Glucose levels of 150 mg/dL or less were not associated with differences in organ use. Levels of 180 mg/dL or less were associated with more OTPDs (3.5 vs. 3.2), a higher rate of four or more OTPDs (42% vs. 34%), and more heart (34% vs. 28%), pancreas (18% vs. 11%), and kidney (85% vs. 81%) use. Levels of 200 mg/dL or less revealed similar results. However, only a level of 180 mg/dL or less was an independent predictor of four or more OTPDs (odds ratio, 1.4). All three levels were associated with higher kidney graft survival after a mean (SD) of 10 (6.0) months of follow-up (97% vs. 95%).

CONCLUSION

Hyperglycemia is common in DNDDs and is associated with lower organ transplantation rates and worse graft outcomes. Targeting a glucose level of 180 mg/dL or less seems to preserve outcomes and is consistent with general critical care guidelines.

LEVEL OF EVIDENCE

Therapeutic study, level II.