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Kim YC, Wolf RM, Busin KM, Vanderhoek SM. Perioperative maintenance of hybrid closed loop insulin pump systems in youth with type 1 diabetes mellitus: A case series. Paediatr Anaesth 2023; 33:862-867. [PMID: 37489542 DOI: 10.1111/pan.14732] [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: 04/11/2023] [Revised: 06/07/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Abstract
Current guidelines support the use of continuous glucose monitoring devices and insulin pumps in minor surgical procedures for pediatric patients with type 1 diabetes mellitus. However, there are few reported cases of using hybrid closed loop technology in the perioperative period. This retrospective case series presents seven pediatric patients with type 1 diabetes who underwent eight surgical procedures with maintenance of hybrid closed loop systems. This paper also provides considerations for future use of hybrid closed loop systems perioperatively.
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Affiliation(s)
- Yoohee Claire Kim
- Department of Pediatrics, Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Risa M Wolf
- Department of Pediatrics, Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly M Busin
- Department of Pediatrics, Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samuel M Vanderhoek
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesia, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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2
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Zapf M, Patel D, Henson P, McEvoy MD, Huang E, Wanderer JP, Fowler L, Mccarthy K, Freundlich RE, Eden S, Shotwell MS, Kertai MD. PeRiOperative Glucose PRAgMatic (PROGRAM) trial protocol and statistical analysis plan for comparing automated intraoperative reminders to standardise insulin administration in surgical patients at high risk of hyperglycaemia. BMJ Open 2023; 13:e072745. [PMID: 37620270 PMCID: PMC10450072 DOI: 10.1136/bmjopen-2023-072745] [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: 02/21/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION Studies finding perioperative hyperglycaemia is associated with adverse patient outcomes in surgical procedures spurred the development of blood glucose guidelines at many institutions. In this trial, we will assess the implementation of a clinical decision support tool that is integrated into the intraoperative portion of our electronic health record and provides real-time best practice recommendations for intraoperative insulin dosing in surgical patients at high risk for hyperglycaemia. METHODS AND DESIGN We will assess this intervention using a sequential and repeated cross-over design at the institutional level with periods of time for wash-out, control and study intervention. The unit of analysis will be the surgical case. The primary outcome will be the frequency of hyperglycaemia (>180 mg/dL (10 mmol/L)) at first postoperative anaesthesia care unit measurement. There are several prespecified secondary analyses focused on perioperative glycaemic control. DISCUSSION This protocol and statistical analysis plan describes the methodology, primary and secondary analyses. The PeRiOperative Glucose PRAgMatic (PROGRAM) trial was approved by the Vanderbilt University Institutional Review Board (IRB), Vanderbilt University Medical Center, Nashville, Tennessee, USA (IRB, 220991). The study results will be disseminated via publication in a peer-reviewed journal and presented at national scientific conferences. The results of PROGRAM trial will inform best practice for perioperative standardised insulin administration in surgical patients at high risk of hyperglycaemia. TRIAL REGISTRATION NUMBER NCT05426096.
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Affiliation(s)
- Matthew Zapf
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dev Patel
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patrick Henson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eunice Huang
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leslie Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Karen Mccarthy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert E Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Svetlana Eden
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Kapellen T, Agwu JC, Martin L, Kumar S, Rachmiel M, Cody D, Nirmala SVSG, Marcovecchio ML. ISPAD clinical practice consensus guidelines 2022: Management of children and adolescents with diabetes requiring surgery. Pediatr Diabetes 2022; 23:1468-1477. [PMID: 36537521 DOI: 10.1111/pedi.13446] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Thomas Kapellen
- Department for Women and Child Health, Hospital for Children and Adolescents, Liebigstrasse 20 Leipzig; Children's Hospital Am Nicolausholz, Bad Kösen, University of Leipzig, Leipzig, Germany
| | - Juliana Chizo Agwu
- Department of Paediatrics, Sandwell and West Birmingham, NHS Trust, Birmingham, UK
| | - Lizabeth Martin
- University of Washington Department of Anesthesiology, Division of Pediatric Anesthesia, Seattle Children's Hospital, Seattle, Washington, USA
| | - Seema Kumar
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Marianna Rachmiel
- Pediatric Endocrinology and Diabetes Institute, Shamir (Assaf Haroffeh) Medical Center, Zerifin, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Declan Cody
- Children's Hospital Ireland Crumlin Dublin, University College Dublin, Dublin, Ireland
| | - Sunkara V S G Nirmala
- Department of Pediatric and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
| | - M Loredana Marcovecchio
- Department of Paediatrics, University of Cambridge and Cambridge University Hospitals, NHS Foundation Trust, Cambridge, UK
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4
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Tang R, Wang H, Peng J, Wang D. A trauma-related survival predictive model of acute respiratory distress syndrome. J Clin Lab Anal 2021; 35:e24006. [PMID: 34545630 PMCID: PMC8605170 DOI: 10.1002/jcla.24006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/02/2021] [Accepted: 09/03/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose The purpose of this study was to construct and validate a simple model for the prediction of survival in patients with trauma‐related ARDS. Methods This is a single‐center, retrospective cohort study using MIMIC‐III Clinical Database. Results 842 patients were included in this study. 175 (20.8%) died in‐hospital, whereas 215 (25.5%) died within 90 days. The deceased group had higher Acute Physiology Score (APS III), Sequential Organ Failure Assessment (SOFA), and Simplified Acute Physiology Score II (SAPS II). In multivariate logistic regression model, independent risk factors for mortality in ARDS patients included age ([odds ratio] OR, 1.035; 95% confidence interval [CI], 1.020–1.049), body mass index (OR, 0.957; 95% CI, 0.926–0.989), red blood cell distribution width (OR, 1.283; 95% CI, 1.141–1.443), hematocrit (OR, 1.055; 95% CI, 1.017–1.095), lactate (OR, 1.226; 95% CI, 1.127–1.334), blood urea nitrogen (OR, 1.025; 95% CI, 1.007–1.044), acute kidney failure (OR, 1.875; 95% CI, 1.188–2.959), sepsis (OR, 1.917; 95% CI, 1.165–3.153), type of admission (emergency vs. elective [OR, 2.822; 95% CI, 1.647–4.837], and urgent vs. elective [OR, 5.156; 95% CI, 1.896–14.027]). The area under the curve (AUC) of the model was 0.826, which was superior than the SAPS II (0.776), APS III (0.718), and SOFA (0.692). In the cross‐validation model, the accuracy of the test set was 0.823, the precision was 0.643, and the AUC was 0.813. Conclusions We established a prediction model using data commonly used in the clinic, which has high accuracy and precision and is worthy of use in clinical practice.
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Affiliation(s)
- Rui Tang
- Department of Respiratory Medicine, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hanghang Wang
- Department of Respiratory Medicine, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Junnan Peng
- Department of Respiratory Medicine, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Daoxin Wang
- Department of Respiratory Medicine, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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5
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Sadhu AR, Patham B, Vadhariya A, Chikermane SG, Johnson ML. Outcomes of "Real-World" Insulin Strategies in the Management of Hospital Hyperglycemia. J Endocr Soc 2021; 5:bvab101. [PMID: 34235360 PMCID: PMC8252645 DOI: 10.1210/jendso/bvab101] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Indexed: 11/28/2022] Open
Abstract
Context Guidelines recommend scheduled long-acting basal and short-acting bolus insulin several times daily to manage inpatient hyperglycemia. In the “real world,” insulin therapy is complicated, with limited data on the comparative effectiveness of different insulin strategies. Objective This work aimed to evaluate the association of different insulin strategies with glucose control and hospital outcomes after adjustment for patient and physician factors that influence choice of therapy. Methods This retrospective, observational study took place at an academic hospital. Participants included noncritically ill hospitalized medical/surgical patients (n = 4558) receiving subcutaneous insulin for 75% or longer during admission. Insulin therapy was grouped into 3 strategies within the first 48 hours: basal bolus (BB: scheduled long and short/rapid n = 2358), sliding scale (SS: short/rapid acting n = 1855), or basal only (BO: long only: n = 345). Main outcome measures included glucose control: hypoglycemic days, hyperglycemic days, euglycemic days, mean glucose; and hospitalization: in-hospital mortality, length of stay (LOS), and readmissions. Results Initial therapy with BB was associated with more hypoglycemic (2.40; CI, 2.04 to 2.82) (P < .001) and fewer euglycemic days (0.90; CI, 0.85 to 0.97) (P = .003) than SS, whereas BO was associated with fewer hyperglycemic days (0.70; CI, 0.62 to 0.79) (P < .001), lower mean glucose (–18.03; CI, –22.46 to –12.61) (P < .001), and more euglycemic days (1.22; CI, 1.09 to 1.37) (P < .001) compared to SS. No difference in mortality, LOS, and readmissions was found. However, decreased LOS was observed in the BB subgroup with a medical diagnostic related group (0.93; CI, 0.89 to 0.97) (P < .001). Conclusion BO had a more favorable hyperglycemia profile than SS. BB, on the other hand, showed worse glycemic control as compared to SS. In the real-world hospital, BO may be a simpler and more effective insulin strategy.
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Affiliation(s)
| | | | - Aisha Vadhariya
- University of Houston, College of Pharmacy, Houston, Texas 77204, USA
| | | | - Michael L Johnson
- University of Houston, College of Pharmacy, Houston, Texas 77204, USA
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Cheuk N, Worth LJ, Tatoulis J, Skillington P, Kyi M, Fourlanos S. The relationship between diabetes and surgical site infection following coronary artery bypass graft surgery in current-era models of care. J Hosp Infect 2021; 116:47-52. [PMID: 34332004 DOI: 10.1016/j.jhin.2021.07.009] [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: 05/12/2021] [Revised: 06/28/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although diabetes is a recognized risk factor for postoperative infections, the seminal Portland Diabetic Project studies in cardiac surgery demonstrated intravenous insulin infusions following open-cardiac surgery achieved near normal glycaemia and decreased deep sternal wound infection to similar rates to those without diabetes. AIM We sought to examine a contemporary cohort of patients undergoing coronary artery bypass graft surgery (CABGS) to evaluate the relationship between diabetes, hyperglycaemia and risk of surgical site infection (SSI) in current-era models of care. METHODS Consecutive patients who underwent CABGS between 2016 and 2018 were identified through a state-wide data repository for healthcare-associated infections. Clinical characteristics and records of postoperative SSIs were obtained from individual chart review. Type 2 diabetes (T2D), perioperative glycaemia and other clinical characteristics were analysed in relation to the development of SSI. FINDINGS Of the 953 patients evaluated, 11% developed SSIs a median eight days post CABGS, with few cases of deep SSIs (<1%). T2D was evident in 41% and more prevalent in those who developed SSIs (51%). On multivariate analysis T2D was not significantly associated with development of SSI (odds ratio (OR) 1.35; P=0.174) but body mass index (BMI) remained a significant risk factor (OR 1.07, P<0.001). In patients with T2D, perioperative glycaemia was not significantly associated with SSI. CONCLUSION In a specialist cardiac surgery centre using perioperative intravenous insulin infusions and antibiotic prophylaxis, deep SSIs were uncommon; however, approximately one in 10 patients developed superficial SSIs. T2D was not independently associated with SSI yet BMI was independently associated with SSI post CABGS.
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Affiliation(s)
- N Cheuk
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Australia.
| | - L J Worth
- Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre, Doherty Institute, Australia; National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia
| | - J Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Australia
| | - P Skillington
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Australia
| | - M Kyi
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Australia
| | - S Fourlanos
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Australia
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Ho KKY, Peng YW, Ye M, Tchouta L, Schneider B, Hayes M, Toomasian J, Cornell M, Rojas-Pena A, Charpie J, Chen H. Evaluation of an Anti-Thrombotic Continuous Lactate and Blood Pressure Monitoring Catheter in an In Vivo Piglet Model undergoing Open-Heart Surgery with Cardiopulmonary Bypass. CHEMOSENSORS (BASEL, SWITZERLAND) 2020; 8:56. [PMID: 35310780 PMCID: PMC8932942 DOI: 10.3390/chemosensors8030056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Blood lactate and blood pressure measurements are important predictors of life-threatening complications after infant open-heart surgeries requiring cardiopulmonary bypass (CPB). We have developed an intravascular nitric oxide (NO)-releasing 5-Fr catheter that contains a lactate sensor for continuous in-blood lactate monitoring and a dedicated lumen for third-party pressure sensor attachment. This device has antimicrobial and antithrombotic properties and can be implanted intravascularly. The importance of this design is its ability to inhibit thrombosis, due to the slow release of NO through the surface of the catheter and around the electrochemical lactate sensors, to allow continuous data acquisition for more than 48 h. An in vivo study was performed using six piglets undergoing open-heart surgery with CPB and cardioplegic arrest, in order to mimic intra-operative conditions for infants undergoing cardiac surgery with CPB. In each study of 3 h, two 5-Fr NO-releasing lactate and blood-pressure monitoring catheters were implanted in the femoral vessels (arteries and veins) and the CPB circuitry to monitor changing lactate levels and blood pressures during and immediately after aortic cross-clamp removal and separation from CBP. Electrical signals continuously acquired through the sensors were processed and displayed on the device's display and via Bluetooth to a computer in real-time with the use of a two-point in vivo calibration against blood gas results. The study results show that lactate levels measured from those sensors implanted in the CPB circuit during CPB were comparable to those acquired by arterial blood gas measurements, whereas lactate levels measured from sensors implanted in the femoral artery were closely correlated with those acquired intermittently by blood gas prior to CPB initiation, but not during CPB. Blood pressure sensors attached to one lumen of the device displayed accurate blood pressure readings compared to those measured using an FDA approved pressure sensor already on the market. We recommend that the sensor be implanted in the CPB's circuit to continuously monitor lactate during CPB, and implanted in the femoral arteries or jugular veins to monitor lactate before and after CPB. Blood pressures dramatically drop during CPB due to lower blood flow into the lower body, and we suspect that the femoral arteries are likely collapsing or constricting on the implanted catheter and disrupting the sensor-to-blood contact. This study shows that the device is able to accurately and continuously monitor lactate levels during CPB and potentially prevent post-surgery complications in infants.
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Affiliation(s)
| | - Yun-Wen Peng
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109, USA
| | - Minyi Ye
- Biocrede Inc., Plymouth, MI 48170, USA
| | - Lise Tchouta
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Bailey Schneider
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - McKenzie Hayes
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - John Toomasian
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Marie Cornell
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Alvaro Rojas-Pena
- Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
- Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - John Charpie
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109, USA
| | - Hao Chen
- Biocrede Inc., Plymouth, MI 48170, USA
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8
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Baron JM, Glatz M, Proksch E. Optimal Support of Wound Healing: New Insights. Dermatology 2020; 236:593-600. [PMID: 31955162 DOI: 10.1159/000505291] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 12/07/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The ultimate goal of wound healing following minor injury is to form a tissue regenerate that has functionality and visual appearance as close to the original skin as possible. The body's physiological response to any wound is traditionally characterised by three distinct steps: inflammation, proliferation and remodelling. SUMMARY New insights suggest that the three phases overlap (and even occur in parallel) in both time and space in the wound, necessitating a clinical approach that targets each stage simultaneously to ensure rapid repair and wound closure without further complications. Ingredients that exhibit activity across each of the three phases, such as dexpanthenol, are of value in the context of minor wound care and scar management. Key Messages: In addition to treatment and ingredient selection, it is also important to consider broader clinical best practices and self-care options that can be used to optimise the management of minor wounds. An individualised approach that can account for a patient's unique requirements and preferences is critical in achieving effective wound recovery.
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Affiliation(s)
- Jens Malte Baron
- Department of Dermatology and Allergology, RWTH Aachen University, Aachen, Germany,
| | - Martin Glatz
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
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9
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Cardona S, Tsegka K, Pasquel FJ, Fayfman M, Peng L, Jacobs S, Vellanki P, Halkos M, Guyton RA, Thourani VH, Galindo RJ, Umpierrez G. Sitagliptin for the prevention of stress hyperglycemia in patients without diabetes undergoing coronary artery bypass graft (CABG) surgery. BMJ Open Diabetes Res Care 2019; 7:e000703. [PMID: 31543976 PMCID: PMC6731905 DOI: 10.1136/bmjdrc-2019-000703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/18/2019] [Accepted: 08/17/2019] [Indexed: 02/07/2023] Open
Abstract
AIMS To determine if treatment with sitagliptin, a dipeptidyl peptidase-4 inhibitor, can prevent stress hyperglycemia in patients without diabetes undergoing coronary artery bypass graft (CABG) surgery. METHODS We conducted a pilot, double-blinded, placebo-controlled randomized trial in adults (18-80 years) without history of diabetes. Participants received sitagliptin or placebo once daily, starting the day prior to surgery and continued for up to 10 days. Primary outcome was differences in the frequency of stress hyperglycemia (blood glucose (BG) >180 mg/dL) after surgery among groups. RESULTS We randomized 32 participants to receive sitagliptin and 28 to placebo (mean age 64±10 years and HbA1c: 5.6%±0.5%). Treatment with sitagliptin resulted in lower BG levels prior to surgery (101±mg/dL vs 107±13 mg/dL, p=0.01); however, there were no differences in the mean BG concentration, proportion of patients who developed stress hyperglycemia (21% vs 22%, p>0.99), length of hospital stay, rate of perioperative complications and need for insulin therapy in the intensive care unit or during the hospital stay. CONCLUSION The use of sitagliptin during the perioperative period did not prevent the development of stress hyperglycemia or need for insulin therapy in patients without diabetes undergoing CABG surgery.
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Affiliation(s)
- Saumeth Cardona
- Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Katerina Tsegka
- Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Maya Fayfman
- Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Limin Peng
- Biostatitics, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Sol Jacobs
- Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Michael Halkos
- Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert A Guyton
- Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vinod H Thourani
- Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rodolfo J Galindo
- Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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10
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Fayfman M, Davis G, Duggan EW, Urrutia M, Chachkhiani D, Schindler J, Pasquel FJ, Galindo RJ, Vellanki P, Reyes-Umpierrez D, Wang H, Umpierrez GE. Sitagliptin for prevention of stress hyperglycemia in patients without diabetes undergoing general surgery: A pilot randomized study. J Diabetes Complications 2018; 32:1091-1096. [PMID: 30253968 PMCID: PMC6668912 DOI: 10.1016/j.jdiacomp.2018.08.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 01/04/2023]
Abstract
AIM We investigated if a dipeptidyl peptidase-4 inhibitor, sitagliptin, can prevent perioperative stress hyperglycemia in patients without prior history of diabetes mellitus undergoing general surgery. METHODS This double-blind pilot trial randomized general surgery patients to receive sitagliptin (n = 44) or placebo (n = 36) once daily, starting one day prior to surgery and continued during the hospital stay. The primary outcome was occurrence of stress hyperglycemia, defined by blood glucose (BG) >140 mg/dL and >180 mg/dL after surgery. Secondary outcomes included: length-of-stay, ICU transfers, hypoglycemia, and hospital complications. RESULTS BG >140 mg/dL was present in 44 (55%) of subjects following surgery. There were no differences in hyperglycemia between placebo and sitagliptin (56% vs. 55%, p = 0.93). BG >180 mg/dL was observed in 19% and 11% of patients treated with placebo and sitagliptin, respectively, p = 0.36. Both treatment groups had resulted in similar postoperative BG (148.9 ± 29.4 mg/dL vs. 146.9 ± 35.2 mg/dL, p = 0.73). There were no differences in length-of-stay (4 vs. 3 days, p = 0.84), ICU transfer (3% vs. 5%, p = 1.00), hypoglycemia <70 mg/dL (6% vs. 11%, p = 0.45), and complications (14% vs. 18%, p = 0.76). CONCLUSION Preoperative treatment with sitagliptin did not prevent stress hyperglycemia or complications in individuals without diabetes undergoing surgery.
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Affiliation(s)
- Maya Fayfman
- Emory University, Department of Medicine, Atlanta, GA, United States of America.
| | - Georgia Davis
- Emory University, Department of Medicine, Atlanta, GA, United States of America
| | - Elizabeth W Duggan
- Emory University, Department of Anesthesiology, United States of America
| | - Maria Urrutia
- Emory University, Department of Medicine, Atlanta, GA, United States of America
| | - David Chachkhiani
- Emory University, Department of Medicine, Atlanta, GA, United States of America
| | - Joanna Schindler
- Emory University, Department of Anesthesiology, United States of America
| | - Francisco J Pasquel
- Emory University, Department of Medicine, Atlanta, GA, United States of America
| | - Rodolfo J Galindo
- Emory University, Department of Medicine, Atlanta, GA, United States of America
| | - Priyathama Vellanki
- Emory University, Department of Medicine, Atlanta, GA, United States of America
| | | | - Heqiong Wang
- Emory Rollins School of Public Health, United States of America
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11
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Jefferies C, Rhodes E, Rachmiel M, Agwu JC, Kapellen T, Abdulla MA, Hofer SE. ISPAD Clinical Practice Consensus Guidelines 2018: Management of children and adolescents with diabetes requiring surgery. Pediatr Diabetes 2018; 19 Suppl 27:227-236. [PMID: 30039617 DOI: 10.1111/pedi.12733] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/10/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Craig Jefferies
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Erinn Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Marianna Rachmiel
- Assaf Haroffeh Medical Center, Zerifin, Sackler School of Medicine, Tel Aviv University, Israel
| | - Juliana C Agwu
- Department of Paediatrics, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Thomas Kapellen
- Department for Women and Child Health, Hospital for Children and Adolescents, University of Leipzig, Leipzig, Germany
| | | | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
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12
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Offodile AC, Chou HY, Lin JAJ, Loh CYY, Chang KP, Aycart MA, Kao HK. Hyperglycemia and risk of adverse outcomes following microvascular reconstruction of oncologic head and neck defects. Oral Oncol 2018; 79:15-19. [PMID: 29598945 DOI: 10.1016/j.oraloncology.2018.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/04/2018] [Accepted: 02/10/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Our aim is to examine the correlation between perioperative hyperglycemia and post-operative outcomes following microvascular reconstruction of head and neck defects. PATIENTS AND METHODS Retrospective review of a prospectively collected database of 350 consecutive patients who underwent microvascular reconstruction of malignant head and neck defects over a 2 year period. The relationship between perioperative hyperglycemia (≥ 180 mg/dL) and the incidence of the following complications was evaluated: flap loss, flap-related complications and surgical site infections (SSI). Sub-group analysis based on timing of hyperglycemia was also performed. RESULTS We identified 313 patients (89.4%) in the normoglycemic group and 37 patients (10.6%) in the hyperglycemic group. Baseline demographics, tumor stage, operative variable were comparable. There were no significant differences in flap-related complications and overall mortality. SSI were significantly higher in the hyperglycemic cohort (48% vs. 28%, p = 0.01). On multivariate analysis, hyperglycemia [OR 2.07; 95% CI, 1.87-4.89], perioperative insulin administration [OR 4.805; 95% CI, 2.18-10.60], prolonged operative time [OR 1.003; 95% CI, 1.002-1.025] and higher Charlson co-morbidity indices [II: OR 2.286 & III: OR 2.284] were independent predictors of SSI. On sub-group analysis, only patients with early (POD 1) post-operative hyperglycemia had a significant OR for SSI (OR 1.88; 95% CI, 1.07-3.29). CONCLUSION Our findings suggest that perioperative hyperglycemia, specifically during the first 24 h post-operatively, is associated with SSI in microvascular head and neck reconstruction. This association highlights the need for strict screening of head and neck patients for hyperglycemia especially in the immediate post-operative period.
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Affiliation(s)
- Anaeze C Offodile
- Department of Plastic and Reconstructive Surgery, MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Hsuan-Yu Chou
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jennifer An-Jou Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Charles Yuen Yung Loh
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kai-Ping Chang
- Department of Otolaryngology-Head & Neck Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Mario A Aycart
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States
| | - Huang-Kai Kao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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13
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Järvelä KM, Khan NK, Loisa EL, Sutinen JA, Laurikka JO, Khan JA. Hyperglycemic Episodes Are Associated With Postoperative Infections After Cardiac Surgery. Scand J Surg 2017; 107:138-144. [PMID: 28934890 DOI: 10.1177/1457496917731190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS To describe the incidence of and risk factors for postoperative infections and the correlation between postoperative hyperglycemia despite tight blood glucose control with infectious and other complications after contemporary cardiac surgery. MATERIAL AND METHODS The study comprised 1356 consecutive adult patients who underwent cardiac surgery between January 2013 and December 2014 and were followed up for 6 months. Patients surviving the first 2 days were included in the analysis. Preoperative demographic information, medical history, procedural details, and the postoperative course were recorded. The target range for blood glucose levels was 4-7 mmol/L and repeated arterial blood samples were obtained during the intensive care unit stay. The associations of blood glucose levels during the first postoperative day and the occurrence of postoperative infections and other significant complications were analyzed. RESULTS Of the study cohort, 9.8% developed infectious complications which were classified as major surgical site infections in 2.2%, minor surgical site infections in 1.1%, lung infections in 2.0%, unclear fever or bacteremia in 0.3%, cannula or catheter related in 2.6%, multiple in 1.5%, and other in 0.2%. The incidence of deep sternal wound infection was 2.0%. Repeated hyperglycemia occurred in 39.7% of patients and was associated with increased rates of postoperative infections, 12.1% versus 8.2%, p = 0.019; stroke, 4.9% versus 1.5%, p < 0.001; and mortality, 6.1% versus 2.1%, p < 0.001, when compared to patients with single or no hyperglycemia. CONCLUSION Every 10th patient develops infectious complications after cardiac surgery. Repeated hyperglycemia is associated with increased rates of infectious complications, stroke, and mortality.
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Affiliation(s)
- K M Järvelä
- 1 Department of Cardiothoracic Surgery, TAYS Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - N K Khan
- 2 Department of Vascular Surgery, Tampere University Hospital, Tampere, Finland
| | - E L Loisa
- 3 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - J A Sutinen
- 3 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - J O Laurikka
- 1 Department of Cardiothoracic Surgery, TAYS Heart Hospital, Tampere University Hospital, Tampere, Finland.,3 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - J A Khan
- 1 Department of Cardiothoracic Surgery, TAYS Heart Hospital, Tampere University Hospital, Tampere, Finland
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14
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Cardona S, Pasquel FJ, Fayfman M, Peng L, Jacobs S, Vellanki P, Weaver J, Halkos M, Guyton RA, Thourani VH, Umpierrez GE. Hospitalization costs and clinical outcomes in CABG patients treated with intensive insulin therapy. J Diabetes Complications 2017; 31:742-747. [PMID: 28161384 DOI: 10.1016/j.jdiacomp.2017.01.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/10/2017] [Accepted: 01/13/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The financial impact of intensive (blood glucose [BG] 100-140mg/dl [5.5-7.8mM] vs. conservative (141-180mg/dl (7.9-10.0mM) glucose control in the ICU in patients, with and without diabetes, undergoing coronary artery bypass graft (CABG) surgery is not known. METHODS This post-hoc cost analysis determined differences in hospitalization costs, resource utilization and perioperative complications in 288 CABG patients with diabetes (n=143) and without diabetes (n=145), randomized to intensive (n=143) and conservative (n=145) glucose control. RESULTS Intensive glucose control resulted in lower BG (131.4±14mg/dl-(7.2±0.8mM) vs. 151.6±17mg/dl (8.4±0.8mM, p<0.001), a nonsignificant reduction in the median length of stay (LOS, 7.9 vs. 8.5days, p=0.17) and in a composite of perioperative complications including wound infection, bacteremia, acute renal and respiratory failure, major cardiovascular events (42% vs 52%, p=0.10) compared to conservative control. Median hospitalization costs were lower in the intensive group ($39,366 vs. $42,141, p=0.040), with a total cost savings of $3654 (95% CI: $1780-$3723), than conservative control. Resource utilization for radiology (p=0.008), laboratory (p=0.014), consultation service (p=0.013), and ICU utilization (p=0.007) were also lower in the intensive group. Compared to patients without perioperative complications, those with complications had longer hospital length of stay (10.7days vs. 6.7days, p<0.001), higher total hospitalization cost ($48,299 vs. $32,675, p<0.001), and higher resource utilization units (2745 vs. 1710, p<0.001). CONCLUSION Intensive glycemic control [BG 100-140mg/dl (5.5-7.8mM)] in patients undergoing CABG resulted in significant reductions in hospitalization costs and resource utilization compared to patients treated with conservative [BG 141-180mg/dl (7.9-10.0mM)] glucose control.
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Affiliation(s)
| | | | - Maya Fayfman
- Department of Medicine, Emory University, Atlanta, GA
| | - Limin Peng
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Sol Jacobs
- Department of Medicine, Emory University, Atlanta, GA
| | | | - Jeff Weaver
- Center for Comprehensive Informatics, Emory University, Atlanta, GA
| | - Michael Halkos
- Joseph B. Whitehead Department of Surgery, Atlanta, GA; Emory University, Atlanta, GA
| | - Robert A Guyton
- Joseph B. Whitehead Department of Surgery, Atlanta, GA; Emory University, Atlanta, GA
| | - Vinod H Thourani
- Joseph B. Whitehead Department of Surgery, Atlanta, GA; Emory University, Atlanta, GA
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15
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Wallia A, Schmidt K, Oakes DJ, Pollack T, Welsh N, Kling-Colson S, Gupta S, Fulkerson C, Aleppo G, Parikh N, Levitsky J, Norvell JP, Rademaker A, Molitch ME. Glycemic Control Reduces Infections in Post-Liver Transplant Patients: Results of a Prospective, Randomized Study. J Clin Endocrinol Metab 2017; 102:451-459. [PMID: 27875061 PMCID: PMC6283442 DOI: 10.1210/jc.2016-3279] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 11/17/2016] [Indexed: 12/24/2022]
Abstract
CONTEXT Previous studies have shown a relationship between glycemic control and posttransplant morbidity. OBJECTIVE We conducted a prospective randomized controlled trial in postliver transplant patients to evaluate intensive inpatient glycemic control and effects on outcomes to 1 year. RESEARCH DESIGN AND INTERVENTION A total of 164 patients [blood glucose (BG) >180 mg/dL] were randomized into 2 target groups: 82 with a BG of 140 mg/dL and 82 with a BG of 180 mg/dL. Continuous insulin infusions were initiated and then converted to subcutaneous basal bolus insulin therapy by our glucose management service. RESULTS The inpatient mean BG level was significantly different (140 group, 151.4 ± 19.5 mg/dL vs 180 group, 172.6 ± 27.9 mg/dL; P < 0.001). Any infection within 1 year occurred in 35 of the 82 patients (42.7%) in the 140 group and 54 of 82 (65.9%) in the 180 group (P = 0.0046). In a time-to-first infection analysis, being in the 140 group resulted in a hazard ratio of 0.54 (95% confidence interval, 0.35 to 0.83; P = 0.004); the difference between the 2 groups was statistically significant at 1 month (P = 0.008). The number with adjudicated transplant rejection was similar between the 2 groups [17 of 82 (20.7%) and 20 of 82 (24.3%) in the 140 and 180 groups, respectively; P = not significant]. Severe hypoglycemia (BG ≤40 mg/dL) occurred in 3 patients (2 in the 140 group and 1 in the 180 group). However, more patients had moderate hypoglycemia (BG, 41 to 70 mg/dL) in the 140 group [27 of 82 (32.9%) vs 10 of 82 (12.2%) in the 180 group; P = 0.003]. Insulin-related hypoglycemia was not associated with the incidence of severe adverse outcomes. CONCLUSIONS Glycemic control of 140 mg/dL safely resulted in a reduced incidence of infection after transplantation compared with 180 mg/dL, but with an increase in moderate hypoglycemia.
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Affiliation(s)
- Amisha Wallia
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine
| | - Kathleen Schmidt
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine
| | - Diana Johnson Oakes
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine
| | - Teresa Pollack
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine
| | - Nicholas Welsh
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine
| | - Susan Kling-Colson
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine
| | - Suruchi Gupta
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine
| | - Candice Fulkerson
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine
| | - Neehar Parikh
- Division of Gastroenterology and Hepatology, Department of Medicine, and
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Department of Medicine, and
| | - J P Norvell
- Division of Gastroenterology and Hepatology, Department of Medicine, and
| | - Alfred Rademaker
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611
| | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine
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16
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Pittas AG, Siegel RD, Lau J. Insulin Therapy and In-Hospital Mortality in Critically Ill Patients: Systematic Review and Meta-analysis of Randomized Controlled Trials. JPEN J Parenter Enteral Nutr 2017; 30:164-72. [PMID: 16517961 DOI: 10.1177/0148607106030002164] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hyperglycemia is common in critically ill hospitalized patients and has been associated with adverse outcomes, including increased mortality. In this review, we examine the effect of insulin therapy on mortality in critically ill patients. METHODS We updated our previous systematic review and meta-analysis to include recently published trials that report data on the effect of insulin therapy initiated during hospitalization on mortality in adult patients with a critical illness. We also include a short primer on the methods of systematic reviews and meta-analyses, outlining the specific steps and challenges of this methodology. We performed an electronic search in the English language of MEDLINE and the Cochrane Controlled Clinical Trials Register and a hand search of key journals and relevant review articles for randomized controlled trials that reported mortality data on critically ill hospitalized adult patients treated with insulin (regardless of method of administration). RESULTS We identified 38 relevant studies that entered the analysis. We found that therapy with insulin in adult patients hospitalized for a critical illness, other than hyperglycemic crises, may decrease mortality in certain groups of patients. The beneficial effect of insulin was evident in the surgical intensive care unit (relative risk [RR], 0.58; confidence interval [CI], 0.22-0.62) and in patients with diabetes (RR, 0.76; CI, 0.62-0.92). There was a trend toward benefit in patients with acute myocardial infarction (RR, 0.89; CI, 0.76-1.03). Targeting euglycemia appears to be the main determinant of the benefit of insulin therapy (RR, 0.73; CI, 0.57-0.94). CONCLUSIONS Insulin therapy in adult patients hospitalized for a critical illness, other than hyperglycemic crises, may decrease mortality in certain groups of patients.
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Affiliation(s)
- Anastassios G Pittas
- Division of Endocrinology, Diabetes and Metabolism and Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center, 750 Washington Street #268, Boston, MA 02111, USA.
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17
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Rizzi M, Trevisan R. Genitourinary infections in diabetic patients in the new era of diabetes therapy with sodium-glucose cotransporter-2 inhibitors. Nutr Metab Cardiovasc Dis 2016; 26:963-970. [PMID: 27514605 DOI: 10.1016/j.numecd.2016.07.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/06/2016] [Accepted: 07/07/2016] [Indexed: 12/11/2022]
Abstract
AIMS To review prevalence and significance of urinary tract (UTI) and genital infections (GI) in diabetes and the effects of sodium glucose cotransporter 2 (SGLT-2) inhibitors on these complications. DATA SYNTHESIS The prevalence of asymptomatic bacteriuria (ASB) is 2-3 times higher in diabetic than in non-diabetic women. The treatment of ASB has no impact on the development of UTIs and/or a decline in renal function. Therefore, there is no indication for screening for and/or treatment of ASB. The incidence of UTI is higher and frequently complicated in diabetic patients, particularly in those with longer duration of disease and of older age. There is no consistent evidence of an association between A1c levels, glycosuria and the risk of ASB and/or UTIs. Diabetes is a known risk factor for Candida colonization and GI, and a poor glycemic control is associated with a higher risk. While patients treated with SGLT-2 inhibitors may have a non-significant increased risk of UTI, they have a clearly increased risk of GI; most of these infections are mild, easy to treat, and the rate of recurrence is low. CONCLUSION Diabetic patients are at high risk of UTIs and of GI. Only GI are associated with poor glycemic control. Although patients treated with SGLT-2 inhibitors have an increased 3-5 fold risk of GI, proper medical education can reduce this risk.
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Affiliation(s)
- M Rizzi
- Infectious Diseases Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - R Trevisan
- Endocrinology and Diabetes Unit, ASST Papa Giovanni XXIII, Bergamo, Italy.
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18
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Santos KAQ, Berto B, Sousa AG, Costa FAAD. Prognosis and Complications of Diabetic Patients Undergoing Isolated Coronary Artery Bypass Surgery. Braz J Cardiovasc Surg 2016; 31:7-14. [PMID: 27074269 PMCID: PMC5062695 DOI: 10.5935/1678-9741.20160002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/30/2015] [Indexed: 01/04/2023] Open
Abstract
Objective: Compare the prognosis and complications of diabetic and non-diabetic patients
undergoing isolated coronary artery bypass surgery at a hospital with a high
surgical volume. Methods: Data of patients who underwent coronary artery bypass surgery from June 2009
to July 2010 were analyzed. We selected diabetic and non-diabetic patients
and evaluated their postoperative and long-term prognosis based on clinical
complications. To reduce the disparity within the sample, statistical
analyses were performed using propensity scores. Results: We included 2,688 patients who underwent coronary artery bypass surgery; 36%
of them had diabetes, their mean age was 62.1±9.49 years and 70%
(1,884) of them were men. Patients with diabetes were older (63±9
years vs. 61±10 years; P<0.001),
more often obese (BMI>25 kg/m2: 70.7% vs.
64.5%; P<0.001), dyslipidemic (50.4%
vs. 41.1%; P<0.001), hypertensive
(89.2% vs. 78.7%; P<0.001), and
presented chronic renal failure (8.3% vs. 3.8%;
P<0.001). They also presented higher rates of acute
renal failure (5.6% vs. 2.7%, P<0.001),
infection (11.4% vs. 7.2%, P<0.001) and
mortality after one year (9.1% vs. 5.6%,
P<0.001). Pneumonia was more common among patients with
diabetes (7.7% vs. 4.0%, P<0.001).
According to propensity scoring, 430 patients (215 diabetics and 215
non-diabetics) had a mean age of 61.3±8.97 years, and 21.2% (91 of
430) were women. However, diabetes was not an independent factor for poor
prognosis. Conclusion: Patients with diabetes were at higher risk for postoperative complications
and mortality after undergoing coronary artery bypass surgery. However,
diabetes did not explain the poor prognosis of these patients after pairing
this factor with the propensity score.
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19
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Thompson BM, Stearns JD, Apsey HA, Schlinkert RT, Cook CB. Perioperative Management of Patients with Diabetes and Hyperglycemia Undergoing Elective Surgery. Curr Diab Rep 2016; 16:2. [PMID: 26699765 DOI: 10.1007/s11892-015-0700-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diabetes mellitus (DM) and hyperglycemia are associated with increased surgical morbidity and mortality. Hyperglycemia is a determinant of risk of surgical complications and should be addressed across the continuum of surgical care. While data support the need to address hyperglycemia in patients with DM in the ambulatory setting prior to surgery and in the inpatient setting, data are less certain about hyperglycemia occurring during the perioperative period-that part of the process occurring on the day of surgery itself. The definition of "perioperative" varies in the literature. This paper proposes a standardized definition for the perioperative period as spanning the time of patient admission to the preoperative area through discharge from the recovery area. Available information about the impact of perioperative hyperglycemia on surgical outcomes within the framework of that definition is summarized, and the authors' approach to standardizing perioperative care for patients with DM is outlined, including the special case of patients receiving insulin pump therapy. The discussion is limited to adult ambulatory non-obstetric patients undergoing elective surgical procedures under general anesthesia.
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Affiliation(s)
- Bithika M Thompson
- Division of Endocrinology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
| | - Joshua D Stearns
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Heidi A Apsey
- Division of General Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | | | - Curtiss B Cook
- Division of Endocrinology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
- Division of Preventative, Occupational and Aerospace Medicine, Mayo Clinic, Scottsdale, AZ, USA
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20
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Stelly MM, Rodning CB, Stelly TC. Reduction in deep sternal wound infection with use of a peristernal cable-tie closure system: a retrospective case series. J Cardiothorac Surg 2015; 10:166. [PMID: 26577944 PMCID: PMC4650955 DOI: 10.1186/s13019-015-0378-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 11/08/2015] [Indexed: 01/22/2023] Open
Abstract
Background Deep sternal wound infections are a rare but serious complication after median sternotomy. We evaluated the incidence of deep sternal wound infection associated with two techniques for sternal closure. Methods In this retrospective case series, we recorded the method of sternal closure in consecutive patients undergoing a variety of cardiothoracic surgical procedures. Sternal closure in the historical control group was performed using trans-sternal, stainless-steel wire sutures; subsequent patients were closed using wire sutures in conjunction with a novel, peristernal cable-tie closure system to reinforce the corpus sterni. Perioperative care was standardized between groups. Demographics, risk factors, and postoperative outcomes were analyzed. Results Between July 2010 and July 2014, 609 consecutive adult patients underwent sternal closure following open median sternotomy at a single hospital in Mobile, Alabama. Sternal closure was accomplished with wire sutures in the first 309 patients and with cable-tie reinforcement in the subsequent 300 patients. Baseline characteristics were comparable between groups, except that the cable-tie group exhibited greater preoperative comorbidity. Mean body mass index was comparable between groups (30.2 ± 6.6 kg/m2 wire suture versus 30.5 ± 7.7 cable-tie, p = 0.568). Deep sternal wound infection occurred in 2.6 % (8/309) patients in the wire-suture group, whereas no deep sternal wound infections were observed in the cable tie group (p = 0.008). Conclusions The peristernal cable-tie system was a simple and reliable method for sternal closure after open median sternotomy, and was associated with a reduced risk of deep sternal wound infection, even in an obese and comorbid population.
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Affiliation(s)
| | - Charles B Rodning
- Department of Surgery, College of Medicine and Medical Center, University of South Alabama, Mobile, Alabama, USA
| | - Terry C Stelly
- Cardiothoracic and Vascular Surgical Associates, 1855 Springhill Avenue, Mobile, 36607, Alabama, USA.
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21
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Umpierrez G, Cardona S, Pasquel F, Jacobs S, Peng L, Unigwe M, Newton CA, Smiley-Byrd D, Vellanki P, Halkos M, Puskas JD, Guyton RA, Thourani VH. Randomized Controlled Trial of Intensive Versus Conservative Glucose Control in Patients Undergoing Coronary Artery Bypass Graft Surgery: GLUCO-CABG Trial. Diabetes Care 2015; 38:1665-72. [PMID: 26180108 PMCID: PMC4542267 DOI: 10.2337/dc15-0303] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 06/11/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The optimal level of glycemic control needed to improve outcomes in cardiac surgery patients remains controversial. RESEARCH DESIGN AND METHODS We randomized patients with diabetes (n = 152) and without diabetes (n = 150) with hyperglycemia to an intensive glucose target of 100-140 mg/dL (n = 151) or to a conservative target of 141-180 mg/dL (n = 151) after coronary artery bypass surgery (CABG) surgery. After the intensive care unit (ICU), patients received a single treatment regimen in the hospital and 90 days postdischarge. Primary outcome was differences in a composite of complications, including mortality, wound infection, pneumonia, bacteremia, respiratory failure, acute kidney injury, and major cardiovascular events. RESULTS Mean glucose in the ICU was 132 ± 14 mg/dL (interquartile range [IQR] 124-139) in the intensive and 154 ± 17 mg/dL (IQR 142-164) in the conservative group (P < 0.001). There were no significant differences in the composite of complications between intensive and conservative groups (42 vs. 52%, P = 0.08). We observed heterogeneity in treatment effect according to diabetes status, with no differences in complications among patients with diabetes treated with intensive or conservative regimens (49 vs. 48%, P = 0.87), but a significant lower rate of complications in patients without diabetes treated with intensive compared with conservative treatment regimen (34 vs. 55%, P = 0.008). CONCLUSIONS Intensive insulin therapy to target glucose of 100 and 140 mg/dL in the ICU did not significantly reduce perioperative complications compared with target glucose of 141 and 180 mg/dL after CABG surgery. Subgroup analysis showed a lower number of complications in patients without diabetes, but not in patients with diabetes treated with the intensive regimen. Large prospective randomized studies are needed to confirm these findings.
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Affiliation(s)
| | | | | | - Sol Jacobs
- Department of Medicine, Emory University, Atlanta, GA
| | - Limin Peng
- Rollins School of Public Health, Emory University, Atlanta, GA
| | | | | | | | | | - Michael Halkos
- Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, GA
| | - John D Puskas
- Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, GA
| | - Robert A Guyton
- Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, GA
| | - Vinod H Thourani
- Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, GA
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22
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Cromarty J, Parikh S, Lim WK, Acharya S, Jackson TJ. Effects of hospital-acquired conditions on length of stay for patients with diabetes. Intern Med J 2015; 44:1109-16. [PMID: 25070621 DOI: 10.1111/imj.12538] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 07/24/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Inpatients with diabetes have longer length of stays (LOS). Understanding patterns of in-hospital complications between patients with diabetes and others may reveal measures to improve patient welfare and minimise LOS. AIM This study evaluates the rates and types of hospital-acquired conditions among patients with and without diabetes and assesses any effects on LOS. METHODS A total of 47 615 admission episodes from The Northern Hospital over 12 months was reviewed. Episodes were divided into four groups: (i) patients without diabetes; (ii) patients with diabetes without end-organ sequelae (EOS); (iii) patients with diabetes with EOS; and (iv) a subset of non-diabetic patients with a Charlson Co-morbidity score ≥1 (comparison group). The Classification of Hospital Acquired Diagnoses (CHADx) was applied to the groups to compare rates and types of inpatient complications. Linear regression was used to analyse the impact of the number of CHADx on LOS. RESULTS Almost 30% of admissions of patients with diabetes and EOS had at least one CHADx, compared with 13% for non-diabetes patients and 17% for the comparison group. The types of CHADx experienced by diabetes patients with EOS were similar to the comparison group. However, rates were 10 times higher. Linear regression demonstrated diabetes patients with EOS have increased LOS and each CHADx per episode has a larger effect on LOS. CONCLUSION We demonstrate that diabetes patients have consistently higher rates of CHADx and longer LOS than similar patients with complex and chronic conditions. This provides a foundation for future studies to investigate preventative practices for this high-risk patient population.
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Affiliation(s)
- J Cromarty
- The Northern Hospital, Melbourne, Victoria, Australia; Northern Clinical Research Centre, Northern Health, Melbourne, Victoria, Australia
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Magliano DJ, Harding JL, Cohen K, Huxley RR, Davis WA, Shaw JE. Excess Risk of Dying From Infectious Causes in Those With Type 1 and Type 2 Diabetes. Diabetes Care 2015; 38:1274-80. [PMID: 26070592 DOI: 10.2337/dc14-2820] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 02/10/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate infection-related mortality in individuals with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS A total of 1,108,982 individuals with diabetes who were registered with the Australian Diabetes register between 2000 and 2010 were linked to the National Death Index. Mortality outcomes were defined as infection-related(A-B) death (ICD codes A99-B99), pneumonia (J12-J189), septicemia (A40 and A41), and osteomyelitis (M86). RESULTS During a median follow-up of 6.7 years, there were 2,891, 2,158, 1,248, and 147 deaths from infection-related(A-B) causes, pneumonia, septicemia, or osteomyelitis, respectively. Crude mortality rates from infections(A-B) were 0.147 and 0.431 per 1,000 person-years in type 1 and type 2 diabetes, respectively. Standardized mortality ratios (SMRs) were higher in type 1 and type 2 diabetes for all outcomes after adjustment for age and sex. For infection-related(A-B) mortality, SMRs were 4.42 (95% CI 3.68-5.34) and 1.47 (1.42-1.53) for type 1 and type 2 diabetes (P < 0.001), respectively. For pneumonia in type 1 diabetes, SMRs were approximately 5 and 6 in males and females, respectively, while the excess risk was ∼20% for type 2 (both sexes). For septicemia, SMRs were approximately 10 and 2 for type 1 and type 2 diabetes, respectively, and similar by sex. For osteomyelitis in type 1 diabetes, SMRs were 16 and 58 in males and females, respectively, and ∼3 for type 2 diabetes (both sexes). CONCLUSIONS Although death owing to infection is rare, we confirm that patients with diabetes have an increased mortality from a range of infections, compared with the general population, and that the increased risk appears to be greater for type 1 than type 2 diabetes.
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Affiliation(s)
- Dianna Josephine Magliano
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jessica L Harding
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Kerryn Cohen
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Rachel R Huxley
- School of Population Health, University of Queensland, Brisbane, Australia
| | - Wendy A Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle, Australia
| | - Jonathan E Shaw
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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Abstract
Open-heart surgery has become a common procedure. Postcardiac surgery management is a critical issue and represents a crucial period in terms of physical recovery. Cardiac rehabilitation is increasingly considered as an integral component of the continuum of care for patients with cardiovascular disease. Its usefulness is now widely accepted, and therefore, it is recommended in most contemporary cardiovascular clinical practice guidelines. Similarly, early pharmacological management can modulate the pathophysiological alterations after cardiac surgery, leading to an improvement in the early and long-term outcome. In this review, we will present recent advances in postcardiac surgery management, focusing on the pathophysiology of the perioperative period and on recent evidences in pharmacological and rehabilitative strategies.
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Ogawa S, Okawa Y, Sawada K, Goto Y, Yamamoto M, Koyama Y, Baba H, Suzuki T. Continuous postoperative insulin infusion reduces deep sternal wound infection in patients with diabetes undergoing coronary artery bypass grafting using bilateral internal mammary artery grafts: a propensity-matched analysis. Eur J Cardiothorac Surg 2015; 49:420-6. [PMID: 25825261 DOI: 10.1093/ejcts/ezv106] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 02/24/2015] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Deep sternal wound infection (DSWI), especially in patients with diabetes mellitus (DM), is a major concern after coronary artery bypass grafting (CABG) with bilateral internal mammary artery (BIMA) grafts. We evaluated the risk of DSWI and other clinical outcomes between continuous insulin infusion therapy (CIT) and insulin sliding scale therapy (IST) in a cohort of DM patients who underwent CABG with BIMA. METHODS The clinical records of DM patients who underwent isolated CABG with BIMA were retrospectively reviewed. The study population consisted of 95 patients who received CIT and 126 patients who received IST. Furthermore, a one-to-one matched analysis based on estimated propensity scores for patients who received CIT or IST yielded two groups comprising 58 patients each. The proportion of patients with DSWI, overall survival rates and major adverse cardiac events were compared between the two groups in the overall and the propensity-matching cohort. RESULTS The prevalence of DSWI requiring debridement and closure was significantly reduced in the CIT group compared with that in the IST group [1/95 (1.1%) vs 9/126 (7.1%), P = 0.031]; these results were not attenuated even after propensity-matching analysis [0/58 (0%) vs 6/58 (10.3%), P = 0.031]. The mean preoperative glucose levels were similar between the two groups (157.5 ± 54.6 vs 176.1 ± ±70 mg/dl, P = 0.063), whereas the mean glucose values were significantly lower on the first and second operative days in the CIT group than in the IST group (132.9 ± 44.1 vs 197.8 ± 78.6 mg/dl, P < 0.0001; 153.5 ± 58.8 vs 199.6 ± 89.1 mg/dl, P < 0.0001, respectively). The glucose variability levels within 24 h postoperatively were significantly higher in the IST group (46.1 ± 19.4 vs 66.4 ± 26.8 mg/dl, P < 0.0001). The 30-day and 1-year survival rates were similar between the two groups (100 vs 99.2%, P = 0.384; 96.6 vs 94.4%, P = 0.454). No results were changed in the propensity-matching models. CONCLUSIONS The CIT approach reduced the variability in glucose concentration and resulted in fewer instances of DSWI after CABG with BIMA grafts.
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Affiliation(s)
- Shinji Ogawa
- Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan
| | - Yasuhide Okawa
- Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan
| | - Koshi Sawada
- Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan
| | - Yoshihiro Goto
- Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan
| | | | - Yutaka Koyama
- Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan
| | - Hiroshi Baba
- Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan
| | - Takahiko Suzuki
- Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan
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Maradit Kremers H, Lewallen LW, Mabry TM, Berry DJ, Berbari EF, Osmon DR. Diabetes mellitus, hyperglycemia, hemoglobin A1C and the risk of prosthetic joint infections in total hip and knee arthroplasty. J Arthroplasty 2015; 30:439-43. [PMID: 25458090 DOI: 10.1016/j.arth.2014.10.009] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 10/07/2014] [Indexed: 02/01/2023] Open
Abstract
Diabetes mellitus is an established risk factor for infections but evidence is conflicting to what extent perioperative hyperglycemia, glycemic control and treatment around the time of surgery modify the risk of prosthetic joint infections (PJIs). In a cohort of 20,171 total hip and knee arthroplasty procedures, we observed a significantly higher risk of PJIs among patients with a diagnosis of diabetes mellitus (hazard ratio [HR] 1.55, 95% CI 1.11, 2.16), patients using diabetes medications (HR 1.56, 95% CI 1.08, 2.25) and patients with perioperative hyperglycemia (HR 1.59, 95% CI 1.07, 2.35), but the effects were attenuated after adjusting for body mass index, type of surgery, ASA score and operative time. Although data were limited, there was no association between hemoglobin A1c values and PJIs.
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Affiliation(s)
| | - Laura W Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tad M Mabry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Elie F Berbari
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Douglas R Osmon
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
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Lee G, Wyatt S, Topliss D, Walker K, Stoney R. A study of a pre-operative intervention in patients with diabetes undergoing cardiac surgery. Collegian 2014; 21:287-93. [DOI: 10.1016/j.colegn.2013.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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LaBoone LM, McLarney JT, Reynolds LR. An interdepartmental collaboration to improve preoperative glycemic control. Hosp Pract (1995) 2014; 42:83-88. [PMID: 25485920 DOI: 10.3810/hp.2014.12.1161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The Centers for Disease Control and Prevention estimates that 25.8 million adults in the United States have diabetes, and these patients experience higher rates of morbidity and mortality postoperatively than patients without diabetes. While several professional organizations have recommended tight glycemic control perioperatively, the data regarding preoperative glycemic control is only emerging. The hemoglobin A1c level, which reflects long-term glycemic control, has been shown to correlate with postoperative outcomes including length of stay, infections, and mortality. This relationship has implications for the preoperative surgical management of patients with diabetes. OBJECTIVES Implemented in 2009, our interdepartmental initiative was designed to improve glycemic control within 5 to 7 days before surgery with a blood glucose target of 100 of 199 mg/dL the morning of surgery. An endocrinologist and a certified diabetes educator evaluate same-day urgent referrals from the anesthesia preoperative clinic, targeting high-risk patients with an HbA1c value of ≥ 9%, a random blood glucose level of ≥ 300 mg/dL, or a fasting blood glucose level of ≥ 240 mg/dL. Our team then creates an individualized preoperative treatment plan based on the patient's prior insulin regimen and diabetes self-management skills. Verbal and written instructions for insulin self-titration and guidance for insulin dose changes in preparation for a fasting state are included. DISCUSSION : With this interdepartmental collaboration, as part of a larger institutional initiative, we hope to improve short- and long-term outcomes for surgical patients with uncontrolled diabetes, as well as improve costs and utilization of health care resources in our institution. Our glycemic control committee, which follows bimonthly metrics, including 90-day readmission rates for surgical patients, has noted a decline from 7.9% in 2009 to 4.5% in the 2012-2013 fiscal year. Our aggressive preoperative and postoperative blood glucose management has been a significant factor in this improvement.
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Mulla I, Schmidt K, Cashy J, Wallia A, Andrei AC, Johnson Oakes D, Aleppo G, Li C, Grady KL, McGee E, Molitch ME. Comparison of glycemic and surgical outcomes after change in glycemic targets in cardiac surgery patients. Diabetes Care 2014; 37:2960-5. [PMID: 25193527 DOI: 10.2337/dc14-1199] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare perioperative glycemic and long-term surgical outcomes in patients undergoing cardiac surgery before and after the recommended 2009 changes in inpatient glycemic targets. RESEARCH DESIGN AND METHODS We performed a retrospective review of patients who underwent cardiac surgery between 4 September 2007 and 30 April 2011. Comparison was made of blood glucose (BG) outcomes 3 days after surgery, and 30-day cardiac outcomes before and after a change in insulin protocol that took place on 1 September 2009, which consisted of raising the glycemic targets during intravenous insulin infusions from 80-110 mg/dL (80-110 group) to 110-140 mg/dL (110-140 group). RESULTS When compared with the 80-110 group (n = 667), the 110-140 group (n = 658) had higher mean postoperative BG levels during the intravenous insulin infusion (141 ± 15 vs. 121 ± 15 mg/dL, P < 0.001) and the subcutaneous insulin period (134 ± 24 vs. 130 ± 23 mg/dL, P < 0.001), and for 3 days postoperatively (141 ± 17 vs. 127 ± 15 mg/dL, P < 0.001). Fewer patients in the 110-140 mg/dL group experienced moderate hypoglycemia (BG <70 mg/dL) (177 vs. 73, P = 0.04). Severe hypoglycemia (BG <40 mg/dL) occurred in only one patient in the 80-110 group and three patients in the 110-140 group. There were no significant differences in mortality or surgical complication rates (with the exception of reintubation) between the groups. CONCLUSIONS The higher glycemic target of 110-140 mg/dL resulted in similar mean glucose values, with significantly less hypoglycemia and no significant differences in mortality/morbidity compared with the more strict target of 80-110 mg/dL.
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Affiliation(s)
- Irena Mulla
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kathleen Schmidt
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - John Cashy
- Division of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Amisha Wallia
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Adin-Cristian Andrei
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Diana Johnson Oakes
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Carrie Li
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kathleen L Grady
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Edwin McGee
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Al-Niaimi AN, Ahmed M, Burish N, Chackmakchy SA, Seo S, Rose S, Hartenbach E, Kushner DM, Safdar N, Rice L, Connor J. Intensive postoperative glucose control reduces the surgical site infection rates in gynecologic oncology patients. Gynecol Oncol 2014; 136:71-6. [PMID: 25263249 DOI: 10.1016/j.ygyno.2014.09.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 09/15/2014] [Accepted: 09/19/2014] [Indexed: 01/04/2023]
Abstract
OBJECTIVE SSI rates after gynecologic oncology surgery vary from 5% to 35%, but are up to 45% in patients with diabetes mellitus (DM). Strict postoperative glucose control by insulin infusion has been shown to lower morbidity, but not specifically SSI rates. Our project studied continuous postoperative insulin infusion for 24h for gynecologic oncology patients with DM and hyperglycemia with a target blood glucose of <139 mL/dL and a primary outcome of the protocol's impact on SSI rates. METHODS We compared SSI rates retrospectively among three groups. Group 1 was composed of patients with DM whose blood glucose was controlled with intermittent subcutaneous insulin injections. Group 2 was composed of patients with DM and postoperative hyperglycemia whose blood glucose was controlled by insulin infusion. Group 3 was composed of patients with neither DM nor hyperglycemia. We controlled for all relevant factors associated with SSI. RESULTS We studied a total of 372 patients. Patients in Group 2 had an SSI rate of 26/135 (19%), similar to patients in Group 3 whose rate was 19/89 (21%). Both were significantly lower than the SSI rate (43/148, 29%) of patients in Group 1. This reduction of 35% is significant (p = 0.02). Multivariate analysis showed an odd ratio = 0.5 (0.28-0.91) in reducing SSI rates after instituting this protocol. CONCLUSIONS Initiating intensive glycemic control for 24h after gynecologic oncology surgery in patients with DM and postoperative hyperglycemia lowers the SSI rate by 35% (OR = 0.5) compared to patients receiving intermittent sliding scale insulin and to a rate equivalent to non-diabetics.
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Affiliation(s)
- Ahmed N Al-Niaimi
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA.
| | - Mostafa Ahmed
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Military Medical Center, 3851 Roger Brook Drive, Fort Sam, Houston, TX 78234, USA
| | - Nikki Burish
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA
| | - Saygin A Chackmakchy
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA
| | - Songwon Seo
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison WI, USA
| | - Stephen Rose
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA
| | - Ellen Hartenbach
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA
| | - David M Kushner
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin, Madison, WI, USA
| | - Laurel Rice
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA
| | - Joseph Connor
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA
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Chondronikola M, Meyer WJ, Sidossis LS, Ojeda S, Huddleston J, Stevens P, Børsheim E, Suman OE, Finnerty CC, Herndon DN. Predictors of insulin resistance in pediatric burn injury survivors 24 to 36 months postburn. J Burn Care Res 2014; 35:409-15. [PMID: 24918945 PMCID: PMC4162820 DOI: 10.1097/bcr.0000000000000017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Burn injury is a dramatic event with acute and chronic consequences including insulin resistance. However, factors associated with insulin resistance have not been previously investigated. The purpose of this study was to identify factors associated with long-term insulin resistance in pediatric burn injury survivors. The study sample consisted of 61 pediatric burn injury survivors 24 to 36 months after the burn injury, who underwent an oral glucose tolerance test. To assess insulin resistance, the authors calculated the area under the curve for glucose and insulin. The diagnostic criteria of the American Diabetes Association were used to define individuals with impaired glucose metabolism. Additional data collected include body composition, anthropometric measurements, burn characteristics, and demographic information. The data were analyzed using multivariate linear regression analysis. Approximately 12% of the patients met the criteria for impaired glucose metabolism. After adjusting for possible confounders, burn size, age, and body fat percentage were associated with the area under the curve for glucose (P < .05 for all). Time postburn and lean mass were inversely associated with the area under the curve for glucose (P < .05 for both). Similarly, older age predicted higher insulin area under the curve. The results indicate that a significant proportion of pediatric injury survivors suffer from glucose abnormalities 24 to 36 months postburn. Burn size, time postburn, age, lean mass, and adiposity are significant predictors of insulin resistance in pediatric burn injury survivors. Clinical evaluation and screening for abnormal glucose metabolism should be emphasized in patients with large burns, older age, and survivors with high body fat.
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Affiliation(s)
- Maria Chondronikola
- Graduate School of Biomedical Sciences, Department of Preventative Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas, United States
| | - Walter J. Meyer
- Shriners Hospitals for Children–Galveston, Texas, United States
- Department of Psychiatry, University of Texas Medical Branch, Galveston, Texas, United States
| | - Labros S. Sidossis
- Shriners Hospitals for Children–Galveston, Texas, United States
- Department of Internal Medicine-Geriatrics, University of Texas Medical Branch, Galveston, Texas, United States
- Institute for Translational Sciences, University of Texas Medical Branch, Galveston, Texas, United States
| | - Sylvia Ojeda
- Shriners Hospitals for Children–Galveston, Texas, United States
| | | | - Pamela Stevens
- Shriners Hospitals for Children–Galveston, Texas, United States
| | - Elisabet Børsheim
- Shriners Hospitals for Children–Galveston, Texas, United States
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States
| | - Oscar E. Suman
- Shriners Hospitals for Children–Galveston, Texas, United States
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States
| | - Celeste C. Finnerty
- Shriners Hospitals for Children–Galveston, Texas, United States
- Institute for Translational Sciences, University of Texas Medical Branch, Galveston, Texas, United States
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States
| | - David N. Herndon
- Shriners Hospitals for Children–Galveston, Texas, United States
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States
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Shah M, Apsey HA, Stearns JD, Schlinkert RT, Seifert KM, Cook CB. Guidelines to improve perioperative management of diabetes mellitus: an example of a successful quality initiative. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/dmt.14.26] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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RUJIROJINDAKUL P, LIABSUETRAKUL T, MCNEIL E, CHANCHAYANON T, WASINWONG W, OOFUVONG M, RERGKLIANG C, CHITTITHAVORN V. Safety and efficacy of intensive intraoperative glycaemic control in cardiopulmonary bypass surgery: a randomised trial. Acta Anaesthesiol Scand 2014; 58:588-96. [PMID: 24628042 DOI: 10.1111/aas.12305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2014] [Indexed: 01/04/2023]
Abstract
BACKGROUND This study aimed to determine the safety and efficacy of intraoperative intensive glycaemic treatment with modified glucose-insulin-potassium solution by hyperinsulinemic normoglycaemic clamp in cardiopulmonary bypass surgery patients. We hypothesised that the treatment would reduce infection rates in this group of patients. METHODS A prospective, randomised, double-blind trial was conducted in cardiopulmonary bypass surgery patients. A total of 199 adult patients (out of a planned 400) were randomly allocated to intensive or conventional treatment with target glucose levels of 4.4-8.3 mmol/l and < 13.8 mmol/l, respectively. The primary outcomes were clinical infection and cytokine levels, including interleukin (IL)-6 and IL-10. The secondary outcomes were morbidity and mortality. RESULTS The study was terminated early because of safety concerns (hypoglycaemia). The clinical post-operative infection rate was 17% in the intensive group and 13% in the conventional group (P = 0.53). The proportion of patients with hypoglycaemia was significantly higher in the intensive group (23%) compared with the conventional group (3%) (P < 0.001). Morbidity and mortality rates were similar for both groups. Anaesthetic duration > 2 h (vs. ≤ 2 h), pre-operative IL-6 level > 15 pg/ml (vs. ≤ 15 pg/ml) and post-operative IL-6 level 56-110 pg/ml (vs. ≤ 55 pg/ml) were independent predictors for post-operative infection. CONCLUSIONS Intraoperative intensive glycaemic treatment significantly increased the risk of hypoglycaemia, but its effect on post-operative infection by clinical assessment could not be determined. Anaesthetic duration, pre-operative and post-operative IL-6 levels can independently predict post-operative infection.
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Affiliation(s)
- P. RUJIROJINDAKUL
- Department of Anesthesiology; Faculty of Medicine; Prince of Songkla University; Hat Yai Songkhla Thailand
| | - T. LIABSUETRAKUL
- Department of Epidemiology Unit; Faculty of Medicine; Prince of Songkla University; Hat Yai Songkhla Thailand
| | - E. MCNEIL
- Department of Epidemiology Unit; Faculty of Medicine; Prince of Songkla University; Hat Yai Songkhla Thailand
| | - T. CHANCHAYANON
- Department of Anesthesiology; Faculty of Medicine; Prince of Songkla University; Hat Yai Songkhla Thailand
| | - W. WASINWONG
- Department of Anesthesiology; Faculty of Medicine; Prince of Songkla University; Hat Yai Songkhla Thailand
| | - M. OOFUVONG
- Department of Anesthesiology; Faculty of Medicine; Prince of Songkla University; Hat Yai Songkhla Thailand
| | - C. RERGKLIANG
- Department of Surgery; Faculty of Medicine; Prince of Songkla University; Hat Yai Songkhla Thailand
| | - V. CHITTITHAVORN
- Department of Surgery; Faculty of Medicine; Prince of Songkla University; Hat Yai Songkhla Thailand
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Abstract
The aging of the U.S. population is leading to an increasing number of surgical procedures performed on older adults. At the same time, the quality of medical care is being more closely scrutinized. Surgical site infection is a widely-assessed outcome. Evidence suggests that strict perioperative serum glucose control among patients with or without diabetes can lower the risk of these infections, but it is unclear whether this control should be applied to older surgical patients. In this clinical review, we discuss current research on perioperative serum glucose management for cardiothoracic, orthopedic, and general/colorectal surgery. In addition, we summarize clinical recommendations and quality-of-care process indicators provided by surgical, diabetes, and geriatric medical organizations.
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Davis EM, Foral PA, Dull RB, Smith AN. Review of insulin therapy and pen use in hospitalized patients. Hosp Pharm 2014; 48:396-405. [PMID: 24421496 DOI: 10.1310/hpj4805-396] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Hyperglycemia is common among hospitalized patients, affecting approximately 40% of patients at the time of hospital admission, despite the fact that 1 in every 8 patients has no previous diagnosis of diabetes. Hyperglycemia has been associated with poor patient outcomes, including higher rates of morbidity and mortality across a range of conditions. This review discusses options for the effective management of hyperglycemia with a focus on the use of disposable insulin pens in the hospital. METHODS Literature, including guidelines for hospital management of hyperglycemia, and information regarding methods of insulin administration were reviewed. RESULTS Appropriate glucose control via administration of insulin within hospitals has been acknowledged as an important goal and is consistent with achieving patient safety. Insulin may be administered subcutaneously using a pen or vial and syringe or infused intravenously. Levels of patient and provider satisfaction are higher with pen administration than with vial and syringe. Insulin pens have many safety and convenience features including enhanced dose accuracy and autocover/autoshield pen needles. CONCLUSION Use of insulin pens instead of vials and syringes can provide several advantages for hospitalized patients, including greater satisfaction among them and health care providers, improved safety, and reduced costs. These advantages can continue following patient discharge.
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Affiliation(s)
| | - Pamela A Foral
- Associate Professor of Pharmacy Practice,Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska
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D'Asta F, Cianferotti L, Bhandari S, Sprini D, Rini GB, Brandi ML. The endocrine response to severe burn trauma. Expert Rev Endocrinol Metab 2014; 9:45-59. [PMID: 30743738 DOI: 10.1586/17446651.2014.868773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The endocrine system is frequently altered after a major burn trauma. Besides the endocrine response to stress characterized by hypercortisolism, several hypothalamus-hypophysis-target gland axes are rapidly perturbed within a few days. These alterations can persist in the long term and deserve an appropriate treatment. Disturbances in water clearance and glucidic metabolism are also common and need to be diagnosed and corrected to decrease morbidity in such patients. Bone and mineral metabolism is deeply compromised and requires correction of mineral abnormalities in order to improve symptoms and prevent bone loss. No large prospective and/or intervention trials are available to date to elaborate age-related, evidence-based recommendations to monitor and treat burn-related endocrine alterations.
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Affiliation(s)
- Federica D'Asta
- a Department of Neuroscience, Psychology, Drug, Research and Child Health, University of Florence, Viale Pieraccini 24, 50139 Florence, Italy
| | - Luisella Cianferotti
- b Department of Surgery and Translational Medicine, Unit of Bone and Mineral Metabolism, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy
| | - Sahil Bhandari
- c Manchester Medical School, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Delia Sprini
- d Department of Internal Medicine, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Giovam Battista Rini
- d Department of Internal Medicine, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Maria Luisa Brandi
- b Department of Surgery and Translational Medicine, Unit of Bone and Mineral Metabolism, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy
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The role of chronic and perioperative glucose management in high-risk surgical closures: a case for tighter glycemic control. Plast Reconstr Surg 2013; 132:996-1004. [PMID: 23783058 DOI: 10.1097/prs.0b013e31829fe119] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The exact risk that poor glucose control introduces to patients undergoing surgical closure has yet to be fully defined. METHODS The authors retrospectively analyzed a prospectively collected database of patients seen at their wound care center to evaluate the effects of chronic and perioperative glucose control in high-risk patients undergoing surgical wound closure. Hemoglobin A1c and blood glucose levels for the 5 days before and after surgical closure were recorded and compared with the primary endpoints of dehiscence, infection, and reoperation. Univariate and multivariate analyses were performed. RESULTS Seventy-nine patients had perioperative glucose levels and 64 had hemoglobin A1C levels available for analysis. Preoperative and postoperative hyperglycemia (defined as any blood glucose measurement above 200 mg/dl) as well as elevated A1C levels (above 6.5 percent or 48 mmol/ml) were significantly associated with increased rates of dehiscence (odds ratio, 3.2, p = 0.048; odds ratio, 3.46, p = 0.028; and odds ratio, 3.54, p = 0.040, respectively). Variability in preoperative glucose (defined as a range of glucose levels exceeding 200 points) was significantly associated with increased rates of reoperation (odds ratio, 4.14, p = 0.025) and trended toward significance with increased rates of dehiscence (p = 0.15). In multivariate regression, only perioperative hyperglycemia and elevated A1c were significantly associated with increased rates of dehiscence. CONCLUSIONS In primary closure of surgical wounds in high-risk patients, poor glycemic control is significantly associated with worse outcomes. Every effort should be made to ensure tight control in both the chronic and subacute perioperative periods. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Revisiting tight glycemic control in perioperative and critically ill patients: when one size may not fit all. J Clin Anesth 2013; 25:499-507. [PMID: 24008187 DOI: 10.1016/j.jclinane.2012.09.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 08/27/2012] [Accepted: 09/26/2012] [Indexed: 01/04/2023]
Abstract
Glycemic control has received intense scrutiny in the last decade as an important aspect of patient care. Earlier studies suggested that tight glycemic control (target level of 80 - 110 mg/dL) improved outcomes in intensive care unit (ICU) patients. Subsequent trials did not confirm the same benefit. Moreover, increased mortality was found in association with such tight control compared with a less strict target. As a result, tight glucose control has become less popular. The interaction between diabetic status and outcomes in relation to glucose control strategies and/or chronic glycemic state in perioperative and critically ill patients was examined. Tight glucose control appears to be more beneficial in patients without diabetes than in those with known diabetes. It also may be more beneficial in improving outcomes in surgical rather than nonsurgical ICU patients, and in decreasing sepsis rather than mortality. Tight glycemic control was associated with a high incidence of hypoglycemia, which may offset some of its potential benefits. Tight glycemic control in the perioperative and intensive care settings should not be totally abandoned either as a clinical practice or as a subject of future research. Beneficial effects of tight glycemic control may be demonstrated when the appropriate glycemic targets are matched to the appropriate population.
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Coan KE, Schlinkert AB, Beck BR, Haakinson DJ, Castro JC, Schlinkert RT, Cook CB. Perioperative management of patients with diabetes undergoing ambulatory elective surgery. J Diabetes Sci Technol 2013; 7:983-9. [PMID: 23911180 PMCID: PMC3879763 DOI: 10.1177/193229681300700421] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective was to assess processes of care for patients with diabetes undergoing elective surgery. METHODS A retrospective review of medical records was conducted to determine frequency of perioperative glucose monitoring, changes in glucose control, and treatment of intraoperative hyperglycemia. RESULTS A total of 268 patients underwent 287 elective procedures. Mean age was 67 years, 63% were men, 97% had type 2 diabetes, and most (57%) were treated with oral hypoglycemic agents. Average perioperative time was approximately 8 h. Mean preoperative hemoglobin A1c was 7.0%; however, this value was checked in only 52% of cases. A glucose measurement was obtained in 89% of cases in the preoperative area and in 87% in the postanesthesia care unit, but in only 33% of cases did a value get checked intraoperatively. Average glucose was 139 mg/dl preoperatively, increasing to 166 mg/dl postoperatively (p <.001). Glucose levels increased regardless of type of outpatient medical therapy used to treat hyperglycemia, except for those on combination oral agents plus insulin (p =.06). CONCLUSIONS These data indicate suboptimal documentation of outpatient hemoglobin A1c. Intraoperative glucose monitoring seldom occurred, despite prolonged periods under anesthesia and perioperative deterioration of glycemic control. Standards need to be developed and interventions are needed to enhance management of diabetes patients undergoing elective procedures.
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Affiliation(s)
- Kathryn E. Coan
- Department of General Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | | | - Brandon R. Beck
- Department of General Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | | | - Janna C. Castro
- Department of Information Technology, Mayo Clinic Arizona, Phoenix, Arizona
| | | | - Curtiss B. Cook
- Division of Endocrinology, Mayo Clinic Arizona, Scottsdale, Arizona
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Wu Y, Pei J, Yang XD, Cheng ZD, Zhao YY, Xiang B. Hyperglycemia and its association with clinical outcomes for patients in the pediatric intensive care unit after abdominal surgery. J Pediatr Surg 2013; 48:801-5. [PMID: 23583137 DOI: 10.1016/j.jpedsurg.2012.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 09/20/2012] [Accepted: 10/02/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE We investigated the incidence of hyperglycemia of patients in the pediatric intensive care unit (PICU) after receiving abdominal surgery and its association with clinical outcomes. METHODS A retrospective review was performed from November 1, 2010 to November 1, 2011 on all PICU admissions after abdominal surgery. Maximum serum glucose concentrations (Gmax) in PICU, PICU length of stay, total hospital length of stay, deep and systemic infection, wound infection and mortality rates were recorded and analyzed. RESULTS A total of 193 children met the inclusion criteria of our research. Maximum glucose levels ranged from 55.7 mg/dL to 415.9 mg/dL (median: 132 mg/dL). Hyperglycemia in PICU was prevalent, with 125 (64.8%) patients having Gmax >110 mg/dL during their PICU stay and 35 (18.8%) having Gmax >200 mg/dL. Average PICU length of stay and total hospital length of stay grew as the maximum glucose levels rose among the four plasma glycemic ranges. The highest serum glucose range patient group also had the highest wound infection rates (14.3% and 11.4%). CONCLUSIONS Hyperglycemia was prevalent among patients after major abdominal surgery in PICU and was correlated with increased PICU length of stay, total hospital length of stay. Appropriate glycemic control may improve clinical outcomes for this group of patients.
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Affiliation(s)
- Yang Wu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Hamilton EJ, Martin N, Makepeace A, Sillars BA, Davis WA, Davis TME. Incidence and predictors of hospitalization for bacterial infection in community-based patients with type 2 diabetes: the fremantle diabetes study. PLoS One 2013; 8:e60502. [PMID: 23536910 PMCID: PMC3607595 DOI: 10.1371/journal.pone.0060502] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 02/27/2013] [Indexed: 12/24/2022] Open
Abstract
Background The few studies that have examined the relationship between diabetes and bacterial infections have utilized administrative databases and/or have had limited/incomplete data including recognized infection risk factors. The aim of this study was to determine the incidence and associates of bacterial infection severe enough to require hospitalization in well-characterized community-based patients with type 2 diabetes. Methods and Findings We studied a cohort of 1,294 patients (mean±SD age 64.1±11.3 years) from the longitudinal observational Fremantle Diabetes Study Phase I (FDS1) and 5,156 age-, gender- and zip-code-matched non-diabetic controls. The main outcome measure was incident hospitalization for bacterial infection as principal diagnosis between 1993 and 2010. We also examined differences in statin use in 52 FDS1 pairs hospitalized with pneumonia (cases) or a contemporaneous non-infection-related cause (controls). During 12.0±5.4 years of follow-up, 251 (19.4%) patients were hospitalized on 368 occasions for infection (23.7/1,000 patient-years). This was more than double the rate in matched controls (incident rate ratio (IRR) (95% CI), 2.13 (1.88–2.42), P<0.001). IRRs for pneumonia, cellulitis, and septicemia/bacteremia were 1.86 (1.55–2.21), 2.45 (1.92–3.12), and 2.08 (1.41–3.04), respectively (P<0.001). Among the diabetic patients, older age, male sex, prior recent infection-related hospitalization, obesity, albuminuria, retinopathy and Aboriginal ethnicity were baseline variables independently associated with risk of first hospitalization with any infection (P≤0.005). After adjustment for these variables, baseline statin treatment was not significant (hazard ratio (95% CI), 0.70 (0.39–1.25), P = 0.22). Statin use at hospitalization for pneumonia among the case-control pairs was similar (23.1% vs. 13.5%, P = 0.27). Conclusions The risk of severe infection is increased among type 2 diabetic patients and is not reduced by statin therapy. There are a number of other easily-accessible sociodemographic and clinical variables that could be used to optimize infection-related education, prevention and management in type 2 diabetes.
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Affiliation(s)
- Emma J. Hamilton
- Department of Endocrinology and Diabetes, Fremantle Hospital, Fremantle, Australia
| | - Natalie Martin
- Department of Geriatric Medicine, Fremantle Hospital, Fremantle, Australia
| | - Ashley Makepeace
- Department of Endocrinology and Diabetes, Fremantle Hospital, Fremantle, Australia
- University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Australia
| | - Brett A. Sillars
- University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Australia
| | - Wendy A. Davis
- University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Australia
| | - Timothy M. E. Davis
- University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Australia
- * E-mail:
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Leung Wai Sang S, Chaturvedi R, Alam A, Samoukovic G, de Varennes B, Lachapelle K. Preoperative hospital length of stay as a modifiable risk factor for mediastinitis after cardiac surgery. J Cardiothorac Surg 2013; 8:45. [PMID: 23497663 PMCID: PMC3618209 DOI: 10.1186/1749-8090-8-45] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Accepted: 02/14/2013] [Indexed: 11/25/2022] Open
Abstract
Background As high-risk cardiac patients frequently remain within hospital while waiting for surgery, the aim of the present study was to determine the role of preoperative length of hospital stay on mediastinitis, and also, to assess contemporary risk factors for this complication. Methods The source population consisted of 6653 consecutive patients undergoing coronary bypass surgery, valve surgery, or both between September 2000 and September 2009 at a single tertiary care hospital. A retrospective cohort analysis was used to assess the effect of 18 preoperative variables, including length of stay, on mediastinitis. Results Mediastinitis developed in 108 patients (1.6%) resulting in an in-hospital mortality rate of 13.9%. Independent predictors of mediastinitis included obesity (2.59, CI 1.58-4.23), COPD (2.44, CI 1.55-3.84), diabetes (2.16, CI 1.44-3.24), and impaired estimated glomerular filtration rate. Preoperative hospital stay was also found to be an independent risk factor leading to a 15% increased risk of mediastinitis per week of stay. The primary wound pathogen was coagulase negative staphylococcus (82%) followed by multi-flora isolates (49%), but was unrelated to hospital stay. Conclusions In addition to the traditional risk factors, prolonged preoperative hospital stay is also a significant and potentially modifiable predictor for the development of mediastinitis following cardiac surgery. All efforts should be made to minimize the delay in operating on hospitalized patients awaiting heart surgery.
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Affiliation(s)
- Stephane Leung Wai Sang
- Divisions of Cardiac Surgery, Royal Victoria Hospital, McGill University Health Center, Quebec, H3A 1A3, Montreal, Canada
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Rendell M, Saiprasad S, Trepp-Carrasco AG, Drincic A. The future of inpatient diabetes management: glucose as the sixth vital sign. Expert Rev Endocrinol Metab 2013; 8:195-205. [PMID: 30736179 DOI: 10.1586/eem.13.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Diabetes is an ever increasing health problem in our society. Due to associated small and large vessel conditions, patients with diabetes are two- to four-fold more likely to require hospitalization than nondiabetic individuals. Furthermore, hyperglycemia in hospitalized patients results in increased susceptibility to wound infections, worse outcomes postcardiac and cerebrovascular events, longer hospital length of stay and increased inpatient mortality. Several studies suggest that tight control of glucose levels yields improvement in these factors. Conversely, other studies have suggested increased mortality after tight glucose management, perhaps as a result of an increased incidence of hypoglycemic events. The most reasonable approach to control of hyperglycemia is to normalize glucose levels as much as possible without triggering hypoglycemia. In the hospital, insulin therapy of hyperglycemia is preferred due to the ability to flexibly manage glucose levels without side effects associated with many alternative antidiabetic agents. Due to the increasing burden of inpatient diabetes, and the detrimental effects of both hyper and hypoglycemia, the authors predict that blood-glucose levels will become the sixth vital sign to be frequently monitored in hospitalized patients and controlled in a narrow range. The future is in the use of insulin pumps controlled by continuous glucose monitors. This technology is complex and has not yet become standard. The development of future inpatient diabetes care will depend on adaptation of hospital systems to advance the new technology.
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Affiliation(s)
- Marc Rendell
- a Creighton Diabetes Center, 601 North 30th Street, Omaha, NE 68131, USA.
- b The Rose Salter Medical Research Foundation, 660 South 85th Street, Omaha, NE 68114, USA
| | - Saraswathi Saiprasad
- c Department of Internal Medicine, Creighton University School of Medicine, 601 North 30th Street, Omaha, NE 68131, USA
| | - Alejandro G Trepp-Carrasco
- d Department of Endocrinology and Metabolism, Creighton University School of Medicine, 601 North 30th Street, Omaha, NE 68131, USA
| | - Andjela Drincic
- e Department of Endocrinology, The University of Nebraska School of Medicine, Nebraska Medical Center, Omaha, NE 68198-5527, USA
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Abstract
Perioperative hyperglycemia has potential significant adverse consequences of increased mortality and morbidity including surgical site infection, renal insufficiency and anemia requiring transfusion. Both diabetic and non-diabetic patients are affected adversely by perioperative hyperglycemia. However, these two subgroups do not necessarily benefit equally from perioperative glycemic control. Moreover, ideal target glucose range as well as the appropriate patient population(s) for whom glycemic control offers the most benefit have yet to be fully elucidated. However, there are clear potential adverse consequences of tight control such as hypoglycemia.
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Affiliation(s)
- Nicholas Russo
- Intensive Care Unit, Medina General Hospital, 1000 E. Washington St, Medina, OH 44256, USA.
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Silinskie KM, Kirshner R, Hite MS. Converting continuous insulin infusion to subcutaneous insulin glargine after cardiac surgery using percentage-based versus weight-based dosing: a pilot trial. Ann Pharmacother 2013; 47:20-8. [PMID: 23324510 DOI: 10.1345/aph.1q698] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Most studies report using percentage of total daily insulin (TDI) for converting therapy from continuous insulin infusion to subcutaneous insulin in cardiac surgery patients. Few studies have evaluated the efficacy of using body weight to calculate the basal insulin dose. OBJECTIVE To compare the efficacy and safety of dosing insulin glargine by weight versus percentage of TDI in cardiac surgery patients transitioning from continuous insulin infusion to subcutaneous insulin. METHODS We conducted a prospective, randomized, open-label, pilot study. Study patients who had a preoperative weight less than 100 kg and were receiving at least 6 hours of a continuous insulin infusion were randomized to receive either 50% of their TDI requirement or 0.5 units/kg of glargine as a one-time dose 2 hours before stopping the continuous insulin infusion. All patients were administered subcutaneous corrective insulin. Blood glucose monitoring occurred before each meal, at bedtime, and with morning laboratory tests for 24 hours after administration of the glargine dose. RESULTS A total of 200 blood glucose measurements were performed in each group. The percentage of blood glucose measurements in target range (80-140 mg/dL) was similar between the weight-based group and the percentage-based group (66% vs 64%, p = 0.75). Median blood glucose after transition was 120 mg/dL (interquartile range [IQR] 99-147) in the weight-based group compared to 127 mg/dL (IQR 107-149; p = 0.03) in the percentage-based group. The median glargine dose was higher in the weight-based group (41 units; IQR 36-44) than in the weight-based group (24 units; IQR 14-30, p < 0.001). The rate of hypoglycemia (blood glucose <60 mg/dL) was 2.5% in each group. CONCLUSIONS In this small cohort, dosing insulin glargine by weight proved to be safe, but larger scale studies are needed before adopting weight-based dosing in this patient population.
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Schierenbeck F, Öwall A, Franco-Cereceda A, Liska J. Evaluation of a continuous blood glucose monitoring system using a central venous catheter with an integrated microdialysis function. Diabetes Technol Ther 2013; 15:26-31. [PMID: 23137021 DOI: 10.1089/dia.2012.0169] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Glycemic control in critically ill patients has been the topic of an interesting debate during the last decade. An accurate continuous glucose monitoring system is essential to better understand this field. This prospective study thus evaluates the accuracy and technical feasibility of a continuous glucose monitoring system using intravascular microdialysis. PATIENTS AND METHODS Thirty patients undergoing cardiac surgery were monitored using a triple-lumen central venous catheter (Eirus TLC; Eirus Medical AB, Solna, Sweden) with an integrated microdialysis function. The catheter functions as a central venous catheter, enabling blood sampling and administration of infusions and medication while simultaneously providing continuous glucose monitoring. The patients were monitored for up to 48 h postoperatively. As reference, arterial blood gas samples were taken every hour and analyzed in a blood gas analyzer. RESULTS Six hundred seven paired samples were obtained for analysis. Using Clarke Error Grid analysis, 100% of the paired samples were in Zones A+B, and 97% were in Zone A. Mean difference (bias) was -0.12 mmol/L, and mean absolute relative difference was 5.6%. Of the paired samples, 97.5% were correct according to International Organization for Standardization criteria. Bland-Altman analysis showed bias ± limits of agreement were -0.12 ± 0.7 mmol/L. No hypoglycemic episodes were observed. CONCLUSIONS Central venous microdialysis is an accurate and reliable method for continuous blood glucose monitoring up to 48 h in patients undergoing cardiac surgery. With the microdialysis function integrated in a central venous catheter, no extra device for the continuous glucose monitoring is required. The system may be useful in critically ill patients.
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Affiliation(s)
- Fanny Schierenbeck
- Section of Cardiothoracic Surgery and Anesthesiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
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Lv WS, Li L, Wen JP, Pan RF, Sun RX, Wang J, Xian YX, Cao CX, Gao YY. Comparison of a multiple daily insulin injection regimen (glargine or detemir once daily plus prandial insulin aspart) and continuous subcutaneous insulin infusion (aspart) in short-term intensive insulin therapy for poorly controlled type 2 diabetes patients. Int J Endocrinol 2013; 2013:614242. [PMID: 23737776 PMCID: PMC3662171 DOI: 10.1155/2013/614242] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 03/27/2013] [Accepted: 04/13/2013] [Indexed: 11/18/2022] Open
Abstract
Aims. To examine the potential differences between multiple daily injection (MDI) regimens based on new long-acting insulin analogues (glargine or detemir) plus prandial insulin aspart and continuous subcutaneous insulin aspart infusion (CSII) in patients with poorly controlled type 2 diabetes. Methods. Patients (n = 119) with poorly controlled type 2 diabetes of a duration exceeding five years were randomly assigned into three groups: Group A treated with CSII using insulin aspart; Group B treated with glargine-based MDI and Group C treated with detemir-based MDI. Results. Good glycemic control was achieved by patients in Group A in a significantly shorter duration than patients in Groups B and C. Total daily insulin, basal insulin dose and dose per kg body weight in Group A were significantly less than those in Groups B and C. Daily blood glucose fluctuation in Group A was significantly less than that in Groups B and C. There were no differences between Groups B and C. Conclusions. Aspart-based CSII may achieve good blood glucose control with less insulin doses over a shorter period compared with glargine or detemir-based MDI. No differences between glargine- and detemir-based MDI were detected in poorly controlled subjects with type 2 diabetes.
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Affiliation(s)
- Wen-shan Lv
- The Department of Internal Medicine, The Affiliated Hospital of Medical College, Qingdao University, Qingdao 266100, China
| | - Li Li
- The Department of Internal Medicine, The Affiliated Hospital of Medical College, Qingdao University, Qingdao 266100, China
| | - Jun-ping Wen
- Department of Endocrinology, Key Laboratory of Endocrinology, Fujian Provincial Hospital, Fujian Medical University, North Branch of Fujian Provincial Hospital, Fujian Provincial Geriatric Hospital, Fuzhou 350001, China
- *Jun-ping Wen: and
| | - Rong-fang Pan
- The Department of Internal Medicine, The Affiliated Hospital of Medical College, Qingdao University, Qingdao 266100, China
| | - Rui-xia Sun
- The Department of Internal Medicine, The Affiliated Hospital of Medical College, Qingdao University, Qingdao 266100, China
| | - Jing Wang
- The Department of Internal Medicine, The Affiliated Hospital of Medical College, Qingdao University, Qingdao 266100, China
| | - Yu-xin Xian
- The Department of Internal Medicine, The Affiliated Hospital of Medical College, Qingdao University, Qingdao 266100, China
| | - Cai-xia Cao
- The Department of Internal Medicine, The Affiliated Hospital of Medical College, Qingdao University, Qingdao 266100, China
| | - Yan-yan Gao
- The Department of Internal Medicine, The Affiliated Hospital of Medical College, Qingdao University, Qingdao 266100, China
- *Yan-yan Gao:
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Schierenbeck F, Franco-Cereceda A, Liska J. Evaluation of a continuous blood glucose monitoring system using central venous microdialysis. J Diabetes Sci Technol 2012; 6:1365-71. [PMID: 23294781 PMCID: PMC3570876 DOI: 10.1177/193229681200600615] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Glycemic control in critically ill patients has been shown to be beneficial. In this prospective study, we evaluated the accuracy and technical feasibility of a continuous glucose monitoring system using intravascular microdialysis. METHOD Fifty patients undergoing cardiac surgery were monitored using a 4 Fr intravenous microdialysis catheter (Eirus SLC™, Dipylon Medical AB, Solna, Sweden) percutaneously placed with the tip of the catheter positioned in the superior vena cava. The catheter was connected to the Eirus™ monitoring system, and the patients were monitored for up to 48 h postoperatively in the intensive care unit (ICU). As reference, arterial blood samples were taken every hour and analyzed in a blood gas analyzer. RESULTS Data were available from 48 patients. A total of 994 paired (arterial blood gas microdialysis) samples were obtained. Glucose correlation coefficient (R2) was 0.85. Using Clarke error grid analysis, 100% of the paired samples were in region AB, and 99% were in region A. Mean glucose level was 8.3 mmol/liter (149 mg/dl), mean relative difference was 0.2%, and mean absolute relative difference was 5%. A total of 99.2% of the paired samples were correct according to International Organization for Standardization (ISO) criteria. Bland-Altman analysis showed that bias ± limits of agreement were 0.02 ± 1.1 mmol/liter (0.36 ± 20 mg/dl). CONCLUSIONS Central venous microdialysis using the Eirus monitoring system is a highly accurate and reliable method for continuous blood glucose monitoring up to 48 h in ICU patients undergoing cardiac surgery. The system may thus be useful in critically ill ICU patients.
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Affiliation(s)
- Fanny Schierenbeck
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Section of Cardiothoracic Surgery and Anaesthesiology, Karolinska University Hospital, Stockholm, Sweden.
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Abstract
Inpatients have a high rate of diabetes (12%-26%) and hyperglycemia (~38%). All patients should have their glycosylated hemoglobin (A1C) checked on admission to help differentiate between long-term and new-onset hyperglycemia. Good glycemic control throughout the hospital stay is associated with decreases in short- and long-term risk of mortality, inpatient complications, length of hospital stay, and health care costs. Insulin is first-line therapy for hyperglycemia; patients with hyperglycemia should be managed using either intravenous (IV) or subcutaneous (SC) insulin algorithms. A hypoglycemia management protocol should be in place at the hospital for safety purposes. For successful glycemic control, insulin algorithms should have dynamic scales, require frequent glucose monitoring, and be simple and easy to use. The algorithm should address transitioning patients from IV to SC insulin and a discharge plan. Insulin analogues are preferred for basal, mealtime, and correction doses instead of human insulins (regular and NPH) because analogues have a more predictable absorption and action profile and less pharmacokinetic fluctuation. Institutions can increase safe insulin use by utilizing insulin algorithms, preprinted order sets, and hypoglycemia protocols; by supporting patient and health care provider education; and by implementing needle-stick prevention techniques.
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Liu HC, Zhou YB, Chen D, Niu ZJ, Yu Y. Effect of intensive vs conventional insulin therapy on perioperative nutritional substrates metabolism in patients undergoing gastrectomy. World J Gastroenterol 2012; 18:2695-703. [PMID: 22690080 PMCID: PMC3370008 DOI: 10.3748/wjg.v18.i21.2695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Revised: 07/06/2011] [Accepted: 07/13/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of intensive vs conventional insulin therapy on perioperative nutritional substrates metabolism in patients undergoing radical distal gastrectomy.
METHODS: Within 24 h of intensive care unit management, patients with gastric cancer were enrolled after written informed consent and randomized to the intensive insulin therapy (IIT) group to keep glucose levels from 4.4 to 6.1 mmol/L or the conventional insulin therapy (CIT) group to keep levels less than 10 mmol/L. Resting energy expenditure (REE), respiratory quotient (RQ), resting energy expenditure per kilogram (REE/kg), and the lipid oxidation rate were monitored by the indirect calorimeter of calcium citrate malate nutrition metabolism investigation system. The changes in body composition were analyzed by multi-frequency bioimpedance analysis. Blood fasting glucose and insulin concentration were measured for assessment of Homeostasis model assessment of insulin resistance.
RESULTS: Sixty patients were enrolled. Compared with preoperative baseline, postoperative REE increased by over 22.15% and 11.07%; REE/kg rose up to 27.22 ± 1.33 kcal/kg and 24.72 ± 1.43 kcal/kg; RQ decreased to 0.759 ± 0.034 and 0.791 ± 0.037; the lipid oxidation ratio was up to 78.25% ± 17.74% and 67.13% ± 12.76% supported by parenteral nutrition solutions from 37.56% ± 11.64% at the baseline; the level of Ln-HOMA-IR went up dramatically (P < 0.05, respectively) on postoperative days 1 and 3 in the IIT group. Meanwhile the concentration of total protein, albumin and triglyceride declined significantly on postoperative days 1 and 3 compared with pre-operative levels (P < 0.05, respectively). Compared with the CIT group, IIT reduced the REE/kg level (27.22 ± 1.33 kcal/kg vs 29.97 ± 1.47 kcal/kg, P = 0.008; 24.72 ± 1.43 kcal/kg vs 25.66 ± 1.63 kcal/kg, P = 0.013); and decreased the Ln-HOMA-IR score (P = 0.019, 0.028) on postoperative days 1 and 3; IIT decreased the level of CRP on postoperative days 1 and 3 (P = 0.017, 0.006); the total protein and albumin concentrations in the IIT group were greater than those in the CIT group (P = 0.023, 0.009). Postoperative values of internal cell fluid (ICF), fat mass, protein mass (PM), muscle mass, free fat mass and body weight decreased obviously on postoperative 7th day compared with the preoperative baseline in the CIT group (P < 0.05, respectively). IIT reduced markedly consumption of fat mass, PM and ICF compared with CIT (P = 0.009 to 0.026).
CONCLUSION: There were some benefits of IIT in decreasing the perioperative insulin resistance state, reducing energy expenditure and consumption of proteins and lipids tissue in patients undergoing gastrectomy.
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