1
|
van der Vaart A, Waanders F, van Beek AP, Vriesendorp TM, Wolffenbutel BHR, van Dijk PR. Incidence and determinants of hypophosphatemia in diabetic ketoacidosis: an observational study. BMJ Open Diabetes Res Care 2021; 9:9/1/e002018. [PMID: 33597187 PMCID: PMC7893606 DOI: 10.1136/bmjdrc-2020-002018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/22/2021] [Accepted: 01/31/2021] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM) characterized by hyperglycemia and metabolic acidosis. Hypophosphatemia in DKA often occurs during hospital admittance for DKA. Literature on the magnitude, determinants and consequences of hypophosphatemia in DKA is scarce. Primary aim of this study was to investigate the incidence and consequences of hypophosphatemia during hospitalisation for DKA. RESEARCH DESIGN AND METHODS Cohort study among individuals with T1DM who were admitted for DKA between 2005 and 2020 in an academic and a non-academic hospital. Multivariate regression models were performed to investigate determinants of the lowest phosphate during the treatment of DKA. RESULTS A total of 127 episodes of DKA among 80 individuals were identified. Age at DKA presentation was 28 (22-46) years, 45% of the cases was female, diabetes duration was 13.2 (8.9-25.5) years with glycosylated hemoglobin levels of 91.9±26.2 mmol/mol. In 9% of all cases, DKA was the first presentation of T1DM. Lowest phosphate levelss reported during the treatment phase were 0.54 (0.32-0.83) mmol/L and hypophosphatemia was present in 74% (62/84). The time to lowest phosphate was 16 (8-23) hours. In multivariate analysis, baseline bicarbonate and hemoglobin at admission were significantly associated with the lowest phosphate level reported. No adverse effects of hypophosphatemia on hospital stay duration, morbidity or mortality were found, even if left untreated. CONCLUSIONS Hypophosphatemia during DKA is common and increases with severe acidosis. However, in this study it was not related to adverse outcomes. Although limitations of this retrospective study should be taken into account, the routine and repeated measurement of phosphate levels in DKA could be reconsidered, provided that possible symptoms related to hypophosphatemia are monitored.
Collapse
Affiliation(s)
- Amarens van der Vaart
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Femke Waanders
- Department of Internal Medicine, Isala, Zwolle, The Netherlands
| | - André P van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - B H R Wolffenbutel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter R van Dijk
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
2
|
Haring MPD, Vriesendorp TM, Klein Wassink‐Ruiter JS, de Haas RJ, Gouw ASH, de Meijer VE. Diagnosis of hepatocellular adenoma in men before onset of diabetes in HNF1A-MODY: Watch out for winkers. Liver Int 2019; 39:2042-2045. [PMID: 31483937 PMCID: PMC6899532 DOI: 10.1111/liv.14235] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/26/2019] [Accepted: 08/27/2019] [Indexed: 12/13/2022]
Abstract
Hepatocyte nuclear factor 1A (HNF1A) maturity-onset diabetes of the young (MODY) is a monogenetic, autosomal dominantly inherited form of diabetes. HNF1A-MODY is associated with HNF1A-inactivated hepatocellular adenoma (H-HCA) formation. Hepatocellular adenoma (HCA) are benign liver tumours and related complications are rare but serious: hepatic haemorrhage and malignant transformation. Guidelines recommend resection of all HCA in men and do not take any co-occurring metabolic disorders into account. We report a family with HCA preceding diabetes mellitus. Male index patient presented with numerous, irresectable HCA. After initial diagnostic and aetiologic uncertainty HNF1A germline mutation c.815G>A (p.Arg272His) was confirmed 8 years later. No HCA-related complications occurred. His diabetic mother was diagnosed with HCA after severe hepatic haemorrhage years before. HNF1A-MODY should be considered in (non-)diabetic (male) patients with H-HCA. We advocate liver biopsy and, if necessary, genetic analysis to precede any intervention for HCA in males and screening for HCA in HNF1A-MODY patients.
Collapse
Affiliation(s)
- Martijn P. D. Haring
- Department of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | | | | | - Robbert J. de Haas
- Department of RadiologyUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | - Annette S. H. Gouw
- Department of Pathology and Medical BiologyUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | - Vincent E. de Meijer
- Department of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| |
Collapse
|
3
|
van Dijk PR, Waanders F, Logtenberg SJJ, Groenier KH, Vriesendorp TM, Kleefstra N, van Goor H, Bilo HJG. Different routes of insulin administration do not influence serum free thiols in type 1 diabetes mellitus. Endocrinol Diabetes Metab 2019; 2:e00088. [PMID: 31592137 PMCID: PMC6775445 DOI: 10.1002/edm2.88] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/03/2019] [Accepted: 07/14/2019] [Indexed: 12/17/2022] Open
Abstract
AIMS Intraperitoneal (IP) insulin administration is a last-resort treatment option for selected patients with type 1 diabetes mellitus (T1DM). As the IP route of insulin administration mimics the physiology more closely than the subcutaneous (SC) route, we hypothesized that IP insulin would result in less oxidative stress (expressed as systemic level of free sulphydryl (R-SH) content) compared to SC insulin in subjects with T1DM. MATERIALS AND METHODS Prospective, observational case-control study. Serum thiol measurements were performed at baseline and at 26 weeks in age- and gender-matched patients with T1DM. Serum-free thiols, compounds with a R-SH group that are readily oxidized by reactive oxygen species, are considered to be a marker of systemic redox status. RESULTS A total of 176 patients, 39 of which used IP and 141 SC insulin therapy were analysed. Mean baseline R-SH concentration was 248 (31) μmol/L. In multivariable analysis, the route of insulin therapy had no impact on baseline R-SH levels. The estimated geometric mean concentrations of R-SH did not differ significantly between both groups: 264 (95% CI 257, 270) for the IP group and 258 (95% CI 254, 261) for the SC group with a difference of 6 (95% CI -2, 14) μmol/L. CONCLUSIONS Based on R-SH as a marker of systemic oxidative stress, these findings demonstrate that the route of insulin administration, IP or SC, does not influence systemic redox status in patients with T1DM.
Collapse
Affiliation(s)
- Peter R. van Dijk
- The Diabetes CentreIsalaZwolleThe Netherlands
- Department of Internal Medicine, University Medical CenterUniversity of GroningenGroningenThe Netherlands
| | - Femke Waanders
- Department of Internal MedicineIsalaZwolleThe Netherlands
| | | | | | - Titia M. Vriesendorp
- The Diabetes CentreIsalaZwolleThe Netherlands
- Department of Internal MedicineIsalaZwolleThe Netherlands
| | - Nanne Kleefstra
- Department of Internal Medicine, University Medical CenterUniversity of GroningenGroningenThe Netherlands
- Langerhans Medical Research GroupOmmenThe Netherlands
- High & Intensive CareGGZ Drenthe Mental Health InstituteAssenThe Netherlands
| | - Harry van Goor
- Department of Pathology and Medical Biology, University Medical CenterUniversity of GroningenGroningenThe Netherlands
| | | |
Collapse
|
4
|
Gerards MC, Venema GE, Patberg KW, Kross M, Potter van Loon BJ, Hageman IMG, Snijders D, Brandjes DP, Hoekstra JBL, Vriesendorp TM, Gerdes VEA. Dapagliflozin for prednisone-induced hyperglycaemia in acute exacerbation of chronic obstructive pulmonary disease. Diabetes Obes Metab 2018; 20:1306-1310. [PMID: 29316157 PMCID: PMC5947126 DOI: 10.1111/dom.13209] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/28/2017] [Accepted: 12/31/2017] [Indexed: 01/13/2023]
Abstract
The aim of the present study was to compare the effectiveness and safety of add-on treatment with dapagliflozin to placebo in patients with prednisone-induced hyperglycaemia during treatment for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We enrolled 46 patients hospitalized for an AECOPD in a multicentre double-blind randomized controlled study in which add-on treatment with dapagliflozin 10 mg was compared with placebo. Glycaemic control and incidence of hypoglycaemia were measured through a blinded subcutaneous continuous glucose monitoring device. Participants in the dapagliflozin group spent 54 ± 27.7% of the time in target range (3.9-10 mmol/L) and participants in the placebo group spent 53.6 ± 23.4% of the time in target range (P = .96). The mean glucose concentration was 10.1 mmol/L in the dapagliflozin group and 10.4 mmol/L in the placebo group (P = .66). One participant using dapagliflozin and 2 participants using placebo experienced symptomatic hypoglycaemia. Treatment with dapagliflozin was safe and there was no difference in risk of hypoglycaemia compared with placebo. Dapagliflozin did not result in better glycaemic control compared with placebo in participants with prednisone-induced hyperglycaemia during AECOPD.
Collapse
Affiliation(s)
- Maaike C. Gerards
- Department of Internal MedicineMC SlotervaartAmsterdamThe Netherlands
| | | | | | - Martijn Kross
- Department of PulmonologyMC SlotervaartAmsterdamThe Netherlands
| | | | | | - Dominic Snijders
- Department of PulmonologySpaarne GasthuisHoofddorpThe Netherlands
| | | | | | | | | |
Collapse
|
5
|
Gerards MC, de Maar JS, Steenbruggen TG, Hoekstra JBL, Vriesendorp TM, Gerdes VEA. Add-on treatment with intermediate-acting insulin versus sliding-scale insulin for patients with type 2 diabetes or insulin resistance during cyclic glucocorticoid-containing antineoplastic chemotherapy: a randomized crossover study. Diabetes Obes Metab 2016; 18:1041-4. [PMID: 27191794 DOI: 10.1111/dom.12694] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 04/19/2016] [Accepted: 05/13/2016] [Indexed: 12/15/2022]
Abstract
The aim of this study was to compare the effectiveness and safety of intermediate-acting insulin (IMI) titrated on body weight and glucocorticoid dose with that of short-acting sliding-scale insulin (SSI) in patients on recurrent high-dose glucocorticoid-containing chemotherapy. We enrolled 26 patients with type 2 diabetes mellitus or random blood glucose level >12 mmol/l in a previous cycle of chemotherapy in a randomized crossover study. In two consecutive cycles of glucocorticoid-containing chemotherapy, participants were treated with either IMI or SSI, as add-on to routine diabetes medication. We compared time spent in target range (3.9-10 mmol/l), measured by continuous glucose monitoring (CGM), and the occurrence of hypoglycaemia. IMI resulted in a higher proportion of glucose values within target range than SSI (34.4 vs 20.9%; p < 0.001). There were no severe or symptomatic hypoglycaemic events. Two participants in each group had a subclinical hypoglycaemia detected only by CGM. Once-daily IMI resulted in better glycaemic control than SSI in patients with glucocorticoid-induced hyperglycaemia during chemotherapy. Safety was not compromised as the incidence of hypoglycaemia was low and not different between both regimens.
Collapse
Affiliation(s)
- M C Gerards
- Department of internal medicine, MC Slotervaart, Amsterdam, The Netherlands.
| | - J S de Maar
- Department of internal medicine, Isala, Zwolle, The Netherlands
| | - T G Steenbruggen
- Department of medical oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J B L Hoekstra
- Department of internal medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - T M Vriesendorp
- Department of internal medicine, Isala, Zwolle, The Netherlands
| | - V E A Gerdes
- Department of internal medicine, MC Slotervaart, Amsterdam, The Netherlands
| |
Collapse
|
6
|
Nijenhuis-Rosien L, Vriesendorp TM, Landman GWD. Comment on Tone et al. Six-Week Versus Twelve-Week Antibiotic Therapy for Nonsurgically Treated Diabetic Foot Osteomyelitis: A Multicenter Open-Label Controlled Randomized Study. Diabetes Care 2015;38:302-307. Diabetes Care 2015; 38:e144. [PMID: 26294780 DOI: 10.2337/dc15-0588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
7
|
Gerards MC, Tervaert ECC, Hoekstra JBL, Vriesendorp TM, Gerdes VEA. Physician's attitudes towards diagnosing and treating glucocorticoid induced hyperglycaemia: Sliding scale regimen is still widely used despite guidelines. Diabetes Res Clin Pract 2015; 109:246-52. [PMID: 26055758 DOI: 10.1016/j.diabres.2015.05.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 05/04/2015] [Accepted: 05/19/2015] [Indexed: 02/08/2023]
Abstract
AIMS Treatment with glucocorticoids for neoplasms and inflammatory disorders is frequently complicated by glucocorticoid induced hyperglycaemia (GCIH). GCIH is associated with adverse outcomes and its treatment has short term and long term benefits. Currently, treatment targets and modalities depend on local protocols and habits of individual clinicians. We explored current practice of screening and treatment of GCIH in patients receiving glucocorticoid pulse therapy. METHODS A factorial survey with written case vignettes. All vignette patients received glucocorticoid pulse therapy. Other characteristics (e.g., indication for glucocorticoid therapy, pre-existent diabetes) varied. The survey was held between November 2013 and May 2014 on 2 nationwide conferences and in hospitals across The Netherlands. Pulmonologists and internists expressed their level of agreement with statements on ordering capillary glucose testing and treatment initiation. RESULTS Respondents ordered screening for GCIH in 85% of vignette patients and initiated treatment in 56%. When initiating treatment, respondents opt for sliding scale insulin in 62% of patients. Sliding scale insulin was more frequently prescribed in patients with pre-existent insulin dependent diabetes (OR 2.4, CI 1.3-4.2) and by residents (vs. specialists, OR 2.1, CI 1.2-3.5). Sixty-nine percent of clinicians experienced a lack of guidelines for GCIH. CONCLUSIONS Clinicians have a strong tendency to screen for GCIH but subsequent initiation of treatment was low. Sliding scale insulin is still widely used in episodic GCIH despite evidence against its effectiveness. This may be due to lacking evidence on feasible treatment options for GCIH.
Collapse
Affiliation(s)
| | | | | | | | - V E A Gerdes
- Slotervaart Hospital, Amsterdam, The Netherlands
| |
Collapse
|
8
|
Soeters MR, van Zeijl CJJ, Boelen A, Kloos R, Saeed P, Vriesendorp TM, Mourits MP. Optimal management of Graves orbitopathy: a multidisciplinary approach. Neth J Med 2011; 69:302-308. [PMID: 21934174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Graves' thyroid disease is a relatively common disorder in endocrinology and general internal medicine practice. Graves' hyperthyroidism is mediated by circulating stimulating autoantibodies. Up to 60% of patients with Graves' hyperthyroidism develop some form of Graves' orbitopathy. Immune reactivity to the thyroid-stimulating hormone receptor is also thought to play a role in the immunopathogenesis of Graves' orbitopathy. Graves' orbitopathy is characterised by a wide open eye appearance, caused by upper eyelid retraction and soft-tissue swelling that causes exophthalmus. Symptoms include photophobia, sandy feeling in the eye, painful eye movements and diplopia. Visual acuity may be reduced. In some cases emergency treatment is necessary to prevent irreversible vision loss. Smoking should be stopped. Mild to moderate Graves' orbitopathy may be an indication for corticosteroid treatment or radiotherapy. Once inflammatory signs and symptoms have waned, surgery can be performed to correct residual diplopia, exophthalmus or lid retraction. The presence of Graves' orbitopathy has consequences for the management of Graves' hyperthyroidism. Adequately controlled Graves' thyroid dysfunction is likely to improve Graves' orbitopathy, while radioactive iodine treatment can worsen the condition. Due to the wide variety in clinical presentation and the possible interference between treatment of thyroid disease and eye disease, the management of more complicated patients with Graves' orbitopathy can best be performed in combined thyroid-eye clinics, in which the patient is seen simultaneously by the ophthalmologist and the endocrinologist.
Collapse
Affiliation(s)
- M R Soeters
- Departments of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, the Netherlands.
| | | | | | | | | | | | | |
Collapse
|
9
|
Vriesendorp TM, Roos YB, Kruyt ND, Biessels GJ, Kappelle LJ, Vermeulen M, Holleman F, DeVries JH, Hoekstra JBL. Efficacy and safety of two 5 day insulin dosing regimens to achieve strict glycaemic control in patients with acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2009; 80:1040-3. [PMID: 19684236 DOI: 10.1136/jnnp.2008.144873] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND In patients with acute ischaemic stroke and hyperglycaemia, prolonged strict glycaemic control may improve clinical outcome. The question is how to achieve this prolonged strict glycaemic control. In this study, the efficacy and safety of two regimens with different basal to meal related insulin ratio are described. METHODS 33 patients with ischaemic stroke and hyperglycaemia at admission were randomised in an open design to receive: (1) conventional glucose lowering therapy, (2) strict glucose control with predominantly basal insulin using intravenous insulin or (3) strict glucose control with predominantly meal related insulin using subcutaneous insulin in the first 5 days after stroke. The target range of glucose control for the last two groups was 4.4-6.1 mmol/l. 16 consecutive patients without hyperglycaemia at admission were included to serve as normoglycaemic controls. RESULTS The median area under the curve (AUC) in the meal related insulin group was 386 mmol/l x 58 h (range 286-662) for days 2-5, and did not differ from the hyperglycaemic control group (median AUC 444 mmol/l x 58 h; range 388-620). There was also no difference in median AUC of the basal insulin group (453 mmol/l x 58 h, range 347-629) and the hyperglycaemic control group on days 2-5. In the first 12 hours, glucose profiles were lower in the groups treated with strict glucose control; median AUC was 90 mmol/l x 12 h (range 77-189) for the hyperglycaemic control group versus 81 mmol/l x 12 h (range 60-118) for the meal related insulin group (p = 0.03) and 74 mmol/l x 12 h (range 52-97) for the basal insulin group (p = 0.008). CONCLUSION In intermittently fed ischaemic stroke patients, strict glycaemic control between day 2 and day 5 with two different basal bolus regimens did not result in lower glucose profiles due to postprandial hyperglycaemia. Continuous enteral feeding may therefore be needed to achieve prolonged strict glycaemic control in acute stroke patients.
Collapse
Affiliation(s)
- T M Vriesendorp
- Department of Internal Medicine, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
van den Berg TJ, Bogers H, Vriesendorp TM, Surachno JS, DeVries JH, ten Berge IJ, Hoekstra JBL. No apparent impact of increased post-operative blood glucose levels on clinical outcome in kidney transplant recipients. Clin Transplant 2009; 23:256-63. [PMID: 19402220 DOI: 10.1111/j.1399-0012.2008.00910.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Our objective is to evaluate whether hyperglycemia in the first 48 h after renal transplantation is independently associated with rejection, post-operative infection and post-transplant diabetes mellitus (PTDM) in a retrospective cohort study. METHODS Patients who received a renal transplant in our hospital in 2003 or 2004 were included. Glucose values until 48 h after surgery were retrieved from laboratory reports. Biopsy proven acute rejection, culture proven infections and PTDM were scored until four months after transplantation. Data were analyzed using univariate analysis and logistic multivariate analysis. RESULTS At least one post-operative glucose value could be retrieved for 150/151 patients. Rejection occurred in 46/150 (30.5%), infection in 47/150 (31.1%) and PTDM in 19/150 (12.6%) patients. When corrected for other risk factors, no relation was found between post-operative glucose levels and rejection (weak inverse relation, OR = 0.82; 95% CI = 0.65-1.03; p = 0.09), post-operative glucose and infections (OR = 0.98; 95% CI = 0.80-1.21; p = 0.84) and post-operative glucose and PTDM (OR = 0.93; 95% CI = 0.70-1.23; p = 0.63). CONCLUSION Increased post-operative blood glucose levels after renal transplantation were not found to be a risk factor for graft rejection. Also, post-operative glucose levels were not found to be associated with PTDM and post-operative infections.
Collapse
Affiliation(s)
- Tijs J van den Berg
- Department of internal medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
11
|
Vriesendorp TM, de Graaff MJ. Hypes, hypers en hypo’s. Crit Care 2008. [DOI: 10.1007/bf03076463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
12
|
Vriesendorp TM, de Vries JH, Hoekstra JBL. [Hyperglycaemia during hospitalisation]. Ned Tijdschr Geneeskd 2007; 151:1278-82. [PMID: 17624157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Patients who are admitted to an intensive care unit for 3 days or longer have an increased survival rate if their blood-glucose levels are strictly controlled by means of intensive insulin therapy. This is true of patients admitted for either surgical or non-surgical indications. For patients undergoing cardiac surgery, strict peri- and postoperative glycaemic control lowers the postoperative complication rate and possibly also mortality. Patients suffering from an acute myocardial infarction, and possibly also patients with acute ischaemic stroke, are likely to benefit from strict glycaemic control. The value of treating hyperglycaemia in other patient groups has not been established. The workload on the nursing staff and the risk of prolonged and serious hypoglycaemia are the most important disadvantages of strict glycaemic control. The optimal duration of strict glycaemic control and the precise target range are not well defined and may well differ per patient group.
Collapse
Affiliation(s)
- T M Vriesendorp
- Academisch Medisch Centrum/Universiteit van Amsterdam, afd. Inwendige Geneeskunde, Secretariaat F4-222, Meibergdreef 9, 1105 AZ Amsterdam.
| | | | | |
Collapse
|
13
|
Vriesendorp TM, DeVries JH, van Santen S, Moeniralam HS, de Jonge E, Roos YBWEM, Schultz MJ, Rosendaal FR, Hoekstra JBL. Evaluation of short-term consequences of hypoglycemia in an intensive care unit. Crit Care Med 2006; 34:2714-8. [PMID: 16943734 DOI: 10.1097/01.ccm.0000241155.36689.91] [Citation(s) in RCA: 178] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Introduction of strict glycemic control has increased the risk for hypoglycemia in the intensive care unit. Little is known about the consequences of hypoglycemia in this setting. We examined short-term consequences (seizures, coma, and death) of hypoglycemia in the intensive care unit. PATIENTS AND METHODS All occurrences of hypoglycemia (glucose of <45 mg/dL) in our intensive care unit between September 1, 2002, and September 1, 2004, were identified. Patients with hypoglycemia (n = 156) were matched for time to hypoglycemia with control patients drawn from the at-risk population (nested case control method). Seizures observed within 8 hrs after hypoglycemia were scored. Discharge summaries for cases and controls were reviewed for occurrence of possible hypoglycemia-associated coma and death. A hazard ratio for in-hospital death was calculated with Cox regression analysis. RESULTS The hazard ratio for in-hospital death was 1.03 (95% confidence interval, 0.68-1.56; p = .88) in patients with a first occurrence of hypoglycemia relative to the controls without hypoglycemia, corrected for duration of intensive care unit admittance before hypoglycemia, age, sex, and Acute Physiology and Chronic Health Evaluation II score at admission. No cases of hypoglycemia-associated death were reported. Hypoglycemic coma was reported in two patients. Seizures after hypoglycemia were observed in one patient. CONCLUSIONS In this study, no association between incidental hypoglycemia and mortality was found. However, this data set is too small to definitely exclude the possibility that hypoglycemia is associated with intensive care unit mortality. In three patients with possible hypoglycemia-associated coma or seizures, a causal role for hypoglycemia seemed likely but could not fully be established.
Collapse
Affiliation(s)
- Titia M Vriesendorp
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Vriesendorp TM, van Santen S, DeVries JH, de Jonge E, Rosendaal FR, Schultz MJ, Hoekstra JBL. Predisposing factors for hypoglycemia in the intensive care unit*. Crit Care Med 2006; 34:96-101. [PMID: 16374162 DOI: 10.1097/01.ccm.0000194536.89694.06] [Citation(s) in RCA: 211] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The introduction of strict glycemic control in the intensive care unit has increased the risk for hypoglycemia. In this study we examined the association between predefined circumstances and the occurrence of hypoglycemia in the intensive care unit. DESIGN : Retrospective cohort study. SETTING Academic medical center. PATIENTS All episodes of hypoglycemia (glucose value <45 mg/dL) in our intensive care unit between September 2002 and September 2004 were identified. Presence of predefined circumstances previously associated with hypoglycemia was scored around the moment of hypoglycemia using a patient data management system and in-hospital charts. Patients with a first hypoglycemic event were contrasted to controls from the same cohort, who were matched for time since admission, to correct for the effect of length of stay. Data were analyzed using conditional logistic regression analysis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 2,272 patients, 156 (6.9%) experienced at least one episode of hypoglycemia. Continuous venovenous hemofiltration with bicarbonate-based substitution fluid (odds ratio [OR], 14; 95% confidence interval [CI], 1.8-106), a decrease of nutrition without adjustment for insulin infusion (OR, 6.6; 95% CI, 1.9-23), diabetes mellitus (OR, 2.6; 95% CI, 1.5-4.7), insulin use (OR, 5.3; 95% CI, 2.8-11), sepsis (OR, 2.2; 95% CI, 1.2-4.1), and inotropic support (OR, 1.8; 95% CI, 1.1-2.9) were associated with hypoglycemia. Simultaneous octreotide and insulin use (OR, 6.0; 95% CI, 0.72-50) may also be associated with hypoglycemia. Gastric residual during enteral nutrition without adjusting insulin infusion, liver failure, continuous venovenous hemofiltration with lactate-based substitution fluid, diminished glomerular filtration rate, dose diminishment of glucocorticoids or catecholamines, and use of beta-blocking agents were not associated with hypoglycemia. Adjusting for age, gender, and Acute Physiology and Chronic Health Evaluation II score at admission did not materially change ORs. CONCLUSION Use of bicarbonate-based substitution fluid during continuous venovenous hemofiltration, a decrease of nutrition without adjustment for insulin infusion, a prior diagnosis of diabetes mellitus, sepsis, and need for inotropic support were found to be associated with hypoglycemia. Simultaneous use of insulin and octreotide may be associated with hypoglycemia.
Collapse
Affiliation(s)
- Titia M Vriesendorp
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
15
|
Abstract
BACKGROUND Maintaining plasma glucose between 80 and 120 mg/dL is beneficial for patients admitted to a surgical intensive care unit, but requires frequent glucose monitoring to ensure adequacy of treatment and detection of hypoglycemia. We examined whether continuous glucose sensing is feasible and reliable during and after major surgical procedures using two commercially available sensors. METHODS Eight patients undergoing abdominal surgery were studied. A CGMS device (Medtronic MiniMed, Northridge, CA) and a GlucoDay device (A. Menarini Diagnostics, Florence, Italy) were placed in the shoulder region, and a second GlucoDay device was placed in the upper leg. Blood glucose was measured every 15 min for a total duration of 12 h. RESULTS Technical failure of the CGMS was observed peroperatively more frequently than postoperatively (66% of all time points vs. 18%, P < 0.001). Technical failure of the GlucoDay device occurred most frequently in the GlucoDay placed in the upper leg (64% vs. 17%, P < 0.001). Accuracy of all three sensors was comparable peroperatively (74%, 76%, and 63% of values in Zone A of the Clarke error grid for the CGMS, GlucoDay shoulder, and GlucoDay upper leg, respectively, P = 0.2). Postoperatively, better accuracy was observed in both sensors placed in the shoulder compared with the GlucoDay placed in the upper leg (73%, 69%, and 51% of values in Zone A for the CGMS, GlucoDay shoulder, and GlucoDay upper leg, respectively, P < 0.001). CONCLUSIONS Technical performance and accuracy of continuous glucose sensors need improvement before continuous glucose sensors can be used to monitor strict glycemic control during and after surgery.
Collapse
Affiliation(s)
- T M Vriesendorp
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands.
| | | | | | | | | |
Collapse
|
16
|
Vriesendorp TM, Morélis QJ, Devries JH, Legemate DA, Hoekstra JBL. Early post-operative glucose levels are an independent risk factor for infection after peripheral vascular surgery. A retrospective study. Eur J Vasc Endovasc Surg 2005; 28:520-5. [PMID: 15465374 DOI: 10.1016/j.ejvs.2004.08.006] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2004] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate whether hyperglycaemia in the first 48 h after infrainguinal vascular surgery is a risk factor for post-operative infection, independent from factors associated with insulin resistance and surgical stress. DESIGN Retrospective cohort study. PATIENTS AND METHODS Patients who underwent infrainguinal vascular surgery in our hospital between March 1998 and March 2003 were included. Glucose values until 48 h after surgery were retrieved from laboratory reports. Post-operative infections, treated with antibiotics, during hospital stay were scored until 30 days after surgery. Data were analysed with univariate and multivariate logistic regression analyses. RESULTS At least one post-operative glucose value was retrieved for 211/275 (77%) patients. The incidence of post-operative infections was 84/275 (31%). When corrected for factors associated with insulin resistance and surgical stress, post-operative glucose levels were found to be an independent risk factor for post-operative infections (odds ratio top quartile versus lowest quartile: 5.1; 95% confidence interval: 1.6-17.1; P=0.007). CONCLUSION Post-operative glucose levels appear to be an independent risk factor for infections after infrainguinal vascular surgery. This finding requires confirmation in a prospective study.
Collapse
Affiliation(s)
- T M Vriesendorp
- Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands.
| | | | | | | | | |
Collapse
|
17
|
Vriesendorp TM, DeVries JH, Hulscher JBF, Holleman F, van Lanschot JJ, Hoekstra JBL. Early postoperative hyperglycaemia is not a risk factor for infectious complications and prolonged in-hospital stay in patients undergoing oesophagectomy: a retrospective analysis of a prospective trial. Crit Care 2004; 8:R437-42. [PMID: 15566589 PMCID: PMC1065066 DOI: 10.1186/cc2970] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2004] [Accepted: 09/02/2004] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Treating hyperglycaemia in hospitalized patients has proven to be beneficial, particularly in those with obstructive vascular disease. In a cohort of patients undergoing resection for oesophageal carcinoma (a group of patients with severe surgical stress but a low prevalence of vascular disease), we investigated whether early postoperative hyperglycaemia is associated with increased incidence of infectious complications and prolonged in-hospital stay. METHODS Postoperative glucose values up to 48 hours after surgery were retrieved for 151 patients with American Society of Anesthesiologists class I or II who had been previously included in a randomized trial conducted in a tertiary referral hospital. Multivariate regression analysis was used to define the independent contribution of possible risk factors selected by univariate analysis. RESULTS In univariate regression analysis, postoperative glucose levels were associated with increased length of in-hospital stay (P < 0.001) but not with infectious complications (P = 0.21). However, postoperative glucose concentration was not found to be an independent risk factor for prolonged in-hospital stay in multivariate analysis (P = 0.20). CONCLUSION Our data indicate that postoperative hyperglycaemia is more likely to be a risk marker than a risk factor in patients undergoing highly invasive surgery for oesophageal cancer. We hypothesize that patients with a low prevalence of vascular disease may benefit less from intensive insulin therapy.
Collapse
Affiliation(s)
- Titia M Vriesendorp
- Research Physician, Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - J Hans DeVries
- Internist-Endocrinologist, Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jan BF Hulscher
- Surgical Resident, Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - Frits Holleman
- Internist-Endocrinologist, Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jan J van Lanschot
- Professor of Surgery, Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - Joost BL Hoekstra
- Professor of Internal Medicine, Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| |
Collapse
|
18
|
|