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Intensive insulin therapy in the surgical intensive care unit

Jean-Charles Preiser, Olivier Lheureux, Aurelie Thooft, Serge Brimioulle, Jacques Goldstein, Jean-Louis Vincent
OBJECTIVES: Tight glycemic control using intermittent blood glucose measurements is associated with a risk of hypoglycemia. Glucose concentrations can now be measured near continuously (every 5-15 min). We assessed the quality and safety of glycemic control guided by a near-continuous glucose monitoring system in ICU patients. DESIGN: Prospective, cluster-randomized, crossover study. SETTING: Thirty-five-bed medico-surgical department of intensive care with four separate ICUs...
April 19, 2018: Critical Care Medicine
Gaëlle Cheisson, Sophie Jacqueminet, Emmanuel Cosson, Carole Ichai, Anne-Marie Leguerrier, Bogdan Nicolescu-Catargi, Alexandre Ouattara, Igor Tauveron, Paul Valensi, Dan Benhamou
In diabetic patients undergoing surgery, we recommend assessing glycaemic control preoperatively by assessing glycated haemoglobin (HbA1c) levels and recent capillary blood sugar (glucose) levels, and to adjust any treatments accordingly before surgery, paying particular attention to specific complications of diabetes. Gastroparesis creates a risk of stasis and aspiration of gastric content at induction of anaesthesia requiring the use of a rapid sequence induction technique. Cardiac involvement can be divided into several types...
March 17, 2018: Anaesthesia, Critical Care & Pain Medicine
Peter J Watkinson, Vicki S Barber, J Duncan Young
BACKGROUND: Observational and interventional studies in patients with both acute medical conditions and long-standing diabetes have shown that improved blood glucose control confers a survival advantage or reduces complication rates. Policies of "tight" glycaemic control were rapidly adopted by many general intensive care units (ICUs) worldwide in the mid 00's, even though the results of the studies were not generalizable to mixed medical/surgical ICUs with different intravenous feeding policies...
March 8, 2018: JMIR Research Protocols
Yamely Mendez, Salim Surani, Joseph Varon
Diabetic ketoacidosis (DKA) is defined as an acute metabolic disorder, which is characterized by an increased presence of circulating ketones, and the development of ketoacidosis in the presence of hyperglycemia. This syndrome occurs as a result of insulin deficiency. Patients can be dramatically ill, however, with aggressive treatment, most patients recover rapidly. Despite being a low-risk condition, the development of acidosis, is one of the admission criteria to the intensive care unit (ICU) for these patients, in order to provide close monitoring, and recognize complications that could result from the use of aggressive therapy, such as continuous infusions if insulin...
February 15, 2017: World Journal of Diabetes
Andrea Balloni, Federico Lari, Fabrizio Giostra
The hyperglycemic reaction to stress is part of adaptive metabolic response to critical illness, especially hypoxia, hemorrhage and sepsis. It involves neuro-endocrine and immune pathways leading to the development of insulin resistance and hepatic glucose production by gluconeogenesis and glycogenolysis. Over the last years the concept of stress related hyperglycemia has been replaced by the concept of dysglycemia and its three domains: hyperglycemia, hypoglycemia and glycemic variability. Each of the three domains is independently associated with increased risk of mortality in patients admitted in intensive care unit and non critically ill patients, both medical and surgical...
January 16, 2017: Acta Bio-medica: Atenei Parmensis
Wouter van Snippenburg, Mariet G J Reijnders, Jose G M Hofhuis, Rien de Vos, Stephan Kamphuis, Peter E Spronk
INTRODUCTION: Thiamine is an essential cofactor in carbohydrate metabolism, and deficiency can therefore cause various organ dysfunctions. Little is known about the prevalence and possible worsening of thiamine deficiency in critically ill patients. In this study, we investigated the prevalence of thiamine deficiency at admission to the intensive care unit (ICU) and hypothesized that intensive insulin therapy, aimed at regulating glucose levels, increases thiamine utilization and therefore might cause or worsen deficiency in patients with limited thiamine stores...
October 2017: Journal of Intensive Care Medicine
Gabriela Sousa, Ana Lopes, Pedro Reis, Vasco Carvalho, Alice Santos, Fernando José Abelha
INTRODUCTION: Postoperative cardiovascular complications might be difficult to assess and are known to be associated with longer hospital stay and increased costs as well as higher morbidity and mortality rates. The aim of this study was to evaluate the predictors for major cardiac events (MCE) after non-cardiac surgery. METHODS: The study included 4398 patients who were admitted to the Surgical Intensive Care Unit between January 1, 2006 and July 19, 2013. Acute physiology and chronic health evaluation II score and simplified acute physiology score (SAPS II) were calculated, and all variables entered as parameters were evaluated independently...
August 2016: World Journal of Surgery
Meagan K Doolin, Todd A Walroth, Serena A Harris, Jessica A Whitten, Andrew C Fritschle-Hilliard
BACKGROUND: Glycemic control decreases morbidity and mortality in critically ill patients. However, limited guidance exists regarding the transition from intravenous (IV) to subcutaneous insulin therapy. A validated protocol for transition is necessary since glycemic variability, hyperglycemia, and hypoglycemia adversely impact patient outcomes. METHOD: The objective was to determine the safest and most effective method to transition critically ill adults from IV to subcutaneous insulin...
July 2016: Journal of Diabetes Science and Technology
Wilma S Leslie, Ian Ford, Naveed Sattar, Kieren G Hollingsworth, Ashley Adamson, Falko F Sniehotta, Louise McCombie, Naomi Brosnahan, Hazel Ross, John C Mathers, Carl Peters, George Thom, Alison Barnes, Sharon Kean, Yvonne McIlvenna, Angela Rodrigues, Lucia Rehackova, Sviatlana Zhyzhneuskaya, Roy Taylor, Mike E J Lean
BACKGROUND: Despite improving evidence-based practice following clinical guidelines to optimise drug therapy, Type 2 diabetes (T2DM) still exerts a devastating toll from vascular complications and premature death. Biochemical remission of T2DM has been demonstrated with weight loss around 15kg following bariatric surgery and in several small studies of non-surgical energy-restriction treatments. The non-surgical Counterweight-Plus programme, running in Primary Care where obesity and T2DM are routinely managed, produces >15 kg weight loss in 33% of all enrolled patients...
February 16, 2016: BMC Family Practice
R Clive Landis, Jeremiah R Brown, David Fitzgerald, Donald S Likosky, Linda Shore-Lesserson, Robert A Baker, John W Hammon
A wide range of pharmacological, surgical, and mechanical pump approaches have been studied to attenuate the systemic inflammatory response to cardiopulmonary bypass, yet no systematically based review exists to cover the scope of anti-inflammatory interventions deployed. We therefore conducted an evidence-based review to capture "self-identified" anti-inflammatory interventions among adult cardiopulmonary bypass procedures. To be included, trials had to measure at least one inflammatory mediator and one clinical outcome, specified in the "Outcomes 2010" consensus statement...
September 2014: Journal of Extra-corporeal Technology
Robert A Palermo, Hannah L Palac, Eric L Wald, Mark S Wainwright, John M Costello, Osama M Eltayeb, Carl L Backer, Conrad L Epting
OBJECTIVE: The objective of this study was to characterize the natural history of metabolic uncoupling (type B hyperlactemia and hyperglycemia) following cardiopulmonary bypass (CPB), and to determine the impact of insulin therapy on time to lactate normalization in patients without low cardiac output. DESIGN: The design used was a retrospective cohort study. SETTING: The study was set in a pediatric cardiac intensive care unit in a tertiary-care urban children's hospital...
November 2015: Congenital Heart Disease
Jan Bláha, Miloš Mráz, Petr Kopecký, Martin Stříteský, Michal Lipš, Michal Matias, Jan Kunstýř, Michal Pořízka, Tomáš Kotulák, Ivana Kolníková, Barbara Šimanovská, Mykhaylo Zakharchenko, Jan Rulíšek, Robert Šachl, Jiří Anýž, Daniel Novák, Jaroslav Lindner, Roman Hovorka, Štěpán Svačina, Martin Haluzík
CONTEXT: Tight glucose control (TGC) reduces morbidity and mortality in patients undergoing elective cardiac surgery, but only limited data about its optimal timing are available to date. OBJECTIVE: The purpose of this article was to compare the effects of perioperative vs postoperative initiation of TGC on postoperative adverse events in cardiac surgery patients. DESIGN: This was a single center, single-blind, parallel-group, randomized controlled trial...
August 2015: Journal of Clinical Endocrinology and Metabolism
Miroslav Pernický, Juraj Papinčák, Adriana Reptová, Soňa Kiňová, Ján Murín
UNLABELLED: The case study describes a case of 49-year-old man with morbid obesity since childhood (BMI 40 kg/m2), arterial hypertension (approx. since aged 15, treated since 2004), dyslipidemia (since 2006), type 2 diabetes mellitus (since 2006, on insulin therapy since 2008) and smoking (until 2011, 20 cigarettes a day). TREATMENT: 16 types of medication, 8 for hypertension, statin, therapy for diabetes, aspirin, allopurinol. In 2010 (when aged 45) hospitalized in our clinic with dyspnoea and chest pain with a high pressure reading of 180/110 mm Hg (identified symptoms of heart failure with LV ejection fraction of 33 %, in NYHA II functional class, echocardiographically: left atrium: 46 mm, left ventricular chamber size in diastole: 70 mm, interventricular septum: 12 mm, septal hypokinesis, Doppler ultrasonography of lower limb arteries (calcification, diffuse atherosclerotic changes, absent stenosis), CT coronary angiography (significant stenosis of the left coronary artery)...
May 2015: Vnitr̆ní Lékar̆ství
James S Krinsley, Jean-Charles Preiser
INTRODUCTION: Hyperglycemia, hypoglycemia and increased glucose variability are independently associated with increased risk of death in critically ill adults. The relationship between time in targeted blood glucose range (TIR) and mortality is not well described and may be a factor that has confounded the results of the major interventional trials of intensive insulin therapy. METHODS: We conducted a retrospective analysis of prospectively collected data involving 3,297 patients with intensive care unit (ICU) lengths of stay (LOS) of ≥ 1...
April 20, 2015: Critical Care: the Official Journal of the Critical Care Forum
J J Mukherjee, P S Chatterjee, M Saikia, A Muruganathan, Ashok Kumar Das
Hyperglycaemia occurs frequently in critically-ill patients. Not only does it occur among patients with pre-existing diabetes mellitus but elevated blood glucose values during an acute illness can also be seen in previously glucose-tolerant individuals (stress hyperglycaemia). Numerous observational studies have shown an increase in morbidity and mortality in critically ill patients with hyperglycaemia. Interestingly, outcomes in individuals with stress hyperglycaemia are worse than that in critically ill hyperglycaemic patients with pre-existing diabetes...
July 2014: Journal of the Association of Physicians of India
Raphaël Cinotti, Carole Ichai, Jean-Christophe Orban, Pierre Kalfon, Fanny Feuillet, Antoine Roquilly, Bruno Riou, Yvonnick Blanloeil, Karim Asehnoune, Bertrand Rozec
INTRODUCTION: Hyperglycemia is a marker of poor prognosis in severe brain injuries. There is currently little data regarding the effects of intensive insulin therapy (IIT) on neurological recovery. METHODS: A sub-group analysis of the randomized-controlled CGAO-REA study (NCT01002482) in surgical intensive care units (ICU) of two university hospitals. Patients with severe brain injury, with an expected ICU length of stay ≥ 48 hours were included. Patients were randomized between a conventional glucose management group (blood glucose target between 5...
September 5, 2014: Critical Care: the Official Journal of the Critical Care Forum
Victoria Sandler, Meaghan R Misiasz, Jocelyn Jones, David Baldwin
Computerized insulin infusion protocols have facilitated more effective blood glucose (BG) control in intensive care units (ICUs). This is particularly important in light of the risks associated with hypoglycemia. End stage renal disease (ESRD) increases the risk of insulin-induced hypoglycemia. We evaluated BG control in 210 patients in 2 medical ICUs and in 2 surgical ICUs who were treated with a computerized insulin infusion program (CIIP). Our CIIP was programmed for a BG target of 140-180 mg/dL for medical ICU patients or 120-160 mg/dL for surgical ICU patients...
September 2014: Journal of Diabetes Science and Technology
Bernardo Moguel-González, Michael Wasung-de-Lay, Pamela Tella-Vega, Constanza Riquelme-Mc-Loughlin, Antonio R Villa, Magdalena Madero, Gerardo Gamba
INTRODUCTION: Acute kidney injury (AKI) associated with cardiac surgery is a common postoperative complication that increases the morbidity and mortality substantially. However, there is limited information of AKI after cardiac surgery in our institution. MATERIAL AND METHODS: We conducted a prospective, observational, and longitudinal analysis of adult patients that underwent to cardiac surgery requiring cardiopulmonary bypass and aortic cross clamp. Patients with preoperative chronic renal insufficiency that were on dialysis, with AKI detected up to 24 h before the procedure, or that received contrast agents 72 h before surgery were excluded...
November 2013: Revista de Investigación Clínica; Organo del Hospital de Enfermedades de la Nutrición
Takehiro Okabayashi, Yasuo Shima, Tatsuaki Sumiyoshi, Akihito Kozuki, Teppei Tokumaru, Tasuo Iiyama, Takeki Sugimoto, Michiya Kobayashi, Masataka Yokoyama, Kazuhiro Hanazaki
OBJECTIVE: The optimal perioperative blood glucose range to improve surgical site infection (SSI) in surgical intensive care unit (ICU) patients remains unclear. We sought to determine whether the incidence of SSI is reduced by perioperative intensive insulin therapy (IT). RESEARCH DESIGN AND METHODS: Patients were randomly assigned to receive perioperative intensive IT, with a target blood glucose range of 4.4-6.1 mmol/L, or intermediate IT, with a target blood glucose range of 7...
June 2014: Diabetes Care
Kevin M Schuster, Kimberly Barre, Silvio E Inzucchi, Robert Udelsman, Kimberly A Davis
BACKGROUND: The role of intensive glycemic control (IGC) in the surgical intensive care unit (SICU) remains controversial. Continuous glucose monitoring systems (CGMSs) may mitigate the major risk of IGC, namely hypoglycemia, and improve clinical outcomes. METHODS: All patients admitted to the SICU requiring insulin infusion were eligible. CGMS (Medtronic Guardian REAL-Time CGM, Northridge, CA) was placed in the subcutaneous tissue of the abdomen or thigh and calibrated every 8 hours, based on capillary (fingerstick) blood glucose (CBG) readings...
March 2014: Journal of Trauma and Acute Care Surgery
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