Journal of diabetes science and technology
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Hypoglycemia is a common and serious problem among patients with diabetes mellitus. It is also perceived as the most important obstacle to tight glucose control using intensive insulin therapy in critically ill patients. Because glucose is an obligatory metabolic fuel for the brain, hypoglycemia always represents an emergency that signals the inability of the brain to meet its energy needs. ⋯ Thus, close and reliable monitoring of the glycemic level is crucial in detecting hypoglycemia. In prospective randomized controlled studies comparing the effects of two glucose regimens, intensive insulin therapy aimed to reach strict glucose control (<110 mg/dl) but increased the incidence of severe hypoglycemia (<40 mg/dl) by four- to sixfold. Severe hypoglycemia is statistically associated with adverse outcomes in intensive care unit patients, although a direct causal relationship has not been demonstrated.
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J Diabetes Sci Technol · Nov 2009
Pilot evaluation of a prototype critical care blood glucose monitor in normal volunteers.
Availability of a highly accurate in-hospital automated blood glucose (BG) monitor could facilitate implementation of intensive insulin therapy protocols through effective titration of insulin therapy, improved BG control, and avoidance of hypoglycemia. We evaluated a functional prototype BG monitor designed to perform frequent automated blood sampling for glucose monitoring. ⋯ Automated phlebotomy can be performed in healthy subjects using this prototype BG monitor. The BG measurement technology had suboptimal accuracy based on a YSI reference. A more accurate BG point-of-care testing meter and strip technology have been incorporated into the future version of this monitor. Development of such a monitor could alleviate the burden of frequent BG testing and reduce the risk of hypoglycemia in patients on insulin therapy.
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Hyperglycemia can be a significant problem in the trauma population and has been shown to be associated with increased morbidity and mortality. Hyperglycemia in the trauma patient, as in other critically ill patients, is caused by a hypermetabolic response to stress and seems to be an entity of its own rather than simply a marker. Although several early studies in a mixed intensive care unit population indicated that insulin protocols aimed at strict glucose control improved outcome, later studies did not support this and, in fact, encountered increased complications due to hypoglycemia. More recent studies in the trauma population, while supporting the correlation between hyperglycemia and increased mortality, seemed to indicate that protocols aimed at moderate glucose control improved outcome while limiting the incidence of hypoglycemic complications.
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J Diabetes Sci Technol · Nov 2009
ReviewChallenges to glycemic measurement in the perioperative and critically ill patient: a review.
Accurate monitoring of glucose in the perioperative environment has become increasingly important over the last few years. Because of increased cost, turnaround time, and sample volume, the use of central laboratory devices for glucose measurement has been somewhat supplanted by point-of-care (POC) glucose devices. ⋯ Without further review, many of these POC glucose measurement devices have found their way into the hospital environment and are used frequently for measurement during intense insulin therapy, where accurate measurements are critical. This review covers the technology behind glucose measurement and the evidence questioning the use of many POC devices for perioperative glucose management.
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Hyperglycemia is commonplace in the critically ill patient and is associated with worse outcomes. It occurs after severe stress (e.g., infection or injury) and results from a combination of increased secretion of catabolic hormones, increased hepatic gluconeogenesis, and resistance to the peripheral and hepatic actions of insulin. The use of carbohydrate-based feeds, glucose containing solutions, and drugs such as epinephrine may exacerbate the hyperglycemia. ⋯ Deranged osmolality and blood flow, intracellular acidosis, and enhanced superoxide production have all been implicated. The net result is derangement of endothelial, immune and coagulation function and an association with neuropathy and myopathy. These changes can be prevented, at least in part, by the use of insulin to maintain normoglycemia.