Journal of diabetes science and technology
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J Diabetes Sci Technol · Nov 2009
ReviewPerioperative and critical illness dysglycemia--controlling the iceberg.
Patients with dysglycemia related to known or unrecognized diabetes, stress hyperglycemia, or hypoglycemia in the presence or absence of exogenous insulin routinely require care during the perioperative period or critical illness. Recent single and multicenter studies, a large multinational study, and three meta-analyses evaluated the safety of routine tight glycemic control (80-110 mg/dl) in critically ill adults. Results led to a call for more modest treatment goals (initiation of insulin at a blood glucose >180 mg/dl with a goal of approximately 150 mg/dl). In this symposium, an international group of multidisciplinary experts discusses the role of tight glycemic control, glucose measurement technique and its accuracy, glucose variability, hypoglycemia, and innovative methods to facilitate glucose homeostasis in this heterogeneous patient population.
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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
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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J Diabetes Sci Technol · Nov 2009
ReviewAn overview of glycemic control in the coronary care unit with recommendations for clinical management.
The observation that elevated glucose occurs frequently in the setting of acute myocardial infarction was made decades ago. Since then numerous studies have documented that hyperglycemia is a powerful risk factor for increased mortality and in-hospital complications in patients with acute coronary syndromes. While some questions in this field have been answered in prior investigations, many critical gaps in knowledge continue to exist and remain subjects of intense debate. This review summarizes what is known about the relationship between hyperglycemia, glucose control, and outcomes in critically ill patients with acute coronary syndromes, addresses the gaps in knowledge and controversies, and offers general recommendations regarding glucose management in the coronary care unit.
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Hyperglycemia in the critically ill is a well-known phenomenon, even in those without known diabetes. The stress response is due to a complex interplay between counter-regulatory hormones, cytokines, and changes in insulin sensitivity. Illness/infection, overfeeding, medications (e.g., corticosteroids), insufficient insulin, and/or volume depletion can be additional contributors. ⋯ A moderate approach to managing critical illness hyperglycemia seems most prudent at this juncture. Future research should ascertain whether there are certain subgroups of patients that would benefit from tighter glycemic goals. It also remains to be seen if tight glucose control is beneficial once hypoglycemia is minimized with technological advances such as continuous glucose monitoring systems.