Journal of diabetes science and technology
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Single center randomized controlled trials could demonstrate a benefit of strict glycemic control on the mortality and morbidity outcomes for critically ill patients. Although observational studies also demonstrate a benefit of tight glucose control for patients in general wards, direct evidence is still lacking. ⋯ Standardization of all required working steps to establish glycemic control needs to be considered to be able to achieve safe and good blood glucose control. Recent developments from diabetes technology will have an important impact in facilitating glucose control in the hospital, although the already established workflows in hospitals will require a substantial reconsideration of diabetes-oriented technology to allow an area-wide implementation and acceptance by health care personnel.
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J Diabetes Sci Technol · May 2008
Improvement in glycemic control and outcome corresponding to intensive insulin therapy protocol development.
Intensive insulin therapy (IIT) has been shown to reduce mortality and morbidity in longer stay, critically ill patients. However, this has been demonstrated in a single site, whereas two multicentric studies have been terminated prematurely mainly due to hypoglycemia. Other difficulties with IIT include efficacy of glycemic control. This report describes how IIT can be improved by protocol simplification and removal of glucose supplementation. ⋯ IIT protocol optimization was associated with increased glycemic control and improved 28-day survival. The better optimized IIT2 protocol provided tighter control than either the IIT1 or CIT protocol, without increased sampling or incidence of hypoglycemia. The clinical effectiveness of the IIT algorithm appeared to be improved by simplifying the protocol to meet the needs of the critical care unit.
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J Diabetes Sci Technol · May 2008
Multicenter validation of a computer-based clinical decision support tool for glucose control in adult and pediatric intensive care units.
Hyperglycemia during critical illness is common, and intravenous insulin therapy (IIT) to normalize blood glucose improves outcomes in selected populations. Methods differ widely in complexity, insulin dosing approaches, efficacy, and rates of hypoglycemia. We developed a simple bedside-computerized decision support protocol (eProtocol-insulin) that yields promising results in the development center. We examined the effectiveness and safety of this tool in six adult and five pediatric intensive care units (ICUs) in other centers. ⋯ A multicenter validation demonstrated that eProtocol-insulin is a valid, exportable tool that can assist clinicians in achieving control of glucose in critically ill adults and children.
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J Diabetes Sci Technol · Mar 2008
An analysis: hyperglycemic intensive care patients need continuous glucose monitoring-easier said than done.
Experts and agencies increasingly advocate tight glycemic control (TGC) using intensive intravenous insulin therapy in critically ill patients. Questions remain about the "best" glucose goal, the universal benefit of TGC in the heterogeneous adult intensive care unit (ICU) population, and concerns about the underrecognized incidence of hypoglycemia and its neuropsychological sequelae. TGC is time-consuming for ICU staff, and pathophysiologic, technical, and personnel factors impact the accuracy of point-of-care glucose monitoring. ⋯ Establishment of reliable CGM may provide the foundation for a closed loop, microprocessed system resulting in an artificial islet cell. This commentary focuses on reports from two respected groups on the potential use of CGM devices in the critically ill. It emphasizes the challenges of applying this technology in the ICU and looks to future refinements to address them.
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J Diabetes Sci Technol · Mar 2008
How much do forgotten insulin injections matter to hemoglobin a1c in people with diabetes? A simulation study.
Forgotten or omitted insulin injections are an important contributing factor to poor glycemic control in people with type 1 diabetes. This study uses mathematical modeling and examines the impact on hemoglobin A1c (HbA1c) levels if insulin injections are forgotten. The simulation concerns people with type 1 diabetes on intensive insulin therapy. ⋯ The magnitude of the possible improvement in HbA1c agrees well with other studies in the relation between adherence and HbA1c levels. The estimated numbers suggest that missing injections are an important reason for suboptimal treatment.