Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewClinical benefits of tight glycaemic control: focus on the intensive care unit.
While stress hyperglycaemia has traditionally been regarded as an adaptive, beneficial response, it is clear that hyperglycaemia and hypoglycaemia are associated with increased risk of death in critically ill intensive care unit (ICU) patients. Recent studies on blood-glucose control failed to fully clarify whether this association is causal. Early proof-of-concept single-centre randomised controlled studies found that maintaining normoglycaemia by intensive insulin therapy, as compared with tolerating hyperglycaemia as an adaptive response, improved patient outcome. ⋯ Finally, the studies on tight blood-glucose control were done with vastly different nutritional and end-of-life strategies. The currently available studies do not allow to confidently recommend one optimal target for glucose in heterogeneous ICU patient groups and settings. Provided that adequate devices for blood-glucose measurement and insulin administration are available, together with an extensive experience of the nursing staff, blood-glucose levels should be controlled as close to normal as possible, without evoking unacceptable fluctuations and hypoglycaemia.
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewMolecular mechanisms behind clinical benefits of intensive insulin therapy during critical illness: glucose versus insulin.
High blood glucose levels have been associated with morbidity and poor outcome in critically ill patients, irrespective of underlying pathology. In a large, randomised, controlled study the use of insulin therapy to maintain normoglycaemia for at least a few days improved survival and reduced morbidity of patients who are in a surgical intensive care unit (ICU). ⋯ We first describe the molecular origin of hyperglycaemia and the impact of the therapy on insulin sensitivity. Next, the molecular basis of glucose toxicity in critical illness and the impact of intensive insulin therapy hereon are described, as well as other non-glucose-toxicity-related metabolic effects of intensive insulin therapy.
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewHow to weigh the current evidence for clinical practice.
This article presents a template for judging trials of tight glucose control in critically ill patients. It reviews threats to both internal validity and generalisability using examples from the current literature. ⋯ These may relate to the setting, the patients or the practical delivery of tight glucose control or other interventions. Once identified, a judgement must be made for each difference of whether it is likely to modify the effect of tight glucose control.
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Best Pract Res Clin Anaesthesiol · Dec 2009
ReviewTight glycaemic control: clinical implementation of protocols.
Implementation of tight glycaemic control in hospitalised patients presents a huge challenge. It concerns many patients, there are many interfering factors and many health-care professionals are involved. The current literature provides little practical guidance. ⋯ An effective, safe and user-friendly algorithm for intravenous insulin administration is presented that can be executed by regular nurses and used in many situations. Practical advice is offered for the use of subcutaneous basal-bolus insulin, for fasting orders and for transition to discharge care. The main safety considerations are discussed.