Point-of-care glucose measurement systems should be used with great caution in critically ill intensive care unit patients Reply

Intensive Care Unit, Reinier de Graaf Hospital, Delft, Netherlands (Meynaar) Intensive Care Unit, Reinier de Graaf Hospital, Delft, Netherlands (van Spreuwel) Intensive Care Unit, Reinier de Graaf Hospital, Delft, Netherlands (Tangkau) Intensive Care Unit, Reinier de Graaf Hospital, Delft, Netherlands (Dawson) Intensive Care Unit, Reinier de Graaf Hospital, Delft, Netherlands (Visser) Department of Clinical Chemistry, Reinier de Graaf Hospital, Delft, Netherlands (Rijks) Department of Rheumatology, Leiden University Medical Centre, Leiden, Netherlands (Vlieland).
Critical care medicine (Impact Factor: 6.31). 01/2010; 38(1):339-340. DOI: 10.1097/CCM.0b013e3181c0da87
Source: PubMed
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    ABSTRACT: To determine the risk factors for development of severe hypoglycemia (defined as glucose <40 mg/dL) in critically ill patients and define the outcomes of this complication. Retrospective database review, including a case-control analysis that matched each patient with severe hypoglycemia with three controls. Adult intensive care unit of a university-affiliated community hospital. A total of 102 patients with at least one episode of severe hypoglycemia extracted from a series of 5,365 medical, surgical, and cardiac patients admitted consecutively between October 1, 1999, and June 15, 2006. A program of intensive glycemic monitoring and management, or tight glycemic control, was implemented on February 1, 2003; 2,666 patients were treated before and 2,699 after this date. Multivariable logistic regression analysis identified diabetes, septic shock, renal insufficiency, mechanical ventilation, severity of illness, reflected by Acute Physiology and Chronic Health Evaluation II score with the age component deleted, and treatment in the tight glycemic control period as independent risk factors for the development of severe hypoglycemia. Mortality was 55.9% among the 102 patients with severe hypoglycemia and 39.5% among the 306 controls (p = .0057). Multivariable logistic regression analysis identified severe hypoglycemia as an independent predictor of mortality for the entire cohort (odds ratio, 2.28; 95% confidence interval, 1.41-3.70; p = .0008). Among patients with severe hypoglycemia, only modified Acute Physiology and Chronic Health Evaluation II score and mechanical ventilation were identified as independent predictors of mortality. A sensitivity analysis was constructed that suggested that quadrupling the rate of severe hypoglycemia and doubling the mortality attributable to severe hypoglycemia would negate the survival benefit of tight glycemic control in this series. Case-control methodology and multivariable logistic regression analysis concurred that even a single episode of severe hypoglycemia was independently associated with increased risk of mortality. Safe implementation of tight glycemic control requires appropriate monitoring to reduce the risk of this complication.
    Critical Care Medicine 10/2007; 35(10):2262-7. DOI:10.1097/01.CCM.0000282073.98414.4B · 6.31 Impact Factor
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    ABSTRACT: To evaluate the accuracy of the AccuChek Inform point-of-care glucose measurement device as compared with central laboratory glucose measurement. Prospective, observational study. A ten-bed mixed closed format intensive care unit ina 500-bed general hospital. The unit has a computerized insulin protocol aiming for 81 to 135 mg/dL. All intensive care unit patients were eligible. None. Paired samples (AccuChek glucose in whole blood calibrated to give whole blood results and central laboratory glucose in serum) were taken simultaneously. In 32 critically ill patients, we obtained the following information: mean +/- standard deviation age 71.6 +/- 11.9 yrs; mean Acute Physiology and Chronic Health Evaluation II score at admission 17.8 +/- 6.7; 239 paired samples were taken from arterial catheters. Mean AccuChek whole blood glucose was 126 +/- 36 mg/dL (7.0 +/- 2.0 mmol/L); mean central laboratory serum glucose was 137 +/- 38 mg/dL (7.6 +/- 2.1 mmol/L). Mean difference was 11 mg/dL (0.61 mmol/L) (8%) (95% Confidence Interval 9-13 mg/dL, p < .001). ISO 15197 guideline requires 95% of point-of-care measurements to be within 15 mg/dL margins with reference <75 mg/dL or within 20% if reference is higher. In total, 216 (90.4%) of AccuChek measurements were within ISO 15197 margins. Because AccuChek was calibrated to give whole blood results, we calculated a correction factor of 1.086 from the two mean values to correct whole blood AccuChek into serum-like results. This is almost the same as the correction factor of 1.080 given by Roche Diagnostics. By multiplying AccuChek whole blood results with 1.086, 225 (94.1%) of results were within the ISO 15197 margins. Hematocrit did not influence AccuChek results in the 0.20 to 0.44 range. Beyond this range, there were not enough data to draw conclusions. In critically ill patients, the accuracy of AccuChek glucose measurement calibrated to give serum-like results with blood samples derived from arterial catheters is acceptable but falls short by about 1% of complying with the ISO 15197 guideline.
    Critical care medicine 10/2009; 37(10):2691-6. DOI:10.1097/CCM.0b013e3181a564fe · 6.31 Impact Factor
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    ABSTRACT: Implementation of strict glucose control in most intensive care units has resulted in increased use of point-of-care glucose devices in the intensive care unit. The aim of this study was to determine the reliability of point-of-care testing glucose meters among critically ill patients under intensive insulin treatment. Prospective observational study. Intensive care unit and non-intensive care unit patients in a tertiary care teaching hospital. A glucose oxidase method was used to validate the point-of-care testing devices. Three different point-of-care testing devices, Accu-Chek Sensor (Roche Diagnostics), Precision (Abbott Diagnostics), and HemoCue were tested. Glucose measurements were performed in duplicate by an experienced technician under standardized conditions in the hospital's laboratory, using arterial (intensive care unit patients) and arterial or venous (non-intensive care unit patients) heparinized whole blood samples. A strong correlation was found between the glucose oxidase method and the Accu-Chek device (r = .9596, p < 0.001). Mean absolute difference between the glucose oxidase and Accu-Chek was -0.32 mmol/L (95% confidence interval -0.84 to 1.48 mmol/L). Using the International Organization for Standardization (ISO) criteria, 27 of 197 samples (13.7%) were inaccurate. In all samples that failed to meet the ISO criteria, glucose values measured by the Accu-Chek device were higher compared with the glucose oxidase method. In another set of experiments among intensive care unit patients, strong positive correlations were also found between the other point-of-care testing devices and the glucose oxidase method. However, paired samples from Accu-Chek, HemoCue, and Precision failed the ISO criteria in 9 of 82 (11.0%), 4 of 82 (4.9%), and 11 of 82 (13.4%) of cases, respectively. In non-intensive care unit patients paired samples from Accu-Chek, HemoCue, and Precision failed the ISO criteria in 3 of 120 (2.5%), 11 of 120 (9.2%), and 16 of 120 (13.3%) cases, respectively. Under standardized conditions, glucose results from three point-of-care testing devices were inaccurate in both intensive care unit and non-intensive care unit patients. Among intensive care unit patients, inaccurate glucose readings were most frequently falsely elevated, resulting in misinterpretation of high glucose values with subsequent inappropriate insulin administration or masking of true hypoglycemia.
    Critical care medicine 10/2008; 36(11):3062-6. DOI:10.1097/CCM.0b013e318186ffe6 · 6.31 Impact Factor