Value of continuous glucose monitoring for minimizing severe hypoglycemia during tight glycemic control
ABSTRACT Tight glycemic control can potentially reduce morbidity and mortality in the intensive care unit but increases the risk of hypoglycemia. The most effective means to avoid hypoglycemia is to obtain frequent blood glucose samples, but this increases the burden to nursing staff. The objective of this study was to assess the ability of a real-time continuous glucose monitor to reduce hypoglycemia (blood glucose <60 mg/dL [3.3 mmol/L]) during standard care or tight glycemic control effected with a proportional integral derivative insulin titration algorithm.
Real-time continuous glucose monitor profiles obtained from an ongoing prospective randomized trial of tight glycemic control were retrospectively analyzed to determine whether the continuous glucose measure had prevented instances of hypoglycemia.
Cardiac intensive care unit.
Children 3 yrs of age or younger undergoing cardiac surgery were studied.
Intravenous insulin infusion and rescue glucose guided by the real-time continuous glucose monitor and the proportional integral derivative algorithm in the tight glycemic control arm (n = 155; target glucose 80-110 mg/dL [4.4-6.1 mmol/L]) and the real-time continuous glucose monitor in the standard care arm (n = 156).
No reduction in hypoglycemia was observed with real-time continuous glucose monitor alarms set at 60 mg/dL (3.3 mmol/L) (zero of 19 occurrences of blood glucose <60 mg/dL [3.3 mmol/L] detected); 18 of 40 subsequent incidences of hypoglycemia were detected after the alarm threshold was increased to 70 mg/dL (3.9 mmol/L). In the tight glycemic control arm, eight incidences were reduced in duration and an additional eight events were prevented with intravenous glucose. In the standard care arm, three of nine occurrences of hypoglycemia were detected with the duration reduced in all cases. On average, one to two false hypoglycemia alarms were observed in each patient.
The real-time continuous glucose monitor in combination with proportional integral derivative control can reduce hypoglycemia during tight glycemic control. The real-time continuous glucose monitor can also reduce hypoglycemia during standard care. However, false alarms increase the overall nursing workload.
SourceAvailable from: Thomas Desaive[Show abstract] [Hide abstract]
ABSTRACT: Achieving adequate glucose control in critically ill patients is a complex but important part of optimal patient management. Until relatively recently, intermittent measurements of blood glucose have been the only means of monitoring blood glucose levels. With growing interest in the possible beneficial effects of continuous over intermittent monitoring and the development of several continuous glucose monitoring (CGM) systems, a round table conference was convened to discuss and, where possible, reach consensus on the various aspects related to glucose monitoring and management using these systems. In this report, we discuss the advantages and limitations of the different types of devices available, the potential advantages of continuous over intermittent testing, the relative importance of trend and point accuracy, the standards necessary for reporting results in clinical trials and for recognition by official bodies, and the changes that may be needed in current glucose management protocols as a result of a move towards increased use of CGM. We close with a list of the research priorities in this field, which will be necessary if CGM is to become a routine part of daily practice in the management of critically ill patients.Critical care (London, England) 06/2014; 18(3):226. DOI:10.1186/cc13921
[Show abstract] [Hide abstract]
ABSTRACT: This literature review examines the current evidence regarding the potential usefulness of tight glycemic control in pediatric surgical patients. In adults, fluctuations in glucose levels and/or prolonged hyperglycemia have been shown to be associated with poor outcomes with respect to morbidity and mortality. This review begins by summarizing the findings of key papers in adult patients and continues by investigating whether or not similar results have been seen in pediatric patients by performing a comprehensive literature review using Medline (OVID). A database search using the OVID interface and including the search terms (exp glucose) AND (exp surgery) AND (exp Paediatric/pediatric) AND (exp Hypoglycaemia/hypoglycemia) AND (exp Hyperglycaemia/hyperglycemia) yielded a total of 150+ papers, of which 24 fulfilled our criteria. We isolated papers utilizing pediatric patients who were hospitalized due to illness and/or surgery. Our review highlights several difficulties encountered in addressing this potentially useful clinical intervention. An absence of scientifically robust and randomized trials and the existence of several small-powered trials yielding conflicting results mean we cannot recommend tight glycemic control in these patients. Differences in study design and disagreements concerning the crucial stage of surgery where hyperglycemia becomes important are compounded by an over-reliance on the discretion of clinicians in the absence of well described treatment protocols. Closer inspection of key papers in adult patients identified fundamental discrepancies between exact definitions of both hyperglycemia and hypoglycemia. This lack of consensus, along with a fear of inducing iatrogenic hypoglycemia in pediatric patients, has resulted in professional bodies advising against this form of intervention. In conclusion, we cannot recommend use of tight glycemic control in pediatric surgical patients due to unclear glucose definitions, unclear thresholds for treatment, and the unknown long-term effects of iatrogenic hypoglycemia on the developing body and brain.International Journal of General Medicine 12/2013; 7:1-11. DOI:10.2147/IJGM.S55649
[Show abstract] [Hide abstract]
ABSTRACT: Diabetes Mellitus (DM) with poor glycemic control is one of the leading causes for cardiovascular mortality in diabetic patients. Tight glycemic control with glycosylated haemoglobin of <7 gms% is recommended as a routine and < 6.5 gms% is recommended for young and newly diagnosed diabetics. Treatment goal aims at achieving near normal blood glucose level, and directed at management of other co morbid conditions such as obesity, hypertension and dyslipidemia. Oral hypoglycemic agents are the preferred drugs, alone or in combination. Preference for glitazones is declining due to the increasing evidences of associated adverse events. Gliptins appear as promising agents with lesser tendency to cause hypoglycemia, but their long term safety and efficacy is yet to be established. We emphasize the role of preventive measures in prediabetics and in established DM, treatment should be individualized and customized to minimize hypoglycemic effects and to retain quality of life.Heart Views 10/2014; 15(4):111. DOI:10.4103/1995-705X.151084