Critical Glucose Control: The Devil Is in the Details

Mayo Clinic Proceedings (Impact Factor: 6.26). 05/2008; 83(4):394-7. DOI: 10.4065/83.4.394
Source: PubMed
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    ABSTRACT: 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. TGC in the ICU requires safe, accurate, robust, rapid, and continuous glucose measurements (CGM) that lack interference from drugs or other substances. 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.
    Journal of diabetes science and technology 03/2008; 2(2):201-4. DOI:10.1177/193229680800200205
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    ABSTRACT: We assessed the performance of a point-of-care (POC) glucose meter system (GMS) with multitasking test strip by using the locally-smoothed (LS) median absolute difference (MAD) curve method in conjunction with a modified Bland-Altman difference plot and superimposed International Organization for Standardization (ISO) 15197 tolerance bands. We analyzed performance for tight glycemic control (TGC). A modified glucose oxidase enzyme with a multilayer-gold, multielectrode, four-well test strip (StatStriptrade mark, NOVA Biomedical, Waltham, MA) was used. There was no test strip calibration code. Pragmatic comparison was done of GMS results versus paired plasma glucose measurements from chemistry analyzers in clinical laboratories. Venous samples (n = 1,703) were analyzed at 35 hospitals that used 20 types of chemistry analyzers. Erroneous results were identified using the Bland-Altman plot and ISO 15197 criteria. Discrepant values were analyzed for the TGC interval of 80-110 mg/dL. The GMS met ISO 15197 guidelines; 98.6% (410 of 416) of observations were within tolerance for glucose <75 mg/dL, and for > or =75 mg/dL, 100% were within tolerance. Paired differences (handheld minus reference) averaged -2.2 (SD 9.8) mg/dL; the median was -1 (range, -96 to 45) mg/dL. LS MAD curve analysis revealed satisfactory performance below 186 mg/dL; above 186 mg/dL, the recommended error tolerance limit (5 mg/dL) was not met. No discrepant values appeared. All points fell in Clarke Error Grid zone A. Linear regression showed y = 1.018x - 0.716 mg/dL, and r2 = 0.995. LS MAD curves draw on human ability to discriminate performance visually. LS MAD curve and ISO 15197 performance were acceptable for TGC. POC and reference glucose calibration should be harmonized and standardized.
    Diabetes Technology &amp Therapeutics 01/2009; 10(6):445-51. DOI:10.1089/dia.2008.0049 · 2.11 Impact Factor
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