Intensive insulin therapy in mixed medical/surgical intensive care units - Benefit versus harm
ABSTRACT Intensive insulin therapy (IIT) improves the outcome of prolonged critically ill patients, but concerns remain regarding potential harm and the optimal blood glucose level. These questions were addressed using the pooled dataset of two randomized controlled trials. Independent of parenteral glucose load, IIT reduced mortality from 23.6 to 20.4% in the intention-to-treat group (n = 2,748; P = 0.04) and from 37.9 to 30.1% among long stayers (n = 1,389; P = 0.002), with no difference among short stayers (8.9 vs. 10.4%; n = 1,359; P = 0.4). Compared with blood glucose of 110-150 mg/dl, mortality was higher with blood glucose >150 mg/dl (odds ratio 1.38 [95% CI 1.10-1.75]; P = 0.007) and lower with <110 mg/dl (0.77 [0.61-0.96]; P = 0.02). Only patients with diabetes (n = 407) showed no survival benefit of IIT. Prevention of kidney injury and critical illness polyneuropathy required blood glucose strictly <110 mg/day, but this level carried the highest risk of hypoglycemia. Within 24 h of hypoglycemia, three patients in the conventional and one in the IIT group died (P = 0.0004) without difference in hospital mortality. No new neurological problems occurred in survivors who experienced hypoglycemia in intensive care units (ICUs). We conclude that IIT reduces mortality of all medical/surgical ICU patients, except those with a prior history of diabetes, and does not cause harm. A blood glucose target <110 mg/day was most effective but also carried the highest risk of hypoglycemia.
Article: Les conséquences de l’hypoglycémie[Show abstract] [Hide abstract]
ABSTRACT: L’hypoglycémie reste un événement fréquent et sévère chez les patients diabétiques et est devenue le facteur limitant de la mise en place d’une stratégie d’insulinothérapie intensive en réanimation. Le glucose est le carburant énergétique indispensable au métabolisme cérébral. Ainsi, l’hypoglycémie constitue une urgence métabolique. Non résolue, elle peut entraîner des dégâts cérébraux permanents et la mort. L’excès relatif ou absolu d’insuline, associé à des apports nutritionnels inadéquats, est la cause principale des épisodes d’hypoglycémies. Ce phénomène est amplifié par la limitation de la synthèse endogène du glucose et par une glycolyse accélérée observées en réanimation. Les symptômes d’alerte de l’hypoglycémie en rapport avec l’activation du système nerveux végétatif ne sont pas spécifiques et les symptômes de neuroglycopénie peuvent être masqués par la sédation. Ainsi, une surveillance rapprochée de la glycémie est indispensable pour détecter les épisodes d’hypoglycémie, en évitant d’utiliser des prélèvements capillaires. Dans les études randomisées évaluant l’impact de deux niveaux de glycémie, la stratégie d’insulinothérapie intensive, destinée à obtenir un contrôle glycémique strict (objectif glycémique inférieur à 6,1 mmol/l), s’accompagne d’une incidence d’hypoglycémies sévères (inférieures à 2,2 mmol/l) multipliée par 4 à 6. La survenue d’une hypoglycémie sévère est associée, statistiquement, à un pronostic péjoratif sans que la responsabilité directe de l’hypoglycémie ait pu être démontrée.Réanimation 07/2008; 17(5):437-441. DOI:10.1016/j.reaurg.2008.04.001
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ABSTRACT: Because it is the product of glycolysis and main substrate for mitochondrial respiration, lactate is the central metabolic intermediate in cerebral energy substrate delivery. Our recent studies on healthy controls and patients following traumatic brain injury (TBI) using [6,6-(2)H2]glucose and [3-(13)C]lactate, along with cerebral blood flow (CBF) and arterial-venous (jugular bulb) difference measurements for oxygen, metabolite levels, isotopic enrichments and (13)CO2 show a massive and previously unrecognized mobilization of lactate from corporeal (muscle, skin, and other) glycogen reserves in TBI patients who were studied 5.7 ± 2.2 days after injury at which time brain oxygen consumption and glucose uptake (CMRO2 and CMRgluc, respectively) were depressed. By tracking the incorporation of the (13)C from lactate tracer we found that gluconeogenesis (GNG) from lactate accounted for 67.1 ± 6.9%, of whole-body glucose appearance rate (Ra) in TBI, which was compared to 15.2 ± 2.8% (mean ± SD, respectively) in healthy, well-nourished controls. Standard of care treatment of TBI patients in state-of-the-art facilities by talented and dedicated heath care professionals reveals presence of a catabolic Body Energy State (BES). Results are interpreted to mean that additional nutritive support is required to fuel the body and brain following TBI. Use of a diagnostic to monitor BES to provide health care professionals with actionable data in providing nutritive formulations to fuel the body and brain and achieve exquisite glycemic control are discussed. In particular, the advantages of using inorganic and organic lactate salts, esters and other compounds are examined. To date, several investigations on brain-injured patients with intact hepatic and renal functions show that compared to dextrose + insulin treatment, exogenous lactate infusion results in normal glycemia.Frontiers in Neuroscience 02/2015; 8. DOI:10.3389/fnins.2014.00408
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ABSTRACT: Background/Aim. Postural impairments and gait disorders in Parkinson's disease (PD) affect limits of stability, impaire postural adjustment, and evoke poor responses to perturbadon. In the later stage of the disease, some patients can suffer from episodic features such as freezing of gait (FOG). Objective gait assessment and monitoring progress of the disease can give clinicians and therapist important information about changes in gait pattern and potential gait deviations, in order to prevent concomitant falls. The aim of this study was to propose a method for identification of freezing episodes and gait disturbances in patients with PD. A wireless inertial sensor system can be used to provide follow-up of the treatment effects or progress of the disease. Methods. The system is simple for mounting a subject, comfortable, simple for installing and recording, reliable and provides high-quality sensor data. A total of 12 patients were recorded and tested. Software calculates various gait parameters that could be estimated. User friendly visual tool provides information about changes in gait characteristics, either in a form of spectrogram or by observing spatiotemporal parameters. Based on these parameters, the algorithm performs classification of strides and identification of FOG types. Results. The described stride classification was merged with an algorithm for stride reconstruction resulting in a useful graphical tool that allows clinicians to inspect and analyze subject's movements. Conclusion. The described gait assessment system can be used for detection and categorization of gait disturbances by applying rule-based classification based on stride length, stride time, and frequency of the shank segment movements. The method provides an valuable graphical interface which is easy to interpret and provides clinicians and therapists with valuable information regarding the temporal changes in gait.Vojnosanitetski pregled. Military-medical and pharmaceutical review 09/2014; 71(9):809-816. DOI:10.2298/VSP130422012D · 0.27 Impact Factor