A folyamatos szubkután glükózmonitorizálás szerepe az intenzív terápiában

A kritikus állapotú betegek stressz-hyperglykaemiájának értékelése az elmúlt évtizedben jelentősen megváltozott. A vércukor szoros kontrolljának mortalitást csökkentő hatását igazolta több jelentős vizsgálat, ugyanakkor az ezt célzó inzulinkezelés megnöveli a hypoglykaemia kockázatát, amely független mortalitási tényező lehet. A hypoglykaemia szempontjából kiemelt jelentőségű a gyermekpopuláció, a fejlődő idegrendszer miatt. Ezek alapján joggal merül fel a vércukorváltozások intenzív osztályos monitorizálásának igénye, különösen gyermek betegeknél. A hagyományos, vérmintából történő vércukor-meghatározások nem tesznek lehetővé kellően szoros monitorizálást. A cukorbetegek számára kifejlesztett, a szövet közti glükóz meghatározásán alapuló módszerek (continuous glucose monitoring) jó alternatívát jelenthetnek az intenzív osztályos monitorizálásra, amennyiben felmérjük a rendszer korlátait. A mérés a szövet közti folyadékban történik, így a szöveti perfúzió változásai zavarhatják a pontosságát. A folyamatos glükózmonitoring módszer intenzív osztályos alkalmazását jelenleg még nem javasolják, amíg a rendszer megbízhatóságáról nem áll rendelkezésre elegendő adat. Összefoglaló közleményükben a szerzők a magyar klinikai gyakorlatban elterjedt Medtronic folyamatos szubkután glükózmonitorizáló rendszert értékelik, részben saját eredményeik alapján. Orv. Hetil., 2013, 154, 1043–1048. | Critical care associated with stress hyperglycaemia has gained a new view in the last decade since the demonstration of the beneficial effects of strong glycaemic control on the mortality in intensive care units. Strong glycaemic control may, however, induce hypoglycaemia, resulting in increased mortality, too. Pediatric population has an increased risk of hypoglycaemia because of the developing central nervous system. In this view there is a strong need for close monitoring of glucose levels in intensive care units. The subcutaneous continuous glucose monitoring developed for diabetes care is an alternative for this purpose instead of regular blood glucose measurements. It is important to know the limitations of subcutaneous continuous glucose monitoring in intensive care. Decreased tissue perfusion may disturb the results of subcutaneous continuous glucose monitoring, because the measurement occurs in interstitial fluid. The routine use of subcutaneous continuous glucose monitoring in intensive care units is not recommended yet until sufficient data on the reliability of the system are available. The Medtronic subcutaneous continuous glucose monitoring system is evaluated in the review partly based on the authors own results. Orv. Hetil., 2013, 154, 1043–1048

Effects of pH, lactate, hematocrit and potassium level on the accuracy of continuous glucose monitoring (CGM) in pediatric intensive care unit

BACKGROUND: Continuous glucose monitoring (CGM) originally was developed for diabetic patients and it may be a useful tool for monitoring glucose changes in pediatric intensive care unit (PICU). Its use is, however, limited by the lack of sufficient data on its reliability at insufficient peripheral perfusion. We aimed to correlate the accuracy of CGM with laboratory markers relevant to disturbed tissue perfusion. PATIENTS AND METHODS: In 38 pediatric patients (age range, 0–18 years) requiring intensive care we tested the effect of pH, lactate, hematocrit and serum potassium on the difference between CGM and meter glucose measurements. Guardian® (Medtronic®) CGM results were compared to GEM 3000 (Instrumentation laboratory®) and point-of-care measurements. The clinical accuracy of CGM was evaluated by Clarke Error Grid -, Bland-Altman analysis and Pearson’s correlation. We used Friedman test for statistical analysis (statistical significance was established as a p < 0.05). RESULTS: CGM values exhibited a considerable variability without any correlation with the examined laboratory parameters. Clarke, Bland-Altman analysis and Pearson’s correlation coefficient demonstrated a good clinical accuracy of CGM (zone A and B = 96%; the mean difference between reference and CGM glucose was 1,3 mg/dL, 48 from the 780 calibration pairs overrunning the 2 standard deviation; Pearson’s correlation coefficient: 0.83). CONCLUSIONS: The accuracy of CGM measurements is independent of laboratory parameters relevant to tissue hypoperfusion. CGM may prove a reliable tool for continuous monitoring of glucose changes in PICUs, not much influenced by tissue perfusion, but still not appropriate for being the base for clinical decisions

Az ICON elektromos kardiometrián alapuló nem invazív hemodinamikai monitor használata a klinikumban

Absztrakt: A kritikus állapotú betegek kezelésében elengedhetetlen fontosságú a hemodinamikai monitorozás. Az utóbbi években az intenzív osztályos ellátás a technika fejlődésének köszönhetően ezen a területen is egyre inkább a nem invazív irányt követi. A néhány évtizeddel ezelőtt rutinszerűen bevezetett invazív hemodinamikai monitorozás használata a gyermek intenzív, valamint egyre több helyen a felnőtt intenzív ellátásban is csökkenő tendenciát mutat. A nem invazív monitorozás elterjedésének oka a biztonságossága, szövődménymentessége mellett a költséghatékonysága is. Összefoglalónk témája az elektromos kardiometrián (electric cardiometry) alapuló ICON® betegmonitor ismertetése, amely egy újonnan kifejlesztett nem invazív, hemodinamikai paramétereket mérő és regisztráló eszköz. Klinikai alkalmazhatósága kiterjed a csecsemő-, gyermek- és felnőttosztályos gyakorlatra is. Az ICON® elektromos kardiometriai monitor működési elve egyszerű: az aortában a vér vezetőképessége az idő függvényében változást mutat, az aortabillentyű nyitása előtt a vörösvérsejtek random elhelyezkedést mutatnak, míg kamrai kontrakció hatására párhuzamos irányultságot vesznek fel. Négy elektróda felhelyezését követően az eszköz a két állapot közti vezetőképesség-változást rögzíti, majd a kapott értékekből a perctérfogatot és a verőtérfogatot méri, valamint más cardiovascularis paramétereket (például szisztémás vascularis rezisztencia) számol a mellkasi elektromos bioimpedancia szívciklushoz kapcsolódó változásainak követésével. Az ICON® legfontosabb előnyei az azonnali és folyamatos mérési lehetőség, illetve a nem invazivitásból fakadó alacsony szövődményráta. Az ICON® új, ígéretes hemodinamikai eszköz az intenzív terápia területén. A nem invazív, valós idejű mérési módszerrel szinte azonnal felmérhető a betegek hemodinamikai statusa, így az optimális terápia indítása késlekedés nélkül elkezdhető. A pontosabb klinikai indikációk meghatározásához további kutatások folyamatban vannak. Orv Hetil. 2018; 159(44): 1775–1781. | Abstract: Establishment of a proper hemodynamic monitoring system in order to achieve optimal care among critically ill patients is fundamental. In contrast to invasive patient-checking systems, which were introduced decades ago and used in both adult and pediatric intensive care, the non-invasive methods have become more popular in recent years due to technical advancements in intensive care and patient monitoring. This increase in popularity can be attributed to the higher degree of safety and reduced complication rates as well as to its being more economical. Our summary focuses on the ICON® patient monitoring system. This newly engineered, non-invasive tool is based on electrical cardiometry, and uses hemodynamic parameters in both neonatal and pediatric care as well as in adults. The operating principle is simple: the conductivity of the blood in the aorta shows time-dependent changes. Prior to the opening of the aortic valve, the orientation of the red blood cells (RBCs) is random, and it is not until the contraction of the aorta that the RBCs and the opening of the aortic valve achieve a parallel position. The tool senses the conductivity between four placed electrodes, and measures the stroke volume (SV) and cardiac output (CO), before calculating other additional parameters (eg.: systemic vascular resistance) by tracing the variation of bioimpedance according to changes in the heart cycle. The most important advantages of ICON® are the measurements that are made available immediately as well as continuously, and the low complication rate that originates from its non-invasive operation. ICON® is a new, promising hemodynamic device in the tool belt of intensive care. Due to the nature of the device, it is possible to evaluate the status of the patient on a continuous basis, allowing for optimal care. To identify the more accurate clinical indications further measures will be necessary. Orv Hetil. 2018; 159(44): 1775–1781

Evaluation of an open access software for calculating glucose variability parameters of a continuous glucose monitoring system applied at pediatric intensive care unit.

BACKGROUND: Continuous Glucose Monitoring (CGM) has become an increasingly investigated tool, especially with regards to monitoring of diabetic and critical care patients. The continuous glucose data allows the calculation of several glucose variability parameters, however, without specific application the interpretation of the results is time-consuming, utilizing extreme efforts. Our aim was to create an open access software [Glycemic Variability Analyzer Program (GVAP)], readily available to calculate the most common parameters of the glucose variability and to test its usability. METHODS: The GVAP was developed in MATLAB(R) 2010b environment. The calculated parameters were the following: average area above/below the target range (Avg. AUC-H/L); Percentage Spent Above/Below the Target Range (PATR/PBTR); Continuous Overall Net Glycemic Action (CONGA); Mean of Daily Differences (MODD); Mean Amplitude of Glycemic Excursions (MAGE). For verification purposes we selected 14 CGM curves of pediatric critical care patients. Medtronic(R) Guardian(R) Real-Time with Enlite(R) sensor was used. The reference values were obtained from Medtronic(R)'s own software for Avg. AUC-H/L and PATR/PBTR, from GlyCulator for MODD and CONGA, and using manual calculation for MAGE. RESULTS: The Pearson and Spearman correlation coefficients were above 0.99 for all parameters. The initial execution took 30 minutes, for further analysis with the Windows(R) Standalone Application approximately 1 minute was needed. CONCLUSIONS: The GVAP is a reliable open access program for analyzing different glycemic variability parameters, hence it could be a useful tool for the study of glycemic control among critically ill patients

Prevalence and etiology of false normal aEEG recordings in neonatal hypoxic-ischaemic encephalopathy.

BACKGROUND: Amplitude-integrated electroencephalography (aEEG) is a useful tool to determine the severity of neonatal hypoxic-ischemic encephalopathy (HIE). Our aim was to assess the prevalence and study the origin of false normal aEEG recordings based on 85 aEEG recordings registered before six hours of age. METHODS: Raw EEG recordings were reevaluated retrospectively with Fourier analysis to identify and describe the frequency patterns of the raw EEG signal, in cases with inconsistent aEEG recordings and clinical symptoms. Power spectral density curves, power (P) and median frequency (MF) were determined using the raw EEG. In 7 patients non-depolarizing muscle relaxant (NDMR) exposure was found. The EEG sections were analyzed and compared before and after NDMR administration. RESULTS: The reevaluation found that the aEEG was truly normal in 4 neonates. In 3 neonates, high voltage electrocardiographic (ECG) artifacts were found with flat trace on raw EEG. High frequency component (HFC) was found as a cause of normal appearing aEEG in 10 neonates. HFC disappeared while P and MF decreased significantly upon NDMR administration in each observed case. CONCLUSION: Occurrence of false normal aEEG background pattern is relatively high in neonates with HIE and hypothermia. High frequency EEG artifacts suggestive of shivering were found to be the most common cause of false normal aEEG in hypothermic neonates while high voltage ECG artifacts are less common

Diet-Induced Obesity Enhances TRPV1-Mediated Neurovascular Reactions in the Dura Mater

OBJECTIVE: Exploring the pathophysiological changes in transient receptor potential vanilloid 1 (TRPV1) receptor of the trigeminovascular system in high-fat, high-sucrose (HFHS) diet-induced obesity of experimental animals. BACKGROUND: Clinical and experimental observations suggest a link between obesity and migraine. Accumulating evidence indicates that metabolic and immunological alterations associated with obesity may potentially modulate trigeminovascular functions. A possible target for obesity-induced pathophysiological changes is the TRPV1/capsaicin receptor which is implicated in the pathomechanism of headaches in a complex way. METHODS: Male Sprague-Dawley rats were fed a regular (n = 25) or HFHS diet (n = 26) for 20 weeks. At the end of the dietary period, body weight of the animals was normally distributed in both groups and it was significantly higher in animals on HFHS diet. Therefore, experimental groups were regarded as control and HFHS diet-induced obese groups. Capsaicin-induced changes in meningeal blood flow and release of calcitonin gene-related peptide (CGRP) from dural trigeminal afferents were measured in control and obese rats. The distribution of TRPV1- and CGRP-immunoreactive meningeal sensory nerves was also compared in whole mount preparations of the dura mater. Metabolic parameters of the animals were assessed by examining glucose and insulin homeostasis as well as plasma cytokine concentrations. RESULTS: HFHS diet was accompanied by reduced food consumption and greater fluid and energy intakes in addition to increased body weight of the animals. HFHS diet increased fasting blood glucose and insulin concentrations as well as levels of circulating proinflammatory cytokines interleukin-1beta and interleukin-6. In obese animals, dural application of the archetypal TRPV1 agonist capsaicin resulted in significantly augmented vasodilatory and vasoconstrictor responses as compared to controls. Diet-induced obesity was also associated with enhanced basal and capsaicin-induced CGRP release from meningeal afferents ex vivo. Except for minor morphological changes, the distribution of dural TRPV1- and CGRP-immunoreactive afferents was similar in control and obese animals. CONCLUSIONS: Our results suggest that obesity induced by long-term HFHS diet results in sensitization of the trigeminovascular system. Changes in TRPV1-mediated vascular reactions and CGRP release are pathophysiological alterations that may be of relevance to the enhanced headache susceptibility of obese individuals