Glucometer accuracy and implications for clinical studies

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Pilot study of the SPRINT glycemic control protocol in a Hungarian medical intensive care unit.

Stress-induced hyperglycemia increases morbidity and mortality. Tight control can reduce mortality but has proven difficult to achieve. The SPRINT (Specialized Relative Insulin and Nutrition Tables) protocol is the only protocol that reduced both mortality and hypoglycemia by modulating both insulin and nutrition, but it has not been tested in independent hospitals. SPRINT was used for 12 adult intensive care unit patients (949 h) at Kálmán Pándy Hospital (Gyula, Hungary) as a clinical practice assessment. Insulin recommendations (0-6 U/h) were administered via constant infusion rather than bolus delivery. Nutrition was administered per local standard protocol, weaning parenteral to enteral nutrition, but was modulated per SPRINT recommendations. Measurement was every 1 to 2 h, per protocol. Glycemic performance is assessed by percentage of blood glucose (BG) measurements in glycemic bands for the cohort and per patient. Safety from hypoglycemia is assessed by numbers of patients with BG < 2.2 (severe) and %BG < 3.0 and < 4.0 mmol/liter (moderate and light). Clinical effort is assessed by measurements per day. Results are median (interquartile range). There were 742 measurements over 1088 h of control (16.4 measurements/day), which is similar to clinical SPRINT results (16.2/day). Per-patient hours of control were 65 (50-95) h. Initial per-patient BG was 10.5 (7.9-11.2) mmol/liter. All patients (100%) reached 6.1 mmol/liter. Cohort BG was 6.3 (5.5-7.5) mmol/liter, with 42.2%, 65.1% and 77.6% of BG in the 4.0-6.1, 4.0-7.0, and 4.0-8.0 mmol/liter bands. Per-patient, median percentage time in these bands was 40.2 (26.7-51.5)%, 62.5 (46.0-75.7)%, and 74.7 (61.6.8-87.8)%, respectively. No patients had BG < 2.2 mmol/liter, and the %BG < 4.0 mmol/liter was 1.9%. These results were achieved using 3.0 (3.0-5.0) U/h of insulin with 7.4 (4.4-10.2) g/h of dextrose administration (all sources) for the cohort. Per-patient median insulin administration was 3.0 (3.0-3.0) U/h and 7.1 (3.4-9.6) g/h dextrose. Higher carbohydrate nutrition formulas than were used in SPRINT are offset by slightly higher insulin administration in this study. The glycemic performance shows that using the SPRINT protocol to guide insulin infusions and nutrition administration provided very good glycemic control in initial pilot testing, with no severe hypoglycemia. The overall design of the protocol was able to be generalized with good compliance and outcomes across geographically distinct clinical units, patients, and clinical practice. © 2012 Diabetes Technology Society

Validation of a virtual patient and virtual trials method for accurate prediction of tight glycemic control protocol performance

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Does tight glycemic control positively impact on patient mortality?

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Enhanced insulin sensitivity variability in the first 3 days of ICU stay: implications for tight glycemic control

Effective tight glycemic control (TGC) can improve outcomes, particularly in cardiovascular surgery, but is difficult to achieve. Variability in insulin sensitivity/resistance resulting from the level and evolution of stress response, particularly early in a patient’s stay, can lead to hyperglycemia and variability, which are associated with mortality. This study quantifies the daily evolution of the variability of insulin sensitivity for cardiovascular surgical and all other ICU patients

Endogenous insulin secretion and suppression during and after sepsis in critically ill patients: implications for tight glycemic control protocols

Introduction: Insulin infusions over 2 U/hr can suppress endogenous insulin secretion in healthy subjects 30-45% [1]. Virtually all tight glycaemic control (TGC) protocols deliver insulin via infusion. This study examines the impact of bolus delivery of insulin in TGC on the endogenous insulin secretion of critically ill patients. Methods: 18 patients from the Christchurch Hospital ICU enrolled in a prospective clinical trial studying sepsis each had two sets of blood samples assayed for insulin and C-peptide. The first set was taken at the commencement of the SPRINT TGC protocol for patients with suspected sepsis. The second set was taken when their SIRS score was consistently below 2. Each set had 4 samples taken at: -1, 10, 40 and 60 min following bolus delivery of insulin as required by SPRINT to capture endogenous insulin secretion during the bolus profile. Bolus size was dictated by the protocol, but was in the range 2-6 units. Model-based methods [2] were used to calculate the endogenous insulin secretion rate for each set of samples. The level of suppression was calculated as the ratio of the secretion rate between 5-15 mins (just after peak plasma insulin) and average of the 0-5 min (basal) and 15-60 min (return to basal) secretion rates identified

Physiological modeling, tight glycemic control, and the ICU clinician: what are models and how can they affect practice?

Critically ill patients are highly variable in their response to care and treatment. This variability and the search for improved outcomes have led to a significant increase in the use of protocolized care to reduce variability in care. However, protocolized care does not address the variability of outcome due to inter- and intra-patient variability, both in physiological state, and the response to disease and treatment. This lack of patient-specificity defines the opportunity for patient-specific approaches to diagnosis, care, and patient management, which are complementary to, and fit within, protocolized approaches

Measurement of W+W− production in association with one jet in proton–proton collisions at sqrt(s) = 8TeV with the ATLAS detector

The production of W boson pairs in association with one jet in pp collisions at View the MathML sources=8 TeV is studied using data corresponding to an integrated luminosity of 20.3 fb−1 collected by the ATLAS detector during 2012 at the CERN Large Hadron Collider. The cross section is measured in a fiducial phase-space region defined by the presence of exactly one electron and one muon, missing transverse momentum and exactly one jet with a transverse momentum above 25 GeV and a pseudorapidity of |η|<4.5|η|<4.5. The leptons are required to have opposite electric charge and to pass transverse momentum and pseudorapidity requirements. The fiducial cross section is found to be View the MathML sourceσWWfid,1-jet=136±6(stat)±14(syst)±3(lumi) fb. In combination with a previous measurement restricted to leptonic final states with no associated jets, the fiducial cross section of WW production with zero or one jet is measured to be View the MathML sourceσWWfid,≤1-jet=511±9(stat)±26(syst)±10(lumi) fb. The ratio of fiducial cross sections in final states with one and zero jets is determined to be 0.36±0.050.36±0.05. Finally, a total cross section extrapolated from the fiducial measurement of WW production with zero or one associated jet is reported. The measurements are compared to theoretical predictions and found in good agreement

Enteral nutrition-associated incretin effect in the critically ill

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