Biliary sludge and recurrent ketoacidosis: a case report

A five year old boy, weighing 14 kg with no family history of diabetes, presented in frank diabetic ketoacidosis. He recovered, but continued to have episodes of ketoacidosis. He was diagnosed to have biliary sludge, which recovered with insulin treatment

Modeling of Effect of Glucose Sensor Errors on Insulin Dosage and Glucose Bolus Computed by LOGIC-Insulin

BACKGROUND: Effective and safe glycemic control in critically ill patients requires accurate glucose sensors and adequate insulin dosage calculators. The LOGIC-Insulin calculator for glycemic control has recently been validated in the LOGIC-1 randomized controlled trial. In this study, we aimed to determine the allowable error for intermittent and continuous glucose sensors, on the basis of the LOGIC-Insulin calculator. METHODS: A gaussian simulation model with a varying bias (0%-20%) and CV (-20% to +20%) simulated blood glucose values from the LOGIC-1 study (n = 149 patients) in 10 Monte Carlo steps. A clinical error grid system was developed to compare the simulated LOGIC-Insulin-directed intervention with the nominal intervention (0% bias, 0% CV). The severity of error measuring the clinical effect of the simulated LOGIC-Insulin intervention was graded as type B, C, and D errors. Type D errors were classified as acutely life-threatening (0% probability preferred). RESULTS: The probability of all types of errors was lower for continuous sensors compared with intermittent sensors. The maximum total error (TE), defined as the first TE introducing a type B/C/D error, was similar for both sensor types. To avoid type D errors, TEs <15.7% for intermittent sensors and <17.8% for continuous sensors were required. Mean absolute relative difference thresholds for type C errors were 7.1% for intermittent and 11.0% for continuous sensors. CONCLUSIONS: Continuous sensors had a lower probability for clinical errors than intermittent sensors at the same accuracy level. These simulations demonstrated the suitability of the LOGIC-Insulin control system for use with continuous, as well as intermittent, sensors.status: publishe

Impact of withholding early parenteral nutrition completing enteral nutrition in pediatric critically ill patients (PEPaNIC trial): Study protocol for a randomized controlled trial

Background: The state-of-the-art nutrition used for critically ill children is based essentially on expert opinion and extrapolations from adult studies or on studies in non-critically ill children. In critically ill adults, withholding parenteral nutrition (PN) during the first week in ICU improved outcome, as compared with early supplementation of insufficient enteral nutrition (EN) with PN. We hypothesized that withholding PN in children early during critical illness reduces the incidence of new infections and accelerates recovery. Methods/Design: The Pediatric Early versus Late Parenteral Nutrition in Intensive Care Unit (PEPaNIC) study is an investigator-initiated, international, multicenter, randomized controlled trial (RCT) in three tertiary referral pediatric intensive care units (PICUs) in three countries on two continents. This study compares early versus late initiation of PN when EN fails to reach preset caloric targets in critically ill children. In the early-PN (control, standard of care) group, PN comprising glucose, lipids and amino acids is administered within the first days to reach the caloric target. In the late-PN (intervention) group, PN completing EN is only initiated beyond PICU-day 7, when EN fails. For both study groups, an early EN protocol is applied and micronutrients are administered intravenously. The primary assessor-blinded outcome measures are the incidence of new infections during PICU-stay and the duration of intensive care dependency. The sample size (n = 1,440, 720 per arm) was determined in order to detect a 5% absolute reduction in PICU infections, with at least 80% 1-tailed power (70% 2-tailed) and an alpha error rate of 5%. Based on the actual incidence of new PICU infections in the control group, the required sample size was confirmed at the time of an a priori- planned interim-analysis focusing on the incidence of new infections in the control group only. Discussion: Clinical evidence in favor of early administration of PN in critically ill children is currently lacking, despite potential benefit but also known side effects. This large international RCT will help physicians to gain more insight in the clinical effects of omitting PN during the first week of critical illness in children

Cost-effectiveness study of early versus late parenteral nutrition in critically ill children (PEPaNIC)

__Background:__ The multicentre randomised controlled PEPaNIC trial showed that withholding parenteral nutrition (PN) during the first week of critical illness in children was clinically superior to providing early PN. This study describes the cost-effectiveness of this new nutritional strategy. __Methods:__ Direct medical costs were calculated with use of a micro-costing approach. We compared the costs of late versus early initiation of PN (n = 673 versus n = 670 pa

Waking up the gut in critically ill patients

Multiorgan failure frequently develops in critically ill patients. While therapeutic efforts in such patients are often focused on the lungs, on the cardiovascular system as well as on the kidneys, it is important to also consider the functional alterations in gut motility and hormone secretion. Given the central regulatory functions of many gut hormones, such as glucagon-like peptide 1, glucagon-like peptide 2, ghrelin and others, exogenous supplementation of some of these factors may be beneficial under conditions of critical illness. From a pragmatic point of view, the most feasible way towards a restoration of gut hormone secretion in critically ill patients is to provide enteral nutritional supply as soon as possible

Corticosteroids for severe sepsis: an evidence-based guide for physicians

Septic shock is characterized by uncontrolled systemic inflammation that contributes to the progression of organ failures and eventually death. There is now ample evidence that the inability of the host to mount an appropriate hypothalamic-pituitary and adrenal axis response plays a major in overwhelming systemic inflammation during infections. Proinflammatory mediators released in the inflamed sites oppose to the anti-inflammatory response, an effect that may be reversed by exogenous corticosteroids. With sepsis, via nongenomic and genomic effects, corticosteroids restore cardiovascular homeostasis, terminate systemic and tissue inflammation, restore organ function, and prevent death. These effects of corticosteroids have been consistently found in animal studies and in most recent frequentist and Bayesian meta-analyses. Corticosteroids should be initiated only in patients with sepsis who require 0.5 μg/kg per minute or more of norepinephrine and should be continued for 5 to 7 days except in patients with poor hemodynamic response after 2 days of corticosteroids and with a cortisol increment of more than 250 nmol/L after a standard adrenocorticotropin hormone (ACTH) test. Hydrocortisone should be given at a daily dose of 200 mg and preferably combined to enteral fludrocortisone at a dose of 50 μg. Blood glucose levels should be kept below 150 mg/dL