Prof. Mridul M. Panditrao tries to explain the pros and cons about the good strategy, whcih became controversial and almost obsolete. He also tries to tract the whole aspect of the phenomenon and reviews/ RCTs/
Strict (Tight) Glycemic control (SGC/TGC), as it is called, was and still is a good strategy. It can be defined as maintenance of the blood glucose level in the range of 80-110 mg /dl. with help of dose variable and intensive insulin therapy (IIT). Since its introduction, there have been conflicting reports of its efficacy and complications. This resulted in slow but steady neglect of this very good idea leading to its almost complete demise.
An effort has been made in this review, to impartially analyze all the available evidence and try to find the reasons for the negative publicity which led to the neglect or worse still, the wrong use of this protocol. Some suggestions for fair and proper implementation of the strategy are put forward.
etc/
Intensive glycemic control aimed at maintaining blood glucose between 80-110 mg/dl in adult ICU patients does not reduce mortality and significantly increases the risk of hypoglycemia compared to conventional control between 140-180 mg/dl. Multiple large randomized controlled trials found no benefit to intensive control and post-hoc analyses determined hypoglycemia independently increases mortality. Current guidelines recommend insulin therapy only for blood glucose over 180 mg/dl and targeting 140-180 mg/dl range to minimize hypoglycemia risk while avoiding hyperglycemia's harmful effects.
The document discusses blood sugar control in ICU patients. It presents two case studies of patients in the ICU with high blood sugar levels and questions around controlling their blood sugar. It then reviews literature showing that hyperglycemia is associated with worse outcomes in critically ill patients. A landmark study called the Leuven study showed that intensive insulin therapy to tightly control blood sugar reduced mortality in the ICU by 34%. However, a later large trial called NICE-SUGAR found that intensive control actually increased mortality compared to conventional control and had higher rates of severe hypoglycemia. The discrepancies in studies' findings may be due to differences in patient populations, treatment protocols, glucose goals achieved, and methods used to measure glucose.
This document provides information on managing diabetes in the intensive care unit (ICU). It discusses reasons for deteriorated glucose control during hospital admissions like stress hyperglycemia and corticosteroid therapy. It recommends maintaining blood glucose between 140-180 mg/dL based on studies showing increased mortality risks outside this range. Insulin protocols presented aim to gradually control hyperglycemia through hourly monitoring and titrating intravenous insulin doses based on blood glucose levels and rate of change.
Glycemic control in the Intensive Care UnitsHanna Yudchyts
This document discusses glycemic control in the intensive care unit (ICU) using the Yale insulin drip protocol. It introduces a case study of a patient with diabetes who underwent coronary artery bypass grafting. It then describes the Yale protocol, which uses an insulin drip to maintain blood glucose between 140-180 mg/dL. The benefits of tight glycemic control in the ICU are discussed. The document concludes by describing how the patient's insulin drip was transitioned to a basal-bolus regimen upon discharge from the ICU in accordance with the Yale protocol.
This document provides guidelines for managing hyperglycemia in ICU patients using insulin therapy. It recommends a target blood glucose range of 100-150 mg/dL. The guidelines describe different types of insulin, including rapid, short, intermediate and long-acting varieties. It presents a protocol for intravenous insulin therapy that involves calculating initial bolus and infusion rates based on the patient's starting blood glucose level. The protocol provides guidance on adjusting the infusion rate based on hourly blood glucose monitoring and includes steps to avoid and treat hypoglycemia.
Nice Sugar Study - Glycemic control in the ICUshivabirdi
The NICE-SUGAR study was a large randomized controlled trial that compared intensive glucose control (80-108 mg/dL) to conventional glucose control (≤180 mg/dL) in over 6,000 critically ill patients. The study found that intensive control was associated with a higher mortality rate (27.5% vs 24.9%) and more episodes of severe hypoglycemia. No differences were seen in other outcomes like length of stay. This significant study challenged prior evidence supporting tight glucose control in the ICU and suggests current practice of more moderate control is safest.
Diabetic Ketoacidosis management updateSCGH ED CME
This document describes a new standardized protocol for treating diabetic ketoacidosis (DKA) that was implemented across a hospital in response to inconsistencies in approach. The key elements of the new protocol include standardized diagnosis criteria, identification of high-risk patients requiring intensive care, standardized fluid resuscitation orders, and a fixed-rate insulin dosing regimen along with maintaining a patient's basal insulin. The goal of the protocol is to improve consistency and allow for better assessment of outcomes while minimizing risks of complications like cerebral edema, pulmonary edema, electrolyte imbalances, and hypoglycemia. Two example cases are provided showing how the protocol would be applied.
SGLT-2 inhibitors lower blood glucose levels by reducing renal glucose reabsorption and increasing glucose excretion in the urine. Empagliflozin is a selective SGLT-2 inhibitor that lowers both fasting and post-prandial plasma glucose levels. In clinical trials, empagliflozin led to an HbA1c reduction of over 1% compared to placebo when used as both monotherapy and add-on therapy to other glucose-lowering medications. Empagliflozin was also associated with weight loss, reduced blood pressure, and a lower risk of hypoglycemia compared to sulfonylurea therapy.
Intensive glycemic control aimed at maintaining blood glucose between 80-110 mg/dl in adult ICU patients does not reduce mortality and significantly increases the risk of hypoglycemia compared to conventional control between 140-180 mg/dl. Multiple large randomized controlled trials found no benefit to intensive control and post-hoc analyses determined hypoglycemia independently increases mortality. Current guidelines recommend insulin therapy only for blood glucose over 180 mg/dl and targeting 140-180 mg/dl range to minimize hypoglycemia risk while avoiding hyperglycemia's harmful effects.
The document discusses blood sugar control in ICU patients. It presents two case studies of patients in the ICU with high blood sugar levels and questions around controlling their blood sugar. It then reviews literature showing that hyperglycemia is associated with worse outcomes in critically ill patients. A landmark study called the Leuven study showed that intensive insulin therapy to tightly control blood sugar reduced mortality in the ICU by 34%. However, a later large trial called NICE-SUGAR found that intensive control actually increased mortality compared to conventional control and had higher rates of severe hypoglycemia. The discrepancies in studies' findings may be due to differences in patient populations, treatment protocols, glucose goals achieved, and methods used to measure glucose.
This document provides information on managing diabetes in the intensive care unit (ICU). It discusses reasons for deteriorated glucose control during hospital admissions like stress hyperglycemia and corticosteroid therapy. It recommends maintaining blood glucose between 140-180 mg/dL based on studies showing increased mortality risks outside this range. Insulin protocols presented aim to gradually control hyperglycemia through hourly monitoring and titrating intravenous insulin doses based on blood glucose levels and rate of change.
Glycemic control in the Intensive Care UnitsHanna Yudchyts
This document discusses glycemic control in the intensive care unit (ICU) using the Yale insulin drip protocol. It introduces a case study of a patient with diabetes who underwent coronary artery bypass grafting. It then describes the Yale protocol, which uses an insulin drip to maintain blood glucose between 140-180 mg/dL. The benefits of tight glycemic control in the ICU are discussed. The document concludes by describing how the patient's insulin drip was transitioned to a basal-bolus regimen upon discharge from the ICU in accordance with the Yale protocol.
This document provides guidelines for managing hyperglycemia in ICU patients using insulin therapy. It recommends a target blood glucose range of 100-150 mg/dL. The guidelines describe different types of insulin, including rapid, short, intermediate and long-acting varieties. It presents a protocol for intravenous insulin therapy that involves calculating initial bolus and infusion rates based on the patient's starting blood glucose level. The protocol provides guidance on adjusting the infusion rate based on hourly blood glucose monitoring and includes steps to avoid and treat hypoglycemia.
Nice Sugar Study - Glycemic control in the ICUshivabirdi
The NICE-SUGAR study was a large randomized controlled trial that compared intensive glucose control (80-108 mg/dL) to conventional glucose control (≤180 mg/dL) in over 6,000 critically ill patients. The study found that intensive control was associated with a higher mortality rate (27.5% vs 24.9%) and more episodes of severe hypoglycemia. No differences were seen in other outcomes like length of stay. This significant study challenged prior evidence supporting tight glucose control in the ICU and suggests current practice of more moderate control is safest.
Diabetic Ketoacidosis management updateSCGH ED CME
This document describes a new standardized protocol for treating diabetic ketoacidosis (DKA) that was implemented across a hospital in response to inconsistencies in approach. The key elements of the new protocol include standardized diagnosis criteria, identification of high-risk patients requiring intensive care, standardized fluid resuscitation orders, and a fixed-rate insulin dosing regimen along with maintaining a patient's basal insulin. The goal of the protocol is to improve consistency and allow for better assessment of outcomes while minimizing risks of complications like cerebral edema, pulmonary edema, electrolyte imbalances, and hypoglycemia. Two example cases are provided showing how the protocol would be applied.
SGLT-2 inhibitors lower blood glucose levels by reducing renal glucose reabsorption and increasing glucose excretion in the urine. Empagliflozin is a selective SGLT-2 inhibitor that lowers both fasting and post-prandial plasma glucose levels. In clinical trials, empagliflozin led to an HbA1c reduction of over 1% compared to placebo when used as both monotherapy and add-on therapy to other glucose-lowering medications. Empagliflozin was also associated with weight loss, reduced blood pressure, and a lower risk of hypoglycemia compared to sulfonylurea therapy.
- Correction insulin is preferable to sliding scale insulin for managing inpatient hyperglycemia as it treats current high blood sugars and prevents future highs through the use of basal, nutritional, and correctional insulin components.
- The case study patient should be started on correctional insulin therapy which includes initiation of basal insulin, nutritional insulin with meals, and additional correctional insulin for blood sugars over target.
- When initiating or adjusting insulin therapy in the hospital, consideration should be given to the patient's diabetes type and weight to determine the total daily insulin dose and regimen. Frequent monitoring and adjustments are important to achieve good glycemic control.
The document discusses different types of insulin available to manage diabetes, including rapid-acting, short-acting, intermediate-acting, long-acting, and premixed insulins. It reviews insulin protocols and addresses patient selection for different regimens. The document also discusses designing and adjusting insulin regimens, including using a basal-bolus approach to better mimic normal physiology.
managing diabetes in critically ill hospitalized patientssumitverma88
This document discusses the management of diabetes in critically ill hospitalized patients. It covers stress hyperglycemia, causes of stress-induced hyperglycemia, proposed mechanisms, effects of prolonged hyperglycemia, past approaches, results of intensive insulin therapy trials, inpatient glucose metrics, intravenous insulin protocols, hypoglycemia management, transitioning to outpatient care, and management of diabetic ketoacidosis, hyperglycemic hyperosmolar state, lactic acidosis, and perioperative care.
This document discusses diabetic emergencies, specifically diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). It covers the pathophysiology, clinical presentation, diagnosis, treatment priorities of volume repletion, potassium replacement, and insulin administration, as well as complications, disposition, and pitfalls in management. The goal of treatment is to correct dehydration, electrolyte imbalances, and acidosis while gradually lowering blood glucose levels.
SGLT-2 inhibitors have shown promising cardiovascular and renal benefits:
1) Trials have found SGLT-2 inhibitors reduce the risk of cardiovascular death in patients with type 2 diabetes and established cardiovascular disease, as well as reducing heart failure hospitalizations in those with diabetes and cardiovascular risk factors.
2) Studies also show SGLT-2 inhibitors improve outcomes for patients with heart failure with reduced ejection fraction, reducing rates of heart failure hospitalization and mortality regardless of diabetes status or background heart failure therapies.
3) SGLT-2 inhibitors were also found to reduce the risk of renal death or progression to end-stage kidney disease in patients with type 2 diabetes and macroalbuminuria.
The document discusses the cardiorenal syndrome, which is when worsening heart failure leads to worsening kidney function or vice versa, outlining the prevalence, causes, and treatment challenges of the condition; it also provides an overview of invasive hemodynamic monitoring techniques that can help evaluate patients with cardiorenal syndrome.
This document discusses the use of SGLT2 inhibitors (SGLT2i) in managing diabetes. It presents three case studies of patients with diabetes and cardiovascular complications who may benefit from SGLT2i treatment. It summarizes clinical trial data showing that empagliflozin lowers HbA1c, fasting plasma glucose, body weight, and blood pressure compared to other antidiabetic drugs. Empagliflozin also reduces visceral and subcutaneous fat. The document concludes that SGLT2i like empagliflozin provide glycemic control and cardiovascular benefits and can be considered as an addition to metformin for treating diabetes.
This case report describes a 25-year-old man with a history of type 2 diabetes who presented with diabetic ketoacidosis (DKA). He reported symptoms of nausea, vomiting, polyuria, polydipsia and weight loss. Laboratory results showed metabolic acidosis, hyperglycemia and ketones consistent with DKA. While being treated for DKA, he developed worsening back pain and new neurological symptoms. Imaging revealed an epidural abscess, which was surgically treated. He required intensive rehabilitation for residual lower extremity weakness following treatment and resolution of the abscess.
The document summarizes findings from the ACCORD clinical trial which compared an intensive glucose lowering strategy targeting an A1C less than 6.0% to a standard strategy targeting an A1C of 7.0-7.9% in adults with type 2 diabetes at high risk for cardiovascular disease. The intensive strategy resulted in lower A1C levels but also increased mortality, did not reduce the risk of major cardiovascular events, and was associated with more hypoglycemia, weight gain, and other side effects. Certain subgroups such as those with an A1C under 8% at baseline or receiving primary prevention may have experienced reduced cardiovascular risk with intensive control.
Fluid responsiveness in critically ill patientsUbaidur Rahaman
This document discusses fluid responsiveness in critically ill patients. It begins by defining fluid responsiveness as an increase in cardiac index after fluid infusion. It then describes three scenarios involving fluid resuscitation: patients with acute blood or fluid loss requiring immediate resuscitation, patients with suspected septic shock where early goal-directed therapy with fluids is important, and ICU patients who have already received fluids and their fluid responsiveness needs to be assessed. The document discusses various methods of assessing preload and preload dependence, including filling pressures, volumes, respiratory variations in inferior vena cava diameter, inspiratory drops in right atrial pressure, and predicting responsiveness through respiratory variations in parameters related to cardiac index. It emphasizes that preload alone
Insulin therapy: art of initiation and titration Saikumar Dunga
The document outlines guidelines for initiating and titrating insulin therapy for type 2 diabetes. It recommends starting with either bedtime intermediate-acting or morning/bedtime long-acting insulin, and titrating the dose to reach fasting glucose targets. If HbA1c remains above 7% after 2-3 months, additional injections of rapid-acting insulin should be added at mealtimes based on pre-meal glucose levels. Further intensification, such as checking postprandial levels and adjusting prandial insulin, is recommended if HbA1c is still not at target. The guidelines provide a step-by-step approach to optimizing insulin regimens based on glucose monitoring.
Practical guide to insulin therapy in primary health care.
Types of insulin (basal-bolus, pre-mixed)
Insulin regimens (augmentation, total replacement)
How to convert from one insulin type to another.
Some challenging cases.
This document discusses glucose-lowering therapies and the clinical place of SGLT2 inhibitor agents. It presents the case of a 52-year-old male patient with type 2 diabetes, hypertension, and coronary artery disease. It analyzes adding empagliflozin or sitagliptin to the patient's current metformin regimen and reviews long-term trial data showing empagliflozin's superior effects on HbA1c reduction, weight loss, and hypoglycemia risk reduction compared to glimepiride. The document also discusses empagliflozin's benefits on blood pressure and potential cardioprotective mechanisms of action beyond glycemic control such as reducing cardiac fibrosis. It emphasizes the importance of individual
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
This document discusses various types of basal insulin, including their history, mechanisms of action, and clinical benefits. It describes early insulins derived from animals that had issues with impurity and antigenicity. It then covers human insulins like NPH insulin and the development of insulin glargine and insulin detemir as basal insulins that more closely mimic the body's natural basal insulin secretion. Insulin degludec is also introduced as a new basal insulin with an ultra-long duration of action of up to 42 hours and flexible dosing intervals. Clinical trials demonstrate the efficacy of basal insulins like glargine, detemir, and degludec in improving glycemic control and reducing
This document provides guidance on evaluating and managing anemia in patients. It discusses evaluating the cause of anemia based on history, physical exam, and lab tests. Causes in critically ill patients especially include blood loss from phlebotomy and bleeding, decreased erythropoiesis from inflammation, and nutritional deficiencies. Transfusions are used to manage anemia but have risks, so restrictive protocols targeting Hgb <7g/dL are recommended except for patients with cardiovascular conditions. New blood substitutes are still experimental and have shown adverse effects.
This document provides an overview of canagliflozin, an SGLT2 inhibitor used to treat type 2 diabetes. It discusses the pathogenesis of type 2 diabetes, progressive beta cell dysfunction, and the kidney's role in glucose regulation. It then reviews canagliflozin's mechanism of action as an SGLT2 inhibitor, increasing urinary glucose excretion and reducing blood glucose levels. The document summarizes canagliflozin's clinical trials, pharmacokinetics, efficacy, safety profile, and effects on renal function and lipids.
The document discusses hyperglycemia in critically ill patients in the ICU. It reviews the causes and effects of hyperglycemia as well as studies showing improved outcomes with intensive insulin therapy to maintain blood glucose between 110-150 mg/dL. Tight glucose control is beneficial but requires continuous monitoring and administration of dextrose to prevent hypoglycemia.
Diabetic ketoacidosis is a severe insulin deficiency that causes the body to break down fat instead of glucose for energy, putting patients at risk for complications without insulin replacement. The document outlines guidelines for monitoring and treating patients with diabetic ketoacidosis via insulin drips, including defining diagnostic criteria, assigning patients to units based on stability, and delineating responsibilities of physicians, nurses, and other staff in titrating insulin drips and monitoring patients' blood glucose and response to treatment.
- Correction insulin is preferable to sliding scale insulin for managing inpatient hyperglycemia as it treats current high blood sugars and prevents future highs through the use of basal, nutritional, and correctional insulin components.
- The case study patient should be started on correctional insulin therapy which includes initiation of basal insulin, nutritional insulin with meals, and additional correctional insulin for blood sugars over target.
- When initiating or adjusting insulin therapy in the hospital, consideration should be given to the patient's diabetes type and weight to determine the total daily insulin dose and regimen. Frequent monitoring and adjustments are important to achieve good glycemic control.
The document discusses different types of insulin available to manage diabetes, including rapid-acting, short-acting, intermediate-acting, long-acting, and premixed insulins. It reviews insulin protocols and addresses patient selection for different regimens. The document also discusses designing and adjusting insulin regimens, including using a basal-bolus approach to better mimic normal physiology.
managing diabetes in critically ill hospitalized patientssumitverma88
This document discusses the management of diabetes in critically ill hospitalized patients. It covers stress hyperglycemia, causes of stress-induced hyperglycemia, proposed mechanisms, effects of prolonged hyperglycemia, past approaches, results of intensive insulin therapy trials, inpatient glucose metrics, intravenous insulin protocols, hypoglycemia management, transitioning to outpatient care, and management of diabetic ketoacidosis, hyperglycemic hyperosmolar state, lactic acidosis, and perioperative care.
This document discusses diabetic emergencies, specifically diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). It covers the pathophysiology, clinical presentation, diagnosis, treatment priorities of volume repletion, potassium replacement, and insulin administration, as well as complications, disposition, and pitfalls in management. The goal of treatment is to correct dehydration, electrolyte imbalances, and acidosis while gradually lowering blood glucose levels.
SGLT-2 inhibitors have shown promising cardiovascular and renal benefits:
1) Trials have found SGLT-2 inhibitors reduce the risk of cardiovascular death in patients with type 2 diabetes and established cardiovascular disease, as well as reducing heart failure hospitalizations in those with diabetes and cardiovascular risk factors.
2) Studies also show SGLT-2 inhibitors improve outcomes for patients with heart failure with reduced ejection fraction, reducing rates of heart failure hospitalization and mortality regardless of diabetes status or background heart failure therapies.
3) SGLT-2 inhibitors were also found to reduce the risk of renal death or progression to end-stage kidney disease in patients with type 2 diabetes and macroalbuminuria.
The document discusses the cardiorenal syndrome, which is when worsening heart failure leads to worsening kidney function or vice versa, outlining the prevalence, causes, and treatment challenges of the condition; it also provides an overview of invasive hemodynamic monitoring techniques that can help evaluate patients with cardiorenal syndrome.
This document discusses the use of SGLT2 inhibitors (SGLT2i) in managing diabetes. It presents three case studies of patients with diabetes and cardiovascular complications who may benefit from SGLT2i treatment. It summarizes clinical trial data showing that empagliflozin lowers HbA1c, fasting plasma glucose, body weight, and blood pressure compared to other antidiabetic drugs. Empagliflozin also reduces visceral and subcutaneous fat. The document concludes that SGLT2i like empagliflozin provide glycemic control and cardiovascular benefits and can be considered as an addition to metformin for treating diabetes.
This case report describes a 25-year-old man with a history of type 2 diabetes who presented with diabetic ketoacidosis (DKA). He reported symptoms of nausea, vomiting, polyuria, polydipsia and weight loss. Laboratory results showed metabolic acidosis, hyperglycemia and ketones consistent with DKA. While being treated for DKA, he developed worsening back pain and new neurological symptoms. Imaging revealed an epidural abscess, which was surgically treated. He required intensive rehabilitation for residual lower extremity weakness following treatment and resolution of the abscess.
The document summarizes findings from the ACCORD clinical trial which compared an intensive glucose lowering strategy targeting an A1C less than 6.0% to a standard strategy targeting an A1C of 7.0-7.9% in adults with type 2 diabetes at high risk for cardiovascular disease. The intensive strategy resulted in lower A1C levels but also increased mortality, did not reduce the risk of major cardiovascular events, and was associated with more hypoglycemia, weight gain, and other side effects. Certain subgroups such as those with an A1C under 8% at baseline or receiving primary prevention may have experienced reduced cardiovascular risk with intensive control.
Fluid responsiveness in critically ill patientsUbaidur Rahaman
This document discusses fluid responsiveness in critically ill patients. It begins by defining fluid responsiveness as an increase in cardiac index after fluid infusion. It then describes three scenarios involving fluid resuscitation: patients with acute blood or fluid loss requiring immediate resuscitation, patients with suspected septic shock where early goal-directed therapy with fluids is important, and ICU patients who have already received fluids and their fluid responsiveness needs to be assessed. The document discusses various methods of assessing preload and preload dependence, including filling pressures, volumes, respiratory variations in inferior vena cava diameter, inspiratory drops in right atrial pressure, and predicting responsiveness through respiratory variations in parameters related to cardiac index. It emphasizes that preload alone
Insulin therapy: art of initiation and titration Saikumar Dunga
The document outlines guidelines for initiating and titrating insulin therapy for type 2 diabetes. It recommends starting with either bedtime intermediate-acting or morning/bedtime long-acting insulin, and titrating the dose to reach fasting glucose targets. If HbA1c remains above 7% after 2-3 months, additional injections of rapid-acting insulin should be added at mealtimes based on pre-meal glucose levels. Further intensification, such as checking postprandial levels and adjusting prandial insulin, is recommended if HbA1c is still not at target. The guidelines provide a step-by-step approach to optimizing insulin regimens based on glucose monitoring.
Practical guide to insulin therapy in primary health care.
Types of insulin (basal-bolus, pre-mixed)
Insulin regimens (augmentation, total replacement)
How to convert from one insulin type to another.
Some challenging cases.
This document discusses glucose-lowering therapies and the clinical place of SGLT2 inhibitor agents. It presents the case of a 52-year-old male patient with type 2 diabetes, hypertension, and coronary artery disease. It analyzes adding empagliflozin or sitagliptin to the patient's current metformin regimen and reviews long-term trial data showing empagliflozin's superior effects on HbA1c reduction, weight loss, and hypoglycemia risk reduction compared to glimepiride. The document also discusses empagliflozin's benefits on blood pressure and potential cardioprotective mechanisms of action beyond glycemic control such as reducing cardiac fibrosis. It emphasizes the importance of individual
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
This document discusses various types of basal insulin, including their history, mechanisms of action, and clinical benefits. It describes early insulins derived from animals that had issues with impurity and antigenicity. It then covers human insulins like NPH insulin and the development of insulin glargine and insulin detemir as basal insulins that more closely mimic the body's natural basal insulin secretion. Insulin degludec is also introduced as a new basal insulin with an ultra-long duration of action of up to 42 hours and flexible dosing intervals. Clinical trials demonstrate the efficacy of basal insulins like glargine, detemir, and degludec in improving glycemic control and reducing
This document provides guidance on evaluating and managing anemia in patients. It discusses evaluating the cause of anemia based on history, physical exam, and lab tests. Causes in critically ill patients especially include blood loss from phlebotomy and bleeding, decreased erythropoiesis from inflammation, and nutritional deficiencies. Transfusions are used to manage anemia but have risks, so restrictive protocols targeting Hgb <7g/dL are recommended except for patients with cardiovascular conditions. New blood substitutes are still experimental and have shown adverse effects.
This document provides an overview of canagliflozin, an SGLT2 inhibitor used to treat type 2 diabetes. It discusses the pathogenesis of type 2 diabetes, progressive beta cell dysfunction, and the kidney's role in glucose regulation. It then reviews canagliflozin's mechanism of action as an SGLT2 inhibitor, increasing urinary glucose excretion and reducing blood glucose levels. The document summarizes canagliflozin's clinical trials, pharmacokinetics, efficacy, safety profile, and effects on renal function and lipids.
The document discusses hyperglycemia in critically ill patients in the ICU. It reviews the causes and effects of hyperglycemia as well as studies showing improved outcomes with intensive insulin therapy to maintain blood glucose between 110-150 mg/dL. Tight glucose control is beneficial but requires continuous monitoring and administration of dextrose to prevent hypoglycemia.
Diabetic ketoacidosis is a severe insulin deficiency that causes the body to break down fat instead of glucose for energy, putting patients at risk for complications without insulin replacement. The document outlines guidelines for monitoring and treating patients with diabetic ketoacidosis via insulin drips, including defining diagnostic criteria, assigning patients to units based on stability, and delineating responsibilities of physicians, nurses, and other staff in titrating insulin drips and monitoring patients' blood glucose and response to treatment.
A thorough look at the pitfalls of Evidence Based Medicine to bear in mind when you read a journal publication - though respect to medical researchers for their efforts to find "the truth" systamatically
NeuroCare is an outpatient neurology clinic, which provides comprehensive care to diagnose , treat and
Prevent diseases of nervous system.
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Testing includes EMG / NCS , EEG, sleep studies, video EEG monitoring, visual evoked potentials, auditory evoked potentials, Lumbar puncture.
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Physical Therapy.
This study investigated the effects of intensive glucose control versus conventional glucose control in critically ill patients admitted to the ICU. Over 6000 patients were randomly assigned to either a tight glucose control target of 81-108 mg/dL or a more conventional target of 180 mg/dL or less. The primary outcome was all-cause mortality within 90 days. Results showed that intensive glucose control was associated with a higher mortality rate compared to conventional control, with 27.5% of patients in the intensive group dying compared to 24.9% in the conventional group. Intensive control also significantly increased the risk of severe hypoglycemia.
ueda2013 management of hyperglycaemia-d.mohamedueda2015
This document provides guidelines for managing hyperglycemia in hospitalized patients who are not in critical care settings. It recommends monitoring blood glucose levels in all patients without known diabetes history and treating hyperglycemia over 140 mg/dL. The target blood glucose range for most non-critical patients is below 140 mg/dL before meals and below 180 mg/dL randomly. It promotes use of basal-bolus insulin regimens over sliding scales to maintain control and discusses transitions of care between hospital and home.
This document discusses ways to prevent high cholesterol through lifestyle changes like maintaining a healthy weight, quitting smoking, eating a healthy diet, and exercising regularly. It identifies risk factors for high cholesterol like smoking, obesity, poor diet, lack of exercise, high blood pressure, diabetes, and family history of heart disease. It also explains how cholesterol levels are calculated and the different types of cholesterol (HDL, LDL, triglycerides), and recommends treatment options like dietary changes or medication.
Cholesterol is a waxy substance found in every cell of the body that is involved in making chemicals, membranes, and vitamins. It is produced in the liver but also consumed through diet. The amount of cholesterol in the body depends on factors like liver production, clearance from the body, intake of saturated fat, and ingested cholesterol. Too much cholesterol circulates in the bloodstream, where it can clog arteries and increase the risk of heart disease and stroke. There are two main types of cholesterol - LDL (bad) and HDL (good). High levels of LDL cholesterol increase risks, while HDL helps remove LDL from arteries and decrease risks.
Michael Landon, Luciano Pavarotti, Patrick Swayze, and Joan Crawford all died of pancreatic cancer. Pancreatic cancer has a very poor prognosis, with most patients dying within a year of diagnosis. Risk factors include smoking, obesity, family history, and certain genetic conditions. Treatment options depend on how advanced the cancer is and may include surgery, chemotherapy, radiation, and targeted therapies. However, pancreatic cancer remains very difficult to treat due to late diagnosis and lack of effective therapies.
From famous actors like Patrick Swayze to America's first woman in space, Sally Ride, the survival rates for pancreatic cancer summarizes grim tales. To date, the overall 5-year-survival rate is 6.7%. Here, I present some of the latest information in the field.
This document shows a chart comparing the 5-year relative survival rates for the top 5 causes of cancer deaths: lung at 18%, colon at 65%, breast at 90%, pancreas at 6%, and prostate at 100%. It also includes a diagram labeling the head, body, and tail of the pancreas as well as treatments for cancer including radiation and chemotherapy.
Cholesterol is a lipid that plays several important roles in the body. It is synthesized primarily in the liver from acetyl-CoA and can also be obtained through diet. Cholesterol synthesis is a multi-step process regulated by the enzyme HMG-CoA reductase. High levels of cholesterol in the bloodstream, especially LDL cholesterol, increase the risk of cardiovascular disease. The body maintains cholesterol homeostasis through mechanisms like reverse cholesterol transport that move cholesterol from tissues back to the liver.
The document discusses cholesterol metabolism and ways to lower cholesterol levels. It covers sources of cholesterol from diet and de novo synthesis, roles of cholesterol in the body, and regulation of cholesterol synthesis through HMG CoA reductase and SREBP-2. Methods discussed for lowering cholesterol include statins which decrease HMG CoA reductase activity, bile sequestering agents which bind bile acids preventing reabsorption, and use of oat bran and niacin.
This document provides information about cholesterol, including:
- Cholesterol is produced by the liver and obtained through food, and high levels can lead to plaque buildup in arteries and heart disease.
- A fasting blood test measures total cholesterol, LDL ("bad"), HDL ("good"), and triglycerides. High LDL and triglycerides or low HDL increases heart disease risk.
- Risk factors for high cholesterol include family history, diet high in saturated/trans fats, obesity, and lack of exercise. Treatment involves lifestyle changes like a low-fat diet, weight loss, exercise, and medications if needed.
The document discusses the perioperative management of diabetes mellitus. It provides criteria for diagnosing diabetes, discusses how surgery and diabetes affect metabolism, and outlines recommendations for preoperative evaluation and glycemic control in the perioperative period. The goals are to maintain good glycemic control, prevent complications, and shift patients back to their usual diabetes medications and diet as quickly as possible after surgery.
Hyperglycemia, or high blood sugar, occurs when the body has too little insulin or cannot use insulin properly to regulate blood glucose levels. Insulin moves glucose from the blood into cells where it is used for energy. Without enough insulin, glucose builds up in the blood. Hyperglycemia can be caused by diabetes, certain medications, critical illness, gestational diabetes, or other factors. High blood glucose levels over time can damage organs and blood vessels. Symptoms of hyperglycemia include increased thirst, frequent urination, blurred vision, and fatigue. Risks include dehydration, blood clots, pancreatitis, and long-term organ damage.
Pancreatic cancer is difficult to diagnose and treat. It often presents at advanced stages with vague symptoms like abdominal pain, weight loss, or jaundice. Risk factors include smoking, family history, certain genetic conditions, older age, obesity, and diabetes. Diagnosis involves imaging tests and biopsy. Treatment depends on stage but may include surgery, chemotherapy, radiation, or palliative care. Outcomes remain poor with low survival rates, making prevention through lifestyle changes important. Continued research seeks better screening methods and more effective therapies.
Lipoproteins- structure, classification, metabolism and clinical significanceNamrata Chhabra
Lipoproteins transport lipids between cells and tissues. They consist of a nonpolar lipid core surrounded by a surface layer of phospholipids and proteins. Lipoproteins are classified based on density into chylomicrons, VLDL, IDL, LDL, and HDL. Chylomicrons transport dietary lipids from the intestine. The liver secretes VLDL, which circulates and is converted to IDL and LDL through lipolysis. HDL transports cholesterol from tissues to the liver. Apolipoproteins associated with each lipoprotein determine its function and metabolism.
This document discusses the different types of diabetes, their causes and symptoms. It covers Type 1 diabetes which occurs when the pancreas does not produce enough insulin, and Type 2 diabetes which happens when the pancreas does not make enough insulin or cells become insulin resistant. Symptoms of high and low blood sugar are explained. Treatment recommendations are provided for hypoglycemia and hyperglycemia. Normal blood sugar ranges are listed for different age groups. Lifestyle factors like diet, exercise and medication adherence are noted as important for diabetes management.
Objectives for the call:
Provide an overview of why glucose control is important in surgical patient outcomes
.Demonstrate an understanding of how anesthetics and surgery can impact the body's ability to remain within glycemic boundaries
.Outline the optimal surgical patient glycemic goal range
.To identify the effectiveness of tight glycemic control on mortality and morbidity of adult patients during the intra and post-operative period
.To discuss possible change ideas to implement glucose control
WATCH: http://goo.gl/3vGq2B
Effect of hydrocortisone on development of shock amongDr fakhir Raza
effects of hydrocortisone on development of shock among patients with severe sepsis the HYPRESS Randomized Clinical Trial American Medical Association caring for the critically ill patients Surviving sepsis campaign, to determine weather hydrocortisone therapy in patients with severe sepsis prevents the development of septic shock
The document discusses the importance of glycemic control for hospitalized patients with diabetes or hyperglycemia. It notes that hyperglycemia is common in hospitalized patients and associated with worse outcomes. The document reviews evidence that intensive insulin therapy to maintain tight glycemic control can reduce mortality, infection rates, and length of stay in intensive care units and improve outcomes for patients with acute myocardial infarction. It discusses guidelines developed for recommended glycemic targets in hospitals.
The DCCT trial showed that intensive diabetes management reduced the risk of eye, kidney, and nerve complications compared to standard management. Intensive therapy aimed for blood glucose levels between 70-120 mg/dl, while standard therapy aimed to avoid symptoms of high or low blood glucose. The risks of intensive therapy were increased hypoglycemia and weight gain. The follow up EDIC study found metabolic memory effects, with long term benefits of early intensive control.
Intensive glucose control in critically ill patients offers no benefit and increases risk of harm. A meta-analysis of 27 randomized trials involving over 17,000 critically ill adults found that intensive glucose control, aimed at tightly regulating blood glucose levels between 80-110 mg/dL, provided no reduction in mortality or other clinical benefits compared to conventional control between 140-180 mg/dL. However, intensive control was associated with a 8.3% higher risk of severe hypoglycemia. Current guidelines recommend conventional glucose control for critically ill patients experiencing persistent hyperglycemia based on the lack of benefit and risk of harm from intensive control.
Clinical Improvement Proceeds Glycemic Homeostasis After Duodenal-jejunal Byp...George S. Ferzli
This document discusses the effects of duodenal-jejunal bypass surgery on non-obese patients with type 2 diabetes. It summarizes that clinical improvement in diabetes indicators like blood glucose and HbA1c levels precedes significant weight loss after the surgery. The surgery is believed to directly impact diabetes through hormonal changes and rearrangement of gastrointestinal anatomy, rather than just indirectly through weight loss. Specifically, bypassing the duodenum and proximal jejunum has been shown to control type 2 diabetes in non-obese animal models by altering gut hormone secretion like GLP-1.
The document discusses management of hyperglycemia in the ICU setting. It provides an overview of glycemic control in critically ill patients, noting that some trials have shown improved outcomes with intensive control while others found increased mortality. It discusses strategies for successful implementation of tight glycemic control programs, including designating champions, developing protocols and order sets, providing education, and tracking metrics. Key aspects of intravenous insulin therapy and protocols are outlined, along with emphasizing the importance of preventing hypoglycemia.
Renal disease in diabetes from prediabetes to late vasculopathy complication...nephro mih
This document provides information about Prof Basset El Essawy's qualifications and a lecture on renal disease in diabetes. It discusses epidemiological data on diabetic kidney disease prevalence in the US, summarizes findings from large diabetes treatment trials, and defines insulin resistance and prediabetes. It also covers prediabetes and nephropathy, presents case studies, and examines insulin resistance and vascular calcification.
The NICE-SUGAR trial was a large multicenter randomized controlled trial that compared intensive glycemic control (81-108 mg/dL) to conventional glycemic control (≤180 mg/dL) in over 6,000 critically ill patients. It found that intensive control increased 90-day mortality compared to conventional control, demonstrating that a target of <180 mg/dL resulted in lower mortality than 81-108 mg/dL. Limitations included the inability to blind treating teams and premature discontinuation of some patients from the study.
ueda2012 ada diabetes hospital management-d.diaaueda2015
1) In-hospital management of diabetes and hyperglycemia is important to improve patient outcomes.
2) Target blood glucose levels for non-ICU patients is below 140 mg/dL pre-meal and below 180 mg/dL randomly, while the target range for ICU patients is 140-180 mg/dL.
3) Insulin therapy is the preferred treatment for achieving glycemic control in the hospital due to its effectiveness and safety compared to oral antihyperglycemic agents.
Surgery for Obesity Duodeno-Jejunal Bypass forType 2 Diabetes in Non-Obese - ...George S. Ferzli
This document summarizes research on the effects of bariatric surgery procedures like gastric bypass and duodenal switch on type 2 diabetes. It finds that these procedures often dramatically improve blood sugar control and can even cure diabetes in many patients. This is believed to be due both to weight loss effects and hormonal changes from rerouting digestion, which increase levels of gut hormones like GLP-1 that stimulate insulin secretion and improve insulin sensitivity. The document reviews long-term studies finding high rates of diabetes remission following various bariatric procedures.
Diabetes is a rapidly and serious health problem in Pakistan. This chronic condition is associated with serious long-term complications, including higher risk of heart disease and stroke. Aggressive treatment of hypertension and hyperlipideamia can result in a substantial reduction in cardiovascular events in patients with diabetes 1. Consequently pharmacist-led diabetes cardiovascular risk (DCVR) clinics have been established in both primary and secondary care sites in NHS Lothian during the past five years. An audit of the pharmaceutical care delivery at the clinics was conducted in order to evaluate practice and to standardize the pharmacists’ documentation of outcomes. Pharmaceutical care issues (PCI) and patient details were collected both prospectively and retrospectively from three DCVR clinics. The PCI`s were categorized according to a triangularised system consisting of multiple categories. These were ‘checks’, ‘changes’ (‘change in drug therapy process’ and ‘change in drug therapy’), ‘drug therapy problems’ and ‘quality assurance descriptors’ (‘timer perspective’ and ‘degree of change’). A verified medication assessment tool (MAT) for patients with chronic cardiovascular disease was applied to the patients from one of the clinics. The tool was used to quantify PCI`s and pharmacist actions that were centered on implementing or enforcing clinical guideline standards. A database was developed to be used as an assessment tool and to standardize the documentation of achievement of outcomes. Feedback on the audit of the pharmaceutical care delivery and the database was received from the DCVR clinic pharmacist at a focus group meeting.
The document discusses various interventions to improve quality of care for patients with diabetes. It describes goals for metabolic control to reduce complications, benchmarking and recognition programs, and the economic impacts of improved diabetes management. It also discusses a model for promoting intensive insulin therapy at the primary care level using basal-bolus insulin regimens along with patient education.
Running head MANAGEMENT OF DIABETES IN ELDERLY HISPANIC AMERICA.docxcowinhelen
Running head: MANAGEMENT OF DIABETES IN ELDERLY HISPANIC AMERICA
MANAGEMENT OF DIABETIS IN ELDERLY HISPANIC AMERICA
8
Nidhi Sharma
NRS433VN
Linnette Nolte
03/12/2017
Abstract
The study was conducted to analyze the management of diabetes within the Hispanic America ethnic group. The research was carried out in the different hospitals in the United States to determine the best management practices for the elderly Hispanic America suffering from diabetes. The research used interviews with the patients and the nurses who offer the services to the patients. The research focused on the population of 65years and above Hispanic America. The result indicates that the patients with good care from the family respond to treatment as the proper management results in glycemic control. The research also got that most of the diabetes has a biological origin.
Management of diabetes in Hispanic America
P)-Population: Adults aged 65 years and above from the ethnic group of Hispanic origin who are the leading majority with the diabetes cases across the country. The other adults aged over 65 years and above but not Hispanic America are excluded from the exercise.
I)-Intervention: The research analysis the best management of Type 2 diabetes which is the most dominant type of the Hispanic America. The research compares the effectiveness of the Bariatric surgery in patients with body mass index, the healthy eating habit, and weight control measures. The best approach will be taught in every hospital holding the patients with diabetes in every two weeks seminar.
C)-Comparison: The procedure will take approximately three months then the result will be compared in line the previous mortality related cases. The progress in the health status of the patients will be matched with prior data before the process started.
O)-Outcome: The healthy eating habit and the weight management proved better in improving the conditions required to sustain the patients. The patients with the caretakers who help them in Glycemic control management improves even faster compared to patients without helpers.
T) – Time: The procedure will be analyzed monthly after every two weeks collection of data in the different hospitals.
Articles
Foundation, C. H. (2003). Guidelines for improving the care of the older person with diabetes mellitus. Journal of the American Geriatrics Society, , 51(5s), 265-280.
The article was written with the efforts of the California Health Foundation in collaboration with America Geriatrics Society concerned with improving the health of the elderly with diabetes on February 25, 2003. The T2D is highly increasing among the Hispanic America who is and 65 years and above. The estimates indicate that the total of approximately 20% adult aged 65 years and above are suffering from the T2D. The research is, therefore, provides the critical analysis of the guidelines required to improve the care of the elder people with T2D by giving a series of recommendatio ...
The NICE-SUGAR trial found that intensive glycemic control (target blood sugar 81-108 mg/dL) using intravenous insulin increased mortality compared to conventional glycemic control (target blood sugar ≤180 mg/dL) in critically ill ICU patients. The trial randomized over 6,000 patients across 42 centers to either intensive or conventional control groups. The primary outcome of 90-day mortality was higher in the intensive group. Therefore, the study concluded that a target blood sugar of less than 180 mg/dL resulted in lower mortality than a more intensive target of 81-108 mg/dL for critically ill ICU patients.
This document discusses challenges in applying clinical trial results for chronic kidney disease (CKD) to elderly patients. It notes that CKD is defined based on kidney structure/function abnormalities for over 3 months, assessed via estimated glomerular filtration rate and albuminuria levels. Frailty is common in CKD patients over 60 and associated with higher mortality and dialysis need. CKD is also linked to impaired cognition and physical function in older adults. However, clinical trials often exclude elderly patients, so guidance is largely based on younger populations. The document calls for more research accounting for frailty, function, and including more representative elderly patients.
SIN SARGATA (ISS), PIED DIABÉTIQUE, GOOD, 17 A.pdfSargata SIN
The study retrospectively analyzed 180 cases of diabetic foot treated at a Cambodian hospital between 2011-2015. Most patients were older farmers over 60 years old. The majority (70%) underwent debridement, while amputation was required for 31%. High blood pressure was present in 46% of patients and end-stage renal failure in 6.1%. The study found diabetic foot complications occurred in both younger and older diabetic patients and were related not only to glycemic control and diabetes duration, but also patient knowledge.
Benjamin Bearnot - New treatments for the infectious complications of substan...Benjamin Bearnot, MD
New treatments for infectious complications of substance use disorders and barriers to implementation were discussed. The scope of substance use disorder problems was reviewed. New highly effective treatments for Hepatitis C like Harvoni and Viekira Pak were presented along with barriers like cost and side effects. New treatments for skin and soft tissue infections like dalbavancin were also discussed. Two case studies were then presented to demonstrate management of patients with these issues. Barriers to treatment included access to care, adherence, and cost. Future directions around integrating care and new treatments were proposed.
This document summarizes findings from a study on outcomes for patients transitioning from peritoneal dialysis to hemodialysis. It finds that planned transitions and transitioning to home hemodialysis can improve outcomes, including lower mortality rates and higher rates of kidney transplantation compared to emergency transitions and in-center hemodialysis. Specifically, the study found a 24% lower risk of death and 36% higher likelihood of transplantation for patients who transitioned to home hemodialysis. The document also provides indicators that can help medical teams better manage patient transitions from peritoneal dialysis to hemodialysis.
Similar to Strict Glycemic Control in Critically ill patients: The Demise of another very good strategy????? (20)
This document discusses key aspects of writing a dissertation for a post-graduate medical degree, including:
1) The role of the guide is to mentor students through the research process, from selecting a topic to publishing findings.
2) Research can be classified as trials, which involve intervention, or observational studies with no active intervention.
3) Key sections of a dissertation include introduction, aim, literature review, methods, results, discussion, and conclusions.
4) Framing a research question, obtaining ethics approval, sample size calculations, and randomization are important methodological considerations.
National Education Policy 2020 What is in it for a student, a parent, a teach...Prof. Mridul Panditrao
Ministry of Human Resource Development of Government of India has projected an elaborate and all-encompassing National Education Policy 2020 (NEP2020). Before independence, the education in India was under the complete control of the “Masters, the British Empire.” The education policies, like the one drawn by Macaulay, as would be obvious, were not for providing any quality education to the Indians, but to churn out the “Babus;” clerks and bureaucrats, to serve the masters, pure and simple. After independence, the society went through series of changes, policies were charted and certain reforms were brought in, but the impact was still not achieved. In 2015, the GOI adapted, “2030 Agenda for Sustainable Development (SD)” and since then the impetus has been initiated. The final culmination of a long drawn and all-inclusive process is NEP2020. NEP2020 has been a very elaborate planning document. The salient features of the issues, principles, aims, vision, challenges and solutions have been dealt with in this article. The main focus has been on the higher education and its implementation. Due importance also has been accorded to other issues such as vocational education, research and online and digital education to mention a few. Overall, it is a commendable and a very positive step forward on the part of the government. Only the time will judge, how much net effective output is actually garnered.
Notwithstanding the unprecedented advances the medical science has achieved, the fundamental value system of it’s practitioners has crumbled to a great extent. The principles and the foundations of the noble profession at present are very shaky and wobbly. The need and greed of lucre is the ‘principal principle’ which seems to be ruling this ‘materialistic’ world. Original guidelines of the Fathers of Medicine seem to be slowly fading away. Therefore it is the necessity in these testing times to introspect deeply and reinvent the vanishing science of ‘Medical Deontology.'
Updated Presentation has been uploaded replete with pertinent examples of the principles to make it more interesting and interactive training session!
Pantoea dispersa: Is it the Next Emerging “Monster” in our Intensive Care Uni...Prof. Mridul Panditrao
Prof. Mridul Panditrao, discusses, a case report; presentation, with unusual symptoms, unusual lab findings, unusual progression, but the same old ususal fatal outcome, in spite of trying everything. The main cause of thisultimately turned out to be Uncommon Genus Pantoea species dispersa. He adds the lextensive literatute Review too
Prof. Mridul Panditrao, dwells upon, the newer applications of Ketamine, good old friend of anaesthesiologists, a trusted weapon! Now is making a strong comeback for diverse indications like chronic/ neuropathic pain and major depressive disorders, in addition to its traditional applications of peri-operative analgesia.
Ultra Sound Guided Regional Analgesia!(USG-RA) :What is Good or bad about it???Prof. Mridul Panditrao
Ultra Sound Guided Regional Analgesia (USG-RA) provides several benefits over traditional landmark-based techniques:
1) Nerves, blood vessels, and other structures can be visualized in real-time to accurately place the needle and avoid unintended punctures.
2) Spread of local anesthetic can be seen as it surrounds the targeted nerves.
3) Individual nerves can be identified and blocked more precisely.
4) Procedures like supraclavicular blocks that were previously risky can be performed safely.
While USG-RA requires an ultrasound machine and two providers, the advantages of improved accuracy, success rates, and safety outweigh the few disadvantages.
This document provides definitions and guidelines for the management of hemorrhagic shock. It defines hemorrhagic shock as reduced tissue perfusion resulting from excessive blood loss. Guidelines recommend rapid diagnosis and treatment of bleeding, optimizing oxygen delivery and volume through fluids and blood products. Early coagulopathy should be monitored and treated with plasma, fibrinogen, platelets and tranexamic acid. Definitive surgical or angiographic intervention is important when bleeding is uncontrolled.
This document provides a detailed summary of Dr. Mridul Panditrao's professional experience and credentials. Over the past 33 years, he has held various roles including Professor, Head of Department, Dean, and Consultant at several hospitals and universities in India, Bahamas, Kuwait, and Jamaica. He has extensive experience in anesthesiology, intensive care, administration, teaching, research, and publishing.
This document discusses fluid balance and fluid compartments in the human body. It defines key terms like total body water, extracellular fluid, intracellular fluid, osmolality, tonicity, electrolytes and explains the distribution and regulation of body water. It also describes hypovolemia, its causes, diagnostic criteria and management approaches for hemorrhagic and non-hemorrhagic hypovolemia. Common intravenous fluids are classified and their properties and uses are explained.
Prof. Mridul Panditrao wants to share his much acclaimed CME lecture in ISACON 2014, Madurai, India and many other places, on one of the very very important but often ununderstood and neglected essential topics in Anesthesia..... Vaporizers!!
Prof. Panditrao has added his original work on the subject of 'Medical Deontology'/Medical Ethics... a Powerpoint version and updated presentation of his editorial on the same topic. He expands his own ideas, priniples and moral values on this very very important but now and virtually neglected topic. The powerpoint presentation has been updated with specific and pertinent examples so that, while training the younger generation, it can become an interactive session
Prof. Mridul M. Panditrao adds another presentation to his collection. This is another Faculty lecture that was delivered at International conference on pain ... ISSPCON 2014, at Mumbai/Bombay, 7th Feb to 9th Feb 2014.
Prof. Mridul M. Panditrao has added another of his very important, useful and in vogue topic to his collection. This is his well acclaimed andwell received faculty lecture at recently concluded International conference on Pain... ISSPCON 2014, at Mumbai/ Bombay from 6th to 9th Feb. 2014.
Professor Panditrao expresses his views about the day to day challenge, faced in clinical practice. Considered to be a simple surgery, but the anesthetic management is very challenging because of the primary pathology, co-morbidities and repeated surgeries involved.
The Anesthesiologist, especially young, faces a major challenge when faced with very ill/ severly moribund, elderly, cachwexic patients with history of fall and lower extremity fractures for elective or ortho surgical procedure. Prof. mridul m. panditrao, explains various problems faced especially with GA, and the best alternatives. Two different approaches of Combined spinal epidual are discussed, with use of adjuvants and also his own randomizede trial and experience.
Aditi Panditrao's Role of health professionals in promoting peace, health & d...Prof. Mridul Panditrao
This document discusses the role of health professionals in promoting peace, health, and development. It covers how everything changed after the splitting of the atom, despite no change in thinking. It then discusses the history of mankind, the state of the world today, and where medical professionals stand. It examines the expected role of doctors to restore health and relieve suffering, and what peace and health mean. It details the bombings of Hiroshima and Nagasaki, the casualties, and health issues faced by survivors. Finally, it proposes solutions like eradicating nuclear weapons and increasing awareness, and discusses how medical professionals can contribute.
My memorable case! AN UNANTICIPATED CARDIAC ARREST & UNUSUAL POST-RESUSCITATI...Prof. Mridul Panditrao
ABSTRACT
A case report of a primigravida, who was admitted with severe pregnancy induced hypertension
(BP 160/122 mmHg) and twin pregnancy, is presented here. Antihypertensive therapy was
initiated. Elective LSCS under general anaesthesia was planned. After the birth of both the babies,
intramyometrial injections of Carboprost and Pitocin were administered. Immediately, she suffered
cardiac arrest. Cardio pulmonary resucitation (CPR) was started and within 3 minutes, she was
successfully resuscitated. The patient initially showed peculiar psychological changes and with
passage of time, certain psycho-behavioural patterns emerged which could be attributed to near
death experiences, as described in this case report.
Ropivacane: A new break through in regional and neuraxial BlockadeProf. Mridul Panditrao
No significant changes in vitals. Minimal bradycardia and fall in BP observed in a few patients.
No significant events like Nausea, Vomiting, Shivering,
Pruritus, Sedation, Respiratory distress etc.
No need for rescue analgesia in 30 patients (75%)
Rescue analgesia given in 10 patients (25%)
Prof. Mridul M. Panditrao, from his University/ medical College days, gives tips on how to write your synopsis for your dissertation after you have registered and started your MD/ MS training programme. he also gives ideas/ steps to come up with a well constructed synopsis. Very useful for the first year MD/ MS PG students
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
2. Dr. Mridul M. Panditrao
CONSULTANT
Department of Anesthesiology
& Intensive Care
Rand Memorial Hospital
Freeport, Grand Bahama
Commonwealth of The Bahamas
3. INTRODUCTION
Problems of Hyperglycemia in ICU patients
One of the most important causes of
morbidity and mortality
In itself maybe one of the major causes of
hospital admissions
Both for medical as well as surgical reasons
Most common reason of maximum number of
hospital days (20% of all hospital days out of
about 14 million hospital days)
4. INTRODUCTION
Etio-pathogenesis of Hyperglycemia
Multiple mechanisms of initiation
Absolute accompaniment with sepsis
Found even in non-diabetic patients
Once started progresses relentlessly
Basic 2 mechanisms
Gluconeogenesis
glycogenolysis
5. INTRODUCTION
Causes of hyperglcemia
Increase in Hepatic Gluconeogenesis:
Due to Increased levels of
Glucagon (Hill, 1991)
Cortisol (Khani, 2001)
Growth hormone
Cytokines IL-1 (Flores, 1990), IL-6, TNF
6. INTRODUCTION
Causes of hyperglcemia
Increase in Hepatic Glycogenolysis
Due to Increased levels of
Adrenaline
Noradrenaline (Watt, 2001)
Cytokines IL-1, IL-6, TNF (Sakurai, 1996)
7. INTRODUCTION
Major physiological factors of hyperglycemia
leading to increased morbidity and mortality
Neutrophil dysfunctions such as impaired
chemotaxis, phagocytosis, adherence, etc.
Compliment inhibition
Glucose stimulating the process of
inflammation as well as acting as a rich
culture medium (glucose rich edema fluid)
Collier B, Dossett L, May A et al. Glucose control and inflammatory response. Nutrition in Clinical Practice
(2008)23;1:3-15
8. INTRODUCTION
The high risk for bacterial infection be it while
having major intervention like surgery or
anesthesia
minor procedures like catheter placements and
intravenous access, especially central lines
Impaired tissue and organ perfusion.
Delayed wound healing
Multi-organ dysfunction syndrme
The proportions of these problems are simply
mind-boggling !
17. Strict (Tight) Glycemic Control
• “SGC/TGC “ as it is called, was and still is a
good strategy.
• All started with a very interesting, path-
breaking study by Van den Burghe et al
• Since its introduction, there have been
conflicting reports of its efficacy and
complications.
• This resulted in slow & steady neglect of a
very good idea leading to its near-total
demise.
Van den Berghe G, Woulters P, Weekers F, et al. Intensive Insulin Therapy in Critically ill patients.
N.Eng.J. Med 2001,345(19): 1359-67.
18. Definition
Maintenance of the Blood Glucose level
in the range of 80-110 mg /dl. with help
of Dose Variable and Intensive Insulin
Therapy (IIT)
19. Greet Van den Burghe et’ al’
• In twelve months period, in Surgical ICU
• In the patients enrolled in the study (N=1548)
• With intensive insulin therapy (IIT) when the
blood glucose levels were maintained < 110 mg/
dl
The conventional group had 1.74 times more mortality
IIT patients had 34% reduction in mortality,
46% reduction in sepsis,
41% reduction in dialysis,
50% reduction in the blood transfusion
44% reduction in polyneuropathy.
20. Building Evidence
This was followed by few encouraging
studies by
• Lazar et al.
• Juvela et al.
• Krinsley et al.
Which were supporting the use of IIT or
strict or tight control of glucose improving
the outcomes.
• Lazar HL, Chipkin SR, Fitzgerald CA, et al. Tight glycemic control in diabetic coronary artery bypass graft patients improves
perioperative outcomes and decreases recurrent ischemic events. Circulation. 2004; 109: 1497–1502.
• Juvela S, Siironen J, Kuhmonen J. Hyperglycemia, excess weight, and history of hypertension as risk factors for poor outcome and
cerebral infarction after aneurysmal subarachnoid hemorrhage J of Neurosurgery 2005;102(6 ) :998-1003
• Krinsley JS et al. Effect of an intensive glucose management protocol on the mortality of criticall illadult patients. Mayo Clinics
Proceedings 2004; 79: 992-1000.
21. Beginning of Conflict
• Then Van den Burghe et al. came back again in 2006,
• “IIT and understanding it’s impact in medical ICU
patients”
• Could not convincingly prove significant reduction in,
in-hospital mortality
• 40% in conventional treatment vs. 37.7% in IIT group,
(p=0.33)
• The saving grace was
• significant reduction in morbidity by prevention of new kidney
injury
• earlier ventilator weaning
• so logically earlier ICU and hospital discharge.
This led to serious introspection, debates & further trials.
Van den Berghe G, Woulters P, Hermans G, et al. Intensive Insulin Therapy in the medical ICU. N.Eng.J. Med 2006,354(5): 449-61.
22. Building up of Conflict
• The plethora of evidence : very conflicting
/argumentive from both perspectives
• A study done on 10000 patients in a level I,
Intensive Care unit
• Extending for over four years
• Goal was: monitoring of the outcome--
Mainly the mortality both in ICU as well as
the hospital.
• Plaut D. A Review of Tight Glycemic Control : ADVANCE for Administrators of laboratory;21.6:42 http://laboratory-
manager.advanceweb.com/Archives/Article-Archives/A-Review-of-Tight-Glycemic-Control.aspx: posted on June 5, 2012,
accessed10/10/2012
23. Building up of Conflict
Authors used 3 glycemic control protocols
i. No control protocol (no glucose
limits)
ii. Target glucose of 80-130 mg per dl.
iii. Standard (tight glucose control) of 80-
110 mg per dl.
• Treggiari MV, Karir V, Yanez ND et al. Intensive Insulin Therapy and mortality in critically ill patients. Crit Care 2008,
12(1): R29
24. Building up of Conflict
The results were striking.
• In all the 3 groups, the use of insulin was
increased by 9%, 25%, and 42% respectively
• But contradictory to the previous thinking,
there was overall higher mortality in group
iii. (Odds Ratio 1.15)
• Especially in patients with ICU stay of 3 or
lesser days
• As would be expected nearly 4 times
increase in the incidence of hypoglycemia
from group i through ii to iii
25. Crescendo of Conflict
Study in a trauma center, retrospective
2000 adults with 2 protocols
i. Pre-TGC (80-200 mg per dl)
ii. Post TGC (80-110 mg per dl)
• Eriksson EA, Christianson DA, Venderkolk WE et al. Tight Blood Glucose Control in trauma patients: who really
benefits? J. Emerg. Trauma, Shock; 4(3): 359-364
26. Crescendo of Conflict
• The most important finding was that the
mortality was significantly higher in Pre
TGC period (21.5%)
• As compared to that of post TGC period
(14.7%)
• Hospital stay was much lesser in Post
TGC
27. Crescendo of Conflict
• To put to rest all these controversies, NIH
funded a study from 2003-2008
• It appeared that TGC had 25% higher
mortality
• The study was voluntarily discontinued
• Welch HG. Schwartz LM, Woloshin S. Over diagnosed, making people sick in the pursuit of health. Publishers:
Beacon Press, Massachusetts, c 2011.
28. Final Straw that broke camel’s..
NICE-SUGAR study (Normoglycemia in Intensive Care
Evaluation-Survival Using Glucose Algorithm Regulation
study)
• Published in 2009,
• 38 tertiary hospitals and 4 community hospitals,
• 6030 patient evaluable in the period of 5 years
(December 2004-November 2008)
• Again the groups were Intensive vs. Conventional;
i.e. 81 to 108 mg per dl vs. <180 mg per dl glucose levels
were the targets
• The patients were randomized but not blinded
• The mean age was 60 years with equal distribution by
gender and Apache II scoring of 21 in each group.
• NICE-SUGAR Study: Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Intensive versus conventional glucose
control in critically ill patients.N Engl J Med 2009, 360:1283-1297.
29. Final Straw that broke camel’s..
The outcome majors were:
• 90-day mortality
• Duration of mechanical ventilation
• renal replacement therapy,
• Length of stay in ICU/hospital & cause of
death.
• 28-day all-cause mortality,
• incidence of organ system failure,
• transfusion requirements
• new positive blood cultures.
30. Final Straw that broke camel’s..
Results were very revealing:
• Mortality at 90 days was 27.5% in IIT group
vs. 24.9% in conventional group (CT)
(Odds Ratio- O.R. 1.14, p=0.02)
• Mortality at 28 days was 22.3% in IIT group
vs. 20.8% in CT ( O.R. 1.09, p=0.17)
• Location of death in ICU
65.9% in IIT vs. 66.3% in CT
In-hospital 26.9% IIT vs. 26.2% CT
31. Final Straw that broke camel’s..
Absolutely no difference, in both groups
in the length of the ICU stay of 6 days
hospital stay of 17 days
on-ventilator stay of 6.6 days in both the
groups
hypoglycemia (glucose levels<40 mg per dl)
was found in 6.8% patients in IIT as
compared to 0.5% in CT ,(O.R.) of 14.7.
32. Outcome
• Total chaos
• Initial confabulation
• Later dilemma
• Final complete indifference and
avoidance/neglect of SGC/TGC
33. WHAT WENT WRONG?
• In their overenthusiasm to implement
the IIT/ SGC/TGC, the Researchers
and clinicians went overboard with
their own half-baked protocols,
without enough planning and giving
consideration to the available
infrastructure!!!!!!
34. Aftermath, review & analysis!
A very interesting review tries to answer few
very important and pertinent queries like:
• How safe is the IIT, with various Glycemic
targets from risk of hypoglycemia?
• How tightly blood glucose must be
controlled for this approach to be effective?
• What role does the accuracy of blood
glucose measurement play in affecting the
study of this method?
Klonoff DC. Intensive insulin therapy in critically ill hospitalized patients; making it safe and effective. J. Diabeteco Sci.
Tecnol 2011; 5(3): 755-67.
35. Aftermath, review & analysis!
One has to understand basic flaw that can creep in
while designing of SGC/TGC:
• Targets/ goals, risks and benefits TGC protocol
(IIT), might be different.
• With the standardization/accuracy of blood
glucose monitoring, the risk of overdosing of
insulin & hypo/hyperglycemia will be reduced
• The various methods of glucose measurement
– Handheld devices (POCT),
– Paper or plastic sticks which use a drop of blood
– Blood gas analyzers/other analyzers in the central
labs),
The values of these methods have inherent fallacies/
variations.
36. Aftermath, review & analysis!
• Accordingly it has been documented
that
Fasting Blood Glucose levels in the venous
sample are :
5 -10% lower than in arterial sample,
may be up to 15% lower than in capillary
sample.
37. Factors which can be considered as
confounding
• Accuracy and reproducibility of results
• User Expertise
• Types of devices
• Anemia causes false evaluation of glucose
levels
• Anemia is one of the commonest findings in
critically ill patients
• As already mentioned, arterial, plasma,
serum, capillary, venous samples give
different results.
38. Et’ tu Insulin?
Which insulin to be given:
The onsets, peaks & duration of various
preparations varies :
Regular: 30-60 min, 2-4 hrs. 6-10 hrs
NPH/Lente 1-2 hrs 4-8 hrs 10-20 hrs.
Lispro/Aspat 5-15 min. 1-2 hrs 4-6 hrs
Glargine/ lantus 1-2 hrs Flat 20-24 hrs.
39. HOW TO OVERCOME?
The Leuven IIT trials were successful and effective because:
• The SGC was applied by the insulin infusion via central
venous line and administered using very precise syringe
infusion pumps
• Subtle dose adjustments, made by ICU nurses, using
guidelines to keep blood glucose to lower normal limit (81-
110 mg per dl)
• ’High level of intuitive decision making’
• The blood glucose level measurement in arterial blood was
carried out at strict time interval points using accurate blood
gas analyzers.
• The measurements were carried out at an intermediate time
interval points if required.
• Patients were always in a non-fasting state at all times.
•Schultz MJ et al http://www.ihe-online.com/feature-articles/strict-or-loose-glycemic-control-in-critically-ill-patients-conflicting-evidence/trackback/1/accessed on 10/10/2012
•Arabi YM, Dabbagh OC, Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients.Crit Care Med 2008, 36:3190-3197.
•De la Rosa GD, Donado JH, Restrepo AH et al: Strict glycemic control in patients hospitalised in a mixed medical and surgical intensive care unit: a randomized clinical trial.Crit care 2008; 12: R120
•Brunkhorst FM, Engel C, Bloos F. et al Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125- 139
•Preiser JC et al. Intensive care Med 2009; 35 (10): 1738 -48
•Preiser JC, Devos P, A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study.
Intensive Care Med 2009, 35:1738-1748.
•Van den Berghe G, Schetz M, Vlasselaers D, et al. Clinical review: Intensive insulin therapy in critically ill patients: NICE-SUGAR or Leuven blood glucose target?
J ClinEndocrinolMetab 2009, 94:3163-3170.
40. HOW TO OVERCOME?
Judging, on the basis of these observations - The
later date trials, reports and assessments----- glaring
fallacies are:
Instead of syringe infusion pumps, volumetric
infusion pumps were used.
Level of knowledge, training about guidelines and
involvement of the ICU nurses is disputed.
In addition the decision making, training was related
to only prevention and correction of hypoglycemia.
Fallacies of blood glucose level measurements played
a major factor
- Use of capillary blood samples as an indicator of
glycemic control is inferior
- So are the assessment of the glucose levels in the
absence of accurate glucose analyzers.
41. HOW TO OVERCOME?
Last but not the least(rather most important
key factor in the success of Leuven trials):
The pure, simple plan and high level of
intuitive decision making
skill and motivation on the part of ICU
nurses
actual absence of highly explicit rules
required in closed loop, paper-based &
computer-based decision support systems
required in sliding scales.
42. HOW TO OVERCOME?
• This discussion about what went, goes and will
go wrong can go on endlessly,
• Especially when discussing improperly and
inadequately designed and executed randomized
trials involving SGC/TGC.
• One has to, without an iota of doubt, accept that
hyperglycemia is deleterious to the critically ill
• There is adequate evidence that lowering of
blood glucose levels have the potential to
prevent injury in already compromised organs in
the patients.
Bagshaw SM, Egi M, George C, et al. Early blood glucose control and mortality in critically ill patients in Australia. Crit Care Med 2009, 37:463-470.
Finney SJ, Zekveld C, Elia A, Evans TW: Glucose control and mortality in critically ill patients. JAMA 2003, 290:2041-2047.
Krinsley JS: Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo ClinProc 2003, 78:1471-1478.
Falciglia M, Freyberg RW, Almenoff PL, et al. Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med 2009, 37:3001-3009.
43. Take Home Message!
So while planning your own strategies to
achieve these targets, one has to keep in mind:
– Perfect planning of design of your protocols!
– Precise methodology to achieve optimal target
levels of blood glucose.
– Critical check of methods and equipment used
to measure and control the glucose.
– Try to extrapolate all the available evidence
from various RCTs to your own circumstances
and infrastructure.
•Chase JG, Shaw G, Le Compte A. et al. Implementation and evaluation of SPRINT protocol for Tight Glycemic control in Critically ill patients: A clinical practice change Critical care 2008; 12: R 49
44. Take Home Message!
Evolving newer strategies/protocol of
maintaining Good Glycemic Control (GGC):
• Continuous variable rate of intravenous insulin
drip especially in:
Patients undergoing major surgery
Remaining NPO for prolonged duration
Patients with Myocardial infarction,
Diabetic keto-acidosis or
Patients on chronic steroid administration.
• SPRINT (Specialized Regulative Insulin
Nutrition Table) protocol
Chase JG, Shaw G, Le Compte A. et al. Implementation and evaluation of SPRINT protocol for Tight Glycemic control in Critically ill
patients: A clinical practice change Critical care 2008; 12: R 49
45. CONCLUSION
• Hyperglycemia in hospitalized, especially
critically ill patients is undoubtedly
harmful
• Adequate glycemic control has been proven
to be beneficial by multiple SGC, TGC
trials carried out by various workers
• Some confounding evidence of supposed
deleterious effects of SGC/TGC has caused
lot of confabulations and dilemmas leading
to near-total demise of a good therapeutic
strategy.
46. CONCLUSION
• One has to be very circumspect
• Have clear understanding of your own
infrastructural and logistical short-
comings while planning and
implementing SGC/TGC protocols
• It would be prudent to do thorough stock
checking and defining our own target
limits of SGC/TGC before embarking on
this promising but tricky journey.