Diabetes en el paciente grave / Diabetes in the critically ill patient

Julio 11, 2017. No. 2746

Estos días se ha enviado información sobre endocrinopatías diversas. Si duda la diabetes es la patología endocrina más frecuente por lo que se harán varios envíos con este tema apasionante. Después seguiremos con tiroides, alteraciones pituitarias y otras endocrinopatías de interés capital en la medicina perioperatoria, medicina crítica y del dolor. Disfrute su lectura Information on endocrinopathies has been sent to you in these days. Diabetes in the most common endocrine pathology, so we will make several submissions with this exciting topic. Later we will continue with thyroid, pituitary alterations and other endocrinopathies of capital interest in perioperative medicine, critical medicine and pain. Enjoy your reading Manejo del diabético grave Management of critically ill patients with diabetes. Silva-Perez LJ1, Benitez-Lopez MA1, Varon J1, Surani S1. World J Diabetes. 2017 Mar 15;8(3):89-96. doi: 10.4239/wjd.v8.i3.89. Abstract Disorders of glucose homeostasis, such as stress-induced hypoglycemia and hyperglycemia, are common complications in patients in the intensive care unit. Patients with preexisting diabetes mellitus (DM) are more susceptible to hyperglycemia, as well as a higher risk from glucose overcorrection, that may results in severe hypoglycemia. In critically ill patients with DM, it is recommended to maintain a blood glucose range between 140-180 mg/dL. In neurological patients and surgical patients, tighter glycemic control (i.e., 110-140 mg/d) is recommended if hypoglycemia can be properly avoided. There is limited evidence that shows that critically ill diabetic patients with a glycosylated hemoglobin levels above 7% may benefit from looser glycemic control, in order to reduce the risk of hypoglycemia and significant glycemic variability. KEYWORDS: Critical care; Diabetes mellitus; Glycemic control; Hypoglycemia; Intensive care unit; Stress hyperglycemia PDF Manejo del paciente grave con diabetes tipo 2. La necesidad de terapia personalizada Management of critically ill patients with type 2 diabetes: The need for personalised therapy. Kar P1, Jones KL1, Horowitz M1, Deane AM1. World J Diabetes. 2015 Jun 10;6(5):693-706. doi: 10.4239/wjd.v6.i5.693. Abstract Critical illness in patients with pre-existing diabetes frequently causes deterioration in glycaemic control. Despite the prevalence of diabetes in patients admitted to hospital and intensive care units, the ideal management of hyperglycaemia in these groups is uncertain. There are data that suggest that acute hyperglycaemia in critically ill patients without diabetes is associated with increased mortality and morbidity. Exogenous insulin to keep blood glucose concentrations < 10 mmol/L is accepted as standard of care in this group. However, preliminary data have recently been reported that suggest that chronic hyperglycaemia may result in conditioning, which protects these patients against damage mediated by acute hyperglycaemia. Furthermore, acute glucose-lowering to < 10 mmol/L in patients with diabetes with inadequate glycaemic control prior to their critical illness appears to have the capacity to cause harm. This review focuses on glycaemic control in critically ill patients with type 2 diabetes, the potential for harm from glucose-lowering and the rationale for personalised therapy. KEYWORDS: Critically ill; Diabetes; Intensive care; Management; Personalised therapy PDF Control de la glucosa en la UCI: Una historia continua. Glucose Control in the ICU: A Continuing Story. Preiser JC1, Chase JG2, Hovorka R3, Joseph JI4, Krinsley JS5, De Block C6, Desaive T7, Foubert L8, Kalfon P9, Pielmeier U10, Van Herpe T11, Wernerman J12. J Diabetes Sci Technol. 2016 Nov 1;10(6):1372-1381. Print 2016 Nov. Abstract In the present era of near-continuous glucose monitoring (CGM) and automated therapeutic closed-loop systems, measures of accuracy and of quality of glucose control need to be standardized for licensing authorities and to enable comparisons across studies and devices. Adequately powered, good quality, randomized, controlled studies are needed to assess the impact of different CGM devices on the quality of glucose control, workload, and costs. The additional effects of continuing glucose control on the general floor after the ICU stay also need to be investigated. Current algorithms need to be adapted and validated for CGM, including effects on glucose variability and workload. Improved collaboration within the industry needs to be encouraged because no single company produces all the necessary components for an automated closed-loop system. Combining glucose measurement with measurement of other variables in 1 sensor may help make this approach more financially viable. KEYWORDS: continuous glucose control; diabetes; intensive care; time in band PDF Año de revisión 2013: Cuidados Críticos - metabolismo. Year in review 2013: Critical Care--metabolism. Lheureux O, Preiser JC. Crit Care. 2014 Oct 27;18(5):571. doi: 10.1186/s13054-014-0571-4. Abstract Novel insights into the metabolic alterations of critical illness, including new findings on association between blood glucose at admission and poor outcome, were published in Critical Care in 2013. The role of diabetic status in the relation of the three domains of glycemic control (hyperglycemia, hypoglycemia, and glycemic variability) was clarified: the association between mean glucose, high glucose variability, and ICU mortality was stronger in the non-diabetic than in diabetic patients. Improvements in the understanding of pathophysiological mechanisms of stress hyperglycemia were presented. Novel developments for the management of glucose control included automated closed-loop algorithms based on subcutaneous glucose measurements and microdialysis techniques. In the field of obesity, some new hypotheses that could explain the 'obesity paradox' were released, and a role of adipose tissue in the response to stress was suggested by the time course of adipocyte fatty-acid binding protein concentrations. In the field of nutrition, beneficial immunological effects have been associated with early enteral nutrition. Early enteral nutrition was significantly associated with potential beneficial effects on the phenotype of lymphocytes. Uncertainties regarding the potential benefits of small intestine feeding compared with gastric feeding were further investigated. No significant differences were observed between the nasogastric and nasojejunal feeding groups in the incidence of mortality, tracheal aspiration, or exacerbation of pain. The major risk factors to develop diarrhea in the ICU were described. Finally, the understanding of disorders associated with trauma and potential benefits of blood acidification was improved by new experimental findings. PDF XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Diabetes y UCI / ICU and diabetic patients

Julio 12, 2017. No. 2747

El efecto de la administración de insulina sobre el péptido c en el diabético tipo 2 grave The effect of insulin administration on c-peptide in critically ill patients with type 2 diabetes. Crisman M1,2, Lucchetta L1, Luethi N1, Cioccari L1, Lam Q3, Eastwood GM1, Bellomo R1,4, Mårtensson J5,6. Ann Intensive Care. 2017 Dec;7(1):50. doi: 10.1186/s13613-017-0274-5. Epub 2017 May 12. Abstract BACKGROUND: In critically ill patients with permissive hyperglycemia, it is uncertain whether exogenous insulin administration suppresses or enhances c-peptide secretion (a marker of pancreatic beta-cell response). We aimed to explore this effect in patients with type 2 diabetes. METHODS: We prospectively enrolled a cohort of 45 critically ill patients with type 2 diabetes managed according to a liberal glucose protocol (target blood glucose 10-14 mmol/l). We recorded the administration of insulin and oral hypoglycemic agents and measured plasma c-peptide as surrogate marker of endogenous insulin secretion on the first two consecutive days in ICU. RESULTS: Overall, 20 (44.4%) patients required insulin to achieve target blood glucose. Insulin-treated patients had higher glycated hemoglobin A1c, more premorbid insulin-requiring type 2 diabetes, and greater blood glucose levels but lower c-peptide levels on admission. Premorbid insulin-requiring diabetes was independently associated with lower admission c-peptide, whereas greater plasma creatinine was independently associated with higher levels. Increases in c-peptide were positively correlated with an increase in blood glucose both in patients who did (r = 0.54, P = 0.01) and did not (r = 0.56, P = 0.004) receive insulin. However, insulin administration was independently associated with a greater increase in c-peptide (P = 0.04). This association was not modified by the use of oral insulin secretagogues. CONCLUSIONS: C-peptide, a marker of beta-cell response, responds to and is influenced by glycemia and renal function in critically ill patients with type 2 diabetes. In addition, in our cohort, exogenous insulin administration was associated with a greater increase in c-peptide in response to hyperglycemia. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN12615000216516). KEYWORDS: Blood glucose; C-peptide; Critical care, beta-cell; Diabetes mellitus; Insulin PDF Hiperglicemia inducida por estrés y el riesgo subsecuente de DM2 en sobrevivientes de UCI Stress Induced Hyperglycemia and the Subsequent Risk of Type 2 Diabetes in Survivors of Critical Illness. Plummer MP1,2, Finnis ME1,2, Phillips LK3,4, Kar P1,2, Bihari S5,6, Biradar V7, Moodie S1, Horowitz M3,4, Shaw JE8, Deane AM1,2. PLoS One. 2016 Nov 8;11(11):e0165923. doi: 10.1371/journal.pone.0165923. eCollection 2016. Abstract OBJECTIVE: Stress induced hyperglycemia occurs in critically ill patients who have normal glucose tolerance following resolution of their acute illness. The objective was to evaluate the association between stress induced hyperglycemia and incident diabetes in survivors of critical illness. DESIGN: Retrospective cohort study. SETTING: All adult patients surviving admission to a public hospital intensive care unit (ICU) in South Australia between 2004 and 2011. PATIENTS: Stress induced hyperglycemia was defined as a blood glucose ≥ 11.1 mmol/L (200 mg/dL) within 24 hours of ICU admission. Prevalent diabetes was identified through ICD-10 coding or prior registration with the Australian National Diabetes Service Scheme (NDSS). Incident diabetes was identified as NDSS registration beyond 30 days after hospital discharge until July 2015. The predicted risk of developing diabetes was described as sub-hazard ratios using competing risk regression. Survival was assessed using Cox proportional hazards regression. MAIN RESULTS: Stress induced hyperglycemia was identified in 2,883 (17%) of 17,074 patients without diabetes. The incidence of type 2 diabetes following critical illness was 4.8% (821 of 17,074). The risk of diabetes in patients with stress induced hyperglycemia was approximately double that of those without (HR 1.91 (95% CI 1.62, 2.26), p<0.001) and was sustained regardless of age or severity of illness. CONCLUSIONS: Stress induced hyperglycemia identifies patients at subsequent risk of incident diabetes. PDF Revisión de la evidencia para los protocolos de manejo de cetoacidosis diabética en adultos. Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols. Tran TTT1, Pease A1, Wood AJ1, Zajac JD1,2, Mårtensson J3, Bellomo R3, Ekinci EII1,2,4. Front Endocrinol (Lausanne). 2017 Jun 13;8:106. doi: 10.3389/fendo.2017.00106. eCollection 2017. Abstract BACKGROUND: Diabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs). OBJECTIVE: To review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes. CONCLUSION: There are major deficiencies in evidence for optimal management of DKA. Current practice is guided by weak evidence and consensus opinion. All aspects of DKA management require RCTs to affirm or redirect management and formulate consensus evidence-based practice to improve patient outcomes. KEYWORDS: diabetes; diabetic ketoacidosis; hypoglycemia; hypokalemia; insulin; metabolic acidosis; protocol; rehydration PDF XIV Congreso Virtual Mexicano de Anestesiología 2017 Octubre 1-Diciembre 31, 2017 Información / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org