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Glycemic targets for people with pre-existing diabetes who are in the critical care setting have not been firmly established. Early trials showed that achieving normoglycemia 4. However, subsequent trials in mixed populations of critically ill patients did not show a benefit of targeting BG levels of 4.
A meta-analysis of trials of intensive insulin therapy in the ICU setting suggested benefit of intensive insulin therapy in surgical patients, but not in medical patients Furthermore, intensive insulin therapy has been associated with an increased risk of hypoglycemia in the ICU setting The use of insulin infusion protocols with proven efficacy and safety minimizes the risk of hypoglycemia 35— Role of Intravenous Insulin There are few occasions when intravenous insulin is required, as most people with type 1 or type 2 diabetes admitted to general medical wards can be treated with subcutaneous insulin.
Intravenous insulin, however, may be appropriate for people who are critically ill with appropriate BG targetspeople who are not eating and in those with hyperglycemia and metabolic decompensation e. The evidence to date suggests there is no benefit to intravenous insulin over subcutaneous insulin post-acute stroke 3, Health-care staff education is a critical component of the implementation of an intravenous insulin infusion protocol.
Intravenous insulin protocols should take into account the patient's current and previous BG levels as well as the rate of change in BGand the patient's usual insulin dose.
Several published insulin infusion protocols appear to be both safe and effective, with low rates of hypoglycemia; however, most of these protocols have only been validated in the ICU setting, where the nurse-to-patient ratio is higher than on medical and surgical wards 3, BG determinations can be performed every 1 to 2 hours until BG has stabilized.
With the exception of the treatment of hyperglycemic emergencies e. DKA and HHSconsideration should be given to concurrently providing people receiving intravenous insulin with some form of glucose e.
Transition from IV insulin to SC insulin therapy Hospitalized people with type 1 and type 2 diabetes may be transitioned to scheduled subcutaneous insulin therapy from intravenous insulin.
Short- or rapid- or fast-acting insulin can be administered 1 to 2 hours before discontinuation of the intravenous insulin to maintain effective blood levels of insulin. If intermediate- or long-acting insulin is used, it can be given 2 to 3 hours prior to intravenous insulin discontinuation.
People without a history of diabetes, who have hyperglycemia requiring more than 2 units of intravenous insulin per hour, likely require insulin therapy and can be considered for transition to scheduled subcutaneous insulin therapy. The initial dose and distribution of subcutaneous insulin at the time of transition can be determined by extrapolating the intravenous insulin requirement over the preceding 6- to 8-hour period to a hour period.
Dividing the total daily dose as a combination of basal and bolus insulin has been demonstrated to be safe and efficacious in medically ill patients 40, Perioperative glycemic control The management of individuals with diabetes at the time of surgery poses a number of challenges. Acute hyperglycemia is common secondary to the physiological stress associated with surgery.
Pre-existing diabetes-related complications and comorbidities may also influence clinical outcomes. Acute hyperglycemia has been shown to adversely affect immune function 42 and wound healing 43 in animal models. Observational studies have shown that hyperglycemia increases the risk of postoperative infections 44,45renal allograft rejection 46and is associated with increased health-care resource utilization Cardiovascular surgery In people undergoing coronary artery bypass grafting CABGa pre-existing diagnosis of diabetes has been identified as a risk factor for postoperative sternal wound infections, delirium, renal dysfunction, respiratory insufficiency and prolonged hospital stays 48— Intraoperative hyperglycemia during cardiopulmonary bypass has been associated with increased morbidity and mortality rates in individuals with and without diabetes 51— A systematic review of randomized controlled trials supports the use of intravenous insulin infusion targeting a blood glucose of 5.
This was demonstrated by a marked reduction in surgical site infections odds ratio 0. Minor and moderate surgery The perioperative glycemic targets for minor or moderate surgeries are less clear.
Older studies comparing different methods of achieving glycemic control during minor and moderate surgeries did not demonstrate any adverse effects of maintaining perioperative BG levels between 5.
Attention has been placed on the relationship between postoperative hyperglycemia and surgical site infections. While the association was well documented, the impact and risks of intensive management was less clear.
The risk of hypoglycemia was increased but there was no increased risk of stroke or death. The included studies looked at the intraoperative and immediate postoperative period and used intravenous insulin to achieve intensive targets.68 Study Guide for An Introduction to Chemistry Chapter Checklist Read the Review Skills section.
If there is any skill mentioned that you have not yet mastered, review the material on that topic before reading this chapter. This page contains the notes for our book Perfect Health Diet: Regain Health and Lose Weight by Eating the Way You Were Meant to Eat (US edition, Scribner, ), plus srmvision.com the following titles to reach the notes for each chapter: Preface; Part I: An Evolutionary Guide to Healthful Eating.
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