Both sc and epicardial adipose tissue is a source of proinflammatory cytokines in cardiac surgery patients and may contribute to the development of postoperative insulin resistance.
OBJECTIVE -To evaluate a fully automated algorithm for the establishment of tight glycemic control in critically ill patients and to compare the results with different routine glucose management protocols of three intensive care units (ICUs) across Europe (Graz, Prague, and London).RESEARCH DESIGN AND METHODS -Sixty patients undergoing cardiac surgery (age 67 Ϯ 9 years, BMI 27.7 Ϯ 4.9 kg/m 2 , 17 women) with postsurgery blood glucose levels Ͼ120 mg/dl (6.7 mmol/l) were investigated in three different ICUs (20 per center). Patients were randomized to either blood glucose management (target range 80 -110 mg/dl [4.4 -6.1 mmol/l]) by the fully automated model predictive control (MPC) algorithm (n ϭ 30, 10 per center) or implemented routine glucose management protocols (n ϭ 30, 10 per center). In all patients, arterial glucose was measured hourly to describe the glucose profile until the end of the ICU stay but for a maximum period of 48 h. CONCLUSIONS -The data suggest that the MPC algorithm is safe and effective in controlling glycemia in critically ill postsurgery patients. RESULTS Diabetes Care 29:271-276, 2006E pidemiological studies have revealed a significant relationship between impaired glycemic control and poor outcome in patients with acute cardiovascular events (1-3), postoperative wound infections (4,5), and trauma (6). Patients with diabetes are affected, but patients with stress hyperglycemia with no previous diagnosis of diabetes also have a poor prognosis (1,2,7,8). Critical illness and trauma induce counterregulatory hormone release and alterations in carbohydrate metabolism such as enhanced hepatic gluconeogenesis, insulin resistance, and relative insulin deficiency (9,10).A growing body of evidence indicates that treatment of hyperglycemia improves clinical outcome (11). In a prospective randomized trial in Leuven, postoperative patients were treated with an intensive insulin protocol (12). Strict glycemic control (80 -110 mg/dl) resulted in a reduction of in-hospital mortality and a decrease in organ system dysfunction compared with moderate hyperglycemia (180 -200 mg/dl). In another study performed on a mixed medical-surgical population, the implementation of an intensive glucose management protocol led to decreased mortality, morbidity, and length of intensive care unit (ICU) stay of critically ill adult patients (13).Based on this clinical evidence, efforts have to be made to maintain strict glycemic control in critically ill patients. To achieve this goal, the implementation of complex intensive insulin infusion protocols based on frequent bedside glucose monitoring is required. Numerous guidelines have been developed and tested to implement tight glycemic control in ICUs (13-18). However, most of these guidelines still require user interventions or intuitive decisions of ICU staff.The development of a closed-loop control system that automatically regulates the dose of insulin based on glucose measurements could permit tight glycemic control without increasing the work-
To study the role of adipose tissue-derived hormones in the pathophysiology of eating disorders, circulating levels of adiponectin, resistin, and other hormonal and metabolic parameters were measured in 16 females with the restrictive subtype of anorexia nervosa (R-AN), 10 females with the binge/purge subtype of anorexia nervosa (P-AN), 15 females with bulimia nervosa (BN), and 12 age-matched healthy females (C). Body mass index (BMI), body fat content, and serum leptin levels were severely decreased in R-AN and moderately decreased in P-AN patients, whereas the BN group did not differ from C in these parameters. Serum soluble leptin receptor levels were increased in R-AN and P-AN and unchanged in BN patients. Circulating adiponectin levels were inversely related to BMI and were unchanged in BN patients and increased by 53% in P-AN and by 96% in R-AN relative to C group, respectively. In contrast, resistin levels in malnourished R-AN and P-AN were not different from either C or BN groups and showed no significant relationship to BMI or body fat content. We suggest that increased adiponectin levels reflect decreased body fat content in AN patients. In contrast, circulating resistin levels do not appear to be closely related to the nutritional status.
Compared with RMP, the eMPC algorithm was more effective and comparably safe in maintaining euglycemia in cardiac surgery patients.
OBJECTIVE -Tight glycemic control improves outcome in critically ill patients but requires frequent glucose measurements. Subcutaneous adipose tissue (SAT) has been characterized as promising for glucose monitoring in diabetes, but it remains unknown whether it can also be used as an alternative site in critically ill patients. The present study was performed to clinically evaluate the relation of glucose in SAT compared with arterial blood in patients after major cardiac surgery.RESEARCH DESIGN AND METHODS -Forty critically ill patients were investigated at two clinical centers after major cardiac surgery. Arterial blood and SAT microdialysis samples were taken in hourly intervals for a period of up to 48 h. The glucose concentration in dialysate was calibrated using a two-step approach, first using the ionic reference technique to calculate the SAT glucose concentration (SATg) and second using a one-point calibration procedure to obtain a glucose profile comparable to SAT-derived blood glucose (BgSAT). Clinical validation of the data was performed by introducing data analysis based on an insulin titration algorithm. CONCLUSIONS -The results indicate good correlation between SATg and blood glucose in patients after major cardiac surgery. Clinical evaluation of the data suggests that with minor limitations, glucose from SAT can be used to establish tight glycemic control in this patient group. RESULTS Diabetes Care 29:1275-1281, 2006M aintaining critically ill patients within strict glycemic limits can dramatically reduce mortality, risk of infection, and other complications and also has substantial socioeconomic impact (1-3). Due to administration of varying doses of parenteral and enteral nutrition, intravenous infusion of medications that affect glucose metabolism, and development of acute insulin resistance during sepsis, tight glycemic control can only be granted by frequent blood glucose monitoring. Although most critically ill and hospitalized patients have routinely placed venous or arterial access lines, glycemic control is still inadequate.The unmanageable workload for the nursing staff and the prevalent fear of hypoglycemia among critical care physicians hinders the implementation of glycemic control in the intensive care unit (ICU) (4).For diabetic patients, alternative-site glucose testing to achieve better, continuous, or automated feedback control of glycemia has been sought for a long time (5-7). Thanks to minimal invasiveness and good correlation with blood glucose, subcutaneous adipose tissue (SAT) is probably the most investigated alternative sampling site (8 -13). Glucose monitoring in SAT would provide more frequent information about glycemia (trend information) and would therefore also be of benefit for critically ill patients.Microdialysis of SAT has been well established for the investigation of the interstitial fluid glucose profile in relation to blood glucose in healthy individuals and diabetic patients (9). Due to critical illness of patients in the ICU, the perfusion status of variou...
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