OBJECTIVE -We performed a randomized trial to compare three insulin-titration protocols for tight glycemic control (TGC) in a surgical intensive care unit: an absolute glucose (Matias) protocol, a relative glucose change (Bath) protocol, and an enhanced model predictive control (eMPC) algorithm. RESEARCH DESIGN AND METHODS-A total of 120 consecutive patients after cardiac surgery were randomly assigned to the three protocols with a target glycemia range from 4.4 to 6.1 mmol/l. Intravenous insulin was administered continuously or in combination with insulin boluses (Matias protocol). Blood glucose was measured in 1-to 4-h intervals as requested by the protocols.RESULTS -The eMPC algorithm gave the best performance as assessed by time to target (8.8 Ϯ 2.2 vs. 10.9 Ϯ 1.0 vs. 12.3 Ϯ 1.9 h; eMPC vs. Matias vs. Bath, respectively; P Ͻ 0.05), average blood glucose after reaching the target (5.2 Ϯ 0.1 vs. 6.2 Ϯ 0.1 vs. 5.8 Ϯ 0.1 mmol/l; P Ͻ 0.01), time in target (62.8 Ϯ 4.4 vs. 48.4 Ϯ 3.28 vs. 55.5 Ϯ 3.2%; P Ͻ 0.05), time in hyperglycemia Ͼ8.3 mmol/l (1.3 Ϯ 1.2 vs. 12.8 Ϯ 2.2 vs. 6.5 Ϯ 2.0%; P Ͻ 0.05), and sampling interval (2.3 Ϯ 0.1 vs. 2.1 Ϯ 0.1 vs. 1.8 Ϯ 0.1 h; P Ͻ 0.05). However, time in hypoglycemia risk range (2.9 -4.3 mmol/l) in the eMPC group was the longest (22.2 Ϯ 1.9 vs. 10.9 Ϯ 1.5 vs. 13.1 Ϯ 1.6; P Ͻ 0.05). No severe hypoglycemic episode (Ͻ2.3 mmol/l) occurred in the eMPC group compared with one in the Matias group and two in the Bath group.CONCLUSIONS -The eMPC algorithm provided the best TGC without increasing the risk of severe hypoglycemia while requiring the fewest glucose measurements. Overall, all protocols were safe and effective in the maintenance of TGC in cardiac surgery patients. Diabetes Care 32:757-761, 2009

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Perioperative initiation of intensive insulin therapy during cardiac surgery reduces postoperative morbidity in nondiabetic patients while having a minimal effect in diabetic subjects.

The aim of this study was to analyse most important epidemiological and clinical aspects of registered snakebites caused by a native common European viper Vipera berus in the Czech Republic over a period of 15 years (1999–2013). Data have been collected retrospectively from a database of the Toxinology Centre belonging to the General University Hospital in Prague. In total, 191 cases of snakebites caused by common viper were registered during the study period. Systemic envenoming occurred in 49 (25.7%) patients, local envenoming without systemic symptoms was recorded in 91 (47.6%) and asymptomatic dry bites were seen in 51 (26.7%) cases, respectively. Twenty-four patients (12.6% of all bites) were treated with administration of antivenom. None of the victims died as a result of snakebite during the observation period. Native viper snakes usually did not cause serious harm to the patients, with the exception of children. Antivenom should be administered in all cases with systemic manifestations, in children even with serious local affection and administered as soon as possible. Envenomed patients should be admitted to the hospital and treated at least under supervision of specialists with experience in snakebite treatment, who can indicate and provide administration of the antivenom.

Background: Testing metabolic effects of a novel calcium-free, magnesium, phosphate and lactate containing solution (Lactocitrate) in combination with citrate anticoagulation. Methods: Patients on CRRT (2,000 ml/h, blood flow (Qb) 100 ml/min, trisodium citrate (4% TSC)) with arterial lactate <3 mmol/l were included. At start, bicarbonate-buffered fluid was changed to Lactocitrate and the substitution of magnesium and phosphorus ceased. At 9 h the Qb was increased to 150 ml/min. At 18 h the CRRT dosage was increased to 3,000 ml/h. Results: In 22 CVVHDF patients and another 23 on CVVH the pH, aHCO₃ and Na (all p > 0.05) showed no significant changes regardless of the increased dosage of 4% TSC at 9 h (p < 0.001). Mg_tot and phosphorus stabilised within normal range. Arterial lactate increased to 1.9 (1.6-2.6) mmol/l at 3,000 ml/h, p < 0.001). Citrate- and lactate-related energetic gains were up to 74 (61-86) kJ/h. Conclusions: The fluid performed well within ordinary CRRT dosage and Qb up to 150 ml/min. Lactate levels mildly increased and no magnesium and phosphorus replenishments were necessary.

The increasing number of patients with refractory angina prompted a search for an effective and safe therapy to improve the quality of their life. New evidence in the pathophysiology of an ischemic myocardium and investigation of the impact of thoracic sympathectomy suggests sympathetic denervation seems to be a possible alternative method for the treatment of refractory angina pectoris.

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