Objective Severely burned patients benefit from intensive insulin therapy (IIT) for tight glycemic control (TGC). We evaluated the clinical impact of automatic correction of hematocrit and ascorbic acid interference for bedside glucose monitoring performance in critically ill burn patients. Methods The performance of two point-of-care glucose monitoring systems (GMS): (a) GMS1, an autocorrecting device, and (b) GMS2, a non-correcting device were compared. Sixty remnant arterial blood samples were collected in a prospective observational study to evaluate hematocrit and ascorbic acid effects on GMS1 vs. GMS2 accuracy paired against a plasma glucose reference. Next we enrolled 12 patients in a pilot randomized controlled trial (RCT). Patients were randomized 1:1 to receive IIT targeting a TGC interval of 111–151 mg/dL and guided by either GMS1 or GMS2. GMS bias, mean insulin rate, and glycemic variability were calculated. Results In the prospective study, GMS1 results were similar to plasma glucose results (mean bias: −0.75[4.0] mg/dL, n=60, P=0.214). GMS2 results significantly differed from paired plasma glucose results (mean bias: −5.66[18.7] mg/dL, n=60, P=0.048). Ascorbic acid therapy elicited significant GMS2 performance bias (29.2[27.2], P<0.001). RCT results reported lower mean bias (P<0.001), glycemic variability (P<0.05), mean insulin rate (P<0.001), and frequency of hypoglycemia (P<0.001) in the GMS1 group than the GMS2 group. Conclusions Anemia and high dose ascorbic acid therapy negatively impact GMS accuracy and TGC in burn patients. Automatic correction of confounding factors improves glycemic control. Further studies are warranted to determine outcomes associated with accurate glucose monitoring during IIT.
Objective The goal of this study was to retrospectively evaluate the clinical impact of an accurate autocorrecting blood glucose monitoring system (BGMS) in children with severe burns. BGMS accuracy is essential for providing appropriate intensive insulin therapy (IIT) and achieving tight glycemic control (TGC) in critically ill patients. Unfortunately, few comparison studies have been performed to evaluate the clinical impact of accurate BGMS monitoring in the high-risk pediatric burn population. Design Retrospective analysis of an electronic health record system. Setting Pediatric burn intensive care unit at an academic medical center. Patients Children (age<18 years) with severe burns (≥20% total body surface area [TBSA]) receiving IIT guided by either a non-correcting (BGMS-1) or an autocorrecting BGMS (BGMS-2). Measurements and Main Results Patient demographics, insulin rates, and BGMS measurements were collected. Frequency of hypoglycemia and glycemic variability was compared between the two BGMS groups. A total of 122 patient charts from 2001–14 were reviewed. Sixty-three patients received IIT using BGMS-1 and 59 via BGMS-2. Patient demographics were similar between the two groups. Mean insulin infusion rates (5.1±3.8 U/hour, n = 535 paired measurements vs. 2.4±1.3 U/hour, n = 511 paired measurements, P<0.001), glycemic variability, and frequency of hypoglycemic events (90 vs. 12, P<0.001) were significantly higher in BGMS-1 treated patients. Compared to laboratory measurements, BGMS-2 yielded the most accurate results (mean±SD bias: −1.7±6.9 mg/dL [−0.09±0.4 mmol/L] vs. 7.4±13.5 mg/dL [0.4±0.7 mmol/L]). BGMS-2 patients achieve glycemic control more quickly (5.7±4.3 hours vs. 13.1±6.9 hours, P<0.001) and stayed within the target glycemic control range longer compared to BGMS-1 patients (85.2±13.9% vs. 57.9±29.1%, P<0.001). Conclusions Accurate autocorrecting BGMS optimizes IIT, improves TGC, and reduces risk for hypoglycemia and glycemic variability. The use of an autocorrecting BGMS for IIT may improve glycemic control in severely burned children.
Point-of-care (POC) testing allows for medical testing to be performed across the disaster-emergency-critical care continuum. The disaster-emergency-critical care continuum begins with the identification of at-risk patients, followed by patient stabilization, and ultimately transfer to an alternate care facility or mobile hospital for comprehensive critical care. Gaps at the interfaces for each of these settings leads to excess mortality and morbidity. Disaster victims are at risk for acute myocardial infarctions, acute kidney injury (AKI), and sepsis. However cardiac biomarker testing, renal function testing, and multiplex rapid pathogen detection are often unavailable or inadequate during disasters. Cardiac biomarker reagents require refrigeration; traditional renal function tests (i.e., serum creatinine) exhibit poor sensitivity for predicting AKI in critically ill patients, and culture-based pathogen detection is too slow to help initiate early-directed antimicrobial therapy. We propose three value propositions detailing how rapid, POC, and environmentally hardened cardiac biomarker, AKI and multiplex pathogen testing harmonizes the interface between disaster, emergency, and critical care.
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