Dynamic tight glycemic control during and after cardiac surgery is effective, feasible, and safe.

BACKGROUND: Tight blood glucose control reduces mortality and morbidity in critically ill patients, but intraoperative glucose control during cardiac surgery is often difficult, and risks hypoglycemia. In this study, we evaluated the safety and efficacy of a nurse-driven insulin protocol (the Aalst Glycemia Insulin Protocol) for achieving a target glucose level of 80-110 mg/dL during cardiac surgery and in the intensive care unit (ICU). METHODS: We included 483 nondiabetics and 168 diabetics scheduled for cardiac surgery with cardiopulmonary bypass. To anticipate rapid perioperative changes in insulin requirement and/or sensitivity during surgery, we developed a dynamic algorithm presented in tabular form, with rows representing blood glucose ranges and columns representing insulin dosages based on the patients' insulin sensitivity. The algorithm adjusts insulin dosage based on blood glucose level and the projected insulin sensitivity (e.g., reduced sensitivity during cardiopulmonary bypass and normalizing sensitivity after surgery). RESULTS: A total of 18,893 blood glucose measurements were made during and after surgery. During surgery, the mean glucose level in nondiabetic patients was within targeted levels except during (112 +/- 17 mg/dL) and after rewarming (113 +/- 19 mg/dL) on cardiopulmonary bypass. In diabetics, blood glucose was decreased from 121 +/- 40 mg/dL at anesthesia induction to 112 +/- 26 mg/dL at the end of surgery (P < 0.05), with 52.9% of patients achieving the target. In the ICU, the mean glucose level was within targeted range at all time points, except for diabetics upon ICU arrival (113 +/- 24 mg/dL). Of all blood glucose measurements (operating room and ICU), 68.0% were within the target, with 0.12% of measurements in nondiabetics and 0.18% in diabetics below 60 mg/dL. Hypoglycemia < 50 mg/dL was avoided in all but four (0.6%) patients (40 mg/dL was the lowest observed value). CONCLUSIONS: The Aalst Glycemia Insulin Protocol is effective for maintaining tight perioperative blood glucose control during cardiac surgery with minimal risk of hypoglycemia.

Implementing a Reminder System in the Northern Part of Belgium to Stimulate Postpartum Screening for Glucose Intolerance in Women with Gestational Diabetes: The "Sweet Pregnancy" Project.

AIMS: To evaluate the feasibility and efficacy of a gestational diabetes (GDM) recall register on the long-term screening uptake postpartum and to evaluate the prevalence of prediabetes postpartum. METHODS: Evaluation of a GDM recall register implemented in 66 obstetrical centers in the northern part of Belgium from 2009 to 2016. Registrants receive yearly reminders to have a fasting plasma glucose test in primary care to timely detect prediabetes. RESULTS: After 6 years, 7269 women were registered. The yearly response rates varied from 74.4% after the first year to 61.8% after the fifth year. The number of women who reported a screening test varied from 67.4% after the first year to 71.9% after the fifth year. Compared to women who responded at least once to a reminder, women who never responded were more often <30 years (41.4% versus 33.9%, p < 0.001) and were more often obese (29.3% versus 20.8%, p ≤ 0.001). Over a period of 6 years, 7.3% (CI 6.0%-8.8%) developed diabetes and 27.4% (CI 23.9%-31.0%) developed impaired fasting glycaemia. CONCLUSION: We show now the long-term feasibility and efficacy of a GDM recall register to stimulate screening postpartum. One-third of women developed prediabetes within 6 years.

Considerations on blood glucose management in Type 2 diabetes mellitus.

In recent years the benefits of more intensive management in preventing or delaying the development and progression of diabetic complications have been well documented. What is not as well documented is how to motivate the person with diabetes to manage the condition, how to set, assess and quantify glucose goals, and the glucose variables that should be routinely measured. This review discusses the importance of setting targets and communicating them in a way that the patient understands. When aiming for a glycaemia target, balance is required (1) between achieving reduction of complications and causing an increased degree of hypoglycaemia, and (2) between what is achievable and what degree of benefit is gained. Target values given in guidelines should be adapted by the clinician to take into account the patient's susceptibility to hypoglycaemia, stage and type of complications, age and life expectancy, co-morbidity, social environment, understanding of the steps required and level of commitment to the treatment. Several suggestions are given regarding possible improvements and amendments to existing guidelines for diabetes management in treating to glucose goal. For example, attention should be drawn to the need to individualize goals and to consider education, long-term support, patient needs and treatment outcome when formulating diabetes management plans. The relative properties of the different glucose variables-fasting plasma glucose (FPG), postprandial plasma glucose (PPG), glycated haemoglobin A(1c) (HbA(1c)), and glycated protein-in terms of their convenience of measurement, usefulness and relevance to the physician and patient are also evaluated. When prioritising the variables to be measured it is suggested that where feasible, HbA(1c) should be the standard measurement by which to gauge risk and treatment efficacy. Serial measurements should be made and, where possible, the use of blood glucose meters encouraged, in order to obtain a blood glucose profile for the patient.