Technology for Hospital Management of Diabetes: Evaluation of Implementation of a Fully Automated Algorithm (Enhanced Model Predictive Control) in an Interacting Infusion Pump System for Establishment of Tight Glycemic Control in Medical Intensive Care Unit Patients

Background

The objective of this study was to investigate the performance of a newly developed decision support system for the establishment of tight glycemic control in medical intensive care unit (ICU) patients for a period of 72 hours.

Methods

This was a single-center, open, non-controlled feasibility trial including 10 mechanically ventilated ICU patients. The CS-1 decision support system (interacting infusion pumps with integrated enhanced model predictive control algorithm and user interface) was used to adjust the infusion rate of administered insulin to normalize blood glucose. Efficacy and safety were assessed by calculating the percentage of values within the target range (80–110 mg/dl), hyperglycemic index, mean glucose, and hypoglycemic episodes (<40 mg/dl).

Results

The percentage of values in time in target was 47.0% (±13.0). The average blood glucose concentration and hyperglycemic index were 109 mg/dl (±13) and 10 mg/dl (±9), respectively. No hypoglycemic episode (<40 mg/dl) was detected. Eleven times (1.5% of all given advice) the nurses did not follow and, thus, overruled the advice of the CS-1 system. Several technical malfunctions of the device (repetitive error messages and missing data in the data log) due to communication problems between the new hardware components are shortcomings of the present version of the device. As a consequence of these technical failures of system integration, treatment had to be stopped ahead of schedule in three patients.

Conclusions

Despite technical malfunctions, the performance of this prototype CS-1 decision support system was, from a clinical point of view, already effective in maintaining tight glycemic control. Accordingly, and with technical improvement required, the CS-1 system has the capacity to serve as a reliable tool for routine establishment of glycemic control in ICU patients.     

Sucralfate in the treatment and prevention of gastric ulcer: multicentre double blind placebo controlled study.

A randomised controlled multicentre trial was performed in 160 patients with gastric ulcer, proved by endoscopy and biopsy, to compare ulcer healing with sucralfate and ranitidine (double blind double dummy design) and to assess the effect of maintenance treatment with sucralfate on ulcer recurrence (double blind placebo controlled design). The healing rates were similar with 4 g sucralfate suspension per day and 300 mg ranitidine per day (82% and 88% after 12 weeks, respectively). Of the 109 patients with healed ulcers, 92 were entered into the maintenance trial and treated with sucralfate tablets (2 g per day) or placebo tablets. Maintenance treatment with sucralfate delayed symptoms of gastric ulcer recurrence. Lifetable analysis showed significant differences between sucralfate and placebo, both after six months (p = 0.018) and after 12 months (p = 0.044). The rates of symptom recurrences were 13% and 34% after six months and 34% and 55% after 12 months for sucralfate and placebo, respectively. The rate of asymptomatic recurrences after 12 months was similar in the two groups (9% and 10%, respectively). The recurrence rate was higher in patients who had never taken non-steroidal anti-inflammatory drugs than in those who had but had stopped on admission to the study. It was also higher in patients with recurrent ulcer and in those with scarring deformation and narrowing of the pylorus. Maintenance treatment with sucralfate slowed the appearance of symptom recurrences of gastric ulcer.     

Altered parenting and the reconstituted family

Reconstituted families are a high incidence phenomena in contemporary society. Because the family continues to be a focus for the delivery of nursing care, nurses must now address the special needs of individuals who are members of reconstituted families. Studies in this area provide important background information regarding behavioral patterns in reconstituted families that can be used for assessment and intervention with these families. Through the use of focused assessment parameters, nurses can collect data that will indicate the special needs of members of reconstituted families. In general, nursing interventions with clients who are a part of a reconstituted family fall into two major categories: (a) developing positive parenting behaviors, and (b) protecting the development of the stepchild.     

Reconstruction of the arteria carotis communis in newborn following extracorporeal membrane oxygenation (ECMO).

With the help of ECMO it is possible to save the lives of newborn infants suffering from severe respiratory distress syndrome not responding to conservative treatment. Using Bartlett's classic venous-arterial perfusion technique in ECMO the right arteria carotis communis had to be sacrificed. Thus, despite the life-saving character of this new method, the ligation of the carotid with all its possible complications had often been a major argument against using this therapy. We are now therefore trying to reconstruct the arteria carotis after decannulating the vessel after extracorporeal membrane oxygenation. In our 8 cases so far, post-op examinations showed no obstruction of blood flow in the vessel. No neurological deficiencies were recorded.     

Therapy of giant aneurysms in the region of the base of the skull

The introduction of microsurgical techniques has given a new impetus to operative therapy of cerebral aneurysms. Method of choice is clip occlusion of the aneurysmal neck, but this goal cannot always be attained. Usually, fusiform shaped aneurysms and so-called giant aneurysms can only be treated by occlusing the feeding vessels. In such cases the preliminary extra-intracranial bypass provides optimal conditions for interrupting the main feeder. Special points of view regarding these rare aneurysms and their haemodynamic relationships to cerebral circulation are discussed. A therapeutical concept is proposed on the basis of three case reports.     

Amiodarone-mediated increase in intracellular free Ca2+ associated with cellular injury to human pulmonary artery endothelial cells

The cardiac antidysrrhythmic drug amiodarone can give rise to potentially fatal pulmonary toxicity in large numbers of patients. The effect of amiodarone on Ca2+ homeostasis and cell injury has been studied using human pulmonary artery endothelial (HPAE) cells in vitro. Amiodarone produced a concentration-dependent increase in intracellular free Ca2+ concentration ( [Ca2+]i) to micromolar levels that are similar to those seen with physiological stimuli that increase [Ca2+]i. Unlike physiological stimuli, the rise in [Ca2+]i produced by amiodarone developed slowly and was maintained over at least 30 min. Omitting Ca2+ from the external medium reversibly prevented the amiodarone-induced rise in [Ca2+]i. Amiodarone treatment increased the apparent first order rate constants for 45Ca2+ influx and efflux in intact HPAE cells. 45Ca2+ accumulation into the endoplasmic reticulum of saponin-permeabilized HPAE cells was decreased by amiodarone treatment. The release of 45Ca2+ from the endoplasmic reticulum stores by the putative intracellular second messengers inositol-1,4,5-trisphosphate, arachidonic acid, and Ca2+ was blocked by amiodarone treatment. The changes in Ca2+ homeostasis coincide with an increase in [3H]deoxyglucose release as a measure of early cell injury by amiodarone. It is concluded that amiodarone can produce an increase in [Ca2+]i by an action on the plasma membrane that allows the influx of external Ca2+. This increase in [Ca2+]i, together with other changes in Ca2+ homeostasis, may be responsible for the early cell injury associated with amiodarone toxicity.