PubMed Health⌕ Search

Biomedical subjects

Susan S Braithwaite

Publications and source records attributed to Susan S Braithwaite.

8 recordsLinked to original sources
PubMed2006

Effects of outcome on in-hospital transition from intravenous insulin infusion to subcutaneous therapy.

It is widely accepted by medical practitioners that diabetes is a major independent risk factor for the development of cardiovascular disease. However, less attention has been directed toward elevated blood glucose as a predictor of poor outcomes in hospitalized patients in cardiac critical care. This has occurred despite documentation of hyperglycemia in a significant proportion of patients admitted for cardiac care and considerable data supporting the use of intravenous (IV) insulin to achieve glycemic control. The increased risk for mortality due to hyperglycemia provides a strong rationale for an intensive approach using insulin to control blood glucose levels in cardiac patients being treated in acute care and surgical settings. IV insulin infusion is the therapy of choice for patients in cardiac critical care units, with transition to a subcutaneous insulin therapy regimen when appropriate. The timing of this transition can be critical. Strong evidence from studies on patients who have undergone cardiac surgery suggests that glycemic control by insulin infusion should be maintained for > or =3 postoperative days. Nonetheless, transition from IV to subcutaneous therapy must occur at some point during the hospital stay. In conclusion, the implementation of measures to achieve glycemic control in acute cardiac care hospital settings can significantly reduce morbidity and mortality and can substantially decrease the costs associated with prolonged hospital stays. This report reviews recent clinical data on the benefits of IV insulin infusion in cardiac patients in critical care and provides recommendations on transitioning patients from IV insulin infusion to subcutaneous therapy.

Blood Glucose↗
PubMed2006

Performance of a dose-defining insulin infusion protocol among trauma service intensive care unit admissions.

BACKGROUND: Among critically ill patients, glycemic control reduces mortality and morbidities, but the use of intravenous insulin infusion is complicated by hypoglycemia. Having a standardized algorithm increases the likelihood of effective and safe utilization of intravenous insulin therapy. A tabular dose-defining protocol for intravenous insulin infusion is described, containing design elements intended to minimize risk for hypoglycemia while seeking control in a narrow target range, and performance is evaluated among critically ill trauma service patients. METHODS: The protocol assigns insulin infusion rate (IR) for ranges of blood glucose (BG). The columns are arranged in order of increasing maintenance rate (MR) for insulin infusion. Patient column assignment is determined according to rate of change of BG. During stable column assignment, the IR is a function of column MR and BG. Within-column, the protocol formula provides that (a) for BG between 70 mg/dL and target BG, the IR increases exponentially to the column MR; and (b) for BG above upper target BG range, the IR increases linearly as an adaptation of the rule of 1800, with slope determined by the column MR. Values for IR calculated by formula are rounded to correspond to BG ranges of the table. Performance was assessed in 27 sequential runs among 24 trauma service patients admitted to a surgical intensive care unit (2004-2005). RESULTS: Using point-of-care measurements, mean preinfusion BG was 230.0 +/- 67.9 mg/dL. BG < 140 mg/dL was reached during all 27 runs (median time 5.0 h), and target BG was < 110 mg/dL during 25 runs (median time 11.0 h). For the group of runs attaining target before interruption of insulin infusion, the average +/- SD of the principal measure of glycemic control, the within-run mean BG, was 113.7 +/- 14.8 mg/dL (coefficient of variation 13%, n = 25 runs). After attaining target, the average within-run SD for BG was 22.9 mg/dL. The within-run frequency of hypoglycemic measurements (BG < 70 mg/dL) as a percentage of BG determinations was 2.4%. In this series, no instance of BG <50 mg/dL was seen. CONCLUSIONS: This report describes a nurse-implemented tabular protocol for intravenous insulin infusion having the advantages of efficacy, safety, and simplicity of use. Wide variability of IR in the neighborhood of BG 110 mg/dL is associated with stable BG response, and protection against hypoglycemia is achieved by rapid decline of IR at BGs in or below the target range.

Adult↗
PubMed1991

Anticruelty care: commentary.

The anticruelty policy is a best-interests test for treatment plans including decisions to forgo life-sustaining therapy for certain incompetent patients. In connection with specific proposed therapy, the policy requires no reference to the patient's unknowable values, subjective experiences, or quality of life. The decision to undertake a treatment plan derives from the caregiver's knowledge of burdens and benefits of that treatment when used in caring for the competent or for those incompetents capable of growth or repair. The caregiver should weigh the potentially cruel effects of treatment against the likelihood of reducing suffering or encumbrance with the treatment. The terms "burden" and "benefit," in fact, are replaced by the terms "cruelty" and "beneficence," as the relevant opposing outcomes that must be weighed. Thus, the anticruelty policy shifts our scrutiny from experiences of the patient that we cannot evaluate to the proposed actions of the competent decision makers and caregivers. Notably, it is a protreatment policy when the goals of medicine are attainable; and it is an anticruelty policy when they are not. The policy does evaluate the world of the patient to the extent that it requires a judgment based upon external appearances about patient pleasure or happiness in living. It presumes to universalize larger societal values about cruelty, beneficence, compassionate concern for the helpless, and certain rights of individuals. And it presumes to universalize on the patient's behalf specific medical values about hopeless injury, timely death, the goals of medicine, and cruelty, which should remain open to societal discussion and revision. The presented definition of hopeless injury does not require brain death, coma, or persistent vegetative state. Specifically, the policy holds that death is timely for a patient with hopeless injury, and that prevention of death for such patients is not a goal of medicine but a cruelty.

Aged↗
PubMedDate not supplied

Intravenous insulin infusion therapy: indications, methods, and transition to subcutaneous insulin therapy.

OBJECTIVE: To describe indications for intravenous (IV) insulin infusion therapy and glycemic thresholds, discuss methods and protocols, and promote use of and access to IV insulin infusion therapy for all appropriate patients in the hospital setting. RESULTS: Randomized, prospectively designed trials support the use of IV insulin infusion therapy for patients in the surgical intensive-care unit, including postoperative cardiac patients and patients having myocardial infarction. Among patients in the surgical intensive-care unit, reanalysis of the data suggested no threshold at which benefit occurred above the blood glucose level of 110 mg/dL. In another study, retrospective analysis of data among critically ill medical and surgical patients suggested a target blood glucose level of 145 mg/dL or less. In other populations, the threshold or ideal target blood glucose range has not been determined. Three protocols for IV insulin infusion are described that maintain blood glucose levels safely below the upper limit of their respective target ranges without substantial risk of hypoglycemia. CONCLUSION: The threshold for initiation of IV insulin infusion is 110 mg/dL for critically ill surgical patients, 140 mg/dL for other medical or surgical patients, 180 mg/dL for patients in whom subcutaneous insulin regimens fail, and 100 mg/dL for pregnant women. The blood glucose target range is 80 to 110 mg/dL for selected critically ill surgical patients, 70 to 100 mg/dL for pregnant women, and 90 to 140 mg/dL for all other patients. Hospitals should develop procedures to make IV insulin infusion therapy available to all appropriate patients.

Algorithms↗
PubMedDate not supplied

Hospital hypoglycemia: not only treatment but also prevention.

OBJECTIVE: To propose a strategy, applicable on general hospital wards, for prevention of hypoglycemia in hospitalized patients. RESULTS: Although the mortality rate among hospitalized patients with hypoglycemia has been shown to be 22.2 to 27% in series that included patients with diabetes, some investigators have shown that hypoglycemia is not an independent predictor of mortality. Outside the critical care setting, the comparative risks of hyperglycemia and hypoglycemia and the relationship of hospital hypoglycemia to intensification of glycemic control have not been determined. The reported incidence of hospital hypoglycemia ranges from 1.2% for hospitalized adults to 20% for nonpregnant patients with diabetes admitted without a metabolic emergency. Among patients receiving antihyperglycemic therapy, the literature describes precipitating events--usually a sudden change of caloric exposure-- and predisposing conditions for hypoglycemic episodes. CONCLUSION: Hospital hypoglycemia is predictable, and it is preventable by measures other than undertreatment of hyperglycemia. Physician orders for antihyperglycemic therapy should be written and, if necessary, be revised so as to respond to the presence of predisposing conditions for hypoglycemia. A ward-based protocol or hospital-wide policy should establish the appropriate response to triggering events. Within the time frame of action of previously administered antihyperglycemic drugs (after abrupt interruption of caloric exposure), the threshold for preventive intravenous administration of dextrose is a glucose concentration of 120 mg/dL.

Humans↗
PubMedDate not supplied

No patient left behind: evaluation and design of intravenous insulin infusion algorithms.

OBJECTIVE: To define the characteristics of performance evaluation, algorithm design, and regulation of insulin delivery by which professionals and the healthcare system might differentiate between methodologies for intravenous insulin infusion. METHODS: Published performance criteria used in the assessment of intravenous insulin infusion algorithms are classified. The structure of intravenous insulin infusion formulae is reviewed, as are technologies that might lead to future improvement. RESULTS: Among published reports, no standardization was discernable for description of algorithm characteristics or performance. Except for time-to-target and hypoglycemic episodes, measures using the patient as unit of observation are not employed consistently. CONCLUSION: The healthcare system needs criteria for evaluation and minimal acceptable standards for assessing performance of any algorithm, decision support system, or closed-loop system for intravenous insulin infusion. Inclusion of patient-based measures is necessary to assess the ability of an algorithm to control variability between patients and within a given run. Standardization of performance reporting will help users to select appropriate methodologies.

Algorithms↗
PubMedDate not supplied

Description and evaluation of a glycemic management protocol for patients with diabetes undergoing heart surgery.

OBJECTIVE: To evaluate a protocol for glycemic management in the treatment of postoperative heart patients with diabetes in the setting of a community hospital. METHODS: The protocol included a standardized guideline in tabular form for nurse-implemented insulin infusion ("drip") therapy for postoperative glycemic control. At the time of discontinuation of the insulin drip, the glycemic status of patients with diabetes was managed by the endocrine department. Overall, 29 patients were assessed without and 29 patients with use of the protocol in a community hospital. RESULTS: From postoperative days 0 through 4, use of the protocol resulted in a greater number of blood glucose determinations, a trend toward greater utilization of insulin drip therapy without a significant increase in the number of patients treated with insulin drip, and no change in the frequency of hypoglycemic episodes. During the same time interval, the percentages of postoperative days during which at least one blood glucose value equaled or exceeded 250 mg/dL were 27.5% without the protocol and 16.8% with use of the protocol (P = 0.0318). The principal finding of the study was reduction in the percentage of postoperative days during which mean blood glucose values equaled or exceeded 200 mg/dL to less than half the previously observed frequency-from 38.4% without the protocol to 16.8% with the protocol (P = 0.0001). The effectiveness of the insulin drip component of the protocol is suggested by a trend, shown on postoperative days 2 through 4, of 70 patient days with mean blood glucose levels <200 mg/dL (58 of these days without insulin drip therapy) and 15 patient days with mean blood glucose values > or =200 mg/dL (none of these days associated with same-day insulin drip therapy). CONCLUSION: A standardized approach to insulin drip therapy, in combination with subspecialty consultation for follow-up glycemic management with use of subcutaneous administration of insulin, can improve glycemic control in postoperative heart patients without continuation of insulin drip therapy outside the critical-care unit. The trends observed on postoperative days 2 through 4, that most patients maintained glycemic control without insulin drip therapy and that all failures of glycemic control occurred among patients who no longer received insulin drip therapy, suggest the possibility of developing criteria for selection of patients for continuation of insulin infusion outside the critical-care unit.

Aged↗