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Archived Comments for: Tight glycaemic control: a prospective observational study of a computerised decision-supported intensive insulin therapy protocol

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  1. Ultradian variation in blood glucose of ICU patients

    Stephen Smith, OHSU

    13 November 2007

    Stephen M. Smith F.J.F.I.C.M., Ph.D. & Daniel S. Hagg M.D.

    Affiliation: Department of Medicine, Division of Pulmonary & Critical Care Medicine (SMS, DSH) Center for Intensive Care Research (SMS, DSH), and Department of Physiology & Pharmacology (SMS)

    Shulman and colleagues strongly advocate the accurate and full description of glucose values when reporting studies of insulin use in the critically ill[1]. This information is essential to define the goal for intensivists attempting to improve outcome by controlling glucose. They report large variation of blood glucose using their computerized decision supported protocol, achieving the target range only 23% of the time. It is important to ask what is the cause for such high variability? De Graaff and colleagues propose that it may reflect an overly complex protocol [2]. Others have pointed out the importance of “a strong leader... and clear guidelines” in establishing tight blood glucose[3]. We suggest an additional contribution towards glucose variation- an ultradian rhythm. We found that glucose varies over the course of the day peaking at ~ 11 am and 10 pm in ICU patients receiving insulin [4]. While the mechanism still remains to be determined the pattern has also been observed in non-critically ill patients with insulin resistance[5]. An ultradian rhythm may underlie some of the glucose variance observed by Shulman and colleagues. Consideration of this pattern in the design of insulin protocols may improve glucose control in the critically ill.

    1. Shulman R, Finney SJ, O'Sullivan C, Glynne PA, Greene R: Tight glycaemic control: a prospective observational study of a computerised decision-supported intensive insulin therapy protocol. Crit Care 2007, 11(4):R75.

    2. de Graaff MJ, Spronk PE, Schultz MJ: Tight glycaemic control: intelligent technology or a nurse-wise strategy? Crit Care 2007, 11(5):421.

    3. Vanhorebeek I, Langouche L, Van den Berghe G: Tight blood glucose control with insulin in the ICU: facts and controversies. Chest 2007, 132(1):268-278.

    4. Smith SM, Oveson KE, Strauss W, Raven K, Lefevre MC, Ahmann AJ, Hagg DS: Ultradian variation of blood glucose in intensive care unit patients receiving insulin infusions. Diabetes Care 2007, 30(10):2503-2505.

    5. Pistrosch F, Koehler C, Wildbrett J, Hanefeld M: Relationship between diurnal glucose levels and HbA1c in type 2 diabetes. Horm Metab Res 2006, 38(7):455-459.

    Competing interests

    Stephen M. Smith and Daniel S. Hagg have no competing interests to disclose.