Subjecting Acute Ischemic Stroke Patients to Continuous Tube Feeding and an Intensive Computerized Protocol Establishes Tight Glycemic Control
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Tight glycemic control (TGC) after ischemic stroke may improve clinical outcome but previous studies failed to establish TGC, principally because of postprandial glucose surges. The aim of the present study was to investigate if safe, effective and feasible TGC can be achieved with continuous tube feeding and a computerized treatment protocol.
We subjected ten acute ischemic stroke patients with admission hyperglycemia (glucose >7.0 mmol/l (126.0 mg/dl)) to continuous tube feeding and a computerized intensive protocol with insulin adjustments every 1–2 h. Two groups of regularly fed patients from a previous study with a similar design served as controls. These groups comprised hyperglycemic patients treated according to an intermediate protocol with insulin adjustments at standard intervals (N = 13), and normoglycemic controls treated according to standard care (N = 15). The primary outcome was the percentage of time within target (4.4–6.1 mmol/l (79.2–109.8 mg/dl)). Secondary outcome was the number of patients with hypoglycemic episodes (glucose <3.0 mmol/l (54.0 mg/dl)).
Median time within target was 55% in the continuously fed intensive group compared to 19% in the regularly fed intermediate group, and 58% in normoglycemic controls. Hypoglycemic episodes occurred in 20% of patients in the continuously fed group—lowest glucose level 2.4 mmol/l (43.2 mg/dl). In contrast, in the regularly fed group, this was 31%—lowest glucose level 1.6 mmol/l (28.8 mg/dl).
TGC after acute ischemic stroke is feasible with continuous tube feeding and a computerized intensive treatment protocol. Although glycemic control is associated with hypoglycemia, no severe hypoglycemia occurred in the continuous tube feeding group.
- Baird, TA, Parsons, MW, Phanh, T, Butcher, KS, Desmond, PM, Tress, BM (2003) Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke 34: pp. 2208-2214 CrossRef
- Capes, SE, Hunt, D, Malmberg, K, Pathak, P, Gerstein, HC (2001) Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 32: pp. 2426-2432 CrossRef
- Chalela, JA, Merino, JG, Warach, S (2004) Update on stroke. Curr Opin Neurol 17: pp. 447-451 CrossRef
- Els, T, Klisch, J, Orszagh, M, Hetzel, A, Schulte-Monting, J, Schumacher, M, Lucking, CH (2002) Hyperglycemia in patients with focal cerebral ischemia after intravenous thrombolysis: influence on clinical outcome and infarct size. Cerebrovasc Dis 13: pp. 89-94 CrossRef
- Parsons, MW, Barber, PA, Desmond, PM, Baird, TA, Darby, DG, Byrnes, G (2002) Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol 52: pp. 20-28 CrossRef
- Yong, M, Kaste, M (2008) Dynamic of hyperglycemia as a predictor of stroke outcome in the ECASS-II trial. Stroke 39: pp. 2749-2755 CrossRef
- Krinsley, JS (2004) Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc 79: pp. 992-1000 CrossRef
- Berghe, WA, Hermans, G, Meersseman, W, Wouters, PJ, Milants, I (2006) Intensive insulin therapy in the medical ICU. N Engl J Med 354: pp. 449-461 CrossRef
- Berghe, WA, Milants, I, Wouters, PJ, Bouckaert, B, Bruyninckx, F (2006) Intensive insulin therapy in mixed medical/surgical intensive care units: benefit versus harm. Diabetes 55: pp. 3151-3159 CrossRef
- Wiener, RS, Wiener, DC, Larson, RJ (2008) Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA 300: pp. 933-944 CrossRef
- Finfer, S, Chittock, DR, Su, SY, Blair, D, Foster, D, Dhingra, V (2009) Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360: pp. 1283-1297 CrossRef
- Griesdale DE, de Souza RJ, van Dam RM, Heyland DK, Cook DJ, Malhotra A. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ. 2009.
- Latorre JG, Chou SH, Nogueira RG, Singhal AB, Carter BS, Ogilvy CS. Effective glycemic control with aggressive hyperglycemia management is associated with improved outcome in aneurysmal subarachnoid hemorrhage. Stroke. 2009.
- Garg, R, Chaudhuri, A, Munschauer, F, Dandona, P (2006) Hyperglycemia, insulin, and acute ischemic stroke: a mechanistic justification for a trial of insulin infusion therapy. Stroke 37: pp. 267-273 CrossRef
- Martini, SR, Kent, TA (2007) Hyperglycemia in acute ischemic stroke: a vascular perspective. J Cereb Blood Flow Metab 27: pp. 435-451 CrossRef
- Gray, CS, Hildreth, AJ, Sandercock, PA, O’Connell, JE, Johnston, DE, Cartlidge, NE (2007) Glucose–potassium–insulin infusions in the management of post-stroke hyperglycaemia: the UK Glucose Insulin in Stroke Trial (GIST-UK). Lancet Neurol 6: pp. 397-406 CrossRef
- Langouche, L, Vanhorebeek, I, Berghe, G (2007) Therapy insight: the effect of tight glycemic control in acute illness. Nat Clin Pract Endocrinol Metab 3: pp. 270-278 CrossRef
- Berghe, G (2004) How does blood glucose control with insulin save lives in intensive care?. J Clin Invest 114: pp. 1187-1195
- Bruno, A, Saha, C, Williams, LS, Shankar, R (2004) IV insulin during acute cerebral infarction in diabetic patients. Neurology 62: pp. 1441-1442
- Hassan, E (2007) Hyperglycemia management in the hospital setting. Am J Health Syst Pharm 64: pp. S9-S14 CrossRef
- McCormick, MT, Muir, KW, Gray, CS, Walters, MR (2008) Management of hyperglycemia in acute stroke: how, when, and for whom?. Stroke 39: pp. 2177-2185 CrossRef
- Vriesendorp TM, Roos YBWEM, Kruyt ND, Biessels GJ, Kappelle LJ, Vermeulen M. Efficacy and safety of two 5-day insulin dosing regimens to achieve strict glycemic control in patients with acute ischemic stroke. J Neurol Neurosurg Psychiatry. 2009 (in press).
- Walters, MR, Weir, CJ, Lees, KR (2006) A randomised, controlled pilot study to investigate the potential benefit of intervention with insulin in hyperglycaemic acute ischaemic stroke patients. Cerebrovasc Dis 22: pp. 116-122 CrossRef
- Kreisel, SH, Berschin, UM, Hammes, HP, Leweling, H, Bertsch, T, Hennerici, MG (2009) Pragmatic management of hyperglycaemia in acute ischaemic stroke: safety and feasibility of intensive intravenous insulin treatment. Cerebrovasc Dis 27: pp. 167-175 CrossRef
- Bruno A, Kent TA, Coull BM, Shankar RR, Saha C, Becker KJ. Treatment of Hyperglycemia in Ischemic Stroke (THIS). A randomized pilot trial. Stroke. 2007.
- Johnston, KC, Li, JY, Lyden, PD, Hanson, SK, Feasby, TE, Adams, RJ (1998) Medical and neurological complications of ischemic stroke: experience from the RANTTAS trial. RANTTAS investigators. Stroke 29: pp. 447-453
- O’Neill, PA, Davies, I, Fullerton, KJ, Bennett, D (1991) Stress hormone and blood glucose response following acute stroke in the elderly. Stroke 22: pp. 842-847
- Christensen, H, Boysen, G, Johannesen, HH (2004) Serum-cortisol reflects severity and mortality in acute stroke. J Neurol Sci 217: pp. 175-180 CrossRef
- Vancheri, F, Curcio, M, Burgio, A, Salvaggio, S, Gruttadauria, G, Lunetta, MC (2005) Impaired glucose metabolism in patients with acute stroke and no previous diagnosis of diabetes mellitus. QJM 98: pp. 871-878 CrossRef
- Kernan, WN, Viscoli, CM, Inzucchi, SE, Brass, LM, Bravata, DM, Shulman, GI (2005) Prevalence of abnormal glucose tolerance following a transient ischemic attack or ischemic stroke. Arch Intern Med 165: pp. 227-233 CrossRef
- Braithwaite, SS (2008) Inpatient insulin therapy. Curr Opin Endocrinol Diabetes Obes 15: pp. 159-166
- Hermayer, KL, Neal, DE, Hushion, TV, Irving, MG, Arnold, PC, Kozlowski, L (2007) Outcomes of a cardiothoracic intensive care web-based online intravenous insulin infusion calculator study at a Medical University Hospital. Diabetes Technol Ther 9: pp. 523-534 CrossRef
- Cordingley, JJ, Vlasselaers, D, Dormand, NC, Wouters, PJ, Squire, SD, Chassin, LJ (2009) Intensive insulin therapy: enhanced model predictive control algorithm versus standard care. Intensive Care Med 35: pp. 123-128 CrossRef
- Hovorka, R, Kremen, J, Blaha, J, Matias, M, Anderlova, K, Bosanska, L (2007) Blood glucose control by a model predictive control algorithm with variable sampling rate versus a routine glucose management protocol in cardiac surgery patients: a randomized controlled trial. J Clin Endocrinol Metab 92: pp. 2960-2964 CrossRef
- Plank, J, Blaha, J, Cordingley, J, Wilinska, ME, Chassin, LJ, Morgan, C (2006) Multicentric, randomized, controlled trial to evaluate blood glucose control by the model predictive control algorithm versus routine glucose management protocols in intensive care unit patients. Diabetes Care 29: pp. 271-276 CrossRef
- Brunkhorst, FM, Engel, C, Bloos, F, Meier-Hellmann, A, Ragaller, M, Weiler, N (2008) Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 358: pp. 125-139 CrossRef
- Courten-Meyers, , Kleinholz, M, Wagner, KR, Myers, RE (1994) Normoglycemia (not hypoglycemia) optimizes outcome from middle cerebral artery occlusion. J Cereb Blood Flow Metab 14: pp. 227-236
- Zhu, CZ, Auer, RN (2004) Optimal blood glucose levels while using insulin to minimize the size of infarction in focal cerebral ischemia. J Neurosurg 101: pp. 664-668 CrossRef
- Chase, JG, Shaw, GM (2007) Is there more to glycaemic control than meets the eye?. Crit Care 11: pp. 160 CrossRef
- Hovorka, R (2008) The future of continuous glucose monitoring: closed loop. Curr Diabetes Rev 4: pp. 269-279 CrossRef
- Wong, AA, Schluter, PJ, Henderson, RD, O’Sullivan, JD, Read, SJ (2008) Natural history of blood glucose within the first 48 hours after ischemic stroke. Neurology 70: pp. 1036-1041 CrossRef
- Subjecting Acute Ischemic Stroke Patients to Continuous Tube Feeding and an Intensive Computerized Protocol Establishes Tight Glycemic Control
Volume 12, Issue 1 , pp 62-68
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- Acute ischemic stroke
- Stroke unit
- Tight glycemic control
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- Author Affiliations
- 1. Department of Neurology, Academic Medical Center, University of Amsterdam, P.O. Box 22700, 1100 DE, Amsterdam, the Netherlands
- 2. Department of Neurology, Rudolf Magnus Institute for Neuroscience, University Medical Center, Utrecht, the Netherlands
- 3. Department of Internal Medicine, Academic Medical Center, Amsterdam, the Netherlands
- 4. Department of Anesthesia, Intensive Care and Pain Management, St. Antonius Hospital, Nieuwegein, the Netherlands
- 5. Department of Neurology, Onze Lieve Vrouwen Gasthuis, Amsterdam, the Netherlands