Manejo da hiperglicemia no paciente hospitalizado não crítico / Management of hyperglycemia in non critical hospitalized patients

Vários estudos observacionais apontam forte associação entre hiperglicemia nos pacientes hospitalizados e desfechos clínicos desfavoráveis, incluindo tempo de internação prolongado, infecção, incapacidade após alta hospitalar e morte. A Associação Americana de Endocrinologistas Clínicos (AACE) e a Associação Americana de Diabetes(ADA) sugerem que a insulinoterapia seja iniciada para o tratamento de hiperglicemia persistente a partir de níveis de glicemia de 180 mg/dL. Para a maioria dos pacientes não críticos internados, a metaglicêmica pré-prandial é <140 mg/dL e a casual <180mg/dL. O esquema de insulinização basal-bolus em associação com doses corretivas ou suplementares para o controle da hiperglicemia pré-prandial é a abordagem recomendada. O plano de alta, a educação do paciente durante a internação e a comunicação clara com os cuidadoressão fundamentais para garantir transição segura para o manejo ambulatorial da glicemia.

Several observational studies suggest a strong association between inpatient hyperglycemia (with or without diabetes) and adverse clinical outcomes, including prolonged hospitalization, infection, disability after hospital discharge and death.The American Association of Clinical Endocrinologists (AACE) and American Diabetes Association (ADA) suggest that insulin therapy is initiated for the treatment of persistent hyperglycemia from glucose levels of 180mg/dL. For most noncritically inpatients, usually the goal of premeal blood glucose should be<140mg/dL and random blood glucose < 180mg/dL. The scheme of basal-bolus insulin, in combination with corrective or additional doses to control premeal hyperglycemia is the recommended approach. Discharge planning, patient education and clear communication with outpatient providers are critical forensuring a safe transition to outpatient glycemic management.

Development of a Critical Pathway of Barbiturate Coma Therapy in the Management for Severe Brain Damage / 간호행정학회지

PURPOSE: This study is a descriptive research to analyze prognostic factors of barbiturate coma therapy (BCT) for severe brain damage patients, to develop a critical pathway (CP) based on the results of analysis and to examine the effect of its clinical application. METHOD: We analyzed medical records of 76 patients who received BCT for more than three days between January 1999 to July 2005. Based on the results of the analysis, we developed a CP and applied it to 12 people during August-December of 2005. RESULT: By application of BCT CP, the mortality rate decreased from 31.6% to 16.7%. It was found that the period of staying at ICU and total period of hospitalization were shortened by 2.78 (13.9%) days and 16.43 (29.4%) days, respectively. The Glasgow coma scale of the recovery group by CP application was 9.03 (4.64) at 72 hours post of BCT and 14.28 (1.82) at discharge from hospital, and DRS was 6.62 (6.38) points. CONCLUSION: By verifying clinical validity of the suggested CP, we believe that we have obtained visible effects standardizing the treatment pathway of BCT for brain damage patients.

Development of a Critical Pathway of Barbiturate Coma Therapy in the Management for Severe Brain Damage / 간호행정학회지

PURPOSE: This study is a descriptive research to analyze prognostic factors of barbiturate coma therapy (BCT) for severe brain damage patients, to develop a critical pathway (CP) based on the results of analysis and to examine the effect of its clinical application. METHOD: We analyzed medical records of 76 patients who received BCT for more than three days between January 1999 to July 2005. Based on the results of the analysis, we developed a CP and applied it to 12 people during August-December of 2005. RESULT: By application of BCT CP, the mortality rate decreased from 31.6% to 16.7%. It was found that the period of staying at ICU and total period of hospitalization were shortened by 2.78 (13.9%) days and 16.43 (29.4%) days, respectively. The Glasgow coma scale of the recovery group by CP application was 9.03 (4.64) at 72 hours post of BCT and 14.28 (1.82) at discharge from hospital, and DRS was 6.62 (6.38) points. CONCLUSION: By verifying clinical validity of the suggested CP, we believe that we have obtained visible effects standardizing the treatment pathway of BCT for brain damage patients.

Efficacy of Low Dose Barbiturate Coma Therapy for the Patients with Intractable Intracranial Hypertension Using the Bispectral(TM) Index Monitoring

OBJECTIVE: Barbiturate coma therapy (BCT) is a useful method to control increased intracranial pressure (IICP) patients. However, the complications such as hypotension and hypokalemia have caused conditions that stopped BCT early. The complications of low dose BCT with Bispectral(TM) index (BIS) monitoring and those of high dose BCT without BIS monitoring have been compared to evaluate the efficacy of low dose BCT with BIS monitoring. METHODS: We analyzed 39 patients with high dose BCT group (21 patients) and low dose BCT group (18 patients). Because BIS value of 40-60 is general anesthesia score, we have adjusted the target dose of thiopental to maintain the BIS score of 40-60. Therefore, dose of thiopental was kept 1.3 to 2.6 mg/kg/hour during low dose BCT. However, high dose BCT consisted of 5 mg/kg/hour without BIS monitoing. RESULTS: The protocol of BCT was successful in 72.2% and 38.1% of low dose and high dose BCT groups, respectively. The complications such as QT prolongation, hypotension and cardiac arrest have caused conditions that stopped BCT early. Hypokalemia showed the highest incidence rate in complications of both BCT. The descent in potassium level were 0.63 +/- 0.26 in low dose group, and 1.31 +/- 0.48 in high dose group. The treatment durations were 4.89 +/- 1.68 days and 3.38 +/- 1.24 days in low dose BCT and high dose BCT, respectively. CONCLUSION: It was proved that low dose BCT showed less severe complications than high dose BCT. Low dose BCT with BIS monitoring provided enough duration of BCT possible to control ICP.

Management of Complex Regional Pain Syndrome Type 1 with Barbiturate Coma Therapy: A case report / 대한통증학회지

Although various treatments for complex regional pain syndrome (CRPS) have been proposed, no well recognized treatment for CRPS has been established. Herein, a case using barbiturate coma therapy for the refractory pain management of a 24-year-old male patient, who suffered from constant stabbing and burning pain, with severe touch allodynia in the left upper extremity following blunt trauma on his forearm is described. Interventional treatments, including permanent spinal cord stimulation and large doses of oral medications, were performed. However, the pain could not be controlled, which lead to frequent emergency room treatment for about 1 month prior to his therapy. He then underwent barbiturate coma therapy due to the uncontrollable pain, with repeated sedation therapy due to his outrageous behavior. His pain became increasingly tolerable and the allodynia was markedly decreased after 5 days of coma therapy.

Barbiturate Coma Therapy in Severe and Refractory Vasospasm Following Subarachnoid Hemorrhage

OBJECTIVE: This study is designed to evaluate the therapeutic effects and prognostic factors for barbituate coma therapy(BCT)in severe and refractory vasospasm following subarachnoid hemorrhage. METHODS: Barbiturate coma therapy was used in 18 patients with severe and refractory vasospasm in spite of "3-H therapy" and intra-arterial papaverine infusion. The authors analyzed the clinical parameters including Glasgow Coma Scale(GCS), electroenceplographic finding, and brain computerized tomography(CT) scan findings in relation to outcome at discharge. RESULTS: Among 18 patients, burst suppression pattern could be obtained in 17. In cases with good outcome, the duration elapsed from coma to drowsiness after BCT was 14.09+/-5.82 days and GCS score at this time was significant in the prediction of final outcome(p<0.05). Patients with ideal burst suppression pattern attainable more than 24 to 48 hours showed good outcome in 81.8%(p<0.05). The group that showed focal low density in the brain CT scan taken before BCT fared better prognosis compared with that of multifocal or diffuse low density(p<0.05), and patients with resolution of perimesencephalic cistern effacement on follow-up brain CT scan taken 48 hours after BCT showed better prognosis(p<0.05). Overall, 72.2% showed improvement of GCS score by 2 or more, and good outcome was noted in 50%. CONCLUSION: The barbiturate coma therapy seems to have a beneficial therapeutic effect on severe and refractory vasospasm and can be considered as a useful therapeutic modality.