ABSTRACT
Continuous subcutaneous insulin infusion (CSII), also called the insulin pump, has emerged as a safe and effective therapy in the last 20 years. Utilization of CSII in several studies has shown reductions in hypoglycemia and improvement in glycemic control compared with multiple daily injections. Diabetes mellitus is often a comorbid condition in patients requiring critical care. Surprisingly, there exist no guidelines for use of CSII in the inpatient setting, and no tested protocols for management of CSII in the hospital. With solid evidence as to the benefits of this therapy in diabetes and the heightened attention to the importance of optimal inpatient glycemic control, guidelines and tested protocols for CSII use during hospitalization are warranted. We share our own guidelines for the inpatient management of the insulin pump which has allowed our hospital to address the unique challenges that pump users present with during acute illness. A general overview of the insulin pump's history, rationale for use, patient selection, and implementation is also discussed.
Subject(s)
Critical Care/methods , Diabetes Mellitus/drug therapy , Hypoglycemic Agents/therapeutic use , Insulin Infusion Systems , Insulin/therapeutic use , Acute Disease , Adolescent , Adult , Age Factors , Blood Glucose/metabolism , Blood Glucose Self-Monitoring , Child , Clinical Protocols , Diabetes Mellitus/metabolism , Diabetes Mellitus/nursing , Diabetic Ketoacidosis/etiology , Diabetic Ketoacidosis/prevention & control , Drug Monitoring/methods , Drug Monitoring/nursing , Evidence-Based Medicine , Glycated Hemoglobin/metabolism , Humans , Hyperglycemia/etiology , Hyperglycemia/prevention & control , Hypoglycemia/chemically induced , Hypoglycemia/metabolism , Hypoglycemia/prevention & control , Hypoglycemic Agents/adverse effects , Infusions, Parenteral , Insulin/adverse effects , Insulin Infusion Systems/adverse effects , Insulin Infusion Systems/statistics & numerical data , Insulin Infusion Systems/trends , Patient Care Planning , Practice Guidelines as TopicABSTRACT
OBJECTIVES: Subjecting the marine bivalve Mytilus edulis to an immediate temperature change has been shown to rapidly alter the animals' ganglionic monoamine levels, as well as its ciliary activity. Recently, we extended this observation to include the organism's ganglionic mu opiate receptor and morphine levels. In the past, we demonstrated that M. edulis ganglionic mu receptors exposed to morphine was coupled to the immediate release nitric oxide (NO). In this study, we measured morphine-induced NO release in M. edulis subjected to acute cold stress. METHODS: NO release was monitored with an NO-selective microprobe. Temporal changes in mu opiate receptor expression were also examined over 24 hours. RESULTS: In this study, we demonstrate that after 12h cold exposure (4 degrees C from 24 degrees C), the estimated relative mu opiate receptor (MOR) gene expression in M. edulis pedal ganglia, measured by real-time PCR, did not differ significantly from the control group (1.23+/-0.25, p>0.05). However, the measured M. edulis pedal ganglia MOR expression demonstrated that ganglia significantly (0.77+/-0.05, p<0.001) down regulated their mu opiate receptor mRNA expression after 24h exposure to the cold water. The mean value for control animal (24 degrees C, n=14) morphine-stimulated NO release was 36.7 +/- 9.8 nM. Morphine additions to cold-treated tissues (4 degrees C, n=7) produced an average of 6.7 +/- 4.9 nM NO, which was a statistically significant difference between 25 degrees C and 4 degrees C animals (p=0.025). CONCLUSION: The study further demonstrates that mu opiate receptor expression is coupled to NO release.
