Trends in practice of blood glucose control in critically ill patients in the Netherlands.

BACKGROUND: Publication of the Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial in 2009 and several observational studies caused a change in the recommendations for blood glucose control in intensive care patients. We evaluated local trends in blood glucose control in intensive care units in the Netherlands before and after the publication of the NICE-SUGAR trial and the revised Surviving Sepsis Campaign (SSC) guidelines in 2012. METHODS: Survey focusing on the timing of changes in thresholds in local guidelines for blood glucose control and interrupted time-series analysis of patients admitted to seven intensive care units in the Netherlands from September 2008 through July 2014. Statistical process control was used to visualise and analyse trends in metrics for blood glucose control in association with the moment changes became effective. RESULTS: Overall, the mean blood glucose level increased and the median percentage of blood glucose levels within the normoglycaemic range and in the hypoglycaemic range decreased, while the relative proportion of hyperglycaemic measurements increased. Changes in metrics were notable after publication of the NICE-SUGAR trial and the SSC guidelines but more frequent after changes in local guidelines; some changes seemed to appear independent of changes in local guidelines. CONCLUSION: Local guidelines for blood glucose practice have changed in intensive care units in the Netherlands since the publication of the NICE-SUGAR trial and the revised SSC guidelines. Trends in the metrics for blood glucose control suggest new, higher target ranges for blood glucose control.

Clinical pharmacology of exogenously administered alkaline phosphatase.

PURPOSE: To evaluate the clinical pharmacology of exogenous alkaline phosphatase (AP). METHODS: Randomized, double-blind, placebo-controlled sequential protocols of (1) ascending doses and infusion duration (volunteers) and (2) fixed dose and duration (patients) were conducted at clinical pharmacology and intensive care units. A total of 103 subjects (67 male volunteers and 36 patients with severe sepsis) were administered exogenous, 10-min IV infusions (three ascending doses) or 24-72 h continuous (132.5-200 U kg(-1) 24 h(-1)) IV infusion with/without preceding loading dose and experimental endotoxemia for evaluations of pharmacokinetics, pharmacodynamics, safety parameters, antigenicity, inflammatory markers, and outcomes. RESULTS: Linearity and dose-proportionality were shown during 10-min infusions. The relatively short elimination half-life necessitated a loading dose to achieve stable enzyme levels. Pharmacokinetic parameters in volunteers and patients were similar. Innate immunity response was not significantly influenced by AP, while renal function significantly improved in sepsis patients. CONCLUSIONS: The pharmacokinetics of exogenous AP is linear, dose-proportional, exhibit a short half-life, and are not influenced by renal impairment or dialysis.

Propofol-nitrous oxide versus thiopental sodium-isoflurane-nitrous oxide for strabismus surgery in children.

STUDY OBJECTIVES: To assess the quality of anesthesia and recovery and the frequency of postanesthetic retching and vomiting with propofol anesthesia for pediatric strabismus surgery. DESIGN: Randomized, open, prospective study. SETTING: University hospital. PATIENTS: Forty children scheduled for strabismus surgery. INTERVENTIONS: The 40 patients were all premedicated with oral midazolam and received intraoperative opioids. They were divided into two groups: Twenty children received propofol at induction, followed by maintenance of anesthesia with propofol infusion and an oxygen-nitrous oxide (O2-N2O) mixture. The other 20 children received thiopental sodium at induction, followed by isoflurane in an O2-N2O mixture. MEASUREMENTS AND MAIN RESULTS: At induction, pain and spontaneous movements were seen significantly more with propofol (11 of 20 vs. 0 of 20 for pain and 13 of 20 vs. 0 of 20 for spontaneous movements; p < 0.001), whereas thoracic rigidity was observed only with thiopental sodium (4 of 20). During maintenance of anesthesia, significantly more oculocardiac reflexes were seen with propofol (10 of 20 vs. 3 of 20; p < 0.02). The interval between termination of anesthesia and extubation was significantly shorter with propofol (13 minutes vs. 16 minutes; p < 0.02). For the first 24 hours after surgery, significantly less retching and vomiting were observed in the propofol group (4 of 20 vs. 11 of 20; p = 0.02). CONCLUSIONS: Propofol induction and maintenance of anesthesia for strabismus surgery in children significantly lowers the frequency of postanesthetic retching and vomiting, but propofol is associated with pain and spontaneous movements at induction and a high frequency of oculocardiac reflexes during maintenance infusion.

The use of midazolam versus propofol for short-term sedation following coronary artery bypass grafting.

Midazolam and propofol were compared in an open randomized study for postoperative sedation during 12 h of mechanical ventilation in 40 patients following coronary artery bypass grafting. After an intravenous loading dose of midazolam (50 micrograms.kg-1) or propofol (500 micrograms.kg-1), a titrated continuous infusion was administered of midazolam (mean dose 38.1 micrograms.kg-1.h-1 (SEM 2.6)) or propofol (mean dose 909 micrograms.kg-1.h-1 (SEM 100)) together with a narcotic analgesic infusion. During mechanical ventilation midazolam and propofol produced a similar quality of sedation, but recovery (midazolam 66 min (SEM 16); propofol 24 min (SEM 7)) and weaning from the ventilator (midazolam 243 min (SEM 44); propofol 154 min (SEM 33)) where faster with propofol. In the 2 groups administration of an intravenous loading dose caused a significant decrease in mean arterial pressure but hemodynamic tolerance during maintenance infusion was good.