Effect of Glucose-Insulin-Potassium Infusion on Hemodynamics in Patients with Septic Shock

BACKGROUND: Glucose-insulin-potassium (GIK) demonstrates a cardioprotective effect by providing metabolic support and anti-inflammatory action, and may be useful in septic myocardial depression. AIM: The aim of this study was to assess role of GIK infusion in improving hemodynamics in patients with septic shock in addition to its role in myocardial protection and preventing occurrence of sepsis-induced myocardial dysfunction and sepsis-induced arrhythmias. METHODS: This study was conducted on 75 patients admitted to the Critical Care Department in Cairo University Hospital with the diagnosis of septic shock during the period from January 2019 to December 2019. Patients were divided into two groups; first group was managed according to the last guidelines of surviving sepsis campaign and was subjected to the GIK infusion protocol while second group was managed following the last guidelines of surviving sepsis campaign only without adding GIK infusion. RESULTS: Patients in the GIK group showed better lactate clearance (50% vs. 46.7%) and less time needed for successful weaning of vasopressors than the control group (3.57±1.16 vs. 3.6±1.45 days) thought not reaching statistical significance. There was no statistically significant difference between both groups regarding development of septic-induced cardiomyopathy (16.7% in the control group vs. 13.3% in the GIK group); however, patients with hypodynamic septic shock showed better improvement in hemodynamic profile in the GIK group. Sepsis-induced arrhythmias occurred more in patients of the control group than in patients of the GIK group with no statistically significant difference between both groups (33.3% vs. 20%, p = 0.243). Few side effects were developed as a result of using GIK infusion protocol. CONCLUSIONS: GIK may help in improving hemodynamics and weaning of vasopressors in patients with refractory septic shock and those with septic induced cardiomyopathy. The use of GIK was well tolerated with minimal adverse reactions.

A COVID-19 patient with recurrent acute limb ischaemia despite two successive types of therapeutic dose anticoagulation and thrombolysis

COVID-19 is caused by the SARS-CoV-2, and its presentation ranges from mild upper respiratory illness to critical disease including acute respiratory distress syndrome and multiorgan dysfunction. While it was initially believed to primarily target the respiratory system, numerous studies have demonstrated it to cause a hypercoagulable state that predisposes to arterial and venous thrombosis. We present a case where a patient with COVID-19 developed acute lower limb ischaemia due to arterial thrombosis in the setting of full-dose enoxaparin, followed by heparin infusion protocol. The patient developed recurrent ischaemia despite thrombolysis in addition to anticoagulation, and eventually required open thrombectomy before making a full recovery.

The effect of the menstrual cycle and hyperglycaemia on hormonal and metabolic responses during exercise

Purpose Variations in substrate metabolism have been identified in women during continuous steady-state aerobic exercise performed at the same relative intensity throughout discrete phases of the menstrual cycle, although some evidence exists that this is abolished when carbohydrate is ingested. This investigation examined the effects of a supraphysiologic exogenous glucose infusion protocol, administered during two phases of the menstrual cycle (follicular and luteal) in eumenorrheic women to identify differences between metabolic, hormonal and substrate oxidative responses. Methods During the experimental conditions, blood glucose was infused intravenously at rates to “clamp” blood glucose at 10 mM in seven healthy females (age 20 ± 1 y, mass 55.0 ± 4.1 kg, $$\dot V{O_{2peak}}$$ V ˙ O 2 p e a k 40.0 ± 1.8 ml/kg/min). Following 30 min of seated rest, participants exercised on a cycle ergometer for 90 min at 60% $$\dot V{O_{2peak}}$$ V ˙ O 2 p e a k . During the rest period and throughout exercise, blood metabolites and hormones were collected at regular intervals, in addition to expired air for the measurement of substrate oxidation. Results Significant differences between ovarian hormones and menstrual phase were identified, with estrogen significantly higher during the luteal phase compared to the follicular phase (213.28 ± 30.70 pmol/l vs 103.86 ± 13.85 pmol/l; p = 0.016), and for progesterone (14.23 ± 4.88 vs 2.11 ± 0.36 nmol/l; p = 0.042). However, no further significance was identified in any of the hormonal, metabolite or substrate utilisation patterns between phases. Conclusion These data demonstrate that the infusion of a supraphysiological glucose dose curtails any likely metabolic influence employed by the fluctuation of ovarian hormones in eumenorrheic women during moderate exercise.

A Budget Impact Analysis of Iron Polymaltose and Ferric Carboxymaltose Infusions

Objective: To compare the direct costs of ferric carboxymaltose (FCM) infusions, and iron polymaltose (IPM) infused via either a slow or rapid infusion; and explore potential savings associated with increased uptake of the least-expensive option at a local hospital.Setting: Hospital staff responsible for manufacturing, administering, and monitoring iron infusions, and the patients that received them at the Royal Hobart Hospital in 2018. Method: Frequency analysis identified the most prescribed iron infusion doses. A time-motion methodology was used to calculate the direct costs for each protocol at these doses. Finally, a budget-impact analysis of encouraging increased use of the least-expensive infusion protocol was conducted. Main outcome measures: Total direct costs for each infusion protocol at common doses. Potential budget savings associated with switching to the lowest costing of these infusion protocols where possible.Results: The most common doses were 0.5g, 1g, 1.5g and 2g. At these dose points, FCM infusions are the least expensive, but only if national health subsidies are applied. In cases where they do not apply, IPM prepared from ampoules and infused using the rapid protocol (‘IPM Ampoules Rapid’) is the least expensive. Switching all applicable FCM infusions and IPM infusions administered using the slow infusion protocol to IPM Ampoules Rapid is projected to yield up to $12,000 worth of savings annually.Conclusions: Increased use of the IPM Ampoules Rapid protocol when government-subsidised options are not available is projected to have cost-saving outcomes. Investigation of implementation strategies to increase the use of this protocol are warranted.

Smart agent system for insulin infusion protocol management: a simulation-based human factors evaluation study

ObjectiveTo compare the insulin infusion management of critically ill patients by nurses using either a common standard (ie, human completion of insulin infusion protocol steps) or smart agent (SA) system that integrates the electronic health record and infusion pump and automates insulin dose selection.DesignA within subjects design where participants completed 12 simulation scenarios, in 4 blocks of 3 scenarios each. Each block was performed with either the manual standard or the SA system. The initial starting condition was randomised to manual standard or SA and alternated thereafter.SettingA simulation-based human factors evaluation conducted at a large academic medical centre.SubjectsTwenty critical care nurses.InterventionsA systems engineering intervention, the SA, for insulin infusion management.MeasurementsThe primary study outcomes were error rates and task completion times. Secondary study outcomes were perceived workload, trust in automation and system usability, all measured with previously validated scales.Main resultsThe SA system produced significantly fewer dose errors compared with manual calculation (17% (n=20) vs 0, p<0.001). Participants were significantly faster, completing the protocol using the SA system (p<0.001). Overall ratings of workload for the SA system were significantly lower than with the manual system (p<0.001). For trust ratings, there was a significant interaction between time (first or second exposure) and the system used, such that after their second exposure to the two systems, participants had significantly more trust in the SA system. Participants rated the usability of the SA system significantly higher than the manual system (p<0.001).ConclusionsA systems engineering approach jointly optimised safety, efficiency and workload considerations.