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Post by papanigon on Feb 1, 2016 19:01:17 GMT -5
yes, blood sugars finger prick. The glucose and or heparin in the line has to be cleared before the central line is used for a blood glucose. Giving iv insulin requires a pump. A chargable item, yes. A pain to hang. A pain to keep track of. Anyway, those units are used to a lot of monitors. and alarms. as well as laboratory orders and results, and witnesses.
Current guidelines for ICU patients recommend maintaining blood glucose levels in the 140-180mg/dL range. This has show to provide lower incidences of hypoglycemia and improved mortality compared to intensive insulin control regimens. An insulin drip is preferred in this case due to the fact that the insulin is provided as an IV with immediate onset of action and a half life of ~10-12 minutes. This also allows a rapid titration and fine tuning of insulin / glucose levels to a desired target range. Yes, an insulin bag is a "pain" to hang and monitor, but keep in mind many ICU patients already have several lines (or a few multi-lumen lines) running, potentially with multiple vasopressors, antibiotics, and fluids running at once. This is why you (usually) have a 1:1 nursing ratio and a team monitoring the patient. Moreover, Afrezza is a rapid acting mealtime insulin. A majority of patients in an ICU are not fed enterally or parentally before being extubated / stepped down (with the exception of TPN's, usually after several days of an ICU admission). Enteral feedings that afrezza would be useful in due to the rapid peak of serum glucose levels post feeding are not common since a TPN is provided as a continuous feed. Therefore, a continuous insulin infusion is appropriate to cover this method of feeding or continuous tube feeds. Plus, how would one administer and titrate afrezza in an intubated patient? Not to mention the potential for drug binding to the intubation tube itself - leading to huge variations in dose provided. Afrezza is not appropriate in an ICU setting. Presently, Afrezza will be converted to IV forms in an ICU setting. Administration through inhalation can be done for other meds currently, so if this would be the case, a modified inhaler would most likely be needed to accommodate ventilators. Most importantly, blood sugar spikes in the ICU setting are usually a result of the bodies stress response from injury in the healing process.
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Post by mnholdem on Feb 1, 2016 19:10:57 GMT -5
Frankly, I would be delighted if we could just manage to stay on topic, which is "what might happen at the Feb 3 conference call". This thread has been hi-jacked from the conference call ideas to the ICU then on to the Boardroom. Could we return to discussing the upcoming conference call for a while? Please? Aren't we all hoping Dr. Matt tells us the patient has been upgraded from critical to stable Absolutely, especially if the patient's name is Afrezza and it's been recently diagnosed as having a severe case of partnerskippedoutbolism. Or would that be a knife wound in the back?
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Post by dooberxl on Feb 1, 2016 23:17:42 GMT -5
Current guidelines for ICU patients recommend maintaining blood glucose levels in the 140-180mg/dL range. This has show to provide lower incidences of hypoglycemia and improved mortality compared to intensive insulin control regimens. An insulin drip is preferred in this case due to the fact that the insulin is provided as an IV with immediate onset of action and a half life of ~10-12 minutes. This also allows a rapid titration and fine tuning of insulin / glucose levels to a desired target range. Yes, an insulin bag is a "pain" to hang and monitor, but keep in mind many ICU patients already have several lines (or a few multi-lumen lines) running, potentially with multiple vasopressors, antibiotics, and fluids running at once. This is why you (usually) have a 1:1 nursing ratio and a team monitoring the patient. Moreover, Afrezza is a rapid acting mealtime insulin. A majority of patients in an ICU are not fed enterally or parentally before being extubated / stepped down (with the exception of TPN's, usually after several days of an ICU admission). Enteral feedings that afrezza would be useful in due to the rapid peak of serum glucose levels post feeding are not common since a TPN is provided as a continuous feed. Therefore, a continuous insulin infusion is appropriate to cover this method of feeding or continuous tube feeds. Plus, how would one administer and titrate afrezza in an intubated patient? Not to mention the potential for drug binding to the intubation tube itself - leading to huge variations in dose provided. Afrezza is not appropriate in an ICU setting. Presently, Afrezza will be converted to IV forms in an ICU setting. Administration through inhalation can be done for other meds currently, so if this would be the case, a modified inhaler would most likely be needed to accommodate ventilators. Most importantly, blood sugar spikes in the ICU setting are usually a result of the bodies stress response from injury in the healing process. Given that you're making claims of efficacy, please explain to me your pharmacokinetic / dynamic rationale for the difference between IV regular insulin vs. Afrezza converted into an IV format. What benefit would there be to giving Afrezza to an intubated patient versus a continuous IV infusion of regular insulin? How would you manage dose titration when a large portion of the drug can potentially stick to the PVC tubing of the intubation kit? Lastly, and also most importantly, why would a nurse NOT just dial up the regular insulin infusion by 1 unit per hour for 1 hour then back down to cover spikes? Keep in mind, insulin administered IV is cleaved to its active form IMMEDIATELY and is active instantaneously. Also, keep in mind that these patients, per the current SCCM guidelines, recommend keeping glucose within a range of 140-180mg/dL. Your comment regarding blood sugar spikes overall, is incorrect. Patients in ICU care are chronically hyperglycemic due to increased cortisol, catecholamines, glucagon, growth hormone, gluconeogenesis, and glycogenolysis as an adaptive response. "Spikes" are an inappropriate characterization of glucose handling in ICU patients. Spikes do happen for various reasons, but your implication is these patients have glucose spikes then return to "normal" ranges. This is incorrect. I apologize for not being clear about the utility and chronic hyperglycemia in ICU patients in my previous post. What clinical benefit is there to rapidly decreasing a glucose spike in an intubated, sedated, and potentially paralyzed patient?
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Post by agedhippie on Feb 2, 2016 8:50:35 GMT -5
Keep in mind, insulin administered IV is cleaved to its active form IMMEDIATELY and is active instantaneously. I have been on the receiving end of this for hyperglycemia (pump occlusions for those who are interested, the pump tube gets blocked and you don't get insulin which can push you towards DKA). They have to restart your pump a while before they disconnect the IV or you will go high again when they stop the IV because the IV insulin clears so fast it is gone before the pump insulin has ramped up. From memory IV delivered insulin clears in about 15 minutes from delivery but that might be wrong. IV delivered insulin has a far faster onset and clearance than Afrezza and is ideal for ER or hospital use, but it is not very practical in day to day use.
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Post by mindovermatter on Feb 2, 2016 9:15:41 GMT -5
One thing is for certain. Matt will have to explain very clearly how Mannkind affords to stay in business going into the 2nd half of the year as money will run out then. He needs to quickly detail a plan to remain solvent because the life of Mannkind hangs in the balance. Tomorrow will hopefully address a clear picture how that happens. The unsettling truth is that it might be very very bad for shareholders but someone has to be sacrificed for the good of the company. And that is usually shareholders.
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Post by patten1962 on Feb 2, 2016 10:12:26 GMT -5
One thing is for certain. Matt will have to explain very clearly how Mannkind affords to stay in business going into the 2nd half of the year as money will run out then. He needs to quickly detail a plan to remain solvent because the life of Mannkind hangs in the balance. Tomorrow will hopefully address a clear picture how that happens. The unsettling truth is that it might be very very bad for shareholders but someone has to be sacrificed for the good of the company. And that is usually shareholders. U can ask this via Facebook or Twitter.
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Post by papanigon on Feb 2, 2016 10:18:39 GMT -5
Patients in ICU care are chronically hyperglycemic due to increased cortisol, catecholamines, glucagon, growth hormone, gluconeogenesis, and glycogenolysis as an adaptive response. "Spikes" are an inappropriate characterization of glucose handling in ICU patients. Spikes do happen for various reasons, but your implication is these patients have glucose spikes then return to "normal" ranges. This is incorrect. I apologize for not being clear about the utility and chronic hyperglycemia in ICU patients in my previous post.
What clinical benefit is there to rapidly decreasing a glucose spike in an intubated, sedated, and potentially paralyzed patient?
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I think you misread my post. IV insulin is preferred in the ICU setting. Afrezza may apply in the future, but not with current applications. In regards to hyperglycemic control and Spikes due to increased cortisol, catecholamines, glucagon, growth hormone, gluconeogenesis, and glycogenolysis as an adaptive response. Yes it is an adaptive response, to injury as I started, but several studies show control of blood sugar levels can help decrease length of stay and improve recovery times. That would be the benefits.
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