Disclosure: Stan Schwartz, MD, FACP,FACE

Disclosure: Stan Schwartz, MD, FACP,FACE

Achieving Excellent Control of Hyperglycemia in Critical Care and Surgery, Safely: Continuous Glucose Monitoring: Does it Have a Future in the Hospital BACK TO THE FUTURE STAN SCHWARTZ MD Clinical Assoc Professor of Medicine, Emeritus Univ. Of Pennsylvania Practice in Diabetes/ Endocrinology , Ardmore, Pa. [email protected] Disclosures re: CGMS 2009: Medtronic 2010- none 2011 none A Solution

ADVERSE OUTCOMES STRESS ADVERSE OUTCOMES EASD EASD 2010 2010 3 Glycemic Control in the Hospital 1. EPIDEMIOLOGIC / PATHOPHYSIOLOGIC Rationale for Glycemic Control EXISTS Adverse outcomes with increased glucose; Brownlee, variability 2. Benefit of Control Highly Likely- Portland, Leuven. others 3. But, High Risk of, and if, have Hypoglycemia NICE, others 4. Has Resulted in a push for Therapeutic Nihilism; 140-180; ACP, to 200

MUST AVOID 5. Rather , Optimize Glycemia, minimize Hypoglycemia 6. Find Therapies and Processes of Care to Optimize Benefit/ Risk Ratio 7. Alternate Pharmacotherapy- Incretins , pramlintide, ranolazine 8. ACCURATE CGMS, open/ closed loop Blinded Trial Data with Medtronic Hospital Sensor Demonstrates Need for Continuous Glucose Monitoring MDT Clinical Trial HGMS Sensor Pt 004 HVSP004 275 250 Glucose (mg/dL)

225 200 Admitting Diagnosis: Necrotizing Fasciitis Reference BG Exposes higher variability, delay in discovering trends , Miss hypos and hyperglycemic peaks MDT Hospital Sensor (blinded to clinician) 175 29%

46% 25% 150 125 100 75 50 Mon 10:00 Mon 22:00 Tue 10:00 Tue 22:00

Wed 10:00 Wed 22:00 Thu 10:00 Day/Time Unpublished individual result from Medtronic sponsored study (HF2004P) Glycemic Control in the Hospital 1. EPIDEMIOLOGIC / PATHOPHYSIOLOGIC Rationale for Glycemic Control EXISTS Adverse outcomes with increased glucose; Brownlee, variability 2. Benefit of Control Highly Likely- Portland, Leuven 3. But, High Risk of, and if, have Hypoglycemia NICE, others 4. Has Resulted in a push for Therapeutic Nihilism; 140-180; ACP, to 200

MUST AVOID 5. Rather , Optimize Glycemia, minimize Hypoglycemia 6. Find Therapies and Processes of Care to Optimize Benefit/ Risk Ratio 7. Alternate Pharmacotherapy- Incretins , pramlintide, ranolazine 8. ACCURATE CGMS, open/ closed loop Therapeutic Nihilism ACP Evidence Based With Clinical Judgement Better Approach Potential for Greater Benefit

at Lower range AS LONG AS NO UNDUE HYPOGLYCEMIA ADA/ AACE Recommendation Chosen by 1 Vote Glycemic Control in the Hospital 1. EPIDEMIOLOGIC / PATHOPHYSIOLOGIC Rationale for Glycemic Control EXISTS Adverse outcomes with increased glucose; Brownlee, variability 2. Benefit of Control Highly Likely- Portland, Leuven 3. But, High Risk of, and if, have Hypoglycemia NICE, others 4. Has Resulted in a push for Therapeutic Nihilism; 140-180; ACP, to 200 MUST AVOID 5. Rather , Optimize Glycemia, minimize Hypoglycemia

6. Find Therapies and Processes of Care to Optimize Benefit/ Risk Ratio 7. Alternate Pharmacotherapy- Incretins , pramlintide, ranolazine 8. ACCURATE CGMS, open/ closed loop Conclusion: 100,000 Foot Level We need , Now, as ROI exists Continuous Glucose Monitoring with Closed-Loop Control of Glycemia Compensate for Imperfect Sensors, Site Issues, and Human Variability and Fallibility by Algorithms: Dialing-in Goal that Avoids Hypoglycemia Adjust DESIGN and USAGE of Imperfect Tools until IDEAL available

Recently Viewed Presentations

  • CS259: Security Analysis of Network Protocols Winter 2008

    CS259: Security Analysis of Network Protocols Winter 2008

    CS259: Security Analysis of Network Protocols Winter 2008 Project Presentations 2 Day 2 - Feb. 21, 2008
  • Agents of Abuse - Southern Methodist University

    Agents of Abuse - Southern Methodist University

    Once METH binds one of two things happens… Option 1: The DAT is reversed, dumping DA out into the synpase. Option 2: Vesicles containing DA dump their DA into the cytosol, building up in the presynaptic neuron, and making a...
  • The Digital Future: Social and Economic Impacts of the ...

    The Digital Future: Social and Economic Impacts of the ...

    To date, courses have been offered on computer technology, economics, language, and remedial coursework Worldlinks : 320 schools in 15 developing countries connected via Internet with schools in 25 developed countries for collaborative learning. Provides financing and training to schools...
  • Land Surveys, Site Location and Map Reading

    Land Surveys, Site Location and Map Reading

    WHY IS IT IMPORTANT FOR BROKERS TO KNOW BASIC LAND SURVEYING ? Real Estate Brokers need to know basic surveying. Three elements of space in surveying. Cardinal direction in surveying. ... LAND SURVEYS, SITE LOCATION AND MAP READING Last modified...
  • Commtap

    Commtap

    Criteria for showing training for intervention techniques on Commtap. In general, intervention techniques should be inclusive - rather than exclusive - of other communication methods (including speech, sign, picture symbols, aided communication);
  • Hálózati adminisztráció - johanyak.hu

    Hálózati adminisztráció - johanyak.hu

    Dr. Johanyák Zs. Csaba © 2011. NB Névfeloldási módok osztályozása a névfeloldás helye szerint. Helyi: gyorsítótár (ált. 10 percig tartja meg)
  • Segmental Hidden Markov Models with Random Effects for ...

    Segmental Hidden Markov Models with Random Effects for ...

    Segmental HMM Random effect segmental HMM Faster learning with ECME Expectation conditional maximization(ECM): Replace the M step of the EM with a sequence of Constrained or conditional maximizations (CM): The set of parameters is divided into subvectors and in the...
  • Student code of conduct - PC\|MAC

    Student code of conduct - PC\|MAC

    No visible ID badge. Untied shoes. Consequences for Violations include. verbal warning. letter home. counselor contact parent. office referral with detention. ... No hooded attire is allowed on campus. Clark Jackets only on campus. DO not write on your body,...