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Glucose Measurement: Confounding Issues in Setting Targets for Inpatient Management

¹ Division of Endocrinology, Ohio State University School of Medicine, Columbus, Ohio
² Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
³ Division of Endocrinology, University of North Carolina School of Medicine, Chapel Hill, North Carolina

Address correspondence and reprint requests to John Buse, MD, PhD, CB# 7110, Old Clinic 5039, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7110. E-mail: jbuse@med.unc.edu

Abbreviations: ADA, American Diabetes Association • CAP, College of American Pathologists • GD, glucose-1-dehydrogenase • ICU, intensive care unit • POC, point of care

The first 300 words of the full text of this article appear below.

	INTRODUCTION

 
Van den Berghe et al. (1) reported a significant reduction in mortality with normoglycemia (target value 80–110 mg/dl) in patients whose medical intensive care unit (ICU) stay was >72 h and reduced morbidity in all patients, regardless of the duration of ICU stay. Although severe hypoglycemia did not occur in the Van den Berghe et al. study, 18.7% of patients in the intensive treatment group compared with 3.1% of those who received conventional therapy did experience hypoglycemia (defined as glucose <40 mg/dl), albeit with no adverse consequences reported. However, altered consciousness is common in the ICU, and even severe hypoglycemia may be unrecognized. Other studies (2,3) examining intensive insulin protocols in various inpatient settings have suggested benefits in clinical outcomes associated with improved glycemic control. In a mixed ICU population, Van den Berghe et al. (2) previously demonstrated reduced morbidity and mortality with three- to fourfold less hypoglycemia than the medical ICU population (2). Thus, careful assessment of glucose measurement and how it may impact the targets selected in the hospital are critical safety issues in intensive management of hyperglycemia. As a result of increasing evidence that tight glycemic control is beneficial in the management of inpatients with diabetes, the American Diabetes Association (ADA) currently recommends a glucose target "as close to 110 mg/dl as possible and generally <180 mg/dl" for critically ill patients (4). The American Association of Clinical Endocrinologists recommends the "upper limits for glycemic targets" of 110 mg/dl in critically ill patients (5).

In practice, it may be difficult to obtain the level of glycemic control (average glucose 111 mg/dl in the intensively managed group) achieved by Van den Berghe et al. Though a wider range of glucose values has been targeted, rarely . . . [Full Text of this Article]

	ASSAY PRINCIPLES—

 
Enzymatic reaction
Detection method
POC techniques
Interstitial fluid glucose monitoring

	PATIENT VARIABLES WITHIN A POPULATION

 
Patient factors
Hypotension.
Hematocrit.
Oxygenation.
pH.
Temperature.
Interfering substances
Drugs.
Other substances.

	SOURCES OF SYSTEMATIC DIFFERENCE BETWEEN INSTITUTIONS—

 
Standards for comparison
Performance of POC devices
Operator error
Source of sample
Arterial samples compared with capillary samples.
Venous samples compared with capillary samples.
Postprandial state.
Differences between plasma and whole blood (specimen matrix)
Arterial whole blood compared with arterial plasma.
Venous whole blood compared with venous plasma.
Capillary whole blood compared with venous plasma.
Ramifications for the clinician

	CONCLUSIONS—

 

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This article has been cited by other articles:

				J. Mahoney and J. Ellison Glucose Measurement: Confounding Issues in Setting Targets for Inpatient Management: Response to Dungan et al. Diabetes Care, July 1, 2007; 30(7): e71 - e71. [Full Text] [PDF]

				K. M. Dungan Glucose Measurement: Confounding Issues in Setting Targets for Inpatient Management: Response to Mahoney and Ellison Diabetes Care, July 1, 2007; 30(7): e72 - e72. [Full Text] [PDF]