Hospital Pharmacy - July/August 2018 - 242

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2.

Hospital Pharmacy 53(4)
Bochicchio et al: Results of a multicenter prospective
pivotal trial of the first inline continuous glucose
monitor in critically ill patients.6

Glycemic control for critically ill trauma patients improves
outcomes but must be balanced with the risks of hypoglycemia and glucose variability. Glucose measurement often
relies on point of care meter testing, which may be inaccurate
and labor-intensive. An inline continuous glucose monitor
(CGM) has been developed to address these current limitations of glucose monitoring and potentially assist nutrition
support clinicians. This multicenter, prospective study evaluated the first human use of an inline near CGM (OptiScanner
5000, OptiScan Biomedical, Hayward, California) for safety
and accuracy in 200 critically ill surgical and trauma patients.
The inline CGM that was used connected to the patient's central venous catheter by intravenous tubing and obtained
plasma sampling of 0.13 mL every 15 minutes. Glucose concentrations were measured by midinfrared spectroscopy and
displayed on the monitor within 7 to 8 minutes. Patients ≥18
years of age with an expected minimum ICU stay of 18 hours
after enrollment who required plasma glucose monitoring
were included. The inline CGM occupied the most proximal
port of a nontunneled central venous catheter and another
access site for obtaining paired samples for comparison was
required.
A total of 3735 glucose measurements obtained by inline
CGM were compared with paired plasma samples analyzed
by a reference standard. The study team, patients, and clinicians were blinded to the plasma glucose concentration readings by both technologies. Treatment decisions were made
based on point of care meter glucose measurements. Most
data points achieved the benchmark for accuracy with 95.4%
of data points in zone A (ie, glucose values that deviate by no
more than 20% from the reference or are in the hypoglycemic range (<70 mg/dL) when the reference is also in the
hypoglycemic range) and 4.5% in zone B (ie, values outside
zone A that are predicted to have no untoward effect toward
the patient if considered for clinical cure) of the Clarke Error
Grid. As a measure of trend accuracy, the mean absolute relative difference (MARD) was 7.6% for all paired glucose
samples. No device-related adverse events were reported,
but the authors indicated that nurses completed 1 devicerelated technical issue intervention per day. The authors concluded that inline continuous glucose monitoring is safe and
accurate for use in critically ill surgical and trauma patients.
This study offers a promising solution for safe and accurate plasma glucose monitoring in critically ill surgical and
trauma patients. The MARD of 7.6% for all paired glucose
samples in this study is favorable because previous literature
based on mathematical models of continuous glucose monitoring indicates that a MARD less than 10% is predictive of
improvement in glycemic control and prevention of glucose
variability.30,31 As midinfrared spectroscopy is not affected
by hemodynamics or temperature, this technology may be

especially advantageous in the critical care setting. In fact,
this technology may allow the future use of closed-loop glucose monitoring and intravenous insulin therapy for glycemic control in critically ill patients. Additional studies are
warranted to investigate the use of this technology for other
patient populations as well as the economic and logistic feasibility of implementation.
3.

Braunschweig et al: Role of timing and dose of
energy received in patients with acute lung injury on
mortality in the Intensive Nutrition in Acute Lung
Injury Trial (INTACT): a post hoc analysis.7

The INTACT was a single-center, randomized, controlled
trial evaluating intensive medical nutrition therapy (IMNT)
(30 kcal/kg and protein 1.5 g/kg) compared with standard
physician-directed EN in patients with acute lung injury
(ALI) from diagnosis to discharge. The trial was stopped
early due to greater mortality (40% IMNT vs 15.8%) despite
no differences in infections, ventilator days, or ICU or hospital days.32 The intent of this post hoc analysis of INTACT
was to compare survivors (n = 56) with nonsurvivors (n =
22) in terms of the timing and/or dose of nutrition provided.
Nonsurvivors were slightly older (64.3 vs 52.2 years), female
(64% vs 43%), moderately to severely malnourished (55%
vs 30%), and had higher sequential organ failure assessment
(SOFA) scores (12.2 vs 8.2). Body mass index (BMI) was
similar in both groups (29.5 vs 30.3 kg/m2). Mean caloric (21
vs 20.8 kcal/kg/d) and protein (0.79 vs 0.91 g/kg/d) intake
were similar between nonsurvivors and survivors, respectively, as well as the amount of intravenous lipid emulsion
(ILE) exposure. After adjusting for older age, female gender,
and SOFA scores, nonsurvivors received significantly higher
mean kcal/kg across the entire study period (OR: 1.14; 95%
CI: 1.02-1.27). Multiple regression analysis showed mean
kcal/kg/d had the strongest association during study days 1 to
7 and predicted subsequent death by day 3. Higher protein
intake also reduced survival during days 1 to 7 (HR: 8.87;
95% CI: 2.3-34.3). Interestingly, for participants still enrolled
on day 8 or after (n = 66), death was significantly reduced by
caloric intake (HR: 0.91; 95% CI: 0.83-1). The investigators
concluded that higher energy and protein intake days 1 to 7
following ALI diagnosis are associated with greater mortality,
while higher energy intake after day 7 reduced mortality.
These data support other studies associating higher energy
intakes with increased hospital mortality33 and similar ventilator days or infections.34 It is worth noting that the majority
of patients enrolled in this trial appear to be medical ICU
patients, based on the admitting diagnosis. It is possible that
energy requirements may be lower during the first 7 days in
the medical ICU compared with the surgical ICU patient. In
addition, there appeared to be a significant number of obese
patients in both groups with mean BMI of ≥30 kg/m2. National
guidelines suggest more conservative caloric dosing for hospitalized patients with obesity than what was targeted in this

Table of Contents for the Digital Edition of Hospital Pharmacy - July/August 2018