Bottom line: Elective surgeries that occur on the weekend and later in the week have an increased risk of mortality, implying that the weekend effect is due to poorer quality of care during weekends, rather than higher-acuity patients presenting on weekends.
Citation: Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ. 2013;346:f2424.
Basal Plus Correction Insulin Regimen Is Effective in Hospitalized Patients with Type 2 Diabetes
Clinical question: Does a basal plus correction insulin regimen (as needed with meals) result in similar glycemic control and lower rates of hypoglycemia compared to a basal-bolus regimen?
Background: Basal bolus is the preferred insulin regimen for non-critically-ill hospitalized patients as per clinical guidelines. But use is limited due to the complexity of the regimen and the fear of inducing hypoglycemia. A less complex, easier-to-implement basal plus correction insulin regimen may be an effective alternative.
Study design: Multicenter, prospective, open-label, randomized study.
Setting: Six hospitals in the U.S.
Synopsis: A group of 375 medical and surgical patients with Type 2 diabetes treated with diet, oral anti-diabetic agents, or low-dose insulin (≤ 0.4 units/kg/day) were randomized to:
- Basal-bolus insulin regimen with glargine once daily and fixed doses of glusiline before meals;
- Basal plus correction insulin (“basal plus”) regimen with glargine once daily and glusiline sliding scale insulin (SSI) before meals; or
- Regular SSI alone.
After the first day of therapy, treatment with basal-bolus and basal-plus regimens resulted in similar improvements in daily blood glucose (BG) (P=0.16), and both were superior to SSI alone (P=0.04). Both regimens also resulted in less treatment failure (defined as mean daily BG of >240 mg/dl or >2 consecutive BG >240 mg/dl) than did treatment with SSI. Hypoglycemia (BG <70 mg/dl) occurred in 16%, 13%, and 3% of patients in the basal-bolus, basal-plus, and SSI groups, respectively (P=0.02). There were no between-group differences in the frequency of severe hypoglycemia (<40 mg/dl; P=0.76).
The study was not powered to evaluate hospital complications (infection, mortality, hospital stay, and readmissions) across groups.
Bottom line: The basal-plus regimen resulted in glycemic control similar to standard basal-bolus regimen and is an effective alternative for the initial management of hyperglycemia in general medical and surgical patients with Type 2 diabetes.
Citation: Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: Basal plus trial. Diabetes Care. 2013;36:2169-2174.
Capnography Can Help Diagnose Diabetic Ketoacidosis in the ED
Clinical question: Can capnography be used as a screening tool to identify patients with diabetic ketoacidosis (DKA)?
Background: Metabolic acidosis is a major criterion for diagnosing DKA. Previous studies have shown that end-tidal carbon dioxide (ETCO2) measurement by capnography can provide an accurate estimation of arterial carbon dioxide tension (PaCO2) and may be a noninvasive, fast, inexpensive measurement of acidosis in DKA. However, those studies were in pediatric patients and had small sample sizes.
Study design: Cross-sectional, prospective descriptive-analytic study.
Setting: The ED of Imam Reza Medical Research and Training Hospital, Tabriz, East Azarbaijan, Iran.
Synopsis: A total of 181 adult patients older than 18 with suspected DKA and blood sugar >250 mg/dl were included in the study. Simultaneous capnography and arterial blood gas (ABG) were obtained on all patients. Urine ketones, complete blood count, serum levels of potassium, urea, and creatinine were collected. Sixty-two patients were found to have DKA, while 119 had other conditions associated with metabolic acidosis. There was a significant linear relationship between pH and ETCO2 (P>0.0001, relative risk (R)=0.253), PaCO2 and ETCO2 (P>0.0001, R=0.572), and bicarbonate (HCO3) and ETCO2 (P>0.0001, R=0.730). ETCO2 values >24.5 mmHg had a sensitivity and specificity of 0.90 for ruling out DKA. No cutoff point could be determined for ruling in DKA.