Embedded Files
elevated blood glucose levels among patients with other critical illnesses, including patients who have had cardiac arrest. The changes are dramatic. Several studies have looked at the utility of intensive insulin protocols in treating critically ill patients with a broad range of illnesses.288–293 In general, the desired level of blood glucose has been in the range of 80 to 140 mg/dL. Frequent monitoring of blood glucose levels and adjustments of insulin are required. These studies have demonstrated a reduction in death and important complications, including infections and renal failure, with aggressive management of hyperglycemia. The frequency of hypoglycemic episodes appears to be low. Physicians treating patients with severe stroke should be aware of the new regimens for treating hyperglycemia. Gray et al274 found that plasma glucose levels spontaneously decline in many patients. A small clinical trial tested the safety of short-term administration of glucose, insulin, and potassium to patients with moderate hyperglycemia.294 The intervention could be given safely, but plasma glucose levels were not significantly lower than in the control group. A subsequent report about a larger cohort treated by the same investigators found that infusions of glucose, insulin, and potassium significantly reduced blood pressure, but no differences in outcomes were noted 7 days after stroke.295 Bruno et al296 treated 24 patients with markedly elevated serum glucose levels (mean 14.7 mmol/L) within 12 hours of onset of stroke. With insulin infusions that required frequent adjustments in response to serum levels, they were able to achieve desired glucose control within 5 hours. Symptomatic hypoglycemia occurred in 5 patients. It is unclear whether the intervention affected outcomes. A British trial (United Kingdom Glucose Insulin in Stroke Trial) is testing the utility of a strategy of achieving euglycemia after stroke.274 Despite the lack of data to guide decisions about management, consensus exists that hyperglycemia should be controlled after stroke.297 A reasonable goal would be to treat those patients’ elevated glucose concentrations (140 to 180 mg/dL). The approach would be similar to that prescribed for other acutely ill patients with concomitant hyperglycemia. H. Conclusions and Recommendations Most of the recommendations about general acute management are based on limited data. Some of the aspects of acute management may never be tested in clinical trials, whereas other aspects of treatment, such as the best strategy for treatment of hyperglycemia or arterial hypertension, likely will be clarified by ongoing or future clinical research. Pending such trials, many of the suggestions that follow are based on consensus and thus are Grade C recommendations. Class I Recommendations1. Airway support and ventilatory assistance are recommended for the treatment of patients with acute stroke who have decreased consciousness or who have bulbar dysfunction causing compromise of the airway (Class I, Level of Evidence C). This recommendation has not changed from previous statements. 2. Hypoxic patients with stroke should receive supplemental oxygen (Class I, Level of Evidence C). This recommendation has not changed since the previous guideline. 3. It is generally agreed that sources of fever should be treated and antipyretic medications should be administered to lower temperature in febrile patients with stroke (Class I, Level of Evidence C). This recommendation has not changed from previous statements. Medications such as acetaminophen can lower body temperature modestly, but the effectiveness of treating either febrile or nonfebrile patients to improve neurological outcomes is not established. Additional research on utility of emergency administration of antipyretic medications is
Report abuse