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Eliotte Hirshberg, MD
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Division of Pulmonary and Critical Care University of Utah Salt Lake City, UT

Correspondence to: Eliotte Hirshberg, MD; e-mail: ellie.hirshberg@hsc.utah.edu

The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2009;135(1):248. doi:10.1378/chest.08-2374
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To the Editor:

Dr. Kittisupamongkol highlights medications as one of the many factors contributing to the disruption of blood glucose homeostasis in the critically ill patient. Commonly prescribed medications in the ICU likely influence glucose and insulin metabolism.1 Our survey was meant to elucidate critical care clinicians' opinions about hyperglycemia, its frequency, and the factors they believe influence blood glucose levels.2 Our survey did not individually address each medication commonly used in the ICU, though we did try to account for medications known to induce peripheral insulin insensitivity (glucocorticoids and vasoactive medications).3 Our survey reflects the opinions of North American intensive care practitioners. Question 3.2 of the survey asked what our respondents thought were the most important factors that contribute to hyperglycemia in the ICU setting. The options did not include an exhaustive list of commonly prescribed medications, but did allow for an “other” box with free text input. Very few respondents ranked the “other” box as a major contributor to hyperglycemia. The use of gatifloxicin in our respondent's patient population was not addressed. The effects of medications on blood glucose metabolism may be underestimated by ICU practitioners, but we reported the 10 factors that they thought contributed most significantly to hyperglycemia.

Accounting for each medication given to a critically ill patient and its overall metabolic effects presents a challenge for even the most astute clinician. All too often, we focus on one problem and a medication to treat it, and forget to account for its side effects. Although stress hyperglycemia in the critically ill patient is a seemingly simple issue, Dr. Kittisupamongkol's statement reminds us how clinician perspective and choice of another medication can influence the understanding and treatment of hyperglycemia. The critical care community is currently struggling to determine the best balance for patients between hyperglycemia and hypoglycemia. I would suggest that the climate is ripe for more prospective studies that account for the medications prescribed, the total number of calories ingested, the total doses of insulin administered, as well as the blood glucose target achieved.

Montori VM, Bistrian BR, McMahon MM. Hyperglycemia in acutely ill patients. JAMA. 2002;288:2167-2169. [PubMed] [CrossRef]
 
Hirshberg E, Lacroix J, Sward K, et al. Blood glucose control in critically ill adults and children: a survey on stated practice. Chest. 2008;133:1328-1335. [PubMed] [CrossRef]
 
Van den Berghe G. Insulin therapy for the critically ill patient. Clin Cornerstone. 2003;5:56-63. [PubMed] [CrossRef]
 

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References

Montori VM, Bistrian BR, McMahon MM. Hyperglycemia in acutely ill patients. JAMA. 2002;288:2167-2169. [PubMed] [CrossRef]
 
Hirshberg E, Lacroix J, Sward K, et al. Blood glucose control in critically ill adults and children: a survey on stated practice. Chest. 2008;133:1328-1335. [PubMed] [CrossRef]
 
Van den Berghe G. Insulin therapy for the critically ill patient. Clin Cornerstone. 2003;5:56-63. [PubMed] [CrossRef]
 
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