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Glucose is a common carrier fluid, and in this particular case is given at a very low concentration (D5%). You need to infuse glucose as part of your parental n

Glucose is a common carrier fluid, and in this particular case is given at a very low concentration (D5%). You need to infuse glucose as part of your parental nutrition regimen. This is standard practice across intensive care units, and they probably wouldn't have gotten approval for the protocol without it. As an aside, my company [1] is working on solving this and other problems by focusing on glucose control. When you keep the blood sugar under control, sepsis develops at much lower rates and mortality decreases across the board by 20-30%. [1] - https://idealmedtech.com https://idealmedtech.com

carbocation 3y ago
D5W is common, sure. My post makes no complaint about D5W being uncommon. The problem here, again, is that this choice led to both sodium and ascorbate administration being different between the two arms. They think they are testing the ascorbate, but they can’t exclude the possibility that they are getting results due to sodium. Since you used this as an opportunity to plug your company, I will say that the company’s claims about reducing mortality from glucose management seem very poorly supported. Your site only lists retrospective studies, but you will need multicenter prospective RCTs to have any credibility with such claims. Saying that “mortality decreases” is easily read as causal language, but there is no data supporting such language. If the effect size is anywhere near as large as you claim, these trials will be very easy to run and won’t need a large sample size.
- ijustlovemath 3y ago
  There are several multicenter RCTs showing the efficacy of glucose control, but none as yet that do it well in a fully automated way. We don't have these studies listed on the website, and that's one thing we could definitely change, but they're pretty easy to find in the literature. You're correct though, that the number of patients needed to demonstrate efficacy in a pivotal trial will be somewhere in the 100-300 range, which is something we're working up to! As with all things in medicine, these things take lots time and lots of capital, but the need is clear and for people who understand that need, there are very few who wouldn't want to incorporate a fully automated glucose control system into their unit. Regarding mortality reduction claims, I'd encourage you to read the work of Van DeBerghe, Krinsley, Kovatchev, Hovorka, Chase, and Umpierrez, to name but a few of the academics who have run larger studies
  - carbocation 3y ago
    Van DeBerghe is cited in the editorial discussing the pivotal practice-changing RCT that showed increased mortality from tight glucose control in the ICU (Finfer NEJM 2009). I think a lot of us intuitively believe that there is a mechanism of glucose control that should be helpful, but like I said, an RCT (of the specific device) will be necessary.
    - ijustlovemath 3y ago
      Absolutely! Yeah, NICE-SUGAR definitely has its flaws, the main one being that it has a lot more hypoglycemia than it should - a combination of the open loop protocol, infrequent sample time, no patient model, and static dosing protocol with only rescue bolusing. We did a series of simulation studies a few years ago comparing various state of the art ICU controllers, and while NICE-SUGAR has excellent time in range, it has poor performance in the hypo range, which has been linked to increased mortality. The key is to get low variability and lots of time in range, but absolutely no hypoglycemia of any kind. That's what it's going to take to crack this problem. We hope our second human trial will continue to show those characteristics, and in a few years, an RCT pivotal trial. Here's the NICE-SUGAR protocol for your reference: https://studies.thegeorgeinstitute.org/nice/docs/ALGORITHM.pdf https://studies.thegeorgeinstitute.org/nice/docs/ALGORITHM.p...

carbocation 3y ago

D5W is common, sure. My post makes no complaint about D5W being uncommon. The problem here, again, is that this choice led to both sodium and ascorbate administration being different between the two arms. They think they are testing the ascorbate, but they can’t exclude the possibility that they are getting results due to sodium. Since you used this as an opportunity to plug your company, I will say that the company’s claims about reducing mortality from glucose management seem very poorly supported. Your site only lists retrospective studies, but you will need multicenter prospective RCTs to have any credibility with such claims. Saying that “mortality decreases” is easily read as causal language, but there is no data supporting such language. If the effect size is anywhere near as large as you claim, these trials will be very easy to run and won’t need a large sample size.

ijustlovemath 3y ago
There are several multicenter RCTs showing the efficacy of glucose control, but none as yet that do it well in a fully automated way. We don't have these studies listed on the website, and that's one thing we could definitely change, but they're pretty easy to find in the literature. You're correct though, that the number of patients needed to demonstrate efficacy in a pivotal trial will be somewhere in the 100-300 range, which is something we're working up to! As with all things in medicine, these things take lots time and lots of capital, but the need is clear and for people who understand that need, there are very few who wouldn't want to incorporate a fully automated glucose control system into their unit. Regarding mortality reduction claims, I'd encourage you to read the work of Van DeBerghe, Krinsley, Kovatchev, Hovorka, Chase, and Umpierrez, to name but a few of the academics who have run larger studies
- carbocation 3y ago
  Van DeBerghe is cited in the editorial discussing the pivotal practice-changing RCT that showed increased mortality from tight glucose control in the ICU (Finfer NEJM 2009). I think a lot of us intuitively believe that there is a mechanism of glucose control that should be helpful, but like I said, an RCT (of the specific device) will be necessary.
  - ijustlovemath 3y ago
    Absolutely! Yeah, NICE-SUGAR definitely has its flaws, the main one being that it has a lot more hypoglycemia than it should - a combination of the open loop protocol, infrequent sample time, no patient model, and static dosing protocol with only rescue bolusing. We did a series of simulation studies a few years ago comparing various state of the art ICU controllers, and while NICE-SUGAR has excellent time in range, it has poor performance in the hypo range, which has been linked to increased mortality. The key is to get low variability and lots of time in range, but absolutely no hypoglycemia of any kind. That's what it's going to take to crack this problem. We hope our second human trial will continue to show those characteristics, and in a few years, an RCT pivotal trial. Here's the NICE-SUGAR protocol for your reference: https://studies.thegeorgeinstitute.org/nice/docs/ALGORITHM.pdf https://studies.thegeorgeinstitute.org/nice/docs/ALGORITHM.p...