Amount Of Bolus Research Articles

Focused Cardiac Ultrasound Findings of Fluid Tolerance and Fluid Resuscitation in Septic Shock.

Compliance with the fluid bonus component of the SEP-1 (severe sepsis and septic shock management) bundle remains poor due to concerns for iatrogenic harm from fluid overload. We sought to assess whether patients who received focused cardiac ultrasound (FCU) and were found to be fluid tolerant (FT) were more likely to receive the recommended 30 mL/kg fluid bolus within 3 hours of sepsis identification. Retrospective, observational cohort study. University-affiliated, tertiary-care hospital in the United States. Emergency department patients presenting with septic shock from 2018 to 2021. The primary exposure was receipt of FCU with identification of fluid tolerance 3 hours from onset of septic shock. None. Two hundred ninety-two of 1,024 patients with septic shock received FCU within 3 hours of sepsis onset. One hundred seventy-seven were determined to be FT. One hundred fifteen patients were determined to have poor fluid tolerance (pFT). FT patients were more likely to reach the recommended 30 mL/kg fluid bolus amount compared with pFT (FT 52.0% vs. pFT 31.3%, risk difference: 20.7%, [95% CI, 9.4-31.9]). Patients who did not receive FCU met the bolus requirement 34.3% of the time. FT patients received more fluid within 3 hours (FT 2,271 mL vs. pFT 1,646 mL, mean difference 625 mL [95% CI, 330-919]). Multivariable logistic regression was used to estimate the association between fluid tolerance FCU findings and compliance with 30 mL/kg bolus after adjustment for patient characteristics and markers of hemodynamic instability. FT with associated with a higher likelihood of meeting bolus requirement (odds ratio 2.17 [1.52-3.12]). Patients found to be FT by FCU were more likely to receive the recommended 30 mL/kg bolus in the SEP-1 bundle when compared with patients found with pFT or those that did not receive FCU. There was no difference between groups in 28-day mortality, vasopressor requirement, or need for mechanical ventilation.

Effect of Acute Brief Social Isolation on Visceral Pain

The sensitivity of somatic pain could be affected by social isolation; however, few studies have examined the impact of social isolation on visceral pain. In the present study, the effect of acute brief social isolation on visceral pain response was investigated. Adult male rats were either reared individually or grouped for 2 hours or 24 hours. Colorectal distention (CRD)-induced abdominal withdrawal reflex (AWR) score and pain threshold were used to assess visceral pain sensitivity. The amount of fecal bolus was used to determine the stress level. Acute brief isolation rearing for 2 hours significantly increased AWR score and reduced visceral pain threshold in rats when compared to group rearing. Similarly, acute isolation for 24 hours resulted in visceral hypersensitivity, as indicated by an increase in the AWR score and a decrease in the visceral pain threshold. Furthermore, the amount of fecal bolus in acute isolation rearing (2 or 24 hours) rats was considerably higher than in the control group rearing rats. Acute short-term social isolation enhances visceral pain sensitivity, which could be related to an increase in stress levels.

Insulin induces a progressive increase in the resistance of subcutaneous tissue to fluid flow: Implications for insulin pump therapy.

AimTo determine the effect of insulin on the resistance of subcutaneous tissue to the flow of infusion fluids.Materials and methodsThirty subjects with type 1 diabetes wore two Accu‐Chek Spirit Combo insulin pumps with Accu‐Chek FlexLink infusion sets (Roche Diabetes Care, Mannheim, Germany) for 7 days. One pump was filled with insulin aspart (Novo Nordisk, Bagsvaerd, Denmark) and used for continuous subcutaneous insulin infusion (CSII). The other pump was filled with insulin diluting medium (IDM; Novo Nordisk) and used to deliver IDM subcutaneously at rates identical to those employed for CSII. Both infusion sites were assessed daily by measuring the pressure required to infuse various bolus amounts of IDM.ResultsOn day 1, maximum pressure (Pmax) and tissue flow resistance (TFR; calculated from measured pressure profiles) were similar for both infusion sites (P > 0.20). During the subsequent study days, the Pmax and TFR values observed at the IDM infusion site remained at levels comparable to those seen on day 1 (P > 0.13). However, at the site of CSII, Pmax and TFR progressively increased with CSII duration. By the end of day 7, Pmax and TFR reached 25.8 */2.11 kPa (geometric mean */geometric standard deviation) and 8.64 */3.48 kPa*s/μL, respectively, representing a remarkable 3.5‐ and 20.6‐fold increase relative to the respective Pmax and TFR values observed on day 1 (P < 0.001).ConclusionOur results suggest that insulin induces a progressive increase in the resistance of subcutaneous tissue to the introduction of fluid; this has important implications for the future design of insulin pumps and infusion sets.

Comparison of Adult Diabetic Ketoacidosis Treatment Protocols From Canadian Emergency Departments

BackgroundDiabetic ketoacidosis (DKA) is a common acute life-threatening complication of poorly controlled diabetes mellitus contributing to considerable mortality and morbidity. Use of standardized treatment protocols improves patient outcomes in the emergency department (ED) for many conditions, but variability in adult DKA treatment protocols has not been assessed across EDs. In this study, we compared DKA treatment protocols from adult EDs across Canada to highlight inconsistencies in recommended DKA management. MethodsED staff in Canada were solicited for their treatment protocols used to guide acute ED DKA management. Information regarding initial fluid resuscitation and maintenance fluid, potassium replacement, insulin therapy and bicarbonate administration was abstracted from each protocol, collated in a table and compared. ResultsThirty-six unique protocols were obtained representing 85 institutions (40 urban and 45 rural, with a 65.1% response rate) across Canada, with no protocol use for 4 urban centres. Similarities in protocols included the intravenous insulin infusion rate and instructions for switching to subcutaneous insulin. Variability was noted in the rate, amount and type of fluid bolus given (0.5 to 2 L of normal saline or Ringer’s lactate over 15 minutes to 2 hours), the criteria determining the amount, potassium supplementation at normo/hypokalemic ranges, when to add dextrose to maintenance fluid, insulin bolus inclusion and bicarbonate administration. ConclusionsThis is the first comparison of adult DKA treatment protocols in Canada. Although several common approaches were identified, variability was found in initial fluid boluses, initial insulin bolus and role of bicarbonate, necessitating further study to ensure local DKA protocols reflect current evidence-based best practices for optimal patient clinical outcomes.

Clinical Evaluation of a Novel CGM-Informed Bolus Calculator with Automatic Glucose Trend Adjustment.

Background: Expert opinion guidelines and limited data from clinical trials recommend adjustment to bolus insulin doses based on continuous glucose monitor (CGM) trend data, yet minimal evidence exists to support this approach. We performed a clinical evaluation of a novel CGM-informed bolus calculator (CIBC) with automatic insulin bolus dose adjustment based on CGM trend used with sensor-augmented pump therapy.Materials and Methods: In this multicenter, outpatient study, participants 6–70 years of age with type 1 diabetes (T1D) used the Omnipod® 5 System in Manual Mode, first for 7 days without a connected CGM (standard bolus calculator, SBC, phase 1) and then for 7 days with a connected CGM using the CIBC (CIBC phase 2). The integrated bolus calculator used stored pump settings plus user-estimated meal size and/or either a manually entered capillary glucose value (SBC phase) or an imported current CGM value and trend (CIBC phase) to recommend a bolus amount. The CIBC automatically increased or decreased the suggested bolus amount based on the CGM trend.Results: Twenty-five participants, (mean ± standard deviation) 27 ± 15 years of age, with T1D duration 12 ± 9 years and A1C 7.0% ± 0.9% completed the study. There were significantly fewer sensor readings <70 mg/dL 4 h postbolus with the CIBC compared to the SBC (2.1% ± 2.0% vs. 2.8 ± 2.7, P = 0.03), while percent of sensor readings >180 and 70–180 mg/dL remained the same. There was no difference in insulin use or number of boluses given between the two phases.Conclusion: The CIBC was safe when used with the Omnipod 5 System in Manual Mode, with fewer hypoglycemic readings in the postbolus period compared to the SBC. This trial was registered at ClinicalTrials.gov (NCT04320069).

Standardizing Care for Patients with Insulin Pumps

<h3>Introduction</h3> An increase in the number of patient with subcutaneous insulin pumps was noted in the surgical population. Multiple types of insulin pumps and various levels of patient knowledge were being noted by perioperative staff. <h3>Identification of the problem</h3> The plan of care was found to be inconsistent for these patients and there was no standardized treatment guideline in place to manage practice. <h3>Objectives of project</h3> The objective of this project was to 1) Standardize the perioperative process of insulin pump management, 2) Create a clinical practice guideline specific for this population, and 3) Systematically educate staff of the new process and guideline. <h3>Method</h3> A multidisciplinary team was assembled and the current practice was analyzed to identify gaps. Multiple areas of practice were identified. Monthly meetings were held with leaders from each area contributing to the practice guideline development. <h3>Outcomes</h3> A multidisciplinary clinical practice guideline was developed in conjunction with endocrinology physicians, hospitalists, anesthesiologists, nurses and pharmacists to standardize the process from pre-admission screening to discharge. A new process was created in the electronic medical record to record the patients pump, basal rate and bolus amounts given. Education for staff was developed and distributed hospital wide. <h3>Discussion</h3> This QI project targeted a clinical gap and created a team from nursing, medicine, pharmacy, nutrition, anesthesiology and informatics to standardize practice for a low volume, high risk process. This project ensures that patients with insulin pumps are identified in the pre-screening unit and are assessed for their independence in pump management. <h3>Conclusion and implications</h3> Patients with insulin pumps are now admitted day of surgery with a detailed plan of care from an endocrinologist. Accurate documentation of patient's insulin pump and activity is now standardized. This assists with communication between nursing staff and anesthesia, and aides in promoting positive outcomes for surgical patients. <h3>Future Research</h3> Comparison of glucose levels pre and post practice guideline implementation for effectiveness of change.

P0652 / #2053: ULTRASOUND GUIDED FLUID RESUSCITATION IN PAEDIATRIC SEPTIC SHOCK - A RANDOMIZED CONTROL TRIAL

Aims & Objectives: To compare the amount of fluid bolus required in children with septic shock, given with ultrasound or clinical guidance. Secondary outcomes were shock reversal time, fluid overload rate at 24 and 72 hrs, ionotrope and ventilator requirement. Methods: It was a randomized control un-blinded pilot study, conducted at the PICU and emergency of a tertiary care Government teaching hospital, from September 2019 to June 2020. Children with congenital heart disease, dengue shock syndrome and anaphylactic shock were excluded. After recieving an initial fluid bolus of 20ml/kg, participants were randomized into ultrasound (study group) and clinical (control group). The study group recieved further fluid boluses on the basis of inferior vena cava collapsibility/distensibility, cardiac contractility and extra-vascular lung water, while children in the control group recieved further fluid boluses only under clinical guidance. Results: 55 children aged 1 month to 12 years were enrolled - 26 in study group and 29 in control group. Shock reversal time (14 ± 5.5 h vs 19.3 ± 8.5 h, p=0.02) and total fluid bolus (39 ± 16.8 vs 60 ± 26.6 ml/kg, p=0.0009) was significantly lower in the study group. However, there was no significant difference in secondary outcomes, including fluid overload rate. Conclusions: Though limited by sample size, our study demonstrated reduced need for fluid boluses and earlier shock reversal if resuscitation was guided by ultrasound. However, multicenter trials with a larger sample size are required to accurately establish the usefulness of ultrasound in fluid resuscitation in children with septic shock.

Bispectral index monitoring during total intravenous anaesthesia: A comparative study between two dosage regimes of propofol

Introduction: The potential long-term complication of intraoperative awareness needs to be addressed. These complications range from mild auditory perceptions to being fully awake. Studies with prospective patient interviews that specifically inquire about awareness have noted an incidence of 0.1 to 0.2 percent in the general population and approximately 1 percent in high-risk populations. Aims and Objectives: Comparative evaluation of two dose regimens of propofol to assess the depth of anesthesia during total intravenou anesthesia using Bispectral index monitor. The objectives were to find the average Bispectral index during propofol anaesthesia, compare and determine, in two groups, the amount of additional bolus or reduction in the infusion rates of propofol in two dose regimens and to correlate the Bispectral indices with hemodynamic monitoring and to assess incidence of postoperative awareness in the two groups. Materials and Methods: This study was conducted as a prospective randomized double-blind study in a teaching hospital. After the approval from the Ethics committee of the institution, 50 ASA I-II patients were randomly divided into two groups (GI and GII). The patients were induced with a standard regimen of 2 mg kg-1 of propofol and 0.1 mg kg-1 of vecuronium and intubated using appropriate sized endotracheal tube. Following intubation, propofol was infused according to the group the patients was allotted. GI received propofol infusion maintenance dose of 10 mg kg-1 hour for the first 10 minutes following intubation, 8 mg. kg-1 hour for the next 10 minutes and thereafter 6 mg kg-1 hour for the entire length of the surgery. GII received propofol infusion maintenance dose of 8 mg kg -1hour for the first 10 minutes following intubation, 6 mg kg -1hour for the next 10 minutes and thereafter 4 mg kg-1 hour for the entire length of the surgery. The Bispectral index, blood pressure and heart rate were monitored during intubation and thereafter every five min

Magnetically-driven implantable pump for on-demand bolus infusion of short-acting glucagon-like peptide-1 receptor agonist

For type 2 diabetic patients, short acting glucagon-like peptide-1 receptor agonist (GLP-1 RA) is often prescribed with frequent needled injections. Long-acting GLP-1 RA for less frequent injections do not mimic physiologic secretion of GLP-1. Therefore, an implantable pump is proposed in this work, which can deliver a short-acting GLP-1 RA, exenatide, without needles and batteries. The implanted pump can infuse an accurate amount of exenatide bolus only when a noninvasive magnetic force is applied from outside the body. The pump includes a safety feature of patterned magnets for actuation to prevent accidental infusion possibly caused by a general household magnet. The reservoir for exenatide is made of a flexible biomaterial and thus, a negative pressure build-up in the reservoir can be prevented even after multiple actuations and almost all drug consumption (~ 94%). This allows a reproducible drug dose for a longer period after implantation, hence less frequent replenishment procedures. The pump is also equipped with an intermediate container with two distinct check-valves and thus, the reservoir of exenatide can be further separated and better prevented from infiltration of the bodily fluid surrounding the implanted pump. When tested in Goto-Kakizaki rats, the pump demonstrates the efficacy of exenatide similar to conventional subcutaneous injections. Therefore, the pump can be promising for patient-friendly, optimal delivery of short-acting GLP-1 RA that better follows the physiologic secretion profile of GLP-1.

1003-P: Estimating an Optimal Meal Bolus for Persons with Diabetes on Multiple Daily Injections Therapy without Carb Counting

Background: MDI therapy requiring carbohydrate (carb) counting can be burdensome for persons with diabetes (PWD). We conducted an in-silico feasibility study assessing the glycemic performance of a post-prandial rather than a carb-based bolus optimizer. Methods: The data were collected from seven adults with T1D (Gender:M2/F5; Age:22-45) on MDI using the Guardian™ Connect continuous glucose monitoring system. All participants had three bolus events matched to three meals for ≥7 days. In the training stage, a glucose-insulin minimal model extracted the rate of glucose appearance in blood (Ra) for each meal. The Ra was taken as an input to adjust in-silico simulated bolus amounts until the greatest time in sensor glucose range (70-180 mg/dL, TIR) within 4hrs was reached. In the testing stage, two bolus strategies were tested: the average of the adjusted bolus from the training set (Uniform Bolus) and the average of the adjusted bolus from the training set associated with the time of day (TOD) of the meal announcement (TOD Bolus). Results: We found increased TIR for TOD Bolus strategy compared to the User Bolus (baseline) strategy (See Table below). Conclusion: The data suggested that the automated bolus optimizer without carb counting may allow for an increased time spent in the target range, without comprising time spent below range while reducing the burden of carb counting for PWD on MDI. Disclosure B. Jiang: Employee; Self; Medtronic. Y. Zhong: Employee; Self; Medtronic. P. Agrawal: None. T.L. Cordero: Employee; Self; Medtronic. R. Vigersky: Employee; Self; Medtronic.

1043-P: Glycemic Profiles and Treatment Patterns: Real-World Data from 8,020 Adults with Type 1 Diabetes Using the Omnipod® Insulin Management System with Cloud-Based Data Management

While clinical trials have demonstrated significant benefits of insulin pump therapy for type 1 diabetes, there is increasing recognition of the importance of real-world population data to better understand the impact of diabetes technology on treatment outcomes. This study retrospectively analyzed data from a large cohort of adults with type 1 diabetes using the Omnipod® Insulin Management System (Insulet Corp., Acton, MA) with an integrated BG meter (Abbott Diabetes Care Inc., Alameda, CA) and data management system (Glooko, Mountain View, CA) to characterize glycemic profiles, insulin use and treatment patterns. From January 2015 through September 2018, pump system data were uploaded to the data management system and matched via device serial number to a second database of self-reported demographic data and de-identified. BG and insulin data from ≥3 mo of system use per patient were analyzed. Adults ≥18 y with type 1 diabetes (n=8,020) were age (mean±SD) 40.8±15.3y, 60% female, 61% used a tubeless insulin pump for ≥1 y and 13% used CGM for &amp;gt;50% of overall time of system use. Glycemic profiles included mean glucose 177±39 mg/dL, estimated A1C 7.8%, percent time in target range 70-180 mg/dL, hypoglycemia &amp;lt;70 mg/dL and hyperglycemia &amp;gt;180 mg/dL: 50.2±17.3, 5.9±5.0, and 43.9±18.3, respectively. The total daily insulin was 43.4±18.7 U/d which was delivered as 54% basal and 46% bolus. There were an average of 4.7±2.2 bolus deliveries per day and the average bolus amount was 4.5±2.8 U. These real-world glycemic profiles in adults with type 1 diabetes using the Omnipod® System support the use of diabetes technology in the management of type 1 diabetes. These data indicate that use of a tubeless insulin pump is associated with outcomes that compare favorably to large national registries including the T1D Exchange. Disclosure J.E. Layne: Employee; Self; Insulet Corporation. J. He: Employee; Self; Insulet Corporation. J. Jantz: Employee; Self; Insulet Corporation. Employee; Spouse/Partner; Insulet Corporation. Y. Zheng: Employee; Self; Insulet Corporation. Stock/Shareholder; Self; Insulet Corporation. E. Benjamin: Employee; Self; Insulet Corporation. T.T. Ly: Employee; Self; Insulet Corporation. Funding Insulet Corporation

1453-P: Glycemic Profiles and Insulin Use in 2,313 Medicare-Eligible Older Adults with Diabetes Using the Omnipod Insulin Management System with Cloud-Based Data Management

Increased access and reimbursement for insulin pumps is critically important for older adults. Recently the Centers for Medicare and Medicaid Services (CMS) issued guidance that the tubeless Omnipod® Insulin Management System (Insulet Corp., Acton, MA) is eligible for coverage under the Medicare Part D (prescription drug) program. This observational study is the first report of glycemic profiles and insulin use in a large cohort of adults aged ≥65 years with diabetes using the Omnipod System and integrated BG meter (Abbott Diabetes Care Inc, Alameda, CA) with a data management system (Glooko, Mountain View, CA). Data uploaded from the pump system to the data management system from January 2015 through September 2018 were matched via device serial number to a second database of self-reported demographic data and de-identified. BG data and insulin use patterns from ≥3 mo of system use per patient were analyzed. Glycemic outcomes included mean glucose, estimated A1C and percent time in range 70-180, &amp;lt;70 and &amp;gt;180 mg/dL. Patients (n=2,313) were mean age 69.7 y (range 65-96 y), 53% female, 23% T1D, 12% T2D, 1% other and 64% not reported. Three percent used CGM for &amp;gt;50% of overall time of system use. Mean glucose was 168±32 mg/dL with an estimated A1C of 7.5%. Percentage time in range 70-180, &amp;lt;70 and &amp;gt;180 mg/dL was 56.8±16.5, 5.3±4.8 and 38.0±17.2, respectively. The total daily insulin was 43.5±22.1 U/d delivered as 55% basal/45% bolus. There was an average of 4.3±1.9 bolus deliveries per day and the average bolus amount was 4.8±3.2 U. These real-world data of a large cohort of Medicare-eligible older adults with diabetes suggest that use of a tubeless insulin pump was associated with glycemic profiles that compare favorably to large national registry data including the T1D Exchange. These results also highlight the importance of access and choice of insulin delivery technology for older adults with diabetes to optimize treatment outcomes. Disclosure J.E. Layne: Employee; Self; Insulet Corporation. J. He: Employee; Self; Insulet Corporation. J. Jantz: Employee; Self; Insulet Corporation. Employee; Spouse/Partner; Insulet Corporation. Y. Zheng: Employee; Self; Insulet Corporation. Stock/Shareholder; Self; Insulet Corporation. E. Benjamin: Employee; Self; Insulet Corporation. T.T. Ly: Employee; Self; Insulet Corporation. Funding Insulet Corporation

1042-P: Real-World Treatment Patterns and Glycemic Profiles of 1,217 Adults with Type 2 Diabetes Using the Omnipod® Insulin Management System with Cloud-Based Data Management

Continuous subcutaneous insulin infusion may help optimize therapy in patients with type 2 diabetes, however, there is little real-world data on pump use in this population. This observational study characterized treatment patterns and glycemic profiles of a large cohort of adults with type 2 diabetes using a tubeless insulin pump (Omnipod® Insulin Management System, Acton, MA) with integrated blood glucose (BG) meter (Abbott Diabetes Care Inc., Alameda, CA) and data management system (Glooko, Mountain View, CA). From January 2015 through September 2018, usage data from the pump system were uploaded to the data management system and matched via device serial number to a second database of self-reported demographic data and de-identified. BG and insulin data from ≥3 mo of system use per patient were analyzed. Glycemic outcomes included mean glucose, estimated A1C and percent time in range 70-180, &amp;lt;70 and &amp;gt; 180 mg/dL. Patients (n=1,217) were age (mean±SD) 56.8±10.8y, 50% female and 58% used a tubeless insulin pump for ≥1 y. Glycemic profile included BG 174±39 mg/dL, estimated A1C 7.7%, time in range 70-180, &amp;lt;70 and &amp;gt;180 mg/dL: 57.8%±20.1, 3.2%±3.9, 39.0%±20.6, respectively. The total daily insulin was 58.3±26.5 U/d delivered as 60% basal/40% bolus with an average of 3.4±1.7 bolus deliveries per day and mean bolus amount of 7.0±3.9 U. CGM was used by 5.5% of the cohort for &amp;gt;50% of overall time of system use. These real-world data characterizing a large cohort of adults with type 2 diabetes provide insight to self-management patterns and glycemic profiles indicating that use of tubeless insulin pump was associated with glycemic control that exceeds U.S. National Healthcare Effectiveness Data and Information Set (HEDIS) standards for adequate diabetes control. Disclosure J.E. Layne: Employee; Self; Insulet Corporation. J. Jantz: Employee; Self; Insulet Corporation. Employee; Spouse/Partner; Insulet Corporation. J. He: Employee; Self; Insulet Corporation. Y. Zheng: Employee; Self; Insulet Corporation. Stock/Shareholder; Self; Insulet Corporation. E. Benjamin: Employee; Self; Insulet Corporation. T.T. Ly: Employee; Self; Insulet Corporation. Funding Insulet Corporation

Novel Bluetooth-Enabled Tubeless Insulin Pump: Innovating Pump Therapy for Patients in the Digital Age.

The Omnipod DASH™ Insulin Management System (Insulet Corp, Billerica, MA) is a discreet, tubeless, wearable insulin pump that holds up to 200 units of U-100 insulin and delivers therapy through customizable basal rates and bolus amounts. This recently FDA-cleared system consists of the insulin pump (“Pod”), which is worn on body and delivers insulin, and the Personal Diabetes Manager (PDM), which is a handheld device used to wirelessly control and monitor the Pod functionality. The PDM can also be paired with the CONTOUR® NEXT ONE blood glucose (BG) meter (Ascensia Diabetes Care, Basel, Switzerland) to wirelessly receive BG readings. This review provides a detailed description of the Pod and PDM. Key features of the Pod are described, including the novel pump delivery mechanism, waterproof (IP28) housing design, and automated cannula insertion. The technology introduced in the new system, such as touchscreen PDM interface, Bluetooth® wireless technology, and wireless internet connectivity, is also presented. Last, Omnipod® Insulin Management System clinical data are reviewed, including early feasibility results for the Omnipod Horizon™ Automated Glucose Control hybrid closed-loop system.

Automatic Detection and Estimation of Unannounced Meals for Multivariable Artificial Pancreas System.

Automatically attenuating the postprandial rise in the blood glucose concentration without manual meal announcement is a significant challenge for artificial pancreas (AP) systems. In this study, a meal module is proposed to detect the consumption of a meal and to estimate the amount of carbohydrate (CHO) intake. The meals are detected based on qualitative variables describing variation of continuous glucose monitoring (CGM) readings. The CHO content of the meals/snacks is estimated by a fuzzy system using CGM and subcutaneous insulin delivery data. The meal bolus amount is computed according to the patient's insulin to CHO ratio. Integration of the meal module into a multivariable AP system allows revision of estimated CHO based on knowledge about physical activity, sleep, and the risk of hypoglycemia before the final decision for a meal bolus is made. The algorithm is evaluated by using 117 meals/snacks in retrospective data from 11 subjects with type 1 diabetes. Sensitivity, defined as the percentage of correctly detected meals and snacks, is 93.5% for meals and 68.0% for snacks. The percentage of false positives, defined as the proportion of false detections relative to the total number of detected meals and snacks, is 20.8%. Integration of a meal detection module in an AP system is a further step toward an automated AP without manual entries. Detection of a consumed meal/snack and infusion of insulin boluses using an estimate of CHO enables the AP system to automatically prevent postprandial hyperglycemia.

Impact of Carbohydrate Counting Errors on Glycemic Control in Type 1 Diabetes

Abstract Patients with type 1 diabetes mellitus (T1DM) typically determine their bolus insulin needs based on methods from Advanced Carbohydrate Counting (ACC). In ACC the amount of required bolus insulin is assumed to be directly proportional to the carbohydrate content of the ingested meal. It is well known that many T1DM patients have difficulties to accurately estimate meal carbohydrates. Though these estimates are used for calculating the meal bolus amount, there is a scarcity of data on how estimation errors affect glycemic control. The current paper analyzes the effect of carb counting errors on glycemic outcomes during basal-bolus-therapy in a simulation study using so-called Deviation Analyses. Furthermore, the effect of inaccurate estimates on the settings of the insulin therapy is studied by means of the previously published Adaptive Bolus Calculator (ABC) algorithm. It is found that whereas random carb counting inaccuracies indeed do lead to an inferior glycemic control, systematic biases in the estimates are expected to hardly affect the results since these are usually implicitly accounted for in the therapy settings.

Measurement of Pharyngo-laryngeal Volume During Swallowing Using 320-Row Area Detector Computed Tomography.

This study aimed to (1) evaluate changes in bolus and air volumes in the pharyngo-laryngeal cavity during swallowing and (2) determine how differences in these volumes during swallowing are influenced by bolus amount using 320-row area detector computed tomography (320-ADCT). Three-, 10-, and 20-ml honey-thick liquids (5% w/v) were presented to ten healthy subjects placed in a 45° reclining position. 3D images were created in 29 phases at an interval of 0.1s for 3.15s. Changes in bolus and air volumes in the pharyngo-laryngeal cavity were calculated. The two one-sided tests were used to determine equivalency of the pharyngo-laryngeal volume of each event (i.e., onset of hyoid elevation, soft palate closure, true vocal cord closure, closure of laryngeal vestibule, epiglottis inversion, pharyngo-esophageal sphincter opening) for each bolus volume. The pharyngo-laryngeal volume during swallowing was about 20ml before swallowing. The volume temporarily increased with tongue loading, but decreased to about 0ml with pharyngeal contraction. Subsequently, the volume returned to the original volume after airway opening. Most of the air was released from the pharyngo-laryngeal space before the bolus flowed into the esophagus during swallowing. As the bolus volume to be swallowed increased, the maximal pharyngo-laryngeal volume increased, but changes in air volume remained constant. 320-ADCT allowed for analysis of dynamic volume changes in the pharyngo-laryngeal cavity, which will increase our knowledge of kinematic and volumetric mechanisms during swallowing.

Impact of Emergency Department Wait Time on Mortality in Severe Sepsis

Impact of Emergency Department Wait Time on Mortality in Severe Sepsis

Diagnostic value of “dysphagia limit” for neurogenic dysphagia: 17 years of experience in 1278 adults

ObjectiveNeurogenic dysphagia (ND) is a prevalent condition that accounts for significant mortality and morbidity worldwide. Screening and follow-up are critical for early diagnosis and management which can mitigate its complications and be cost-saving. The aims of this study are to provide a comprehensive investigation of the dysphagia limit (DL) in a large diverse cohort and to provide a longitudinal assessment of dysphagia in a subset of subjects. MethodsWe developed a quantitative and noninvasive method for objective assessment of dysphagia by using laryngeal sensor and submental electromyography. DL is the volume at which second or more swallows become necessary to swallow the whole amount of bolus. This study represents 17years experience with the DL approach in assessing ND in a cohort of 1278 adult subjects consisting of 292 healthy controls, 784 patients with dysphagia, and 202 patients without dysphagia. A total of 192 of all patients were also reevaluated longitudinally over a period of 1–19months. ResultsDL has 92% sensitivity, 91% specificity, 94% positive predictive value, and 88% negative predictive value with an accuracy of 0.92. Patients with ALS, stroke, and movement disorders have the highest sensitivity (85–97%) and positive predictive value (90–99%). The clinical severity of dysphagia has significant negative correlation with DL (r=−0.67, p<0.0001). ConclusionsWe propose the DL as a reliable, quick, noninvasive, quantitative test to detect and follow both clinical and subclinical dysphagia and it can be performed in an EMG laboratory. SignificanceOur study provides specific quantitative features of DL test that can be readily utilized by the neurologic community and nominates DL as an objective and robust method to evaluate dysphagia in a wide range of neurologic conditions.

Hypotension: Preventing the Fall

Childbearing Poster Presentation Purpose for the Program The staff in the labor and delivery (L&D) unit at Baylor University Medical Center noticed an increased incidence of hypotension after epidural placement, which required ephedrine for treatment. Data collection began to determine if the perception was accurate and if there were recognizable patterns. Initial surveys that evaluated knowledge regarding hypotension were given to various nurses on each shift. Additionally, 69 retrospective random chart audits were conducted, which evaluated baseline blood pressure before and after epidural placement and evaluated the use of ephedrine to treat hypotension. Our initial data suggested a staff knowledge deficit and a postepidural hypotension rate of 22.67%. Proposed Change The L&D Comprehensive Unit‐Based Safety Program (CUSP) felt this data reflected a quality improvement opportunity. Based on our process modeling flow chart and fishbone diagram, we developed a goal to reduce postepidural hypotension in the obstetric patient population by 5% with the implementation of nursing education and clarification of order sets. Implementation, Outcomes, and Evaluation To correct the knowledge deficit and inconsistent use of order sets, we developed and provided educational in‐services. The in‐services focused on potential exaggerating or precipitating factors and the prevention and corrective measures of postepidural hypotension. We also focused on improving communication between registered nurses (RNs) and anesthesiologists, empowering the RNs to ask more questions regarding procedure type, medications given, timing, and amount of preload versus co‐load. Additionally, our documentation system was revised to facilitate improved documentation of interventions, including intravenous fluid bolus timing and amount. Biweekly random chart audits were performed to evaluate progress and percentage of hypotension. Through standardized education and improved collaboration between RNs and anesthesiologists, Baylor University Medical Center's hypotension rate in the obstetric population decreased from 22.67% to 8%. Implications for Nursing Practice Though literature states that hypotension affects up to 80% of parturient women, we aim to decrease the incidence of maternal/fetal response and promote safe passage with efforts focused on prevention, recognition, and early intervention,