Glycemic Control In The Pediatric Intensive Care Unit Of Leuven: Two Years Of Experience
Go to: Critically ill patients have a severe dysregulation of their glucose homeostasis. Observational studies have shown that both hyperglycemia and hypoglycemia are associated, by a J-curved relation, with increased mortality rate in patients with severe illness.1 This association between stress hyperglycemia and poor outcome is known not only for critically ill adults but also for critically ill infants and children.2–7 Normalization of blood glucose levels within age-adjusted tight limits (tight glycemic control, TGC) leads to a reduction in the mortality and morbidity rate as was shown in three randomized controlled trials in the surgical, medical, and pediatric intensive care unit (PICU) of the Leuven University in Belgium.8–10 The trial in the Leuven PICU was performed with 700 infants and children who were randomly allocated to the intensive insulin therapy (IIT) group or the conventional insulin therapy (CIT) group.10 The target blood glucose ranges in the IIT group were the age-adjusted normal fasting levels of glycemia: 50–80 mg/dl for infants and 70–100 mg/dl for children. In the CIT group, insulin was administered only to prevent blood glucose levels from exceeding 215 mg/dl (which is the renal threshold). An important reduction in the duration of PICU stay, inflammatory response, and mortality was noted. Inevitably, IIT also led to an increased incidence of (short-lasting) hypoglycemia: approximately 25% patients had at least one hypoglycemic event (blood glucose < 40 mg/dl) during their entire stay in the PICU. The fear of causing iatrogenic hypoglycemic episodes,11 in addition to some follow-up clinical trials that either could not confirm this survival benefit or have even resulted in an increased mortality in patients who were treated with IIT, Continue reading >>
Management Of Hyperglycemia In The Pediatric Intensive Care Unit; Implementation Of A Glucose Control Protocol.
Abstract OBJECTIVE: To evaluate a stepwise nurse-driven glucose control protocol for the treatment of hyperglycemia in critically ill pediatric patients. SETTING: Academic pediatric intensive care unit. DESIGN: Prospective observational study. PATIENTS: A total of 50 consecutively admitted critically ill children with hyperglycemia >8 mmol/L (>145 mg/dL) were included and treated according to the glucose control protocol. MEASUREMENTS AND MAIN RESULTS: Demographic data and clinical parameters were collected and different steps in the protocol were evaluated. Data were expressed as medians with interquartile ranges. Fifty children (28 boys), aged 3.5 yrs (range, 1.2 -9.3 yrs) were treated in 18 mos. Forty-two children had multiple organ failure. Eight children died. Insulin treatment was initiated 4 hrs after the first episode of hyperglycemia was documented (median blood glucose, 11.4 mmol/L, [207 mg/dL] [9.7-14.5 mmol/L, 176-264 mg/dL]). Blood glucose was <8 mmol/L (<145 mg/dL) within 12 hrs of initiating insulin therapy in 47 (94%) of 50 children (median, 5 hrs). Duration of treatment was 34 hrs (17-72 hrs) and the maximum insulin dose ranged between 20 and 200 mIU/kg/hr (median, 70 mIU/kg/hr). Episodes of severe hypoglycemia <2.2 mmol/L (<47 mg/dL) did not occur. CONCLUSION: The use of a stepwise nurse-driven glucose control protocol resulted in normoglycemia within 12 hrs for 94% of the children involved. Episodes of severe hypoglycemia did not occur. We conclude that the glucose control protocol is effective in treating hyperglycemia in critically ill children. Further studies are necessary to assess safety before the protocol could also be implemented in other pediatric intensive care units. Continue reading >>
Pediatric Hypoglycemia Treatment & Management
Approach Considerations Short-term treatment of hypoglycemia consists of an intravenous (IV) bolus of dextrose 10% 2.5 mL/kg. The critical sample should be drawn before the glucose is administered. After the bolus is administered, an IV infusion that matches normal hepatic glucose production (approximately 5-8 mg/kg/min in an infant and about 3-5 mg/kg/min in an older child) should be continued. This should be adjusted to maintain the plasma glucose level at more than 3 mmol/L. Children with hyperinsulinemia may have much higher needs. Glucagon infusion at rates of 0.005-0.02 mg/kg/h should be used as a temporary treatment in children with hyperinsulinism in whom adequate amounts of dextrose cannot be given. It can cause a rash and decreased appetite if used over the long term. Long-term care of children with hypoglycemia varies based on the etiology. In infants with one of several disorders (eg, ketotic hypoglycemia, glycogen-storage disorder, free fatty acid metabolism defect, mild hyperinsulinism), hypoglycemia can be prevented with frequent feedings involving a specifically designed diet and a rapid response with parenteral dextrose when feeding is inadequate because of GI problems or other illnesses. Fructose must be avoided in children with fructose diphosphatase deficiency. A hierarchical approach is used to treat hyperinsulinism. The first step is usually frequent feeding. The next step is typically the administration of diazoxide. Octreotide is usually the second-line medical therapy. The calcium channel blocker nifedipine is also useful. Surgery is recommended if these treatments fail or if an insulin-producing tumor is suspected. Surgery is a first-line option in infants with persistent hyperinsulinemic hypoglycemia of infancy with documented focal lesions th Continue reading >>
Pediatric Diabetic Ketoacidosis Treatment & Management
Approach Considerations In patients with diabetic ketoacidosis, the first principals of resuscitation apply (ie, the ABCs [airway, breathing, circulation]). [3] Outcomes are best when children are closely monitored and a changing status is promptly addressed. [39, 2] Give oxygen, although this has no effect on the respiratory drive of acidosis. Diagnose by clinical history, physical signs, and elevated blood glucose. Fluid, insulin, and electrolyte (potassium and, in select cases, bicarbonate) replacement is essential in the treatment of diabetic ketoacidosis. Early in the treatment of diabetic ketoacidosis, when blood glucose levels are very elevated, the child can continue to experience massive fluid losses and deteriorate. Strict measurement of fluid balance is essential for optimal treatment. Continuous subcutaneous insulin infusion therapy using an insulin pump should be stopped during the treatment of diabetic ketoacidosis. Inpatient care Children with severe acidosis (ie, pH < 7.1) or with altered consciousness should be admitted to a pediatric intensive care unit. In cases in which the occurrence of diabetic ketoacidosis signals a new diagnosis of diabetes, the process of education and support by the diabetes team should begin when the patient recovers. In cases in which diabetic ketoacidosis occurs in a child with established diabetes, explore the cause of the episode and take steps to prevent a recurrence. Following recovery from diabetic ketoacidosis, patients require subcutaneous insulin therapy. Outpatient care Organize outpatient care through the pediatric diabetes care team. Consultations Consult a neurosurgeon if cerebral edema is suspected. Once the child has recovered, he or she can resume a normal diet. Guidelines The International Society for Pediatr Continue reading >>
Hyperglycemic Clamp: A Single Experiment To Simultaneously Assess Insulin Secretion And Insulin Sensitivity In Children † 420
The state of hyperinsulinemia/insulin resistance determines the likelihood that an individual will develop premature atherosclerotic vascular disease. Therefore, various methods to assess in vivo insulin sensitivity have been developed. In adults, it has been shown that the hyperglycemic clamp assesses both insulin sensitivity and insulin secretion in the same individual simultaneously. Our study aimed to determine if in children the insulin sensitivity index derived from a hyperglycemic clamp is a reliable estimate of insulin sensitivity during a hyperinsulinemic-euglycemic clamp. 34 healthy children (age 12.6±0.3 yrs; 18M, 16F; 9 prepubertal, 25 pubertal; 15 Black, 19 White) were studied. Each participated in a 2h hyperglycemic clamp (225mg/dl) & a 3h hyperinsulinemic(40mU/m2/min)-euglycemic clamp in random order. Insulin sensitivity during the euglycemic clamp (IS-EU) was calculated over the last 30 min by dividing glucose disposal rate by steady state insulin concentration. During the hyperglycemic clamp insulin sensitivity index (IS-HY) was calculated over the last 60 min by dividing glucose disposal rate by endogenous insulin levels. During the hyperglycemic clamp insulin sensitivity was 12.0±1.4 mg/kg/min per uU/ml, first phase insulin was 126.6±18.6 uU/ml, and second phase insulin was 146.1±15.5 uU/ml. During the euglycemic clamp, insulin sensitivity was 10.6±1.0 mg/kg/min per uU/ml. The correlation between IS-HY and IS-EU was r=0.82, p=0.005 in the total group. This correlation was stronger in males (r=0.87, p<0.001) than in females(r=0.55, p=0.01), comparable in prepubertal (r=0.78, p=0.007) and pubertal subjects (r=0.79, p=<0.001) as well as White (r=0.76, p<0.001) and Black children (r=0.74, p=0.001). In summary, the hyperglycemic clamp technique is a r Continue reading >>
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Diabetes Mellitus
See also: Background: Diabetic ketoacidosis (DKA) is the combination of hyperglycemia, metabolic acidosis, and ketonaemia. It may be the first presentation for a child with previously undiagnosed diabetes. It can also be precipitated by illness, or poor compliance with taking insulin. All patients presenting with a blood glucose level (BGL) ≥ 11.1mmol/l should have blood ketones tested on a capillary sample using a bedside OptiumTM meter. If this test is positive (>0.6 mmol/l), assess for acidosis to determine further management. Urinalysis can be used for initial assessment if blood ketone testing is not available. The biochemical criteria for DKA are: 1. Venous pH < 7.3 or bicarbonate <15 mmol/l 2. Presence of blood or urinary ketones If ketones are negative, or the pH is normal in the presence of ketones, patients can be managed with subcutaneous (s.c.) insulin (see ' new presentation, mildly ill' below). Assessment of children and adolescents with DKA 1. Degree Of Dehydration (often over-estimated) None/Mild ( < 4%): no clinical signs Moderate (4-7%): easily detectable dehydration eg. reduced skin turgor, poor capillary return Severe(>7%): poor perfusion, rapid pulse, reduced blood pressure i.e. shock 3. Investigations Venous blood sample (place an i.v. line if possible as this will be needed if DKA is confirmed) for the following: FBE Blood glucose, urea, electrolytes (sodium, potassium, calcium, magnesium, phosphate) Blood ketones (bedside test) Venous blood gas (including bicarbonate) Investigations for precipitating cause: if clinical signs of infection consider septic work up including blood culture For all newly diagnosed patients: Insulin antibodies, GAD antibodies, coeliac screen (total IgA, anti-gliadin Ab, tissue transglutaminase Ab) and thyroid function Continue reading >>
Sccm Unveils Insulin Infusion Guidelines For Glycemic Control
The Society of Critical Care Medicine assembled the Glycemic Control Task Force, a multiprofessional group of experts charged with summarizing the information available in a practical way. In 2001, a landmark publication from Leuven changed the intensive care unit (ICU) practice of hyperglycemia management around the world.(1) The reported reduction in morbidity and mortality made the critical care community quasi-instinctively follow an aggressive management approach to hyperglycemia with intensive insulin therapy (IIT). The initial optimism was followed by concerns regarding the universal applicability of this treatment given the heterogeneity of the ICU case mix, severity of illness and resource environments. Difficulties regarding the morbidity and mortality rates of hypoglycemia, appropriateness of measurement devices and need for frequent monitoring (e.g., nursing care time, opportunity, cost) were appreciated early. Furthermore, new trials, including one from the original Leuven group,(2) did not corroborate the initial findings. Subsequently, the medical community was surrounded by a series of contradictory results. Confusion, uncertainties and questions regarding “external validity” of the results flourished. Given these circumstances, the medical community at large felt the need for guidelines from professional societies. The Society of Critical Care Medicine (SCCM), under the leadership of its former president Judith Jacobi, BCPS, PharmD, FCCM, assembled the Glycemic Control Task Force, a multiprofessional group of experts charged with summarizing the information available in a practical way. This group, which included intensivists from adult and pediatric medical and surgical ICUs, pharmacists, nurses, endocrinologists, and outcomes researchers, publ Continue reading >>
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Hyperglycemia, Dysglycemia And Glycemic Control In Pediatric Critical Care
Abstract Although once considered a benign consequence to the stress of severe illness or injury, a significant body of evidence compiled over the past decade shows that hyperglycemia in critically ill patients is associated with poor outcomes. In both adults and pediatric studies, there is a strong association with hyperglycemia with higher morbidity and mortality, and in some prospective studies, controlling hyperglycemia improves outcomes. These data have resulted in a number of national and international consensus statements and guidelines recommending active glycemic control – though primarily directed at the critically ill or injured adult. Due to the lack of pediatric-specific data, it has been unclear how pediatric intensivists should incorporate glycemic control into their practice. During the past decade data from both retrospective and prospective studies have also shown significant associations between hypoglycemia and dysglycemia (i.e., glycemic variability) and poor outcomes. From the current data, it appears that both hyper- and hypoglycemia occurs in patients who have higher illness severities and require more organ support measures. A number of pediatric-specific protocols have been developed and published which suggest that approaches to identify and manage hyperglycemia in critically ill children can be effectively and safely implemented, and interestingly in many cases hypoglycemic rates are less than that which occurs spontaneously. Although most pediatric practitioners support active glycemic control in certain subsets of patients, it is unclear how widespread standardized, consistent glycemic management has been incorporated into practice. Prospective trials have yielded disparate outcome findings regarding glycemic control in the pediatric ICU. Continue reading >>
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Ispad Clinical Practice Consensus Guidelines 2014
Editor in Chief: Mark A. Sperling, Pittsburgh, USA. Guest Editors: Carlo Acerini, Maria E Craig, Carine de Beaufort, David M Maahs and Ragnar Hanas. Introduction Carlo Acerini, Maria E Craig, Carine de Beaufort, David M Maahs and Ragnar Hanas. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 1–3. Uploaded: 2. Sept 2014 Download Introduction Chapter 1: Definition, epidemiology, diagnosis and classification Craig ME, Jefferies C, Dabelea D, Balde N, Seth A, Donaghue KC. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 4–17. Uploaded: 2. Sept 2014 Download Chapter 1 Chapter 2: Phases of Type 1 Diabetes Couper JJ, Haller MJ, Ziegler A-G, KnipM, Ludvigsson J, Craig ME. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 18–25. Download Chapter 2 Chapter 3: Type 2 diabetes Zeitler P, Fu J, Tandon N, Nadeau K, Urakami T, Bartlett T, Maahs D. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 26-46. Uploaded: 2. Sept 2014 Download Chapter 3 Chapter 4: The Diagnosis and Management of Monogenic diabetes Rubio-Cabezas O, Hattersley AT, Njølstad PR, Mlynarski W, Ellard S,White N, Chi DV, Craig ME. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 47-64. Uploaded: 2. Sept 2014 Download Chapter 4 Chapter 5: Management of cystic fibrosis-related diabetes Moran A, Pillay K, Becker DJ, Acerini CL. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 65-76. Uploaded: 2. Sept 2014 Download Chapter 5 Chapter 6: Diabetes education Lange K, Swift P, Pankowska E, Danne T. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 77-85. Uploaded: 2. Sept 2014 Download Chapter 6 Chapter 7: The delivery of ambulatory diabetes care Pihoker C, Forsander G, Fantahun B, Virmani A, Luo X, Hallman M, Wolfsdorf J, Maahs DM. Published in Pediatric Diabetes 2014: 15(Suppl. 20): 86-101. Up Continue reading >>
Pediatric Critical Illness Hyperglycemia And Glycemic Control Registry
The objective in this project is to assemble a consortium of pediatric critical care centers of varying size, acuity, and composition to evaluate our glycemic control protocol on at least 250 children with hyperglycemia in different critical care units. ***This Study is supported by an R21 Grant (MRR) from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Many studies over the past decade have demonstrated that clinical outcomes can be improved in critically ill adults by aggressive management of hyperglycemic with insulin infusions (Van Den Berghe 2001, Van Den Berghe 2006, Krinsey 2004, Treggari 2008, Scalea, 2007, Lang 2007). Yet, in some of these studies and other recent trials (i.e. Glucontrol (Preiser, 2009) VISEP (Brunkhorst, 2008) and (NICE-SUGAR, 2009)), have highlighted the potential and real risks of glycemic control (namely iatrogenic hypoglycemia) and questioned how effectively glucose can be controlled in critical illness. One reason for the suboptimal glycemic control witnessed in some trials may be not rigorously refined and validated. Even as such, many medical oversight committees (including the Institutes of Healthcare Improvement, the American Diabetes Association, and Society of Critical Care Medicine, among others) continue to recommend regular and aggressive glycemic control in critically ill patients. Although not specifically included nor excluded from such recommendations, most pediatric intensivists have not incorporated glycemic control into regular practice primarily due to concerns of therapy induced hyperglycemia - although there are reports of protocols that appear to be effective at controlling BG levels with low rates of hypoglycemia (Preissig et al 2008, Verhoeven et al 2009). Our group at Emory University a Continue reading >>
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- Early Glycemic Control and Magnitude of HbA1c Reduction Predict Cardiovascular Events and Mortality: Population-Based Cohort Study of 24,752 Metformin Initiators
- Association of Glycemic Variability in Type 1 Diabetes With Progression of Microvascular Outcomes in the Diabetes Control and Complications Trial
Control Of Hyperglycaemia In Paediatric Intensive Care (chip): Study Protocol
Abstract There is increasing evidence that tight blood glucose (BG) control improves outcomes in critically ill adults. Children show similar hyperglycaemic responses to surgery or critical illness. However it is not known whether tight control will benefit children given maturational differences and different disease spectrum. The study is an randomised open trial with two parallel groups to assess whether, for children undergoing intensive care in the UK aged ≤ 16 years who are ventilated, have an arterial line in-situ and are receiving vasoactive support following injury, major surgery or in association with critical illness in whom it is anticipated such treatment will be required to continue for at least 12 hours, tight control will increase the numbers of days alive and free of mechanical ventilation at 30 days, and lead to improvement in a range of complications associated with intensive care treatment and be cost effective. Children in the tight control group will receive insulin by intravenous infusion titrated to maintain BG between 4 and 7.0 mmol/l. Children in the control group will be treated according to a standard current approach to BG management. Children will be followed up to determine vital status and healthcare resources usage between discharge and 12 months post-randomisation. Information regarding overall health status, global neurological outcome, attention and behavioural status will be sought from a subgroup with traumatic brain injury (TBI). A difference of 2 days in the number of ventilator-free days within the first 30 days post-randomisation is considered clinically important. Conservatively assuming a standard deviation of a week across both trial arms, a type I error of 1% (2-sided test), and allowing for non-compliance, a total sample Continue reading >>
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Insulin Therapy In Hyperglycemic Children With Severe Acute Asthma
Objectives: The aim of this study was to assess the effect of intravenous (IV) insulin administration in children with severe acute asthma (SAA) and hyperglycemia on IV salbutamol consumption and length of stay (LOS) in a pediatric intensive care unit (PICU). Methods: Retrospective, descriptive study of the clinical course before and after implementation of an insulin protocol for the treatment of hyperglycemia (i.e. blood glucose >8 mmol/L or 144 mg/dL, respectively) in the PICU of a tertiary care university hospital. Admissions between 1994 and 2010 were reviewed. The insulin protocol was introduced in 2006. Results: A total of 131 pediatric patients with SAA complicated by hyperglycemia requiring IV salbutamol were included. Severity of illness before and after implementation of the insulin protocol did not significantly differ. The insulin-treated patient group had significantly higher maximum blood glucose levels and higher cumulative IV salbutamol dose than the non-treated group. There were no differences between these groups in the duration of IV salbutamol administration and LOS. Conclusions: In view of the lack of difference in outcomes and considering that the insulin protocol is labor-intensive, the question is whether this protocol is efficacious for the treatment of pediatric SAA associated with hyperglycemia. Continue reading >>
Sample Medical Guidelines
State of Wisconsin Emergency Medical Services Sample Medical Guidelines Note: · Most pediatric patients with hyperglycemia have diabetic ketoacidosis (DKA), which is a life-threatening complication of diabetes that includes severe dehydration and metabolic acidosis. · Sodium bicarbonate is contraindicated. · In children, the parents may not know the child has diabetes before the first episode of DKA. · The first clues of new onset diabetes may be excessive thirst or urination, including inappropriate wetting (e.g. wetting the bed or wetting pants). Priorities Assessment Findings Chief Complaint “High blood sugar,†Breathing Fast, Vomiting, Abdominal Pain, “Diabetic Coma†OPQRST Check onset/duration of symptoms. Identify possible contributing factors. Associated Symptoms/ Pertinent Negatives Fever/Chills. Signs/Symptoms of infection. Polyuria, Polydipsia, Polyphagia, Adequate food and water intake? Increasing thirst? Increasing urine output? SAMPLE Known history of Diabetes. Medications for diabetes. Initial Exam ABCs and correct any immediately life-threatening problems. Detailed Focused Exam General Appearance: Appears sick? Dehydrated? Kussmaul’s Respirations? Smell of Acetone on breath. Heart: Tachycardia? Hypotension? Resp: Rapid Respiration GI: Diffuse Abdominal Tenderness Skin: Cool, pale, diaphoretic? Warm, dry, flushed? Tenting? Neuro: ALOC? Focal deficits (CVA)? Goals of Therapy Use IV fluids to reduce glucose level, improve hydration, improve acid-base balance. Transport to hospital for insulin therapy to treat acidosis. Monitor for cerebral edema. Monitoring BP, HR, RR, EKG, SpO2, repeat glucose, neuro checks EMERGENCY MEDICAL RESPONDER (EMR) · Routine Medical Care. · Oxygen as needed. · Monitor vitals. EMERGENC Continue reading >>
A Randomized Trial Of Hyperglycemic Control In Pediatric Intensive Care
Whether an insulin infusion should be used for tight control of hyperglycemia in critically ill children remains unclear. We randomly assigned children (≤16 years of age) who were admitted to the pediatric intensive care unit (ICU) and were expected to require mechanical ventilation and vasoactive drugs for at least 12 hours to either tight glycemic control, with a target blood glucose range of 72 to 126 mg per deciliter (4.0 to 7.0 mmol per liter), or conventional glycemic control, with a target level below 216 mg per deciliter (12.0 mmol per liter). The primary outcome was the number of days alive and free from mechanical ventilation at 30 days after randomization. The main prespecified subgroup analysis compared children who had undergone cardiac surgery with those who had not. We also assessed costs of hospital and community health services. A total of 1369 patients at 13 centers in England underwent randomization: 694 to tight glycemic control and 675 to conventional glycemic control; 60% had undergone cardiac surgery. The mean between-group difference in the number of days alive and free from mechanical ventilation at 30 days was 0.36 days (95% confidence interval [CI], −0.42 to 1.14); the effects did not differ according to subgroup. Severe hypoglycemia (blood glucose, <36 mg per deciliter [2.0 mmol per liter]) occurred in a higher proportion of children in the tight-glycemic-control group than in the conventional-glycemic-control group (7.3% vs. 1.5%, P<0.001). Overall, the mean 12-month costs were lower in the tight-glycemic-control group than in the conventional-glycemic-control group. The mean 12-month costs were similar in the two groups in the cardiac-surgery subgroup, but in the subgroup that had not undergone cardiac surgery, the mean cost was signifi Continue reading >>
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Approach To Hypoglycemia In Infants And Children
INTRODUCTION In healthy individuals, maintenance of a normal plasma glucose concentration depends upon: A normal endocrine system for integrating and modulating substrate mobilization, interconversion, and utilization. Functionally intact enzymes for glycogen synthesis, glycogenolysis, glycolysis, gluconeogenesis, and utilization of other metabolic fuels for oxidation and storage. An adequate supply of endogenous fat, glycogen, and potential gluconeogenic substrates (eg, amino acids, glycerol, and lactate). Adults are capable of maintaining a near-normal plasma glucose concentration, even when fasting for weeks or, in the case of obese subjects, months [1]. In contrast, healthy neonates and young children are unable to maintain normal plasma glucose concentrations after even a short fast (24 to 36 hours) and exhibit a progressive decline in plasma glucose concentration to hypoglycemic values [2,3]. Continue reading >>
