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fluid pills [url=http://www.catalog.com/viagra_online_q3d/blog/2009/12/02/tramadol_pharmacy_reviews]can tramadol cause liver damage[/url] The detrimental effects of hyperglycemia are not clearly understood but include increasing tissue acidosis secondary to anaerobic glycolysis, lactic acidosis, and free radical production.[358][359] Hyperglycemia also may affect the blood–brain barrier and the development of brain edema[360] and may be associated with an increased risk of hemorrhagic transformation of the infarction.[361] Unfortunately, the contribution of hyperglycemia to poor outcomes may be affected by other factors.[362] Elevations of blood glucose concentration may be secondary to the stress of the acute cerebrovascular event.[363] In particular, hyperglycemia after stroke in nondiabetic patients may be a stress response.[364] Candelise et al[365] found that hyperglycemia is a marker of a more severe stroke. Thus, the poor outcomes among patients with hyperglycemia may in part reflect the seriousness of the vascular event itself. Recent clinical and imaging studies have highlighted the importance of hyperglycemia as a negative prognostic factor.271,278,279,280,,282 Baird et al[366] found that persistent hyperglycemia (blood glucose level >200 mg/dL) during the first 24 hours after stroke independently predicted expansion of the volume of ischemic stroke and poor neurological outcomes. These reports provide reasonable evidence that persistent elevations of blood glucose levels are associated with neurological worsening.[367][368] These data suggest that management of hyperglycemia is an important part of acute management of patients with ischemic stroke. The outstanding issues relate to the effectiveness of management of stroke-associated hyperglycemia in improving outcomes after stroke and the level of glucose concentration that should be sought during the first 24 hours. On the basis of the aforementioned data, the panel concluded that the level of hyperglycemia that previously mandated emergency treatment in the setting of stroke was too high. The exact level of blood glucose that should prompt interventions is not known. A reasonable approach would be to initiate treatment among patients with a blood glucose level >200 mg/dL. The management of hyperglycemia among patients with stroke likely will be influenced by the approach to treating 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.[369][370][371][372][373][374] 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 al[375] 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.[376] 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.[377] Bruno et al[378] 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.[379] Despite the lack of data to guide decisions about management, consensus exists that hyperglycemia should be controlled after stroke.[380] 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.
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