@2024 Afarand., IRAN

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ISSN: 2252-0805    The Horizon of Medical Sciences 2018;24(1):67-72

Background
About 20% of patients in the intensive unit care have diabetes [1]. FASTHUG (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head of bed elevation, stress ulcer prophylaxis, Glucose control) is a specialist care standard, partly focusing on the regular and target blood glucose monitoring in patients with critical conditions [2].
Previous Studies
… [3-5].The standard sample for testing glucose is a blood sample of the venous. However, for continuous monitoring of glucose levels in diabetic patients, glucose in the interstitial fluid and small sample of peripheral blood (0.3 to 2 μL) can be measured by the glucometer using Point-of-Care method [6]. … [7-10]. Despite two major glucometer advantages, namely, the use of low blood volume and accelerated glucose response, the study reported glucose meter errors of 12% which included the use of inadequate blood volume, finger tightness, use of expired tape, and abnormal hematocrit [11]. … [12]. Therapeutic intervention based on incorrect and unrealized blood glucose results in lethal complications, especially hypoglycemia. Patients in the special department due to the deterioration of clinical conditions and sedation cannot develop neurogenic and neurological symptoms of glucose decline [13]. In the edematous diabetic patients in the intensive care units, the first drop of blood fingertip, is apparently different from blood i.e. the first drop is yellow and is similar to the interstitial fluid. Sometimes nurses doubt the use of this drop for glucometer [14].
Aim(s)
Since the first drop of fingertip is used in the glucometer in the health centers of the country, this study aimed to compare the measurement of glucose level through the first and second fingertip blood and venous blood samples of edematous diabetic patients in stroke intensive care unit.
Research type
This cross-sectional study is descriptive-analytic.
Research society, place and time
This study was conducted among edematous diabetic patients in stroke intensive care unit in Ghaem Health-Training Center in Mashhad in 2013.
Sampling method and number
Selection of samples was done through non-probabilistic and convenience sampling method. To estimate the sample size, a preliminary study was conducted on 10 patients who were randomly selected from the population under study. To determine the sample size according to the Cochran formula for experimental interventions and the formula for estimating means, with the considerations of other researches [15] and the maximum sample size, the final sample size was determined to be 103. This selection continued to reach the sample size, and then all patients were assigned specific codes and ethical codes were observed for all patients. Inclusion criteria included patient satisfaction, upper limb edema, lack of blistering, burns of infectious diseases (AIDS and hepatitis), non-disturbance in coagulation tests (hemophilia) or impaired effective background on the research glucometer and recorded hematocrit between 35.0% and 45.0% on the test sheet because the accuracy of glucometer is acceptable for hematocrits of 35.0% to 45.0% [16].
Used devices&materials
The presence of diabetes was confirmed by examination of the patients' files, and their edema was performed using the criteria for determining the degree of edema after 5 seconds of the pressure on the first knuckle of the thumb, on the back of patient`s hand skin and measuring the depth of the dent at the skin surface with the researcher's tool. This device was an engineering graded metallic ruler made of non-flexible steel in millimeters. Grade 1, 2, 3, and 4 of the edema refers to the formation of dent on the skin at 2, 4, 6, and 8 mm respectively [12]. Patients' blood samples were collected according to the standards of the Health Reference Laboratory Committee. Preparation of the first drop of fingertip, was obtained after a gentle massage on the skin and disinfection of the site with 70% ethanol with a niche pen and under the supervision of an experienced laboratory co-worker. Considering the effect of glucometer preparation time on the interstitial fluid content and the degradation of the test results, two glucometers were used. In order to uniform the sampling conditions for all sample units, all blood stripes were made using a series of hologram. Before the sampling, both glucometers were calibrated and the blood serum code number was adjusted. The ACCU Check glucometer model Active (MANHEIM, Germany) and the Hologram Series A236639967 and A236639953 were used by the EU accredited US Food and Drug Administration and glucometer validation inquiries at the Department of Health Department's Office of Equipment. Naturally, glucose in the fingertip sample (complete blood) is approximately 15% less than that of the plasma. This brand of glucometer with the aim of comparing two different sources of glucose, has calculated and considered this difference during the auto-calibration of the device [17]. Preparation of a sample of next drop of fingertip blood, after cleaning the first drop with dry sterilized cotton, continued until the deformity of the appearance of the secreted fluid to blood, and after reaching the target, the amount of glucose in the next drop was immediately measured by the second device. Glucometers were labeled numerically 1 and 2 and were alternately transmitted to measure the first and next drop. Ultimately, blood samples were collected using standard venipuncture methods, after closure of the tourniquet, 8 cm above the elbow bend, disinfection of the site with 70% ethanol and 7 cc nocturnal blood of the middle cubital vein. After inserting the specification of the research unit into the test tubes and putting them in a special box, they were immediately delivered to the Ghaem laboratory for less than half an hour. Samples were examined after centrifugation and serum isolation using glucose oxidase enzyme kit (Parsazmoon, Iran) and with the help of the BT3500 (Biotecnica Instrument, Italy) apparatus for measuring glucose. Data analysis was performed using SPSS 17 software. The Kolmogorov-Smirnov test was used to examine the normal distribution of data. Then analysis of variance with repeated measures and paired t-test were used for intragroup and intergroup comparison respectively and Bland-Altman plot was used to determine the correlation between the first and second drops of the fingertip and venous blood sample.
Findings by Text
The mean age of patients was 57.08±18.82 years and their mean hematocrit was 38.94±5.20. A total of 49 subjects were male (Table 1).The mean glucose level in the pilot study for the first drop, next drop, and standard venous was 178.20±71.35, 175.30±68.60 and 157.10±66.31 respectively. For the main study, there was a significant difference between the mean values of glucose in the first drop, the next drop and the standard venous (p=0.026; Table 2).There was no significant difference in the glucose level of two first and second blood samples from the fingertip with the mean difference 2.0±86.6 and they were in the same level and homogenous (p=0.257; t=1.140). However, there was a significant difference between the first and second drop samples with the standard venous sample that is the mean blood glucose difference in the first and the second drop of fingertip i.e. 22.5±40.7 (p=0.023; t=2.308) and 20.5±83.6 (p=0.031; t=2.182) respectively was significantly higher than the standard venous sample. There was a strong correlation between the amount of glucose in the first drop and the second drop of fingertip and only 5 samples (4.8%) were not in the 85% confidence interval (Figure 1). The difference in mean glucose measurement in the first drop with the standard venous, as well as the difference in measurement with the next blood fingertip with the standard venous showed that the dispersion of the data was very high (Figures 2 and 3).
Main comparison to the similar studies
After searching for resources, the same research that was carried out on a variety of drops from fingertip was not found. Therefore, the comparison of consensus and opposite views was limited to comparative studies between the fingertip and venous samples. Research on non-hospitalized diabetic patients indicated that the mean glucose level of fingertip sample 129.0±45.0 mg/dl was more than the mean glucose level of their venous blood sample 123.0±44.1 mg/dl [20]. The same results have been reported in two other studies [21, 22] which was consistent with the current study. … [23-29].
Suggestions
It is suggested that such studies of blood glucose monitoring be done one a series-time basis on sequentially secreted fingertip blood drops in patients with various conditions affecting the accuracy of glucometry such as receiving inotropic drugs such as dopamine.
Limitations
One of the limitations of this study was the possibility of reduction of glucose levels in the event of a delayed transfer or centrifugation of serum glucose.
Conclusions
Using the first or next capillary drop of blood has the same glucometry results, and there is no difference in glucose levels between the first and second fingertip drop samples.
Acknowledgments
Researchers from the Vice-Chancellor of Research of Mashhad University of Medical Sciences, participants, head nurses and employee of the Stroke Intensive Care Unit and Ghaem Laboratory of Mashhad are sincerely appreciated for their good cooperation.
Conflict of interest
Non-declared
Ethical Permissions
The present research is conducted in compliance with the rights of authors in the use of texts, print and electronic resources, as well as approval of the plan with the code approved by the Ethics Committee 89970 and the contract number 511/1146 of the Research Deputy of Mashhad University of Medical Sciences.
Funding Sources
This research is based on the Master's thesis dissertation on special care nursing approved by the Research Council of Mashhad University of Medical Sciences

TABLES and CHARTS

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