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SEPSIS
AND GLYCEMIA: READ THE FINE PRINT!
by Irl B. Hirsch, MD
(Endocrine Practice, April 2008)
Recently, Brunkhorst et
al (1) published an important article that addressed
the topic of intensive insulin therapy in patients
with severe sepsis. For safety reasons, the trial
was discontinued early. Among the 537 patients
randomized,
a significant difference existed in blood glucose
levels:112 mg/dL in those assigned to intensive
insulin therapy in comparison with 151 mg/dL in
those assigned to conventional therapy. At 28 days,
however, no difference was noted in the rate of
death or the mean score for organ failure. Besides
no improvement in outcomes, severe hypoglycemia
(defined as a blood glucose level of less than 40
mg/dL) occurred more frequently in the group
receiving intensive insulin therapy. Although no
serious adverse event directly resulted in death,
the severe hypoglycemia was more often classified as
life-threatening and resulted in prolonged
hospitalization. Why were the findings in this
analysis so different from those in the initial
study (in 2001) by Van den Berghe et al (2) in the
surgical intensive care unit (ICU) in Leuven,
Belgium? The current investigators used the same
protocol as Van den Berghe et al. Furthermore, why
were the results in the second Leuven study
involving medical ICU patients (3) similar to the
results in this study? Perhaps several issues need
to be considered in an effort to answer these
questions—and also as they pertain to other
studies.
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Implementation and evaluation of the SPRINT protocol
for tight glycaemic control in critically ill
patients: a clinical practice change
Critical
Care 2008, 12:R49
Stress induced
hyperglycaemia is prevalent in critical care.
Control of blood glucose levels to within a 4.4-6.1
mmol/L range or below 7.75 mmol/L can reduce
mortality and improve clinical outcomes. The
specialized relative insulin and nutrition tables
(SPRINT) protocol is a simple wheel-based system
that modulates insulin and nutritional inputs for
tight glycaemic control.
SPRINT achieved a high
level of glycaemic control on a severely ill
critical cohort population. Reductions in
mortality were observed compared to a retrospective
hyperglycaemic cohort. Range and peak blood
glucose metrics were no longer correlated with
mortality outcome under SPRINT.
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to read more
A plea
for intense glucose management to control
hyperglycemia in the ICU
IV insulin
infusion protocols reduce hyperglycemia and other
hospital morbidities.
by Carl J. Pepine,
MD, CHIEF MEDICAL EDITOR, Cardiology Today
As
practitioners understand, we are seeing an epidemic
of diabetes. Currently at least 7% of the U.S.
population or more than 20 million people are
affected.Sadly, when I make rounds it is also
disappointing to see that glycemia control seems to
be poorly managed among hospitalized patients in
CCUs who may or may not even have had a prior
diagnosis of diabetes. Too often in response to my
questions about an ACS patient’s high blood glucose,
our resident will respond, “Oh, I’ve got it
covered.” All clinicians need to know is that this
is clearly not optimal.
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INTENSIVE INSULIN THERAPY IN THE CRITICALLY ILL
GERIATRIC PATIENT
Critical Care Nurse Quarterly 2008,
31:14–18
Abstract: Tight
glucose control can significantly improve outcomes
of critically ill geriatric patients in the critical
care unit (CCU). In the past, blood glucose levels
were managed by a point-of-care testing every 4 to 6
hours and using a sliding scale of insulin therapy.
This article explores the need for more intensive
intravenous insulin therapies. Studies have shown
that patient outcomes improve by having a specific
set of standing orders, a well-defined algorithm,
and empowering the CCU nurses with these tools.
Methods for initiating intensive intravenous insulin
therapies are discussed along with some of the
biggest challenges faced by CCU nurses at the
bedside...
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GLUCOSE CONTROL AFTER SEVERE BRAIN INJURY
Current
Opinion in Clinical Nutrition and Metabolic Care
2008, 11:134–139
Abstract: A substantial body of
evidence supports the use of intensive insulin
therapy in general critical care practice,
particularly in surgical intensive care unit
patients. The impact of intensive insulin therapy on
the outcome of critically ill neurological patients,
however, is still controversial. While avoidance of
hyperglycemia is recommended in neurointensive care,
no recommendations exist regarding the optimal
target for systemic glucose control after severe
brain injury.
An
increase in brain metabolic demand leading to a
deficiency in cerebral extracellular glucose has
been observed in critically ill neurological
patients and correlates with poor outcome. In this
setting, a reduction of systemic glucose below 6
mmol/l with exogenous insulin has been found to
exacerbate brain metabolic distress. Recent studies
have confirmed these findings while showing
intensive insulin therapy to have no substantial
benefit on the outcome of critically ill
neurological patients.
Questions persist regarding the optimal target for
glucose control after severe brain injury. Further
studies are needed to analyze the impact of
intensive insulin therapy on brain glucose
metabolism and outcome of critically ill
neurological patients. According to the available
evidence, a less restrictive target for systemic
glucose control (6–10 mmol/l) may be more
appropriate...
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INPATIENT GLYCEMIC CONTROL ON THE VASCULAR SURGERY
SERVICE
Endocrine
Practice 2008;14:185-192
Abstract:
Patients admitted to the vascular surgery service
with underlying diabetes were enrolled in a study of
use of a preprinted basal-bolus insulin order set
based
on a total daily dose of 0.5 U/kg (0.25 U/kg of
insulin glargine and 0.25 U/kg of insulin aspart
divided into 3 equal mealtime doses). Outcomes
included the mean glycemic control at each of 5
established time intervals, the percentage of blood
glucose measurements within the target range of 70
to 180 mg/dL, the incidence of hypoglycemia, and the
insulin dosages. Historical control patients with
diabetes from the same hospital service were used
for comparison.
The
use of a standardized basal-bolus weight-based
insulin regimen was successful at achieving improved
glycemic control as well as reducing the incidence
of hypoglycemia in an inpatient population with
diabetes...
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