Tight
Glycemic Control in Critically Ill Patients
Recently published trials of tight glycemic control
in critically ill patients have documented lack of
treatment benefit and frequent severe hypoglycemia.
The NICE-SUGAR trial raised the question of
potential treatment-related harm and also documented
significant hypoglycemia. The COIITSS Study
evaluated intensive insulin therapy in critically
ill patients with sepsis who were treated with
glucocorticoids and reported a high incidence of
hypoglycemia (16.4% vs7.8%in the conventional
treatment group) without apparent benefit. These
large complex multicenter trials that evaluated
insulin therapy during critical illness consistently
demonstrated high rates of hypoglycemia with tight
insulin therapy. However, they did not investigate
the possibility of identifying patient
subpopulations at increased risk for
treatment-related hypoglycemia.
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Could
Susceptibility to Low Hematocrit Interference Have
Compromised the Results of the NICE-SUGAR Trial?
The recently published findings of the Normoglycemia
in Intensive Care Evaluation and Survival Using
Glucose Algorithm Regulation (NICE-SUGAR) trial
have dramatically changed clinician attitudes toward
the achievement of euglycemia in intensive care unit
(ICU) patients. In defending the proof-of concept
studies that validated the efficacy of normalizing
blood glucose in the ICU, Van den Berghe et al.
pointed out numerous variances between their
original studies and those of the NICE-SUGAR trial.
They included differences in blood gucose targets,
insulin administration, blood sampling, nutritional
strategies, clinician expertise, and the relative
accuracy of the glucose measurement devices.
Recently, Clinical Chemistry presented a very
interesting Q& A on the use of blood glucose meters
to achieve tight glucose control in patients in the
ICU. Because one of our ICUs participated in the
NICE-SUGAR trial, we report here some interesting
and relevant data that shed more light on the
NICE-SUGAR trial, data that yield more questions
than answers.
More>
Lessons Learned from
Glycemia Control Studies
Hyperglycemia occurs in patients with diabetes and
in nondiabetic patients during acute illness.
Epidemiologic and observational studies have
demonstrated that hyperglycemia is associated with
significant adverse outcomes. Nevertheless, studies
evaluating the benefits of normalizing glycemia have
produced inconsistent results. For instance,
intensive control of hyperglycemia had been shown to
provide microvascular benefit in type 1 and type 2
diabetic patients, but its macrovascular benefits
had only been clearly demonstrated in type 1
diabetic patients. Moreover, although initial
studies in critically ill patients showed decreased
morbidity and mortality with tight glycemic control,
subsequent studies yielded conflicting results. A
series of recent studies provide further insight and
show that intensive glycemic control in type 2
diabetic patients does provide macrovascular benefit
but is associated with increased risk of
hypoglycemia. In the critically ill patient, tight
glycemic control could be detrimental; thus, a less
aggressive glycemic target of 140 to 180 mg/dL is
preferred.
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Inpatient
Glucose Control:
A Glycemic Survey of 126 U.S. Hospitals
Journal of
Hospital Medicine 2009;4:E7–E17. VC 2009 Society of
Hospital Medicine.
Curtiss B. Cook, MD, FACP, Gail L. Kongable, RN, MSN,
FNP, Daniel Jason Potter, MA, Victor J. Abad, MA, Dora
E. Leija, MA, Marcy Anderson, MS, Mayo Clinic College of
Medicine, Scottsdale, Arizona. The Epsilon Group
Virginia, LLC, Charlottesville, Virginia. Medical
Automation Systems, Charlottesville, Virginia.
A total of 12,559,305 POC-BG measurements were analyzed:
2,935,167 from the ICU and 9,624,138 from the non-ICU.
Patient-day-weighted mean POC-BG was 165 mg/dL for ICU
and 166 mg/dL for non-ICU. Hospital hyperglycemia (>180
mg/dL) prevalence was 46.0% for ICU and 31.7% for
non-ICU. Hospital hypoglycemia (<70 mg/dL) prevalence
was low at 10.1% for ICU and 3.5% for non-ICU. For ICU
and non-ICU there was a significant relationship between
number of beds and patient-day-weighted mean POC-BG
levels, with larger hospitals ( 400 beds) having lower
patient-day weighted mean POC-BG per patient day than
smaller hospitals (<200 beds, P < 0.001). Rural
hospitals had higher POC-BG levels compared to urban and
academic hospitals (P < 0.05), and hospitals in the West
had the lowest values.
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Sliding
Scale vs Tight Glycemic Control
Diabetes In
Control
Patients treated with TC experienced more blood
glucose measurements in the target range as compared
with patients treated with SS with relatively low
hypoglycemia rates.
Development of hyperglycemia during hospitalization is
an area of concern in patients with and without diabetes
mellitus. Tight glycemic control has been debated for
critically ill and noncritically ill patients with
hyperglycemia. Although many studies have been performed
in the critically ill, adequate data are not available
in the noncritically ill population.
To compare traditional sliding scale (SS) with a tight
glycemic control (TC) algorithm. The primary endpoint
was the percentage of total blood glucose measurements
in the target range of 80-150 mg/dL. The secondary
endpoint evaluated was safety, defined as percentage of
all blood glucose measurements that were 0-60 mg/dL.More >>
Inpatient
Hyperglycemia Management:
The
Voyage Continues!
Dr. Rattan
Juneja and Dr. Tim Meakem; Editorial: Crit Care Med 2009
Vol. 37, No. 12
We have known for some time now the strong association
between hyperglycemia and increased risk of
complications in hospitalized patients. We have also
known that in-hospital hyperglycemia confers increased
risk of mortality not only in patients with diabetes,
but especially in those who manifest hyperglycemia for
the first time during critical illness. These findings
were supported in the sentinel clinical trial by van den
Berghe et al, in which critically ill surgical patients
randomized to a tight glucose target of 80 to 110 mg/dL
experienced significant reductions in morbidity and
mortality when compared with a glucose range of 180 to
200 mg/dL. This trial was the genesis for the concept
and promotion of tight glucose control (TGC) in all
critically ill patients.
More >>
Glucose
Control and Its Implications
for the
General Surgeon
MAYA LEGGETT,
M.D., BRIAN G. HARBRECHT, M.D. From the Department of
Surgery, University of Louisville, Louisville Kentucky,
for the American Surgeon.
THERE HAS BEEN AN INCREASING amount of literature over
the last few years describing the importance of glucose
control in hospitalized patients. Normalization of blood
glucose levels in both diabetic and nondiabetic patients
has been proposed to improve outcome and reduce the
short term and long term adverse consequences of
hyperglycemia. Several regulatory or advisory groups
have even promoted tight glucose control as a process
that should be monitored in critically ill patients to
assess the quality of care.
More >>
PROS AND
CONS:
Tight Perioperative Glycemic Control
Journal of
Cardiothoracic and Vascular Anesthesia, Vol 23, No 6
(December), 2009
Lee A. Fleisher, MD and Bonnie L. Milas, MD, Section
Editors of the Journal of Cardiothoracic and Vascular
Anesthesia weigh the pros and cons of this
subject.More >>
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