glycemic control in critically ill patients
DESCRIPTION
Glycemic Control in Critically Ill Patients. Evaluation of conventional v. intensive blood glucose control. DANELLE BLUME UNIVERSITY OF GEORGIA COLLEGE OF PHARMACY 2013 PHARM.D. CANDIDATE. Hyperglycemia in the ICU. A common occurrence in both diabetic and non-diabetic patients - PowerPoint PPT PresentationTRANSCRIPT
EVALUATION OF CONVENTIONAL V. INTENSIVE BLOOD GLUCOSE CONTROL
Glycemic Control in Critically Ill Patients
DANELLE BLUMEUNIVERSITY OF GEORGIA COLLEGE OF PHARMACY
2013 PHARM.D. CANDIDATE
Hyperglycemia in the ICU
A common occurrence in both diabetic and non-diabetic patients
Defined as a blood glucose > 200 mg/dlEtiology
Severe trauma, disease, infection, surgery, etc. result in the activation of the hypothalamic pituitary adrenal (HPA) axis Release of glucagon, growth hormone, and cortisol in
addition to norepinephrine and epinephrine Blood insulin levels remain normal or low
Insulin resistance, preexisting or not Fluids (D5W), Medications, TPN, etc.
Treatment of Hyperglycemia
Insulin infusionTitrate every hour
according to protocol
Hypoglycemia in the ICU
Blood glucose < 70mg/dl Result of overcorrection
of hyperglycemiaWhipple’s triad
Signs and/or symptoms consistent with hypoglycemia
Low plasma glucose Relief of symptoms after
plasma glucose is increased Life threatening
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Treatment of Hypoglycemia
Intravenous glucose (25g) as a 50% solution Followed by constant infusion of 5% or 10%
dextroseIf IV access not possible:
Glucagon (1.0 mg for adults) SC or IMGoal glucose: 110-180, but this is a wide
range and a debatable one
Conflicting Findings
Initial trials suggested that intensive glucose control could reduce mortality among patients in surgical ICU and reduce morbidity among those in a medical ICU* Subsequent studies have NOT confirmed this
NICE-SUGAR trial shows increased risk of death in patients assigned to intensive glucose control
* Van den Berghe G, Wouters P, Week- ers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345:1359-
67. Van den Berghe G, Wilmer A, Her- mans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med 2006; 354:449-61.
NICE-SUGAR
Normoglycemia in Intensive Care Evaluation—Survival Using Glucose Algorithm Regulation
A multicenter, randomized, controlled trial 6104 adults in ICUs in 42 hospitals between 2004 & 2008 Intensive blood glucose control group (target BG range 81-
108 mg/dl) v. conventional glucose control (target 180 mg/dl or less)
Intervention continued until patient was eating, discharged from ICU, or died
Primary outcome: death within 90 days after randomization Severe hypoglycemia = 40 mg/dl or less Moderate hypoglycemia = between 41 and 70 mg/dl
NICE-SUGAR
Evidence: IaRecommendation Grade: A
Overall Conclusion:Although hypoglycemia was significantly more common among patients assigned to intensive versus conventional glucose control, the association of hypoglycemia with death was similar in the two groups
NICE-SUGAR
Post-hoc analysisWhether hypoglycemia leads to death in critically ill patients is
unclearFindings
Even after adjustment for events occurring after the first episode of hypoglycemia, moderate hypoglycemia was associated with an increased risk of death of 40% and severe hypoglycemia with a doubling of the risk Causal relationship is plausible because hypoglycemia may increase
mortality by impairment of other systems Hypoglycemia may be a marker of severe underlying disease
processes Autonomic function, alteration of blood flow and composition,
white-cell activation, vasoconstriction, and the release of inflammatory cytokines
Relevance
A wise man once said, “Hyperglycemia in the acute setting isn’t going to kill you but hypoglycemia will.” Hal Richards, Pharm.D., BCNSP, Candler Hospital
Thus, until we have data that says otherwise, intensive glucose control in the ICU should be avoided. A target blood glucose of 130-180 mg/dl is a reasonable goal
References
Annetta MG, Ciancia M, Proietti R. Diabetic and nondiabetic hyperglycemia in the ICU. Current Anaesthesia & Critical Care, 2006 17:6, 385-390.
LexiComp. Version 1.10.0(159), 2012. McDonnell ME, and Umpierrez GE. Insulin therapy for the
management of hyperglycemia in hospitalized patients. Endocrinology and Metabolism Clinics of North America, March 2012 41:1, 175-201.
NICE-SUGAR investigators. Hypoglycemia and Risk of Death in Critically Ill Patients. N Engl J Med 2012;367:1108-18.