Evaluation of conventional v. intensive blood glucose control
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Transcript Evaluation of conventional v. intensive blood glucose control
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
Defined as a blood glucose > 200 mg/dl
Etiology
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 infusion
Titrate every hour
according to protocol
Hypoglycemia in the ICU
Blood glucose < 70mg/dl
Result of overcorrection
of hyperglycemia
Whipple’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% dextrose
If IV access not possible:
Glucagon (1.0 mg for adults) SC or IM
Goal 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: Ia
Recommendation 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 analysis
Whether hypoglycemia leads to death in critically ill patients is unclear
Findings
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.