The Impact of a Normoglycemic Management Protocol on Clinical Outcomes in the Trauma Intensive Care Unit

Introduction and evaluation of a computerised insulin protocol

OBJECTIVE

To lower glucose levels in all patients in the intensive care unit (ICU) to the target range of 4.5-7.5 mmol/l using a nurse-driven computerised insulin protocol in combination with bedside glucose measurement.

DESIGN

Cohort study.

SETTING

Mixed adult ICU.

PATIENTS AND PARTICIPANTS

All 182 patients admitted to the ICU during a 3-month period were studied, except for 3 patients admitted for diabetic keto-acidosis.

INTERVENTIONS

Five steps were taken to improve glucose regulation: (1) Nurses were authorised to adjust insulin dosage using a protocol. (2) Glucose was measured more often. (3) Glucose was measured at the bedside. (4) Consecutive protocols aimed for successively lower glucose levels; the final protocol had a target range of 4.5-7.5 mmol/l. (5) The protocol was computerised. MEASUREMENTS AND RESULT: Mean glucose decreased from 9.23 mmol/l without protocol to 7.68 mmol/l with the final protocol. This final protocol with the target of 4.5-7.5 mmol/l was evaluated more extensively. Glucose levels were measured a total of 1854 times in 179 ICU admissions during 552 ICU treatment days. The median glucose level was 7.0 mmol/l, and 53.1% of glucose measurements were within the target range of 4.5-7.5 mmol/l. One episode of hypoglycaemia (glucose </= 2.2 mmol/l) occurred, representing 0.5% of patients or 0.05% of glucose measurements.

CONCLUSIONS

The combined strategy of successively more ambitious nurse-driven (computerised) insulin protocols and bedside glucose measurement resulted in acceptably low glucose levels with very few episodes of hypoglycaemia.

[Multicenter study on the prevalence of hyperglycemia among hospitalized patients with parenteral nutrition]

OBJECTIVE

The aim of this cross-sectional national multicentric study was to determine the prevalence of hyperglycemia in patients with parenteral nutrition and to assess other clinical factors associated with this complication.

METHOD

All Spanish hospital pharmacy services were invited to participate in the study.

RESULTS

Twenty eight (28) pharmacy services agreed to participate. The study included 442 patients. The prevalence of hyperglycemia (plasma levels > 200 mg/dL) was 26.7%. Eighty four point two per cent of the patients received less than 3.5 mg/kg/minute of glucose, this infusion rate being considered as the safe threshold. In most patients, follow-up of glycemia was based on capillary blood determination with reactive strips and in 27.6% of the cases in which insulin was prescribed, it was added to the parenteral nutrition bag, in full or in part. No significant correlations were found between glycemia and the clinical factors studied (disorders, fever, medication), except for insulin.

CONCLUSIONS

This national multicentric study of the prevalence of hyperglycemia among patients with parenteral nutrition, leaded by hospital pharmacists, was a joint effort aimed to better understand this metabolic complication. Findings are consistent with those reported by other authors and have allowed us to describe the current situation.

Hyperglycemia during critical illness

BACKGROUND

We sought to review the literature describing the benefits of tight glycemic control in critically ill patients, comparing outcome differences in subgroup populations.

METHODS

We searched PubMed for relevant literature on the topic of hyperglycemia and its management in the intensive care unit.

RESULTS

Overwhelming evidence in both surgical and medical patients conclusively demonstrates that hyperglycemia is a marker of severity of illness and is also an independent determinant of bad outcome, largely from infectious complications. Randomized trial evidence, in conjunction with historically controlled trials, supports the use of intensive insulin therapy and euglycemic control in critically ill patients, with nondiabetics possibly benefiting even more than diabetic patients. Euglycemia is best achieved, and hypoglycemia attenuated, through use of a protocolized approach. Further elaboration as to what threshold range defines euglycemia in patient subpopulations is needed and what pitfalls must be avoided in this practice. Development of continuous blood glucose monitoring has started and will someday be incorporated into routine practice in the same way that continuous electrocardiographic monitoring and pulse oximetry are standards of care in the intensive care unit.

CONCLUSIONS

Hyperglycemia is a predictor of death and complications in critically ill patients. Early aggregated study results show that control of hyperglycemia improves outcomes. Well-designed studies involving thousands of patients have started to better elucidate the concomitant promoters of hyperglycemia and to better quantify the benefits from tight glycemic control.

Perioperative glucose control

PURPOSE OF REVIEW

Hyperglycemia occurs commonly among acutely ill patients owing to a combination of counterregulatory and stress responses, as well as insulin resistance and deficiency, and is associated with increased morbidity and mortality in a variety of different patient populations. This manuscript reviews the adverse consequences of hyperglycemia in these different settings and focuses on perioperative glycemic management.

RECENT FINDINGS

Hyperglycemia has a number of effects on the native immune system that may explain its role in increasing the risk of infection. Insulin may exert its beneficial effects by altering lipid metabolism as well as by modulating endothelial function through several mechanisms. Hyperglycemia during cardiac surgery is associated with increased risk of postoperative complications, including death. Several interventional studies have concluded that intensive glycemic management is beneficial, but there are limited data available from general surgical populations.

SUMMARY

Hyperglycemia is associated with adverse outcomes in acutely ill adult patients and its treatment has been shown to improve mortality and morbidity in a variety of different settings. Additional studies are needed in heterogeneous populations of critically ill patients as well as in other populations of acutely ill patients, especially general surgical patients, to confirm the early studies and define the correct glycemic target.

Intensive Insulin Therapy in Postoperative Intensive Care Unit Patients

RATIONALE

Intensive insulin therapy (IIT) may reduce mortality in mechanically ventilated postoperative patients.

OBJECTIVES

To assess the risks and benefits of IIT in different institutions.

DESIGN

Retrospective, blinded-to-outcome selection of patient cohorts from four hospitals.

METHODS

Selection of a cohort of patients with clinical features similar to those reported in a recent study of IIT and of all mechanically ventilated postoperative patients from each hospital. Retrieval of information on glucose control. Assessment of risks and benefits and final outcomes.

MEASUREMENTS AND MAIN RESULTS

We selected 783 consecutive patients with similar clinical and demographic features to the IIT trial control group and four general cohorts for a total of 4,150 consecutive mechanically ventilated postoperative patients. In these patients, glucose levels were measured 212,663 times for a mean value of 8.22 +/- 2.7 mmol/L (148 +/- 49 mg/dl). Intensive care unit (ICU) mortality varied from 2.2 to 13.6%. The incidence of hypoglycemia (defined as < 2.2 mmol/L) varied from 1.4 to 2.7%. Assuming a beneficial effect of IIT as reported, the number needed to treat to save one life varied from 38 in one ICU to 125 in another, whereas the rate of hypoglycemia (number needed to harm) varied from 7 to 13.

CONCLUSIONS

The number needed to treat to prevent an ICU death and the associated risk of hypoglycemia (number needed to harm) with IIT vary widely according to baseline mortality, case mix, and case selection. Rational decision analysis in individual ICUs should take these factors into account.

Glycemic control, diabetic status, and mortality in a heterogeneous population of critically ill patients before and during the era of intensive glycemic management: six and one-half years experience at a university-affiliated community hospital

Hyperglycemia occurs commonly in acutely and critically ill patients and has been associated with adverse clinical consequences. An emerging body of literature describes the beneficial effects of intensive glycemic monitoring and treatment (tight glycemic control, or "TGC"). This manuscript reviews the experience of a cohort of 5365 non-cardiac surgery patients admitted to the adult intensive care unit of a university-affiliated community hospital before and after implementation of TGC. Significant decreases in mortality occurred among medical and surgical patients during the TGC era, but not among trauma patients. Non-diabetics who sustained hyperglycemia had an especially high risk of mortality, and benefited greatly from treatment. Further investigations will be needed to identify the most appropriate glycemic targets for different populations of patients.