The Importance of Normoglycemia in Critically Ill Patients

The Role of Nondiabetic Hyperglycemia in Critically Ill Patients with Acute Ischemic Stroke

In this study, we aim to elucidate the association between nondiabetic hyperglycemia and the short-term prognosis of critically ill patients with acute ischemic stroke. We extracted data using the Medical Information Mart for Intensive Care IV from 2008 to 2019. The primary outcomes were set as intensive care units (ICU) and in-hospital mortality. We developed a Cox proportional hazards model to determine the nonlinear association between serum glucose levels and primary outcomes. Of the 1086 patients included, 236 patients had hyperglycemia. Patients with hyperglycemia were associated with higher ages, female gender, higher Charlson Comorbidity Index scores, and higher Acute Physiology Score III scores. After propensity score matching, 222 pairs remained. The hyperglycemia group had a significantly higher ICU mortality (17.6% vs. 10.8%; p = 0.041). Meanwhile, no significant differences in ICU length of stay (5.2 vs. 5.2; p = 0.910), in-hospital mortality (26.6% vs. 18.9%, p = 0.054), and hospital length of stay (10.0 vs. 9.1; p = 0.404) were observed between the two groups. The Kaplan–Meier curves for ICU and in-hospital survival before matching suggested significant differences; however, after matching, they failed to prove any disparity. Non-diabetic patients with acute ischemic stroke have poor clinical characteristic while encountering hyperglycemic events; therefore, careful monitoring in the acute phase is still required.

Clinical and epidemiological study of stress hyperglycemia among medical intensive care unit patients in Central India

BACKGROUND

Stress hyperglycemia is common in patients presenting at the emergency medical ward and is associated with poor prognosis and increased risk of mortality.

AIMS AND OBJECTIVE

To study and determine the prevalence and factors associated with stress hyperglycemia.

MATERIALS AND METHODS

A cross-sectional observational study was performed on 536 nondiabetic patients presented to the Intensive Care Unit (ICU) at Gandhi Medical College and allied Hamidia Hospital, Bhopal, between March 31, 2015, and May 28, 2015. A detailed history including demographic profile, presence of chronic disease, history of hospitalization and ICU admission, surgical status, and major reason for ICU admission (i.e., predominant diagnostic category) was collected. Hematological and other parameters based on profile of study population were also analyzed.

RESULTS

Out of 536 patients, 109 (20.33%) had stress hyperglycemia. Out of 109 patients with stress hyperglycemia, 87 (16.23%) patients had glycated hemoglobin (HbA1c) <5.7% and 22 (4.10%) patients had HbA1c between 5.7% and 6.4%. Mean age of the study population was 40.27 ± 1.44 years, with male dominance. Mean random blood glucose level was 181.46 ± 3.80 mg/dl. Frequency of stress hyperglycemia was 24.13% in stroke, 19.54% in multiple organ dysfunction syndrome (MODS), 17.24% in chronic kidney disease (CKD), 12.64% in central nervous system (CNS) infection, 8.05% in chronic liver disease (CLD), and 8.05% in seizure patients. Association between stroke and stress hyperglycemia was significant (P = 0.036). Association between hospital stay more than 7 days and stress hyperglycemia was significant in stroke patients (P = 0.0029), CKD patients (P = 0.0036), CLD (P = 0.0099), and MODS patients (P = 0.0328).

CONCLUSIONS

The factors associated with stress hyperglycemia were stroke, MODS, CKD, CNS infection, CLD, seizure patients, with prolonged hospital stay and expected proportion.

Accuracy of glycemic measurements in the critically ill

BACKGROUND

Recent evidence emphasizes the importance of maintaining normoglycemia in critically ill patients to reduce morbidity and mortality. Different analytical methods of varying accuracy exist for obtaining and measuring blood glucose in critically ill patients. The purpose of this study was to determine if there were differences in blood glucose values measured by whole blood capillary and arterial samples using three different bedside blood glucose meters and a blood gas analyzer as compared to a reference blood glucose analyzer.

METHODS

Sixty subjects were recruited from a university hospital medical/surgical intensive care unit. Matching capillary and arterial samples were analyzed by a clinical blood glucose reference analyzer (YSI, Yellow Springs Instrument, Yellow Springs, OH) and three blood glucose meters (Lifescan [Milpitas, CA] SureStepFlexx, Roche [Indianapolis, IN] Accu-Chek Inform, and Abbott [Alameda, CA] FreeStyle). Additionally, the arterial samples were analyzed by a point-of-care blood gas analyzer (Chiron 865, Bayer, Tarrytown, NY).

RESULTS

Data analysis included repeated-measures analysis of variance, Consensus Error Grid analysis, Bland-Altman plots, and numerical estimates of inaccuracy. With capillary samples there were high numbers of errors as compared to the reference instrument. Measurement of blood glucose with arterial samples demonstrates a higher degree of accuracy. With arterial samples, the Abbott FreeStyle blood glucose meter and the blood gas analyzer glucose exhibited the lowest median and mean relative absolute deviation.

CONCLUSION

In critically ill adult patients, measurement of blood glucose using arterial samples is recommended. Using arterial blood, the Abbott FreeStyle blood glucose meter and the point-of-care blood gas analyzer (Bayer Chiron 865) were shown to be highly accurate instruments to measure arterial blood glucose.

Impact of human factors on clinical protocol performance: a proposed assessment framework and case examples

BACKGROUND

Hyperglycemia is prevalent in critical care and tight control can save lives. Current ad-hoc clinical protocols require significant clinical effort and can often produce highly variable results. Thus, tight control remains elusive as there is not enough understanding of the relationship between control performance and protocol design, particularly with regard to how a given protocol is implemented.

METHODS

This article examines the role of human factors and how individuals relate to technological protocols in clinical settings. The study consists of an overall brief review that is used to create a first graphical representation of the impact of human factors in clinical medical protocol implementations. This initial framework is examined in the context of two similar, but different, case studies-the specialized relative insulin and nutrition tables glycemic control protocol and the TREAT system for antibiotic selection.

RESULTS

A graphical framework relating the human factors impact on medical protocol implementation is created. This framework describes the primary impacts on performance as resulting from clinical burden and protocol transparency. Their primary effect is on compliance with the protocol, which directly affects performance and outcome, particularly in long-term studies versus short pilot studies.

SUMMARY

Compliance is a key element in obtaining the best clinical outcome that a given protocol can provide. The issues that most affect compliance are quite often unrelated to the patient or treatment, but are a function of the protocol design and its ability to integrate (by its design) into a given clinical setting. A framework for examining these issues in design and in post-hoc assessment is therefore proposed and examined in two brief case studies.

Blood glucose control in critical care patients - a review of the literature

The role of hyperglycaemia in critical illness, and its corresponding treatment, has been an area of controversy, fuelled by conflicting research findings. The aims of this study were to critically evaluate the literature and present an historical review of the sequence of published papers relating to blood glucose control in critical care. Their subsequent impact together with the implications for patient care is discussed. This article is based on a systematic review of papers relating to glycaemic control in critical care patients. The review was conducted using the MedLine, CINAHL and EMBASE databases using key search terms (details of the search terms can be found after the conclusion of the paper) for the period 1950-2006. The searches resulted in 4863 papers being screened for relevance to the historic progression of glycaemic management in critical care patients, by title and then abstract. Of these, 209 were accessed, and their reference lists were snowballed for further papers. Papers that were repeatedly quoted throughout the literature and were therefore considered important in the historical development of accepted critical care practice were finally subjected to rigorous appraisal. These totalled 91 papers and included 18 randomized controlled trials, an additional 28 research papers, 25 editorials and 20 reviews. This critical evaluation of published work indicates that the evidence for the benefit of this therapy may not be as compelling as previously indicated, and its widespread use may have been premature. From a nursing perspective, this demonstrates the importance of maintaining a questioning attitude to new therapies and reviewing best practice in the light of evolving evidence.

Nurses' rationale for blood glucose monitoring in critical care

Morbidity and mortality in a critical care environment is improved when there is tight control of blood glucose. This study aimed to explore nurses' rationale for blood glucose monitoring in a critical care setting. An exploratory qualitative design was utilized in one acute division of a large NHS Trust in Scotland. Volunteers were sought by letter and through posters in the clinical area. Five staff nurses from two critical care areas volunteered to take part in one-to-one interviews that were tape-recorded. All transcripts were analysed using content analysis. Nurses described differing perspectives on blood glucose monitoring. Nurses did not know the blood glucose level that defines hyperglycaemia, a knowledge gap which impacts on care intervention. Three sisters from the wards were interviewed to determine their perceptions of the reasons for the poor response rate. They identified several issues thought to impact on staff volunteering for research.

A review of the use of insulin protocols to maintain normoglycaemia in high dependency patients

AIM

This paper critically examines the evidence base for and issues involved in the introduction of an insulin protocol to maintain normoglycaemia in patients within a medical/surgical high dependency ward.

BACKGROUND

A growing body of evidence has linked hyperglycaemia to worsened clinical outcomes. This has led to intravenous insulin protocols becoming a new standard of care in intensive care units. However, the use and benefits of insulin protocols within high dependency units have not yet been addressed in the literature.

METHODS

The literature was examined for the 10-year period up to January 2005. The databases searched were MEDLINE, OVID, CINHAL, the British Nursing Index, the EBSCO collection, the COCHRANE library, the Department of Health, and guidelines within the Scottish Intercollegiate Guidelines Network and National Institute for Clinical Excellence using the key words insulin, protocol, hyperglycaemia, critical care, intensive care and high dependency.

RESULTS

The literature reports that both medical and surgical intensive care patients treated with intravenous insulin protocols to maintain normoglycaemia experienced significantly reduced mortality and morbidity. Resulting hypoglycaemic episodes were limited with no incidence of patient deterioration. A review of published intravenous insulin protocols used in intensive care settings revealed their safe and effective use in nurse to patient ratios similar to those present in high dependency units.

CONCLUSIONS

In the light of this evidence, it would seem safe and ethically correct to enable high dependency patients to benefit from this cheap intervention. An insulin protocol tailored for the glycaemic control of high dependency patients has been suggested, although it may have to be commenced in conjunction with other fluid and nutrition protocols to safeguard the risk of hypoglycaemic events. Further research into the safety and benefit of insulin protocols in high dependency populations is required.

RELEVANCE TO CLINICAL PRACTICE

The stress of critical illness often leads to hyperglycaemia, which is linked to worsened clinical outcomes. Both medical and surgical intensive care patients treated with intravenous insulin protocols to maintain normoglycaemia experienced significantly reduced mortality and morbidity. This paper identifies that, to date, no research into the benefits of glycaemic control in high dependency populations has been published. The case for the introduction of insulin protocols into high dependency units is therefore examined and an insulin protocol suggested.

Implementing an intensive glucose management initiative: strategies for success

Glycemic control has become a hallmark for this ICU. Collectively, staff and hospital leaders changed a culture of casual attitudes toward chaotic glycemic control to an evidence-based atmosphere of decreased mortality, which has received local and national recognition. Implementation of a protocol , which seemed radical at the time, showed significant patient outcomes. Characterized by teamwork and education, the process was developed, initiated and continually evaluated for improvement, with a cornerstone of patient safety. The rich database allows for continual analysis of outcomes.

Barriers to Glucose Control in the Intensive Care Unit

Despite published evidence supporting glycemic control in critically ill patients, achieving euglycemia remains a problem in the intensive care units (ICUs) of many institutions. Clinicians seeking to implement the findings of published evidence in their practice face many potential barriers that make euglycemia difficult to achieve in patients in the ICU. Developing a comprehensive understanding of the many barriers to ICU glucose control can aide clinicians in attempting to change practice and improve patient outcomes. Barriers to ICU glucose control include the role of different health professionals in glucose management, communication among health care professionals, guidelines, protocols, ICU culture, fear of hypoglycemia, glucose monitoring, education, systems analysis, health care resources, nutritional needs, and drug utilization. By ensuring compliance, changing ICU culture, developing guidelines and protocols, and incorporating a multidisciplinary approach, clinicians can achieve glycemic control in the critically ill population and improve patient outcomes.