Improving glycaemic control in a metabolically stressed patient in ICU

Application of a glycaemic control optimization programme in patients with stress hyperglycaemia

BACKGROUND

Stress-induced hyperglycaemia (SHG) can be observed in as high as 75% of critically ill patients, which can induce severe complications or adverse events. However, conventional intensive insulin therapy (CIIT) tends to induce hypoglycaemia and glucose variability.

AIMS

This study investigated the clinical effects of a blood glycaemic control optimization programme (BGCOP) in patients with stress hyperglycaemia post hepatobiliary or pancreatic surgery.

DESIGN

This study is a randomized, controlled, prospective clinical observation.

METHODS

Eighty-six patients with postoperative SHG were randomly divided into a control and experimental groups. Participants in the control group underwent CIIT, while participants in the experimental group underwent blood glycaemic control optimization programme (BGCOP). A range of 7·8-10·0 mmol/L was designated as the target range for effective control of blood sugar. The validity index, adverse events and complications were compared between two groups.

RESULTS

Compared to participants treated with CIIT, participants treated with BGCOP reached the target range of blood sugar levels more quickly (p = 0·000). The high glycaemic index (p = 0·000), incidence of hypoglycaemia (p = 0·011), and other adverse events as well as the incidence of abdominal infection (p = 0·026), incision infection (p = 0·044), and lung infection (p = 0·047) were significantly lower in participants who underwent the BGCOP than in patients treated with CIIT.

CONCLUSION

BGCOP can more effectively control blood sugar levels compared with CIIT in patients with SHG after hepatobiliary or pancreatic surgery.

RELEVANCE TO CLINICAL PRACTICE

This study provides a direction for blood glycaemic control in patients with stress hyperglycaemia post hepatobiliary or pancreatic surgery.

Postoperative hyperglycaemia of diabetic patients undergoing cardiac surgery - a clinical audit

BACKGROUND

Previous studies have shown that hyperglycaemia is associated with postoperative complications in cardiac surgical patients. Conversely, well-controlled glucose levels are said to reduce major infectious complications in diabetic patients.

AIM/OBJECTIVES

The purpose of this clinical audit was to evaluate the blood glucose levels of diabetic patients undergoing cardiac surgery and to determine the effectiveness of postoperative glycaemic control.

METHODS

A group of 150 patients from a large Irish cardiac surgery centre was selected by convenience sampling. An audit tool was designed to capture the patients' blood glucose levels, treatment regimes and postoperative complications.

FINDINGS

The findings showed major variations between 'high', 'good' and 'borderline' blood glucose levels in the pre- and postoperative phase. Although blood glucose testing practices seemed inconsistent, mean levels measured 'borderline'. Furthermore, the treatment regimes varied greatly and suggest a lack of consensus regarding the management of postoperative hyperglycaemia. A total of 52% (n = 78) patients developed 114 complications with a level of 21.4% (n = 32) postoperative wound infections.

CONCLUSION

The findings from this audit highlight the importance of regular blood glucose testing to enable early detection of hyperglycaemia and timely initiation of appropriate treatments regimes for diabetic patients undergoing cardiac surgery. Findings also show that hyperglycaemia derangement may make a difference in the recovery phase. While patients will benefit from lesser wound infections, hospitals might save costs involved with treating postoperative complications.

RELEVANCE TO PRACTICE

More consistent blood glucose testing might be achieved through the use of evidence-based protocols. However, the education of staff is as important as it develops knowledge on the complex metabolic interactions of diabetic patients undergoing cardiac surgery. While this means investing in staff education and policy development, costs for daily care and expensive treatments for complications will be saved as patient recovery will be speedier and less eventful.

Nurse-led implementation of an insulin-infusion protocol in a general intensive care unit: improved glycaemic control with increased costs and risk of hypoglycaemia signals need for algorithm revision

Background

Strict glycaemic control (SGC) has become a contentious issue in modern intensive care. Physicians and nurses are concerned about the increased workload due to SGC as well as causing harm through hypoglycaemia. The objective of our study was to evaluate our existing degree of glycaemic control, and to implement SGC safely in our ICU through a nurse-led implementation of an algorithm for intensive insulin-therapy.

Methods

The study took place in the adult general intensive care unit (11 beds) of a 44-bed department of intensive care at a tertiary care university hospital. All patients admitted during the 32 months of the study were enrolled. We retrospectively analysed all arterial blood glucose (BG) results from samples that were obtained over a period of 20 months prior to the implementation of SGC. We then introduced an algorithm for intensive insulin therapy; aiming for arterial blood-glucose at 4.4 – 6.1 mmol/L. Doctors and nurses were trained in the principles and potential benefits and risks of SGC. Consecutive statistical analyses of blood samples over a period of 12 months were used to assess performance, provide feedback and uncover incidences of hypoglycaemia.

Results

Median BG level was 6.6 mmol/L (interquartile range 5.6 to 7.7 mmol/L) during the period prior to implementation of SGC (494 patients), and fell to 5.9 (IQR 5.1 to 7.0) mmol/L following introduction of the new algorithm (448 patients). The percentage of BG samples > 8 mmol/L was reduced from 19.2 % to 13.1 %. Before implementation of SGC, 33 % of samples were between 4.4 to 6.1 mmol/L and 12 patients (2.4 %) had one or more episodes of severe hypoglycaemia (< 2.2 mmol/L). Following implementation of SGC, 45.8 % of samples were between 4.4 to 6.1 mmol/L and 40 patients (8.9 %) had one or more episodes of severe hypoglycaemia. Of theses, ten patients died while still hospitalised (all causes).

Conclusion

The retrospective part of the study indicated ample room for improvement. Through the implementation of SGC the fraction of samples within the new target range increased from 33% to 45.8%. There was also a significant increase in severe hypoglycaemic episodes. There continues to be potential for improved glycaemic control within our ICU. This might be achieved through an improved algorithm and continued efforts to increase nurses' confidence and skills in achieving SGC.