Glucose Control in the Critically Ill

Reviewed and revised 3 February 2013

OVERVIEW

  • Routine management in ICU involves avoiding complications of hyperglycaemia (infections) and hypoglycaemia (arrhythmias, neurological damage, cardiac events)
  • Traditional goals have varied
  • Tight glucose control was in vogue following the Leuven trials led by Greet Van Den Berghe, but this was over-turned by the subsequent definitive  NICE-SUGAR trial
  • In Australasia the ‘standard’ glucose control target is usually < 10mmol/L

DYSGLYCEMIA

Glucose variability is associated with worse morbidity and mortality, as shown by Badawai et al, 2012:

  • retrospective observational study
  • n = 194,772 ICU patients with LOS >48 hours
  • risk of mortality progressively increased with severity and duration of deviation from euglycemia and with increased variability in a ‘dose-dependent’ manner
  • severe intensive care unit-acquired hyperglycemia, hypoglycemia, and variability are associated with similar risks of mortality

EXAMPLE OF A PROTOCOL FOR GLUCOSE CONTROL IN THE ICU

EVIDENCE FOR GLUCOSE CONTROL

Before NICE-SUGAR

  • The 1995 DIGAMI study found that intensive blood glucose control in diabetic patients with acute myocardial infarctions improved mortality, though the subsequent DIGAMI-II trial did not favour any particular glucose control strategy
  • The 2001 Leuven Surgical Trial led by Greet Van Den Berghe was a landmark study that signalled the trend to intensive glucose control in ICU (Paul Marik has called November 8th 2001, the day this paper was publsihed along with the Rivers EGDT trial, ‘the darkest day in the history of intensive care’). This study found that ICU mortality decreased from 8 to 4.6% with tight control (BSL 4.5-6.5).
  • In 2006 the Leuven Medical Trial was published, it found improved morbidity but not mortality in medical ICU pateints receiving intensive insulin therapy
  • The 2008 VISEP study showed that intensive insulin therapy in patients with severe sepsis did not affect mortality or oragan failure, but raised concerns due to higher rates of severe hypoglycaemia   and serious adverse events.

Although considered landmark studies, the Leuven trials have many problems:

  • single centre
  • open label
  • trials stopped early because of observed benefit, which may have exaggerated treatment effect
  • difference found through sub-group analysis
  • observed difference may have been due to chance
  • the studies are not externally valid, except to ICUs with similar high glucose loads on day 1 and high rates of supplemental or total parental nutritiono on day 2

NICE SUGAR

  • A definitive MC RCT of over 6000 ICU patients found increased mortality and more severe hypoglycemias in the intensive control group (glucose 4.6-6 mM)  compared to the conventional therapy group
  • this study contradicted, and superseded the Leuven trials
  • A 2012 post-hoc analysis found a dose-response relationship between severe hypoglycemia and mortality, and that intensive control was associated with more episodes severe hypoglycemia

FUTURE DIRECTIONS

  •  intensive insulin therapy could conceivably come back into vogue with the development of accurate, continuous glucose monitoring +/- computerised feedback systems
  • determining how diabetic hyperglycemia and stress-induced hyperglycemia should be managed as separate entities in the critically ill
  • role of glucose variability control

References and Links

LITFL

Journal articles

  • Badawi O, Waite MD, Fuhrman SA, Zuckerman IH. Association between intensive care unit-acquired dysglycemia and in-hospital mortality. Crit Care Med. 2012 Dec;40(12):3180-8.PMID: 22971590.
  • Egi M, Finfer S, Bellomo R. Glycemic control in the ICU. Chest. 2011 Jul;140(1):212-20. PMID: 21729892.
  • Finfer S, et al. Clinical review: Consensus recommendations on measurement of blood glucose and reporting glycemic control in critically ill adults. Crit Care. 2013 Jun 14;17(3):229 PMC3706766.
  • Flower O, Finfer S. Glucose control in critically ill patients. Intern Med J. 2012 Jan;42(1):4-6. doi: 10.1111/j.1445-5994.2011.02631.x. PubMed PMID: 22276558.
  • Henderson WR, Finfer S. Differences in outcome between the NICE-SUGAR and Leuven trials: possible methodological explanations. Crit Care Resusc. 2009Sep;11(3):175-7. PMID: 19737117.
  • Myburgh JA, Chittock DR. Differences in outcome between the NICE-SUGAR and Leuven trials: biological mechanisms of intensive glucose control in critically ill patients. Crit Care Resusc. 2009 Sep;11(3):178-9. PMID: 19737118.
  • Smith FG, Sheehy AM, Vincent JL, Coursin DB. Critical illness-induced dysglycaemia: diabetes and beyond. Crit Care. 2010;14(6):327. PMC3220014.

FOAM and web resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.