insulin therapy and glycemic control in the...
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Michael VerbiestNurse Team Leader Intensive CareAntwerp University Hospital Belgium
Insulin therapy andglycemic control in the ICU
Antwerp University Hospital
• 7 university hospitals in Belgium
• 600 beds, + 2500 employees
• Intensive Care Unit: 45 beds (adults & children)
• Surgery (transplantation)/internal
• +/- 3000 admissions/year
Stress hyperglycemia
• Prevalence: 50%-80% of the critically ill patients
• ↑Hepatic glucose output and ↓insulin sensitivity
• Contributing factors:
• Inflammatory mediators
• Excessive release of counter – regulatory hormons
• Medication
• (par)enteral nutrition
• Dialysis
Intensive vs conventional
• Hypothese: SH as a (in)direct predictor of ↑morbidity and ↑ mortality
• IGFBP-1
Intensive Insulin therapy vs. moderate insulin therapy
• Intervention group: Intensive Insulin therapy
• Target: (4.4mmol/l – 7.8 mmol/l) = (80mg/dl – 110mg/dl)
• Control group: conventional insulin therapy
• start at 12,2mmol/l = 215mg/dl Target: 10mmol/l- 11,1mmol/l = 180mg/dl – 200mg/dl
50% reduction of mortality (los >5 d)
Reduction of severe infection and organ failure
What about other subgroups?
Safety? Reproducibility? Universality?
• Conflicting results in other trials - Methodological shortcomings:
• No standardized glucose measuring methode
• Insufficient time for tight control
• Lack of training and technical support
• High prevalence of severe hypoglycemia (< 2,2mmol/l = < 40mg/dl)
Discussion:
• Optimal bloodsugar range? Intensive vs moderate
• Optimal Time in Range?
• Patientoutcome after hypoglycemia?
Severe hypoglycemia (<40 mg/dl)
Three domains in glycemic control
1. Hyperglycemia: the focus of the interventional trials
2. Hypoglycemia: the “unifying complication”
3. Glycemic variability: a hidden factor impacting the
interventional trials
Cumulative impact of disturbances in different
domains
• Hypoglycemia has the strongest association with
mortality.
• Increasing glycemic targets into the hyperglycemic
range may increase mortality.
• GV is associated with additional harm and is an
additional therapeutic target.
Risk groups OR (95% CI)
Hypo 2.5 (2.0-3.1)
Hypo + Hyper 4.8 (3.4-6.8)
Hypo + Hyper + GV 6.8 (3.9-9.2)
Glycemic control at ICU
• Physycian led - nurse driven vs. Computer assisted
• Computer assisted protocols:
+ Decrease in glucose variability
- No diffirence in hypoglycemic episodes
- ↑ frequency bloodsamples and adjustments
- TIR nurse vs. Computer (60,01% vs. 68%)
CAIP
Glycemic control in ICU
• Modified Yale Protocol : target: 4,4mmol/l – 7,8mmol/l = 80mg/dl – 140 mg/dl
• 1x/h until in range
• 2x/h
• 6x/24u
• Frequency ↑
• Corticoids
• Somatostatine
• Start (par)enteral nutrition
Modified Yale Protocol
Avoid glycemic variability
• Continu IV drip infusion
• Always the same insuline concentration: 50E/50cc NaCl 0.9%
• Visibility of trends in patient record
• Electronic warning system
• Continu glycemic monitoring
Glycemic trends
Early start (par)enteral feeding
• Nutritional needs of the patient
• BEE Harris Benedict, Penn state 2014
• Nutritional risk screening: stress factor (severe infection,
burns, …)
• Exact weight (bedbalance)
• Exact amount of calories and proteins:
• Indirect calorimetry (O²-CO² consumption in the ventilated
blood) (golden standard)
• Selection of the right nutritional therapy
• Enteral/parenteral
• Multidisciplinairy meeting with dietist
Indirect calorimetry
Bed balance
187 – 188 kg
Nutritional Risk Screening
Energy: Total caloric requirement
Enteral feeding in the critically ill patients
• Start < 24u. if hemodynamic and gastro intestinal tract
stable
• Stepwise, based on residual level and nutrition needs
• Prokinetics
• Head of the bed : 30°
• Always use a volumetric pump
• Start parenteral feeding when calorietargets are not in
range.
Conclusion
• Research possibilities
• Multicenter trial: intensive vs moderate insulin therapy
• Computer assisted protocols
• Continuous glycemic measurement
• Long term: Predisposing factors for the development of diabetes mellitus after Intensive Care admission. (based
on Hba1c, SAPS3 and Frindisk scale) :
follow up in an early stage
Insulin therapy and glycemic control in critically illpatients is teamwork.
Sources
• Egi M, Bellomo R, Stachowski E et al. Hypoglycemia and outcome in critically ill
patients. 2010 Mar;85(3):217-24
• Finfer S, Chittock D, Yushuo S. et al. Intensive versus Conventional Glucose
Control in Critically Ill Patients. N Engl J Med 2009;360:1283-97.
• Mesotten D. Continuous glucose sensors for glycaemic control in the ICU: have
we arrived? Critical Care 2013. 17:1004
• Van Ackerbroeck S, Schepens T, De Block C. Incidence and predisposing factors
for the development of disturbed glucose metabolism and DIabetes mellitus
AFter Intensive Care admission: the DIAFIC study. Critical Care 2015;19:355
• Van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in
critically ill patients. N Engl J Med, Vol. 345, No. 19
• Van den Berghe G, Wilmer A, Hermans G et al. Intensive Insulin Therapy in the
Medical ICU. N Engl J Med 2006;354:449-61.