Post on 22-Jan-2018
transcript
Glycemic Control in Adult
Intensive Care PatientsJoshua Alderman
Adult-Gerontology Acute Care Nurse Practitioner Track
University of Connecticut
In adult medical/surgical
intensive care patients, what is
the effect of intensive vs.
conventional glycemic control
on mortality and the incidence
of hypoglycemic events?
Neuman Systems Theory
Provides a holistic and system-based approach to nursing, and states there is constant energy exchange with the environment
Examines how the patient-system responds to actual or potential stressors; these responses can be used as a guide as to how severe illness is
Primary, secondary, and tertiary nursing prevention/intervention is utilized to retain, attain, and maintain patient-system wellness
In acute care we focus on the secondary and tertiary prevention/intervention
Neuman Systems Theory
Prevalence of Hyperglycemia in ICU
Australian study from 2013 found approximately 80% of the
1,000 patient’s developed hyperglycemia at some point
within the first 48 hours in the ICU (Farrokhi et al., 2013)
Other studies have shown this percentage to be even higher
Major Causes of Hyperglycemia in the
ICU
Critical illness and Stress Hyperglycemia
Immobility
IV fluids containing dextrose and feedings
Drugs including: corticosteroids, catecholemines
(particularly epinephrine), beta blockers, octreotide
History of Diabetes mellitus, and related disorders such as
DKA and HHNK
Critical Illness and Hyperglycemia
Increased levels of counter-regulatory hormones and
cytokines cause insulin resistance
This resistance results in impaired cellular glucose uptake
as well as hepatic glycogenesis/gluconeogenesis leading to
hyperglycemia
These mechanisms are believed to be a way for the body to
provide more “fuel” for vital organs
Why is Glucose Control
Important in the ICU?
Deleterious Effects of
Hyperglycemia
Impaired immune function
Inflammation and Coagulopathy
Oxidant Stress
Deleterious Effects of Hyperglycemia
These factors can lead to acute complications including, but not limited to:
Poor wound healing
Severe infections
Kidney injury
Critical illness polyneuropathy
Hypovolemia
Poor wound healing
Given these consequences, the question is
not whether to control glucose, but rather
what is the optimal level of glycemic
control during critical illness?
The Push for Intensive Glycemic Control
AKA Intensive Insulin Therapy (IIT)
In 2001, Van den Berghe G, et al. published their landmark
article “Intensive Insulin Therapy in Critically Ill Patients” in
the New England Journal of Medicine
The study asked, in surgical ICU patients, how does
intensive glycemic control (80-110 mg/dl) compare to
conventional glycemic control (180-200 mg/dl) in reducing
mortality?
The Push for Intensive Glycemic Control
12-month single center, non-blinded, randomized,
controlled trial with 1,548 mostly surgical ICU patients
The trial found ICU mortality to be 4.6% in the intensive
group vs. 8% in the conventional group (p < 0.04)
However, hypoglycemic events for the intensive group
were seen much more often than with the conventional
group (7% vs. 0.5%, respectively)
The trial concluded that intensive glucose therapy at or
below 110 mg/dl reduced morbidity and mortality in the
surgical intensive care unit
The Push for Intensive Glycemic Control
Quick Adoption of IIT throughout critical care
However, as research progressed, a number of new trials
began to show that intensive glycemic control may not be
as beneficial as once thought
Follow-up Lueven Trial
One of the major limitations of the Lueven Surgical Trial
was the lack of medical patients
In 2006, the Lueven investigators published a follow-up
RCT to their 2001 study focusing on 1,200 medical
patients
“Intensive insulin therapy significantly reduced
morbidity but not mortality among all patients in the
medical ICU.”
First to contradict 2001 study
Further Data Against IIT
In the years following, several other RCTs concluded
similar findings to the 2006 Lueven study
The VISEP and Glucontrol trials were both terminated
early due to safety concerns related to the high
incidence of hypoglycemic events
Both of these studies concluded mortality was not
significantly affected with IIT, and the risk of
hypoglycemia was significant
The NICE-SUGAR Trial
This trial put the nail in the coffin of the research
supporting IIT
In 2009, the “Normoglycemia in Intensive Care
Evaluation – Survival Using Glucose Algorithm
Regulation” was published
This was a large, multi-center, parallel-group, RCT with
6,104 patients in medical/surgical 42 ICUs with the
hypothesis that IIT would decrease 90-day mortality
The NICE-SUGAR Trial
Those expected to require 3 or more days in ICU were
randomly placed into an IIT group (81-108 mg/dl) or
conventional group (144-180 mg/dl)the two groups had
similar characteristics at baseline
A total of 829 patients (27.5%) in the intensive-control
group and 751 (24.9%) in the conventional-control group
died (p = 0.02); no effect on ICU LOS, Hospital LOS, or days
of mechanical ventilation
Severe hypoglycemia presented in 6.8% of the IIT vs. only
0.5% of the conventional group
Can computers help?
In 2014, Kalfon et al. published the Computerized
Glucose Control in Critically Ill Patients trial
Large, multi-center, RCT with 2,646 mixed ICU patients
Used computerized glucose control with computer-aided
clinical decision making tool
Found that IIT with computer-aided tech could not
significantly change 90-d mortality (32.3% IIT vs. 34.1%
conventional), and hypoglycemic risk was greater
Limitations Shared by the RCTs
Inability to blind ICU staff
Use of subjective inclusion criteria (expected ICU LOS >2 or
3 days)
Inability to keep patients in the target glucose ranges
“Diabetes Paradox”
Although the exact rationale remains unknown, it appears
the chronicity of higher glucose levels in diabetics actually
reduces the harm of hyperglycemia when critically ill
The benefit of IIT in the 2001 Lueven trial was seen to be
greatest in the non-diabetic population (mortality rate 4.8%
in IIT group vs. 8.4% in the conventional group)
Hypoglycemia and Mortality
Since the NICE-SUGAR trial, the Lueven Trial, NICE-
SUGAR, and CGAO-REA authors published post-hoc
analyses of their studies examining hypoglycemia and
it’s association with mortality
All three studies determined that hypoglycemia is
independently associated with increased mortality
In 2010, the Leuven investigators found that there is a
threefold increase in the risk of death associated with a
single severe hypoglycemic event (<40 mg/dl)
Hypoglycemia and Mortality
NICE-SUGAR investigators supported that moderate (41-70
mg/dl) and severe hypoglycemia (<40 mg/dl) are associated
with increased mortality (particularly in those with
distributive shock)
Mortality rate was 23.5% in those without hypoglycemic
event
Morality rates for moderate vs. severe hypoglycemic events
were 28.5% and 35.4%, respectively
Summary
IIT adult medical/surgical ICUs has the potential to
increase mortality
IIT is strongly associated with greater incidence of
severe hypoglycemia (BG <40 mg/dl)
Hypoglycemia is independently associated with
increased mortality and increased LOS
Due to glucose variability, it is difficult to keep
glucose within target ranges
Recommendations for Practice
Insulin therapy should be initiated when BG reaches >180
mg/dl
The target range for blood glucose should be 140-180 mg/dl
The best way to achieve target glucose levels and reduce
hypoglycemia is by reducing use of fluids with containing
dextrose and using insulin only when necessary
Enteral feeding is the method of choice over parenteral
How would Neuman’s System Theory be used in the
management of hyperglycemia?
1. Check BG level and
monitor S/Sx
hyperglycemia
2. Diagnosis of
treatable
hyperglycemia
>180 mg/dl
3. BG Target
Range of 140-
180 mg/dl
4. Determining
best treatment
plan to reduce
hyperglycemia
5. Restriction of
IVF containing
dextrose and
short-acting insulin
therapy;
continuous enteral
feedings
6. Continuously evaluating BG
and assessing patient’s core and
lines of defense after treatment
Current Practice
Despite being recommended in several guidelines (e.g.
Surviving Sepsis), the best evidence on proper glycemic
control is not being practiced universally
Not all ICU protocols have been updated to reflect current
evidence
Practitioners do not always follow current guidelines or
their specific ICUs protocol
How can the APRN increase awareness of evidence and best
incorporate it into standard practice?
APRN Role in Implementing the
Evidence
LEADER
COLLABORATER
EDUCATER
CLINICIAN
ADVOCATE
Practice/Policy Change and Impact
Patient/Family
Community
Nursing/Hospital
Environment
Future Research
Glucose variability effects and control
More over, with the development and implementation of
better tech/glucose variability control, could intensive
glycemic control be viable?
Should diabetics be managed differently?
Certain populations should be examined further (e.g.
neurosurgical/trauma/on corticosteroids)
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References
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