Insulin therapy and glucose control in the medical icu
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Insulin Therapy and Glucose Control in the Medical ICU. Thomas E. Van der Kloot. Seminal Studies. ( + ) Van den Berghe 2001 – surgical ( - ) VISEP 2005 ( - ) GLUCONTROL 2007 ( +/- ) Van den Berghe 2006 – medical (?) NICE SUGAR – ongoing – near completion of enrollment.

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Insulin Therapy and Glucose Control in the Medical ICU

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Insulin therapy and glucose control in the medical icu

Insulin Therapy and Glucose Control in the Medical ICU

Thomas E. Van der Kloot


Seminal studies

Seminal Studies

  • (+) Van den Berghe 2001 – surgical

  • (-) VISEP 2005

  • (-) GLUCONTROL 2007

  • (+/-) Van den Berghe 2006 – medical

  • (?) NICE SUGAR – ongoing – near completion of enrollment


Insulin therapy and glucose control in the medical icu

Intensive Insulin Therapy in the Medical ICU

Greet Van den Berghe, M.D., Ph.D., Alexander Wilmer, M.D., Ph.D., Greet Hermans, M.D., Wouter Meersseman, M.D., Pieter J. Wouters, M.Sc., Ilse Milants, R.N., Eric Van Wijngaerden, M.D., Ph.D., Herman Bobbaers, M.D., Ph.D. and Roger Bouillon, M.D., Ph.D.

N Engl J Med

Volume 354;5:449-461

February 2, 2006


Insulin therapy and glucose control in the medical icu

Effect of Intensive Insulin Therapy on Morbidity

Van den Berghe, G. et al. N Engl J Med 2006;354:449-461


Insulin therapy and glucose control in the medical icu

Kaplan-Meier Curves for In-Hospital Survival

Van den Berghe, G. et al. N Engl J Med 2006;354:449-461


Conclusions

Conclusions

  • Intensive insulin therapy significantly reduced morbidity but not mortality among all patients in the medical ICU

  • Although the risk of subsequent death and disease was reduced in patients treated for three or more days, these patients could not be identified before therapy

  • Further studies are needed to confirm these preliminary data


Van den berghe studies

SICU - 2001

MICU - 2006

Control Glucose

153 mg%

153 mg%

Intervention Glucose

103 mg%

111 mg%

APACHE II

9

23

Control Mortality

8%

40%

Intervention Mortality

4.6%

37.3%

Control Mortality>5 Days

20.2%

54.9%

Intervention Mortality>5 Days

10.6%

45.9%

Van den Berghe Studies


Mmc initiatives glucose control

MMC Initiatives – Glucose Control

  • 2006 - 2007

    • “Yale Protocol”

  • 2008

    • MMC-wide protocols

    • Infusions:

      • Tight (CTICU): 80 - 110

      • Standard (CCM): 90 - 129

      • Conservative (CVA/Head trauma): 120 – 179

    • ICU > Transition > Floor > Discharge

  • 2009

    • ? MHVN/State-wide standardization??


Keys to success

Local example (CTICU/R1)

Nursing leadership

Tools to support the process

Orders

Protocol

Data collection

Feedback - Data

Keys to Success


Order sets scm

Order Sets (SCM)


Titration algorithm

Titration Algorithm


Mmc scu 4 1 8 07 9 30 08

MMC SCU 4: 1/8/07 – 9/30/08


Hypoglycemia

Hypoglycemia

  • Independent risk factor for ICU mortality?

    • Van der Berghe NEJM 2006

    • Krinsley CCM 2007

  • Brief episodes may be well-tolerated & safe, at least in the short-term

    • Vriesendorp CCM 2006

  • Inconsistent definition(s)

  • Unclear significance of mild vs. profound hypoglycemia


  • Hypoglycemia rates in published iv insulin protocols

    Hypoglycemia Rates in Published IV Insulin Protocols


    Hypoglycemia glucose 50 q3 2007 q2 2008

    HYPOGLYCEMIA (glucose <50)(Q3 2007 – Q2 2008)

    • 7656 ICU patient days (with at least one glucose value)

    • 50310 glucose values (6.57 values/patient day)

    • Rate per glucose value = 0.0029 (0.29%)

    • Rate per patient day = 0.0191 (1.9%)


    D 50 use pre vs post yale iip

    11/17/06 - 01/08/07

    32 amps used in 1463 patient days

    2.2% rate

    01/08/07 - 2/28/07

    37 amps used in 1470 patient days

    2.5% rate

    D50 USE PRE vs. POST YALE IIP


    Emerging complicating issues

    Emerging & Complicating Issues


    Insulin therapy and glucose control in the medical icu

    CCM 2005 Dec;33(12):2778-85


    Variable effect of glucose control in diabetics vs non diabetics egi et al ccm 2008

    Variable effect of glucose control in diabetics vs. non-diabeticsEgi, et al, CCM 2008


    Variability in glucose levels is associated with mortality in sepsis ali et al ccm 2008

    Variability in glucose levels is associated with mortality in sepsisAli, et al, CCM 2008


    The future

    More & better data – NICE SUGAR

    Continuous glucose monitoring

    Automated feedback loop therapy

    Minimize variability

    THE FUTURE


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