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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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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
slide3
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

slide4
Effect of Intensive Insulin Therapy on Morbidity

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

slide5
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
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 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
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
the future
More & better data – NICE SUGAR

Continuous glucose monitoring

Automated feedback loop therapy

Minimize variability

THE FUTURE
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