Your SlideShare is downloading. ×
Hyperglyceminin Icu Md2008
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Introducing the official SlideShare app

Stunning, full-screen experience for iPhone and Android

Text the download link to your phone

Standard text messaging rates apply

Hyperglyceminin Icu Md2008

1,485
views

Published on

Published in: Health & Medicine

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
1,485
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
96
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Hyperglycemia and the Critically Ill Patient Tony Gerlach, PharmD, BCPS The Ohio State University Medical Center
  • 2. Objectives
    • Review the consequences of hyperglycemia in ICU patients
    • Summarize the pathophysiology of hyperglycemia in ICU patients
    • Review the effects of intensive insulin therapy on outcomes
  • 3. Effects of Insulin
    • Decrease glucose
    • Anabolic effects
      • Increase protein, glycogen synthesis
      • Inhibits lipolysis
    • Decreases Hypertriglyceridemia, TNF, prostaglandins, Plasminogen activator inhibitor, & free radicals
  • 4. Glucose control in Healthy People with out Diabetes Insulin Release Glucagon Decrease Glucose Intake
  • 5. Causes of Hyperglycemia: Glucose Intake
    • Excess Calories
      • Enteral/Parenteral Nutrition
      • Drugs diluents (e.g., D5W)
      • Propofol
      • Peritoneal dialysis with high dextrose formulas
  • 6. Causes of Hyperglycemia: Stress Response
    • Shock and SIRS
      • Increased stress hormones
        • Endogenous catecholamines
        • ACTH
        • Glucagon
        • Cortisol
        • Growth Hormone
        • Pro-inflammatory Cytokines
  • 7. Causes of Hyperglycemia: Medications And Disease
    • Corticosteroids
    • Catecholamines
      • Epi, NE, Dopamine, Dobutamine
    • Sympathomimetics
    • Immunosupressants
      • Cyclosporin
      • Tacrolimus
    • Diabetes
    • Pancreatitis
  • 8. Epidemiology of Hypoglycemia in the ICU
    • Variable
      • Patient types
      • Different definitions
      • Under diagnosis of DM
    • In one study in a SICU 74.5 % were hyperglycemic when only 13 % had a DM
    • One study in MICU 50 % where hyperglycemic when those w/ DM excluded
      • Mean glucose 194 +/- 66 mg/dL
  • 9. Long-term Glycemic Control and Postoperative Infection Complications % Arch Surg 2006;141:375-80. ** Statistically Significant
  • 10. Hyperglycemia and Mortality Mayo Clin Proc. 2003;78:1471-8 . %
  • 11. Hyperglycemia, Infectious Complication and Mortality in Trauma Patients J Trauma 2004;56:1058-62. %
  • 12. Effects of Hyperglycemia
    • Intravascular fluid balance
      • Dehydration
      • Glucosuria
    • Immune Function
      • Abnormal WBC function
        • Granulocyte adhesion, chemotaxis, phagocytosis, intracellular killing
      • Impaired complement activity
  • 13. Sternal Wound Infections in Diabetics undergoing Cardiac Surgery Ann Thorac Surg 1999;67:352-62 % ** Statistically Significant
  • 14. Intensive Insulin Therapy and Outcomes in SICU Patients N Engl J Med 2001;345:1359-67. % ** Statistically Significant
  • 15. Intensive Insulin Therapy and Outcomes in Mixed ICU Patients Mayo Clin Proc 2004;79:992-1000 * Statistically Significant
  • 16. Intensive Insulin Therapy and Outcomes in MICU Patients N Engl J Med 2006;354:449-61 % * Statistically Significant
  • 17. Blood Glucose and Insulin Requirements during ICU Stay Crit Care Med 2003;31:359-66 mg/dL Units/h per cal/kg
  • 18. Early versus Late Intensive Insulin Therapy in ICU Patients ** Statistically Significant Inten Care Med 2008;34:881-7
  • 19. Hyperglycemia and mortality in VA ICU patients
    • Analysis of over 216,000 admission
    • Mortality increased by 40 % in those with mild hyperglycemia (111-145 mg/dl)
    • In 154,000 without DM mortality did not increase until glucose > 146 mg/dL
    • Greatest risk for patients admitted for cardiovascular disorders (MI, USA, Stroke)
    • Diagnosis with no relationship include: COPD, hepatic failure, GI neoplasm, and orthopedic disorders
    ADA 2006 Scientific Sessions Medscape July 23, 2006
  • 20. GluControl Study
    • Mean Age 65 yrs
    • 40 % MICU pts
    • Mean Glucose
      • 118 low range
      • 144 high range
    • No difference in length of stay
    SCCM 2007 Scientific Sessions Medscape February 2007
  • 21. What is the Optimal Glucose Range?
    • Waiting for results of NICE-SUGAR
    • Goal is to recruit 6100 pts
    • Comparing low range
      • 80-110 mg/dl
      • 140-180 mg/dl
  • 22. Optimal Glucose Target
    • Target ranges differ between study
    • Appears upper threshold to be 145-150 mg/dL
    • Normal glucose (< 110 to 120 mg/dL) is associated with better outcomes during post hoc analysis (Crit Care Med 2003;31;359-66)
  • 23. OSUMC Insulin Infusion Protocol
    • Consider initiating if 3 consecutive blood glucose values > 200 mg/dL
    • Insulin Solution : IV regular insulin 100 units per 100 mL 0.9% NaCL
    • Serum Glucose Goal Range: 110 - 150 mg/dL
    • Assessment: Serum or capillary glucose q1 hour
    • Patient must receive dextrose CONTINUOUSLY during insulin infusion (e.g. D5W at 10 mL/hour, TPN, or enteral nutrition)
  • 24. OSUMC Insulin Infusion Protocol
    • Initiate insulin infusion at 2 units/hour
    • Monitor ABG q1 hour and adjust the insulin infusion rate as directed in the following table.
    • Frequency of glucose checks can be reduced to q2 hours if patient is medically stable and insulin infusion rate has not changed for 3 hours.
    • Resume q1 hour glucose checks if there is a major change in clinical condition or if the glucose concentration is out of the goal range.
    • Rate of decline in glucose concentration should be less than 100 mg/dL/hour
  • 25. OSUMC Experience ** Statistically Significant %
  • 26. Source of Dextrose
    • Remember to give patient a source of carbohydrates (dextrose) to prevent hypoglycemia
    • Acceptable sources are:
      • Tube Feeds
      • TPN
      • Dextrose 5% at 10-40 ml/hr for most patients
    • Considered decreasing insulin infusion if stop tube feeds, TPN< or Dextrose in MIV and increase monitoring
  • 27. OSUMC Nursing Hypoglyecmia Policy
    • Repeat Glucose < 55 or > 400 mg/dL
    • Glucose < 40 mg/dL is considered critical value
    • Symptoms
      • Autonomic: Tremble, shaking, diaphoresis, tachycardia,
      • Neuro: Dizziness, change in consciousness, Fatigue, blurred vision, slow thinking
  • 28. Final Thoughts
    • Small amount of continuous IV dextrose (D5W at 10-40 ml/hr) decreases hypoglycemia
    • Decrease insulin or start D5 when stopping Tube feeds
    • Need to transition to scheduled insulin if insulin > 2 units/hr
    • When patient travels verify glucose
    • When in doubt stop drip and get glucose