Hyperglyceminin Icu Md2008


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Hyperglyceminin Icu Md2008

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