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ICN Vic - glucose control in diabetics

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Professor Rinaldo Bellomo is an Intensivist at the Austin Hospital in Melbourne. He is Professor of Medicine at Melbourne University, and Honorary Professor of Medicine at Monash University, Melbourne and The University of Sydney.

He is one of the most eminent researchers in Intensive Care Medicine today and has been named one of the most influential scientific minds of our time.

In this thought-provoking talk Professor Bellomo discusses glycemic control of critically ill diabetic patients in the ICU.

Published in: Health & Medicine
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ICN Vic - glucose control in diabetics

  1. 1. RINALDO BELLOMO INTENSIVE CARE UNIT AUSTIN HOSPITAL, MELBOURNE, AUSTRALIA Defining the correct glucose target in critically ill diabetic patients? (why intensivists are becoming diabetologists)
  2. 2. Glucose control in ICU and post-op  Hyperglycemia in ICU patients is almost universal  Glycaemic control in ICU and post-operatively is an article of faith. The reasons we apply it are:  We are intensivists and we are secretly sworn upon a sacred oath to normalize all physiology  Physiological reasoning (hyperglycemia induces glycosuria. Glycosuria may cause dehydration which may be bad. So we should avoid hyperglycemia)
  3. 3. Why treat hyperglycemia in ICU II  2. Association with specific risk (some diabetics with poor glucose control develop diabetic keotacidosis or hyperomolar non-ketotic diabetic coma. So we should avoid hyperglycemia )  3. Association with general risk (hyperlycemia in ICU is independently associated with mortality and maybe even with infection [which came first hyperglycemia or infection?]. So we should avoid hyperglycemia)
  4. 4. Could we be wrong?
  5. 5. Impossible!
  6. 6. ITT: the new black!
  7. 7. Serious problems  Single centre  Protagonist involved in direct patient care  Outcome to 28 days only  Glycaemic control data only in am bloods  P level low (0.04)  Most of the effect in cardiac surgery patients but with controls carrying a mortality of 5.1%!  High mortality in other controls for a given mean APACHE score
  8. 8. The big trial
  9. 9. IIT increases mortality
  10. 10. The problems with applying belief systems to everyone
  11. 11. As expected
  12. 12. Glycemia in diabetics is different
  13. 13. Hypoglycemia is similar
  14. 14. Despite higher overall glucose levels diabetics develop hypoglycaemia three times as often (which must mostly be iatrogenic)
  15. 15. • High rate of hypoglycemia and 3% excess mortality in intensive control group • Cardiovascular cause of death more common in the intensive control group • Hypo independently associated with increased mortality • Association strongest among patients with distributive shock
  16. 16. hypoglycemia per se may be harmful Chemoreceptors in carotid glomus Cardiac baroreceptor sensitivity Heart rate variability Sympathetic outflow Cardiovascular instability Hypoglycemia
  17. 17. Previous hypoglycaemia increases hypothalamic activation during subsequent hypoglycaemia (which inhibits sympathetic activation – the so-called habituation response to stress)
  18. 18. Hypoglycemia is ”silent” in ICU Which makes it particularly bad 3 4 5 6 7 9 8 10 BloodGlucoseLevel(mmol/L) 3.9 • Activation of hormonal counterregulation – Adrenaline – Noradrenaline – Cortisol – Growth hormone – Glucagon • Neuroglycopenic symptoms – Confusion – Weakness – Drowsiness – etc… No Diabetes invisible
  19. 19. But things may well be even trickier in diabetics! The concept of relative hypoglycemia 3 4 5 6 7 9 8 10 BloodGlucoseLevel(mmol/L) No Diabetes 30% 30% Diabetes • Evidence from ’clamp studies’ • 30% drop from baseline triggers hormonal/neuroglycopenic responses (relative hypoglycemia) • Hypoglycemia counter-regulation can occur within a normal blood glucose range in patients with chronic poor glucose control The adverse effects of hypoglycemia may happen at a normal glucose level in diabetics Do we have reasons to believe this is true?
  20. 20. Questions  How does chronic glycaemic control influence the relationship between acute glycaemia and outcome  What is hypoglycaemia in a diabetic patient?  Is it the same as in a non-diabetic?  Is there a different response?  If so what does it mean?
  21. 21. Conventional range 10-14 mmol/l
  22. 22. Ketones
  23. 23. MIMIC database (Harvard) Mortality and relative hypoglycemia (>30% fall b/w 2 consecutive blood gases)
  24. 24. Frequency of relative hypoglycemia and risk of death
  25. 25. Where to from here?  Evidence that glucose control in ICU matters (NICE- SUGAR trial)  Evidence that hypoglycaemia is bad  Evidence that relative hypoglycaemia exists  Evidence that it may also be bad  Evidence that diabetics (esp. bad ones) are different and at particular risk of relative and absolute hypoglycaemia  Evidence we can assess chronic glycaemic control on admission by HbA1c  Evidence we can decrease relative hypoglycaemia with liberal glycaemic control in diabetics  RCTs applied for and likely to start soon

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