Glycemic Control in Critical Illness.ppt

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Glycemic Control in Critical Illness.ppt

  1. 1. Glycemic Control in Critical Illness A Review of the Evidence Seminar Preview Peter Purrington, MD March 14, 2007 USAFP Annual Meeting
  2. 2. Bottom Line Up Front • Critically ill patients without Diabetes can be hyperglycemic. • Intensive glycemic control reduces morbidity and mortality in critically ill patients. • A target serum glucose below 140 mg/dl is recommended to achieve reductions in morbidity and mortality in critically ill patients.
  3. 3. 2001 Hypothesis, retrospective studies, early RCT 2003 20062004 Further RCT, observational studies Consensus opinion Review Meta-Analysis Evolution of a Concept
  4. 4. Where it all Began • 2001 – Beth Israel Deaconess, Boston • Subjective data describing stress hyperglycemia and similar complications as with DM. • Hypothesis that insulin use to improve glycemic control reduces these complications. • Call for Randomized Controlled Trials. Critical Care Medicine 2001 Jan;17(1):107-24
  5. 5. Where it all Began • 2001 – Catholic University of Leuven, Belgium • Randomized Controlled Trial in the Surgical Intensive Care setting. • Demonstrated intensive insulin therapy to maintain blood glucose at or below 110mg/dl reduces morbidity and mortality among critically ill patients. N Engl J Med 2001 Nov 8;345(19):1359-67
  6. 6. And then… • 2003 – Royal Brompton Hospital, London. • Prospective, Observational study in a med/surg ICU. • Increased insulin administration associated with increased ICU mortality. • Control of glucose levels rather than absolute levels of exogenous insulin account for mortality benefit. JAMA 2003 Oct 15;290(15):2041-7
  7. 7. And then… • 2003 – Catholic University of Leuve, Belgium • Randomized controlled trial. • Supports metabolic control, not insulin dose, related to beneficial effects of intensive insulin therapy. Crit Care Med 2003 Feb;31(2):359-66
  8. 8. And then… • 2004 – Stamford Hospital, Connecticut • Case-control study using an ICU protocol for intensive glucose management. • Protocol (maintain GLU <140 mg/dl) decreased mortality, organ dysfunction, and length of stay. Mayo Clin Proc 2004 Aug;79(8):992-1000
  9. 9. And… • 2004 – Surviving Sepsis Campaign • Concensus opinion. • Recommend maintenance of blood glucose <150 mg/dl after initial stabilization. Crit Care Med 2004 Mar;32(3):858-73
  10. 10. But wait, there’s more… • 2006 – Catholic University Leuven, Belgium • Review article. • Strict glycemic control reduces morbidity and mortality through several mechanisms. Crit Care Clin 2006 Jan;22(1):119-29
  11. 11. A Look to the Future… • NICE-SUGAR Study – The George Institute • Multi-center, randomized, controlled trial. • Compare glucose range of 81-108 mg/dl to that of less than 180 mg/dl. • Hypothesis: no difference in relative risk of death between patients in control group vs. study group. • Patients currently being enrolled. ClincalTrials.gov; www.thegeorgeinstitute.org
  12. 12. Summary • Critically ill patients without Diabetes can be hyperglycemic. • Intensive glycemic control reduces morbidity and mortality in critically ill patients. • A target serum glucose below 140 mg/dl is recommended to achieve reductions in morbidity and mortality in critically ill patients. • Further Studies are ongoing.

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