its evidence based presentation in hyperglycemia in critically care

1. Dr. Santosh Kumar Bhaskar
Professor Anaesthesiology
HYPERGLYCEMIA IN CRITICALLY
ILL PATIENTS

2. Definition
"transient hyperglycaemia
during acute illness –
usually restricted to
patients without prior
evidence of diabetes with
reversion to normal after
discharge.“

3. Hyperglycaemia which is
Transient
Reversible
Associated with severe
acute illness
In a patient previously not
diabetic

6. Is hyperglycemia bad?

7.  Hyperglycaemia - whether on admission or
longitudinally - is an negative prognostic in
several patient groups:
 Trauma
 Severe head injury
 Subarachnoid haemorrhage
 Myocardial infarction
 Sepsis
 Stroke

8. Evidence regarding glycaemic
control in the critically ill
 1995: the DIGAMI trial

9. Evidence regarding glycaemic
control in the critically ill
 2001: The Leuven Intensive Insulin Therapy
Trial

11. Post study commentary
 The goalposts for what should be an
acceptable BSl had shifed worldwide;
everybody was obsessively micromanaging
their insulin pumps within a narrow range of
4.4-6.1 mmol/L.
 However, not all was well. European trials of
this protocol did not find the expected benefit,
and in fact had to stop prematurely because
too many patients were having hypoglycaemic
episodes.

12. Evidence regarding glycaemic
control in the critically ill
 2009: NICE-SUGAR

16.  A post hoc analysis of the NICE-SUGAR data
was published in 2012, digging deeper and
unearthing the prevalence of hypoglycaemia.
Patients who had episodes of hypoglycaemia
were twice as likely to die, and patients with
"intensive" BSL control were ten times as
likely to have a hypoglycaemic episode
compared to "relaxed" controls. The authors
conclude that hypoglycaemia and death had a
dose-response relationship, and that this
relationship was strongest for patients with
"distributive shock".

17. Evidence regarding glycaemic
control in the critically ill
 2014: Most recent opinions

19. Evidence regarding glycaemic
control in the critically ill
 Feasibility of closed loop system

20. In summary...
 A recent review by Mesotten et al (2015) makes
recommendation which is "not based on
findings from randomised controlled trials,
but merely represents a very common,
pragmatic approach by physicians at the
bedside".
 Keep their BSL between 4 and 8 if you can.
 Definitely keep it under 10
 Definitely keep it above 2.2

21. Thank
s