Michael VerbiestNurse Team Leader Intensive CareAntwerp University Hospital Belgium

Insulin therapy andglycemic control in the ICU

Antwerp University Hospital

• 7 university hospitals in Belgium

• 600 beds, + 2500 employees

• Intensive Care Unit: 45 beds (adults & children)

• Surgery (transplantation)/internal

• +/- 3000 admissions/year

Stress hyperglycemia

• Prevalence: 50%-80% of the critically ill patients

• ↑Hepatic glucose output and ↓insulin sensitivity

• Contributing factors:

• Inflammatory mediators

• Excessive release of counter – regulatory hormons

• Medication

• (par)enteral nutrition

• Dialysis

Intensive vs conventional

• Hypothese: SH as a (in)direct predictor of ↑morbidity and ↑ mortality

• IGFBP-1

Intensive Insulin therapy vs. moderate insulin therapy

• Intervention group: Intensive Insulin therapy

• Target: (4.4mmol/l – 7.8 mmol/l) = (80mg/dl – 110mg/dl)

• Control group: conventional insulin therapy

• start at 12,2mmol/l = 215mg/dl Target: 10mmol/l- 11,1mmol/l = 180mg/dl – 200mg/dl

50% reduction of mortality (los >5 d)

Reduction of severe infection and organ failure

What about other subgroups?

Safety? Reproducibility? Universality?

• Conflicting results in other trials - Methodological shortcomings:

• No standardized glucose measuring methode

• Insufficient time for tight control

• Lack of training and technical support

• High prevalence of severe hypoglycemia (< 2,2mmol/l = < 40mg/dl)

Discussion:

• Optimal bloodsugar range? Intensive vs moderate

• Optimal Time in Range?

• Patientoutcome after hypoglycemia?

Severe hypoglycemia (<40 mg/dl)

Three domains in glycemic control

1. Hyperglycemia: the focus of the interventional trials

2. Hypoglycemia: the “unifying complication”

3. Glycemic variability: a hidden factor impacting the

interventional trials

Cumulative impact of disturbances in different

domains

• Hypoglycemia has the strongest association with

mortality.

• Increasing glycemic targets into the hyperglycemic

range may increase mortality.

• GV is associated with additional harm and is an

additional therapeutic target.

Risk groups OR (95% CI)

Hypo 2.5 (2.0-3.1)

Hypo + Hyper 4.8 (3.4-6.8)

Hypo + Hyper + GV 6.8 (3.9-9.2)

Glycemic control at ICU

• Physycian led - nurse driven vs. Computer assisted

• Computer assisted protocols:

+ Decrease in glucose variability

- No diffirence in hypoglycemic episodes

- ↑ frequency bloodsamples and adjustments

- TIR nurse vs. Computer (60,01% vs. 68%)

CAIP

Glycemic control in ICU

• Modified Yale Protocol : target: 4,4mmol/l – 7,8mmol/l = 80mg/dl – 140 mg/dl

• 1x/h until in range

• 2x/h

• 6x/24u

• Frequency ↑

• Corticoids

• Somatostatine

• Start (par)enteral nutrition

Modified Yale Protocol

Avoid glycemic variability

• Continu IV drip infusion

• Always the same insuline concentration: 50E/50cc NaCl 0.9%

• Visibility of trends in patient record

• Electronic warning system

• Continu glycemic monitoring

Glycemic trends

Early start (par)enteral feeding

• Nutritional needs of the patient

• BEE Harris Benedict, Penn state 2014

• Nutritional risk screening: stress factor (severe infection,

burns, …)

• Exact weight (bedbalance)

• Exact amount of calories and proteins:

• Indirect calorimetry (O²-CO² consumption in the ventilated

blood) (golden standard)

• Selection of the right nutritional therapy

• Enteral/parenteral

• Multidisciplinairy meeting with dietist

Indirect calorimetry

Bed balance

187 – 188 kg

Nutritional Risk Screening

Energy: Total caloric requirement

Enteral feeding in the critically ill patients

• Start < 24u. if hemodynamic and gastro intestinal tract

stable

• Stepwise, based on residual level and nutrition needs

• Prokinetics

• Head of the bed : 30°

• Always use a volumetric pump

• Start parenteral feeding when calorietargets are not in

range.

Conclusion

• Research possibilities

• Multicenter trial: intensive vs moderate insulin therapy

• Computer assisted protocols

• Continuous glycemic measurement

• Long term: Predisposing factors for the development of diabetes mellitus after Intensive Care admission. (based

on Hba1c, SAPS3 and Frindisk scale) :

follow up in an early stage

Insulin therapy and glycemic control in critically illpatients is teamwork.

Sources

• Egi M, Bellomo R, Stachowski E et al. Hypoglycemia and outcome in critically ill

patients. 2010 Mar;85(3):217-24

• Finfer S, Chittock D, Yushuo S. et al. Intensive versus Conventional Glucose

Control in Critically Ill Patients. N Engl J Med 2009;360:1283-97.

• Mesotten D. Continuous glucose sensors for glycaemic control in the ICU: have

we arrived? Critical Care 2013. 17:1004

• Van Ackerbroeck S, Schepens T, De Block C. Incidence and predisposing factors

for the development of disturbed glucose metabolism and DIabetes mellitus

AFter Intensive Care admission: the DIAFIC study. Critical Care 2015;19:355

• Van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in

critically ill patients. N Engl J Med, Vol. 345, No. 19

• Van den Berghe G, Wilmer A, Hermans G et al. Intensive Insulin Therapy in the

Medical ICU. N Engl J Med 2006;354:449-61.