Rationale for Maintaining Glycemic Control in the Hospital
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Transcript of Rationale for Maintaining Glycemic Control in the Hospital
Rationale for Maintaining Glycemic Control in the Hospital
Glucose targets for hospitalized patients
ICU Non-ICU
ADA ≤110 mg/dL FPG 90-130 mg/dL; midpoint 110 mg/dL
Postprandial: <180 mg/dL
ACE ≤110 mg/dL FPG ≤110 mg/dLPostprandial ≤180 mg/dL
ADA. Diabetes Care. 2007;30:S4-41.ACE. Endocr Pract. 2004;10:77-82.
Glycemic control in the ICU
• Intensive IV insulin – BG target: 80-110 mg/dL
• Conventional treatment– BG target: 180-200 mg/dL
• Achieved morning BG– 103 mg/dL vs 153 mg/dL
Van den Berghe G et al. N Engl J Med. 2001;345:1359-67.
Intensive
Conventional
Days after admission
0 50 100 150 200 2500
80
84
88
92
96
100
In-hospital survival
(%)
N = 1548 surgical patients; 63% cardiac
-34
-46-41
-50
-44
-60
-50
-40
-30
-20
-10
0
Intensive insulin therapy in surgical ICU reduces morbidity and mortality
Reduction(%)
Poly-neuropathy
In-hospitalmortality Sepsis Dialysis
Blood transfusions*
N = 1548 surgical ICU patients
Van den Berghe G et al. N Engl J Med. 2001;345:1359-67. *Median number
P < 0.001
P = 0.01
P = 0.003
P = 0.007
P < 0.001
IV insulin infusion protocols: Comparison of targets and recommendations
Author
Target glucose(mg/dL)
Bolus(U)
Initial infusion rate
(U/hr)
Insulin infused BG >200
mg/dL(U)
Highest hourly dose(U)
Bode 100–150 0 8 41 11
Boord 120–180 0 1 14.3 4.3
Chant 90–144 0 6 42 15
Furnary 100–150 12 6.5 59.5 18.5
Goldberg 100–139 4.5 4.5 26 9
Kanji 80–110 3 3 41 12
Krinsley <140 0 10 40 10
Marks 120–180 0 1 54 18
Van den Berghe 80–110 0 4 40 15
Zimmerman 101–150 10 4 88 21
Wilson M et al. Diabetes Care. 2007;30:1005-11.
Essential elements of an IV insulin protocol
• Correct hyperglycemia safely and effectively
• Adjust insulin infusion rate to attain and maintain BG target range
• Correct insulin infusion rate without under- or overcompensation
• Maintain rate adjustments as insulin sensitivity or nutritional status changes
• Respond to hypoglycemia or rapid BG fall
• Transition to sc insulin when appropriate
Clement SC et al. Diabetes Care. 2004;27:553-591.
Insulin infusion to normalize BG recommended for patients with STEMI + complicated courses
During acute management of STEMI in patients with hyperglycemia, it is reasonable to administer insulin infusion to normalize BG, even in those with an uncomplicated course
After acute phase of STEMI, individualize diabetes treatment; select combinations of agents that achieve optimal glycemic control and are well tolerated
ACC/AHA STEMI guidelines: Strict glucose control
Antman EM et al. J Am Coll Cardiol. 2004;44:671-719.
II IIaIIa IIbIIb IIIIII
B
B
C
Class and level of evidence
Diabetes is an independent risk factor in patients with UA/NSTEMI
Attention should be directed toward tight glucose control
ACC/AHA NSTEMI guidelines: Diabetes
Braunwald E et al. www.acc.org
Medical treatment in the acute phase and decisions on whether to perform stress testing, angiography, and revascularization should be similar in diabetic and nondiabetic patients
II IIaIIa IIbIIb IIIIII
A
C
B
Class and level of evidence