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Management of Inpatient Hyperglycemia

and Diabetes in Older Adults

Diabetes Care 2017;40:509–517 | DOI: 10.2337/dc16-0989

 

Adults aged 65 years and older are the fastest growing segment of the U.S. population, and their number is expected to double to 89 million between 2010 and 2050. The prevalence of diabetes in hospitalized adults aged 65–75 years and over 80 years of age has been estimated to be 20% and 40%, respectively. Similar to general populations, the presence of hyperglycemia and diabetes in elderly patients is associated with increased risk of hospital complications, longer length of stay, and increased mortality compared with subjects with normoglycemia. Clinical guidelines recommend target blood glucose between 140 and 180 mg/dL (7.8 and 10 mmol/L) for most patients in the intensive care unit (ICU). A similar blood glucose target is recommended for patients in non- ICU settings; however... Read more

Improving Glycemic Control Safely in Non-Critical Care Patients: A Collaborative Systems Approach in Nine Hospitals
Gregory A. Maynard, MD, MS, MHM; Diana Childers, MD, FHM; Janet Holdych, PharmD, CPHQ; Heather Kendall, RN, MSN, PHN; Tom Hoag, RN, BS; Karen Harrison, RN, MSN, CCRN; The Joint Commission Journal on Quality and Patient Safety 2017; 43:179–188

Hospitalized patients with uncontrolled hyperglycemia are at increased risk for a variety of adverse outcomes, including prolonged hospital stay, infectious complications, and
death. In the United States, one in four adult hospitalized inpatients has a known diagnosis of diabetes, and another 12% have hyperglycemia without a preexisting diagnosis. Hypoglycemia is also an important inpatient problem. Insulin is one of the most common sources of inpatient adverse drug events, and more than half of these events are preventable. Professional societies and standards organizations, on the basis of consensus and local experience, have highlighted
the importance of optimizing inpatient glycemic control and reducing hypoglycemia. Systematic reviews or metaanalyses regarding large-scale efforts to improve inpatient glycemic control and reduce hypoglycemia could not be located in the literature.

 

In late 2011 Dignity Health (San Francisco), the largest hospital provider in California, set out to significantly improve hypoglycemia, uncontrolled hyperglycemia, and glycemic control across a diverse group of 9 hospitals within its 39- hospital system in three states. PDF | Online

From SCCM 2017

Revisiting Tight Glucose Control in the ICU:

Lower mortality risk with lower glucose target

 

More stringent glucose control in critically ill patients led to a lower mortality without a significant increase in severe hypoglycemia,  possibly reopening a discussion that many experts considered over, it was reported here.

 

Patients treated to a glucose target of  80 to 110 mg/dL had a 36% lower 30-day mortality compared with patients treated to a target of 90 to 140 mg/dL.  The lower target was achieved with less than 1% incidence of severe hypoglycemia. More >

Tight Glycemic Control in Critically Ill Children
M.S.D. Agus, D. Wypij, E.L. Hirshberg, V. Srinivasan, E.V. Faustino, P.M. Luckett, J.L. Alexander, L.A. Asaro, M.A.Q. Curley, G.M. Steil, and V.M. Nadkarni, for the HALF-PINT Study Investigators and the PALISI Network*

In multicenter studies, tight glycemic control targeting a normal blood glucose level
has not been shown to improve outcomes in critically ill adults or children after
cardiac surgery. Studies involving critically ill children who have not undergone cardiac
surgery are lacking.

 

In a 35-center trial, we randomly assigned critically ill children with confirmed hyperglycemia (excluding patients who had undergone cardiac surgery) to one of two ranges of glycemic control: 80 to 110 mg per deciliter (4.4 to 6.1 mmol per liter; lower-target group) or 150 to 180 mg per deciliter (8.3 to 10.0 mmol per liter; higher target group). Clinicians were guided by continuous glucose monitoring and explicit methods for insulin adjustment. The primary outcome was the number of intensive care unit (ICU)–free days to day 28. More >

Precision Medicine, Glycemic Control and the Problems of Identifying Friend from Foe
Mark E. Nunnally, MD, FCCM, New York University Langone Medical Center

“Friendly fire” is a military concept that describes risks to troops from their own weaponry during combat operations. In broad terms, knowing the target and hitting the target are key principles in avoiding collateral damages. Medicine will never be combat, but similar principles apply when one cannot identify and treat the things that matter most in disease.

The lessons of tight glycemic control in the intensive care unit are still being learned. The promise of a simple, inexpensive and initially promising therapy have devolved into uncertainties about harm. Enthusiasm for tight protocols in response to large effect sizes in a randomized, controlled trial could not be replicated in larger studies. Explanations for the irreproducibility and the suggestion of harm focused on hypoglycemia and plasma glucose level variability. As enthusiasm waned, interest shifted from maximizing benefits from tight control to minimizing the harms of permissive hyperglycemia. More>

Safety and Efficacy of Personalized Glycemic Control

in Critically Ill Patients: A 2 year Before and After Interventional Trial
James S Krinsley MD, FCCM; Jean-Charles Preiser MD, PhD; Irl B. Hirsch MD

Our understanding of the relationship of glycemia to outcomes of critically ill patients has evolved considerably in the 15 years since publication of the first randomized trial of intensive insulin therapy. Observational and randomized trial data have demonstrated that hyperglycemia, hypoglycemia and increased glucose variability are independently associated with mortality. In addition, an emerging body of literature has highlighted differences in the relationship of glucose metrics to outcomes when comparing patients with and without diabetes and a review of the interventional trials of intensive insulin therapy suggested greater benefit of treatment among patients without diabetes.

Observational data has underscored the importance of preadmission glycemia. Among a cohort
of critically ill diabetic patients, those with A1C levels > 7% had higher probability of... More >

Use of a Computer-Guided Glucose Management System to Improve Glycemic Control and Address National Quality Measures

A 7-Year Retrospective Observational Study at a Tertiary Care Teaching Hospital
Robert J. Tanenberg, MD, FACP; Sandra Hardee, PharmD, CDE; Caitlin Rothermel, MA,
MPH; Almond J Drake, 3rd, MD, FACE


Inpatient hyperglycemia, hypoglycemia, and glucose variability are associated with increased
mortality. The use of electronic Glucose Management Systems (eGMS) to guide intravenous
(IV) insulin infusion have been found to significantly improve blood glucose (BG) control. This
retrospective observational study evaluated the 7-year (1/2009-12/2015) impact of the
EndoTool® eGMS in intensive and intermediate units at Vidant Medical Center, a 900-bed
tertiary teaching hospital. More >

A Liberal Glycemic Target in Critically Ill Patients with Poorly Controlled Diabetes?
Jan Gunst, Greet Van den Berghe, Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium

Due to severe physical stress, critically ill patients commonly develop hyperglycemia. Multiple observational studies have shown a U-shaped association between glycemic levels in the intensive care unit (ICU) and the risk of death, with the lowest risk of death associated with glucose levels that are normal for age. Three landmark randomized controlled trials (RCTs) performed in Leuven and several subsequent single-center studies found that treating pronounced hyperglycemia [>215 mg/dL (11.9 mmol/L)] with insulin to target age-adjusted normoglycemia [80–110 mg/dL (4.4–6.1 mmol/L) for adults, 60–100 mg/dL (3.9–5.6 mmol/L) for children, 50–80 mg/dL (2.8–4.4 mmol/L) for infants] reduced morbidity and mortality for both critically ill adults and children.

Soon after these landmark RCTs, many ICUs worldwide adopted tight glycemic control (TGC) as part of their standard of care. Unfortunately, worldwide implementation of some degree of glycemic control impeded the design of a repeat multicenter RCT. Subsequent multicenter RCTs no longer compared TGC to severe hyperglycemia, but to an intermediate glycemic target, in general <180 mg/dL (10 mmol/L). Compared to an intermediate target, these multicenter trials did not find an outcome benefit from targeting normoglycemia and the NICE-SUGAR study even found harm. Therefore... More >

© 2017.  MDNLLC

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