Glycaemic Control Flashcards
Who is at risk of developing hyperglycaemia?
- Known or undiagnosed diabetes mellitus
- Stress hyperglycaemia in acute illness
How common is hyperglycaemia in critically ill patient?
What causes stress hyperglycaemia?
90% of all critically ill patients develop blood glucose > 6mmol/L
- Inflammatory cytokines, counterregulatory hormones (cortisol, adrenaline) increase peripheral insulin resistance and hepatic glucose production
- Iatrogenic - glucocorticoids, parenteral and enteral nutrition
What are the effects of hyperglycaemia on critically ill?
Severe hyperglycaemia > 14 mmol/L is associated with adverse clinical outcomes especially trauma, myocardial infarction, SAH
Should daily OHGAs and non-insulin injectables be continued in critically ill?
What is the most effective way to treat hyperglycaemia in critically ill?
Usually no.
- High incidence of hepatic and renal impairment - unsuitable
- High risk of prolonged severe hypoglycaemia
- Not easily titrated to target
- Undesirable side effects in critically ill - nausea, emesis, slow gastric emptying
Management of hyperglycaemia in ICU
1. Basal bolus insulin + sliding scale or
2. IV insulin infusion
- To start if blood glucose > 10 mmol/L
- Short IV half life (6 minutes)
What is the appropriate glycaemic target for critically ill?
What are the evidence
Most association advocate for liberal glycaemic control between 8-10 mmol/L
For tight control (4-6 mmol/L):
1. Van den Berghe (2001) - 34% reduction in mortality with tight glycaemic control
(Subsequent studies failed to replicate)
–> Meta-analysis: did not show significant difference in mortality between tight vs control
Against tight control:
1. NICE-SUGAR:
- 90-day mortality significantly higher in tight glycaemic group
- Cardiovascular mortality and severe hypoglycaemic events significantly more
What is hypoglycaemia
Blood glucose < 4 mmol/L
AMS occurs when < 2.8 mmol/L
Severe hypoglycaemia < 2.2 mmol/L
