Sepsis - Glycemic Control

Question 1

Intensive Insulin Therapy in SICU Study 2001

Answer 1

SICU patients
Glucose <200
Lower group had 32% reduced ICU and in-hospital mortality

Question 2

Intensive Insulin Therapy in MICU Study 2006

Answer 2

Pts expected to be in ICU >=3days

If actually in ICU >=3d, in-hospital mortality reduced by 18% for glucose <110
No difference in mortality in the aggregate groups

Question 3

NICE-SUGAR

Answer 3

NEJM 2009
6000 MICU & SICU pts, international, expected ICU stay >=3d

Intensive group target Gluc81-108 had higher 90-d mortality than group targeting <180

Question 4

COIITS

Answer 4

JAMA 2010
ICU pts on steroids randomized to 80-100 vs 180-200

No difference in mortality, ICU stay, ventilator free days, or pressor free days

Question 5

Current recommendations for glycemic control in ICU pts

Answer 5

Optimal range is in flux, but recommend 140-180

Question 6

BHIP Results

Answer 6

Mean glucose 144 with <40

Should NOT be used for DKA/HHS

Question 7

Factors to determine when to transition pts from BHIP to SC

Answer 7

1. HD stability
2. Dietary stability
3. Pending surgical or invasive procedures

Question 8

Insulin SC components to switch to from BHIP

Answer 8

1. Basal insulin: NPH or Lantus
2. QAC insulin: Regular if TFs, Aspart if POs
3. ISS (regular or aspart pending TFs vs POs)

Question 9

Dose conversion from BHIP to SC

Answer 9

1. Total daily dose of BHIP = avg insulin gtt for past 6-12 hrs x 24h
2. Corrected TDD = 0.6 * TDD
3. Give 50% of CTDD as basal, 50% as nutritional. If NPO, give all CTDD as basal
4. ISS based on CTDD (80 = high)
5. Stop insulin gtt 1-2h AFTER 1st dose of nutritional insulin or 2h after 1st dose of basal