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Insulin Therapy and Glucose Control in the Medical ICU

Insulin Therapy and Glucose Control in the Medical ICU. Thomas E. Van der Kloot. Seminal Studies. ( + ) Van den Berghe 2001 – surgical ( - ) VISEP 2005 ( - ) GLUCONTROL 2007 ( +/- ) Van den Berghe 2006 – medical (?) NICE SUGAR – ongoing – near completion of enrollment.

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Insulin Therapy and Glucose Control in the Medical ICU

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  1. Insulin Therapy and Glucose Control in the Medical ICU Thomas E. Van der Kloot

  2. Seminal Studies • (+) Van den Berghe 2001 – surgical • (-) VISEP 2005 • (-) GLUCONTROL 2007 • (+/-) Van den Berghe 2006 – medical • (?) NICE SUGAR – ongoing – near completion of enrollment

  3. Intensive Insulin Therapy in the Medical ICU Greet Van den Berghe, M.D., Ph.D., Alexander Wilmer, M.D., Ph.D., Greet Hermans, M.D., Wouter Meersseman, M.D., Pieter J. Wouters, M.Sc., Ilse Milants, R.N., Eric Van Wijngaerden, M.D., Ph.D., Herman Bobbaers, M.D., Ph.D. and Roger Bouillon, M.D., Ph.D. N Engl J Med Volume 354;5:449-461 February 2, 2006

  4. Effect of Intensive Insulin Therapy on Morbidity Van den Berghe, G. et al. N Engl J Med 2006;354:449-461

  5. Kaplan-Meier Curves for In-Hospital Survival Van den Berghe, G. et al. N Engl J Med 2006;354:449-461

  6. Conclusions • Intensive insulin therapy significantly reduced morbidity but not mortality among all patients in the medical ICU • Although the risk of subsequent death and disease was reduced in patients treated for three or more days, these patients could not be identified before therapy • Further studies are needed to confirm these preliminary data

  7. SICU - 2001 MICU - 2006 Control Glucose 153 mg% 153 mg% Intervention Glucose 103 mg% 111 mg% APACHE II 9 23 Control Mortality 8% 40% Intervention Mortality 4.6% 37.3% Control Mortality>5 Days 20.2% 54.9% Intervention Mortality>5 Days 10.6% 45.9% Van den Berghe Studies

  8. MMC Initiatives – Glucose Control • 2006 - 2007 • “Yale Protocol” • 2008 • MMC-wide protocols • Infusions: • Tight (CTICU): 80 - 110 • Standard (CCM): 90 - 129 • Conservative (CVA/Head trauma): 120 – 179 • ICU > Transition > Floor > Discharge • 2009 • ? MHVN/State-wide standardization??

  9. Local example (CTICU/R1) Nursing leadership Tools to support the process Orders Protocol Data collection Feedback - Data Keys to Success

  10. Order Sets (SCM)

  11. Titration Algorithm

  12. MMC SCU 4: 1/8/07 – 9/30/08

  13. Hypoglycemia • Independent risk factor for ICU mortality? • Van der Berghe NEJM 2006 • Krinsley CCM 2007 • Brief episodes may be well-tolerated & safe, at least in the short-term • Vriesendorp CCM 2006 • Inconsistent definition(s) • Unclear significance of mild vs. profound hypoglycemia

  14. Hypoglycemia Rates in Published IV Insulin Protocols

  15. HYPOGLYCEMIA (glucose <50)(Q3 2007 – Q2 2008) • 7656 ICU patient days (with at least one glucose value) • 50310 glucose values (6.57 values/patient day) • Rate per glucose value = 0.0029 (0.29%) • Rate per patient day = 0.0191 (1.9%)

  16. 11/17/06 - 01/08/07 32 amps used in 1463 patient days 2.2% rate 01/08/07 - 2/28/07 37 amps used in 1470 patient days 2.5% rate D50 USE PRE vs. POST YALE IIP

  17. Emerging & Complicating Issues

  18. CCM 2005 Dec;33(12):2778-85

  19. Variable effect of glucose control in diabetics vs. non-diabeticsEgi, et al, CCM 2008

  20. Variability in glucose levels is associated with mortality in sepsisAli, et al, CCM 2008

  21. More & better data – NICE SUGAR Continuous glucose monitoring Automated feedback loop therapy Minimize variability THE FUTURE

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