Finding the Sweet Spot: Identification of Optimal Glucose Levels in Critically Injured Patients

Abstract

Background Conflicting data exist regarding optimal glycemic control in critically ill trauma patients. We therefore compared glucose parameters and outcomes among three different glycemic control regimens in a single trauma ICU, hypothesizing that a moderate regimen would yield optimal avoidance of hyper- and hypoglycemia with equivalent outcomes when compared to a more aggressive approach. Methods We retrospectively reviewed 1422 trauma patients with at least 3-day ICU stay and 5 glucose measurements from May 2001 – January 2010, spanning three non-overlapping, sequential glucose control protocols: ‘relaxed’, ‘aggressive’, and ‘moderate’. For each, we extracted mean blood glucose, hypoglycemic and hyperglycemic event frequency, and glucose variability, and investigated their association with outcomes. Results Mortality was associated with elevated mean glucose (135.6 vs. 126.2 mg/dL), more frequent hypoglycemic (2.67 ± 7 vs. 1.28 ± 5) and hyperglycemic (30.6 ± 28 vs. 16.0 ± 22 per 100 patient-ICU-days) events, and higher glucose variability (37.1 ± 20 vs. 29.4 ± 20; all p < 0.001). Regression identified hyperglycemic episodes (p < 0.05) as an independent predictor of mortality. The ‘moderate’ regimen had rare hyperglycemia, low glucose variability, and intermediate mean blood glucose range and frequency of hypoglycemia. Multiorgan failure and mortality did not differ between groups. Conclusions Hyperglycemic events (glucose > 180 mg/dL) most strongly predicted mortality. Of glucose control protocols analyzed, the ‘moderate’ protocol had fewest hyperglycemic events. As outcomes were otherwise equivalent between ‘moderate’ and ‘aggressive’ protocols, we conclude that hyperglycemia can be safely avoided using a moderate glycemic control protocol without inducing hypoglycemia.

Mortality Rate Associated with Admission Hyperglycemia in Traumatic Femoral Fracture Patients Is Greater Than Non-Diabetic Normoglycemic Patients but Not Diabetic Normoglycemic Patients

“…Such results indicate that the associated co-morbidity of diabetes, even if the blood sugar level in the in DN group remained normal, still accounted for a higher mortality. Some studies had revealed that the implementation of a stricter glucose control regimen in trauma patients did not lower the mortality of the patients with DH [ 37 , 38 ]. The prospective, randomized controlled NICE-SUGAR study was performed to delineate the optimal target range for blood glucose level in critically ill patients and found the mortality was even higher in the critically ill patients than those under conventional glucose control [ 39 ].…”

Subcutaneous versus intravenous insulin therapy for glucose control in non-diabetic trauma patients. A randomized controlled trial

“…Previous studies have also reported difficulties with intravenous insulin‐based regimens in maintaining BGL in the range of 4·4–6·1 m m with 40–80% of blood glucose readings falling outside this range 11 . In fact, emerging data suggest that tight glycaemic control regimens could be associated with increased morbidity and mortality, 7,19,20 and recent guidelines recommend keeping the blood glucose under moderate control (between 7·8 and 11·1 m m , and below 8·3 m m , according to the American College of Physicians practice guidelines, 21 and Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock, 22 respectively). These guidelines are well supported by trials carried out in general ICU patients; however, the optimal glucose target range for blood glucose in trauma patients remains unclear.…”

Implementation of an institution-wide acute stroke algorithm: Improving stroke quality metrics

“…Examples of this include transfusion practices,[203441] glucose management,[792740] gunshot wounds,[128] and stab wounds. [5650] By comparing stroke care to trauma practices, our goal was to reinforce a reproducible system, such that every stroke would be treated in an identical fashion.…”