Glycemic Levels in Critically Ill Patients: Are Normoglycemia and Low Variability Associated with Improved Outcomes?

Signal, Matthew; Compte, Aaron Le; Chase, J. Geoffrey

doi:10.1177/193229681200600506

Cited by 59 publications

(52 citation statements)

References 25 publications

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“…The TIR 80-110 mg/dL in this investigation, conducted by what many would consider the most experienced team of clinicians performing BG control in the world, was higher in the patients who were treated using the computer-guided protocol but, nevertheless, was only 68.6 versus 60.1%. Chase and collaborators evaluated the relationship of TIR 72-126 mg/dL to mortality in a cohort of 784 patients admitted to a single New Zealand mixed medical-surgical ICU, demonstrating that TIR >70% was independently associated with probability of survival [50]. They subsequently performed a post hoc analysis of data from the Glucontrol trial of IIT [4,51], a study that was terminated prematurely by its oversight board because of protocol violations and the inability of the clinicians to achieve the targeted BG range.…”

Section: Time In Targeted B Rangementioning

confidence: 98%

Glycemic control in the critically ill: What have we learned since NICE-SUGAR?

Krinsley

2015

Hospital Practice

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Since publication of the Normoglycemia in Intensive Care Evaluation - Survival Using Glucose Algorithm Regulation trial in 2009, demonstrating increased 90-day mortality in a large cohort of critically ill patients treated with the intensive, rather than moderate blood glucose (BG) target, enthusiasm has dampened for 'tight glucose control' in intensive care units. Nevertheless, a burgeoning literature has clarified limitations of the interventional trials of intensive insulin therapy in the critically ill and explored key clinical aspects of glycemic control in this population. This review provides an overview of the last 6 years of research in this field. Topics include advances in understanding the domains of glycemic control - hyperglycemia, hypoglycemia and glucose variability; the role of diabetic status in modulating the relationship of these domains of control to mortality; the importance of premorbid glucose control in patients with diabetes; the central role that measurement frequency has in determining success in achieving desired BG control and, finally, new data exploring time in targeted BG range, a potentially 'unifying' metric.

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Section: Time In Targeted B Rangementioning

confidence: 98%

Glycemic control in the critically ill: What have we learned since NICE-SUGAR?

Krinsley

2015

Hospital Practice

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“…Glycaemic control protocols need to be both safe and effective for all patients, and be able to account for patient variability, before potential clinical benefits can be assessed (Penning et al, 2015, Chase et al, 2008a, Krinsley and Preiser, 2015, Signal et al, 2012. Indeed, meta-analysis studies have recently shown that studies where glycaemic protocols achieved the targeted range reported reduced mortality, while others showed no beneficial outcome or increased mortality (Mesotten andVan den Berghe, 2009, Griesdale et al, 2009).…”

Section: Discussionmentioning

confidence: 99%

Virtual Trials of the NICE-SUGAR Protocol: The Impact on Performance of Protocol and Protocol Compliance

et al. 2017

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Hypoglycaemia, hyperglycaemia and blood glucose (BG) variability are associated with worsened outcomes in critical care. However, NICE-SUGAR trial showed no clinical benefit from intensive insulin therapy. This study compares the table-based NICE-SUGAR and model-based STAR protocols to assess their relative capability to achieve safe, effective control for all patients. Validated virtual patients (n=443) were used to simulate glycaemic outcomes of the NICE-SUGAR and STAR protocols. Key outcomes evaluate tightness and safety of control for all patients: %BG in 80-144 mg/dL range (PTR); PerPatient Mean BG (PPM_BG); and Incidence of Hypoglycaemia (BG<40 mg/dL). These metrics determine performance overall, for each patient, and safety. Results are assessed for NICE-SUGAR measuring perprotocol (~24/day) and at reported average rate (~3-hourly; ~8/day). STAR measures 1-3-hourly, averaging 12/day. Glycaemic control protocols need to be both safe and effective for all patients before potential clinical benefits can be assessed. NICE-SUGAR clinical results do not match results expected from their protocol, and show reduced safety and performance in comparison to STAR.

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“…Administration of vasopressors, corticosteroids, enteral or parenteral nutrition -as well as the discontinuation of these therapies due to a variety of procedures performed in critical patients -leads to significant daily variability in glycemic levels. 22 Despite the benefits of adequate glycemic control in critically ill patients, 7,[23][24][25] retrospective studies have shown an association between increased glycemic variability and increased mortality. 22,26 There is a thin threshold between protective care and a potentially harmful approach to the patient, significantly elevating the risk of severe hypoglycemia.…”

Section: Discussionmentioning

confidence: 99%

Hyperglycemia in critical patients: Determinants of insulin dose choice

Paliosa

Teixeira

Rosa

et al. 2017

Rev. Assoc. Med. Bras.

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Objective: To identify factors that can determine the choice of intermittent subcutaneous regular insulin dose in critically ill patients with hyperglycemia. Method: Cross-sectional study in a general adult ICU with 26 beds, data collected between September and October 2014. The variables analyzed were: sex, age, previous diagnosis of diabetes mellitus, use of corticosteroids, use of lactulose, sepsis, fasting, enteral nutrition, use of dextrose 5% in water, NPH insulin prescription and blood glucose level. Patients with one or more episodes of hyperglycemia (blood glucose greater than 180 mg/dL) were included as a convenience sample, not consecutively. Those with continuous insulin prescription were excluded from analysis. Results: We included 64 records of hyperglycemia observed in 22 patients who had at least one episode of hyperglycemia. The median administered subcutaneous regular human insulin was 6 IU and among the factors evaluated only blood glucose levels were associated with the choice of insulin dose administered. Conclusion: Clinical characteristics such as diet, medications and diagnosis of diabetes mellitus are clearly ignored in the decision-making regarding insulin dose to be administered for glucose control in critically ill patients with hyperglycemia.

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Glycemic Levels in Critically Ill Patients: Are Normoglycemia and Low Variability Associated with Improved Outcomes?

Cited by 59 publications

References 25 publications

Glycemic control in the critically ill: What have we learned since NICE-SUGAR?

Glycemic control in the critically ill: What have we learned since NICE-SUGAR?

Virtual Trials of the NICE-SUGAR Protocol: The Impact on Performance of Protocol and Protocol Compliance

Hyperglycemia in critical patients: Determinants of insulin dose choice

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