Hyperglycemia-Am I A Control Freak? COPYRIGHT © 2013, ALL RIGHTS RESERVED From the Publishers of.

Hyperglycemia-Am I A Control Freak?

COPYRIGHT © 2013, ALL RIGHTS RESERVED

From the Publishers of

Copyright © 2013

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Dear Consult Gurus;

I need your sage advice regarding our newest

associate who is being considered for contract

renewal in our partnership track.

He joined us in 2010 after completion of his

residency and now does most of the care of our

hospitalized patients. While he seems to be

excellent I have a major gripe with his

mismanagement of our seriously ill patients in the

ICU.

My complaint relates to his management of our

ICU patients who develop hyperglycemia.

Dear Consult Gurus;

I need your sage advice regarding our newest

associate who is being considered for contract

renewal in our partnership track.

He joined us in 2010 after completion of his

residency and now does most of the care of our

hospitalized patients. While he seems to be

excellent I have a major gripe with his

mismanagement of our seriously ill patients in the

ICU.

My complaint relates to his management of our

ICU patients who develop hyperglycemia.

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Based on my training (I began practice 10 years

ago) I’ve made sure that our critically ill ICU

patients have their glucose tightly controlled with

a target glucose 80-110 mg/dl and I’ve used

intensive insulin therapy to achieve that. Our

newest associate though is much less strict and he

seems to accept a serum glucose as high as 180 or

even 200 mg/dL. I don’t know if its laziness or a

knowledge deficit but I think he is wrong.

We are deciding on his contract in a few days.

Should we show him a contract or show him the

door?A.B.Corncob Medical

Assoc.

Based on my training (I began practice 10 years

ago) I’ve made sure that our critically ill ICU

patients have their glucose tightly controlled with

a target glucose 80-110 mg/dl and I’ve used

intensive insulin therapy to achieve that. Our

newest associate though is much less strict and he

seems to accept a serum glucose as high as 180 or

even 200 mg/dL. I don’t know if its laziness or a

knowledge deficit but I think he is wrong.

We are deciding on his contract in a few days.

Should we show him a contract or show him the

door?A.B.Corncob Medical

Assoc.

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Hyperglycemia is associated with perioperative complications

Is there evidence to support intensive insulin treatment in critically ill patients?

What is the ideal serum glucose for a critically ill patient

A.B. completed training 2001New associate completed training 2010

Issues

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Van den Berghe, G. et al.: N Engl J Med 2001;345:1359-67

Intensive insulin therapy to maintain blood glucose at or below 110 mg/dL reduces morbidity and mortality among critically ill patients in the surgical intensive care unit.

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Van den Berghe G et al.: N Engl J Med 2006;354:449-61

No mortality difference between intensive insulin therapy with strict control ( glucose 80-110mg/dL) vs. conventional Rx (glucose < 180 mg/dL)

Less mortality / morbidity in those treated in ICU for 3 or more days These patients could not be identified prior to therapy

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NICE - SUGAR

Worldwide, multicenter (6104 pts, 42 hospitals)Expected to be in ICU > 3 daysIntensive glucose control: 81-108 mg/LConventional glucose control: < 180mg/dLIv insulin given if glu > 180Mean glucose intensive control: 108Mean glucose conventional control: 144

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NICE - SUGAR

Intensive glucose control increased 90 day mortalityIntensive control mortality 27.5%Conventional control mortality 24.9%

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ACP Guideline: 2011

DO NOT USE intensive insulin therapy to strictly control glucose in non-SICU / MICU hospitalized patients

DO NOT USE intensive insulin therapy to normalize serum glucose in SICU / MICU patients

Target blood glucose in SICU / MICU patients 140-200mg/dL

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Critically ill I.V. insulin for persistent hyperglycemia (180 mg/dl) Once insulin begun target glucose 140-180 mg/dl

Not Critically ill Persistent blood glucose < 140 mg/dl if can be done

safely

Diabetes: Hospitalized patient

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