Basic HTML Version
96
VOLUME 9 NUMBER 2 • JUNE 2012
HANDS ON
SA JOURNAL OF DIABETES & VASCULAR DISEASE
most important factor to impact on mortality, and hypoglycaemia must be
guarded against at all times.
It is noticeable in the various studies done in the ICUs internationally
that in the units where protocols were not algorithm or computer-driven,
the rate of hypoglycaemic events was very low and insulin use was ra-
tional, based on individual decisions for a specific clinical situation. An
example of an algorithm that can form the basis of decision making in an
individual patient is seen in Table 4.
Conclusion
Glucose control in the in-hospital patient requires dedication, an under-
standing of the targets of treatment, the need for close monitoring, and
rational decision making. The physician must understand the goal of the
intervention, the individual patient and his/her specific requirements, as
well as the post-discharge follow up of the patient.
All glucose levels are important and cannot be ignored. They must be
interpreted in the context of the individual patient and require appropriate
action to be taken. The suggested protocols and algorithms are to be used
with insight and adjusted to the individual unit. Education of the staff is cru-
cial and the limitations of each example must be explained and monitored
until the treating physician is satisfied the staff can implement them safely.
References
American Diabetes Association
1.
Clin Pract Recommendations
2012;
35
(Suppl 1):
44–47.
Capes SE, Hunt D, Malmberg K,
2.
et al
. Stress hyperglycaemia and increased risk of
death after myocardial infarction in patients with and without diabetes: a systematic
overview.
Lancet
2000;
355
: 773–778.
Amrein K, Ellmerer M, Hovorka R,
3.
et al
. Hospital glucose control: safe and reliable
glycaemic control using enhanced model predictive control algorithm in medical ICU
patients.
Diabetes, Tech Therapeut
2010;
12
(5): 405–412.
Brunkhorst FM, Engel C, Bloos F,
4.
et al
. Intensive insulin therapy and Pentastarch
resuscitation in severe sepsis.
N Engl J Med
2008;
10
(358): 125–139.
Distiller L. The infamous sliding scale: the myth persists.
5.
Specialist Forum
2011:
26–30.
Blaha J, Kopecky P, Matias M,
6.
et al
. Comparison of three protocols for tight glycemic
control in cardiac surgery patients.
Diabetes Care
2009;
32
: 757–761.
Lazaar HL, Chipkin SR, Fitzgerald CA,
7.
et al
. Tight control in the diabetic coronary
artery bypass graft patients improves peri-operative outcomes and decreases
recurrent ischemic events.
Circulation
2004;
109
(12): 1497–1502
Ingels C, Debaveye Y, Milants I,
8.
et al
. Strict blood glucose control with insulin during
intensive care after cardiac surgery:impact on 4 year survival, dependency on medical
case and quality of life.
Eur Heart J
2006;
27
: 2716–2729.
Malesker MA, Foral PA, McPhillips AC,
9.
et al
. An efficiency evaluation of protocols for
tight glycemic control in intensive care units.
Am J Crit Care
2007;
16
: 589–598.
Additional reading
Bartnik M, Ryden L, Ferrari R,
•
et al
. The prevalence of abnormal glucose regulation
in patients with coronary artery disease across Europe : The Euro Heart Survey on
diabetes and the heart.
Eur Heart J
2004;
25
: 1880–1890.
Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin
•
infusions reduces the risk of deep sternal wound infection in diabetic patients after
cardiac surgical procedures.
Ann Thoracic Surg
1999;
67
(20): 352–362.
Goyal A, Mahaffey KW, Garg J,
•
et al
. Prognostic significance of the change in glucose
levels in the first 24 hours after acutemyocardial infarction: results from the CARDINAL
study.
Eur Heart J
2006;
27
: 1289–1297.
Griesdale DE, de Souza RJ, Van DamRM,
•
et al
. Intensive insulin therapy and mortality
among critically ill patients: a mota-analysis including NICE-SUGAR study data. Can
Med Assoc J
2009;
180
: 821–827.
Hu D -Y, Pan C-Y, Yu J -M, China Heart Survey Group. The relationship between
•
coronary artery disease and abnormal glucose regulation in China: The China Heart
Survey.
Eur Heart J
2006;
27
: 2573–2579.
Krinsley JS, Grover A. Severe hypoglycaemia in critically ill patients: risk factors and
•
outcomes.
Crit Care Med
2007:
35
; 2262–2267.
Krinsley JS. Effect of intensive glucose management protocol on the mortality of
•
critically ill adult patients.
Mayo Clin Proc
2004:
79
(8): 992–1000.
Kosiborod M, Rathore SS, Inzucchi SE,
•
et al
. Admission glucose and mortality in
elderly patients hospitalized with acute myocardial infarction : implications for patients
with and without recognized diabetes.
Circulation
2005;
111
: 3078–3086.
Malmberg K. Prospective randomized study of intensive insulin treatment on long
•
term survival after acute myocardial infarction in patients with diabetes mellitus.
Br
Med J
1997;
314
: 1512–1515.
Malmberg K, Norhammer A, Wedel H, Ryder l. Glycometabolic state at admission:
•
Important risk marker of mortality in conventionally treated patients with DM and
acute myocardial infarction. DIGAMI study.
Circulation
1999;
99
: 2626–2632.
Malmberg K, Ryden L, Wedel H,
•
et al
. DIGAMI-2 Investigators. Intense metabolic
control by means of insulin in patients with diabetes mellitus and acute myocardial
infarction.
Euro Heart J
2005;
26
: 650–661.
Mellbin LG, Malmberg K, Norhammer A,
•
et al
. Prognostic implications of glucose
lowering treatment in patients with acute myocardial infarction and diabetes:
experiences from an extended follow-up of the DIGAMI-2 study.
Diabetologia
26 Feb
2011, published online.
Nerenberg KA, Goyal A, Xavier D,
•
et al
. Piloting a novel algorithm for glucose control
in the coronary care unit.
Diabetes Care
2012;
35
: 19–24.
NICE –SUGAR Study Investigators. Intensive versus conventional glucose control in
•
critically ill patients.
N Engl J Med
2009:
360
(13); 1283–1297.
Umpierrez GE, Isaacs SD, Yu X,
•
et al
. Hyperglycaemia: an independent marker of
in-hospital mortality in patients with undiagnosed diabetes.
J Clin Endocrinol Metab
2002;
87
(3): 978–982.
Umpierrez GE, Smiley D, Jacobs S,
•
et al
. Randomised study of basal-bolus insulin
therapy in the inpatient management of patients with type 2 diabetes undergoing
general surgery. (RABBIT 2 surgery).
Diabetes Care
2011;
34
: 256–261.
Van den Berghe G, Wouters P, Weekers F,
•
et al
. Intensive insulin therapy in critically ill
patients.
N Engl J Med
2001;
345
(19): 1359–1367.
Van den Berghe G, Wouters PJ, Kesteloot K, Hilleman DE. Analysis of health care
•
resource utilization with intensive insulin therapy in critically ill patients.
Crit Care Med
2006;
34
(3): 612–616.
Wiener RS, Wiener DC, Larson KJ. Benefits and risks of tight glucose control in
•
critically ill adults. A meta-analysis.
J Am Med
Assoc 2008;
300
: 933–944.
Zerr KJ, Furnary AP, Grunkemeier GL,
•
et al
. Glucose control lowers the risk of
wound infection in Diabetics after open heart operations.
Ann Thorac Surg
1997;
63
: 356–361.
Congratulations to Dr Bert Evans and Celeste van Zyl
on winning the March book giveaway of
Fast Food For
Sustained Energy
by Gabi Steenkamp.
If you would like to purchase a copy, visit your local
book store.