Case Study. Case Study. Glycemic Control-2001 How Low Can You Go? Evidence for Glycemic Control- So What? Now What?

Transcription

1 Age-Adjusted Prevalence of Diagnosed Diabetes per 100 Adult Population, by State, United States, 1994 Evidence for Glycemic Control- So What? Now What? 1994 Cindy Sayre, MN, ARNP University of Washington Medical Center County-level Estimates of Diagnosed Diabetes for Adults aged 20 years: United States 2007 Diabetes Prevalence, 2007 Case Study Mr. Rogers is a 54 year old patient admitted S/P CABG to your telemetry unit. He has had diabetes for 13 years. His home medications include metformin and glyburide. His Hgb A1C is 11.4%. What are his glucose goals while in the hospital? Case Study Mr. Roger s glucose goal should be mg/dl <250 mg/dl mg/dl mg/dl Glycemic Control-2001 How Low Can You Go? Van den Berghe-Single Site Tight Glycemic Control

2 Evidence-Van den Berghe (1) Study Group was S/P Open Heart Surgery (Surgical ICU) Blood glucose maintained between = reduced mortality from 11 to 7 %. Entire population compared to patients with blood glucose between % vs 14 % at day 3 26% vs 17% at day 5 Only 13% of the patients had a diagnosis of diabetes 98% of the patients required insulin infusion to Achieve glucose goal!! Glycemic Control-2010 Hypoglycemia is Not NICE* Multiple Sites Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation Intensive versus Conventional Glucose Control in Critically Ill Patients Engl J Med Mar 26;360(13): Epub 2009 Mar 24. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345: NICE-SUGAR Trial design: Patients admitted to the ICU were randomized to intensive glucose control ( mg/dl; n = 3,054) vs. conventional glucose control (<180 mg/dl; n = 3,050). Insulin was given intravenously and nutrition was given enterally. All-cause mortality at 90 days: % (p = 0.02) (p < 0.001) % for intensive group vs. 24.9% for conventional group (p = 0.02) All-cause mortality at 90 days Intensive glucose control Average 115 mg/dl Severe hypoglycemia Conventional glucose control Average 144 mg/dl NICE-SUGAR Investigators. N Engl J Med 2009;360: Severe hypoglycemia: 6.8% vs. 0.5% (p < 0.001), respectively Nice Sugar Conclusions Among patients admitted to the ICU, intensive glucose control increased mortality an absolute 2.6% at 90 days Severe hypoglycemia was more common in the intensive control group Comparison Leuven and NICE SUGAR 2748 pts 1 center 1100 kcal/d mg/dl Arterial sampling Guideline Education 70% reached target 6x inc hypoglycemia Reduced morbidity 3% AR mortality reduction 6100 pts 41 centers 880 kcal/day mg/dl Arterial/venous/cap Strict Algorithm <50% reached target 13x inc hypoglycemia Neutral morbidity 3% AR mortality increase Van den Berghe J Clin Endocrinol Metab 2009;94:3163 Slide courtesy of Abe DeSantis, MD

3 ADA/AACE Response (this study) should NOT lead to an abandonment of the concept of good glucose management in the hospital setting. ADA/AACE Response Uncontrolled high blood glucose can lead to serious problems for hospitalized patients, such as dehydration and increased propensity to infection. March, 2009 Hyperglycemia in the Hospital Stress can cause hyperglycemia in nondiabetic patients and can exacerbate preexisting diabetes Increased insulin resistance Stress-induced release of Glucocorticosteroids Growth Hormone Bed rest Impaired insulin secretion Catecholamine release Diabetes Care in the Hospital ADA Goals- Critically ill -Insulin initiated for persistent hyperglycemia >180 mg/dl. Once therapy is started goal is mg/dl Diabetes Care in the Hospital Non-critically ill -No clear evidence for specific goals. Premeal-<140 mg/dl, Random <180 mg/dl More Stringent goals for stable patients with previous tight glycemic control Less Stringent for patients with severe co-morbidities Diabetes Care in the Hospital Glucose monitoring for any patient not known to be a diabetic who receives therapy associated with high risk for hyperglycemia steroids, TPN, Tube feed If the non-diabetic patient is hyperglycemic, treatment should be started

4 Case Study Mr. Roger s glucose goal should be mg/dl <250 mg/dl mg/dl mg/dl Glycemic Variability Glycemic Variability Ms. Hopkins is a 44 year old patient with a history of end stage liver disease. Her glucose levels today have been: mg/dl mg/dl mg/dl mg/dl What Risk Might This Pose? Determined by Standard Deviation of Mean Glucose Level divided into Quartile. Glycemic Variability Definition-Standard deviation of the mean glucose level Strong Independent Predictor for Mortality In Critically Ill Patients Measures to Reduce Glycemic Variability Optimal execution of glycemic management protocols Use infusion algorithm appropriately Give SQ insulin in Basal/Bolus fashion Just Say NO to traditional Sliding Scales Krinsley, J.A.: Critical Care Med 2008; 36 (11)

5 Subcutaneous Insulin Maintaining Physiologic Insulin Delivery in the Hospital What s New In 2010? Standardized Hgb A1C Can now be used for Diagnosis->6.5% BE THE PANCREAS! Slide courtesy of Abe DeSantis, MD Hemoglobin A1C, 2009 Hemoglobin A1C Correlation between HbA1C level and mean plasma glucose level 6% 126 mg/dl 7% 154 mg/dl 8% 9% 10% 11% 12% 183 mg/dl 212 mg/dl 240 mg/dl 269 mg/dl 298 mg/dl from Clinical Practice Recommendation. Diabetes Care 33:Supple 1, 2010 New High Dose Algorithm High Dose Insulin Infusion For Use When Traditional Insulin Infusion ineffective X 3 hours-need a Provider Order

6 Where Do We Go Wrong Safety First Error Categories Wrong Drug Wrong Dose Extra Dose Dose Omission Wrong Time Check glucose levels as indicated Hourly for Infusions QAC & HS for Subcutaneous Q6 for Patients who are NPO Think Critically about Insulin Every Time Match Insulin to Calories Where Do We Go Wrong Part 2 Questions? Error Origin Administration-34% Transcription/Order Processing-27% Prescribing-22% Monitoring-13% casayre@u.washington.edu