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Glycemic Control in Critical Illness A Review of the Evidence Seminar Preview

This seminar preview discusses the evidence supporting intensive glycemic control in critically ill patients, highlighting the benefits and recommended target serum glucose levels. It also explores the evolution of this concept and ongoing studies in the field.

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Glycemic Control in Critical Illness A Review of the Evidence Seminar Preview

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  1. Glycemic Control in Critical IllnessA Review of the EvidenceSeminar Preview Peter Purrington, MD March 14, 2007 USAFP Annual Meeting

  2. Bottom Line Up Front • Critically ill patients without Diabetes can be hyperglycemic. • Intensive glycemic control reduces morbidity and mortality in critically ill patients. • A target serum glucose below 140 mg/dl is recommended to achieve reductions in morbidity and mortality in critically ill patients.

  3. Evolution of a Concept 2001 2003 2004 2006 Hypothesis, retrospective studies, early RCT Consensus opinion Review Meta-Analysis Further RCT, observational studies

  4. Where it all Began • 2001 • Beth Israel Deaconess, Boston • Subjective data describing stress hyperglycemia and similar complications as with DM. • Hypothesis that insulin use to improve glycemic control reduces these complications. • Call for Randomized Controlled Trials. Critical Care Medicine 2001 Jan;17(1):107-24

  5. Where it all Began 2001 Catholic University of Leuven, Belgium Randomized Controlled Trial in the Surgical Intensive Care setting. Demonstrated intensive insulin therapy to maintain blood glucose at or below 110mg/dl reduces morbidity and mortality among critically ill patients. N Engl J Med 2001 Nov 8;345(19):1359-67

  6. And then… • 2003 • Royal Brompton Hospital, London. • Prospective, Observational study in a med/surg ICU. • Increased insulin administration associated with increased ICU mortality. • Control of glucose levels rather than absolute levels of exogenous insulin account for mortality benefit. JAMA 2003 Oct 15;290(15):2041-7

  7. And then… • 2003 • Catholic University of Leuve, Belgium • Randomized controlled trial. • Supports metabolic control, not insulin dose, related to beneficial effects of intensive insulin therapy. Crit Care Med 2003 Feb;31(2):359-66

  8. And then… • 2004 • Stamford Hospital, Connecticut • Case-control study using an ICU protocol for intensive glucose management. • Protocol (maintain GLU <140 mg/dl) decreased mortality, organ dysfunction, and length of stay. Mayo Clin Proc 2004 Aug;79(8):992-1000

  9. And… • 2004 • Surviving Sepsis Campaign • Concensus opinion. • Recommend maintenance of blood glucose <150 mg/dl after initial stabilization. Crit Care Med 2004 Mar;32(3):858-73

  10. But wait, there’s more… • 2006 • Catholic University Leuven, Belgium • Review article. • Strict glycemic control reduces morbidity and mortality through several mechanisms. Crit Care Clin 2006 Jan;22(1):119-29

  11. A Look to the Future… • NICE-SUGAR Study • The George Institute • Multi-center, randomized, controlled trial. • Compare glucose range of 81-108 mg/dl to that of less than 180 mg/dl. • Hypothesis: no difference in relative risk of death between patients in control group vs. study group. • Patients currently being enrolled. ClincalTrials.gov; www.thegeorgeinstitute.org

  12. Summary • Critically ill patients without Diabetes can be hyperglycemic. • Intensive glycemic control reduces morbidity and mortality in critically ill patients. • A target serum glucose below 140 mg/dl is recommended to achieve reductions in morbidity and mortality in critically ill patients. • Further Studies are ongoing.

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