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Diabetes Management
Glucose Control in the Critically Ill Patient
Utilizing Computerized Intravenous Insulin Dosing
Samuel E Crockett, MD
Associate Professor of Medicine, Department of Medical Education, University of Central Florida College of Medicine
Abstract
Hyperglycemia and hypoglycemia in the critically ill patient are associated with increased morbidity and mortality. Numerous studies have
investigated the benefits of glucose control in the critically ill patient receiving intravenous insulin. Tight glucose control (blood glucose
80–110mg/dl) in this patient population has been difficult to achieve. When accomplished, it has been accompanied by an increased risk of
hypoglycemia and in some studies increased mortality. Computer-guided glucose management systems (CGGMS) offer an alternative to
paper protocols for the attainment of improved glucose control in critically ill patients requiring intravenous insulin. CGGMS provide a way
to achieve improved glucose control with reduced hypoglycemia while reducing insulin infusion calculation errors and standardizing insulin
therapy, thus improving patient safety.
Keywords
Hyperglycemia, hypoglycemia, tight glucose control, computer-guided glucose management system, intravenous insulin
Disclosure: The author has no conflicts of interest to declare. As a consultant, he works with a healthcare system that uses a computerized glucose management system.
Received: September 17, 2009 Accepted: November 30, 2009
Correspondence: Samuel E Crockett, MD, PO Box 740060, Orange City, FL 32774. E: drummer63@cfl.rr.com
Inpatient hospital hyperglycemia is associated with increased morbidity randomized to different target goals, the optimum target glucose range
and mortality.
1,2
This is particularly true in the critically ill patient is likely to always be dependent on the method of control.
admitted to the intensive care unit (ICU).
3–9
Critically ill patients who
require ICU care for more than five days have as high as a 20% risk of Background
death and significant morbidity.
10
Hyperglycemia associated with insulin Numerous studies have investigated the benefits of glycemic control in
resistance is commonly encountered in the critically ill patient and critically ill patients.
3–9,18,19
A retrospective study in a mixed medical–
is seen not only in those patients with pre-existing diabetes but also surgical ICU investigated a heterogeneous patient population with a
in those patients with undiagnosed diabetes and those with stress treatment blood glucose goal of <140mg/dl. A significant improvement
hyperglycemia.
11
Retrospective and post hoc analysis of large in mortality and morbidity was demonstrated compared with those
randomized controlled studies of intensive insulin therapy in the ICU patients with blood glucose >140mg/dl.
18
Hyperglycemia and hypo-
suggests that patients with newly discovered hyperglycemia are at a glycemia affect the prognosis of hospitalized patients with diabetes and
greater mortality risk than patients with euglycemia or those with a cardiac disease, and cardiovascular surgical patients.
8,19,20
Hyperglycemia
previous diagnosis of diabetes.
1,12
Adverse outcomes have been on admission in the patient with acute coronary syndrome or
reported in various critically ill populations.
3–5,8,9
In several patient myocardial infarction (MI) has been associated with increased
populations, improved morbidity and mortality has been reported at mortality,
19
whereas reduction of glycemia is associated with improved
blood glucose ranges defined as ‘tight’ (glucose 80–110mg/dl) or those outcomes.
21
Optimal clinical outcomes were shown to be associated
below 140mg/dl.
3,4
Areas of controversy and discussion are ongoing with mean glucose values between 100 and 140mg/dl for those patients
related to the appropriate blood glucose goals in critically ill patients, with acute coronary syndrome,
19
who displayed higher mortality
as well as how and when to measure blood glucose and what the most associated with glucose levels lower than 100mg/dl or with mean blood
appropriate glucose and study metrics should be.
13–16
The one glucose levels increasing above 140mg/dl, albeit increasing at a less
consistent finding with the highest statistical significance in all steep rate per mg/dl. Cardiovascular surgical patients with diabetes and
outcome studies is the increase in the incidence of hypoglycemia hyperglycemia have decreased wound infections and morbidity with
associated with glucose control.
3–6,17
The contribution of ‘hypoglycemic improved glucose control.
8
events’ to outcomes associated with glycemic control protocols
remains a topic of interest and major concern.
16
Until studies are Three major prospective, randomized, controlled trials (RCT) of over
completed with the same, near-zero hypoglycemia incidence 1,000 critically ill ICU patients have been reported in the medical
© TOUCH BRIEFINGS 2009 45
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