Glycemic control in_the_icu

Glycemic control in_the_icu

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  Glycemic Control inthe ICU Steven Podnos MD
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  Hyperglycemia • Occurs inup to 50% of ICU patients due to underlying DM , steroids, and/or stress of illness • Is a MARKER of worse outcomes in many different ICU illnesses
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  Control of Glucosein ICU • One early study (van den Berghe) found a decreased mortality with intensive control of glucose (IIT), but was limited to Cardiac Surgery patients , often on TPN • Two large recent trials of IIT were stopped due to 1) lack of benefit with IIT and 2) increased hypoglycemia
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  Stress Hormones andHyperglycemia • Glucagon,Glucocorticoids,Norepinephrine • Epinephrine • Tumor Necrosis factor • All these hormones are secreted with stress of illness and produce elevated glucose through various methods
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  Ill Effects ofHyperglycemia • Direct Immune suppression • Excess insulin causes cellular damage • Direct cellular toxicity and release of inflammatory mediators in presence of hyperglycemia
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  Hypoglycemia • Brain requiresadequate glucose levels or coma/death results in minutes
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  Why is ConsensusChanging? • Early studies suggested benefit to Intensive Insulin Therapy (IIT) • Later studies do not-some show harm from hypoglycemia and no mortality benefit • Studies differ in many variables: SICU vs MICU, parenteral vs enteral nutrition, degree of illness (APACHE 2 scores), intensity of control • More studies pending
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  Recommendations • Current consensusseems to be liberalizing glucose control to 140-180. • Evidence weak of benefit • Some suggest it is swings in glucose levels that may be harmful rather than absolute levels. • May be more appropriate to use constant insulin drip to keep levels higher than sliding scale which has more glucose fluctuations (unproven)