SSC 2012 Guidelines

Glucose ControlC. Sprung

• Glucose Control• Bicarbonate Therapy

Copyright 2014 SCCM/ESICM

Glucose Control• We recommend protocolized approach to

blood glucose management, commencing insulin dosing when two consecutive blood glucose levels are >180 mg/dL.

• This protocolized approach should target upper blood glucose <180 mg/dL rather than <110 mg/dL (Grade 1A).

Slide 2Copyright 2014 SCCM/ESICM

NICE-SUGAR Investigators. N Engl J Med. 2009;360:1283–1297van den Berghe et al. N Engl J Med. 2001;345:1359–1367

Dellinger et al. Crit Care Med. 2013;41:580–637Dellinger et al. Intensive Care Med. 2013;39:165-228

Glucose Control

• Large randomized single-center trial (predominantly cardiac surgical ICU) demonstrated reduced ICU mortality with intensive intravenous insulin targeting blood glucose to 80–110 mg/dL.

van den Berghe et al. N Engl J Med. 2001;345:1359–1367

• Second randomized trial of intensive insulin therapy using this protocol enrolled medical ICU patients with anticipated ICU length of stay of >3 days; overall mortality was not reduced.

van den Berghe et al. N Engl J Med. 2006;354:449–461

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Dellinger et al. Crit Care Med. 2013;41:580–637Dellinger et al. Intensive Care Med. 2013;39:165-228

Intensive Insulin Therapy in Critically Ill Patients

van den Berghe et al. N Engl J Med. 2001;345:1359-1367

P = 0.005P = 0.01

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Intensive Insulin Therapy in Critically Ill Patients

van den Berghe et al. N Engl J Med. 2006;354:449-461

P = 0.40P = 0.02

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But…..

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Glucose Control• Subsequent RCTs studied mixed

populations of surgical and medical ICU patients and found that intensive insulin therapy did not significantly decrease mortality, whereas the NICE-SUGAR trial demonstrated an increased mortality.

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Brunkhorst et al (VISEP). N Engl J Med. 2008;358:125–139Preiser et al (Glucontrol). Intensive Care Med. 2009;35:1738-1748

Annane et al (COIITSS). JAMA .2010;303:341–348NICE-SUGAR Investigators. N Engl J Med. 2009;360:1283–1297

Dellinger et al. Crit Care Med. 2013;41:580–637Dellinger et al. Intensive Care Med. 2013;39:165-228

VISEP Intensive Insulin Trial

Brunkhorst et al (VISEP). N Engl J Med. 2008;358:125-139

P=0.36

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Preiser et al (Glucontrol). Intensive Care Med .2009;35:1738-1748

0 10 20 30 40 50 60 70 80 90Time, days

100

90

80

70

60

50

40

30

20

10

0Hos

pita

l sur

viva

l pro

babi

lity

(%)

P = 0.386

Intensive Glucose Control

Control

Intensive vs. Conventional Glucose Control in Critically Ill Patients

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Days

Su

rviv

al

0 30 60 90 120 150 180 210 240 270 300 330 360 390

0.0

0.2

0.4

0.6

0.8

1.0

254 147 132 128 121 119 117 7 4 4 4 3 Conventional

255 151 128 124 119 118 118 6 4 2 2 1 1 1 Intensive

Conventional Glucose controlIntensive Insulin Therapy

A

Intensive Insulin Therapy for Septic Shock - COIITSS Study

Annane et al (COIITSS). JAMA. 2010;303:341-348

P=0.57

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Intensive vs. Conventional Glucose Control in Critically Ill Patients

NICE-SUGAR Investigators. N Engl J Med. 2009;360:1283-1297

P=0.03

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Glucose Control• As there is no evidence that targets between

140 and 180 mg/dL are different from targets of 110 to 140 mg/dL, the recommendations use an upper target blood glucose ≤180 mg/dL without a lower target other than hypoglycemia.

• Treatment should avoid hyperglycemia (>180 mg/dL), hypoglycemia, and wide swings in glucose levels.

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Dellinger et al. Crit Care Med. 2013;41:580–637Dellinger et al. Intensive Care Med. 2013;39:165-228

Tight Glycemic Control in the ICU: Systematic Review and Meta-analysis

Marik and Preiser. Chest. 2010;137:544-551

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02468

101214161820

LEUVEN I

LEUVEN II

VISEP

GLUCONTROL

COIIT

TS

NICE-S

UGAR

% Intensive insulintherapy

% Control5.1%

0.8%

18.7%

3.1%

17%

4.1%

8.7%

2.7%

16.4%

7.8% 6.8%

0.5%

Severe Hypoglycemia ≤40 mg/dL (2.2 mmol/L)

Treatment vs. control P<0.001

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Glucose ControlMortality in clinical trials of intensive insulin therapy by high or moderate control groups

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Dellinger et al. Crit Care Med. 2013;41:580–637Dellinger et al. Intensive Care Med. 2013;39:165-228

Glucose Control• We recommend blood glucose values be

monitored every 1-2 hours until values and insulin infusion rates are stable, then every 4 hours thereafter (Grade 1C).

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Glucose Control• We recommend that glucose levels obtained

with point-of-care testing of capillary blood be interpreted with caution, as such measurements may not accurately estimate arterial blood or plasma glucose values (Ungraded).

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Glucose Control• Capillary point-of-care testing found to be

inaccurate with frequent false glucose elevations over range of glucose levels, but especially in hypoglycemic and hyperglycemic glucose ranges and in hypotensive patients or patients receiving catecholamines..

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Hoedemaekers et al. Crit Care Med. 2008;36:3062–3066Khan et al. Arch Pathol Lab Med. 2006;130:1527–1532

Desachy et al. Mayo Clin Proc. 2008;83:400–405Fekih Hassen et al. Diabetes Res Clin Pract. 2010;87:87–

91Dellinger et al. Crit Care Med. 2013;41:580–637

Dellinger et al. Intensive Care Med. 2013;39:165-228

Bicarbonate Therapy• We recommend against the use of sodium

bicarbonate therapy for the purpose of improving hemodynamics or reducing vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH ≥7.15 (Grade 2B).

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