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Liberal Glycemic Control in Critically Ill Patients With Type 2 Diabetes: An Exploratory Study.
Crit Care Med. 2016 09; 44(9):1695-703.CC

Abstract

OBJECTIVES

The optimal blood glucose target in critically ill patients with preexisting diabetes and chronic hyperglycemia is unknown. In such patients, we aimed to determine whether a " liberal" approach to glycemic control would reduce hypoglycemia and glycemic variability and appear safe.

DESIGN

Prospective, open-label, sequential-period exploratory study.

SETTING

Medical-surgical ICU.

PATIENTS

During sequential 6-month periods, we studied 83 patients with preexisting type 2 diabetes and chronic hyperglycemia (glycated hemoglobin, ≥ 7.0% at ICU admission).

INTERVENTION

During the "standard care" period, 52 patients received insulin to treat blood glucose concentrations greater than 10 mmol/L whereas during the "liberal" period, 31 patients received insulin to treat blood glucose concentrations greater than 14 mmol/L.

MEASUREMENTS AND MAIN RESULTS

Time-weighted mean glucose concentrations and the number and duration of moderate (< 4.0 mmol/L) and severe (≤ 2.2 mmol/L) hypoglycemic episodes were recorded, with moderate and severe hypoglycemic episodes grouped together. Glycemic variability was assessed by calculating the coefficient of variability for each patient. Safety was evaluated using clinical outcomes and plasma concentrations of markers of inflammation, glucose-turnover, and oxidative stress. Mean glucose (TWglucoseday 0-7, standard care: 9.3 [1.8] vs liberal: 10.3 [2.1] mmol/L; p = 0.02) and nadir blood glucose (4.4 [1.5] vs 5.5 [1.6] mmol/L; p < 0.01) were increased during the liberal period. There was a signal toward reduced risk of moderate-severe hypoglycemia (relative risk: liberal compared with standard care: 0.47 [95% CI, 0.19-1.13]; p = 0.09). Ten patients (19%) during the standard period and one patient (3%) during the liberal period had recurrent episodes of moderate-severe hypoglycemia. Liberal therapy reduced glycemic variability (coefficient of variability, 33.2% [12.9%] vs 23.8% [7.7%]; p < 0.01). Biomarker data and clinical outcomes were similar.

CONCLUSIONS

In critically ill patients with type 2 diabetes and chronic hyperglycaemia, liberal glycemic control appears to attenuate glycemic variability and may reduce the prevalence of moderate-severe hypoglycemia.

Authors+Show Affiliations

1Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.2Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia.3Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.4School of Medicine, The University of Melbourne, Melbourne, VIC, Australia.5Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.6National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia.7National Health and Medical Research Council Centre of Research Excellence (CRE) in the Translation of Nutritional Science into Good Health, University of Adelaide, Adelaide, SA, Australia.8Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

27315191

Citation

Kar, Palash, et al. "Liberal Glycemic Control in Critically Ill Patients With Type 2 Diabetes: an Exploratory Study." Critical Care Medicine, vol. 44, no. 9, 2016, pp. 1695-703.
Kar P, Plummer MP, Bellomo R, et al. Liberal Glycemic Control in Critically Ill Patients With Type 2 Diabetes: An Exploratory Study. Crit Care Med. 2016;44(9):1695-703.
Kar, P., Plummer, M. P., Bellomo, R., Jenkins, A. J., Januszewski, A. S., Chapman, M. J., Jones, K. L., Horowitz, M., & Deane, A. M. (2016). Liberal Glycemic Control in Critically Ill Patients With Type 2 Diabetes: An Exploratory Study. Critical Care Medicine, 44(9), 1695-703. https://doi.org/10.1097/CCM.0000000000001815
Kar P, et al. Liberal Glycemic Control in Critically Ill Patients With Type 2 Diabetes: an Exploratory Study. Crit Care Med. 2016;44(9):1695-703. PubMed PMID: 27315191.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Liberal Glycemic Control in Critically Ill Patients With Type 2 Diabetes: An Exploratory Study. AU - Kar,Palash, AU - Plummer,Mark P, AU - Bellomo,Rinaldo, AU - Jenkins,Alicia J, AU - Januszewski,Andrzej S, AU - Chapman,Marianne J, AU - Jones,Karen L, AU - Horowitz,Michael, AU - Deane,Adam M, PY - 2016/6/18/entrez PY - 2016/6/18/pubmed PY - 2017/6/1/medline SP - 1695 EP - 703 JF - Critical care medicine JO - Crit Care Med VL - 44 IS - 9 N2 - OBJECTIVES: The optimal blood glucose target in critically ill patients with preexisting diabetes and chronic hyperglycemia is unknown. In such patients, we aimed to determine whether a " liberal" approach to glycemic control would reduce hypoglycemia and glycemic variability and appear safe. DESIGN: Prospective, open-label, sequential-period exploratory study. SETTING: Medical-surgical ICU. PATIENTS: During sequential 6-month periods, we studied 83 patients with preexisting type 2 diabetes and chronic hyperglycemia (glycated hemoglobin, ≥ 7.0% at ICU admission). INTERVENTION: During the "standard care" period, 52 patients received insulin to treat blood glucose concentrations greater than 10 mmol/L whereas during the "liberal" period, 31 patients received insulin to treat blood glucose concentrations greater than 14 mmol/L. MEASUREMENTS AND MAIN RESULTS: Time-weighted mean glucose concentrations and the number and duration of moderate (< 4.0 mmol/L) and severe (≤ 2.2 mmol/L) hypoglycemic episodes were recorded, with moderate and severe hypoglycemic episodes grouped together. Glycemic variability was assessed by calculating the coefficient of variability for each patient. Safety was evaluated using clinical outcomes and plasma concentrations of markers of inflammation, glucose-turnover, and oxidative stress. Mean glucose (TWglucoseday 0-7, standard care: 9.3 [1.8] vs liberal: 10.3 [2.1] mmol/L; p = 0.02) and nadir blood glucose (4.4 [1.5] vs 5.5 [1.6] mmol/L; p < 0.01) were increased during the liberal period. There was a signal toward reduced risk of moderate-severe hypoglycemia (relative risk: liberal compared with standard care: 0.47 [95% CI, 0.19-1.13]; p = 0.09). Ten patients (19%) during the standard period and one patient (3%) during the liberal period had recurrent episodes of moderate-severe hypoglycemia. Liberal therapy reduced glycemic variability (coefficient of variability, 33.2% [12.9%] vs 23.8% [7.7%]; p < 0.01). Biomarker data and clinical outcomes were similar. CONCLUSIONS: In critically ill patients with type 2 diabetes and chronic hyperglycaemia, liberal glycemic control appears to attenuate glycemic variability and may reduce the prevalence of moderate-severe hypoglycemia. SN - 1530-0293 UR - https://www.unboundmedicine.com/medline/citation/27315191/Liberal_Glycemic_Control_in_Critically_Ill_Patients_With_Type_2_Diabetes:_An_Exploratory_Study_ L2 - https://dx.doi.org/10.1097/CCM.0000000000001815 DB - PRIME DP - Unbound Medicine ER -