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Liberal Glucose Control in ICU Patients With Diabetes: A Before-and-After Study.
Crit Care Med. 2018 06; 46(6):935-942.CC

Abstract

OBJECTIVES

To assess the feasibility, biochemical efficacy, and safety of liberal versus conventional glucose control in ICU patients with diabetes.

DESIGN

Prospective, open-label, sequential period study.

SETTING

A 22-bed mixed ICU of a tertiary hospital in Australia.

PATIENTS

We compared 350 consecutive patients with diabetes admitted over 15 months who received liberal glucose control with a preintervention control population of 350 consecutive patients with diabetes who received conventional glucose control.

INTERVENTIONS

Liberal control patients received insulin therapy if glucose was greater than 14 mmol/L (target: 10-14 mmol/L [180-252 mg/dL]). Conventional control patients received insulin therapy if glucose was greater than 10 mmol/L (target: 6-10 mmol/L [108-180 mg/dL]).

MEASUREMENTS AND MAIN RESULTS

We assessed separation in blood glucose, insulin requirements, occurrence of hypoglycemia (blood glucose ≤ 3.9 mmol/L [70 mg/dL]), creatinine and white cell count levels, and clinical outcomes. The median (interquartile range) time-weighted average blood glucose concentration was significantly higher in the liberal control group (11.0 mmol/L [8.7-12.0 mmol/L]; 198 mg/dL [157-216 mg/dL]) than in the conventional control group (9.6 mmol/L [8.5-11.0 mmol/L]; 173 mg/dL [153-198 mg/dL]; p < 0.001). Overall, 132 liberal control patients (37.7%) and 188 conventional control patients (53.7%) received insulin in ICU (p < 0.001). Hypoglycemia occurred in 6.6% and 8.6%, respectively (p = 0.32). Among 314 patients with glycated hemoglobin A1c greater than or equal to 7%, hypoglycemia occurred in 4.1% and 9.6%, respectively (p = 0.053). Trajectories of creatinine and white cell count were similar in the groups. In multivariable analyses, we found no independent association between glucose control and mortality, duration of mechanical ventilation, or ICU-free days to day 30.

CONCLUSIONS

In ICU patients with diabetes, during a period of liberal glucose control, insulin administration, and among patients with hemoglobin A1c greater than or equal to 7%, the prevalence of hypoglycemia was reduced, without negatively affecting serum creatinine, the white cell count response, or other clinical outcomes. (Trial Registration: Australian New Zealand Clinical Trials Registry; ACTRN12615000216516).

Authors+Show Affiliations

Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia. Department of Anesthesia and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, Roma, Italy.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia. Department of Perioperative, Intensive Care and Emergency Medicine, Università degli Studi di Trieste, Ospedale di Cattinara, Strada di Fiume, Trieste, Italy.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia. Department of Perioperative, Intensive Care and Emergency Medicine, Università degli Studi di Trieste, Ospedale di Cattinara, Strada di Fiume, Trieste, Italy.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia. Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia. Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, VIC, Australia.Department of Endocrinology and Diabetology, Austin Hospital, Heidelberg, VIC, Australia. Department of Medicine Austin Health, The University of Melbourne, Melbourne, VIC, Australia.Department of Intensive Care, Royal Melbourne Hospital, Parkville, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia. Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, VIC, Australia.Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia. Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden.

Pub Type(s)

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

Language

eng

PubMed ID

29509570

Citation

Luethi, Nora, et al. "Liberal Glucose Control in ICU Patients With Diabetes: a Before-and-After Study." Critical Care Medicine, vol. 46, no. 6, 2018, pp. 935-942.
Luethi N, Cioccari L, Biesenbach P, et al. Liberal Glucose Control in ICU Patients With Diabetes: A Before-and-After Study. Crit Care Med. 2018;46(6):935-942.
Luethi, N., Cioccari, L., Biesenbach, P., Lucchetta, L., Kagaya, H., Morgan, R., Di Muzio, F., Presello, B., Gaafar, D., Hay, A., Crisman, M., Toohey, R., Russell, H., Glassford, N. J., Eastwood, G. M., Ekinci, E. I., Deane, A. M., Bellomo, R., & Mårtensson, J. (2018). Liberal Glucose Control in ICU Patients With Diabetes: A Before-and-After Study. Critical Care Medicine, 46(6), 935-942. https://doi.org/10.1097/CCM.0000000000003087
Luethi N, et al. Liberal Glucose Control in ICU Patients With Diabetes: a Before-and-After Study. Crit Care Med. 2018;46(6):935-942. PubMed PMID: 29509570.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Liberal Glucose Control in ICU Patients With Diabetes: A Before-and-After Study. AU - Luethi,Nora, AU - Cioccari,Luca, AU - Biesenbach,Peter, AU - Lucchetta,Luca, AU - Kagaya,Hidetoshi, AU - Morgan,Rhys, AU - Di Muzio,Francesca, AU - Presello,Barbara, AU - Gaafar,Duaa, AU - Hay,Alison, AU - Crisman,Marco, AU - Toohey,Roisin, AU - Russell,Hollie, AU - Glassford,Neil J, AU - Eastwood,Glenn M, AU - Ekinci,Elif I, AU - Deane,Adam M, AU - Bellomo,Rinaldo, AU - Mårtensson,Johan, PY - 2018/3/7/pubmed PY - 2019/9/20/medline PY - 2018/3/7/entrez SP - 935 EP - 942 JF - Critical care medicine JO - Crit Care Med VL - 46 IS - 6 N2 - OBJECTIVES: To assess the feasibility, biochemical efficacy, and safety of liberal versus conventional glucose control in ICU patients with diabetes. DESIGN: Prospective, open-label, sequential period study. SETTING: A 22-bed mixed ICU of a tertiary hospital in Australia. PATIENTS: We compared 350 consecutive patients with diabetes admitted over 15 months who received liberal glucose control with a preintervention control population of 350 consecutive patients with diabetes who received conventional glucose control. INTERVENTIONS: Liberal control patients received insulin therapy if glucose was greater than 14 mmol/L (target: 10-14 mmol/L [180-252 mg/dL]). Conventional control patients received insulin therapy if glucose was greater than 10 mmol/L (target: 6-10 mmol/L [108-180 mg/dL]). MEASUREMENTS AND MAIN RESULTS: We assessed separation in blood glucose, insulin requirements, occurrence of hypoglycemia (blood glucose ≤ 3.9 mmol/L [70 mg/dL]), creatinine and white cell count levels, and clinical outcomes. The median (interquartile range) time-weighted average blood glucose concentration was significantly higher in the liberal control group (11.0 mmol/L [8.7-12.0 mmol/L]; 198 mg/dL [157-216 mg/dL]) than in the conventional control group (9.6 mmol/L [8.5-11.0 mmol/L]; 173 mg/dL [153-198 mg/dL]; p < 0.001). Overall, 132 liberal control patients (37.7%) and 188 conventional control patients (53.7%) received insulin in ICU (p < 0.001). Hypoglycemia occurred in 6.6% and 8.6%, respectively (p = 0.32). Among 314 patients with glycated hemoglobin A1c greater than or equal to 7%, hypoglycemia occurred in 4.1% and 9.6%, respectively (p = 0.053). Trajectories of creatinine and white cell count were similar in the groups. In multivariable analyses, we found no independent association between glucose control and mortality, duration of mechanical ventilation, or ICU-free days to day 30. CONCLUSIONS: In ICU patients with diabetes, during a period of liberal glucose control, insulin administration, and among patients with hemoglobin A1c greater than or equal to 7%, the prevalence of hypoglycemia was reduced, without negatively affecting serum creatinine, the white cell count response, or other clinical outcomes. (Trial Registration: Australian New Zealand Clinical Trials Registry; ACTRN12615000216516). SN - 1530-0293 UR - https://www.unboundmedicine.com/medline/citation/29509570/Liberal_Glucose_Control_in_ICU_Patients_With_Diabetes:_A_Before_and_After_Study_ L2 - https://dx.doi.org/10.1097/CCM.0000000000003087 DB - PRIME DP - Unbound Medicine ER -