FRCA Notes

Glycaemic Control in Critical Care

Resources

  • Hyperglycaemia in the critically ill patient is associated with:
    • Pro-inflammatory effects
    • Increased susceptibility to infection e.g. wound infections
    • Increased mortality - hyperglycaemia is a negative prognostic factor in a variety of patient cohorts (trauma, TBI, SAH, MI, sepsis, stroke)

  • Historical practices, of either allowing hyperglycaemia or tight glucose control, have not been robustly proven to improve patient outcomes
  • As such, many patients nowadays are given a glucose target of <10mmol/L, or 6-10mmol/L

Leuven I & Leuven II (2001 & 2006)

  • Leuven I was a single centre trial of surgical ITU patients comparing tight vs. conventional glucose control
  • Tight control was associated with:
    • Reduced mortality by 34%
    • Reduced sepsis
    • Reduced critical illness polyneuropathy
    • Reduced acute renal failure
  • Leuven II, however, did not replicate these results in medical ITU patients

VISEP (2008)

  • Intensive insulin therapy in patients with severe sepsis
  • Did not affect organ failure or mortality
  • Increased rates of severe hypoglycaemia and serious adverse events

NICE SUGAR (2009)

  • Patients were randomised to either tight (4.5 - 6mmol/L) or conventional (<10mmol/L) glucose control
  • Tight control was associated with:
    • Increased mortality (2.6%)
    • Significant increase in hypoglycaemia (10x), which was itself associated with mortality especially in cases of distributive shock

CONTROLING (2021)

  • Patients were given either indvidualised or standard (<10mmol/L )glucose targeting, and the impact on 90-day mortality was assessed
  • Targeting a patient’s usual glycaemic level did not show a survival benefit compared to conventional control (<10mmol/L)

International recommendations for glucose control in the adult non-diabetic critically ill (2010)

  • Aim <10mmol/L (7.8 - 10mmol/L acceptable)
  • Avoid severe hypoglycaemia of <2.2mmol/L
  • Arterial glucose sampling (rather than capillary or venous blood)
  • Laboratory or blood gas analysis (rather than point-of-care analysers)

Surviving Sepsis (2012)

  • Protocolised approach to glucose management when two consecutive blood glucose levels >10mmol/L
  • Should target an upper level of blood glucose <10mmol/L (rather than tighter control of <6.1mmol/L)
  • Caution using point-of-care capillary blood glucose results, as they may not accurately reflect arterial blood/plasma glucose levels