Liberal Versus Conventional Glucose Targets in Critically Ill Diabetic Patients: An Exploratory Safety Cohort Assessment

Muzio, F.; Presello, Barbara; Glassford, Neil J; Tsuji, I.; Eastwood, Glenn M; Deane, Adam M.; Ekinci, Elif I; Bellomo, Rinaldo; Mårtensson, Johan

doi:10.1097/ccm.0000000000001742

Cited by 41 publications

(23 citation statements)

References 25 publications

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“…According to our local unit protocol for diabetic patients [9, 10], intravenous or subcutaneous insulin was administered at a blood glucose level (BGL) above 14 mmol/l targeting a BGL between 10 and 14 mmol/l. Diabetes diagnosis was confirmed by the medical records or by the next-of-kin.…”

Section: Methodsmentioning

confidence: 99%

The effect of insulin administration on c-peptide in critically ill patients with type 2 diabetes

Crisman

Lucchetta

Luethi

et al. 2017

Ann. Intensive Care

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BackgroundIn critically ill patients with permissive hyperglycemia, it is uncertain whether exogenous insulin administration suppresses or enhances c-peptide secretion (a marker of pancreatic beta-cell response). We aimed to explore this effect in patients with type 2 diabetes.MethodsWe prospectively enrolled a cohort of 45 critically ill patients with type 2 diabetes managed according to a liberal glucose protocol (target blood glucose 10–14 mmol/l). We recorded the administration of insulin and oral hypoglycemic agents and measured plasma c-peptide as surrogate marker of endogenous insulin secretion on the first two consecutive days in ICU.ResultsOverall, 20 (44.4%) patients required insulin to achieve target blood glucose. Insulin-treated patients had higher glycated hemoglobin A1c, more premorbid insulin-requiring type 2 diabetes, and greater blood glucose levels but lower c-peptide levels on admission. Premorbid insulin-requiring diabetes was independently associated with lower admission c-peptide, whereas greater plasma creatinine was independently associated with higher levels. Increases in c-peptide were positively correlated with an increase in blood glucose both in patients who did (r = 0.54, P = 0.01) and did not (r = 0.56, P = 0.004) receive insulin. However, insulin administration was independently associated with a greater increase in c-peptide (P = 0.04). This association was not modified by the use of oral insulin secretagogues.ConclusionsC-peptide, a marker of beta-cell response, responds to and is influenced by glycemia and renal function in critically ill patients with type 2 diabetes. In addition, in our cohort, exogenous insulin administration was associated with a greater increase in c-peptide in response to hyperglycemia. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN12615000216516).Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-017-0274-5) contains supplementary material, which is available to authorized users.

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Section: Methodsmentioning

confidence: 99%

The effect of insulin administration on c-peptide in critically ill patients with type 2 diabetes

Crisman

Lucchetta

Luethi

et al. 2017

Ann. Intensive Care

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“…However, the liberal strategy significantly reduced (p < 0.01) the measured GV according to the coefficient of variability. (59) In another interesting study recently reported by Di Muzio et al, (60) the researchers performed a prospective analysis of 80 critical patients by applying a conventional strategy (glycemic target: 6-10 mmol/L) or a later liberal strategy (10 - 14mmol/L). Patients subjected to the liberal strategy had a lower relative number of episodes of hypoglycemia as determined by a decrease in blood glucose to below 30% of the premorbid average glycemic value estimated from HbA1c at ICU admission.…”

Section: Introductionmentioning

confidence: 99%

“…Patients subjected to the liberal strategy had a lower relative number of episodes of hypoglycemia as determined by a decrease in blood glucose to below 30% of the premorbid average glycemic value estimated from HbA1c at ICU admission. (60) …”

Section: Introductionmentioning

confidence: 99%

Dysglycemia in the critically ill patient: current evidence and future perspectives

Aramendi¹,

Burghi²,

Manzanares³

2017

Revista Brasileira De Terapia Intensiva

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Dysglycemia in critically ill patients (hyperglycemia, hypoglycemia, glycemic variability and time in range) is a biomarker of disease severity and is associated with higher mortality. However, this impact appears to be weakened in patients with previous diabetes mellitus, particularly in those with poor premorbid glycemic control; this phenomenon has been called "diabetes paradox". This phenomenon determines that glycated hemoglobin (HbA1c) values should be considered in choosing glycemic control protocols on admission to an intensive care unit and that patients' target blood glucose ranges should be adjusted according to their HbA1c values. Therefore, HbA1c emerges as a simple tool that allows information that has therapeutic utility and prognostic value to be obtained in the intensive care unit.

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“…Critically ill diabetic patients have a different response to insulin therapy than non-diabetic patients, perhaps due to their relative tolerance to glycemic variability and hyperglycemia (5)(6)(7). The literature has demonstrated that a one-size-fits-all approach to glycemic management is flawed, as surgical patients, cardiac patients, and medical patients have different responses to glucose targets (2,3,8).…”

mentioning

confidence: 99%

“…A study ICU that has short lengths of stay may have a different experience with glucose management than one that has longer lengths of stay. Many patients are managed with subcutaneous insulin and the impact of excluding this group is often lacking from study data collection (7). In short, the methods of patient selection yield an internally valid positive result in a subset of patients, but often are not generalizable to other patient populations.…”

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confidence: 99%

Glucose management in the intensive care unit: are we looking for the right sweet spot?

Beesley

Lanspa

2016

Ann. Transl. Med.

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In a recently published issue of Critical Care Medicine, Kar and colleagues investigated glucose management of critically ill patients with type 2 diabetes. In this commentary, we discuss the challenges of investigating glucose control in the critically ill, why so many internally valid studies in this field lead to conflicting results, and the obstacles preventing investigators from reaching a conclusive answer.

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Liberal Versus Conventional Glucose Targets in Critically Ill Diabetic Patients: An Exploratory Safety Cohort Assessment

Abstract: In a safety cohort of critically ill diabetic patients, a blood glucose concentration target of 10-14 mmol/L resulted in fewer episodes of negative glycemic distance or relative hypoglycemia and reduced insulin administration compared with a target of 6-10 mmol/L.

Cited by 41 publications

References 25 publications

The effect of insulin administration on c-peptide in critically ill patients with type 2 diabetes

The effect of insulin administration on c-peptide in critically ill patients with type 2 diabetes

Dysglycemia in the critically ill patient: current evidence and future perspectives

Glucose management in the intensive care unit: are we looking for the right sweet spot?

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