Rationale for Maintaining Glycemic Control in the Hospital

1
Rationale for Maintaining Glycemic Control in the
Hospital
2
Glucose targets for hospitalized patients
ADA. Diabetes Care. 200730S4-41. ACE. Endocr
Pract. 20041077-82.
3
Glycemic control in the ICU
N 1548 surgical patients 63 cardiac

• Intensive IV insulin
• BG target 80-110 mg/dL
• Conventional treatment
• BG target 180-200 mg/dL
• Achieved morning BG
• 103 mg/dL vs 153 mg/dL

Intensive
Conventional
In-hospital survival()
0
50
100
150
200
250
Days after admission
Van den Berghe G et al. N Engl J Med.
20013451359-67.
4
Intensive insulin therapy in surgical ICU reduces
morbidity and mortality
N 1548 surgical ICU patients
Poly-neuropathy
In-hospitalmortality
Blood transfusions
Sepsis
Dialysis
Reduction ()
P 0.01
P 0.007
P lt 0.001
P 0.003
P lt 0.001
Median number
Van den Berghe G et al. N Engl J Med.
20013451359-67.
5
IV insulin infusion protocols Comparison of
targets and recommendations
Wilson M et al. Diabetes Care. 2007301005-11.
6
Essential elements of an IV insulin protocol

• Correct hyperglycemia safely and effectively
• Adjust insulin infusion rate to attain and
  maintain BG target range
• Correct insulin infusion rate without under- or
  overcompensation
• Maintain rate adjustments as insulin sensitivity
  or nutritional status changes
• Respond to hypoglycemia or rapid BG fall
• Transition to sc insulin when appropriate

Clement SC et al. Diabetes Care. 200427553-591.
7
ACC/AHA STEMI guidelines Strict glucose control
Class and level of evidence
I
IIa
IIb
III
Insulin infusion to normalize BG recommended for
patients with STEMI complicated courses During
acute management of STEMI in patients with
hyperglycemia, it is reasonable to administer
insulin infusion to normalize BG, even in those
with an uncomplicated course After acute phase of
STEMI, individualize diabetes treatment select
combinations of agents that achieve optimal
glycemic control and are well tolerated
B
B
C
Antman EM et al. J Am Coll Cardiol.
200444671-719.
8
ACC/AHA NSTEMI guidelines Diabetes
Class and level of evidence
I
IIa
IIb
III
Diabetes is an independent risk factor in
patients with UA/NSTEMI
A
Medical treatment in the acute phase and
decisions on whether to perform stress testing,
angiography, and revascularization should be
similar in diabetic and nondiabetic patients
C
Attention should be directed toward tight glucose
control
B
Braunwald E et al. www.acc.org