Journal Club ICU
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1 Journal Club ICU
2 Crit Care Med Aug;46(8):
3 Introduction
4 Stress hyperglycemia SH SH >124 mg/dl or >200 mg/dl Lancet 2009;373:1798.
5 stress hyperglycemia Lancet 2009;373:1798.
6 SH Critical Care 2013;17:305.
7 SH etc. etc. Lancet 2009;373:1798.
8 20032 ICU Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003;78(12): retrospective cohort study P C C I C O 1
9 2005 g Admission hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma. 2005;59(1):80. P I B ICU 1003 (DM ) / C O d L ) )g g 0 Sd L 2 ) B g 2.2 ) g d m
10 ICU
11 1997 DIGAMI study Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group. BMJ 1997; P I C O DM >200 mg/dl AMI mg/dl ( 3.4 ) ARR 11% RR 0.72 (0.55 to 0.92) (<200mg/dL)
12 normoglycemia Intensive insulin therapy(iit)
13 2001 Leuven Intensive insulin therapy in critically ill patients. van den B,N Engl J Med Nov 8;345(19): P I C O ICU 1548 IIT BS mg/dL ( BS mg/dL (BS 215mg/dL ICU IIT 103 vs. 153 mg/dl ICU IIT 4.6 vs. 8.5 % ( P 0.04) IIT 5.1 vs. 0.8% IIT ICU
14 2006 Leuven Intensive insulin therapy in critically ill patients. van den B,N Engl J Med Nov 8;345(19): P I C ICU( >3 ) 1200 IIT BS mg/dL BS mg/dL (BS 215mg/dL O IIT 105 vs 160 mg/dl 37.3 vs (P 0.33) IIT IIT ICU
15 Leuven trial IIT g/ ( TPN) ( )
16 2008 VISEP Intensive insulin therapy and pentastarch resuscitation in severe sepsis Brunkhorst FM N Engl J Med Jan 10;358(2): factorial trial P I C O ICU 537 IIT BS mg/dL ( BS mg/dL 28 (SOFA) HES vs. Ringer IIT IIT (<40 mg/dl) (17.0% vs 4.0%) IIT
17 2009 Glucontrol A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units Preiser JC, Intensive Care Med Oct;35(10): P ICU 1101 I IIT BS mg/dL C ( BS mg/dL O ICU IIT 8.7 vs. 2.7%) ICU IIT
18 2009 NICE-SUGAR Intensive versus conventional glucose control in critically ill patients. NICE-SUGAR Study Investigators, N Engl J Med. 2009;360(13):1283. P I ICU 6022 IIT BS mg/dL C ( BS 180mg/dL O IIT (27.5 vs. 24.1%) (P 0.02) (BS 40mg/dL)IIT (6.8 vs. 0.5%) IIT
19 ICU (BG Target) (BG Target) Primary Outcome (%) ( ) Van den Berghe et al(leuven I) 2001 (n=1548) mg/dL mg/dL ICU 4.6 vs 8.0(p=0.04) 5 vs 0.7(p ) Van den Berghe et al(leuven II) 2006 (n=1200) mg/dL mg/dL ICU 24.2 vs 26.8(p=NS) 18.7 vs 3.1(p=0.001) Brunkhorst et al(visep) 2008 Preiser et al(glucontrol) 2009 Finfer et al(nice-sugar) 2009 (n=488) (n=1078) (n=6104) mg/dL mg/dL 28,SOFA 24.7 vs 26(p=NS) 17.0 vs 4.1(p=0.001) mg/dL mg/dL ICU 17.2 vs 15.3(p=NS) 8.7 vs 2.7(p=0.0001) mg/dL <180mg/dL vs 24.9(p=0.02) 6.8 vs 0.5(p=0.001) NS= IIT or
![IIT OR 7.7 [95% CI 6.6-9.9] IIT OR 0.95 [95% CI 0.87-1.](/docs-images/87/95109126/images/20-0.jpg "05] Toward Understanding Tight Glycemic Control in the ICU.")
20 IIT OR 7.7 [95% CI ] IIT OR 0.95 [95% CI ] Toward Understanding Tight Glycemic Control in the ICU. A Systematic Review and Metaanalysis. Chest 2010;137:544.
21 AACE/ADA 2009 <180 mg/dl SFAR/SRLF ( ) 2010 <180 mg/dl ACP mg/dL SCCM mg/dl AACE/ACE mg/dl SSCG mg/dL SFAR French Society of Anesthesia and Resuscitation SRLF(=FICS) French Intensive care society AACE:American Asoosciation of Clinical Endocrinologist ACE American Collage of Endocrinology mg/dL
22 IIT IIT
23 41-70 mg/dl <40 mg/dl NICE-SUGAR, post hoc analysis HR 1.41 [95% CI ] HR 2.1 [95% CI ] OR 1.41 [95% CI ] N Engl J Med 2012;367: retrospective cohort study Crit Care Med. 2007;35:2262.
24 Glycemic variability J Diabetes Sci Technol. 2010;4:1382. Crit Care Resusc. 2014;16:13. standard deviation Anesthesiology. 2006;105:244. coefficient of variation (SD/average) >20% Nutrition July 12, in press Intensive Care Med, 2011;37:583. Endocr Pract. 2014;20:41. Crit Care. 2014;18:R86.
25 Crit Care Med. 2008;36:2316. Crit Care. 2013;17:229.
26 CGM Continuous Glucose Monitoring
27 CGM ( ) FGM(Freestyle ) flash glucose monitoring CGM ( 14 ) SAP( 620G/640G) sensor augmented pump CGM 6
28 Clinical Question CGM +
29 Crit Care Med Aug;46(8):
30 P ICU 77 I C CGM IGM O
31 BG Blood Glucose CGM IGM TIR TB70 Continuous glucose monitoring Intermittent Glucose monitoring Time in range (90-150mg/dL) The time spent with BG less than 70mh/dL BG 70mg/dL CV Coefficient of variation GLI Glycemic lability index
32 Methods
33 Study design ICU 35
34 Inclusion 18 APACHEII 10 3 ICU 6 BS 150mg/dL / ICU
35 Exclusion or (HIT) (=GlucoClear)
36 GlucoClear (Edwards Lifescience) 20G ICU Diabetes Technol Ther 2014;16:858.
37 Randomized in a crossover design 28 or 50 ICU ICU CGM (=IGM (=CGM ICU
38 CGM IGM CGM ICU ICU 72 /ICU / CGM mg / dl mg / dl IGM
39
40 Meynaar 4 BG BG Intensive Care Med 2007;33: / BG 2009
41 Table1a. ( ) NG OG NP OP (U/hr) NP (U/hr) OG BG (mmol/l) NG BG (mmol/l) BG mmol/l 18 mg/dl ~ ~81 81~ NG*OP/OG 81~135 ~81 OP 135~ NG<OG*0.9 2NG-OG OP 135~180 NG OG*0.9 MAX(OP*1.2 OP+0.4) 180~270 NG OG*0.9 MAX(OP*1.2 OP+1) 270~360 NG OG*0.9 MAX(OP*1.5 OP+1.5) 360~ NG OG*0.9 MAX(OP*2 OP+2) Table1b ( ) NG OG Bolus 0 162~ ~ ~ ~ ~ ( NG-OG) OP/6 Table1c NG OG 0 81~135 54~162 6 ~ ~ NP 25ml/h MAX(4,OP+1) 25ml/h MAX(8,OP+1) 10 Bolus 25ml/h 8 25ml/h 12 NG ml OG Dr
42 CGM 2 CGM >40mg/dL or CGM BG CGM 20mg/dL BG 20mg/dL CGM
43 Outcome Measures CV Coefficient of variation ) GLI Glycemic lability index TIR90-150(%) Time in range (90-150mg/dL) ( ( BG mg/dl) ( ( TB70(%) The time spent with BG less than 70mh/dL BG 70mg/dL 1)CV / 2)GLI Σ[{ glucose (mmol/l)} 2 hr -1 ] wk -1 3) BG 70mg/dL ( 12 Down time 32
44 Shapiro-Wilk t U SPSS p<0.05
45 Results
46 (11), (9) (2) (1) IGM 38 CGM 39
47 Baseline Characteristics CGM IGM n
48 CGM BS BS BS 4-6
49 Results CV GLI TIR
50 Results i. CGM20.5 vs IGM39.5 CGM (p ) ii. iii. TB70) % vs CGM (p 0.05 ) CGM IGM CGM
51 Discussion
52 CGM CGM TIR IGM TIR
53 GlucoClear down-time ICU FDA Limitation ICU
54 Conclusion CGM
55 GlucoClear GlucoClear Edwards Lifesciences 2015 DEXCOM
56 <180mg/dL CGM pilot study CGM
57
58 Stress hyperglycemia Stress hyperglycemia (SH) (glucose diffusion gradient) ( mg/dl ) Crit Care 2010;14:231. Crit Care 2013;17:305. stress hyperglycemia ICU J Crit Care 2012;27:153. Stress hyperglycemia
59 Stress hyperglycemia hypovolemia >220 mg/dl Crit Care 2013;17:305. Stress Hyperglycemia(SH) = moderate SH ahr 2.99; 95% CI, severe SH ahr 11.43; 95% CI, Am J Med 2012;125:1036.
60 one size fits all JC Preiser
61 DM non DM HbA1c >7% ICU diabetes paradox Crit Care Med 2011;39:105. relative hypoglycemia Lancet 2000;356:1970. glucose diffusion gradient mg/dl) Paul E Marik. Crit Care Med. 2016;44:1433.
62 Closed loop systems CGM artificial pancreas
63 Closed loop Intensive IT mg/dL vs. intermediate IT mg/dl N=447 (<80mg/dL) SSI IIT 4.1 vs 9.8%
64 IIT mg/dL CGM Closed loop system
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