Journal Club 2018.9.4 ICU
Crit Care Med. 2018 Aug;46(8):1224-1229
Introduction
Stress hyperglycemia SH SH >124 mg/dl or >200 mg/dl Lancet 2009;373:1798.
stress hyperglycemia Lancet 2009;373:1798.
SH Critical Care 2013;17:305.
SH etc. etc. Lancet 2009;373:1798.
20032 ICU Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003;78(12):1471. 68 retrospective cohort study P C C I C O 1
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
ICU
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; 314 7093 1512-1515 P I C O DM >200 mg/dl AMI 24 620 130-200 mg/dl ( 3.4 ) 44 33 ARR 11% RR 0.72 (0.55 to 0.92) (<200mg/dL)
normoglycemia Intensive insulin therapy(iit)
2001 Leuven Intensive insulin therapy in critically ill patients. van den B,N Engl J Med. 2001 Nov 8;345(19):1359-67. P I C O ICU 1548 IIT BS 80 110mg/dL ( BS180 200mg/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
2006 Leuven Intensive insulin therapy in critically ill patients. van den B,N Engl J Med. 2001 Nov 8;345(19):1359-67. P I C ICU( >3 ) 1200 IIT BS 80 110mg/dL BS180 200mg/dL (BS 215mg/dL O IIT 105 vs 160 mg/dl 37.3 vs. 40.0 (P 0.33) IIT IIT ICU
Leuven trial IIT 200-300g/ ( TPN) ( )
2008 VISEP Intensive insulin therapy and pentastarch resuscitation in severe sepsis Brunkhorst FM N Engl J Med. 2008 Jan 10;358(2):125-39. 2 2 factorial trial P I C O ICU 537 IIT BS 80 110mg/dL ( BS180 200mg/dL 28 (SOFA) HES vs. Ringer IIT IIT (<40 mg/dl) (17.0% vs 4.0%) 28 90 IIT
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. 2009 Oct;35(10):1738-48. P ICU 1101 I IIT BS 80 110mg/dL C ( BS140 180mg/dL O ICU IIT 8.7 vs. 2.7%) ICU IIT
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 81 108mg/dL C ( BS 180mg/dL O 90 90 IIT (27.5 vs. 24.1%) (P 0.02) (BS 40mg/dL)IIT (6.8 vs. 0.5%) IIT
ICU (BG Target) (BG Target) Primary Outcome (%) ( ) Van den Berghe et al(leuven I) 2001 (n=1548) 80-110mg/dL 180-200mg/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) 80-110mg/dL 180-200mg/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) 80-110mg/dL 180-200mg/dL 28,SOFA 24.7 vs 26(p=NS) 17.0 vs 4.1(p=0.001) 80-110mg/dL 140-180mg/dL ICU 17.2 vs 15.3(p=NS) 8.7 vs 2.7(p=0.0001) 80-108mg/dL <180mg/dL 90 27.5 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 0.87-1.05] Toward Understanding Tight Glycemic Control in the ICU. A Systematic Review and Metaanalysis. Chest 2010;137:544.
AACE/ADA 2009 <180 mg/dl SFAR/SRLF ( ) 2010 <180 mg/dl ACP 2011 140-200mg/dL SCCM 2012 150-180 mg/dl AACE/ACE 2015 140-180 mg/dl SSCG 2016 140 180mg/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 140-180mg/dL
IIT IIT
41-70 mg/dl <40 mg/dl NICE-SUGAR, post hoc analysis HR 1.41 [95% CI 1.21-1.62] HR 2.1 [95% CI 1.59-2.77] OR 1.41 [95% CI 1.21-1.62] N Engl J Med 2012;367:1108-18. 5000 retrospective cohort study Crit Care Med. 2007;35:2262.
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 2018. July 12, in press Intensive Care Med, 2011;37:583. Endocr Pract. 2014;20:41. Crit Care. 2014;18:R86.
Crit Care Med. 2008;36:2316. Crit Care. 2013;17:229.
CGM Continuous Glucose Monitoring
CGM ( ) FGM(Freestyle ) flash glucose monitoring CGM ( 14 ) SAP( 620G/640G) sensor augmented pump CGM 6
Clinical Question CGM +
Crit Care Med. 2018 Aug;46(8):1224-1229
P ICU 77 I C CGM IGM O
BG Blood Glucose CGM IGM TIR 90-150 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
Methods
Study design 4 858 ICU 35
Inclusion 18 APACHEII 10 3 ICU 6 BS 150mg/dL / ICU
Exclusion or (HIT) (=GlucoClear)
GlucoClear (Edwards Lifescience) 20G ICU Diabetes Technol Ther 2014;16:858.
Randomized in a crossover design 28 or 50 ICU ICU CGM (=IGM (=CGM ICU
CGM IGM CGM ICU ICU 72 /ICU / CGM 40 220 mg / dl 70 180 mg / dl IGM
Meynaar 4 BG BG Intensive Care Med 2007;33:591 596. / BG 2009
Table1a. ( ) NG OG NP 0 162 0 0 162 216 1 OP (U/hr) NP (U/hr) OG BG (mmol/l) NG BG (mmol/l) BG mmol/l 18 mg/dl 0 216 270 2 0 270 360 3 0 360 4 54~81 54 0 54~81 81~ NG*OP/OG 81~135 ~81 OP 135~ NG<OG*0.9 2NG-OG 108-162 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 0 162~216-3 0 216~270-6 0 270~360-9 0 360~ - 12 162~ ( NG-OG) OP/6 Table1c NG OG 0 81~135 54~162 6 ~54 30 54~81 2 4 NP 25ml/h MAX(4,OP+1) 25ml/h MAX(8,OP+1) 10 Bolus 25ml/h 8 25ml/h 12 NG 54 20 50ml OG Dr
CGM 2 CGM >40mg/dL or CGM BG CGM 20mg/dL BG 20mg/dL CGM
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
Shapiro-Wilk t U SPSS p<0.05
Results
3261 100 77 23 (11), (9) (2) (1) IGM 38 CGM 39
Baseline Characteristics CGM IGM n
CGM BS BS BS 4-6
Results CV GLI TIR 90 150
Results i. CGM20.5 vs IGM39.5 CGM (p ) ii. iii. TB70) 0.4 0.9% vs. 1.6 3.4 CGM (p 0.05 ) CGM IGM CGM
Discussion
CGM CGM TIR 90-150 IGM TIR
GlucoClear down-time ICU FDA Limitation ICU
Conclusion CGM
GlucoClear GlucoClear Edwards Lifesciences 2015 DEXCOM
<180mg/dL CGM pilot study CGM
Stress hyperglycemia Stress hyperglycemia (SH) (glucose diffusion gradient) ( 140-220 mg/dl ) Crit Care 2010;14:231. Crit Care 2013;17:305. stress hyperglycemia ICU J Crit Care 2012;27:153. Stress hyperglycemia
Stress hyperglycemia hypovolemia >220 mg/dl Crit Care 2013;17:305. Stress Hyperglycemia(SH) = moderate SH ahr 2.99; 95% CI, 2.07-4.31 severe SH ahr 11.43; 95% CI, 7.50-17.42 Am J Med 2012;125:1036.
one size fits all JC Preiser
DM non DM HbA1c >7% ICU diabetes paradox Crit Care Med 2011;39:105. relative hypoglycemia Lancet 2000;356:1970. glucose diffusion gradient 180-260 mg/dl) Paul E Marik. Crit Care Med. 2016;44:1433.
Closed loop systems CGM artificial pancreas 50 2 2016 4
Closed loop Intensive IT 80-110mg/dL vs. intermediate IT 140-180 mg/dl N=447 (<80mg/dL) SSI IIT 4.1 vs 9.8%
IIT 140-180mg/dL CGM Closed loop system