Safe Glycemic Control Research Articles

Controle glicêmico e terapia insulínica em sepse e doença crítica

OBJETIVO: Revisar a literatura sobre a fisiopatologia de hiperglicemia e controle glicemico em criancas e adultos com sepse e doenca critica. FONTES DE DADOS: Pesquisa nao sistematica da literatura medica atraves da base de dados MEDLINE usando os termos hiperglicemia, controle glicemico, terapia insulinica intensiva, sepse e terapia intensiva. Os artigos foram selecionados de acordo com sua relevância, conforme a opiniao dos autores. SINTESE DOS DADOS: A hiperglicemia e frequente em criancas com doencas criticas e esta associada a desfecho negativo. Em adultos, nao ha um consenso sobre a eficacia e seguranca do controle glicemico. Descrevemos os possiveis mecanismos envolvidos em toxicidade da glicose e os efeitos beneficos do controle glicemico. Estudos iniciais demonstraram que o uso de insulina para atingir controle glicemico reduziu a morbimortalidade em terapia intensiva em adultos; no entanto, estudos recentes nao confirmaram esses achados. E importante destacar que o controle glicemico esta evidentemente associado a aumento da incidencia de hipoglicemia. A eficacia do controle glicemico ainda nao foi estudada em criancas criticamente doentes. CONCLUSAO: O controle glicemico e uma nova opcao terapeutica em terapia intensiva. Evidencias conflitantes em adultos significam que, antes de aplicar esta abordagem em pediatria, e necessario avalia-la em ensaio clinico.

Current Literature: Standardization of IV Insulin Therapy Improves the Efficiency and Safety of Blood Glucose Control in Critically Ill Adults.

Aggressive glycemic control improves mortality and morbidity in critically ill adults; however, implementation of such a strategy can be logistically difficult. This study evaluates the efficiency and safety of a nurse-managed insulin protocol in critically ill adults. Combined retrospective-prospective before-after cohort study. Twenty-one bed medical/surgical intensive care unit (ICU) in a tertiary care hospital. Two cohorts of 50 consecutive ICU patients requiring insulin infusions. Patients in the control cohort received insulin infusions titrated according to target blood glucose ranges and sliding scales at the physician's discretion. Patients in the interventional cohort received an insulin infusion adjusted using a standardized protocol targeting a blood glucose of 4.5 to 6.1 mmol/L (81 to 110 mg/dL). Efficiency was measured by comparing the time to reach, and the time spent within, the target range between cohorts. Safety was assessed by comparing the incidence of severe hypoglycemia, the frequency of rescue dextrose administration, and the cumulative time that the infusion was held for hypoglycemia between cohorts. Patients in the interventional cohort reached their target more rapidly (11.3± 7.9 vs 16.4 ± 12.6 hours; p = .028) and maintained their blood glucose within the target range longer (11.5 ± 3.7 vs 7.1 ± 5.0 hours/day; p < .001) than controls. The standardized protocol yielded a 4-fold reduction in the incidence of severe hypoglycemia (4 vs 16%; p = .046) and reduced the median frequency of dextrose rescue therapy (0 [0 to 0.91] vs 0.17 [0 to 1.2] episodes/patient per day; p = .01) as compared with controls. Standardization of intensive insulin therapy improves the efficiency and safety of glycemic control in critically ill adults.

Standardization of intravenous insulin therapy improves the efficiency and safety of blood glucose control in critically ill adults.

Aggressive glycemic control improves mortality and morbidity in critically ill adults, however implementation of such a strategy can be logistically difficult. This study evaluates the efficiency and safety of a nurse-managed insulin protocol in critically ill adults. Combined retrospective-prospective before-after cohort study. Twenty-one bed, medical/surgical ICU in a tertiary care hospital. Two cohorts of 50 consecutive ICU patients requiring insulin infusions. Patients in the control cohort received insulin infusions titrated according to target blood glucose ranges and sliding scales at the physician's discretion. Patients in the interventional cohort received an insulin infusion adjusted using a standardized protocol targeting a blood glucose of 4.5-6.1 mmol/l (81-110 mg/dl). Efficiency was measured by comparing the time to reach, and the time spent within, the target range between cohorts. Safety was assessed by comparing the incidence of severe hypoglycemia, the frequency of rescue dextrose administration and the cumulative time that the infusion was held for hypoglycemia between cohorts. Patients in the interventional cohort reached their target more rapidly (11.3+/-7.9 vs 16.4+/-12.6 h; p=0.028) and maintained their blood glucose within the target range longer (11.5+/-3.7 vs 7.1+/-5.0 h/day; p<0.001) than controls. The standardized protocol yielded a four-fold reduction in the incidence of severe hypoglycemia (4 vs 16%; p=0.046) and reduced the median frequency of dextrose rescue therapy (0 [0-0.91] vs 0.17 [0-1.2] episodes/patient per day; p=0.01) as compared to controls. Standardization of intensive insulin therapy improves the efficiency and safety of glycemic control in critically ill adults.

New aspects of insulin therapy in type 1 and type 2 diabetes.

Tight control of the blood glucose level decreases the frequency of complications of both type 1 and type 2 diabetes mellitus. Until recently, the available short, intermediate, and long-acting forms of insulin could not readily be used to achieve tight glycemic control without introducing an unacceptably high risk of hypoglycemia or demanding an impracticably rigid lifestyle. With the introduction of faster-acting insulin analogues, lispro and aspart, and a peakless long-acting insulin analogue, glargine, the goal of safe and effective tight glycemic control may now be within reach for many patients. The use of these new insulins allows the clinician and patient an expanded range of options for achieving good control of fasting and postprandial blood glucose levels.