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Title: Liberal Glycemic Control in Critically Ill Patients With Type 2 Diabetes: An Exploratory Study.
Austin Authors: Kar, Palash;Plummer, Mark P;Bellomo, Rinaldo ;Jenkins, Alicia J;Januszewski, Andrzej S;Chapman, Marianne J;Jones, Karen L;Horowitz, Michael;Deane, Adam M
Affiliation: Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
National Health and Medical Research Council Centre of Research Excellence (CRE) in the Translation of Nutritional Science into Good Health, University of Adelaide, Adelaide, SA, Australia
Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
School of Medicine, The University of Melbourne, Melbourne, VIC, Australia
Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
Issue Date: Sep-2016
Publication information: Critical Care Medicine 2016; 44(9): 1695-703
Abstract: The optimal blood glucose target in critically ill patients with preexisting diabetes and chronic hyperglycemia is unknown. In such patients, we aimed to determine whether a " liberal" approach to glycemic control would reduce hypoglycemia and glycemic variability and appear safe. Prospective, open-label, sequential-period exploratory study. Medical-surgical ICU. During sequential 6-month periods, we studied 83 patients with preexisting type 2 diabetes and chronic hyperglycemia (glycated hemoglobin, ≥ 7.0% at ICU admission). During the "standard care" period, 52 patients received insulin to treat blood glucose concentrations greater than 10 mmol/L whereas during the "liberal" period, 31 patients received insulin to treat blood glucose concentrations greater than 14 mmol/L. Time-weighted mean glucose concentrations and the number and duration of moderate (< 4.0 mmol/L) and severe (≤ 2.2 mmol/L) hypoglycemic episodes were recorded, with moderate and severe hypoglycemic episodes grouped together. Glycemic variability was assessed by calculating the coefficient of variability for each patient. Safety was evaluated using clinical outcomes and plasma concentrations of markers of inflammation, glucose-turnover, and oxidative stress. Mean glucose (TWglucoseday 0-7, standard care: 9.3 [1.8] vs liberal: 10.3 [2.1] mmol/L; p = 0.02) and nadir blood glucose (4.4 [1.5] vs 5.5 [1.6] mmol/L; p < 0.01) were increased during the liberal period. There was a signal toward reduced risk of moderate-severe hypoglycemia (relative risk: liberal compared with standard care: 0.47 [95% CI, 0.19-1.13]; p = 0.09). Ten patients (19%) during the standard period and one patient (3%) during the liberal period had recurrent episodes of moderate-severe hypoglycemia. Liberal therapy reduced glycemic variability (coefficient of variability, 33.2% [12.9%] vs 23.8% [7.7%]; p < 0.01). Biomarker data and clinical outcomes were similar. In critically ill patients with type 2 diabetes and chronic hyperglycaemia, liberal glycemic control appears to attenuate glycemic variability and may reduce the prevalence of moderate-severe hypoglycemia.
DOI: 10.1097/CCM.0000000000001815
ORCID: 0000-0002-1650-8939
Journal: Critical Care Medicine
PubMed URL: 27315191
Type: Journal Article
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