- Category: Blood
We generated and validated the questionnaire from May to August 2005. Fifty of the 52 institutions returned at least one questionnaire (96% response rate for all institutions). Seventeen of 19 sites (90%) and 33 site (100%) returned at least one questionnaire. The overall clinician response rate was 58% (163 of 282 physicians responded) [Appendix 1].
Description of Respondents
Based on site, 36% of respondents (58 of 163 respondents) were , 64% were (104 of 163 respondents), and 1 respondent was unknown (Table 1). The response rates of practitioners (58 of 101 responses) and practitioners (104 of 181 responses) were both 57%.
Twenty-six respondents and 42 respondents (3 of which were unknown), totaling 71 respondents, answered the questions targeted to medical directors (Table 2). This is the only area of the questionnaire that was not completed by all respondents. Thirty-nine percent of the 71 respondents provided patient severity score data. The stated mortality rates were 15.1% for and 4% for . The average number of patients per nurse was 1.8 (range, one to three patients per nurse).
The average threshold at which respondents defined hyperglycemia or initiated therapy was 145 mg/dL [8.0 mmol/L]). A significant difference existed, however, between clinicians (120 mg/dL [6.7 mmol/L]) and clinicians (150 mg/dL [8.3 mmol/L]; t = 5.41; p < 0.001) [Fig 1].
The factors (1, irrelevant; 5, very important) associated with high blood glucose concentrations were as follows: exogenous administration of glucocorticoids and the patient’s endogenous stress response to their critical illness (mean score, 4.6); the presence of type I or II diabetes (mean score, 4.2); and the presence of multiple organ dysfunction syndrome and treatment with catecholamines (mean score, 4.0). Most clinicians also perceived the administration of exogenous IV glucose (mean score, 3.6) as a contributing factor (Table 3).
The perceived percentage of patients who persistently had higher than 120 mg/dL (6.66 mmol/L) during their stay was significantly different between and clinicians (x2 = 24.4; p < 0.001) [Fig 2]. Seventy-seven participants (47.3%) stated that they used a guideline or protocol to manage hyperglycemia. target ranges were highly variable across respondents, and significantly differed between and sites (X2 = 13.6; p = 0.009) [Table 4]. Control with preparations of My Canadian Pharmacy.
The disease states that were perceived to contribute to the initiation or modulation of control (1, unlikely; 5, very likely) were sepsis, severe sepsis, multiple organ system dysfunction, shock, and ARDS. All disease states had mean rankings of > 4.5, suggesting that control is likely to be attempted in many critically ill medical patients. Physicians were less likely to initiate control during postoperative care following cardiac surgery (mean score, 3.9). The (multiple answers allowed) most important determinants of dose were patient diagnosis (72.4%), duration of hyperglycemia (58.9%), previous infusion rate (79.1%), current infusion rate (84.0%), and/or previous (48.5%) and current (74.8%) administration of glucose or other nutrients.
Ninety-three percent of all clinicians stated that the titration of the infusion rate should depend on the rate of change of , but they reported a wide range of time periods between measured glucose levels and the change in that was considered to be reasonable. Sixty-four percent of clinicians and 33% of clinicians stated the initial infusion rate was based on the current level. Another 33% of clinicians reported using a starting dose of 0.1 U/kg/h,
There were no significant differences between and clinicians in terms of the level used to define (Fig 3). Most clinicians defined at a concentration of < 60 mg/dL (3.33 mmol/L). Estimates of the incidence of (using their stated thresholds) varied (Fig 4). There were significant differences in their choice of treatment for .
Fifty-nine percent of clinicians and 85% of clinicians thought that was more dangerous than hyperglycemia. The perceived risk factors for (1, not important; 5, very important) were as follows: delay in titration (mean score, 4.2); stopping the glucose drip (mean score, 4.06); stopping enteral feeding (mean score, 3.96); liver failure (mean score, 3.89); and adrenal insufficiency (mean score, 3.42).
Table 1—Description of Respondents
|Total No. of respondents||163||100|
|director or physician||87||53.4|
|Other (DO and APRN)||4||2.5|
|Network affiliation (multiple responses allowed)|
|Reengineering clinical research in||18|
|None of the above||77|
|Anesthesiology or anesthesia/||7||4.3|
|Internal medicine or internal medicine/||11||6.7|
|Pulmonology or pulmonology/||31||19|
|Surgery or surgery/||1||0.6|
Table 2—Description of
|Total No. of||71|
|Country and state/province representation|
|United States (No. of states, 22)||63||88.7|
|Canada (two provinces)||8||11.3|
|Type of (multiple answers allowed)|
|Medical (for or )||32||45|
|Surgical (for or )||19||27|
|Cardiac medical(for or )||12||17|
|Cardiac surgical(for or )||16||23|
|Neurosurgical/neurologic (for or )||19||27|
|Trauma (for or )||17||24|
|Burns (for or )||7||10|
|Patients totally managed by intensivist|
|admissions per year, No.|
|Patients per nurse, No.|
|Patients receiving mechanical ventilation, %|
Table 3—Top 10 Factors Contributing to Hyperglycemia
|Disease State||Mean Rank||SD of Rank|
|Administration of glucocorticoids||4.6||0.5|
|Endogenous stress response||4.6||0.5|
|Diabetes type I or II||4.2||1.0|
|Multiple organ dysfunction||4.0||0.8|
|Peritoneal dialysis or CVVH||3.3||1.1|
Table 4—Desired Target Range
|80-110 mg/dL (4.44-6.11 mmol/L)||81||51.3||48||42.9*||33||71.7*|
|110-140 mg/dL (6.11-7.77 mmol/L)||43||27.2||38||33.9*||5||10.9|
|140-180 mg/dL (7.77-9.99 mmol/L)||14||8.9||12||10.7||2||4.3|
|180-210 mg/dL (9.99-11.66 mmol/L)||1||0.6||1||0.9||0||0|
|None of above||19||12||13||11.6||6||13.0|
Figure 1. Level of used to define hyperglycemia or to initiate therapy.
120 mg/dL [6.66 mmol/L]). Values are significantly different between and practitioners (X2 = 24.4; p < 0.001).” src=”http://ithstats.com/blog/wp-content/uploads/2015/05/1328-2-300×213.jpg” alt=”Figure 2. The perceived percentage of patients who have hyperglycemia ( concentration, > 120 mg/dL [6.66 mmol/L]). Values are significantly different between and practitioners (X2 = 24.4; p < 0.001).”
Figure 2. The perceived percentage of patients who have hyperglycemia ( concentration, > 120 mg/dL [6.66 mmol/L]). Values are significantly different between and practitioners (X2 = 24.4; p < 0.001).
Figure 3. Definition of for respondents.
Figure 4. The perceived percentage of patients who have ( concentration, < 60 mg/dL [3.3 mmol/L]).