Outcomes about Blood Glucose Control in Critically III Adults and Children

  • 21/Mar/2016
  • Category: Blood

questionnaireWe 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%.

Related Data

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).


Hyperglycemia

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.

Control

Blood Glucose Control

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

Items No. %
Total No. of respondents 163 100
Respondent description
director or physician 87 53.4
Fellow 31 19
Nurse (RN) 41 25.2
Other (DO and APRN) 4 2.5
Gender
Female 79 49
Male 82 51
Network affiliation (multiple responses allowed)
Reengineering clinical research in 18
ARDSnet 31
PALISI network 51
None of the above 77
Primary specialty
Anesthesiology or anesthesia/ 7 4.3
Cardiac surgery 2 1.2
Internal medicine or internal medicine/ 11 6.7
Neurosurgery 1 0.6
Nursing 24 14.7
84 51.5
Pulmonology or pulmonology/ 31 19
Surgery or surgery/ 1 0.6
Other 2 1.2

Table 2—Description of

Items No. % Range
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)
17 24
45 63
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
23 88.5
44 100
All types 67 95
beds, no.
22.4 14.9 10-75
23.7 9.7 7-61
All types 23.2 11.8 7-75
admissions per year, No.
1,550 1,320 300-7,000
1,349 567 460-3,200
All types 1,421 907 300-7,000
attendings, No.
6.4 4.4
7.6 3.0
All types 7.2 3.6
Patients per nurse, No.
1.9 0.16 1-3
1.7 0.39 1.5-2
All types 1.8 0.34 1-3
Patients receiving mechanical ventilation, %
54.4 19.6 25-90
48.9 17.5 20-90
All types 50.7 18.1 20-90

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
Catecholamines 4.0 0.8
IV glucose 3.6 1.1
Excess nutrition 3.5 1.1
Obesity 3.4 1.0
Peritoneal dialysis or CVVH 3.3 1.1
Pancreatitis 3.3 1.1

Table 4—Desired Target Range

Target Range Overall
No. % No. I% No. %
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
Total 158 100 112 100 46 100

Figure 1. Level of blood glucose used to define hyperglycemia or to initiate insulin therapy.

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 hypoglycemia for respondents.

Figure 3. Definition of for respondents.

Figure 4. The perceived percentage of ICU patients who have hypoglycemia (blood glucose concentration, < 60 mg/dL [3.3 mmol/L]).

Figure 4. The perceived percentage of patients who have ( concentration, < 60 mg/dL [3.3 mmol/L]).