Treatment of Hyperglycemia in Critically Ill Patients: Comparison of Different Glucose Management Protocols

ABSTRACT

Blaha J, Kremen J, Anderlova K, Svacina S, Kunstyr J and Haluzik M

Increased blood glucose levels frequently occur in critically ill patients both with and without previous presence of diabetes. Numerous studies have shown that its normalization by intensive insulin treatment markedly improve the outcome of critically ill patients. Several glucose management protocols have been developed and showed different effectiveness in normalizing blood glucose. Here we describe 3 glucose management protocols from 3 different European cardiosurgical centers: General University Hospital in Prague, Medical University in Graz, Royal Brompton Hospital in London and compare them with the glucose management protocol from “Leuven study”. We further tested the effectiveness of these protocols in 10 randomly selected patients from each center. We show that continuous insulin infusion is a necessary prerequisite for satisfactory blood glucose control in critically ill patients both with and without previous history of insulin-treated diabetes. Implementation of iv insulin boluses in combination with continuous insulin infusion did not further improve glucose control in this study.

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Role of Intravenous Insulin Therapy In Critically Ill Patients

ABSTRACT

Greet H. Van den Berghe, MD, PhD

Objective: To summarize the novel evidence for maintaining normoglycemia with intensive insulin therapy during intensive care in critically ill patients, with or without diabetes, in the surgical intensive-care unit.

Results: Although the association between hyperglycemia and adverse outcomes of trauma or surgical procedures necessitating intensive care was known, only one intervention study has investigated the causality of this association. This study showed that tight blood glucose control with insulin, aiming for strict normoglycemia (80 to 110 mg/dL or 4.5 to 6.1 mmol/L) during intensive care, dramatically decreased morbidity and mortality. The clinical benefits were present whether or not patients had previously diagnosed diabetes, and they seemed independent of severity and type of critical illness. Multivariate logistic regression analysis indicated that metabolic control, rather than insulin dose per se, statistically explains the beneficial effects of intensive insulin therapy on outcomes of critical illness. Other metabolic effects besides blood glucose control, however, such as normalization of dyslipidemia, and immunologic effects, such as suppression of excessive inflammation and improvement of macrophage function, accompany glycemic control in critically ill patients. These effects seem to surpass the level of glycemic control in explaining the clinical benefits of intensive insulin therapy on sepsis, organ failure, and death. Ongoing studies are attempting to clarify the mechanisms that underlie the beneficial effects of this simple and cost-saving intervention.

Conclusion: The available evidence favors targeting normoglycemia (blood glucose levels of less than 110 mg/dL or 6.1 mmol/L) by insulin infusion in all adult surgical

intensive-care patients. Whether these findings are applicable to nonsurgical intensive-care or to pediatric patients in the intensive care unit remains unclear.

(Endocr Pract. 2004;10[Suppl 2]:17-20)

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intensive insulin therapy in Critically Ill Patients

ABSTRACT

GREET VAN DEN BERGHE, M.D., PH.D., et al.

Background Hyperglycemia and insulin resistance are common in critically ill patients, even if they have not previously had diabetes. Whether the normalization

of blood glucose levels with insulin therapy improves the prognosis for such patients is not known.

Methods We performed a prospective, randomized, controlled study involving adults admitted to our surgical intensive care unit who were receiving mechanical

ventilation. On admission, patients were randomly assigned to receive intensive insulin therapy (maintenance of blood glucose at a level between 80 and

110 mg per deciliter) or conventional treatment (infusion of insulin only if the blood glucose level exceeded 215 mg per deciliter and maintenance of glucose at a level between 180 and 200 mg per deciliter).

Results At 12 months, with a total of 1548 patients enrolled, intensive insulin therapy reduced mortality during intensive care from 8.0 percent with conventional

treatment to 4.6 percent (P<0.04, with adjustment for sequential analyses). The benefit of intensive insulin therapy was attributable to its effect on mortality among patients who remained in the intensive care unit for more than five days (20.2 percent with conventional treatment, as compared with 10.6 percent with intensive insulin therapy; P=0.005). The greatest reduction in mortality involved deaths due to

multiple-organ failure with a proven septic focus. Intensive insulin therapy also reduced overall in-hospital mortality by 34 percent, bloodstream infections by 46 percent, acute renal failure requiring dialysis or hemofiltrationby 41 percent, the median number of red-cell transfusions by 50 percent, and critical-illness polyneuropathy by 44 percent, and patients receiving intensive therapy were less likely to require prolonged mechanical ventilation and intensive care.

Conclusions Intensive insulin therapy to maintain blood glucose at or below 110 mg per deciliter reduces morbidity and mortality among critically ill patients

in the surgical intensive care unit. (N Engl J Med 2001;345:1359-67.)

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Intensive Insulin Therapy in Critically Ill Hospitalized Patients: Making it Safe and Effective

ABSTRACT

David C. Klonoff, M.D., FACP

Intensive insulin therapy (IIT) for hyperglycemia in critically ill patients has become a standard practice. Target levels for glycemia have fluctuated since 2000, as evidence initially indicated that tight glycemic control to so-called normoglycemia (80–110 mg/dl) leads to the lowest morbidity and mortality without hypoglycemic

complications. Subsequent studies have demonstrated minimal clinical benefit combined with greater hypoglycemic morbidity and mortality with tight glycemic control in this population. The consensus glycemic targets were then liberalized to the mid 100s (mg/dl).

Handheld POC blood glucose (BG) monitors have migrated from the outpatient setting to the hospital environment because they save time and money for managing critically ill patients who require IIT. These devices are less accurate than hospital-grade POC blood analyzers or central laboratory analyzers.

Three questions must be answered to understand the role of IIT for defined populations of critically ill patients: (1) How safe is IIT, with various glycemic targets, from the risk of hypoglycemia? (2) How tightly must BG be controlled for this approach to be effective? (3) What role does the accuracy of BG measurements play in affecting the safety of this method? For each state of impaired glucose regulation seen in the hospital, such as hyperglycemia, hypoglycemia, or glucose variability, the benefits, risks, and goals of treatment, including IIT, might differ.

With improved accuracy of BG monitors, IIT might be rendered even more intensive than at present, because patients will be less likely to receive inadvertent overdosages of insulin. Greater doses of insulin, but with dosing based on more accurate glucose levels, might result in less hypoglycemia, less hyperglycemia, and less glycemic variability. (J Diabetes Sci Technol 2011;5(3):755-767)

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Intensive Insulin Therapy for The Treatment of Hyperglycemia in Critically Ill Adults: A Qualitative Systematic Review and Critical Appraisal of the Evidence

ABSTRACT

Rattan Juneja MD; Michael E. Stuart, MD; Sheri A. Strite

Background: Hyperglycemia in intensive care patients is associated with high mortality, but optimal management of this population with insulin therapy is Methods: We utilized the extensive search from a recent published meta-analysis and conducted an updated search using MEDLINE (2008-2009), the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. We assessed bias of trials using a detailed checklist to document the overall quality of the evidence for mortality and hypoglycemia in intensive care populations.

Findings: We included a total of 17 clinical trials totaling 12,345 patients. All included trials were rated as being at medium risk of bias. We identified eight groups of patients in which intensive insulin treatment has been compared to less intensive insulin therapy. Mortality rates varied by patient population with rates of < 16% in predominantly surgical patients with mixed conditions to nearly 75% in neurosurgical patients. Overall, mortality rates ranged from 4% to 74% but the overall level of evidence for mortality was inconclusive. Hypoglycemia rates ranged from 0% to 94% and the overall level of evidence for hypoglycemia was borderline.

Interpretation: The evidence is insufficient for determining the effect of intensive

insulin treatment compared to less intensive treatment in acutely ill hyperglycemic

patients. The evidence does not justify guideline recommendations for specific glycemic target ranges for adults being treated in intensive care units. Further research is needed, but should be carefully planned with attention to trial bias, populations, type of insulin protocols used, adherence, co-interventions, and frequency of blood glucose testing to avoid the heterogeneity and bias present in currently available research.

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Intensive Insulin Therapy and Mortality in Critically Ill Patients

ABSTRACT

Miriam M Treggiari, Veena Karir, N David Yanez, Noel S Weiss, Stephen Daniel and Steven A Deem

Introduction Intensive insulin therapy (IIT) with tight glycemic control may reduce mortality and morbidity in critically ill patients and has been widely adopted in practice throughout the world. However, there is only one randomized controlled trial showing unequivocal benefit to this approach and that study population was dominated by post-cardiac surgery patients. We aimed to determine the association between IIT and mortality in a mixed population of critically ill patients.

Methods We conducted a cohort study comparing three consecutive time periods before and after IIT protocol implementation in a Level 1 trauma center: period I (no

protocol); period II, target glucose 80 to 130 mg/dL; and period III, target glucose 80 to 110 mg/dL. Subjects were 10,456 patients admitted to intensive care units (ICUs) between 1 March 2001 and 28 February 2005. The main study endpoints

were ICU and hospital mortality, Sequential Organ Failure Assessment score, and occurrence of hypoglycemia. Multivariable regression analysis was used to evaluate mortality and organ dysfunction during periods II and III relative to period I.

Results Insulin administration increased over time (9% period I, 25% period II, and 42% period III). Nonetheless, patients in period III had a tendency toward higher adjusted hospital mortality (odds ratio [OR] 1.15, 95% confidence interval [CI] 0.98, 1.35) than patients in period I. Excess hospital mortality in period III was present primarily in patients with an ICU length of stay of 3 days or less (OR 1.47, 95% CI 1.11, 1.93 There was an approximately fourfold increase in the incidence of hypoglycemia from periods I to III.

Conclusion A policy of IIT in a group of ICUs from a single institution was not associated with a decrease in hospital mortality. These results, combined with the findings from several recent randomized trials, suggest that further study is needed

prior to widespread implementation of IIT in critically ill patients.

Critical Care 2008, 12:R29 (doi:10.1186/cc6807)

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Insulin Therapy for Critical Ill Hospitalized Patients

ABSTRACT

Anastassios G. Pittas, MD; Richard D. Siegel, MD; Joseph Lau, MD

Background: Hyperglycemia is common in critically ill hospitalized patients, and it is associated with adverse outcomes, including increased mortality. The objective of

this meta-analysis was to determine the effect of insulin therapy initiated during hospitalization on mortality in adult patients with a critical illness.

Methods: An electronic search in the Englishlanguage articles of MEDLINE and the Cochrane Controlled Clinical Trials Register and a hand search of key journals and relevant review articles were performed. Randomized controlled trials that reported mortality data on critically ill hospitalized adult patients who were treated

with insulin were selected. Data on patient demographics, hospital setting, intervention (formulation and dosage of insulin, delivery method, and duration of therapy), mortality outcomes, adverse events, and methodological quality were extracted.

Results: Thirty-five trials met the inclusion criteria. Combining data from all trials using a random-effects model showed that insulin therapy decreases short-term mortality by 15% (relative risk [RR], 0.85; 95% confidence interval [CI], 0.75-0.97). In subgroup analyses, insulin therapy decreased mortality in the surgical intensive care unit (RR, 0.58; 95% CI, 0.22-0.62), when the aim of therapy was glucose control (RR, 0.71; 95% CI, 0.54-0.93), and in patients with diabetes mellitus (RR, 0.73; 95% CI, 0.58-0.90). A near-significant trend toward decreasing mortality was seen in patients with acute myocardial infarction who did not receive reperfusion therapy (RR, 0.84; 95% CI, 0.71-1.00). No randomized trials of insulin in the medical intensive care unit were identified.

Conclusion: Insulin therapy initiated in the hospital in critically ill patients has a beneficial effect on shortterm mortality in different clinical settings.

(Arch Intern Med. 2004;164:2005-2011)

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Improvement of Glucose Control in The Intensive Care Unit (An Interdisciplinary Collaboration Study)

ABSTRACT

By Ulrike Holzinger, MD, Monika Feldbacher, RN, Adelbert Bachlechner, RN, Reinhard Kitzberger, MD, Valentin Fuhrmann, MD, and Christian Madl, MD

Background Strict glycemic control in critically ill patients is challenging for both physicians and nurses.

Objectives To determine the effect of focused education of intensive care staff followed by implementation of a glucose control protocol.

Methods A prospective observational study in a medical intensive care unit in a university hospital. After intensive education of nurses and physicians, a glucose control protocol with a nurse-managed insulin therapy algorithm was developed and implemented. Every measured blood glucose value and insulin dose per hour and per day were documented in 36 patients before and 44 patients after implementation of

the protocol.

Results Median blood glucose levels decreased after implementation of the protocol (133 vs 110 mg/dL; P < .001). The amounts of time when patients’ blood glucose levels were less than 110 mg/dL and less than 150 mg/dL increased after implementation of the protocol (8% vs 44%; 75% vs 96%; P<.001). The median use of insulin increased after implementation of the protocol (28 vs 35 IU/day; P=.002). Diabetic patients had higher median blood glucose levels than did nondiabetic patients both before (138 vs 131 mg/dL) and after (115 vs 108 mg/dL; P<.001) implementation, although median insulin use also increased (before implementation, 33 vs 26 IU/day; P=.04; after implementation, 46 vs 30 IU/day; P < .001).

Conclusions Use of a collaboratively developed glucose control protocol led to decreased median blood glucose levels and to longer periods of normoglycemia. Despite increased insulin use, glucose control was worse in diabetic patients.

(American Journal of Critical Care. 2008;17:150-158)

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Hypoglycemic Events in Intesive Care Patients: Analysis by Insulin Administration Method and Sample Type

ABSTRACT

By Marta Raurell Torredà, RN, MSN, Emilia Chirveches Pérez, RN, MSN, Maite Domingo Aragón, RN, Rosa Martínez Ribe, RN, Emma Puigoriol Juvanteny, MStat, and Quintí Foguet Boreu, MD, PhD

Background Intensive insulin treatment is associated with an increased risk of hypoglycemia, so strict glycemic monitoring is essential. The best type of sample for identifying hypoglycemia remains under debate.

Objectives To establish the number of hypoglycemic events in intensive care patients relative to insulin administration method and the method used to collect the blood sample.

Methods Retrospective descriptive study lasting 6 months. Hypoglycemia was defined as a blood glucose level less than 80 mg/dL (mild: 50-79 mg/dL, severe: <50 mg/dL), measured with a bedside glucometer and blood from the arterial catheter

or fingerstick, in critically ill patients who require insulin administered subcutaneously (with sliding scales) or via continuous intravenous perfusion (intense infusion protocol with a nurse-managed insulin therapy algorithm).

Results Analysis of the 6636 samples from 144 critically ill patients revealed 188 mildly hypoglycemic samples (2.8%) and 3 severely hypoglycemic samples (0.04%). The prevalence of mild hypoglycemia was greater when insulin was administered

intravenously (3.2%) rather than subcutaneously (2.3%; P = .04). Among patients receiving insulin intravenously, hypoglycemia was found more often in arterial (4.5%) than in capillary (2.8%) blood (P = .01). The prevalence of hypoglycemia in capillary blood samples did not differ significantly between subcutaneous (2.3%) and intravenous (2.8%) insulin therapies (P = .21).

Conclusions With a target blood glucose level of 110 to 140 mg/dL, few hypoglycemic events are detected in critically ill patients, regardless of whether insulin is administered intravenously or subcutaneously. Analysis of solely arterial samples may yield a higher prevalence of hypoglycemia than otherwise.

(American Journal of Critical Care. 2011;20:e115-e121)

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Hyperglycemia related Mortality in Critically Ill Patients Varies with Admission Diagnosis

ABSTRACT

Mercedes Falciglia, MD; Ron W. Freyberg, MS; Peter L. Almenoff, MD; David A. D’Alessio, MD; Marta L. Render, MD

Objectives: Hyperglycemia during critical illness is common and is associated with increased mortality. Intensive insulin therapy has improved outcomes in some, but not all, intervention trials. It is unclear whether the benefits of treatment differ among specific patient populations. The purpose of the study was to determine the association between hyperglycemia and risk–adjusted mortality in critically ill patients and in separate groups stratified by admission diagnosis. A secondary purpose was to determine whether mortality risk from hyperglycemia varies with

intensive care unit type, length of stay, or diagnosed diabetes. Design: Retrospective cohort study.

Setting: 173 U.S. medical, surgical, and cardiac intensive care units.

Patients: 259,040 admissions from October 2002 to September 2005; unadjusted mortality rate, 11.2%.

Interventions: None.

Measurements and Main Results: A two–level logistic regression model determined the relationship between glycemia and mortality. Age, diagnosis, comorbidities, and laboratory variables were used to calculate a predicted mortality rate, which was then

analyzed with mean glucose to determine the association of hyperglycemia with hospital mortality. Hyperglycemia was associated with increased mortality independent of illness severity. Compared with normoglycemic individuals (70–110 mg/dL), adjusted odds of mortality (odds ratio, [95% confidence interval]) for mean glucose 111–145, 146–199, 200–300, and >300 mg/dL was 1.31(1.26 –1.36), 1.82(1.74 –1.90), 2.13(2.03–2.25), and 2.85(2.58–3.14), respectively. Furthermore, the adjusted odds of mortality related to hyperglycemia varied with admission diagnosis, demonstrating a clear association in some patients (acute myocardial infarction, arrhythmia, unstable angina, pulmonary embolism) and little or no association in others. Hyperglycemia was associated with increased mortality independent of intensive care unit type, length of stay, and diabetes.

Conclusions: The association between hyperglycemia and mortality implicates hyperglycemia as a potentially harmful and correctable abnormality in critically ill patients. The finding that hyperglycemia–related risk varied with admission diagnosis suggests differences in the interaction between specific medical conditions and injury from hyperglycemia. The design and interpretation of future trials should consider the primary disease states of patients and the balance of medical conditions in the intensive care unit studied. (Crit Care Med 2009; 37:000–000).

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Hyperglycemia in the Critically Ill: Consequences and Treatment

ABSTRACT

Laura E. Ridge

Hyperglycemia has long been recognized as a common occurrence in the critically ill, even without a history of diabetes. During times of stress or injury, nonnal glucose metabolism is altered because of changes in endocrine secretions and peripheral insulin resistance, resulting in stress hyperglycemia. Although hyperglycemia is a nonnal part of the stress response, it has recently been recognized to be associated with increased mortality and morbidity. Furthennore, insulin therapy has been shown to decrease mortality and improve other patient outcomes. However, many questions remain unanswered concerning the efficacy of insulin therapy. It is still unclear how tight glucose control should be and which patient types benefit from the treatment. More research is needed before insulin therapy can be widely used.

Hyperglycemia in Critically Ill Patients

ABSTRACT

Melissa Knieriem, DVM, DACVECC; Cynthia M. Otto, DVM, PhD, DACVECC; Douglass Macintire, DVM, MS, DACVIM, DACVECC

Hyperglycemia is common in critically ill humans. Recent clinical trials have shown a

significant reduction in morbidity and mortality rates with the use of intensive insulin therapy to maintain strict normoglycemia in critically ill patients. Hyperglycemia is associated with many detrimental effects, including reduced immune function, increased inflammation and coagulation, and modulation of the endothelium. Most of the evidence regarding the adverse effects of hyperglycemia is

derived from humans with diabetes, cardiac failure, or traumatic brain injury. In addition to its anabolic effects on metabolism, insulin has antiinflammatory properties.To define the potential risks and benefits of intensive insulin therapy in critically ill animals, prospective, randomized clinical trials are necessary. 

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Hyperglycemia in Critical Illness (A Review)

ABSTRACT

David Brealey, MB BS, BSc, Ph.D., FRCA, MRCP, and Mervyn Singer, MB BS, M.D., FRCP(Lon), FRCP(Edin)

Hyperglycemia is commonplace in the critically ill patient and is associated with worse outcomes. It occurs after severe stress (e.g., infection or injury) and results from a combination of increased secretion of catabolic hormones, increased hepatic gluconeogenesis, and resistance to the peripheral and hepatic actions of insulin. The use of carbohydrate-based feeds, glucose containing solutions, and drugs such as epinephrine may exacerbate the hyperglycemia. Mechanisms by which hyperglycemia cause harm are uncertain. Deranged osmolality and blood flow, intracellular acidosis, and enhanced superoxide production have all been implicated. The net result is derangement of endothelial, immune and coagulation function and an association with neuropathy and myopathy. These changes can be prevented, at least in part, by the use of insulin to maintain normoglycemia (J Diabetes Sci Technol 2009;3(6):1250-1260). 

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Hyperglycemia in Critical Care Illness

INTRODUCTION

Dr Neeru Gera,  Department of Endocrinology, Max Healthcare, New Delhi

Critically ill patients who require intensive care for more than five days carry 20% risk of death and significant morbidity. Hyperglycemia and insulin resistance are common in critical care settings, even observed in those without preexisting diabetes.

Newly detected hyperglycemia (admission or fasting blood glucose >126 mg/dl or two random blood glucose >200 mg/dl) in one study [1] was associated with higher in-hospital mortality (16%) than established diabetes (3%) or normal blood glucose (1.7%).The risk of in-hospital complications and ICU death increase by 3% for each 20 mg/dl increase in blood glucose above 100 mg/dl. 

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Evaluation of Nursing WOrk Effort and Perceptions about Blood Glucose Testing in Tight Glycemic Control

ABSTRACT

By Daleen Aragon, RN, PhD, CCRN.

Background Tight glycemic control is important in critically ill patients and involves insulin infusions and monitoring of blood glucose levels. Hourly measurements of blood glucose levels and adjustments of intravenous insulin doses require additional work by nurses.

Objectives To evaluate the nursing work incurred with and nursing perceptions about tight glycemic control and blood glucose monitoring.

Methods A variety of intensive care units were studied. Surveys were used to gain information about nurses’ perceptions. Time-in-motion observations were used to determine the time taken to measure blood glucose levels and adjust insulin doses. Results Nurses thought that tight glycemic control was important and that the work associated with it was substantial. Nurses thought that easier and automated forms of blood glucose monitoring are needed. They preferred using an arterial catheter to obtain blood samples to avoid excessive finger sticks. The total number of blood glucose measurements was 77 954. The mean time taken for hourly blood glucose monitoring and adjustment of insulin doses was 4.72 minutes. The estimated costs of time spent on glycemic control during a 1-year period were $182 488 for nurses’ salaries and $58 500 for supplies.

Conclusions Although most nurses endorse tight glycemic control, the work associated with it is burdensome and costly. Because up to 2 hours might be required for tight glycemic control for a single patient in a 24-hour period, the costs in time and money are high. Easier clinical methods for monitoring blood glucose levels are needed. (American Journal of Critical Care. 2006;15:370-377)

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Glycemic Control in Non Diabetic Critically Ill Patients

INTRODUCTION

Farnoosh Farrokhi, MD, Fellow of Endocrinology, Dawn Smiley, MD, Assistant Professor of Medicine, Guillermo E. Umpierrez, MD, Professor of Medicine

Hyperglycemia is a common and costly health care problem in hospitalized patients. In hospital hyperglycemia is defined as any glucose value >7.8 mmol/l (140 mg/dl). Hyperglycemia is present in 40% of critically ill patients and in up to 80% of patients after cardiac surgery, with w 80% of ICU patients with hyperglycemia having no history of diabetes prior to admission. The risk of  hospital complications relates to the severity of hyperglycemia, with a higher risk observed in patients without a history of diabetes compared to those with known diabetes. Improvement in

glycemic control reduces hospital complications and mortality; however, the ideal glycemic target has not been determined. A target glucose level between 7.8 and 10.0 mmol/l (140 and 180 mg/dl) is recommended for the majority of ICU patients. This

review aims to present updated recommendations for the inpatient management of hyperglycemia in critically ill patients with and without a history of diabetes. 

Best Practice & Research Clinical Endocrinology & Metabolism 25 (2011) 813–824.

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Effect of Hyperglycemia on Prognosis of Critically Ill Patients Des Not Differ Diabetics from Non diabetics

ABSTRACT

Yon Hee Shim, M.D., Chul Ho Chang, M.D., Jong Seok Lee, M.D., Seung Jung Kim, M.D., and Cheung Soo Shin, M.D.

Background: Hyperglycemia is common in critically ill patients, even in those without diabetes, and it is known to increase mortality in patients with or without diabetes in the settings of acute myocardial infarction or acute stroke. However, the clinical effects of admission hyperglycemia are uncertain, and no data is available that compares the prognosis in a heterogenous group of critically ill patients. The aim of this study was to evaluate the effect of hyperglycemia on prognosis in a heterogenous group of critically ill patients with or without diabetes.

Methods: The medical records of 858 consecutive adult patients admitted to a general intensive care unit (ICU) at a University Hospital over 21 months were reviewed. Patients with no records of blood glucose measurements and patients with normoglycemia during the first 3 days were excluded. The remaining 349 patients with hyperglycemia were divided into two groups according to a previous history of diabetes. Hyperglycemia was defined as a fasting blood glucose level of 140 mg/dl or more, or a random blood glucose level of 200 mg/dl or more on 2 or more determinations. The primary end-point of the study was ICU and in-hospital mortality, and its secondary end-point included length of stay in the ICU and hospital.

Results: There were no significant differences in ICU mortality (17.6/19.0%), in-hospital mortality (24.5/24.3%), ICU length of stay (6.6 ± 11.9/6.6 ± 10.4 days), and hospital length of stay (11.4 ± 29.0/12.8 ± 24.3 days) between diabetics and nondiabetics.

Conclusions: Our results indicate that the effects of hyperglycemia on the  prognosis of critically ill patients do not differ diabetics from nondiabetics. (Korean Journal Anesthesiol 2004; 47: S 10-S 13)

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Difference in Glucose Values Obtained from Point of Care Glucose Meters and Laboratory Analysis in Critically Ill Patients

ABSTRACT

By Anjannette Cook, RN, BSN, Delyla Laughlin, RN, Margery Moore, RN, BSN, Doreen North, RN, Kathleen Wilkins, RN, BA, BSN, Gay Wong, RN, BSN, Allyson Wallace-Scroggs, RN, MSc, and Lisa Halvorsen, RN, PhD, APRN-BC.

Background Blood for glucose analysis is often obtained interchangeably from indwelling catheters and fingersticks.

Objectives To determine the level of agreement between glucose values obtained by laboratory analysis and with a pointof-care device for blood from 2 different sources: fingerstick and a central venous catheter.

Methods A method-comparison design was used. Point-of-care values for blood from fingersticks and catheters were compared with laboratory values for blood from catheters in a convenience sample of 67 critically ill patients. The effects of hematocrit level and finger edema on differences in glucose values between the

2 methods were also evaluated. A t test was used to determine differences in glucose values obtained via the 2 methods. Differences and limits of agreement were also calculated.

Results Laboratory glucose values for blood from a catheter differed significantly from point-of-care values for blood from the catheter (t1,66 = -9.18; P < .001) and from a fingerstick (t1,66 =6.53; P < .001). Glucose values for the 2 methods differed by 20mg/dL or more for 1 of 6 patients (15%) for catheter samples and for 1 of 5 (21%) for fingerstick samples. Point-of-care glucose values for fingerstick and catheter samples did not differ (P = .98). Hematocrit level significantly explained the difference in glucose values between the 2 methods for both catheter (R2 = 0.288;

P < .001) and fingerstick (R2 = 0.280; P = .02) samples.

Conclusions Use of a commonly used point-of-care device when precise glucose values are needed may lead to faulty treatment decisions. (American Journal of Critical Care. 2009;18:65-72)

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Comparison of Point of Care and Laboratory Glucose Analysis in Critically Ill Patients

ABSTRACT

By Teresita Lacara, RN, BSN, Caroline Domagtoy, RN, BSN, Donna Lickliter, RN,

Kathy Quattrocchi, RN, BSN, Lydia Snipes, RN, Joánne Kuszaj, RN, MSN, CCRN,

and MaryClare Prasnikar, RN, MSN, CCRN

Background Blood for point-of-care analysis of glucose levels is often obtained from different sources (fingerstick, arterial or central venous catheter).

Objectives To examine agreement between point-of-care and laboratory glucose values and to determine effects of hematocrit, serum carbon dioxide, and mean arterial pressure on the accuracy of point-of-care values.

Methods Point-of-care values were compared with laboratory values. In 49 critically ill patients, blood was obtained first from a catheter for laboratory testing and then from the catheter and via fingerstick for point-of-care testing. Bias, precision, and rootmean- square differences were calculated to quantify differences in values between the 2 methods. A t test was used to determine differences in values between each point-of-care blood source and the laboratory value. Multiple regression analysis was used to determine if serum level of carbon dioxide, hematocrit, and/or

mean arterial pressure significantly contributed to the difference in bias and precision for the point-of-care blood sources.

Results Mean laboratory glucose level was 135 (SEM 5.3, range 58-265) mg/dL. In point-of-care testing, bias ± precision and root-mean-square differences were 2.1 ± 12.3 and 12.35, respectively, for fingerstick blood and 0.6 ± 10.6 and 10.46 for catheter blood. Values for point-of-care and laboratory tests did not differ significantly. For catheter samples, hematocrit and serum carbon dioxide contributed significantly to difference scores between point-of-care and laboratory values (P < .001).

Conclusions Glucose values for point-of-care samples did not differ significantly from laboratory values. For catheter samples, hematocrit and serum carbon dioxide levels accounted for the difference between point-of-care and laboratory glucose

values. (American Journal of Critical Care. 2007;16:336-347)

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