Liberal glycemic control in critically Ill patients with type 2 diabetes: an exploratory study

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dc.contributor.authorKar, P.
dc.contributor.authorPlummer, M.P.
dc.contributor.authorBellomo, R.
dc.contributor.authorJenkins, A.J.
dc.contributor.authorJanuszewski, A.S.
dc.contributor.authorChapman, M.J.
dc.contributor.authorJones, K.L.
dc.contributor.authorHorowitz, M.
dc.contributor.authorDeane, A.M.
dc.date.issued2016
dc.description.abstractObjectives: 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. Design: Prospective, open-label, sequential-period exploratory study. Setting: Medical-surgical ICU. Patients: During sequential 6-month periods, we studied 83 patients with preexisting type 2 diabetes and chronic hyperglycemia (glycated hemoglobin, ≥ 7.0% at ICU admission). Intervention: 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. Measurements and Main Results: 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 moderatesevere 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. Conclusions: 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.
dc.description.statementofresponsibilityPalash Kar, Mark P. Plummer, Rinaldo Bellomo, MD, Alicia J. Jenkins, Andrzej S. Januszewski, Marianne J. Chapman, Karen L. Jones, Michael Horowitz, Adam M. Deane
dc.identifier.citationCritical Care Medicine, 2016; 44(9):1695-1703
dc.identifier.doi10.1097/CCM.0000000000001815
dc.identifier.issn0090-3493
dc.identifier.issn1530-0293
dc.identifier.orcidPlummer, M.P. [0000-0002-9640-1911]
dc.identifier.orcidChapman, M.J. [0000-0003-0710-3283]
dc.identifier.orcidJones, K.L. [0000-0002-1155-5816]
dc.identifier.orcidHorowitz, M. [0000-0002-0942-0306]
dc.identifier.orcidDeane, A.M. [0000-0002-7620-5577]
dc.identifier.urihttp://hdl.handle.net/2440/102412
dc.language.isoen
dc.publisherLippincott Williams & Wilkins
dc.relation.grantNHMRC
dc.rightsCopyright © 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
dc.source.urihttp://ovidsp.tx.ovid.com/sp-3.22.1b/ovidweb.cgi?QS2=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
dc.subjectHumans
dc.subjectDiabetes Mellitus, Type 2
dc.subjectHyperglycemia
dc.subjectHypoglycemia
dc.subjectChronic Disease
dc.subjectCritical Illness
dc.subjectInsulin
dc.subjectBlood Glucose
dc.subjectHypoglycemic Agents
dc.subjectCritical Care
dc.subjectProspective Studies
dc.subjectAged
dc.subjectMiddle Aged
dc.subjectFemale
dc.subjectMale
dc.subjectControlled Before-After Studies
dc.subjectGlycated Hemoglobin
dc.titleLiberal glycemic control in critically Ill patients with type 2 diabetes: an exploratory study
dc.typeJournal article
pubs.publication-statusPublished

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