Rationale for Maintaining Glycemic Control in the Hospital

Glucose targets for hospitalized patients

ICU Non-ICU

ADA ≤110 mg/dL FPG 90-130 mg/dL; midpoint 110 mg/dL

Postprandial: <180 mg/dL

ACE ≤110 mg/dL FPG ≤110 mg/dLPostprandial ≤180 mg/dL

ADA. Diabetes Care. 2007;30:S4-41.ACE. Endocr Pract. 2004;10:77-82.

Glycemic control in the ICU

• Intensive IV insulin – BG target: 80-110 mg/dL

• Conventional treatment– BG target: 180-200 mg/dL

• Achieved morning BG– 103 mg/dL vs 153 mg/dL

Van den Berghe G et al. N Engl J Med. 2001;345:1359-67.

Intensive

Conventional

Days after admission

0 50 100 150 200 2500

80

84

88

92

96

100

In-hospital survival

(%)

N = 1548 surgical patients; 63% cardiac

-34

-46-41

-50

-44

-60

-50

-40

-30

-20

-10

0

Intensive insulin therapy in surgical ICU reduces morbidity and mortality

Reduction(%)

Poly-neuropathy

In-hospitalmortality Sepsis Dialysis

Blood transfusions*

N = 1548 surgical ICU patients

Van den Berghe G et al. N Engl J Med. 2001;345:1359-67. *Median number

P < 0.001

P = 0.01

P = 0.003

P = 0.007

P < 0.001

IV insulin infusion protocols: Comparison of targets and recommendations

Author

Target glucose(mg/dL)

Bolus(U)

Initial infusion rate

(U/hr)

Insulin infused BG >200

mg/dL(U)

Highest hourly dose(U)

Bode 100–150 0 8 41 11

Boord 120–180 0 1 14.3 4.3

Chant 90–144 0 6 42 15

Furnary 100–150 12 6.5 59.5 18.5

Goldberg 100–139 4.5 4.5 26 9

Kanji 80–110 3 3 41 12

Krinsley <140 0 10 40 10

Marks 120–180 0 1 54 18

Van den Berghe 80–110 0 4 40 15

Zimmerman 101–150 10 4 88 21

Wilson M et al. Diabetes Care. 2007;30:1005-11.

Essential elements of an IV insulin protocol

• Correct hyperglycemia safely and effectively

• Adjust insulin infusion rate to attain and maintain BG target range

• Correct insulin infusion rate without under- or overcompensation

• Maintain rate adjustments as insulin sensitivity or nutritional status changes

• Respond to hypoglycemia or rapid BG fall

• Transition to sc insulin when appropriate

Clement SC et al. Diabetes Care. 2004;27:553-591.

Insulin infusion to normalize BG recommended for patients with STEMI + complicated courses

During acute management of STEMI in patients with hyperglycemia, it is reasonable to administer insulin infusion to normalize BG, even in those with an uncomplicated course

After acute phase of STEMI, individualize diabetes treatment; select combinations of agents that achieve optimal glycemic control and are well tolerated

ACC/AHA STEMI guidelines: Strict glucose control

Antman EM et al. J Am Coll Cardiol. 2004;44:671-719.

II IIaIIa IIbIIb IIIIII

B

B

C

Class and level of evidence

Diabetes is an independent risk factor in patients with UA/NSTEMI

Attention should be directed toward tight glucose control

ACC/AHA NSTEMI guidelines: Diabetes

Braunwald E et al. www.acc.org

Medical treatment in the acute phase and decisions on whether to perform stress testing, angiography, and revascularization should be similar in diabetic and nondiabetic patients

II IIaIIa IIbIIb IIIIII

A

C

B

Class and level of evidence