Glycemic control in peri operative patients

Posted by e-Medical PPT Thursday, December 22, 2011
Hyperglycemia is common in critically ill surgical patients, regardless of whether they had diabetes before hospital admission.
Control of blood glucose has been shifting toward progressively tighter glucose control in diabetics, a paradigm shift also reflected in the care of critically ill patients. 
Elevated blood glucose (BG) is associated with increased mortality in the ICU setting.
Hyperglycemia also causes substantial morbidity in critical illness, including increased risk of nosocomial infection, increased infarct size with worsened outcomes in myocardial infarction and ischemic cerebrovascular accident, and increased protein catabolism after burn injury.
Hyperglycemia affects immune function
Clinicians have also observed that elevated glucose promotes dehydration and inflammation.
Post-operative patients are relatively insulin resistant

The Studies
Van den Berghe and associates examined whether the control of hyperglycemia in critically ill patients can lead to improved outcomes in a prospective randomized trial. Study patients were admitted to the ICU for mechanical ventilation. Patients were randomly assigned to one of two groups: the first group received intensive insulin therapy with the goal of trying to maintain glucose at between 80 and 110 mg/dL (ie, normoglycemia), while in the conventional treatment arm the goal glucose was kept between 180 and 200 mg/dL.

This study showed that intensive insulin control lowered mortality by > 40%. It also showed that there was a decreased requirement for ventilator support. Interestingly, a decreased need for renal replacement therapy was also demonstrated. Control of hyperglycemia also decreased septic episodes in the patients randomized to intensive insulin therapy by > 40%.
In totality, these studies make a compelling case that normoglycemia should be the rule rather than the exception in surgical patients in the ICU.

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