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Effect of an Intensive Glucose Management Protocol on the Mortality of Critically Ill Adult Patients

      OBJECTIVE

      To assess the effect of an intensive glucose management protocol in a heterogeneous population of critically ill adult patients.

      PATIENTS AND METHODS

      This study consisted of 800 consecutive patients admitted after institution of the protocol (treatment group, between February 1, 2003, and January 10, 2004) and 800 patients admitted immediately preceding institution of the protocol (baseline group, between February 23, 2002, and January 31, 2003). The setting was a 14-bed medical-surgical intensive care unit (ICU) in a university-affiliated community teaching hospital. The protocol involved intensive monitoring and treatment to maintain plasma glucose values lower than 140 mg/dL. Continuous intravenous insulin was used if glucose values exceeded 200 mg/ dL on 2 successive occasions.

      RESULTS

      The 2 groups of patients were well matched, with similar age, sex, race, prevalence of diabetes mellitus, Acute Physiology and Chronic Health Evaluation II scores, and distribution of diagnoses. After institution of the protocol, the mean glucose value decreased from 152.3 to 130.7 mg/dL (P<.001), marked by a 56.3% reduction in the percentage of glucose values of 200 mg/dL or higher, without a significant change in hypoglycemia. The development of new renal insufficiency decreased 75% (P=.03), and the number of patients undergoing transfusion of packed red blood cells decreased 18.7% (P=.04). Hospital mortality decreased 29.3% (P=.002), and length of stay in the ICU decreased 10.8% (P=.01).

      CONCLUSION

      The protocol resulted in significantly improved glycemic control and was associated with decreased mortality, organ dysfunction, and length of stay in the ICU in a heterogeneous population of critically ill adult patients. These results support the adoption of this low-cost intervention as a standard of care for critically ill patients.
      APACHE (Acute Physiology and Chronic Health Evaluation), ICU (intensive care unit), LOS (length of stay), RBC (red blood cells)
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      REFERENCES

        • Wahab NN
        • Cowden EA
        • Pearce NJ
        • Gardner MJ
        • Merry H
        • Cox JL
        • ICONS Investigators
        Is blood glucose an independent predictor of mortality in acute myocardial infarction in the thrombolytic era?.
        J Am Coll Cardiol. 2002; 40: 1748-1754
        • Capes SE
        • Hunt D
        • Malmberg K
        • Gerstein HC
        Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview.
        Lancet. 2000; 355: 773-778
        • Malmberg K
        • Norhammar A
        • Wedel H
        • Ryden L
        Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study.
        Circulation. 1999; 99: 2626-2632
        • Foo K
        • Cooper J
        • Deaner A
        • et al.
        A single serum glucose measurement predicts adverse outcomes across the whole range of acute coronary syndromes.
        Heart. 2003; 89: 512-516
        • Malmberg K
        • DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group
        Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus.
        BMJ. 1997; 314: 1512-1515
        • Sala J
        • Masia R
        • Gonzalez de Molina FJ
        • REGICOR Investigators
        • et al.
        Short-term mortality of myocardial infarction patients with diabetes or hyperglycaemia during admission.
        J Epidemiol Community Health. 2002; 56: 707-712
        • Williams LS
        • Rotich J
        • Qi R
        • et al.
        Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke.
        Neurology. 2002; 59: 67-71
        • Capes SE
        • Hunt D
        • Malmberg K
        • Pathak P
        • Gerstein HC
        Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview.
        Stroke. 2001; 32: 2426-2432
        • Kagansky N
        • Levy S
        • Knobler H
        The role of hyperglycemia in acute stroke.
        Arch Neurol. 2001; 58: 1209-1212
        • Parsons MW
        • Barber PA
        • Desmond PM
        • et al.
        Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study.
        Ann Neurol. 2002; 52: 20-28
        • Bruno A
        • Levine SR
        • Frankel MR
        • NINDS rt-PA Stroke Study Group
        • et al.
        Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial.
        Neurology. 2002; 59: 669-674
        • Estrada CA
        • Young JA
        • Nifong LW
        • Chitwood Jr, WR
        Outcomes and perioperative hyperglycemia in patients with or without diabetes mellitus undergoing coronary artery bypass grafting.
        Ann Thorac Surg. 2003; 75: 1392-1399
        • Guvener M
        • Pasaoglu I
        • Demircin M
        • Oc M
        Perioperative hyperglycemia is a strong correlate of postoperative infection in type II diabetic patients after coronary artery bypass grafting.
        Endocr J. 2002; 49: 531-537
        • Latham R
        • Lancaster AD
        • Covington JF
        • Pirolo JS
        • Thomas CS
        The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients.
        Infect Control Hosp Epidemiol. 2001; 22: 607-612
        • Golden SH
        • Peart-Vigilance C
        • Kao WH
        • Brancati FL
        Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes.
        Diabetes Care. 1999; 22: 1408-1414
        • Yendamuri S
        • Fulda GJ
        • Tinkoff GH
        Admission hyperglycemia as a prognostic indicator in trauma.
        J Trauma. 2003; 55: 33-38
        • Krinsley JS
        Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients.
        Mayo Clin Proc. 2003; 78: 1471-1478
        • Van den Berghe G
        • Wouters P
        • Weekers F
        • et al.
        Intensive insulin therapy in critically ill patients.
        N Engl J Med. 2001; 345: 1359-1367
        • Furnary AP
        • Gao G
        • Grunkemeier GL
        • et al.
        Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting.
        J Thorac Cardiovasc Surg. 2003; 125: 1007-1021
        • Knaus WA
        • Draper EA
        • Wagner DP
        • Zimmerman JE
        APACHE II: a severity of disease classification system.
        Crit Care Med. 1985; 13: 818-829
        • Knaus WA
        • Wagner DP
        • Draper EA
        • et al.
        The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults.
        Chest. 1991; 100: 1619-1636
        • Bone RC
        • Balk RA
        • Cerra FB
        • American College of Chest Physicians/Society of Critical Care Medicine
        • et al.
        Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.
        Chest. 1992; 101: 1644-1655
        • Bernard GR
        • Vincent JL
        • Laterre PF
        • Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) Study Group
        • et al.
        Efficacy and safety of recombinant human activated protein C for severe sepsis.
        N Engl J Med. 2001; 344: 699-709
        • Acute Respiratory Distress Syndrome Network
        Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.
        N Engl J Med. 2000; 342: 1301-1308
        • Coursin DB
        • Murray MJ
        How sweet is euglycemia in critically ill patients? [editorial].
        Mayo Clin Proc. 2003; 78: 1460-1462
        • Das UN
        Is insulin an antiinflammatory molecule?.
        Nutrition. 2001; 17: 409-413
        • Das UN
        Is insulin an endogenous cardioprotector?.
        Crit Care. 2002; 6: 389-393
        • Hansen TK
        • Thiel S
        • Wouters PJ
        • Christiansen JS
        • Van den Berghe G
        Intensive insulin therapy exerts antiinflammatory effects in critically ill patients and counteracts the adverse effect of low mannose-binding lectin levels.
        J Clin Endocrinol Metab. 2003; 88: 1082-1088
        • Van den Berghe G
        • Wouters PJ
        • Bouillon R
        • et al.
        Outcome benefit of intensive insulin therapy in the critically ill: insulin dose versus glycemic control.
        Crit Care Med. 2003; 31: 359-366
        • Finney SJ
        • Zekveld C
        • Elia A
        • Evans TW
        Glucose control and mortality in critically ill patients.
        JAMA. 2003; 290: 2041-2047
        • Annane D
        • Melchior JC
        Hormone replacement therapy for the critically ill [editorial].
        Crit Care Med. 2003; 31: 634-635
        • Van den Berghe G
        • Bouillon R
        Optimal control of glycemia among critically ill patients [letter].
        JAMA. 2004; 291: 1198-1199
        • Finney SJ
        • Evans TW
        Optimal control of glycemia among critically ill patients [reply].
        JAMA. 2004; 291: 1199

      Linked Article

      • Tight Blood Glucose Control With Insulin in “Real-Life” Intensive Care
        Mayo Clinic ProceedingsVol. 79Issue 8
        • Preview
          Throughout the past decades, development of high-tech monitoring systems as well as mechanical and pharmacological support of vital organs has enabled physicians to “rescue” patients who would otherwise die of insults that induce profound hypoxia or shock. Despite this technological revolution, which also allowed intensive care medicine to be recognized as a medical subspecialty, outcome of many diseases for which patients are being treated in intensive care units (ICUs) has not improved dramatically.
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      • Correction
        Mayo Clinic ProceedingsVol. 80Issue 8
        • Preview
          Incorrect table: In the article by Krinsley entitled “Effect of an Intensive Glucose Management Protocol on the Mortality of Critically Ill Adult Patients,” published in the August 2004 issue of the Mayo Clinic Proceedings (Mayo Clin Proc. 2004;79:992-1000), Table 2 on page 995 was incorrect. A correct version of Table 2 is shown below.
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