I found this article labeled “Don’t control hyperglycemia in ICU” and it stated not to use insulin for patients whether diabetic or not. I truly can’t understand the reasoning – can you?
I think the title “Don’t Manage Hyperglycemia in ICU” is not a correct interpretation of the action point “Explain that intensive insulin therapy to control blood glucose in hospitalized patients did not offer short- or long-term mortality benefits, leading the American College of Physicians to recommend against its use in ICU patients.” At least I hope that some sort of management should take place.
To me the paper just states that intensive insulin therapy had not benefits on short or long term mortality. Again it shows how narrow minded scientists can be. If the rate of mortality is the only control figure then we can go back to stoneage - no need for pumps, cgms, test stripes, your bad luck if you happen to develop kidney, eye or nerve problems - remember you are still alive and that counts for our mortality statistics. In other words they say that they are only liable for the death of a patient. For other damages diabetics will have no ground to proof that their mistreatment in the hospital was related to complications they developed later. Blame it all on the patient tactics - I love it.
In fact there is good evidence suggesting that for a T1 in DKA, normalizing bg’s rapidly with insulin may cause other problems (especially cerebral edema). Some papers call the preferred approach “low-dose” insulin (e.g. http://pediatrics.aappublications.org/cgi/content/full/113/2/e133 (
I know that most of us here are really sensitive to having good normal bg’s, and think of that as the leading (if not only) picture of our health, if we’re in intensive care it’s likely we have other more pressing issues.
Except with diabetes, there’s no “more pressing” or “less pressing”, it’s always pressing. I understand where the ICU people are coming from however the fact that they are willing to punt on BG reinforces my desire to stay out of there.
Part of the issue you have is with the poor reporting done on the two cited papers. The key points are that intensive insulin therapy does not seem to lead to the best outcomes in the ICU and the ACP recommends against using intensive therapy to strictly control or normalize blood sugars. They also recommend a target of 140-200 mg/dl.
Given the situation in a hospital and the fact that intensive therapy involves counting carbs and specific timing, it is not surprising and probably safer that you don’t have a nurse attempting to count your carbs and then coming in an hour after your meal with your bolus.
And if you are in the ICU, you are probably there for a reason and your body is probably fighting very hard to elevate your blood sugar as well, so 140-200 mg/dl in the ICU is actually probably a reasonable target.
It is not the best reporting or writing.
I’ve also heard about sudden normalization of blood sugars causing neuropathies.
I agree with the others’ take on the paper, however I don’t know that I agree with the paper! I’ve been ‘stuck’ in ICU for days after coming out of DKA. Once I have been in DKA since being on a pump - at that point I demanded that I be given control of my diabetes care (once no longer acidotic) because I wasn’t satisfied with their handling of it. However, I’ve always been told (and I’ve been in DKA about 5 times, in 4 different hospitals) that I COULDN’T be released until my BGs were stabilized under 130 or 140 for 12 hours (they were checking every 3-4 hours).
Regardless of my experiences and opinion, I think the confusion with the article comes in with their horribly written opening statement that ‘There’s no need to use insulin therapy to control blood glucose in hospitalized patients – with or without known diabetes’…which sounds like they’re saying ‘Diabetics don’t need insulin!’
I think that those who post often here, tend to be on the obsessive-compulsive side of bg control. I count myself among them (although maybe not the most OC). I don’t think docs and nurses in an ICU would really grok our viewpoint.
I myself suffer from these issues - not only do I worry about keeping my numbers good, but it really really bothers me to see a syringe or needle in somebody else’s hands, and dang it, if somebody’s gonna poke something through my skin, it really bothers me if it’s not me doing the poking. I’m told this is typical of “control freak” tendencies. Probably have a lot of grooves in my psyche after so many decades.
Funny, I’m the same way about flu shots. I’d REALLY rather give the shot myself, but I restrain myself and let the nurse do it. I think it’s an intramuscular shot, so I might just goof it up anyway, but the idea of someone else shooting something into me is unnerving!
One of the reasons is that following trauma or surgery the body has a large natural spike in blood sugar levels in normal healthy non-diabetics. It’s part of the healing process. So controlling this spike, may be non-beneficial to the person. One of the medical students who blog with me researched this topic and blogged about it: http://diabeticallymindnumbing.blogspot.com/2011/01/diabetics-and-surgery.html.
While this is about surgery, the reasoning can potentially be extrapolated to any trauma/ICU situation.
As an ICU Nurse , these papers are not talking about patients who are in there for DKA. They are referring to patients , who are extremely sick, in there with sepis , pneumonia, cardiac arrest, cardiac surgery etc. whether they are diabetic or not. Most of these patients are on Respirators, dont eat, are on continous tube feedings, and multiple drugs to sedate them and keep their blood pressure up.
Tight Blood glucose control in the ICU patients has only shown to benifit the Post Cardiac Surgery patient , ie (80-120) to help prevent post op mediasteinal wound infections. The Medical ICU patients , ie the sepsis , pneumonia etc kinds of patients according to research show no benefit in keeping them that tight, and actually increases their mortality rate after the first 3 days in the ICU. The tight glucose control treatment protocols involve Regular Insulin drips that give insulin every hour and patients Blood glucose are monitored every hour also.
Though I did not read this particular paper, they are probably referring to controlling Hyperglycemia with Insulin drips, which even when tightly monitored in an ICU setting can cause extreme hypoglycemia due to the stress response and counterregulartory hormones we secrete when we are critically ill.
Did you read the article at all? This has ABSOLUTELY nothing to do with intensive insulin therapy in a general or long-term setting. This is discussing a clinical trial of acute management of hyperglcaemia in a crisis situation. Don’t refer to scientists and clinicians as narrow minded when you clearly don’t understand the basic concepts that are presented in the article.
I haven’t read the paper, only some of the responses. My initial reaction is that if I’m in the ICU I think I’ve got bigger problems than maintaining tight BG control. First things first - keep me alive.
Terry
Exactly
Yup. Considering how understaffed and overworked many nursing units are these days, especially in critical care, it just wouldn’t be safe to layer tight glycemic control on top of other, more life-threatening priorities. Many of these articles are poorly written, though, so I’d always recommend going to the primary source for more clarity (in this case the ACP).
Agreed medpage is directed toward people with medical/scientific training and usually gives a synopsis of the basic facts with lots of jargon.
Of course there are bigger problems no doubts about that. But 20 years ago I have been in ICU and had big problems to get anyone interested in getting my numbers below 300. Being extradited to people with poor knowledge about glucose control or carb counting was very tough. This is why I am alarmed that the paper was summed up as “Don’t control hyperglycemia in ICU”. I am okay with raising the levels to 140 to 200 in times of crisis. But people simplify and at the end the statement about less control becomes don’t control.
Wow…Tim I didn’t know that normalizing bg’s rapidly with insulin may cause cerebral edema. When I was in DKA I remember the nurse came into my room and said that the Doctor ordered that he not let my bg’s go down lower than 400. I remember fussing at the nurse (LOL) because they were letting my bg’s stay that high. I wish he would have told me why they were keeping it high. Or, at lease making it come down slowly. Just when I thought I knew it all! LOL…Just goes to show you learn something new everyday. Thanks!
Thanks for the reference, SuFu! What bothered me about the paper is that they said not to control BGs in patients both diabetic and non-diabetic. It seems to me that you have 2 different cases there.
When my non-diabetic mother had pneumonia near the end of her life, her BG went to 140, one of my friends said, Oh, she must be diabetic!, and I said, NO, it’s just that she’s very sick.
But a diabetic in the same situation must surely go a lot higher than that, and be unable to maintain even the elevated level. And the advice in the paper SEEMED to be saying not to give insulin. Maybe it was just bad writing, but having been at 600+ when I had my coma last September, it seems that extremely high BGs would do more damage than good! And the paper seemed to be ignoring that. Maybe what is needed is research in what would be an appropriate BG for patients who are critically ill which is physiological, but not damaging.
Hmm, I had some experience in the NICU, junior was ok, MrsAcidRock had a fever when she was born but she had to spend a week there on antibiotics and it was a very rough place. Two people I’d waited on when I was a waiter lost their daughter but her child survived in the NICU but died 6 months later. I think 4/6 of the other kids in there when we were their died within a year. We felt very wierd sort of being in and out like we were.
That being said, while I sympathize with the administrative decision to punt on diabetes management other than the most crude, basic level, I don’t think that’s a good idea. Sure, if I get run over by a bus and am a mess, glue me back together but if it’s something manageable, the plan shouldn’t be “don’t worry about BG”, it should be included with the other whatevers. I read medical records at work and am regularly shocked by the stuff I’ve seen involving PWD. Which is not my focus at work but it’s hard to overlook. Pumps/ CGMs, etc. aren’t rocket science and, barring horriffic abdominal injuries, I would expect the people in the ICU to at least try to keep things in line, or let MrsAcidRock do it? Oh wait, she doesn’t know anything about running a pump either. 