CONTRÔLE PERIOPERATOIRE DE LA GLYCEMIE Jean-Charles Preiser Philippe Devos Soins Intensifs Généraux Soins Intensifs Généraux C.H.U. Sart Tilman – Liège

CONTRÔLE PERIOPERATOIRE CONTRÔLE PERIOPERATOIRE DE LA GLYCEMIEDE LA GLYCEMIE

Jean-Charles PreiserJean-Charles PreiserPhilippe DevosPhilippe Devos

Soins Intensifs GénérauxSoins Intensifs GénérauxC.H.U. Sart Tilman – LiègeC.H.U. Sart Tilman – Liège

SAC SAC CharleroiCharleroi

7 novembre 20067 novembre 2006

AU PROGRAMME…AU PROGRAMME…

INSULINO-RESISTANCE POST- INSULINO-RESISTANCE POST- OPERATOIRE OPERATOIRE

PROGRAMME ERASPROGRAMME ERAS EFFETS CLINIQUESEFFETS CLINIQUES CONTRÔLE DE LA GLYCEMIE AUX CONTRÔLE DE LA GLYCEMIE AUX

SOINS INTENSIFSSOINS INTENSIFS

LENGTH OF STAYLENGTH OF STAY


TYPETYPESURGERYSURGERY

BLOODBLOODLOSSESLOSSES



BLOODBLOODLOSSESLOSSES


INSULIN INSULIN RESISTANCERESISTANCE



INSULIN INSULIN RESISTANCERESISTANCE





Stress opératoireStress opératoire

Allongement durée d’hospitalisation (LOS)Allongement durée d’hospitalisation (LOS)

Hormones de stress/Cytokines proinflammatoiresHormones de stress/Cytokines proinflammatoires

Résistance à l’insulineRésistance à l’insuline

RELATIVE INSULIN SENSITIVITY RELATIVE INSULIN SENSITIVITY RELATED TO THE TYPE OF SURGERYRELATED TO THE TYPE OF SURGERY

Thorell A et al, Curr Opin Clin Nutr Metab Care 1999; 2: 69Thorell A et al, Curr Opin Clin Nutr Metab Care 1999; 2: 69

0

50

100

Per

cen

t (%

)

muscles

glucoseglucose

cerveau

acides grasacides gras

érythrocytes

LymphocytesG.Blancs

intestin

glutamine

foiefoie

TissusTissusagressésagressés

lactatelactate

Adaptations métaboliques à l’agression

Insulino-résistance

alaninealanine

adipocytes

glycéroll

Insulino-résistance

InsulinoInsulinoindépendanceindépendance

POSTOP vs DIABETES IIPOSTOP vs DIABETES IICarbohydrate MetabolismCarbohydrate Metabolism

PostopPostop Type II diabetesType II diabetes

HyperglycemiaHyperglycemia ++ ++

Insulin sensitivityInsulin sensitivity -- --

Glucose productionGlucose production ++ ++

GLUT4 translocationGLUT4 translocation -- --

Glycogen formationGlycogen formation -- --

Ljunqgvist Clin Nutr 2001Ljunqgvist Clin Nutr 2001

LIVER gluconeogenesis,from amino acids, lactateand glycerol glycogenolysis

INSULIN-DEPENDENT TISSUES

- SKELETAL MUSCLE, MYOCARDIUM

- ADIPOSE TISSUE

- LIVER

insulin dependentglucose uptake

glycolysis

glycerol synthesis from trigycerides hydrolysis

lactate and alanine synthesis (not in liver)

NON-INSULIN

DEPENDENT TISSUES

(all other tissues including

brain, kidney, immune system, etc.)

glucose uptake

glucose oxidation

plasma glucose

KIDNEY

gluconeogenesis

futilecycles

alanine lactate glycerol

CHO METABOLISM DURING STRESSCHO METABOLISM DURING STRESSBiolo et al Intensive Care Med 2002:28:1512Biolo et al Intensive Care Med 2002:28:1512

TIME COURSE OF INSULIN TIME COURSE OF INSULIN RESISTANCERESISTANCE

Thorell Curr Opin Clin Nutr Metab Care 1999Thorell Curr Opin Clin Nutr Metab Care 1999

0

20

40

60

80

100

120

0 1 6 10 20

Time (days)

Insu

lin s

ensi

tivi

ty (

%)

WHO IS RESPONSIBLE?WHO IS RESPONSIBLE?

Hormones (« counter-regulatory »)Hormones (« counter-regulatory ») GlucagonGlucagon Steroïds Steroïds GHGH Catecholamines Catecholamines

Inflammatory mediatorsInflammatory mediators : : TNF, IL1, IL6,…TNF, IL1, IL6,…

Insulin (receptor)-mediated feedback mechanismsInsulin (receptor)-mediated feedback mechanisms

INSULIN RESISTANCEINSULIN RESISTANCE

Is not beneficialIs not beneficial Should be treated or avoidedShould be treated or avoided Can be decreased by epidural Can be decreased by epidural

analgesia and preoperative CHOanalgesia and preoperative CHO Allows normoglycemia during feedingAllows normoglycemia during feeding Decreases postoperative morbidityDecreases postoperative morbidity





ERAS

Enhanced Recovery After colorectal SurgeryEnhanced Recovery After colorectal Surgery

apport oral glucides préopapport oral glucides préop

analgésie épiduraleanalgésie épidurale

mobilisation préopératoire précocemobilisation préopératoire précoce

=> réduction durée d’hospitalisation (LOS)=> réduction durée d’hospitalisation (LOS)

ERAS

Glucides préopGlucides préop

solution orale (12.5%) solution orale (12.5%)

800 ml la veille à minuit et 400 ml 2-3h avant chirurgie800 ml la veille à minuit et 400 ml 2-3h avant chirurgie

Réduction résistance à l’insulineRéduction résistance à l’insulineAmélioration de la balance azotéeAmélioration de la balance azotée

Réduction de l’anxiété préopRéduction de l’anxiété préop

Réduction nausée et vomissements postopRéduction nausée et vomissements postop

Amélioration du bien-être postopAmélioration du bien-être postop

Réduction durée hospitalisationRéduction durée hospitalisationHausel J. et al.Hausel J. et al.

EFFECTS OF PREOP CHOEFFECTS OF PREOP CHONygren Curr Opin Clin Nutr Metab Care 2001Nygren Curr Opin Clin Nutr Metab Care 2001

-60

-50

-40

-30

-20

-10

0

10

20

Insulin resistance (%

change from preop)

Cholecystectomy Colorectal Arthroplasty

Preop CHO

No preop CHO

PREOPERATIVE CHOPREOPERATIVE CHO

20% glucose IV20% glucose IV 12.5 % CARBOHYDRATE DRINK12.5 % CARBOHYDRATE DRINK

800 at midnight + 400 ml 2-3 hrs prior to 800 at midnight + 400 ml 2-3 hrs prior to surgery (295 mOsm/l)surgery (295 mOsm/l)

GASTRIC EMPTYING??GASTRIC EMPTYING??

EFFECTS OF CHO ON GASTRIC EFFECTS OF CHO ON GASTRIC VOLUME AND pHVOLUME AND pH

Hausel Anesth Analg 2001Hausel Anesth Analg 2001

TreatmentTreatment Gastric volume Gastric volume (ml) - IQR(ml) - IQR

Acidity (pH)Acidity (pH)

IQRIQR

Overnight fast Overnight fast (n=89)(n=89)

6-41 6-41 1.6-4.01.6-4.0

Placebo (n=86)Placebo (n=86) 12-3512-35 1.6-2.51.6-2.5

CHO 12.5 % CHO 12.5 % (n=80)(n=80)

7-417-41 1.6-2.71.6-2.7

ERAS

POSTOPERATIVE INSULIN RESISTANCEPOSTOPERATIVE INSULIN RESISTANCE

Is not beneficialIs not beneficial

Should be treated or avoidedShould be treated or avoided

Can be decreased by epidural analgesia and Can be decreased by epidural analgesia and preoperative CHOpreoperative CHO

Allows normoglycemia during Allows normoglycemia during feedingfeeding

Decreases postoperative morbidityDecreases postoperative morbidity

Hausel J. et al.Hausel J. et al.

INSULIN RESISTANCEINSULIN RESISTANCE

Is not beneficialIs not beneficial Should be treated or avoidedShould be treated or avoided Can be decreased by epidural Can be decreased by epidural

analgesia and preoperative CHOanalgesia and preoperative CHO Allows normoglycemia during feedingAllows normoglycemia during feeding Decreases postoperative morbidityDecreases postoperative morbidity









TIGHT GLYCAEMIA CONTROL:TIGHT GLYCAEMIA CONTROL:The dream comes trueThe dream comes true

BenefitsBenefits•Reduces complication Reduces complication raterate•Reduces mortalityReduces mortality•Decreases LOSDecreases LOS•CheapCheap•Easily accessibleEasily accessible

Risks /constraintsRisks /constraints•HypoglycemiaHypoglycemia•EquipmentEquipment•Human resourcesHuman resources

GLUCOSE CONTROL AND MORTALITY GLUCOSE CONTROL AND MORTALITY IN CRITICALLY ILL PATIENTSIN CRITICALLY ILL PATIENTS

Finney JAMA 2003;290:2041Finney JAMA 2003;290:2041

530 patients : cardiothoracic surgery (90%)530 patients : cardiothoracic surgery (90%) Ranges of glycemia : Ranges of glycemia :

0.8-1.10.8-1.1 1.1-1.41.1-1.4 1.4-1.81.4-1.8 1.8-2.01.8-2.0 >2.0>2.0

Decreased mortality when glycemia < 1.4 g/lDecreased mortality when glycemia < 1.4 g/l « Control of glucose levels rather than of absolute levels « Control of glucose levels rather than of absolute levels

of exogenous insulin appear to account for the mortality of exogenous insulin appear to account for the mortality benefit with intensive insulin therapy » benefit with intensive insulin therapy »

CONSTRAINTS AND RISKS OF CONSTRAINTS AND RISKS OF TIGHT GLUCOSE CONTROLTIGHT GLUCOSE CONTROL

ConstraintsConstraints Frequent checksFrequent checks

CostCost TimeTime

NursesNurses ExamsExams

EquippmentEquippment GlucometersGlucometers Automated syringesAutomated syringes

RisksRisks HypoglycemiaHypoglycemia

Often asymptomatic Often asymptomatic (altered mental status)(altered mental status)

Neurological symptomsNeurological symptoms Adrenergic Adrenergic

manifestationsmanifestations

THE REAL LIFE (2003)THE REAL LIFE (2003)

Glycaemia Threshold IC Units

110 mg/dL 3

120 mg/dL 5

150 mg/dL 19

180 mg/dL 5

200 mg/dL 4

02468

101214161820

# ce

ntr

es

110 120 150 180 200

Glycaemia threshold (mg/dL)Survey on European ICUs in 2003Survey on European ICUs in 2003

GLUCONTROL STUDY - Ph. Devos ESICM 2005GLUCONTROL STUDY - Ph. Devos ESICM 2005

ANZICS survey ANZICS survey 29 hospitals29 hospitals

IssueIssue FrequencyFrequency

IIT protocol for every ptIIT protocol for every pt

IIT protocol in selected ptsIIT protocol in selected pts

10 %10 %

31% (ICU >3d – sepsis - surgery)31% (ICU >3d – sepsis - surgery)

At least Once blood glucose > 6.1 mMAt least Once blood glucose > 6.1 mM

At least once Blood glucose > 11.1 At least once Blood glucose > 11.1 mMmM

91.7 %91.7 %

36.2 %36.2 %

Insulin therapyInsulin therapy 31.1%31.1%

Trigger to start insulinTrigger to start insulin 11.5 mM (9.4-14.0)11.5 mM (9.4-14.0)

Survivors (90%)Survivors (90%)

vs nonsurvivorsvs nonsurvivors

Max BG 9.5 mM Insulin - 8.3%Max BG 9.5 mM Insulin - 8.3%

Max BG 12.0 mM Insulin - 14.3%Max BG 12.0 mM Insulin - 14.3%

D Angus – Ed Abraham AJRCCM 2005 DecD Angus – Ed Abraham AJRCCM 2005 Dec

CURRENT MULTI-CENTRE STUDIES ON CURRENT MULTI-CENTRE STUDIES ON

TIGHT GLUCOSE CONTROL IN ICUSTIGHT GLUCOSE CONTROL IN ICUS DesignDesign PrimPrim

End-ptEnd-pt

Nb ptsNb pts

requiredrequired

Nb hospNb hosp CurrentCurrent

statusstatus

VISEPVISEP 2x22x2

Random Random fluid + BGfluid + BG

MortalityMortality 600600 1717 StoppedStopped

GlucontrolGlucontrol Open labelOpen label

Random/ctrlRandom/ctrl

Stratified Stratified

ICU ICU mortalitymortality

28942894 2424 StoppedStopped

NICE-NICE-SugarSugar

Open labelOpen label

Random/ctrlRandom/ctrl

StratifiedStratified

90-d 90-d mortalitymortality

45004500 2323 OngoingOngoing

TIGHT GLYCAEMIA CONTROL:TIGHT GLYCAEMIA CONTROL:Does the dream come true orDoes the dream come true or

time to wake up? time to wake up?

BenefitsBenefits•Reduces complication Reduces complication rate ?rate ?•Reduces mortality?Reduces mortality?•Decreases LOS?Decreases LOS?•CheapCheap•Easily accessibleEasily accessible

Risks - costsRisks - costs•HypoglycemiaHypoglycemia•EquippmentEquippment•Human resourcesHuman resources

REASONS FOR REASONS FOR DISCONTINUATIONDISCONTINUATION

VISEPVISEP (March 2005 – 488 patients) (March 2005 – 488 patients) Unacceptably high rate of hypoglycemiaUnacceptably high rate of hypoglycemia No beneficial effect on outcomeNo beneficial effect on outcome

VISEP STUDY VISEP STUDY 488 patients in 17 centres488 patients in 17 centres

28-d mort 90-d mort Rate hypo

IIT

CIT

GLUCONTRGLUCONTROLOL

A Multi-Centre Study Comparing the A Multi-Centre Study Comparing the Effects of Two Glucose Control Effects of Two Glucose Control Regimens by Insulin in Intensive Regimens by Insulin in Intensive Care Unit PatientsCare Unit Patients

SAMPLE SIZESAMPLE SIZE

Expected outcomeExpected outcome (considering a baseline (considering a baseline ICU mortality of 20%) ICU mortality of 20%) 4% decrease of absolute ICU mortality (20% 4% decrease of absolute ICU mortality (20%

relative)relative) Power 80%Power 80% 1447 patients /group (total 2894) required (initial 1447 patients /group (total 2894) required (initial

estimate)estimate)

GLUCONTROGLUCONTROLL Prospective, randomised, controlled, Prospective, randomised, controlled,

investigator-blinded and multicentric studyinvestigator-blinded and multicentric study Aimed at comparing the effects of two Aimed at comparing the effects of two

regimens of insulin therapy, respectively regimens of insulin therapy, respectively titrated to achieve a blood sugar level titrated to achieve a blood sugar level between 4.4 and 6.1 mmol/l (80 and 110 mg/dl, between 4.4 and 6.1 mmol/l (80 and 110 mg/dl,

respectively) = respectively) = GROUP AGROUP A and between 7.8 and 10.0 mmol/l (140 and 180 mg/dl, and between 7.8 and 10.0 mmol/l (140 and 180 mg/dl,

respectively) = respectively) = GROUP BGROUP B

GLUCONTROGLUCONTROLL Primary Outcome : absolute intensive care unit Primary Outcome : absolute intensive care unit

(ICU) mortality (target = 4%-decrease).(ICU) mortality (target = 4%-decrease). Secondary outcome variables : Secondary outcome variables :

in-hospital and 28-day mortality, in-hospital and 28-day mortality, lengths of stays in ICU and in the hospital, lengths of stays in ICU and in the hospital, length of ICU stay without life-support therapy, length of ICU stay without life-support therapy,

number and clinical signs of episodes of number and clinical signs of episodes of hypoglycaemia, hypoglycaemia,

rates of infections and organ failures, rates of infections and organ failures, number of red-cells transfusions.number of red-cells transfusions.

Inclusion criteriaInclusion criteria 18 years or older18 years or older admitted in an ICUadmitted in an ICU

Exclusion criterionExclusion criterion Absence of signed informed consentAbsence of signed informed consent


GLUCONTROGLUCONTROLL

Planning :Planning : Interim analysis each 100 ICU deathsInterim analysis each 100 ICU deaths In order to detect a 4% decrease of absolute mortality In order to detect a 4% decrease of absolute mortality

3500 patients to be included3500 patients to be included


7 countries7 countries Austria, Belgium, France, Israel, The Austria, Belgium, France, Israel, The

Netherlands, Slovenia and Spain.Netherlands, Slovenia and Spain.

21 units in 19 centres21 units in 19 centres


Planning :Planning : Interim analysis each 100 ICU deathsInterim analysis each 100 ICU deaths In order to detect a 4% decrease of absolute mortality In order to detect a 4% decrease of absolute mortality

3500 patients to be included3500 patients to be included

STUDY STOPPED ON MAY 29th, 2006STUDY STOPPED ON MAY 29th, 2006 Safety concernSafety concern High rate of unintended protocol violations High rate of unintended protocol violations

1108 recruited patients1108 recruited patients1099 randomized patients1099 randomized patientsPatients available for the Patients available for the

analysis: analysis: n = 1091 n = 1091 Group A: 538 patientsGroup A: 538 patientsGroup B: 553 patientsGroup B: 553 patients

Length of observation: Length of observation: from 1 to 56 days (median: 5; IQR: 3 – 10)from 1 to 56 days (median: 5; IQR: 3 – 10)

GLUCONTROLGLUCONTROL

0

20

40

60

80

100

120

140

160

180

1 2 3 4 5 6 7 8 9 1011 12 13 14 15 16 17 1819 20 21

Unit

Nu

mb

er

of

pati

en

ts

1091 patients


0.69960.69965.0 (3.0 – 10.5)5.0 (3.0 – 10.5)5.0 (3.0 – 10.0)5.0 (3.0 – 10.0)ICU LOS, dayICU LOS, day

0.69590.69594.0 %4.0 %3.5 %3.5 %ReadmissionReadmission

0.99850.998541.3 %41.3 %

32.8 %32.8 %

18.4 %18.4 %

8.1 %8.1 %

41.6 %41.6 %

31.8 %31.8 %

18.6 %18.6 %

8.0 %8.0 %

CategoryCategory

Medical Medical

Scheduled SurgeryScheduled Surgery

Emergency SurgeryEmergency Surgery

Trauma Trauma

0.8320.832342/208342/208336/199336/199Sex ratio, M/FSex ratio, M/F

0.9840.98465 (51 – 74)65 (51 – 74)65 (51-74)65 (51-74)Age, yrAge, yr

PPGroup BGroup B

(n = 553)(n = 553)Group AGroup A

(n = 538)(n = 538)

Median (IQR)


10 20 30 40 50 60 70 80 90 100

Age, yr

Group A

140

120

100

80

60

40

20

0

Frequency

10 20 30 40 50 60 70 80 90 100

Age, yr

Group B160

140

120

100

80

60

40

20

0

Frequency


Group AGroup A

(n = 538)(n = 538)Group BGroup B

(n = 553)(n = 553) PP

SubCategorySubCategory

TraumaTrauma

NeurologicalNeurological

GastroenterologicalGastroenterological

OrthopaedicOrthopaedic

RenalRenal

CardiacCardiac

RespiratoryRespiratory

VascularVascular

HematologicalHematological

OtherOther

5.9 %5.9 %

15.1 %15.1 %

18.1 %18.1 %

1.2 %1.2 %

2.2 %2.2 %

34.0 %34.0 %

18.9 %18.9 %

1.6 %1.6 %

0.4 %0.4 %

2.8 %2.8 %

6.1 %6.1 %

13.3 %13.3 %

14.7 %14.7 %

0.6 %0.6 %

2.7 %2.7 %

34.5 %34.5 %

18.9 %18.9 %

3.4 %3.4 %

0.8 %0.8 %

5.1 %5.1 %

0.23040.2304


Group AGroup A


(n = 553)(n = 553) PP

APACHE II scoreAPACHE II score 20 (15 - 25)20 (15 - 25) 20 (15 – 26)20 (15 – 26) 0.7280.728

SOFA scoreSOFA score 7 (5 – 9)7 (5 – 9) 7 (5 – 9)7 (5 – 9) 0.6050.605

Preexisting Diabetes:Preexisting Diabetes:

Type of diabetes: Type of diabetes:

Insulin- dependent Insulin- dependent

Non insulin-Non insulin-dependentdependent

HbA1c:HbA1c:

> 6.5 % > 6.5 %

16.4 %16.4 %

34.4 %34.4 %

65.6 %65.6 %

16.3 %16.3 %

23.7 %23.7 %

28.0 %28.0 %

72.0 %72.0 %

25.1 %25.1 %

0.00560.0056

0.39460.3946

0.05350.0535

GCSGCS 15 (8 -15)15 (8 -15) 15 (9 – 15)15 (9 – 15) 0.7740.774

Median (IQR)


300

250

200

150

100

50

Group A Group B

p < 0.0001


118 (109-131)118 (109-131) 144 (127-163) 144 (127-163)

Number of glycemia/patients: From 2 to 856 measures (median: 33; IQR: 14 - 85)Number of glycemia/patients: From 2 to 856 measures (median: 33; IQR: 14 - 85)

Blo

od

glu

cose

, m

g/d

l

80

90

100

110

120

130

140

150

160

170

180

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Treatment, days

Group A

Group B

Median with IQR

* * * * * * * * **

* * * * *

* p < 0.001


Blo

od

glu

cose

, m

g/d

l

80

90

100

110

120

130

140

150

160

170

180

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Treatment, days

Group A

Group B

Median with IQR

* * * * * * * * **

* * * * *

* p < 0.001


Blo

od

glu

cose

, m

g/d

l

80

90

100

110

120

130

140

150

160

170

180

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Treatment, days

Blo

od

glu

cose

, m

g/d

l

Group A

Group B

Median with IQR

* * * * * * * * **

* * * * *

* p < 0.001


160

140

120

100

80

60

40

20

0

Variability of blood glucose

Group A Group BSD

of

blo

od

glu

cose

, m

g/d

l

p NS


50 100 150 200 250 300

Blood glucose (integrated), mg/dl

300

250

200

150

100

50

Blo

od g

luco

se (

ari

thm

eti

c m

ean),

mg/d

lY = 4.14 + 0.98 X r² = 0.928


< 0.0001< 0.00012 (0 – 5)2 (0 – 5)0 (0 – 1)0 (0 – 1)Insulin free days, Insulin free days, daysdays

< 0.0001< 0.00010.4 (0.0 – 0.4 (0.0 – 1.4)1.4)

1.8 (1.0 – 1.8 (1.0 – 2.9)2.9)

Insulin rate, U/hrInsulin rate, U/hr

<0.0001<0.000157.757.784.684.6Patients treated by Patients treated by insulin IV (ITT), %insulin IV (ITT), %

<0.0001<0.000166.966.996.896.8Patients treated by Patients treated by insulin IV (PP), %insulin IV (PP), %

PPGroup BGroup B


(n = 538)(n = 538)

Median (IQR)


Group A

INS

ULI

N F

RE

E D

AYS

, d

ays

Group B

15

10

5

0

p < 0.0001


Median with IQR

Median (IQR)


< 0.0001< 0.00012.7 %2.7 %9.8 %9.8 %Patients with Patients with hypoglycemia < 40, %hypoglycemia < 40, %

PPGroup BGroup B


(n = 538)(n = 538)

Multivariable analysis: hypoglycemia < 60 mg/dlMultivariable analysis: hypoglycemia < 60 mg/dl

Adjusted ORAdjusted OR 95 % CI95 % CI pp

Group AGroup A

DeathDeath

Apache IIApache II

7.007.00

2.082.08

1.071.07

4.85 - 10.114.85 - 10.11

1.28 – 3.381.28 – 3.38

1.04 – 1.091.04 – 1.09

0.00010.0001

0.00310.0031

0.00010.0001

Multivariable analysis: hypoglycemia < 40 mg/dlMultivariable analysis: hypoglycemia < 40 mg/dl


Group AGroup A

DeathDeath

Apache IIApache II

3.683.68

2.592.59

1.071.07

1.95 – 6.951.95 – 6.95

1.34 – 5.031.34 – 5.03

1.03 – 1.111.03 – 1.11

0.00010.0001

0.0480.048

0.00060.0006


0.700.705 (3-11)5 (3-11)5 (3-10)5 (3-10)ICU LOS, daysICU LOS, days

0.190.199.769.7612.2712.27Mortality rate, %Mortality rate, %

PPGroup BGroup B


(n = 538)(n = 538)

Median (IQR)



PPGroup BGroup B


(n = 538)(n = 538)

Median (IQR)


0

2

4

6

8

10

12

14

16

0 100 200 300 400 500 600 700 800 900 1000 1100 1200

Number of inclusions

Cum

ula

tive D

eath

rate

, %

Group A Group B


0.00020.000211.6 %11.6 %18.3 %18.3 %Death among patients Death among patients

with Hypoglycemia < with Hypoglycemia < 40, %40, %


PPGroup BGroup B


(n = 538)(n = 538)

Median (IQR)


Univariable analysisUnivariable analysis

Crude ORCrude OR 95 % CI95 % CI pp

Group AGroup A 1.281.28 0.88 - 1.880.88 - 1.88 0.1980.198

Multivariable analysisMultivariable analysis


Group AGroup A

Gender (male)Gender (male)

Age, yrAge, yr

Apache IIApache II

SOFASOFA

1.311.31

1.781.78

1.021.02

1.041.04

1.081.08

0.88 – 1.950.88 – 1.95

1.15 - 2.751.15 - 2.75

1.01 – 1.041.01 – 1.04

1.02 – 1.071.02 – 1.07

1.01 – 1.161.01 – 1.16

0.1780.178

0.00930.0093

0.00110.0011

0.00030.0003

0.02910.0291


RISK OF DEATHRISK OF DEATH

Non diabetic patients: 855Non diabetic patients: 855Diabetic patients: 236Diabetic patients: 236

Type I : 64Type I : 64Type II: 144Type II: 144Unsuspected (HbA1c > 6.5 %): 28Unsuspected (HbA1c > 6.5 %): 28


Group AGroup A


(n = 553)(n = 553) PP

Previous Diabetes:Previous Diabetes:

Type of diabetes: Type of diabetes:

Insulinodependent Insulinodependent

Non Non InsulinodependentInsulinodependent

Unsuspected prior Unsuspected prior

admission admission

with HbA1c > 6.5 %with HbA1c > 6.5 %

HbA1c:HbA1c:

> 6.5 % > 6.5 %

19.0 %19.0 %

5.8 %5.8 %

11.0 %11.0 %

2.2 %2.2 %

16.3 %16.3 %

24.2 %24.2 %

6.0 %6.0 %

15.4 %15.4 %

2.9 %2.9 %

25.1 %25.1 %

0.04120.0412

0.60410.6041

0.05350.0535


Group AGroup A Group BGroup B PP

Non diabetic patients Non diabetic patients

855 patients:855 patients:

Deaths Deaths

Diabetic patientsDiabetic patients

236 patients 236 patients

DeathsDeaths

436436

12.6 %12.6 %

102102

10.8 %10.8 %

419419

10.3 %10.3 %

134134

8.21 %8.21 %

0.2810.281

0.5000.500


TIGHT GLYCAEMIA CONTROL:TIGHT GLYCAEMIA CONTROL:

RisksRisks

BenefitsBenefits

TIGHT GLUCOSE CONTROL WITH TIGHT GLUCOSE CONTROL WITH INTENSIVE INSULIN THERAPYINTENSIVE INSULIN THERAPY

Hazards ofhyperglycemia Risks of

hypoglycemia

Being funambulist may not be accessible to everyone

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CONTRÔLE PERIOPERATOIRE DE LA GLYCEMIE Jean-Charles Preiser Philippe Devos Soins Intensifs Généraux Soins Intensifs Généraux C.H.U. Sart Tilman – Liège