1	Sweet’N Low et. Al Hyperglycemia’N Nutrition Support Food Feud: Clinical Pearls for 2004 Albert Barrocas, MD, FACS Methodist Hospital New Orleans, LA Tuesday February 10, 2004
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3	Objectives List the benefits of euglycemia (and risks of hyperglycemia) Develop an algorithm for the monitoring, prevention and management of hyper- and hypo- glycemia. (Laissez Les Bons Temps Rouler!!)
4	Starvation Vs. Stress
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6	Stress Hyperglycemia a. k. a. “diabetes of stress” or “pseudo-diabetes” Associated with increased morbidity and mortality Potential enhancement by TPN Insulin resistance (peripheral & hepatic) Elderly at higher risk
7	When Sweet Turns “Sour” Increased mortality and disability in non-diabetic patients. Increased CVC infection rates in diabetic patients. (McMahon) Increased mortality from AMI in diabetic patient (Malmberg et. al.) Impaired immunologic response to infection (Rayfield et. al.) Impaired gastrointestinal motility (Oster-Jorgensen et.al) Increased cardiovascular tone (Guigliano et. al.)
8	Other Potential Detrimental Effects of Hyperglycemia Increased incidence of mediastinits in diabetic patients undergoing CABG Hyperosmolarity (2Na+Gluc/18+Bun/2.8) Osmotic diuresis Electrolyte imbalance Glycation (glycosylation) of immunoglobulins (Hennessey et. al.)
9	Hyperglycemia – In Vitro Abnormalities Granulocyte adhesion Chemotaxis Phagocytosis Respiratory burst Intracellular killing Complement function Predisposing environment for Candida albicans infection
10	Hyperglycemia - How sweet it is ! How sweet is sweet? 220 mg/dL ? 200 mg/dL ? 180 mg/dL ? 150 mg/dL ? 145 mg/dL ? 130 mg/dL ? 120 mg/dL ? 110 mg/dL ?
11	Hyperglycemia Contributing Factors Rule of Ds Dextrose –PB, TPN, EN, PO liquids Diabetes Disease (Stress, Insulin resistance) Drugs (Steroids, Propofol, vasopressors, et. al.) Dialysis – CAPD, CAVHD Decreased intravascular volume Decreasing youth (aging) Doctors et. al. Da family , Doughnuts et. al.
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13	Insulin Vs. Glucose - Hero or Villain? Glucose Control And Mortality in Critically Ill Patients. Finney et. al. JAMA 290, 2003 End point- ICU mortality Six bands (ranges) of glycemic control Proportion of admission time spent by individual patient in each band was measured Conclusions: Increased insulin administration positively associated with ICU death regardless of glucose level Control of glucose level appear to account for mortality benefit Speculative glucose upper limit of 145 mg/dL
14	Management of Hyperglycemia Reduce CHO & Insulin resistance – TPN: <25 kcal/kg/d (total calories) - “permissive underfeeding” Protein 1.2 – 1.5 gm/kg/d Parenteral Willett, Atkins formulas? Set goal range (mg/dL) 80-110 Van den Berghe et. al. 80-120 (100-150 if medically stable ) McMahon <145 Finney et. al. Goal rate <4 mg/kg/min. Begin @ 3mg/kg/min (actual/usual wt.) If > 10% above ideal, use ideal wt. (Rosmarin et. al.)
15	Management of Hyperglycemia Remember: The lower the maximum goal level, the greater the risk of hypoglycemia. Infuse low and slow and increase according to monitored glucose levels. Minnie (Sweet) Pearls(@ Glucose): 1 mmol =180 mg To convert mmol/L to mg/dl, multiply by 18 To convert mg/dL to mmol/L, multiply by 0.05551
16	Sliding - Sliding Scales
17	Insulin in TPN Solution Plasma glucose level reasonably controlled < 200 mg/dL Influencing factors controlled Dose not requiring change < 24 hr. Administration dose: 0.1 IU/gm CHO/L Increase by 0.05 IU/gm CHO/L until glucose controlled.
18	Insulin Infusions Multiple Protocols 1 IU/ml in NaCl Limited to ICU or closely monitored units Frequent glucose determinations & rate adjustment – q. 1 hr. initially 1-2 IU/hr. initially, titrated according to established protocols and ranges of glucose levels
19	Insulin Infusions Multiple Protocols Mirtallo – 2 IU/hr. Initiate @>180mg/dL Adjusted until <200 mg/dL, limit<15 IU/hr. Van den Berghe et. al. - “Strict algorithm”. Initiate @>110mg/dL, limit 50 IU/hr. Mizock - Brown & Dodek - 3 IU bolus + 2 IU/hr. @>207 mg/dL Comprehensive nomogram – no limit Monitor, monitor, monitor
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21	Management of Hypoglycemia Varied definitions < 60mg/dL, Sx? Dextrose 50% IVP 25 – 50 ml ½ - 1 amp 12.5 - 25 gm Glucagon (Subcutaneous, IM or IV) 0.5 - 1 mg repeat in 20 min if needed Self-injectors available Oral O. J., glucose tabs, et. al. Sublingual sugar
22	Pearls, Aphorisms & Lagniappe If a little is good, a lot is not necessarily better Halitosis is better than no breath at all. The enemy of good is better. When at first you don’t succeed, consult. The ignorance of facts does not make them disappear. Man who looks at leopard through bamboo pole sees only one spot.
23	Pearls, Aphorisms & Lagniappe Often the therapy is worse than the disease. Primum non noncere. When you are up to part of your anatomy in alligators, it is hard to remember that your primary purpose was to drain the swamp. Illegitimi non carborundum. NCP June 2004 Issue “Enhancing Response to NS in Critical Patients” Invited review article: “Hyperglycemia and Nutrition Support: Theory and Practice” McCowen & Bistrian (a.ka. et. al.) Nutrition Week 2004 - Practice Posters N44, 63, 65
24	A.S.P.E.N. Rhoads Research Foundation Request for Proposals Intensive Glycemic Control in Critically Ill Patients Receiving TPN Purpose The principal objective of this request is to support meritorious hypothesis-driven clinical research that examines the role of intensive glucose management in critically ill patients receiving total parenteral nutrition (TPN).
25	Sweet’N Low et. Al Hyperglycemia’N Nutrition Support Food Feud: Clinical Pearls for 2004 Albert Barrocas, MD, FACS Methodist Hospital New Orleans, LA Tuesday February 10, 2004