First Trial of Intensive Glycemic Control in Critically Ill Emergency Department Patients
Department of Emergency Medicine
Cohen, Jason; Goedecke, Erik; Mangolds, Virginia; Przyklenk, Karin
Medical Subject Headings
Hypoglycemic Agents; Insulin; Critical Illness; Emergency Service, Hospital
Critical Care | Emergency Medicine | Endocrinology, Diabetes, and Metabolism
Background:Reports in the literature have shown that hyperglycemia and insulin resistance are a common occurrence in critically ill patients and are associated with adverse outcomes.1,2 In recent years, several randomized studies have demonstrated a significant reduction in morbidity and mortality when intensive glycemic control is instituted in the ICU.3,4,5These findings have led to the near universal adoption of aggressive glycemic control as a standard of care in this setting. Rivers et al. (2001) demonstrated that providing critical care services at the earliest possible stage of patient presentation can improve patient outcomes. Out of necessity, critical care starts in the emergency department (ED) and cannot be delayed until patients reach the ICU. This is particularly important given that many patients today are spending longer hours in the ED and being managed by Emergency Physicians. Therefore, since treatment of relative hyperglycemia has been shown to benefit patients in the critical care setting and providing critical care at the earliest stage of patient care improves outcomes, the evaluation of tight glycemic control in the ED setting merits significant consideration.
Objectives: This study seeks to evaluate the efficacy of tight glycemic control on morbidity and mortality in critically ill patients when instituted in the ED. As critical care services are becoming a larger part of ED practice and wait times for critical care beds can range from hours to days, we hypothesize that instituting intensive glycemic control while the patient is in the ED may offer morbidity and mortality benefits comparable to those demonstrated in the ICU setting.
Methods: All adult, non-trauma, non-pregnant patients presenting to the Emergency Department of a university tertiary care center and identified as critically ill were eligible for enrollment on a convenience basis. Critical illness was determined upon the patient’s assignment to ICU admission. After obtaining written, informed consent from the patient or the patient’s family member, the randomization envelope was opened and the patient was assigned to either receive the ED standard of care as determined by the patient’s treating physician or intensive glycemic control. The intensive glycemic control protocol involved assessment of the patient’s blood glucose level as determined by a finger-stick measurement, with the subsequent institution of an insulin drip to maintain blood glucose levels between 80-110 mg/dL. The insulin drip was held for any period of time that the patient was out of the ED to obtain tests or studies and discontinued upon their transfer to the ICU. The patient’s severity of illness was determined by the calculation of an APACHE II score. Primary endpoints included in-hospital mortality, hospital length of stay, incidence of bacteremia, and requirement for vasopressors. Secondary endpoints included transfusion requirements, incidence of acute renal failure, length of mechanical ventilation, and length of ICU admission. Categorical variables were compared between groups by Fisher’s Exact Test, and continuous variables were compared by t-test.
Results: In the intention-to-treat analysis, 48 patients are enrolled to date. There was no statistically significant difference in age between the groups (63+3 vs. 54+4, p =0.14). We found that, despite randomization, patients in the treatment group had a significantly higher acuity level as determined by their preliminary Apache II scores (12+2 vs. 20+2,p Conclusion:The preliminary results of our pilot study suggest that the institution of intensive glycemic control in the ED ameliorated the higher degree of mortality and longer hospital stays that would have been expected for the treatment population given their level of acuity. Continued enrollment and analysis with the hopes of matching the groups for acuity should establish whether the attenuation seen in mortality and length of hospital stay is attributable to intensive glycemic control.
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3. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med2001; 345:1359-1367.
4. Rivers E, Nguyen B, Havstad S, et al., Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. N Engl J Med2001; 345:1368-1377.
5. Van den Berghe G., Wilmer A., Hermans G., Meersseman W., Wouters P.J., Milants I., Van Winjngaerden E., Bobbaers H., Bouillon R. Intensive Insulin Therapy in the Medical ICU. N Engl J Med2006; 354:449-461.
Cyrkler, Jennifer E., "First Trial of Intensive Glycemic Control in Critically Ill Emergency Department Patients" (2006). University of Massachusetts Medical School. Senior Scholars Program. Paper 16.
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