Elsevier

Mayo Clinic Proceedings

Volume 79, Issue 8, August 2004, Pages 992-1000
Mayo Clinic Proceedings

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

https://doi.org/10.4065/79.8.992Get rights and content

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.

Section snippets

PATIENTS AND METHODS

The Stamford Hospital is a 305-bed community hospital that serves as a major teaching affiliate of the Columbia University College of Physicians and Surgeons; it maintains freestanding residency programs in internal medicine, family practice, general surgery, and obstetrics-gynecology. The adult ICU has 14 beds. The unit has a “hybrid” configuration, merging characteristics of both “open” and “closed” models. Medical and surgical residents write all orders in the unit; they are supervised

Comparison of Baseline Group and Treatment Group

Selected characteristics of the baseline group and treatment group are reported in Table 1. There was no significant difference between the 2 groups in age, sex, race, percentage of patients with diabetes, severity of illness at ICU admission as defined by the APACHE II score, or percentage of patients admitted to the medical vs surgical service. No significant difference was noted between the baseline group and treatment group regarding the number of patients, age, or APACHE II scores in each

DISCUSSION

The salient finding of this study is that a protocol designed to maintain blood glucose levels lower than 140 mg/dL was associated with a 29.3% decrease in mortality among a heterogeneous population of critically ill adult patients. The principal strengths of this study include the large number of patients evaluated, the consistent findings among the subpopulations analyzed, and the generalizability of the results.

The main limitation of the study is its use of historical controls in a

CONCLUSION

This study evaluated the effects of an intensive glycemic management protocol instituted in a medical-surgical ICU of a university-affiliated community hospital. The reduction in the mortality rate during the intervention period was 29.3%, associated with a decrease in the LOS in the ICU and a reduction in the development of new renal insufficiency and packed RBC transfusion requirements. The setting and the reasonable goal of the protocol—maintenance of blood glucose levels lower than 140

ADDENDUM

Since completion of the manuscript, an additional 300 patients have been admitted to the ICU and monitored to hospital discharge. The median (interquartile range) APACHE II score of these patients was 16 (11-23), and the hospital mortality rate was 14.3% (unpublished data).

REFERENCES (33)

  • K Foo et al.

    A single serum glucose measurement predicts adverse outcomes across the whole range of acute coronary syndromes

    Heart

    (2003)
  • K Malmberg et al.

    Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus

    BMJ

    (1997)
  • J Sala et al.

    Short-term mortality of myocardial infarction patients with diabetes or hyperglycaemia during admission

    J Epidemiol Community Health

    (2002)
  • LS Williams et al.

    Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke

    Neurology

    (2002)
  • SE Capes et al.

    Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview

    Stroke

    (2001)
  • N Kagansky et al.

    The role of hyperglycemia in acute stroke

    Arch Neurol

    (2001)

    • Cited by (0)

    View full text
    Copyright © 2004 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.