Ebook Reducing mortality in critically ill patients: Part 2
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Ebook Reducing mortality in critically ill patients: Part 2
Part IIInterventions that Increase MortalityTight Glycemic Control8Cosimo Chelazzi, Zaccaria Ricci, and Stefano Romagnoli8.1General Principles: Stress Ebook Reducing mortality in critically ill patients: Part 2s-Induced HyperglycemiaStress-induced hyperglycemia is common in critically ill and surgical patients, with an incidence of 50 % and 13 %. respectively [I]. Critical illness is associated with alterations in homeostasis, i.e.. the ability of the organism to keep a physiologic balance [2]. When envir Ebook Reducing mortality in critically ill patients: Part 2onmental/endogenous stimuli challenge this balance, a shift to a state of “allostasis” occurs, whose target is to reach a new steady state involving aEbook Reducing mortality in critically ill patients: Part 2
ll systems, including metabolism. During acute critical illness, this response is adaptive, while in prolonged/chronic critical illness is seen as malPart IIInterventions that Increase MortalityTight Glycemic Control8Cosimo Chelazzi, Zaccaria Ricci, and Stefano Romagnoli8.1General Principles: Stress Ebook Reducing mortality in critically ill patients: Part 2 activates the hypothalamic-pituitary-adrenal axis (HPA) with increased secretion of cortisol, which in turn promotes hepatic glycogenolysis and gluconeogenesis. TNF-a inhibits gene transcription for glucose transporter family 4 (GLUT-4), inhibiting intracellular insulin-dependent glucose uptake in Ebook Reducing mortality in critically ill patients: Part 2adipocytes and myocytes [4]. Other metabolic features include decreased levels of insulin-like growth factor-1. reduced peripheral T4-T3 conversion, aEbook Reducing mortality in critically ill patients: Part 2
nd suppression of testosterone secretion. Endogenous catecholamines increase as well. This neurohormonal response progressively drives the metabolism Part IIInterventions that Increase MortalityTight Glycemic Control8Cosimo Chelazzi, Zaccaria Ricci, and Stefano Romagnoli8.1General Principles: Stress Ebook Reducing mortality in critically ill patients: Part 2, such as while blood cells [2]. Hepatic glycogenolysis andc. Chelazzi, MD (El) • s. RomagnoliDepartment of Anesthesia and Intensive Care. Oncological Anesthesiology and Intensive Care Unit. Largo Brambilla, 3, Florence. Italy e-mail: cosimochelazzi@gmail.comz. RicciPediatric Cardiac Intensive Care Ebook Reducing mortality in critically ill patients: Part 2Unit. Department of Pediatric Cardiac Surgery.Bambino Gesil Children's Hospital. Rome. Italy© Springer International Publishing Switzerland 2015G. LanEbook Reducing mortality in critically ill patients: Part 2
doni et al. (eds.). Reducing Mortality ill Critically III Patients. in inm/nio -1 01A 11414 rr o6364c. Chelazzi etal.protein breakdown are enhanced inPart IIInterventions that Increase MortalityTight Glycemic Control8Cosimo Chelazzi, Zaccaria Ricci, and Stefano Romagnoli8.1General Principles: Stress Ebook Reducing mortality in critically ill patients: Part 2perglycemia is observed ("stress hyperglycemia'7"stress diabetes”) whose severity is related to extent and severity of the causing event (see below). In case of prolonged critical illness, insulin resistance, hypercatabolism, and deleterious consequences of acute hyperglycemia become relevant. These Ebook Reducing mortality in critically ill patients: Part 2 include: increased susceptibility to infections, mitochondrial dysfunction, persistent inflammation. immune paralysis, anemia, and. possibly, increasEbook Reducing mortality in critically ill patients: Part 2
ed mortality [3].8.2Clinical Associations of Stress-Induced HyperglycemiaStress-induced hyperglycemia is associated with worse outcomes in many clinicPart IIInterventions that Increase MortalityTight Glycemic Control8Cosimo Chelazzi, Zaccaria Ricci, and Stefano Romagnoli8.1General Principles: Stress Ebook Reducing mortality in critically ill patients: Part 2 patients, those who died had significantly higher glycemia at admission in intensive care unit (ICƯ) and during their stay [9].Patients with acute myocardial infarction and stroke are particularly susceptible to acute hyperglycemia [5, 7. 8. 10-12]. Hyperglycemic trauma patients had increased ICU/h Ebook Reducing mortality in critically ill patients: Part 2ospital length of stay and higher mortality rates, possibly related to increased nosocomial infections and duration of mechanical ventilation (MV) f 1Ebook Reducing mortality in critically ill patients: Part 2
3]. In patients with traumatic brain injury, hyperglycemia at admission was independently related to worse neurological outcomes [14]. After coronary Part IIInterventions that Increase MortalityTight Glycemic Control8Cosimo Chelazzi, Zaccaria Ricci, and Stefano Romagnoli8.1General Principles: Stress Ebook Reducing mortality in critically ill patients: Part 2ns, longer ICƯ length of stay, and increased risk for stroke, myocardial infarction, sepsis, or death [15. 16]. Among noncardiac surgical patients, hyperglycemia is associated with higher risk of overall and cardiovascular 30-day mortality.This evidence prompted researchers to implement strategies t Ebook Reducing mortality in critically ill patients: Part 2o control hyperglycemia in critically ill patients. Although initial results were promising, safety concerns arose about hypoglycemia during continuouEbook Reducing mortality in critically ill patients: Part 2
s insulin infusion. The optimal blood glucose target, the ideal method for glucose monitoring, and insulin protocols are still a matter of debate.8.3TPart IIInterventions that Increase MortalityTight Glycemic Control8Cosimo Chelazzi, Zaccaria Ricci, and Stefano Romagnoli8.1General Principles: Stress Ebook Reducing mortality in critically ill patients: Part 2ical patients to receive intensive insulin therapy (IIT) with continuous intravenous insulin infusion or conventional blood glucose management [17]. Targeted blood glucose for IIT patients was 80-110 mg/dL. while for controls was 180-200 mg/dL. In all patients, a mix of glucose infusion and parenter Ebook Reducing mortality in critically ill patients: Part 2al/enteral nutrition was used to reach the caloric intake and prevent hypoglycemia. The results of this study were a significant reduction in ICƯ (-42Ebook Reducing mortality in critically ill patients: Part 2
%) and in-hospital mortality (-34 %) in the IIT group compared with controls. Intensive8 Tight Glycemic Control65insulin therapy was associated with Part IIInterventions that Increase MortalityTight Glycemic Control8Cosimo Chelazzi, Zaccaria Ricci, and Stefano Romagnoli8.1General Principles: Stress Ebook Reducing mortality in critically ill patients: Part 2e lower in the nr group. Only 3 % of the enrolled patients were diabetic. The incidence of hypoglycemia was significantly higher in the III group. The strikingly positive results of this study fostered great interest around glycemic control. The results were partially reproduced in diabetic patients Ebook Reducing mortality in critically ill patients: Part 2 undergoing coronary artery bypass and treated with n r to target a blood glucose of 100-150 mg/dL. with a reduction in mortality rale and mediastinitEbook Reducing mortality in critically ill patients: Part 2
is when compared to historical controls [I8J. In 2003. Krinsley confirmed better survival rates for patients receiving IIT to target a glycemia of <14Part IIInterventions that Increase MortalityTight Glycemic Control8Cosimo Chelazzi, Zaccaria Ricci, and Stefano Romagnoli8.1General Principles: Stress Ebook Reducing mortality in critically ill patients: Part 2ITT was associated with an absolute 10 % reduction in mortality rates for long-staying patients: nr was associated with reduced ICU and hospital length of slays, duration of MV. and incidence of acute renal failure. Hypoglycemia was more common among patients undergoing IIT [191. However, in 2008 th Ebook Reducing mortality in critically ill patients: Part 2e VISEP trial compared the effects of IIT (blood glucose 80-110 mg/dL) versus conventional therapy (180-200 ĩììg/dL) in 537 septic, critically ill patEbook Reducing mortality in critically ill patients: Part 2
ients and did not show any difference in MV. severity of organ failure. and 28-day mortality [20].Recently, two large trials have challenged the initiPart IIInterventions that Increase MortalityTight Glycemic Control8Cosimo Chelazzi, Zaccaria Ricci, and Stefano Romagnoli8.1General Principles: Stress Ebook Reducing mortality in critically ill patients: Part 2ventional glucose control (140-180 mg/dL). The study was interrupted for protocol violations, and although I IT was associated with increased risk of hypoglycemia and a trend toward increased mortality, blood glucose levels were poorly controlled [211- The Normoglycemia in Intensive Care Evaluation- Ebook Reducing mortality in critically ill patients: Part 2Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial, including 6.104 mcdical/surgical patients, compared IIT (81-108 mg/dL) with conventionEbook Reducing mortality in critically ill patients: Part 2
al treatment (<180 mg/dL). Patients undergoing I1T showed higher rates of hypoglycemia and 90-day mortality (+2.6 %) [221. Finally, in 2010. the COITIPart IIInterventions that Increase MortalityTight Glycemic Control8Cosimo Chelazzi, Zaccaria Ricci, and Stefano Romagnoli8.1General Principles: Stress Ebook Reducing mortality in critically ill patients: Part 210 mg/dL and below 150 mg/dL [23J.8.4The Risk of Hypoglycemia: Role of Nutrition and DiabetesDespite a clear increase in mortality was shown only in the NICE-SUGAR trial, the risk for hypoglycemia was constantly higher in patients undergoing ITT. Some issues need to be underlined. In the two Leuven Ebook Reducing mortality in critically ill patients: Part 2trials, a mean nonprotein daily caloric intake of 20 kCal/kg was achieved mostly with glucose administration; median daily infused insulin was about 7Ebook Reducing mortality in critically ill patients: Part 2
1 units. In the NICE-SUGAR, the median daily caloric intake w as 11.04±6.08 kCal/kg. with a median daily dose of insulin of 50.2 units. This observatiPart IIInterventions that Increase MortalityTight Glycemic Control8Cosimo Chelazzi, Zaccaria Ricci, and Stefano Romagnoli8.1General Principles: Stress Ebook Reducing mortality in critically ill patients: Part 2 recently underlined by a meta-analysis by Marik and Preiser [24].66c. Chelazzi etal.Ill 2011 the Leuven group demonstrated that early administration of parenteral nutrition is associated with increased infections and cholestasis [25]. In the experimental group, a median daily dose of 58 units of in Ebook Reducing mortality in critically ill patients: Part 2sulin was administered, lower than the dose administered in the original Leuven trials of 2001 and 2006. These results point out that the concomitantEbook Reducing mortality in critically ill patients: Part 2
infusion of glucose and insulin, rather than the sole tight glycemic control, can be beneficial for critically ill patients [26]. Concomitant administGọi ngay
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