Yoğun Bakım Ünitesinde Hiperglisemili Hastaya Yaklaşım/Yönetim
Özet
Yoğun bakım ünitelerinde hiperglisemi yönetimi, mortalite ve morbiditeyi doğrudan etkileyen kritik bir süreçtir. Yoğun bakıma yatan hastalarda, mevcut diyabetin yanı sıra stres faktörlerine bağlı olarak gelişen hiperglisemi sıklıkla görülür ve bu durum hücresel düzeyde mitokondriyal hasara ile inflamatuar reaksiyonlara yol açar. Tedavide temel amaç hipovolemi ve enfeksiyon gibi riskleri azaltırken hipoglisemiyi önlemektir. NICE-SUGAR gibi geniş kapsamlı çalışmaların ardından, uluslararası ve ulusal kılavuzlar genel olarak kan şekeri başlangıç sınırını 180 mg/dL, hedef aralığı ise 140-180 mg/dL olarak kabul etmiştir. Tedavide ani değişen ihtiyaçlara hızla yanıt verebilmesi nedeniyle sürekli intravenöz insülin infüzyonu en güvenilir yöntemdir; subkütan uygulamalardan şok ve hipotansiyon durumlarında kaçınılmalıdır. Özellikle enteral ve parenteral beslenme alan hastalarda glisemik değişkenliği azaltmak adına bazal insülin desteği ile 4-6 saatlik periyotlarla düzeltme dozları kombine edilmelidir.
Hyperglycemia management in intensive care units is a critical process directly impacting mortality and morbidity. In critically ill patients, hyperglycemia often arises from both pre-existing diabetes and stress-induced factors, leading to mitochondrial damage and inflammatory cascades at the cellular level. The primary objective of therapy is to achieve a stable glycemic balance and prevent hypoglycemia while mitigating risks like infections and hypovolemia. Following extensive clinical trials such as NICE-SUGAR, international and national guidelines have widely established an insulin initiation threshold of 180 mg/dL and a target glucose range of 140-180 mg/dL. Continuous intravenous insulin infusion represents the gold standard for treatment due to its capacity for rapid dose titration, whereas subcutaneous regimens should be avoided during shock or hypotension. Furthermore, for patients receiving total enteral or parenteral nutrition, combining basal insulin with correctional doses every 4 to 6 hours is strongly recommended to minimize glycemic variability.
Referanslar
Federation ID. IDF atlas 9th edition. 2019; https://www.diabetesatlas.org/en/.
Jiang HJ, Stryer D, Friedman B, Andrews R. Multiple hospitalizations for patients with diabetes. Diabetes Care. 2003;26:1421–1426. [PubMed]
Donnan PT, Leese GP, Morris AD. Hospitalizations for people with type 1 and type 2 diabetes compared with the nondiabetic population of Tayside, Scotland: a retrospective cohort study of resource use. Diabetes Care. 2000;23:1774–1779. [PubMed]
Sampson MJ, Dozio N, Ferguson B, Dhatariya K. Total and excess bed occupancy by age, speciality and insulin use for nearly one million diabetes patients discharged from all English Acute Hospitals. Diabetes Research & Clinical Practice. 2007;77:92–98. [PubMed]
FG Smith, Sheehy AM, Vincent JL, et al. Critical illness-induced dysglycaemia: diabetes and beyond Crit Care, 2010;10:327.
Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. DiabetesCare. 2004, 27: 553-591.
Egi M, Bellomo R, Stachowski E, et al. Blood glucose concentration and outcome of critical illness: the impact of diabetes Crit Care Med, 2008;36:2249-2255.
McCowen KC, Malhotra A, Bistrian BR. Stress-induced hyperglycemia. Crit Care Clin 2001; 17:107.
Saberi F, Heyland D, Lam M, et al. Prevalence, incidence, and clinical resolution of insulin resistance in critically ill patients: an observational study. JPEN J Parenter Enteral Nutr 2008; 32:227.
UpToDate Glycemic control in critically ill adult and pediatric patients, Authors:Renee D Stapleton, MD, PhDDaren K Heyland, MD, FRCPC, MScSection Editors:Polly E Parsons, MDAdrienne G Randolph, MD, MScDeputy Editor:Geraldine Finlay, MD, Mar 31, 2022 (15.04.2022 tarihinde https://www.uptodate.com/contents/glycemic-control-in-critically-ill-adult-and-pediatric-patients adresinden alınmıştır.)
Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345: 1359–67
investigators NSs. Intensive versus conventional glucose control in critically ill patients. New England Journal of Medicine. 2009;360:1283–1297.
Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, Moerer O, Gruendling M, Oppert M, Grond S, Olthoff D, Jaschinski U, John S, Rossaint R, Welte T, Schaefer M, Kern P, Kuhnt E, Kiehntopf M, Hartog C, Natanson C, Loeffler M, Reinhart K. Intensive insulintherapy and pentastarch resuscitation in severe sepsis. New England Journal ofMedicine. 2008;358:125–139.
Preiser J-C, Brunkhorst F. Tight glucose control and hypoglycemia. Critical Care Medicine. 2008;36:1391–1392.
Preiser J-C, Devos P, Ruiz-Santana S, Melot C, Annane D, Groeneveld J, Iapichino G, Leverve XM, Nitenberg G, Singer P, Wernerman J, Joannidis M, Stecher A, Chiolero R. A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Intensive Care Medicine. 2009;35:1738–1748.
Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283–1297.
Turkiye Endokrinoloji ve Metabolizma Hastalıkları Derneği Temd Diabetes Mellitus ve Komplikasyonlarının Tanı, Tedavi ve İzlem Kılavuzu-2019 213-215.
EtieMoghissi, Mary Korytkowski, Monica DiNardo, et al. (2009) American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Endocrine Practice: May 2009, Vol. 15, No. 4, pp. 353-369.
Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43:304–377
Qaseem A, Chou R, Humphrey LL, et al. Inpatient glycemic control: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Am J Med Qual. 2014;29:95–98.
Amiel SA, Aschner P, Childs B, Cryer PE, de Galan BE, Frier BM, Gonder-Frederick L, Heller SR, Jones T, Khunti K, Leiter LA, Luo Y, McCrimmon RJ, Pedersen-bjergaard U, Seaquist ER, Zoungas S. Hypoglycaemia, cardiovascular disease, and mortality in diabetes: epidemiology, pathogenesis, and management. Lancet Diabetes & Endocrinology. 2019;7:385–396. [PubMed]
Boden G. Gluconeogenesis and glycogenolysis in health and diabetes. Journal of Investigative Medicine. 2004;52:375–378. [PubMed]
van de Werve G, Jeanrenaud B. Liver glycogen metabolism: An overview. Diabetes/Metabolism Reviews. 1987;3:47–78. [PubMed]
Stentz FB, Umpierrez GE, Cuervo R, Kitabchi AE. Proinflammatory cytokines, markers of cardiovascular risks, oxidative stress, and lipid peroxidation in patients with hyperglycemic crises. Diabetes. 2004;53:2079–2086. [PubMed]
Reyes-Umpierrez D, Davis G, Cardona S, Pasquel FJ, Peng L, Jacobs S, Vellanki P, Fayfman M, Haw S, Halkos M, Guyton RA, Thourani VH, Umpierrez GE. Inflammation and oxidative stress in cardiac surgery patients treated to intensive versus conservative glucose targets. Journal of Clinical Endocrinology & Metabolism. 2016;102:309–315. [PMC free article] [PubMed]
Hulkower RD, Pollack RM, Zonszein J. Understanding hypoglycemia in hospitalized patients. Diabetes Management (Lond). 2014;4:165–176. [PMC free article] [PubMed]
Gerich JE, Lorenzi M, Bier DM, Tsalikian E, Schneider V, Karam JH, Forsham PH. Effects of physiologic levels of glucagon and growth hormone on human carbohydrate and lipid metabolism. Studies involving administration of exogenous hormone during suppression of endogenous hormone secretion with somatostatin. Journal of Clinical Investigation. 1976;57:875–884. [PMC free article] [PubMed]
Rizza RA, Mandarino LJ, Gerich JE. Dose-response characteristics for effects of insulin on production and utilization of glucose in man. American Journal of Physiology - Endocrinology & Metabolism. 1981;240:E630–E639. [PubMed]
McCowen KC, Malhotra A, Bistrian BR. Stress-induced hyperglycemia. Critical Care Clinics. 2001;17:107–124. [PubMed]
Sakharova OV, Inzucchi SE. Endocrine assessments during critical illness. Crit Care Clin 2007; 23: 467-90.
Yendamuri S, Fulda GJ, Tinkoff GH. Admission hyperglycemia as a prognostic indicator in trauma. J Trauma 2003; 55:33.
Lanspa MJ, Krinsley JS, Hersh AM, et al. Percentage of Time in Range 70 to 139 mg/dL Is Associated With Reduced Mortality Among Critically Ill Patients Receiving IV Insulin Infusion. Chest 2019; 156:878.
Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc 2003; 78:1471.
Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 2002, 87:978-982.
Braithwaite SS: Through the eyes of the A1C: a call to re-examine stres hyperglycemia. Crit Care Med 2010, 38:717-719.
Newton CA, Smiley D, Bode BW, Kitabchi AE, Davidson PC, Jacobs S, Steed RD, Stentz F, Peng L, Mulligan P, Freire AX, Temponi A, Umpierrez GE. A comparison study of continuous insulin infusion protocols in the medical intensive care unit: Computer-guided vs. standard column-based algorithms. Journal of Hospital Medicine. 2010;5:432–437. [PMC free article] [PubMed]
Marvin MR, Inzucchi SE, Besterman BJ. Computerization of the Yale insulin infusion protocol and potential insights into causes of hypoglycemia with intravenous insulin. Diabetes Technology & Therapeutics. 2013;15:246–252. [PMC free article] [PubMed
Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med 2012; 40:3251.
Lazar HL, McDonnell M, Chipkin SR, et al.; Society of Thoracic Surgeons Blood Glucose Guideline Task Force. The Society of Thoracic Surgeons practice guideline series: blood glucose management during adult cardiac surgery. Ann Thorac Surg 2009;87:663–669
Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med 2012;40:3251–3276
Dickerson RN, Wilson VC, Maish GO 3rd, et al. Transitional NPH insulin therapy for critically ill patients receiving continuous enteral nutrition and intravenous regular human insulin. JPEN J Parenter Enteral Nutr 2013; 37:506.
Wilson M, Weinreb J, Hoo GW. Intensive insulin therapy in critical care: a review of 12 protocols. Diabetes Care 2007;30:1005–1011
Moghissi ES, Korytkowski MT, DiNardo M, et al.; American Association of Clinical Endocrinologists; American Diabetes Association. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009;32:1119–1131
Pasquel FJ, Spiegelman R, McCauley M, et al. Hyperglycemia during total parenteral nutrition: an important marker of poor outcome and mortality in hospitalized patients. Diabetes Care 2010; 33: 739–41.
Laesser CI, Cumming P, Reber E, Stanga Z, Muka T, Bally L. Management of glucose control in noncritically ill, hospitalized patients receiving parenteral and/or enteral nutrition: a systematic review. J Clin Med 2019; 8: 935.
