CENTRE PROMOCIONAT

The aim of the thesis is to examine the relationship between the systemic inflammatory response, as evidenced by both CRP and albumin, on plasma glucose, plasma and red cell concentrations of vitamins and trace elements in a nutrition screen cohort and a critical illness cohort.

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Table 1-5: Summary of the hyperglycaemia studies.

Author (S)/ year Subject Population Findings Comments

Malmberg, 1997 DIGAMI 1 study. Stockholm/Sweden. Hyperglycemia and patients with critical illness. 620 patients with diabetes and acute myocardial

infarction. Medical ICU.

A significant reduction in haemoglobin A1c in both groups. Significantly more in infusion group.

30% reduction of one year mortality rate in intervention.

97% of all deaths in both groups occurred due to cardiovascular causes. There was a significant reduction in these events in the intervention group

-The subjects were patients with diabetes. -Cardiac patients (MI).

-The findings may suggest that long term glycaemic control may be important in the prevention cardiovascular causes of death in patients with diabetes.

-After DIGAMI study the intervention to control plasma glucose levels in patients with myocardial infarction become a standard practice.

-Glycaemia focussed study. Scott et al, 1999.

England, the UK.

Hyperglycemia and patients with critical illness. 50 patients with stroke. Medical ICU.

-Glucose potassium insulin (GKI) infusion treatment to control mild to moderate hyperglycemia in patients with stoke is reported to be safe, practical, and has a significant improvement of lowering the high plasma glucose without any significant episodes of hypoglycaemia ,

cardiovascular events and excess mortality rate at first four week post stroke.

-Pilot study.

-Non- diabetic patients. -Patients with acute stroke.

62 Van Den Berghe et

al, 2001. Belgium Hyperglycemia and patients with critical illness. 1,548 critically ill patients/ surgical ICU.

Significant reduction mortality rate. Decrease in overall hospital mortality rate, bloodstream infection, acute renal failure that required dialysis or

heamofltration, red cell transfusion, clinical illness polyneuropathy, the need for mechanical ventilation.

- Prospective randomized controlled study.

- Heterogeneous surgical ICU population, lead to difficulties to extrapolate the result to medical ICU patients. -63% cardiac patients.

-Male: Female ratio 71:29. -Single-centre study. Van Den Berghe et

al, 2003 Belgium Hyperglycemia and patients with critical illness. Extension study to Van Den Berghe et

al, 2001 study.

Same number of patients.

Normoglycaemia was achieved safely within 24 hours of the ICU admission.

- Heterogeneous medical and surgical. ICU patients.

Krinsley, 2004 Stamford, Conn, the USA. Hyperglycemia and patients with critical illness. 1,600 medical- surgical ICU

critically ill patients.

-No significant changes in ICU infection acquired rate.

-Significant improvement of patient’s glucose levels.

- Significant improvement in renal function.

-Significant reduction in mortality rate between control and treatment group by 21% to 15% respectively (29%

reduction in overall mortality rate of ICU patients after applying the protocol).

- ICU length of stay was decreased from

- Heterogeneous medical and surgical ICU patients.

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3.6 days in control group to 3 days in treatment group. Malmberg, 2005 DIGAMI 2 study. Stockholm/Sweden Hyperglycemia and patients with critical illness. 1253 patients with diabetes and acute myocardial

infarction.

-There was no significant improvement in the morbidity and mortality rates in patients who have diabetes and presented with acute myocardial infarction after acutely induction of long term insulin treatment compared with conventional treatment.

- The study epidemiological analysis demonstrates that the plasma glucose level is a strong, independent prognostic factor for long term mortality among those patients, which in turn glucose control is an essential part of their management.

-Multicentre prospective randomized blinded controlled study.

-44 centres were in Sweden, Finland, Norway, Denmark, The Netherlands, and the UK.

-Glycaemia focussed study.

The CREATE- ECLA Trial Group Investigation, 2005 The USA Hyperglycemia and patients with critical illness. 20,210 patients with ST-segment elevation myocardial infarction (STEMI).

- No marked difference in the mortality rate within 7 and 30 days.

-No significant differences between the both groups in the occurrence of ventricular fibrillation, tachycardia, advanced second or third degree heart block, electromechanical dissociation, and fluid volume overload.

-A new episode of heart failure in both groups after 7 and 30 days of ICU

- Randomized controlled study - Cardiac patients.

- High dose of GIK infusion has neutral effect on mortality.

64 admission.

-Hypoglycaemia episodes were more common in intervention group as well as hyperkalemia.

- High dose of GIK infusion has no significant effect on the mortality rate on patients with ST- segment elevation myocardial Infarction.

Van Den Berghe et

al, 2006 Belgium Hyperglycemia and patients with critical illness. 1,200 medical ICU patients. - hypoglycemia 73% and 62% in conventional and intensive treatment group respectively.

- A reduction of the ICU mortality rate by 10% among intensive insulin therapy group who stayed more than five days. - A significant improvement in the time of mechanical ventilation weaning, discharge from medical ICU and hospital among intensive insulin treatment group of patients.

- Prospective randomized controlled study.

- Heterogeneous medical ICU patients. - Single-centre study.

Krinsley,2006 Stamford, Conn, the USA. Hyperglycemia and patients with critical illness. 5,365 non-cardiac surgical ICU patients.

- Hospital mortality rate was low among patients who plasma glucose level was between 4.0 -5.5 mmol/l, and increased progressively with the increasing in the level of plasma glucose.

- The mortality rate was 40% higher among patients with diabetes.

-Prospective cohort study.

- Heterogeneous medical, surgical and trauma ICU patients.

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- Hypoglycemic episodes were 1% in control group and 2% in intervention group.

Cheung and colleagues (2006) New South Wales, Australia. Hyperglycemia and patients with critical illness. 240 patients with acute myocardial infarction.

- There was no significant difference in mortality rate between two groups. -There were low rate of cardiac failure and of reinfarction rate in the insulin infusion therapy group.

-There was 13 hypoglycaemia events in insulin infusion therapy group compare with only 2 events in the conventional therapy group.

-Multicentre open-label randomized controlled clinical study.

- 6 hospitals in the state of New South Wales, Australia. Treggiari et al, 2008 Washington/ the USA Hyperglycemia and patients with critical illness. 10,456 medical, surgical, trauma and neurosurgical ICU patients.

-Plasma glucose at ICU admission was lower after applying of intensive insulin treatment protocol.

-The proportions of patients receiving insulin infusion increased dramatically over the study periods.

-The average SAPS II and APS III scores were lower in period III than in periods I and II.

-Reduction in the requirement of mechanical ventilation.

-An increase in hypoglycaemia episodes three to four times from period I to III.

- Cohort study.

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-Hypoglycemic was the main cause of death.

-The overall ICU mortality rate was significantly different between periods II and III compared with period I. -There was an increase in the mortality rate in patients that stayed ≤ 3 days in ICU.

-A policy of intensive insulin therapy in a group of ICUs from a single

institution was not associated with a decrease in hospital mortality. Egi et al, 2008

Australia and New Zealand.

Hyperglycemia and patients with critical illness.

4,946 ICU patients. -There was a strong association between plasma glucose level and the mortality rate in non-diabetic critically ill patients compared with those with diabetes.

-The mortality rate was four times greater in patients without diabetes. -This may support the hyperglycaemia may have poor outcome in critically ill patients who do not have pervious history of diabetes.

- Retrospective observational cohort study. - Heterogeneous ICU patients.

67 The NICE-SUGAR

2009

Australia and New Zealand.

Hyperglycemia and patients with critical illness.

6,104 medical and surgical ICU patients from 42 hospitals.

-Patients treated with intensive glucose control had a higher mortality rate than conventional glucose control patients in 90 days of ICU admission.

- Randomized controlled study.

- Evaluation of the ICU mortality rate at 90 days of ICU admission.

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