Steuerung des Blutzuckers – Ist ideal gleich optimal?

Starke Schwankungen des Blutzuckerspiegels sowie insbesondere Hypoglykämien beeinflussen in erheblichem Ausmaß Verlauf und Outcome von Intensivpatienten. Doch auch bei einer liberalen Blutzuckerführung sind Hypoglykämien nicht immer sicher zu vermeiden. Geeignete Messverfahren und Therapiealgorithmen können dazu beitragen, solche Probleme zu entschärfen.

Kernaussagen

• Die zum Teil kontroversen Studienresultate zur BZ-Kontrolle auf der Intensivstation erlauben kein einfaches Kochrezept und keine simplen evidenzbasierten Empfehlungen.

• Klar ist, dass schwere Hypo- und Hyperglykämien sowie Schwankungen des BZ vermieden werden müssen.

• Bis geeignete kontinuierliche Messmethoden verfügbar sind, ist eine mit Fingerspitzengefühl durchgeführte, an den Einzelfall angepasste, liberale Einstellung des BZ ein praktikabler und sinnvoller Weg.

• Individuell zur jeweiligen Abteilung passende Algorithmen sollte man im Team erarbeiten, schulen und umsetzen.

• Neue Verfahren der BZ-Messung und prädiktive Algorithmen könnten die BZ-Kontrolle in der täglichen Praxis vereinfachen und zu einer positiven Prognose der Patienten beitragen.

• Literatur

• 1 DellʼAquila AM, Ellger B. Perioperative glycemic control: what is worth the effort?. Curr Opin Anaesthesiol 2013; 26: 438-443
• 2 Preiser JC, Chase JG, Hovorka R. et al. Glucose Control in the ICU: A Continuing Story. Journal of Diabetes Science and Technology 2016; 10: 1372-1381
• 3 Krinsley JS. Glycemic control in the critically ill: What have we learned since NICE-SUGAR?. Hosp Pract 2015; 43: 191-197
• 4 Bersoux S, Cook CB, Kongable GL. et al. Benchmarking glycemic control in U.S. Hospitals. . Endocrine Practice 2014; 20: 876-883
• 5 Bochicchio GV, Scalea TM. Glycemic control in the ICU. Advances in Surgery 2008; 42: 261-275
• 6 Ellger B, Van den Berghe G. Tight glycaemic control: from bed to bench and back. Best Practice & Research Clinical Anesthesiology 2009; 23: VII-IX
• 7 Brutsaert E, Carey M, Zonszein J. The clinical impact of inpatient hypoglycemia. J Diabetes Complications 2014; 28: 565-572
• 8 Duning T, van den Heuvel I, Dickmann A. et al. Hypoglycemia aggravates critical illness-induced neurocognitive dysfunction. Diabetes Care 2010; 33: 639-644
• 9 van den Berghe G, Wouters P, Weekers F. et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345: 1359-1367
• 10 Boutin JM, Gauthier L. Insulin infusion therapy in critically ill patients. Canadian Journal of Diabetes 2014; 38: 144-150
• 11 Kuppinger D, Hartl WH. In search of the perfect glucose concentration for hospitalized patients: a brief review of the meta-analyses. Nutrition 2013; 29: 708-712
• 12 Honiden S, Inzucchi SE. Analytic review: glucose controversies in the ICU. Journal of Intensive Care Med 2011; 26: 135-150
• 13 Evans AS, Hosseinian L, Mechanick JI. Emerging paradigms on glucose management in the intensive care unit. Minerva Endocrinologica 2014; 39: 261-273
• 14 Van Herpe T, Mesotten D, Wouters PJ. et al. LOGIC-Insulin Algorithm-Guided Versus Nurse-Directed Blood Glucose Control During Critical Illness: The LOGIC-1 single-center randomized, controlled clinical trial. Diabetes Care 2013; 36: 188-194
• 15 Haluzik M, Mraz M, Kopecky P. et al. Glucose control in the ICU: is there a time for more ambitious targets again?. Journal of Diabetes Science and Technology 2014; 8: 652-657
• 16 Nobels F, Lecomte P, Deprez N. et al. Tight glycaemic control: clinical implementation of protocols. Best Practice & Research Clinical Anesthesiology 2009; 23: 461-472
• 17 Klonoff DC. Intensive insulin therapy in critically ill hospitalized patients: making it safe and effective. J Diabetes Sci Technol 2011; 5: 755-767
• 18 Bothe MK, Dickens L, Reichel K. et al. The use of reinforcement learning algorithms to meet the challenges of an artificial pancreas. Expert Review of Medical Devices 2013; 10: 661-673
• 19 Wernerman J, Desaive T, Finfer S. et al. Continuous glucose control in the ICU: report of a 2013 round table meeting. Crit Care 2014; 18: 226
• 20 Aragon D. Evaluation of nursing work effort and perceptions about blood glucose testing in tight glycemic control. Am J Crit Care 2006; 15: 370-377
• 21 Desachy A, Vuagnat AC, Ghazali AD. et al. Accuracy of bedside glucometry in critically ill patients: influence of clinical characteristics and perfusion index. Mayo Clinic proceedings Mayo Clinic 2008; 83: 400-405
• 22 Le HT, Harris NS, Estilong AJ. et al. Blood glucose measurement in the intensive care unit: what is the best method?. Journal of Diabetes Science and Technology 2013; 7: 489-499
• 23 Blake DR, Nathan DM. Point-of-care testing for diabetes. Critical Care Nursing Quarterly 2004; 27: 150-161
• 24 Basu A, Dube S, Veettil S. et al. Time lag of glucose from intravascular to interstitial compartment in type 1 diabetes. Journal of Diabetes Science and Technology 2015; 9: 63-68
• 25 Bay C, Kristensen PL, Pedersen-Bjergaard U. et al. Nocturnal continuous glucose monitoring: accuracy and reliability of hypoglycemia detection in patients with type 1 diabetes at high risk of severe hypoglycemia. Diabetes Technology & Therapeutics 2013; 15: 371-377
• 26 Siegelaar SE, Barwari T, Hermanides J. et al. Microcirculation and its relation to continuous subcutaneous glucose sensor accuracy in cardiac surgery patients in the intensive care unit. Journal of Thoracic and Cardiovascular Surgery 2013; 146: 1283-1289
• 27 Brunner R, Adelsmayr G, Herkner H. et al. Glycemic variability and glucose complexity in critically ill patients: a retrospective analysis of continuous glucose monitoring data. Crit Care 2012; 16: R175
• 28 Kosiborod M, McGuire DK. Glucose-lowering targets for patients with cardiovascular disease: focus on inpatient management of patients with acute coronary syndromes. Circulation 2010; 122: 2736-2744
• 29 Saur NM, England MR, Menzie W. et al. Accuracy of a novel noninvasive transdermal continuous glucose monitor in critically ill patients. Journal of Diabetes Science and Technology 2014; 8: 945-950
• 30 Gottschalk A, Welp HA, Leser L. et al. Continuous Glucose Monitoring in Patients Undergoing Extracorporeal Ventricular Assist Therapy. PLoS One 2016; 11: e0148778
• 31 Foulke GE, Harlow DJ. Effective measures for reducing blood loss from diagnostic laboratory tests in intensive care unit patients. Crit Care Med 1989; 17: 1143-1145
• 32 Schierenbeck F, Owall A, Franco-Cereceda A. et al. Evaluation of a continuous blood glucose monitoring system using a central venous catheter with an integrated microdialysis function. Diabetes Technology & Therapeutics 2013; 15: 26-31
• 33 Blixt C, Rooyackers O, Isaksson B. et al. Continuous on-line glucose measurement by microdialysis in a central vein. A pilot study. . Crit Care 2013; 17: R87
• 34 Flower OJ, Bird S, Macken L. et al. Continuous intra-arterial blood glucose monitoring using quenched fluorescence sensing: a product development study. Critical Care and Resuscitation 2014; 16: 54-61
• 35 Schultz MJ, Harmsen RE, Korevaar JC. et al. Adoption and implementation of the original strict glycemic control guideline is feasible and safe in adult critically ill patients. Minerva Anestesiologica 2012; 78: 982-995