1. Hyperglycemia-Am I A Control Freak? COPYRIGHT © 2013, ALL RIGHTS RESERVED From the Publishers of

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3. Copyright © 2013 Dear Consult Gurus; I need your sage advice regarding our newest associate who is being considered for contract renewal in our partnership track. He joined us in 2010 after completion of his residency and now does most of the care of our hospitalized patients. While he seems to be excellent I have a major gripe with his mismanagement of our seriously ill patients in the ICU. My complaint relates to his management of our ICU patients who develop hyperglycemia. Dear Consult Gurus; I need your sage advice regarding our newest associate who is being considered for contract renewal in our partnership track. He joined us in 2010 after completion of his residency and now does most of the care of our hospitalized patients. While he seems to be excellent I have a major gripe with his mismanagement of our seriously ill patients in the ICU. My complaint relates to his management of our ICU patients who develop hyperglycemia.

4. Copyright © 2013 Based on my training (I began practice 10 years ago) I’ve made sure that our critically ill ICU patients have their glucose tightly controlled with a target glucose 80-110 mg/dl and I’ve used intensive insulin therapy to achieve that. Our newest associate though is much less strict and he seems to accept a serum glucose as high as 180 or even 200 mg/dL. I don’t know if its laziness or a knowledge deficit but I think he is wrong. We are deciding on his contract in a few days. Should we show him a contract or show him the door? A.B. Corncob Medical Assoc. Based on my training (I began practice 10 years ago) I’ve made sure that our critically ill ICU patients have their glucose tightly controlled with a target glucose 80-110 mg/dl and I’ve used intensive insulin therapy to achieve that. Our newest associate though is much less strict and he seems to accept a serum glucose as high as 180 or even 200 mg/dL. I don’t know if its laziness or a knowledge deficit but I think he is wrong. We are deciding on his contract in a few days. Should we show him a contract or show him the door? A.B. Corncob Medical Assoc.

5. Copyright © 2013 Hyperglycemia is associated with perioperative complications Is there evidence to support intensive insulin treatment in critically ill patients? What is the ideal serum glucose for a critically ill patient A.B. completed training 2001 New associate completed training 2010 Issues

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7. Van den Berghe, G. et al.: N Engl J Med 2001;345:1359-67 Intensive insulin therapy to maintain blood glucose at or below 110 mg/dL reduces morbidity and mortality among critically ill patients in the surgical intensive care unit.

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9. Van den Berghe G et al.: N Engl J Med 2006;354:449-61 No mortality difference between intensive insulin therapy with strict control ( glucose 80-110mg/dL) vs. conventional Rx (glucose < 180 mg/dL) Less mortality / morbidity in those treated in ICU for 3 or more days  These patients could not be identified prior to therapy

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11. NICE - SUGAR Worldwide, multicenter (6104 pts, 42 hospitals) Expected to be in ICU > 3 days Intensive glucose control: 81-108 mg/L Conventional glucose control: < 180mg/dL Iv insulin given if glu > 180 Mean glucose intensive control: 108 Mean glucose conventional control: 144

12. Copyright © 2013 NICE - SUGAR Intensive glucose control increased 90 day mortality Intensive control mortality 27.5% Conventional control mortality 24.9%

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14. ACP Guideline: 2011 DO NOT USE intensive insulin therapy to strictly control glucose in non-SICU / MICU hospitalized patients DO NOT USE intensive insulin therapy to normalize serum glucose in SICU / MICU patients Target blood glucose in SICU / MICU patients 140- 200mg/dL

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16. Critically ill  I.V. insulin for persistent hyperglycemia (180 mg/dl)  Once insulin begun target glucose 140-180 mg/dl Not Critically ill  Persistent blood glucose < 140 mg/dl if can be done safely Diabetes: Hospitalized patient

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