Effects of Hyperglycemia on Neurologic Outcome in Stroke Patients

Alison S. Paolino; Krista M. Garner

Disclosures

J Neurosci Nurs. 2005;37(3):130-135. 

In This Article

Hyperglycemic Management

Lowering serum glucose to near-normoglycemic levels reduces morbidity and mortality regardless of patients' DM history (AACE, 2003). In years past, apathy often reigned when strict inpatient glycemic control was suggested because implementing this strategy had not been closely analyzed (McCowen et al., 2001). Recent data, however, have shown that it is safe, feasible and prudent to further lower glucose levels with a continuous insulin infusion or sliding-scale regimen (Van den Berghe et al., 2001).

The strict means of glycemic control has sparked interest. Van den Berghe et al. (2001) found that patients with blood glucose levels maintained at less than 110 mg/dL with a continuous infusion had a 32% reduction in morality and shorter ICU stays. In a metaanalysis of 26 studies, Capes et al. (2001) found that patients with blood glucose levels of 110-126 mg/dL had a higher risk of in-hospital mortality than those who maintained levels lower than 110 mg/dL. Krinsley (2003) also found that mortality was lowest among patients with mean serum glucose values between 80 and 99 mg/dL, but increased significantly and progressively as mean serum glucose values exceeded this range. Table 2 features the recommended glucose target levels from the AACE.

Strict glycemic control in the ICU can be achieved with a continuous insulin infusion or a sliding-scale regimen. A continuous insulin infusion is considered superior to a sliding-scale regimen because it allows for an immediate response to a specific blood glucose level, with potential for frequent adjustments. Serum glucose levels are required every 1-2 hours when using a continuous insulin infusion, promoting tighter control of glycemic levels. In contrast, the sliding-scale method allows only for a retrospective assessment of glucose requirements, and the arbitrary scale cutoff points may not be relevant to patients. Consequently, a sliding scale may result in overall higher glycemic levels (Brown & Dodek, 2001). Van den Berghe et al. (2003) determined that blood glucose levels lower than 110 mg/dL could be reached effectively and safely within 24 hours of ICU admission, and maintained throughout the ICU stay with a continuous insulin infusion using a titration algorithm. Fig 1 lists the conditions for which intravenous insulin therapy is indicated.

Table 1.

 

Risk Factors for the Development of Stress Hyperglycemia in Critical Illness

The most common complication of insulin therapy, either with sliding-scale or continuous infusion, is hypoglycemia. Symptoms of hypoglycemia include palpitations, anxiety, weakness, fatigue, confusion, behavioral changes, loss of consciousness, and seizures. Van den Berghe et al. (2003) found that hypoglycemia, while uncommon, occurred more often in the patients receiving intensive insulin therapy to maintain blood glucose level lower than 110 mg/dL. Van den Berghe et al. (2003) concluded the risk of hypoglycemia was outweighed by the benefits of intensive insulin therapy and tighter glycemic control.

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