Glycemic control in the ICU: a multicenter survey

Abstract

Background

Intensive insulin therapy has recently been shown to decrease morbidity and mortality in the critically ill population in a large randomized clinical trial.

Objective

To determine the beliefs and attitudes of ICU clinicians about glycemic control.

Design

Self-administered survey.

Participants

ICU nurses and physicians in five university-affiliated multidisciplinary ICUs.

Results

A total of 317 questionnaires were returned from 233 ICU nurses and 84 physicians. The reported clinically important threshold for hypoglycemia was 4 mmol/l (median, IQR 3–4 mmol/l). In non-diabetic patients, the clinically important threshold for hyperglycemia was 10 mmol/l (IQR 9–12 mmol/l); however, nurses had a significantly higher threshold than physicians (difference of 0.52 mmol/l (95% CI 0.09–0.94 mmol/l, P=0.018). In diabetic patients, the clinically important threshold for hyperglycemia was also 10 mmol/l (IQR 10–12 mmol/l), and again nurses had a significantly higher threshold than physicians (0.81 mmol/l, 95% CI 0.29–1.32 mmol/l, P=0.0023). Avoidance of hyperglycemia was judged most important for diabetic patients (87.7%, 95% CI 84.1–91.3%), patients with acute brain injury (84.5%, 95% CI 80.5–88.5%), patients with a recent seizure (74.4%, 95% CI 69.6–79.3%), patients with advanced liver disease (64.0%, 95% CI 58.7–69.3%), and for patients with acute myocardial infarction (64.0%, 95% CI 58.7–69.3%). Physicians expressed more concern than nurses about avoiding hyperglycemia in patients with acute myocardial infarction (P=0.0004). ICU clinicians raised concerns about the accuracy of glucometer measurements in critically ill patients (46.1%, 95% CI 40.5–51.6%).

Conclusions

Attention to these beliefs and attitudes could enhance the success of future clinical, educational and research efforts to modify clinician behavior and achieve better glycemic control in the ICU setting.