Volume 7 Number 2 July 2006 - JICS - The Intensive Care Society

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Volume 7 Number 2 18 Surveys & Audits continued glucose results being within their set range (a very tight range of only 1.7mmol.l -1 ). Only 5 of the 26 units had recollection of a survey/audit being completed within the previous12 months, with control levels ranging from 55% to 85%. This would seem to indicate scope for further improvements in achieving targets, and that very tight ranges can be applied in a general intensive care unit. Conclusions Most ICUs (23 of 26, 91.4% of beds) in Scotland use formalised approaches to maintaining normoglycaemia, with only 3 units (8.6% of beds) having no formal control mechanism. Discrepancies were identified in the definitions of normoglycaemia as well as the tolerance range (i.e. between 1.5 & 4mmol.l -1 ) accepted. Although there is scope for improving the audit of glycaemic control within Scottish ICUs, the practice of tight control has to be seen in the wider context of overall intensive care. E S Jack a , M J E Neil b a. SpR Intensive Care Unit, Victoria Infirmary, Glasgow. G42 9TY. 0141 201 5320 correspondence to ewanwendy@supanet.com b. SpR Department of Anaesthesia, Ninewells Hospital, Dundee. 01382 60111 References 1. Malmberg K, Ryden L, Hamsten A, et al. Effects of insulin treatment on cause-specific one-year mortality and morbidity in diabetic patients with acute myocardial infarction. DIGAMI (Diabetes Insulin-Glucose in Acute Myocardial Infarction) Study Group. Eur Heart J 1996; 17: 1337–1344 2. Scott, J. F.; Gray, C. S.; O'Connell, J. E.; Alberti, K. G. M. M. Glucose and insulin therapy in acute stroke; why delay further? Qjm 1998; 91: 511-515 3. Laird AM. Miller PR. Kilgo PD. Meredith JW. Chang MC. Relationship of early hyperglycemia to mortality in trauma patients. J Trauma-Injury Infection & Critical Care 2004; 56: 1058-62. 4. Van den Berghe, G; Wouters, P; Weekers, F et al. Intensive Insulin Therapy in Critically Ill Patients. NEJM 2001. 345: 1359-1367. 5. Cariou, A; Vinsonneau, C; Dhainaut, J-F. Adjunctive therapies in sepsis: An evidence-based review. CCM 2004; 32: S562-S570. 6. The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342: 1301-1308. 7. Bernard GR, Vincent JL, Laterre PF, et al: Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344: 699–709 8. Annane D. Sebille V. Charpentier C. et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288(7): 862-71. 9. http://www.survivingsepsis.org/ July 2006 The Journal of the Intensive Care Society
Volume 7 Number 2 Surveys & Audits continued 19 An Audit and Review of Hypoglycaemia in Critical Care A N Thomas, E M Boxall, G Sabbagh, Dr J Eddleston, T Dunne, A Stevens, P Murphy Summary The incidence of hypoglycaemia during critical illness was audited by asking staff across a critical care network to complete pre-printed forms attached to glucose vials used to treat this complication. Twenty eight episodes were identified in 2764 patient days, with a median blood glucose 2.3 mmol.l -1 , (range 1.3 to 4.0 mmol.l -1 ). A more complete record of the circumstances associated with hypoglycaemia was obtained than from reviewing 22 unstructured critical incident reports. The importance of maintaining calorie intake and monitoring night time glucose were identified as potentially preventative measures in 76 hypoglycaemic episodes. A risk register was produced to provide recommendations on how such events can be avoided. Details of the database and pre-printed forms can be found on the ICS website 1 . Key Words Glucose, hypoglycaemia, insulin, intensive care, adverse events, critical incident, glucometer. Tight control of blood glucose has been shown to improve survival and reduce morbidity in critical illness 2 . Intensive insulin protocols are, however, associated with the risk of hypoglycaemia 2,3,4 . This paper describes a structured method of auditing hypoglycaemia and reviews the circumstances associated with hypoglycaemic episodes. A literature review revealed other potential situations where hypoglycaemia may occur; these situations are described and strategies to minimise these risks are discussed. Methods The study was part of a wider investigation into intravenous drug administration in critical care, conducted with local research ethics committee approval across the Greater Manchester critical care network. Pre-printed forms (available on the ICS web site 1 ) requesting details of hypoglycaemic episodes were attached to vials of strong glucose solution used in their treatment. Staff accessing these vials to treat hypoglycaemia completed the forms and placed them in their unit’s critical incident box. The data was entered into an Access database (Microsoft Access, Microsoft inc. Seattle USA). The study was conducted for a 4-week period in units across the network at times staggered between the start of February and mid April 2005. To obtain a larger sample of hypoglycaemic episodes than would be found in such a short audit period, critical incident forms in one ICU were hand-searched to identify all hypoglycaemic episodes reported from August 2002 until January 2005. For similar reasons, a second unit also prospectively reviewed their observation charts during March 2004 to identify all episodes where the blood glucose fell below 3.0 mmol.l -1 . We therefore collected episodes of hypoglycaemia by prospective audit using pre-printed forms, by retrospective review of critical incidents, and by review of observation charts. The information from all of the episodes identified using these 3 methods were then entered on an SPSS spreadsheet (SPSS for Windows 11.4. SPSS inc. Chicago Il) for subsequent analysis. Results A total of 76 hypoglycaemic episodes were identified, 28 from completed pre-printed from the glucose vials, 26 from the retrospective review of critical incidents and 22 from the prospective chart review. The median blood hypoglycaemic level recorded using the pre-printed forms was 2.3 mmol.l -1 (range 1.3 to 4.0 mmol.l -1 ). Reports were received from 8 intensive care units with a median of 3 per unit (range 1 to 6). These units had a total of 97 beds open at the time with an occupancy rate of 95%, so the 28 episodes occurred in approximately 2764 bed days. All of the units were using tight glucose control protocols (target range 4.0 to 8.0 mmol.l -1 ). The median hypoglycaemic level for the single unit retrospective record review was 2.1 mmol.l -1 (range 1.1 – 3.9 mmol.l -1 ). To increase the sample size and facilitate identification of factors associated with hypoglycaemia we included results from previous hypoglycaemia critical incidents and a retrospective chart review with the main audit from the glucose bottle forms (76 episodes in total). From within this combined record the median hypoglycaemic level at the time of recording was 2.5 mmol.l -1 (range 1.1-4.0 mmol.l -1 ). The median blood glucose concentration recorded before the episode of hypoglycaemia was 5.4 mmol.l -1 (range 2.4 – 13 mmol.l -1 ) in the 60 incidents where this information was available. The median time between this reading and the hypoglycaemic episode was 3 hours (range 1 to 6 hours) in the 39 records where this could be July 2006 The Journal of the Intensive Care Society
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Volume 7 Number 2 July 2006 - JICS - The Intensive Care Society

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