A study involving intensivists from 90 ICUs in northwest Europe has confirmed significant variability in glycaemic control practice. The Clinical Services Journal reports.
Since the landmark Leuven study in 2001,1 numerous studies have been published on the role of glycaemic control. The emerging picture is that while treating hyperglycaemia could be beneficial, normoglycaemic control carries a risk of unwanted hyperglycaemic injury through over control and can lead to marked variability in glucose levels, which is associated with poorer outcomes.2
The issue of variability was recently discussed at the Intensive Care Society State of the Art Meeting, following a major comparative survey of practices across 90 adult ICU departments in the UK, Germany and the Benelux. Gavin Troughton PhD and David Edbosimba Msc, from Sphere Medical presented the findings as part of a presentation and scientific poster.3
Elevated blood glucose is a widely recognised response to critical illness, with around two thirds of patients admitted to the intensive care unit (ICU) requiring intravenous insulin therapy (IIT) in order to avoid hyperglycaemia. However, IIT also carries the risk of hypoglycaemic episodes and injury. Sphere’s study involved intensivists from 90 adult intensive care units (ICU) and aimed to understand the current practices, protocols and challenges of glycaemic control practice using IIT.
The study confirmed that there are still controversies over what constitutes optimal glucose management in critical care, resulting in its finding that care protocols remain highly variable across northwest European ICUs. Eighty per cent of Intensivists surveyed also cited problems with implementing their adopted glycaemic control protocols for a number of reasons. “Blood testing is at the heart of many of these issues. Frequent blood glucose monitoring is essential for optimally managing insulin therapy and protocols often require hourly measurement of blood glucose until patient stability is achieved. Any variations that could affect glucose levels, such as insulin or feed changes, require reverting to hourly measurement until stability is evident,” observed Dr Gavin Troughton, Sphere Medical.
Consequently, the study found that nurse dependency and time taken to undertake the frequent blood glucose monitoring, essential for optimally monitoring IIT, was the most commonly cited issue when implementing protocols. Although arterial blood gas analysers (BGA) are the gold standard for measuring glucose samples, the survey found only 70% of tests were made using this method for IIT monitoring. This means that there is still a widespread use of capillary samples and test strips (potentially to reduce time to result and workloads) that can lead to significantly biased results,4 or BGA testing may not be undertaken as often as necessary.
To overcome the issues arising around blood testing for IIT, a number of continuous and intermittent systems are now commercially available for glucose monitoring in ICUs. For example, the next generation Proxima patient dedicated blood gas analysis system (Sphere Medical, Cambridge, UK) now allows rapid measurement of glucose levels directly at the bedside. This makes rapid and frequent measurement of arterial blood samples easy, supporting better glycaemic control in the critically ill.
As a patient dedicated system, Proxima is always connected to the patient via their arterial line and ready to go instantly. Since results are also delivered without the caregiver leaving the patient’s bedside, this significantly reduces time compared to conventional benchtop analysers. The design means the system can travel with the patient on their pathway through the hospital. This is possible since the Proxima sensor contains an array of biosensor technology on a silicon chip, each a miniaturised version of the electrochemical sensors used in a traditional blood gas analyser.
In addition to the sensor, the next generation Proxima system includes a medical grade tablet monitor with an intuitive touchscreen user interface. All results are reported to the monitor and can be seamlessly transferred directly into laboratory information systems and electronic patient records. This is a key requirement for the successful implementation of point-of-care (POC) testing.
As an ex-vivo analyser operating as a closed system, blood is drawn directly from the patient and over the Proxima sensor. Following analysis, all blood is returned to the patient, meaning that there is no blood loss and risk of iatrogenic anaemia is reduced. Furthermore, infection risk to staff and patients is minimised as the arterial line remains closed throughout sampling. The design of the system also reduces pre-analytical errors due to the delivery of a high integrity blood sample direct to the sensor for immediate analysis with no mixing or anti-coagulant required.
The addition of glucose to the new Proxima’s analyte panel is significant since, as previously discussed, glucose measurements play a key part in the care of critically ill patients. Both hyperglycaemia and hypoglycaemia are associated with increased morbidity and mortality in intensive care unit (ICU) patients. Keeping patients in normal glycaemic range is difficult with current systems. The ability to regularly monitor arterial blood glucose using Proxima will support closer clinical management for improved glycaemic control.
“Proxima is already redefining how arterial blood gas testing is carried out in critically ill patients through its use for the close monitoring of patients in the UK, Germany and Belgium,” said Dr Wolfgang Rencken, chief executive officer, Sphere Medical. “Based on clinical feedback, we have launched our next generation Proxima which is now even better placed to support rapid and frequent measurements of blood gases, electrolytes and metabolites without blood loss. The addition of glucose to the analyte panel is the most significant new parameter, enabling better glycaemic control in the critically ill.”
Professor of anaesthesia and intensive care medicine, Mike Grocott, University of Southampton, also commented: “The recent time and motion study we conducted at University Hospital Southampton clearly highlighted the workflow benefits of using Proxima on critically ill, unstable patients. We look forward to the opportunity to use this device on a larger patient group within the ICU.”
To read the glycaemic control scientific poster, or for more information on the new Proxima bedside blood gas monitoring system, please view: www.spheremedical.com/ glycaemic-control.
1. Van den Berghe G et al, Intensive Insulin Therapy in Critically Ill Patients, N Engl J Med 2001, 345:1359-67
2. Krinsley J, Glycemic control in the critically ill - 3 domains and diabetic status means one size does notfit all! Critical Care2013, 17:131
3. Troughton G, Egbosimba D. A comparative survey of glycaemic control practice in the UK, Germany and BeNeLux. Intensive Care Society State of the Art Meeting, December 2016. (available to download at www.spheremedical.com/glycaemic-control).
4. Petersen J et al, Comparison of POCT and central laboratory blood glucose results using arterial, capillary, and venous samples from MICU patients on a tight glycemic protocol Clin Chim Acta2008 396:10-13
5. Mitchel K, Salmon K, Troughton G, Egbosimba D, Grocott M, Time and motion study of Proxima arterial blood gas (ABG) sampling, poster presentation, BACCN 2016
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