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Recommandations formalisées d’experts. Contrôle de la glycémie en réanimation et en anesthésieGlycemic control in intensive care unit and during anaesthesia

Diabetes and hyperglycemic events in cardiac surgical patients are associated with postoperative morbidity and mortality. The causes of dysglycemia, the abnormal fluctuations in blood glucose concentrations, in the perioperative period include surgical stress, surgical techniques, medications administered perioperatively, and patient factors. Both hyperglycemia and hypoglycemia lead to poor outcomes after cardiac surgery. While trying to control blood glucose concentration tightly for better postoperative outcomes, hypoglycemia is the main adverse event. Currently, there is no definite consensus on the optimum perioperative blood glucose concentration to be maintained in cardiac surgical patients. This review provides an overview of perioperative glucose homeostasis, the pathophysiology of dysglycemia, factors that affect glycemic control in cardiac surgery, and current practices for glycemic control in cardiac surgery.

The prevalence of type 2 diabetes mellitus and the potential for perioperative dysglycaemia (hyperglycaemia, hypoglycaemia, stress-induced hyperglycaemia, or glucose variability) continue to increase dramatically. The majority of investigations on perioperative glycaemic control focused on critically ill patients and concentrated on goals of therapy, level of intensity of insulin infusion, feeding regimes, concerns over hypoglycaemia, and promulgation of recent guidelines calling for less strict glucose control. Areas of perioperative glycaemic control that deserve further investigation include preoperative identification of patients with undiagnosed type 2 diabetes and other forms of dysglycaemia, determination of appropriate intraoperative glucose goals, and establishment of the impact and natural history of perioperative abnormalities in glucose homeostasis. In the heterogeneous adult perioperative population, it is unlikely that one standard of perioperative glycaemic control is appropriate for all patients. This review presents recent evidence and expert guidance to aid preoperative assessment, intraoperative management, and postoperative care of the dysglycaemic adult patient.

Le contrôle de la glycémie en réanimation est l’objet de nombreuses controverses. En France, il n’existe pas de donnée sur l’adhésion aux recommandations.

Étude ancillaire d’une enquête un jour donné faite entre janvier et mai 2009.

Lors d’un audit réalisé dans 66 unités de réanimation, les données concernant l’existence d’un protocole de contrôle glycémique et son application ont été recueillies par des internes.

Le jour de l’audit, un protocole formalisé de contrôle glycémique a été identifié pour 89 % des patients hospitalisés dans les 66 unités du réseau. Six [4–9] mesures de la glycémie ont été réalisées par patient, soit un total de 3645 mesures sur l’ensemble des sites. La médiane de glycémie la plus haute était de 1,6 g/L [1,4–2,1]. Une hypoglycémie (< 0,8 g/L) et une hyperglycémie (> 1,4 g/L chez les non-diabétiques et > 1,8 g/L pour les diabétiques) ont été observées chez 81 (15 %) et 326 (58 %) patients, respectivement. Deux (0,36 %) hypoglycémies sévères (< 0,4 g/L) ont été notées. Les facteurs associés à l’application du contrôle glycémique étaient : score de défaillance d’organe élevé, choc électrique externe en urgence, ventilation mécanique, surveillance de pression intracrânienne, corticothérapie et ratio patients/IDE inférieur à 2,5. Le seul facteur associé au risque d’hypoglycémie était la défaillance hépatique.

Des protocoles de contrôle glycémique sont présents dans plus de 80 % des services de réanimation, mais leur suivi est imparfait. Néanmoins, la glycémie médiane respecte les recommandations actuelles. L’hypoglycémie sévère est un événement très rare en réanimation.

The interest of tight glucose control in ICU is still debated. In France, no data are available regarding this therapy and the implementation of its guidelines.

Sub-study of a one-day audit performed between January and May 2009.

During a one-day audit performed in 66 ICUs, trained residents collected data regarding the presence of a formal glucose control protocol and its practical application.

A formalized glucose control protocol was found in 88% of patients. During the day before the audit, 3645 glycemia measurements were performed accounting for six measurements [4–9] per patient with a median higher value of 1.6 [1.4–2.1]. Hypoglycemia (< 0.8 g/L) and hyperglycemia (> 1.4 g/L in non-diabetic and > 1.8 g/L in diabetic patients) were found in 81 (15%) and 326 (58%) patients respectively. Two episodes (0.36%) of severe hypoglycemia (< 0.4 g/L) were reported. Factors associated with glucose control protocol application were: a high SOFA score, cardioversion, mechanical ventilation, intracranial pressure monitoring, steroid use and nurse to patient ratio less than 1/2.5. Hepatic failure was the only factor associated with hypoglycemia.

Glucose control protocols are available in more than 80% ICUs but their implementation is still imperfect. However, the median glycemia meets international current recommendations. Severe hypoglycemia is a very rare event in ICU.