الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Diabetes is an important health condition and the number of individuals with diabetes can be expected to grow rapidly over the coming decades. Specific metabolic abnormalities induced by diabetes can adversely affect the mechanical performance or increase the myocardial vulnerability to ischemic insults. Evidence is emerging and suggests that insulin per se is therapeutic for critically ill patients; insulin administration and improved metabolic control during the acute phase of AMI reduce myocardial damage, improve contractility and mortality.
Patients with diabetes have an increased incidence of atherosclerotic cardiovascular disease and acute coronary syndrome. Coronary artery disease is the most common underlying cause of death in type 2 diabetes. In addition, hyperglycemia occurs in 66% of patients admitted to coronary care unit who are not known to be diabetic. Hyperglycemia in hospitalized patients, irrespective of its cause, is unequivocally associated with adverse outcomes.
Hyperglycemia in hospitalized patients, irrespective of its cause, is unequivocally associated with adverse outcomes. Hyperglycemia occurs in patients with known or undiagnosed diabetes, or it occurs during acute illness in those with previously normal glucose tolerance is termed (“stress hyperglycemia”) . Intervention directed at reducing blood glucose (BG) levels has resulted in improved outcome in these patients.
Treatment of hyperglycemia in critically ill patients on the basis of the available evidence, insulin infusion should be used to control hyperglycemia in the majority of critically ill patients in the ICU setting, with a starting threshold of no higher than 180 mg/dl (10.0 mmol/L( Once IV insulin therapy has been initiated, the glucose level should be maintained between 140 and 180 mg/dl (10.0 mmol/L), and greater benefit may be realized at the lower end of this range. Although strong evidence is lacking, somewhat lower glucose targets may be appropriate in selected patients. Targets less than 110 mg/dL (6.1 mmol/L), however, are not recommended. Use of insulin infusion protocols with demonstrated safety and efficacy, resulting in low rates of occurrence of hypoglycemia, is highly recommended.
There are various routes and methods through which insulin is administered in hospitals. The traditional “sliding-scale” insulin regimens, usually consisting of regular insulin without any intermediate or long acting insulin, are very widespread. Their popularity appears to derive from their ease of use, reduction of phone calls to doctors, and a misconception by some medical and nursing staff that they improve blood glucose control.
There are several problems associated with the use of the SSI regimen, The regimen typically results in an increase in the number of insulin injections received, and insulin is given retrospectively for high blood glucose values and not given during euglycemia or before anticipated hyperglycemia attributable to concurrent or planned meals. Patients are often awakened during the night for blood glucose monitoring and insulin therapy, which may increase the incidence of nocturnal hypoglycemia. In addition, there is no standard SSI regimen, and dosages vary widely between patients, providers, and institutions.
Furthermore, some evidence suggests that SSI regimens carry additional risk of glycemic events instead of protecting against them. In both retrospective and non randomized studies, not only have SSI regimens been associated with an increase in hyperglycemia and hypoglycemia, but they have also been associated with an increased length of stay for hospitalized diabetic patients. Additionally, there is no evidence to suggest any short- or long-term benefit from tight glycemic control during hospitalization for most co-morbid medical conditions.
The present study included 120 patients, admitted with acute coronary syndrome, in the coronary care units, in whom random blood glucose (RBG )was above 140 mg/dl and aimed at evaluating the degree of control of diabetes in the intensive care unit by the conventional methods of insulin treatment using subcutaneous sliding scale regarding achievement of the target range of 140-180mg/dl ,time needed to achieve the target range, number of readings outside the target range, number of attacks of hypoglycemia during achievement of the target, coronary outcome with blood glucose target between 140-180mg/dl and to evaluate the incidence of different complications, including hypoglycemia, cardiac arrhythmia, need for mechanical ventilation, infection, re-infarction, heart failure, and mortality during hospital admission.
All individuals included in the study were subjected to thorough history taking, complete clinical examination and routine laboratory investigations. Every individual had his blood glucose level measured every 6 hours, using either Continuous Glucose Monitoring System (CGMS) or traditional finger sticks, for 72 hours. Conventional method using subcutaneous insulin to control blood glucose every 6 hours is the one used in these patients according to the following table:
If the blood glucose: give:
200-250mg 5 units
251-300mg 10 units
301-350mg 15 units
351-400mg 20 units
When the blood glucose exceed 400 mg, insulin infusion is given using infusion pump with 50 units actrapid in 50 cm normal saline, with blood glucose measurement every hour till reach 200mg & then return to the subcutaneous schedule.
The study showed that the use of conventional subcutaneous sliding scale insulin in critically ill patients was associated with several problems as we mentioned before and must be replaced by insulin infusion. The incidence of hypoglycemia was higher with the use of sliding scale (26.67%), mortality had been occurred in 2 patients, the need for revascularization occurred in 2 patients. The incidence of coronary events and the total clinical complications were higher when compared with the results occurred in patients using insulin infusion; what’s mean that it is not recommended for use in critically ill patients. A long time was taken to achieve the needed target (mean time was18.8±15.42).
Subcutaneously administered insulin is the preferred method for achieving and maintaining glucose control in non-ICU patients with diabetes or stress hyperglycemia. The recommended components of inpatient subcutaneous insulin regimens are a basal, a