Management strategies of dysglycaemia in critically ill adult patients : a scoping review

Abstract

Management strategies of dysglycaemia in critically ill adult patients: a scoping review. Background: Dysglycaemia comprises of hypoglycaemia, hyperglycaemia and glycaemic variability. It is a biomarker of disease severity and my lead to increased mortality in critically ill patients. Dysglycaemia is common in critically ill patients and also presents in non-diabetic patients. However, blood glucose/dysglycaemia management strategies for critically patients remain ad hoc, which increases the risks for complications associated with dysglycaemia. Objective: The objective of the study was to explore, identify and map the evidence available on management strategies of dysglycaemia in critically ill adult patients in the critical care unit, and to identify evidence gaps relating to the management of dysglycaemia in critically ill adult patients. Design: A Scoping review was done according to the Joanna Briggs Institute (JBI) methodology. Data source and search strategy: Medline and CINAHL databases were searched to identify articles that examine glucose control in the critical care unit (CCU). Articles that were published from 2001 until 2023 were evaluated and the search was limited to articles published in English. We used the following search terms: Glucose monitoring OR glucose control OR glycaemic control OR dysglycaemia NOT Diabetes mellitus OR Diabetes OR Diabetic AND Critically ill OR intensive care patients OR critical care patients. Only original articles were included while case reports as well as editorial letters, opinion papers, and surveys were excluded. The search strategy was compiled by the author and an experienced information specialist executed the search. Eligibility criteria and study selection: Population - (i) patients 18 years or older, (ii) female and male patients, (iii) patients of any race and ethnicity, (iv) patients admitted to the critical care unit following a medical or surgical diagnosis, (v) studies from 2001 up to 2023. Concept – Sampling method of blood glucose, frequency monitored, target range of blood glucose guiding treatment (hypo or hyper), method of Insulin or Dextrose administration, evaluation. Context – Critical care units and high care units. All publications were screened by the researcher and a supervisor. Results were discussed, and the screening and data extraction process was amended as necessary, before making final decisions. Titles, abstracts, and full texts of all the publications were screened by the researcher and supervisor independently to ascertain inclusions. Disagreements were settled without the need for a 3rd party involvement. Once the results were available, it was exported into EndNote and Rayyan, an online systematic review software. Duplicates were removed by the researcher, and articles were reviewed for inclusion and exclusion. Additional relevant material was not deemed necessary, so no authors were contacted during this period. Lastly, reference lists were searched and screened for potential sources. Data extraction: A data charting form was created in Excel and data extraction variables were drawn up as columns. This was done to ensure important details were not omitted and to ensure that the data captured were in line with the study’s objectives and inclusion criteria. The data charting form was continuously updated. With the aid of a data extraction tool created for this study, the data from the eligible studies were then charted. The form was used to capture all the relevant data and specific key characteristics regarding included variables of blood glucose control. Only one reviewer charted the results independently and these were reviewed by another reviewer. Disagreements were solved through discussion. Results: The primary search strategy identified 2261 potentially relevant papers (see Figure 2). Duplicates were removed at this stage (in Rayyan), and a total of 1908 articles remained. Articles which had restricted access to full text was 160. A total of 1748 records remained at this stage. The titles and abstracts, as well as full-text articles were screened, of which 1732 were excluded. The selection at this stage included 16 studies. Two (2) additional studies were identified through a manual search of the reference lists of these studies. Uncertainty existed over the optimum treatment goal for glycaemia in the critically ill population. The largest prospective multicenter trial, which revealed an increase in mortality in patients receiving intense insulin therapy, could not duplicate the findings of randomized controlled trials from the early 2000s that showed a benefit of very tight glucose control. The present research largely focused on the clinical benefit and hypoglycaemia risk of intensive insulin therapy; however, there was no consensus on the ideal blood glucose control range, the patients who should receive it, when to initiate treatment, and how to minimize the risk. Conclusion: There’s more to blood glucose measurement than meets the eye. It is much more comprehensive and is not as simple as sampling blood for testing, and a lot of factors need to be taken into consideration. There are many diverse and different views regarding target range of blood glucose, frequency of testing, and sampling of blood. Conclusions cannot simply be drawn from the articles as there were too many diverse views and results.