Glucose control in T2DM ICU patients Survey

A Survey Of Intensivists’ Opinion And Self-Reported Practice of Glucose Control In Critically Ill Patients With Pre-existing Type-2 Diabetes

Dear Colleague,

We are conducting a survey of Intensive Care Specialists to learn more about:

(i) your opinions and practice of glucose control in critically ill adult patients in Australian and New Zealand Intensive Care Units (ICUs), and

(ii) how the results from the NICE-SUGAR trial has affected you practice

In regards to the first point we are referring to adult patients with type 2 diabetes (T2DM) who are admitted for ‘general’ reasons and not patients with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemia states (HHS, HHNK or HONK)

In particular, we seek to understand your preferences in relation to blood glucose management for T2DM patients and your willingness to enroll T2DM patients into a future randomised controlled trial (RCT) of liberal versus standard blood glucose targets for T2DM patients admitted to Intensive Care Unit (ICU).

Your participation is voluntary and all responses are strictly confidential, you may skip any questions you do not want to answer.

Your contact details have been obtained from the ANZICS database.

The study has been approved by the Royal Adelaide Hospital Human Research Ethics Committee. HREC reference number: HREC/16/RAH/228

Only aggregated responses will be reported.

If you are currently working as an ICU Specialist in Australia or New Zealand and caring for adult patients, we would be grateful if you could take the time to complete this survey. The survey should take 5 minutes or less to complete.

Should you wish to contact the investigator or lodge a complaint about the conduct of this study:
Primary Investigator: Alexis Poole
Email: Alex.Poole@sa.gov.au
Phone: 08 8222 4624
Mob: 0439 488 395
Or
RAH human research ethics committee: Dr Andrew Thornton
Email: Health.CALHNResearchEthics@sa.gov.au
Phone: 08 8222 4139

1.I understand the purpose of the survey and agree to take part

Yes

Part 1: About you and where you work

4.Which of these best describes the ICU you predominantly practice in?

Public metropolitan

Private metropolitan

Public regional

Private regional

5.How many beds does this ICU have?

1 - 10

11 - 20

21 - 30

More than 30

Part 2: How you monitor and manage blood glucose levels for patients in your ICU

6.Excluding protocols for patients admitting for with diabetic ketoacidosis (DKA), does your ICU have a blood glucose management protocol that is specific to patients with diabetes?

Yes

Unsure

7.What method do you predominately use to measure blood glucose concentrations within your ICU?

Point of care glucometers

Arterial blood gas

Central laboratory results

Other

8.How frequently (on average) do you think that blood glucose concentrations are measured in your ICU from patients with diabetes with an arterial line insitu?

Part 3: How you currently monitor and manage blood glucose levels for ICU patients with either a central or arterial line insitu.

9.Of the following options, please indicate what algorithm you predominantly use when treating hyperglycaemia in patients within your ICU.

Basic nomogram (i.e. changes to insulin infusion only uses the current blood glucose concentration and recommends increment or reduction based on these two variables)

Dynamic protocol (i.e. changes to insulin infusion uses preceding and current blood glucose concentrations/insulin rates and recommends increment or reduction based on these two variables)

Dynamic protocol that incorporates nutritional intake as well

Computerized protocols (i.e. adjustment of insulin based on computerized modelling)

No protocol used

10.Which of the following methods would you initially use when treating hyperglycaemia in T2DM patients expected to stay longer than 24 hours in ICU:

Subcutaneous insulin administration only

Subcutaneous insulin followed by intravenous insulin administration

Intravenous insulin therapy only

Intravenous insulin therapy followed by subcutaneous insulin

I do not mind which mode of therapy is initially used, so I let the junior medical staff decide

11.In the unit that you predominantly work and according to that protocol when is insulin commenced on ICU patients.

Insulin is started for blood glucose ≥ 6.1 mmol/l and titrated to achieve blood glucose concentrations 4.5-6.0 mmol/l as per Leuven studies

Insulin is started blood glucose ≥ 10.1 mmol/l and titrated to achieve blood glucose concentrations between 6.0-10.0 mmol/l as per NICE-SUGAR

Neither as insulin is started at a threshold blood glucose concentration greater than Leuven but less than NICE-SUGAR (i.e. between 6.1-10.0 mmol/l)

Neither as insulin is started at a threshold greater than NICE-SUGAR

Part 4: Please indicate the extent to which you agree with each of the following statements concerning the current evidence for the glucose control in T2DM patients admitted to the intensive care unit:

13.Please indicate how concerned about inducing further harm associated with NOT treating blood glucose concentrations >10 mmol/l in patients without pre-existing diabetes?

Yes, this is a major concern

Yes, but not a major concern

No, it is not a concern

14.Please indicate how much you are concerned about inducing further harm associated with NOT treating blood glucose concentrations > 10 mmol/l in patients with diabetes?

Yes, this is a major concern

Yes, but not a major concern

No, it is not a concern

16.There is currently sufficient evidence to determine the optimal blood glucose range for patients with T2DM admitted to the ICU.

17.I would be prepared to enroll ICU patients with T2DM into a randomized trial of liberal blood glucose control (10-14 mmol/l).

18.I am concerned about the potential for increased risk of infection if T2DM patients only had insulin commenced for blood glucose concentrations ≥ 14 mmol/l

19.I am concerned about the potential for hypoglycaemia (<4.0mmol/l) when aiming for blood glucose concentrations between 6-10 mmol/l in patients with T2DM

20.The lowest blood glucose concentration that I think is safe for patients with T2DM to tolerate during ICU admission is:

Between 6.0 and 10.0 mmol/l

Between 4.0 and 5.9 mmol/l

Between 3.0 and 3.9 mmol/l

Between 2.3 and 2.9 mmml/l

21.Please select the specific patient groups you would be willing to enroll into enroll into a liberal blood glucose concentrations study for T2DM patients (tick all that apply).

22.Do you think it would be feasible to have two glucose protocols one for patients with and one for without diabetes?