Hostname: page-component-586b7cd67f-rcrh6 Total loading time: 0 Render date: 2024-11-27T22:43:18.020Z Has data issue: false hasContentIssue false
  • English
  • Français

Variability in Physician Care Practices for Glucose Treatment in Stroke Patients

Published online by Cambridge University Press:  02 December 2014

Leanne K. Casaubon ,
Alexandra Saltman ,
Valentina Peeva ,
Marguerite Ennis ,
Ngan Lam ,
Frank L. Silver  and
Moira K. Kapral
Leanne K. Casaubon*
Affiliation:
University Health Network University of Toronto, Toronto
Alexandra Saltman
Affiliation:
University Health Network
Valentina Peeva
Affiliation:
University Health Network
Marguerite Ennis
Affiliation:
Applied Statistician, Markham, Ontario, Canada
Ngan Lam
Affiliation:
University Health Network
Frank L. Silver
Affiliation:
University Health Network University of Toronto, Toronto
Moira K. Kapral
Affiliation:
University Health Network University of Toronto, Toronto
*
Dept. of Medicine, University of Toronto, Division of Neurology - Stroke Program, Toronto Western Hospital, West Wing 5-448, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada.
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Background:

Hyperglycemia is noted in up to 60% of stroke patients. Practice guidelines recommend glucose monitoring following stroke but provide few management recommendations. We examined physician care practices for glucose management in stroke patients.

Methods:

Emergency physicians, family physicians, general internists, intensive care specialists and neurologists in Ontario comprised the study population. A mailed, self-administered survey inquired about glucose management practices. Proportions of responses for survey questions were determined. Chi-square analysis was used for comparing physician groups.

Results:

Surveys were mailed to 2,280 physicians; 26.8% returned surveys. There were 278 respondents who reported providing stroke patient care. For physicians treating glucose in stroke patients, 16.6% targeted glucose 4.0-6.0 mmol/l, 52% targeted 6.1-8.0 mmol/l, 13.6% targeted 8.1-12.0 mmol/l, 0.8% targeted 12.1-15.0 mmol/l, and 7.5% were unsure. Comparing specialties, 32% of intensivists, 17.5% of neurologists, 13% of general internists, 14% of emergency physicians, and 0% of family physicians reported targeting 4.0-6.0 mmol/l (p=0.026). Overall, 44% reported aiming for target glucose within 12 hours and 77% within 24 hours from hospital presentation. Intensive care specialists treated glucose most aggressively, including 20% treating, with insulin infusion, patients with no diabetes and initial glucose 6.0-8.0 mmol/l. Emergency physicians were most conservative when treating glucose in stroke patients.

Conclusion:

There is variability in the aggressiveness of glucose management in stroke patients by different physician specialty groups, reflecting the lack of evidence available to guide hyperglycemia management in this setting. These results highlight an important gap in knowledge and recommendations for stroke patient care that must be addressed to ensure optimal patient outcomes.

Résumé:

RÉSUMÉ:Contexte:

Près de 60% des patients atteints d'un accident vasculaire cérébral (AVC) présentent une hyperglycémie. Les lignes directrices recommandent de surveiller le glucose après un AVC, mais elles fournissent peu de recommandations de traitement. Nous avons examiné les pratiques des médecins à ce sujet.

Méthodes:

La population de l'étude était constituée des urgentologues, des médecins de famille, des internistes, des intensivistes et des neurologues de l'Ontario. Nous avons distribué par la poste un questionnaire à compléter au sujet de leur attitude thérapeutique concernant le glucose. Nous présentons les réponses aux questions de l'enquête sous forme de proportions. Le test du chi-carré a été utilisé pour comparer les groupes de médecins.

Résultats:

Des questionnaires ont été postés à 2 280 médecins ; 26,8% ont retourné le questionnaire. Deux cent soixante-dix-huit répondants ont rapporté qu'ils traitaient des patients porteurs d'AVC. Parmi ceux qui traitaient le glucose chez les patients porteurs d'un AVC, 16,6% ciblaient un glucose entre 4,0 et 6,0 mmol/L, 52% ciblaient un glucose entre 6,1 et 8,0 mmol/L, 13,6% ciblaient un glucose entre 8,1 et 12,0 mmol/L, 0,8% ciblaient un glucose entre 12,1 et 15,0 mmol/L et 7,5% étaient indécis. Si nous comparons les réponses par spécialité, 32% des intensivistes, 17,5% des neurologues, 13% des internistes, 14% des urgentologues et 0% des médecins de famille ont rapporté une cible de 4,0 à 6,0 mmol/L (p = 0,026). Dans l'ensemble, 44% ont rapporté un chiffre cible pour le glucose dans les 12 heures et 77% dans les 24 heures de l'arrivée du patient à l'hôpital. Les intensivistes étaient ceux qui traitaient le glucose de la façon la plus agressive et 20% d'entre eux traitaient les patients non diabétiques avec un glucose initial de 6,0 à 8,0 mmol/L par une infusion d'insuline. Les urgentologues étaient les plus conservateurs dans le traitement du glucose chez les patients porteurs d'un AVC.

Conclusion:

Il existe une certaine variabilité dans l'attitude thérapeutique de différents groupes de spécialistes concernant le glucose chez les patients présentant un AVC. Cette constatation reflète l'absence de données pour guider le traitement de l'hyperglycémie dans ce contexte et souligne une lacune importante dans les connaissances et les recommandations thérapeutiques sur l'AVC qu'on devra combler pour optimiser le pronostic des patients atteints d'AVC

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 35 , Issue 5 , November 2008 , pp. 573 - 582
Copyright
Copyright © The Canadian Journal of Neurological 2008

References

1. Melamed, E. Reactive hyperglycaemia in patients with acute stroke. J Neurol Sci. 1976;29(2-4):267–75.Google Scholar
2. Matz, K, Keresztes, K, Tatschl, C, Nowotny, M, Dachenhousenm, A, Brainin, M, et al. Disorders of glucose metabolism in acute stroke patients: an under recognized problem. Diabetes Care. 2006; 29(4):792–7.CrossRefGoogle Scholar
3. Christensen, H, Boysen, G. Blood glucose increases early after stroke onset: a study on serial measurements of blood glucose in acute stroke. Eur J Neurol. 2002; 9(3):297–301.CrossRefGoogle Scholar
4. Capes, SE, Hunt, D, Malmberg, K, Pathak, P, Gerstein, HC. Stress hyperglycemia and prognosis of stroke in non-diabetic and diabetic patients: a systematic overview. Stroke. 2001; 32(10): 2426–32.Google Scholar
5. Jorgensen, HS, Reith, J, Nakayama, H, Kammersgaard, LP, Houth, JG, Raaschou, HO, et al. Potentially reversible factors during the very acute phase of stroke and their impact on the prognosis: is there a large therapeutic potential to be explored? Cerebrovasc Dis. 2001; 11(3):207–11.CrossRefGoogle Scholar
6. de Courten-Myers, G, Myers, RE, Schoolfield, L. Hyperglycemia enlarges infarct size in cerebrovascular occlusion in cats. Stroke. 1988; 19(5):623–30.CrossRefGoogle ScholarPubMed
7. Nedergaard, M. Transient focal ischemia in hyperglycemic rats is associated with increased cerebral infarction. Brain Res. 1987; 408(1-2):79–85.Google Scholar
8. Chew, W, Kucharczyk, J, Moseley, M, Derugin, N, Norman, D. Hyperglycemia augments ischemic brain injury: in vivo MR imaging/spectroscopic study with nicardipine in cats with occluded middle cerebral arteries. Am J Neuroradiol. 1991; 12(4):603–9.Google Scholar
9. Garg, R, Chaudhuri, A, Munschauer, F, Dandona, P. Hyperglycemia, insulin, and acute ischemic stroke: a mechanistic justification for a trial of insulin infusion therapy. Stroke. 2006; 37(1):267–73.Google Scholar
10. Song, EC, Chu, K, Jeong, SW, Jung, KH, Kim, SH, Kim, M, et al. Hyperglycemia exacerbates brain edema and perihematomal cell death after intracerebral hemorrhage. Stroke. 2003; 34(9): 2215–20.Google Scholar
11. de Courten-Myers, GM, Kleinholz, M, Wagner, KR, Myers, RE. Normoglycemia (not hypoglycemia) optimizes outcome from middle cerebral artery occlusion. J Cereb Blood Flow Metab. 1994; 14(2):227–36.CrossRefGoogle ScholarPubMed
12. Capes, SE, Hunt, D, Malmberg, K, Gerstein, HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet. 2000; 355(9206):773–8.CrossRefGoogle ScholarPubMed
13. Krinsley, JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003; 78(12):1471–8.CrossRefGoogle ScholarPubMed
14. Bochicchio, GV, Sung, J, Joshi, M, Bochicchio, K, Johnson, SB, Meyer, W, et al. Persistent hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma. 2005; 58(5): 921–4.Google Scholar
15. Malmberg, K, Ryden, L, Efendic, S, Herlitz, J, Nicol, P, Waldenstrom, A, et al. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol. 1995; 26(1):57–65.Google Scholar
16. Van den Berghe, G, Wouters, P, Weekers, F, Verwaest, C, Bruyninckx, F, Miet, S, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001; 345(19):1359–67.Google Scholar
17. Pittas, AG, Siegel, RD, Lau, J. Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials. Arch Intern Med. 2004; 164(18):2005–11.Google Scholar
18. Fath-Ordoubadi, F, Beatt, KJ. Glucose-insulin-potassium therapy for treatment of acute myocardial infarction: an overview of randomized placebo-controlled trials. Circulation. 1997; 96(4):1152–6.Google Scholar
19. Gray, CS, Hildreth, AJ, Sandercock, PA, O’Connell, JE, Johnston, DE, Cartlidge, NE, et al. Glucose-potassium-insulin infusions in the management of post-stroke hyperglycaemia: the UK glucose insulin in stroke trial (GIST-UK). Lancet Neurol. 2007; 6(5):397–406.CrossRefGoogle ScholarPubMed
20. Canadian Stroke Network and the Heart and Stroke Foundation of Canada; Canadian Stroke Strategy. Canadian best practice recommendations for stroke care; 2006. Ottawa: 2006.Google Scholar
21. Adams, HP Jr, del Zoppo, G, Alberts, MJ, Bhatt, DL, Brass, L, Furlan, A, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association stroke council, clinical cardiology council, cardiovascular radiology and intervention council, and the atherosclerotic peripheral vascular disease and quality of care outcomes in research interdisciplinary working groups. Stroke. 2007; 38(5):1655–711.Google Scholar
22. Broderick, J, Connolly, S, Feldmann, E, Hanley, D, Kase, C, Krieger, D, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association stroke council, high blood pressure research council, and the quality of care and outcomes in research interdisciplinary working group. Stroke. 2007; 38(6):2001–23.Google Scholar
23. Stewart, A. Basic statistics and epidemiology: a practical guide. Oxford: Radcliff Medical Press; 2002.Google Scholar
24. Murros, K, Fogelholm, R, Kettunen, S, Vuorela, AL, Valve, J. Blood glucose, glycosylated haemoglobin, and outcome of ischemic brain infarction. J Neurol Sci. 1992; 111(1):59–64.Google Scholar
25. Candelise, L, Landi, G, Orazio, EN, Boccardi, E. Prognostic significance of hyperglycemia in acute stroke. Arch Neurol. 1985; 42:661–3.Google Scholar
26. Whitcomb, BW, Pradhan, EK, Pittas, AG, Roghmann, MC, Perencevich, EN. Impact of admission hyperglycemia on hospital mortality in various intensive care unit populations. Crit Care Med. 2005; 33(12):2772–7.Google Scholar
27. The West of Scotland Coronary Prevention Study Group. Computerised record linkage: compared with traditional patient follow-up methods in clinical trials and illustrated in a prospective epidemiological study. J Clin Epidemiol. 1995; 48(12):1441–52.Google Scholar
28. Canada, Post. [cited 2008 Feb]. Available from: www.canadapost.ca/business/tools/pg/fsamaps/pdf/Canada.pdfGoogle Scholar