J Clin Neurol.  2009 Dec;5(4):167-172. 10.3988/jcn.2009.5.4.167.

Aggressive Glucose Control for Acute Ischemic Stroke Patients by Insulin Infusion

Affiliations
  • 1Department of Neurology, Eulji General Hospital, Eulji University College of Medicine, Seoul, Korea. nrkoomh@chol.com
  • 2Department of Neurology, Dong-Eui Medical Center, Busan, Korea.
  • 3Department of Biostatistics, Korea University College of Medicine, Seoul, Korea.

Abstract

BACKGROUND AND PURPOSE
Hyperglycemia after acute ischemic stroke (AIS) is associated with poor outcomes. However, there is no consensus as to the optimal method for glycemic control. We designed an insulin infusion protocol for aggressive glucose control and investigated its efficacy and safety. METHODS: We applied our protocol to patients within 48 hours after AIS or transient ischemic attack (TIA) with an initial capillary glucose level of between 100 and 399 mg/dL (5.6-22.2 mmol/L). An insulin solution comprising 40 or 50 U of human regular insulin in 500 mL of 5% dextrose was administered for 24 hours. Capillary glucose was measured every 2 hours and the infusion rate was adjusted according to a nomogram with a target range of 80-129 mg/dL (4.4-7.2 mmol/L). Changes in glucose and overall glucose levels during insulin infusion were analyzed according to the presence of diabetes or admission hyperglycemia (admission glucose >139 mg/dL or 7.7 mmol/L) by the generalized estimating equation method. RESULTS: The study cohort comprised 115 consecutive patients. Glucose was significantly lowered from 160+/-57 mg/dL (8.9+/-3.2 mmol/L) at admission to 93+/-28 mg/dL (5.2+/-1.6 mmol/L) during insulin infusion (p<0.05). Laboratory hypoglycemia (capillary glucose <80 mg/dL or 4.4 mmol/L) occurred in 91 (71%) patients, 11 (10%) of whom had symptomatic hypoglycemia. Although glucose levels were significantly lowered and maintained within the target range in all patients, overall glucose levels were significantly higher in patients with diabetes or hyperglycemia (p<0.05). CONCLUSIONS: Our insulin-infusion protocol was effective in glycemic control for patients with AIS or TIA. Further modification is needed to improve the efficacy and safety of this procedure, and tailored intervention should be considered according to glycemic status.

Keyword

ischemic stroke; hyperglycemia; insulin

MeSH Terms

Capillaries
Cohort Studies
Consensus
Glucose
Humans
Hyperglycemia
Hypoglycemia
Insulin
Ischemic Attack, Transient
Nomograms
Stroke
Glucose
Insulin

Figure

  • Fig. 1 The distribution of capillary glucose at 2 hours after insulin infusion with regard to target range (TR).

  • Fig. 2 Change of mean capillary glucose during insulin infusion according to the presence of diabetes.

  • Fig. 3 Change of mean capillary glucose during insulin infusion according to the presence of admission hyperglycemia.


Reference

1. Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke. 2001. 32:2426–2432.
Article
2. Scott JF, Robinson GM, French JM, O'Connell JE, Alberti KG, Gray CS. Prevalence of admission hyperglycaemia across clinical subtypes of acute stroke. Lancet. 1999. 353:376–377.
Article
3. Toni D, Sacchetti ML, Argentino C, Gentile M, Cavalletti C, Frontoni M, et al. Does hyperglycaemia play a role on the outcome of acute ischaemic stroke patients? J Neurol. 1992. 239:382–386.
4. Quinn TJ, Lees KR. Hyperglycaemia in acute stroke--to treat or not to treat. Cerebrovasc Dis. 2009. 27:Suppl 1. 148–155.
Article
5. Allport L, Baird T, Butcher K, Macgregor L, Prosser J, Colman P, et al. Frequency and temporal profile of poststroke hyperglycemia using continuous glucose monitoring. Diabetes Care. 2006. 29:1839–1844.
Article
6. Baird TA, Parsons MW, Phanh T, Butcher KS, Desmond PM, Tress BM, et al. Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke. 2003. 34:2208–2214.
Article
7. Kiers L, Davis SM, Larkins R, Hopper J, Tress B, Rossiter SC, et al. Stroke topography and outcome in relation to hyperglycaemia and diabetes. J Neurol Neurosurg Psychiatry. 1992. 55:263–270.
Article
8. Weir CJ, Murray GD, Dyker AG, Lees KR. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study. BMJ. 1997. 314:1303–1306.
Article
9. Williams LS, Rotich J, Qi R, Fineberg N, Espay A, Bruno A, et al. Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke. Neurology. 2002. 59:67–71.
Article
10. Gentile NT, Seftchick MW, Huynh T, Kruus LK, Gaughan J. Decreased mortality by normalizing blood glucose after acute ischemic stroke. Acad Emerg Med. 2006. 13:174–180.
Article
11. Bhalla A, Wolfe CD, Rudd AG. Management of acute physiological parameters after stroke. QJM. 2001. 94:167–172.
Article
12. Stead LG, Gilmore RM, Bellolio MF, Mishra S, Bhagra A, Vaidyanathan L, et al. Hyperglycemia as an independent predictor of worse outcome in non-diabetic patients presenting with acute ischemic stroke. Neurocrit Care. 2009. 10:181–186.
Article
13. Farrokhnia N, Björk E, Lindbäck J, Terent A. Blood glucose in acute stroke, different therapeutic targets for diabetic and non-diabetic patients? Acta Neurol Scand. 2005. 112:81–87.
Article
14. Clinical Research Center for Stroke. Available at: http://www.strokecrc.or.kr/.
15. European Stroke Organisation (ESO) Executive Committee. ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis. 2008. 25:457–507.
16. 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: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007. 38:1655–1711.
Article
17. Bruno A, Kent TA, Coull BM, Shankar RR, Saha C, Becker KJ, et al. Treatment of hyperglycemia in ischemic stroke (THIS): a randomized pilot trial. Stroke. 2008. 39:384–389.
18. Bruno A, Saha C, Williams LS, Shankar R. IV insulin during acute cerebral infarction in diabetic patients. Neurology. 2004. 62:1441–1442.
Article
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. 6:397–406.
Article
20. Walters MR, Weir CJ, Lees KR. A randomised, controlled pilot study to investigate the potential benefit of intervention with insulin in hyperglycaemic acute ischaemic stroke patients. Cerebrovasc Dis. 2006. 22:116–122.
Article
21. Zhu CZ, Auer RN. Optimal blood glucose levels while using insulin to minimize the size of infarction in focal cerebral ischemia. J Neurosurg. 2004. 101:664–668.
Article
22. Fuentes B, Castillo J, San José B, Leira R, Serena J, Vivancos J, et al. The prognostic value of capillary glucose levels in acute stroke: the GLycemia in Acute Stroke (GLIAS) study. Stroke. 2009. 40:562–568.
Article
23. Bruno A, Biller J, Adams HP Jr, Clarke WR, Woolson RF, Williams LS, et al. Acute blood glucose level and outcome from ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Neurology. 1999. 52:280–284.
Article
24. Gray CS, Hildreth AJ, Alberti GK, O'Connell JE. GIST Collaboration. Poststroke hyperglycemia: natural history and immediate management. Stroke. 2004. 35:122–126.
25. Alvarez-Sabin J, Molina CA, Montaner J, Arenillas JF, Huertas R, Ribo M, et al. Effects of admission hyperglycemia on stroke outcome in reperfused tissue plasminogen activator--treated patients. Stroke. 2003. 34:1235–1241.
Article
26. Bruno A, Levine SR, Frankel MR, Brott TG, Lin Y, Tilley BC, et al. Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology. 2002. 59:669–674.
Article
27. Els T, Klisch J, Orszagh M, Hetzel A, Schulte-Mönting J, Schumacher M, et al. Hyperglycemia in patients with focal cerebral ischemia after intravenous thrombolysis: influence on clinical outcome and infarct size. Cerebrovasc Dis. 2002. 13:89–94.
Article
Full Text Links
  • JCN
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr