Sliding Scale vs Tight Glycemic Control?

[sheryl1304]

[color=#0a264e]sliding scale vs tight glycemic control

is there a difference or are they the same thing?

[ukstudent]

Two different concepts.

Sliding scale just means there is a written protocol for how much insulin to give depending on blood sugar results. In my hospital it is also used to distinguish sub-q and IV insulin drip's, but that is not really what it means.

Tight control means how aggressive you are in keeping a low blood sugar. At one point we used tight control on everyone and the docs wanted the BS to be 80. I have even given in the past, insulin for a BS in the 90's. Studies now show that this is not helpful and can be detrimental to patient survival. We no longer use tight control and do not start insulin until BS's are above 160 for non diabetic patients.

[classicdame, MSN, EdD]

That one study did not change the mind of many researchers who still claim that tighter control is the only way to prevent short and longterm complications. But the control parameters have changed. Anything over 150 is still too high (fasting) and many studies show that cardiac patients and patients with wounds heal faster if controlled, but do not have to be as tight as 90 mg/dl fasting.

[luvRNs, BSN, MSN, RN]

The evidence is mounting substantially that tight control is really the way to go. The key is blood glucose variability. If a hospitalized patient is kept within the parameters, ICU LOS and overall mortality both go down. Still under investigation is what tight control parameters should be, and are they different for different polulations ( like open heart surgical patients vs. medical patients)

Hope tihs helps

[HamsterRN, ADN, RN]

A sliding scale is a method for controlling blood sugar and "tight control" refers to a blood sugar control goal, in our ICU this refers to a range of 80-110 using an insulin gtt, although we only use this range for post open-heart patients since these are the only type of patients where the evidence supports the use of tight control. The ACCORD and NICE-SUGAR studies both showed that aggressively controlling blood sugar significantly increases mortality risk (by 14% when aggressively ltreating blood sugars less than 170 according to the NICE-SUGAR study, and the ACCORD study also showed a significantly increased risk of mortality when diabetics were controlled to an A1C of 6 as opposed to 7). The NICE-SUGAR study looked specifically at hospitalized patients, one conclusion that has been drawn from this is that when patients are acutely ill, increased blood sugar is a healthy defensive mechanism. This does not mean that a blood sugar of 225 should not be treated, but the evidence does seem to show that for most hospitalized patients, controlling blood sugars less than 170 increases mortality risk, and for Septic patients blood sugars of less than 200 should not be treated.

[Jolie, BSN]

A sliding scale is a method for controlling blood sugar and "tight control" refers to a blood sugar control goal, in our ICU this refers to a range of 80-110 using an insulin gtt, although we only use this range for post open-heart patients since these are the only type of patients where the evidence supports the use of tight control. The ACCORD and NICE-SUGAR studies both showed that aggressively controlling blood sugar significantly increases mortality risk (by 14% when aggressively ltreating blood sugars less than 170 according to the NICE-SUGAR study, and the ACCORD study also showed a significantly increased risk of mortality when diabetics were controlled to an A1C of 6 as opposed to 7). The NICE-SUGAR study looked specifically at hospitalized patients, one conclusion that has been drawn from this is that when patients are acutely ill, increased blood sugar is a healthy defensive mechanism. This does not mean that a blood sugar of 225 should not be treated, but the evidence does seem to show that for most hospitalized patients, controlling blood sugars less than 170 increases mortality risk, and for Septic patients blood sugars of less than 200 should not be treated.

Very interesting. I have virtually no experience with diabetics on an in-patient basis, so this is all new to me. What were the causes of death in patients with increased mortality related to tight control?

[classicdame, MSN, EdD]

I recommend you look up the studies and decide for yourself. Things tend to get mis-communicated. Remember the study that 94,000 people in the US were dying of med errors yearly? TOTALLY WRONG. 94,000 was an extrapolated number. It was a conclusion from the researchers that if every hospital in the US had the same med errors as the few that were studied then the rate could be that high. So sometimes it is best to read the study.

www.diabetes.org

[HamsterRN, ADN, RN]

The cause of increased mortality is not known. The mortality rate was corrected for incidents of hypglycemia. Since many of the participants in the ACCORD study were taking oral antihyperglyecmics which carry a known risk of MI and stroke, it was thought this could account for the findings. But the NICE-SUGAR study used only IV and SQ insulin and still showed a similar increase in mortality related severity of control.

[luvRNs, BSN, MSN, RN]

I agree with Hamster's response. My use of the term 'tight control" was misleading. She is correct about both studies. Many institutions are now re-defining their goals based on these, and are now aware that glucose control is not a " one size fits all".

What does seem to be clear is that glucose variability persists when sliding scale are employed.