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Endocrinology - Diabetes
Hyperglycaemia is prevalent among critically ill patients and can directly affect outcomes or indicate increased underlying morbidity or mortality. The optimal degree of glycemic control in critical care settings has been debated for over two decades, particularly since a landmark study reported reduced mortality in surgical ICU patients managed with intensive (INT) blood glucose (BG) control using insulin and dextrose to maintain levels between 4.4–6.1 mmol/L (80–110 mg/dL), compared to conventional glucose control (CONV) with levels between 10–11.1 mmol/L (180–200 mg/dL).
Maintaining consistent glycemic control in critically ill patients is challenging due to unstable hemodynamic, fluctuating medications, and varying nutritional intake. The substantial workload required for insulin therapy and glucose monitoring, as well as the impact on the patient—such as sleep disturbances and discomfort—must be weighed against the desired outcomes of reducing morbidity and mortality. An effective glycemic management program relies on a robust protocol that ensures consistent implementation, adherence, effective monitoring, and ongoing quality assessment.
Table 1: Summary of recommended guidelines for glycemic control in critically ill adults.
| Statement | Good Practice Recommendation
| Rationale |
When should insulin therapy be initiated for critically ill adults based on glucose levels?
| Glycemic management protocols to address persistent hyperglycemia at or above 180 mg/dL in critically ill adults should be implemented. | Both the ADA & AACE recommend initiating insulin infusion therapy for critically ill adults with persistent severe hyperglycaemia. This approach is crucial as significant hyperglycaemia in critically ill patients can lead to osmotic diuresis, endothelial glycocalyx dysfunction, inflammation, and potentially increased mortality, particularly in nondiabetic patients.
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| Should insulin infusion therapy aim to achieve BG targets of 80–139 mg/dL or for unselected or subgrouped critically ill adults? | Glycemic management protocols and procedures that minimize the risk of hypoglycemia in critically ill adults and promptly address any occurrences of hypoglycemia. | The titration of insulin infusion to achieve lower BG targets (INT: 80–139 mg/dL) compared to higher targets (CONV: 140–200 mg/dL) to minimize the risk of hypoglycemia., should be avoided. Forty-four RCTs compared insulin infusion targets of INT to CONV among mixed populations of ICU patients. Targeting INT was associated with lower ICU length of stay, reduced infection risk, however, it increased frequency of severe hypoglycaemia.
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| For critically ill adults starting insulin therapy, should continuous IV infusion or intermittent subcutaneous insulin be preferred? | Using continuous IV insulin infusion rather than intermittent subcutaneous insulin in the acute management of hyperglycemia in critically ill adults, should be recommended. | Six studies comparing outcomes of IV insulin infusion versus intermittent subcutaneous insulin in critically ill adults with hyperglycemia found that IV insulin infusion had no significant effect on mortality. However, IV therapy was associated with an increased incidence of hypoglycemic episodes.
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| For adult ill patients receiving insulin infusion therapy, should BG monitoring be conducted frequently (interval ≤ 1 hr) or less frequently (interval > 1 hr) during periods of glycemic instability? | Frequent (≤ 1 hr) glucose monitoring is recommended in the management of hyperglycemia in ill adults on IV insulin during periods of glycemic instability. | Six RCTs assessing this outcome revealed that more frequent blood glucose monitoring was linked to decreased incidence of hypoglycemia. Benefits of increased monitoring frequency include enhanced glycemic control, reduced hypoglycemia rates, and earlier detection. ADA & AACE recommend monitoring every 30 minutes to 2 hours during insulin infusions. |
Abre: American Diabetes Association (ADA), American Association of Clinical Endocrinology (AACE), blood glucose (BG), intravenous (IV), intensive (INT), intensive care unit (ICU), conventional (CONV)
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