Strategies for Achieving Glycemic Control: Management of Hyperglycemia in the Critical Care Setting

Management of Hyperglycemia in the Critical Care Setting

Key Points

  • Hyperglycemia is common in critically ill patients, both with and without diabetes.

  • Hyperglycemia is a predictor of adverse outcomes, including mortality.

  • Significant improvements in mortality and morbidity with intensive glycemic management have been demonstrated in some randomized, controlled trials and in “before and after” comparisons such as the Mixed Med-Surg ICU study.

  • Glycemic goals for critically ill patients:

    • Target blood glucose range is 140-180 mg/dL.

    • Lower blood glucose targets may be appropriate for some patients but 110 mg/dL should be considered the lower limit for all patients.

    • Reassess insulin regimen if blood glucose is <100 mg/dL, and adjust insulin regimen if blood glucose is <70 mg/dL (unless explained by a missed meal or other specific factors).

  • Intravenous insulin, using a validated protocol to minimize hypoglycemia, is the preferred approach in critical care settings (for specific protocols, see Protocols and Order Sets).

Suggested Reading

Clinical Guidelines

American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66.

Deedwania P, Kosiborod M, Barrett E; American Heart Association Diabetes Committee of the Council on Nutrition, Physical Activity, and Metabolism. Hyperglycemia and acute coronary syndrome: a scientific statement from the American Heart Association Diabetes Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation 2008;117:1610-1619.

Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15:353-369.

Qaseem A, Humphrey LL, Chou R, Snow V, Shekelle P. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011;154:260-267.

Society of Hospital Medicine. The case for supporting inpatient glycemic control programs now: the evidence and beyond. 2008.

Additional Reading

Anthony M. Treatment of hypoglycemia in hospitalized adults: a descriptive study. Diabetes Educ. 2007;33:709-715.

Bode BW, Braithwaite SS, Steed RD, Davidson PC. Intravenous insulin infusion therapy: indications, methods, and transition to subcutaneous insulin therapy. Endocr Pract 2004;10(suppl 2):71-80.

Braithwaite SS, Buie MM, Thompson CL, et al. Hospital hypoglycemia: not only treatment but also prevention. Endocr Pract. 2004;10(suppl 2):89-99.

Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591.

Cook CB, McNaughton DA, Braddy CM, et al. Management of inpatient hyperglycemia: assessing perceptions and barriers to care among resident physicians. Endocr Pract. 2007;13:117-125.

Cook CB, Wellik KE, Kongable GL, Shu J. Assessing inpatient glycemic control: what are the next steps? J Diabetes Sci Technol. 2012;6:421-427.

Davidson PC, Steed RD, Bode BW. Glucommander: a computer-directed intravenous insulin system shown to be safe, simple, and effective in 120,618 h of operation. Diabetes Care. 2005;28:2418-2423.

DeSantis AJ, Schmeltz LR, Schmidt K, et al. Inpatient management of hyperglycemia: the Northwestern experience. Endocr Pract. 2006;12:491-505.

Furnary AP, Braithwaite SS. Effects of outcome on in-hospital transition from intravenous insulin infusion to subcutaneous therapy. Am J Cardiol. 2006;98:557-564.

Furnary AP, Wu Y. Clinical effects of hyperglycemia in the cardiac surgery population: the Portland Diabetic Project. Endocr Pract. 2006;12(suppl 3):22-26.

Garber AJ, Moghissi ES, Bransome ED Jr, et al. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract. 2004;10:77-82.

Garg R, Jarry A, Pendergrass M. Delay in blood glucose monitoring during an insulin infusion protocol is associated with increased risk of hypoglycemia in intensive care units. J Hosp Med. 2009;4:E5-E7.

Goldberg PA, Siegel MD, Sherwin RS, et al. Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care. 2004;27:461-467.

Goldberg PA. Memoirs of a root canal salesman: the successful implementation of a hospital-wide intravenous insulin infusion protocol. Endocr Pract. 2006;12(suppl 3):79-85.

Griesdale DEG, de Souza RJ, van Dam RM, et al. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. Can Med Assoc J. 2009;180:821-827.

Hellman R. A systems approach to reducing errors in insulin therapy in the inpatient setting. Endocr Pract. 2004;10(suppl 2):100-108.

Hovorka R, Kremen J, Blaha J, et al. Blood glucose control by a model predictive control algorithm with variable sampling rate versus a routine glucose management protocol in cardiac surgery patients: a randomized controlled trial. J Clin Endocrinol Metab. 2007;92:2960-2964.

Kanji S, Buffie J, Hutton B, et al. Reliability of point-of-care testing for glucose measurement in critically ill adults. Crit Care Med. 2005;33:2778-2785.

Kansagara D, Fu R, Freeman M, Wolf F, Helfand M. Intensive insulin therapy in hospitalized patients: a systematic review. Ann Intern Med. 2011;154:268-282.

Kavanagh BP, McCowen KC. Clinical practice. Glycemic control in the ICU. N Engl J Med. 2010;363:2540-2546.

Klonoff DC. Intensive insulin therapy in critically ill hospitalized patients: making it safe and effective. J Diabetes Sci Technol. 2011;5:755-767.

Kosiborod M, Inzucchi SE, Krumholz HM, et al. Glucometrics in patients hospitalized with acute myocardial infarction: defining the optimal outcomes-based measure of risk. Circulation. 2008;117:1018-1027.

Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003;78:1471-1478.

Moghissi ES. Reexamining the evidence for inpatient glucose control: new recommendations for glycemic targets. Am J Health Syst Pharm. 2010;67:S3-S8.

Moghissi ES, Hirsch IB. Hospital management of diabetes. Endocrinol Metab Clin North Am. 2005;34:99-116.

Nazer LH, Chow SL, Moghissi ES. Insulin infusion protocols for critically ill patients: a highlight of differences and similarities. Endocr Pract 2007;13:137-146.

Shetty S, Inzucchi SE, Goldberg PA, Cooper D, Siegel MD, Honiden S. Adapting to the new consensus guidelines for managing hyperglycemia during critical illness: The Updated Yale Insulin Infusion Protocol. Endocr Pract. 2012;18:363-370.

Swanson CM, Potter DJ, Kongable GL, Cook CB. Update on inpatient glycemic control in hospitals in the United States. Endocr Pract. 2011;17:853-861.

The NICE SUGAR Study: Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283-1297.

Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:978-982.

Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97:16-38.

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Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359-1367.

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Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008;300:933-944.