Management of Hyperglycemia in Hospitalized Patients: Critical Care Setting

Abstract

Increased blood glucose (BG) levels is common in critically ill patients both with and without a previous history of diabetes. Morbidity and mortality related to hyperglycemia is an important issue when managing BG in critically ill patients. Thus far, however, the characteristics of patients who may benefit from intensive insulin therapy remain to be clearly defined, as does the effect of different BG algorithms, the method of measuring BG, and the influence of different nutritional strategies. Intensive care units (ICUs) around the world have adopted insulin infusion protocols to achieve stringent BG targets in critically ill patients. Different insulin algorithms have been developed with variable effectiveness. Most of those algorithms require considerable training and experience. Computer decision support systems might improve the outcomes of patients in the ICU. Intensive insulin infusion managed using software-guided programs achieves tighter glycemic control and equal or fewer hypoglycemic episodes than paper protocols. The measurement of BG concentrations in the ICU is performed intermittently in the majority of ICUs, using either arterial blood gas analyzers, glucose meters, or central laboratory. Blood gas analyzers are considered the best compromise between accuracy and practicality. Real-time continuous glucose monitoring (RTCGM) offers interesting possibilities: automatic measurement of large numbers of BG values and alarms that warn whenever ‘outlier' values are reached. Data published to date from some randomized studies in ICUs have indicated a lower incidence of hypoglycemia when RTCGM is used in adults under mechanical ventilation and after cardiac surgery; however, until further studies provide sufficient evidence for its accuracy and safety, the use of RTCGM alone in not recommended.