Medical intensive care unit patients with hyperglycemia: is it possible a hypoglycemic risk close to zero?

Abstract

In patients with diabetic or stress hyperglycemia hospitalized for acute cardiovascular disease, the occurrence of hypoglycemia increases the risk of mortality and morbidity without this being counterbalanced by a reduction in events related to a tighter glycemic control. The guidelines on this topic agree in excluding intensive treatment, but are very discordant in recommending a conventional (<180 mg/dl) or milder (<200 mg/dl) blood glucose control. In 1256 hyperglycemic patients (mean age 74 ± 12 years) admitted to the medical intensive care unit (MICU) for acute coronary syndrome or acute heart failure, we adopted a nurse-led protocol of mild blood glucose control with subcutaneous administration of insulin, called "BBC200" (basal-bolus correction insulin regimen with glycemic target <200 mg/dl), with the aim at maintaining average blood glucose <200 mg/dl and an indication for intravenous insulin only for blood glucose >350 mg/dl. A retrospective analysis was carried out for assessing the occurrence of hypoglycemic episodes (blood glucose <70 mg/dl) and therapeutic failure (persistent hyperglycemia with values >240 mg/dl). Mean blood glucose was 261 ± 72 mg/dl on admission and 173 ± 50 mg/dl during treatment. Five patients (0.2%) required intravenous insulin infusion. There was only one case of severe hypoglycemia (≤40 mg/dl) due to an error of administration, and 2 cases of moderate hypoglycemia (41-70 mg/dl), with a total hypoglycemia rate of 0.24%. Transient therapeutic failure occurred in 27% of cases. In MICU hyperglycemic patients, the simple, intuitive and economical "BBC200" protocol could lead to a hypoglycemic risk very close to zero (0.24%), with a significant reduction in hypoglycemia-related clinical events and a modest increase in persistent hyperglycemic phenomena.