Tight Glycemic Control

Intervention

Indications

Cautions

Side effects

Protocol

Notes

Intensive insulin therapy (or tight glycemic control)

Critically ill patients with stress-induced hyperglycemia (sepsis, stroke, traumatic brain injury, myocardial infarction, trauma, burns, cardiothoracic surgery, and major noncardiac surgery)

Adequate caloric support must be provided

Diabetic patients are more prone to develop hypoglycemia, hypokalemia, and electrocardiographic alterations

Severe hypoglycemia

Still debated. A general blood glucose target of 110–140 mg/dL for both nondiabetic and diabetic patients in good metabolic control; unclear for poorly controlled diabetic patients

Intensive insulin therapy (blood glucose target of 81–110 mg/dL) is associated with higher mortality due to a greater incidence of severe hypoglycemia, especially in diabetic patients

Furthermore, glucose variability rather than stable hyperglycemia is associated with worse outcomes in critically ill and surgical patients, and glucose stability should be sought whenever treating these patients

The effect of nutrition and insulin coadministration may be particularly beneficial for previously nondiabetic patients

References

Mazeraud A, Polito A, Annane D et al (2014) Experimental and clinical evidences for glucose control in intensive care: is infused glucose the key point for study interpretation? Crit Care 18(4):232PubMedCentralPubMed

Marik PE, Bellomo R (2013) Stress hyperglycemia: an essential survival response! Crit Care 17(2):305PubMedCentralPubMed

Schulman RC, Mechanick JI (2012) Metabolic and nutrition support in the chronic critical illness syndrome. Respir Care 57(6):958–977PubMed

Qi C, Pekala PH (2000) Tumor necrosis factor-alpha-induced insulin resistance in adipocytes. Proc Soc Exp Biol Med 223(2):128–135PubMed

Salim A, Hadjizacharia P, Dubose J et al (2009) Persistent hyperglycemia in severe traumatic brain injury: an independent predictor of outcome. Am Surg 75(1):25–29PubMed

Finney SJ, Zekveld C, Elia A et al (2003) Glucose control and mortality in critically ill patients. JAMA 290(15):2041–2047CrossRefPubMed

Baird TA, Parsons MW, Phan T et al (2003) Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke 34(9):2208–2214CrossRefPubMed

Capes SE, Hunt D, Malmberg K et al (2000) Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 355(9206):773–778PubMed

Krinsley JS (2003) Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc 78(12):1471–1478PubMed

10.

Capes SE, Hunt D, Malmberg K et al (2001) Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 32(10):2426–2432CrossRefPubMed

11.

Parsons MW, Barber PA, Desmond PM et al (2002) Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol 52(1):20–28PubMed

12.

Iwakura K, Ito H, Ikushima M et al (2003) Association between hyperglycemia and the no-reflow phenomenon in patients with acute myocardial infarction. J Am Coll Cardiol 41(1):1–7PubMed

13.

Bochicchio GV, Sung J, Joshi M et al (2005) Persistent hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma 58(5):921–924PubMed

14.

Rovlias A, Kotsou S (2000) The influence of hyperglycemia on neurological outcome in patients with severe head injury. Neurosurgery 46(2):335–342; discussion 342–343CrossRefPubMed

15.

Jones KW, Cain AS, Mitchell JH et al (2008) Hyperglycemia predicts mortality after CABG: postoperative hyperglycemia predicts dramatic increases in mortality after coronary artery bypass graft surgery. J Diabetes Complications 22(6):365–370PubMed

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Glycemic Control in the Critically IllDecember 22, 2016In "CRITICAL CARE"