During a critical illness, the body’s response to stress can result in hyperglycemia (blood glucose levels of >12 mmol/L), even in patients without diabetes. Uncontrolled hyperglycemia during a stay in the intensive care unit can increase the risk of bloodstream infections, acute renal failure, prolonged inflammation, polyneuropathies, and even death1,2.
Although attempting to control glucose within very strict parameters (4.5 to 6.0 mmol/L) has the potential to cause further harm, more recent research shows optimal levels to target at <10 mmol/L3,4. Maintaining blood glucose levels below this target in critically ill adults requires a careful balance of intravenous insulin and nutrition to ensure levels are controlled but do not fall below hypoglycemic thresholds.
Our team is here to support you as you work toward improving glycemic control in your intensive care unit. Get started with the resources through the links below or contact us today.
- Initiate a regional written policy to prevent hyperglycemia in all adult surgical/medical ICU patients with or without diabetes mellitus
- Use a validated written or computerized protocol/algorithm for an intravenous insulin regimen that allows for predefined adjustments in the insulin infusion rate based on glucose levels and insulin dosage. If your ICU does not currently have a glucose protocol/algorithm, check our resources page for samples of protocols with demonstrated safety and efficacy, which you can adapt to fit your local context
- Use the insulin protocol to control blood glucose below a threshold of 10.0 mmol/L4. Avoid hypoglycemic events (reporting threshold of <3.5 mmol/L)
- Do not attempt to tightly control glucose to achieve targets of normoglycemia (blood glucose levels of 4.4 to 6.1 mmol/L)5. Strict glucose control has been associated with increased hypoglycemic events, which may increase mortality4
- Identify and collect data on balancing measures, to monitor for unintended consequences of improvement efforts. These should include safety measures, particularly for episodes of severe hypoglycemia
- Ensure that all physicians, nurses, hospital pharmacists, dieticians and other clinical staff in the ICU have been trained in the insulin regimes. Support ongoing peer discussion and provider education
- Work within your local context to use strategies to increase compliance with your organization’s policy, including the use of computer decision support systems, provider reminder systems, preprinted orders, auditing and feedback
- Use an identify-and-mitigate strategy to immediately remedy patients who are not on the protocol, or do not have appropriate glycemic control. Provide real-time clinician feedback. Analyze and eliminate system failures
- Engage and involve patients and families in their glycemic care
In order to achieve these goals, teams working on glycemic control should set specific goals and target outcomes, measure and analyze data, and revise for continual improvement and sustainability. This can be accomplished using quality improvement processes and methodology.
Frequently Asked Questions
- Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. NEJM. 2001;345 (19): 1359-67
- Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. NEJM. 2006;354(5) 449-61
- Griesdale DE., 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. CMAJ 2009; 180(8): 799-800
- NICE-SUGAR study investigators, Finfer S, Chittock DR Su SY, et al. Intensive versus conventional glucose control in critically ill patients. NEJM. 2009; 360(13): 1283-97
- Qaseem A, Humphrey LL, Chou R, et al. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: A clinical practice guidelines from the American College of Physicians. Ann Intern Med. 2011;154:260-267.