This Documentation is intended to accompany the Digital Intern Insulin Educator and Digital Intern Glucose Management module and is meant to support and explain the recommendations made by those products. This information is not meant to provide medical advice, inform medical decisions, or be used in any way other than in conjunction with Digital Intern products. If you are a medical professional caring for a patient, you must always rely on your own training, expertise, and judgment to determine if the Digital Intern recommendations are appropriate for your patient.
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Hyperglycemia commonly occurs in critically ill patients, even in patients without pre-existing diabetes mellitus. Critically ill patients with severe injury or infection can experience insulin resistance and hyperglycemia due to altered carbohydrate metabolism.1 An insulin infusion is the preferred method for management of hyperglycemia in this patient population as it can be easily titrated and closely monitored.2,3 (Class I, Level A) The goal of the insulin infusion is to decrease blood glucose levels while avoiding hypoglycemia as both hyper and hypo-glycemia are associated with adverse outcomes and death.2,4
The target goal for blood glucose control in non-surgical critically ill patients has been described in the NICE-SUGAR trial. The NICE-SUGAR trial demonstrated that intensive glucose control, targeting a blood glucose range of 81-108 mg/dL, was associated with higher incidence of 90-day mortality (OR 1.14; 95%CI 1.02-1.28; ARI 2.6%; NNH 38) and risk of severe hypoglycemia (OR 14.7; 95%CI 9.0-25.9) than when compared to a more conventional blood glucose control of < 180 mg/dL. Additionally, there were no differences in mechanical ventilation (p=0.56), renal replacement therapies (p=0.39), duration of ICU care (p=0.84) or length of hospital stay (p=0.86).5
Therefore, intensive glucose control is not recommended for critically ill patients.5 (Class III) Target glucose of < 180 mg/dL is recommended for persistent hyperglycemia.2,3,5 (Class I, Level A) For most critically ill patients a target glucose range of 140-180 mg/dL is recommended.2 (Class IIa, Level B) Tighter goals may be considered (i.e. 110-140 mg/dL) for select patients if it can be achieved while avoiding hypoglycemia.6,7 (Class IIa, Level B) Alternatively, higher glucose goals may be considered in terminally ill patients or in patients with severe co-morbidities.2 (Class IIb, Level C)
When starting intravenous insulin, consider the target glucose range and most current blood glucose level to determine an initial infusion rate. Adjustments to the infusion rate will consider the target glucose range and increase or decrease the dose based on both the current glucose and the patient’s glycemic response.
Hypoglycemia is defined as a blood glucose level < 70 mg/dL.2-4,8-11 Early identification and treatment of hypoglycemia is essential avoid severe hypoglycemia (blood glucose level < 50 mg/dL) and adverse events. Certain hospitalized patients may be at higher risk for hypoglycemia including: elderly, critically ill, decreased nutritional intake, interruptions in glucose monitoring, and not responding appropriately to glucose trends.2-4,8-11 Treatment of hypoglycemia in patients unable to swallow and with intravenous access is listed in Table 1.
Intravenous insulin should be initiated, adjusted, and monitored based on protocols or algorithms that pre-define adjustments to the infusion rate based on glycemic changes and insulin doses.2,3 (Class IIb, Level C)
1. Mizock, B. A. Alterations in carbohydrate metabolism during stress: a review of the literature. Am J Med. 1995; 98(1): 75–84.
2. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009; 32: 1119–1131.
3. Umpierrez GU, 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; (1):16-38.
4. Clement S, Braithwaite SS, Magee MF, et al. American Diabetes Association Diabetes in Hospitals Writing Committee. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004; 27: 553–591.
5. Finfer S, Chittock DR, Su SY-S, et al. NICESUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009; 360: 1283–1297.
6. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001; 345: 1359–1367.
7. Steg PG, James SK, Atar D, et al. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012; 33: 2569–2619
8. Maynard G, Lee J, Phillips G, Fink E, Renvall M. Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm. J Hosp Med. 2009; 4:3-15.
9. Smith WD, Winterstein AG, Johns T, Rosenberg E, Sauer BC. Causes of hyperglycemia and hypoglycemia in adult inpatients. Am J Health Sys Pharm. 2005; 62: 714-19.
10. Krinsley JS, Grover A. Severe hypoglycemia in critically ill patients: risk factors and outcomes. Crit Care Med. 2007; 35: 2262-67.
11. Kagansky N, Levy S, Rimon E, et al. Hypoglycemia as a predictor of mortality in hospitalized elderly patients. Arch Intern Med. 2003; 163: 1825-29.
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