Glycemic Control in the Medical Intensive Care Unit

Abstract

Hyperglycemia in the critically ill is a well-known phenomenon, even in those without known diabetes. The stress response is due to a complex interplay between counter-regulatory hormones, cytokines, and changes in insulin sensitivity. Illness/infection, overfeeding, medications (e.g., corticosteroids), insufficient insulin, and/or volume depletion can be additional contributors. Acute hyperglycemia can adversely affect fluid balance (through glycosuria and dehydration), immune and endothelial function, inflammation, and outcome. While there are several insulin infusion protocols that are able to safely and effectively treat hyperglycemia, the bulk of accumulated evidence does not support a causal relationship between acute hyperglycemia and adverse outcomes in the medical intensive care unit. Meta-analysis of randomized controlled trials suggests there is no benefit to tightening glucose control to normal levels compared to a reasonable and achievable goal of 140 to 180 mg/dl. There is a significantly increased risk of hypoglycemia. Although there is some evidence that patients without known diabetes have worse outcomes than those with known diabetes, more recent evidence is conflicting. Glycemic control in critically ill patients should not be neglected, as studies have not tested tight versus no/poor control, but tight versus good control. A moderate approach to managing critical illness hyperglycemia seems most prudent at this juncture. Future research should ascertain whether there are certain subgroups of patients that would benefit from tighter glycemic goals. It also remains to be seen if tight glucose control is beneficial once hypoglycemia is minimized with technological advances such as continuous glucose monitoring systems.

Diabetes aggravates acute pancreatitis and inhibits pancreas regeneration in mice

“…During the last 10 years an intensified insulin therapy for critically ill patients has been a major issue of discussion. An intensified insulin therapy has been found to be of benefit or of no benefit to patients, depending on the clinical study [36][37][38]. Possibly this discrepancy may be resolved by the assumption that an intensified insulin therapy is beneficial to certain subsets of patients, whereas in other subsets of critically ill patients the risk of hypoglycaemia will outweigh beneficial effects.…”

Role of continuous subcutaneous glucose monitoring in intensive care

“…A fentieken túl a stresszhez kapcsolódó hyperglykaemiában szerepet ját-szik a kritikus betegségekben a tumornekrózis-faktor-α-(TNF-α-) és interleukin-1-(IL-1-) szint emelkedése, amely hozzájárul a kulcsfontosságú perifériás és hepatikus inzulinrezisztencia kialakulásához [2,3,4,5,6,7]. Az intenzív betegellátás és a hyperglykaemia fontos kapcsolatát a Web of Science adatbázisban a témában közölt irodalom mennyisége reprezentálja, amely 2000 óta meredek emelkedést mutat (1. ábra).…”

Glycemic Control in Cardiac Surgery

“…Two additional single centers, randomized studies showed a trend towards a higher mortality in the TGC arm (72,73). TGC is strongly associated with an even sixfold-increase in episodes of severe hypoglycemia (glucose levels < 2.2 mmole/l, 40 mg/dl) (20) and, as mentioned before, this state can have dramatically adverse effects such as coma or even death (74). The recent NICE-SUGAR study showed that an intensive glucose control increased mortality among ICU adults, and that an 81-108 mg/dl target was too ambitious and potentially dangerous (12).…”