Update on glucose control during and after critical illness

Abstract

Purpose of reviewThere is a complex bidirectional relationship between critical illness and disordered glucose metabolism. This review aims to provide a comprehensive summary of the recent evidence focused on the relationship between critical illness and disordered glucose metabolism through the distinct phases of prior to, during, and after an acute illness that requires admission to the intensive care unit (ICU).Recent findingsRecent data suggest that preexisting glucose metabolism affects the optimal blood glucose target during critical illness, with preliminary data suggesting that glucose targets should be ‘personalized’ based on preexisting glycemia. Because of the close association between critical illness and disordered glucose metabolism, there is a need to optimize glucose monitoring in the ICU with rapid, precise, and cost-efficient measurements at the bedside. Recent studies have evaluated the use of various methodologies, with a focus on the use of near-continuous glucose monitoring. For those patients with preexisting diabetes who survive ICU, nocturnal hypoglycemia may be an unrecognized and important issue when discharged to the ward. There is increasing evidence that patients with high blood glucose during their acute illness, so called ‘stress hyperglycemia’, are at increased risk of developing diabetes in the years following recovery from the inciting event. Critically ill patients with COVID-19 appear at greater risk.SummaryThere have been important recent insights in the approach to glucose monitoring and glucose targets during critical illness, monitoring and administration of glucose-lowering drugs on discharge from the ICU, and longitudinal follow-up of patients with stress hyperglycemia.

Survey on Nutrition in Neurological Intensive Care Units (SONNIC)—A Cross-Sectional Survey among German-Speaking Neurointensivists on Medical Nutritional Therapy

“…Consequently, the actual calories provided may vary based on the monitoring of metabolic tolerance like blood glucose and phosphate levels [26]. Although trials comparing outcomes using metabolic monitoring versus standards of care are lacking; the concept is convincing on a pathophysiologic level [37][38][39]. The lack of evidence for NICU patients is reflected by the heterogeneity in metabolic monitoring strategies in our survey.…”

Laborchemisches und kalorimetrisches Monitoring der medizinischen Ernährungstherapie auf der Intensiv- und Intermediate Care Station

“…Bezüglich der anzustrebenden Konzentrationen lauten die älteren Empfehlungen der DGEM aus dem Jahr 2013 [ 16 ]: „Bei kritisch Erkrankten können Blutzuckerkonzentrationen zwischen 140–200 mg/dl (7,7–11,0 mmol/l) toleriert werden und es soll ein Zielwert von 110 mg/dl (6,1 mmol/l) nicht unterschritten werden.“ Eine Individualisierung nach der Ausgangs-HbA1c-Konzentration hat bisher keinen Vorteil gezeigt [ 17 ], bei Diabetes Typ II können jedoch nach neuesten Erkenntnissen möglicherweise auch höhere Konzentrationen (< 250 mg/dl bzw. < 13,9 mmol/l) toleriert werden [ 18 , 19 ].…”

“…Eine Individualisierung nach der Ausgangs-HbA1c-Konzentration hat bisher keinen Vorteil gezeigt [17], bei Diabetes Typ II können jedoch nach neuesten Erkenntnissen möglicherweise auch höhere Konzentrationen (< 250 mg/dl bzw. < 13,9 mmol/l) toleriert werden [18,19].…”

Nutrition support, carbohydrate feeding and insulin sensitivity in the critically ill patient: a complex relationship

“…Insulin resistance in peripheral tissues is meant to support the delivery of glucose to the vital organs, and triggers stress hyperglycaemia which occurs in 50-85% of patients admitted in intensive care including in patients with no previous history of diabetes prior to admission [3]. During the late and recovery phases, insulin resistance can persist and trigger type 2 diabetes, especially in the presence of a family history of diabetes, higher BMI or genetic predispositions [4].…”