Critical Care Medicine-Neurologic Disorders>>>>>Shock States
Question 5#

A 65-year-old man with a history of heavy alcohol use presents to the emergency department with severe abdominal pain and is diagnosed with alcoholic pancreatitis. He is noted to have a BP of 70/40 mm Hg after receiving 3 L of IV normal saline and is admitted to the ICU for management of severe pancreatitis and shock. On ICU day 1 and 2, his blood glucose levels are noted to be greater than 250 mg/dL on multiple consecutive measurements.

Which of the following statements regarding glycemic control in critically ill adults is correct?

a. Hyperglycemia is associated with better clinical outcomes compared with normoglycemia
b. Insulin therapy to achieve blood glucose of <110 mg/dL is recommended
c. Insulin therapy to achieve blood glucose of 140 to 180 mg/dL is recommended
d. Seizure is the most common adverse effect of intensive insulin therapy
e. Hypoglycemia is associated with better clinical outcomes than normoglycemia

Correct Answer is C

Comment:

Correct Answer: C

Both hyperglycemia and hypoglycemia are associated with worse clinical outcomes in critically ill patients based on the results of multiple prospective randomized trials and retrospective data. Hyperglycemia is variably defined as glucose measurements greater than 180 mg/dL or 200 mg/dL. Hypoglycemia is typically a blood glucose less than 80 mg/dL. Literature on hyperglycemia is mainly retrospective and describes an association with increased mortality in a variety of patient populations including critically ill medical and surgical patients. Multiple prospective randomized controlled trials have examined intensive insulin therapy to target strict glucose control, typically 81 to 110 mg/dL, compared with conventional glucose control. These studies have demonstrated that intensive insulin therapy results in a higher rate of hypoglycemia, which is the most common adverse effect, and thereby increased mortality. Currently, it is recommended to maintain blood glucose of 140 to 180 mg/dL to avoid dangerous hypoglycemia or hyperglycemia (answer C is correct). 

References:

  1. Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-1297.
  2. Falciglia M, Freyberg RW, Almenoff PL, D’Alessio DA, Render ML. Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med. 2009;37(12):3001-3009.
  3. Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med. 2012;40(12):3251-3276.
  4. Rhodes A, Evans LE, Alhazzani W, et al Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2016. Crit Care Med. 2017;45(3):486-552.