A 75-year-old male with a history of hypertension, chronic renal insufficiency, and type 2 diabetes mellitus is admitted to the intensive care unit (ICU) with shock secondary to bowel perforation. His blood glucose is 304 mg/dL on presentation and 275 mg/dL on recheck an hour later.
hich of the following is the MOST appropriate for management of hyperglycemia?A. Start insulin glargine 0.2 mg/kg/d and correction insulin with a sliding scale of regular insulin every 6 hours with a goal glucose target between 80 and 110 mg/dL
Correct Answer: D
A single center trial published in 2001 involving approximately 1,500 surgical ICU patients showed significantly decreased ICU mortality in patients who were managed with intensive glucose control (target blood glucose of 80-110 mg/dL) when compared to patients with conventional glucose control (target blood glucose of 180-200 mg/dL). Most of the patients in this trial had undergone cardiac surgery and the mortality benefit was in patients who were in the ICU for 5 days or longer. This mortality benefit was not seen in 1,100 critically ill medical patients from the same center.
The subsequent Normoglycemia in Intensive Care Evaluation — Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial was a larger (approximately 6,000 patients), multicenter trial that showed that intensive glucose control (target blood glucose 81-108 mg/dL) was associated with higher mortality and increased risk of hypoglycemia when compared to conventional glucose control (target blood glucose <180 mg/dL). Furthermore, a post hoc analysis of the NICE-SUGAR database showed that hypoglycemia was associated with increased mortality. Based on these findings, the Surviving Sepsis guideline recommend a protocolized approach to glucose control targeting a blood glucose <180 mg/dL. Other experts recommend a target glucose between 140 and 180 mg/dL from the NICE-SUGAR trial (patients in the conventional glucose management group had a mean time-weighted glucose level of 144 ± 23 mg/dL). Although a basal/bolus insulin regimen is recommended for management of hyperglycemia in non-ICU patients, absorption of subcutaneously delivered medications can be variable because of shock or edema. Continuous intravenous insulin infusions are recommended for glucose management in ICU patients. The half-life of iv insulin is short (<15 minutes) and can be titrated to bring a patient’s blood glucose levels to targeted range more rapidly than subcutaneous insulin. Insulin infusions can also be adjusted quickly based on changes in the patient’s clinical status.