Blood glucose on day of intensive care unit admission as a surrogate of subsequent glucose control in intensive care

Stress hyperglycemia is the transient increase in blood glucose as a result of complex hormonal changes that occur during critical illness. It has been described in the critically ill for nearly 200 years; patient harm, including increases in morbidity, mortality, and lengths of stay, has been associated with hyperglycemia, hypoglycemia, and glucose variability. However, there remains a contentious debate regarding the optimal glucose ranges for this population, most notably within the past 15 years. Recent landmark clinical trials have dramatically changed the treatment of stress hyperglycemia in the intensive care unit (ICU). Earlier studies suggested that tight glucose control improved both morbidity and mortality for ICU patients, but later studies have suggested potential harm related to the development of hypoglycemia. Multiple trials have tried to elucidate potential glucose target ranges for special patient populations, including those with diabetes, trauma, sepsis, cardiac surgery, and brain injuries, but there remains conflicting evidence for most of these subpopulations. Currently, most international organizations recommend targeting moderate blood glucose concentration to levels <180 mg/dL for all patients in the intensive care unit. In this review, the history of stress hyperglycemia and its treatment will be discussed including optimal glucose target ranges, devices for monitoring blood glucose, and current professional organizations’ recommendations regarding glucose control in the ICU.

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Improvement of Glucose Control in the Intensive Care Unit: An Interdisciplinary Collaboration Study

American Journal of Critical Care ◽

10.4037/ajcc2008.17.2.150 ◽

2008 ◽

Vol 17 (2) ◽

pp. 150-156 ◽

Cited By ~ 9

Author(s):

Ulrike Holzinger ◽

Monika Feldbacher ◽

Adelbert Bachlechner ◽

Reinhard Kitzberger ◽

Valentin Fuhrmann ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Blood Glucose ◽

Glucose Control ◽

Care Staff ◽

Diabetic Patients ◽

Control Protocol ◽

Glucose Levels ◽

Blood Glucose Levels ◽

Insulin Use

Background Strict glycemic control in critically ill patients is challenging for both physicians and nurses. Objectives To determine the effect of focused education of intensive care staff followed by implementation of a glucose control protocol. Methods A prospective observational study in a medical intensive care unit in a university hospital. After intensive education of nurses and physicians, a glucose control protocol with a nurse-managed insulin therapy algorithm was developed and implemented. Every measured blood glucose value and insulin dose per hour and per day were documented in 36 patients before and 44 patients after implementation of the protocol. Results Median blood glucose levels decreased after implementation of the protocol (133 vs 110 mg/dL; P < .001). The amounts of time when patients’ blood glucose levels were less than 110 mg/dL and less than 150 mg/dL increased after implementation of the protocol (8% vs 44%; 75% vs 96%; P<.001). The median use of insulin increased after implementation of the protocol (28 vs 35 IU/day; P=.002). Diabetic patients had higher median blood glucose levels than did nondiabetic patients both before (138 vs 131 mg/dL) and after (115 vs 108 mg/dL; P<.001) implementation, although median insulin use also increased (before implementation, 33 vs 26 IU/day; P=.04; after implementation, 46 vs 30 IU/day; P < .001). Conclusions Use of a collaboratively developed glucose control protocol led to decreased median blood glucose levels and to longer periods of normoglycemia. Despite increased insulin use, glucose control was worse in diabetic patients.

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