Critical Care: Glucose Control

Question 1

Describe the results of van den Berghe (2001)

Answer 1

population: surgical ICU
intervention: BG 80-110 mg/dL
comparison: standard of care
outcome: morbidity and mortality benefit, despite increased risk of hypoglycemia (5.1% vs 0.8%)

Question 2

Describe the results of van den Berghe (2006)

Answer 2

population: medical ICU patients
intervention: BG 80-110 mg/dL
comparison: standard of care
outcome: reduction in ventilator time, length of stay, mortality in patients. hypoglcemia was higher than previously, at 18%.

Question 3

Describe the results of NICE-SUGAR (2009)

Answer 3

Population: 6000 critically ill medical and surgical patients
Intervention: 81-108 mg/dL
Comparison: standard of care (180 mg/dL)
Outcome: higher mortality and higher risk of hypoglcemia in intensive BG control group

Question 4

Describe the 2012 Society of Critical Care Medicine guidelines for BG control in ICU

Answer 4

1. Guidelines for insulin infusion to manage hyperglycemia in critically ill patients suggest a trigger for insulin of 150 mg/dL, with a goal of 150 mg/dL or less.
2. Maintain values less than 180 mg/dL using an insulin protocol that achieves a low rate of hypoglyemia.

Question 5

Describe the 2016 Surviving Sepsis Campaign guidelines for BG control

Answer 5

1. 2016 SSC guidelines recommend initiating insulin when two consecutive BG readings are greater than 180 mg/dL.
2. The target BG concentration is 180 mg/dL or less for patients with sepsis.

Question 6

What strategy should be used for a continuous insulin infusion approach to achieve glycemic control in critically ill patients?

Answer 6

1. Validated dosing protocol
2. Consider BG concentration,
3. Rate of change,
4. insulin infusion rate.

Question 7

Considerations for using SubQ insulin vs. IV insulin?

Answer 7

IV insulin is preferred for:

1. Type 1 diabetes
2. Patients with hyperglycemia who are hemodynamically unstable
3. Patients in whom long-acting basal insulin should not be initiated because of changing clinical status

Question 8

For whom is subQ insulin in ICU appropriate?

Answer 8

Once patients are in stable condition, they can be considered for transitioning to a protocol-driven subQ insulin regimen

Question 9

SubQ insulin is not appropriate for which patients?

Answer 9

1. Taking vasopressors
2. Patient with significant peripheral edema
3. Patients for whom rapid correction of BG is warranted

Question 10

Why should subcutaneous sliding scale or correctional insulin not be the sole method of glucose control in critically ill patients?

Answer 10

1. A baseline of insulin, adjusted daily, must be used at a minimum. This is so that hyperglycemia can be prevented, rather than corrected.
2. The regularly scheduled administration of basal or rapid-acting insulin can be subcutaneous.

Question 11

For a continuous insulin infusion approach, monitoring of BG every ____ hours is typically needed to provide safe and effective therapy

Answer 11

1-2 hours

Question 12

Point of care testing can ________ plasma glucose values.

Answer 12

Overestimate

Question 13

Overestimation of blood glucose is more common in patients with what characteristics?

Answer 13

1. Anemia
2. Hypotension
3. Hypoperfusion

Question 14

Overestimation of blood glucose is more common in patients when the blood glucose is:

Answer 14

In the hypoglycemic or hyperglycemic range

Question 15

Measuring of blood glucose by _______ is recommended in patients with _____

Answer 15

1. Arterial or venous whole blood sampling
2. Patients with shock or severe peripheral edema
3. and for patients on prolonged insulin infusion.