GLYCEMICCONTROLINICU

Dr Ashutosh Tiwari
MBBS,DNB,FICCM,IDCCM,MNAMS(INDIA)
Listofcontents
INTRODUCTION
EPIDEMIOLOGY

PATHOGENESIS

TRIALS FOR SUPPORT IN GLYCEMIC CONTROL

MONITORING OF SUGARS IN ICU PATIENTS

GLYCEMIC TARGETS

HYPERGLYCEMIA MANAGEMENT

TAKE HOME MESSAGE

INTRODUCTION
Hyperglycemia in ICU setting has been a common finding

in critically ill patients.

It is associated with increased morbidity, mortality and

longer hospital stay regardless of reason for admission.

Stress hyperglycemia is defined as blood sugar level >140

mg% without a previous history of DM or HbA1C >6.5%.

Hyperglycemia control in non critically ill patient is

equally important as it causes longer
hospitalisation,infections,impaired healing and mortality.
Epidemiology
The incidence of acute hyperglycemia is difficult to define
and may vary from 40-90% depending upon threshold

used to define abnormal blood glucose.

Hyperglycemic patient can be broadly classified as known

diabetic or stress hyperglycemic patients.

Bajwa et.al in 2011 reported 38.73% of patients had

hyperglycemia(BS >140mg%) on admission to ICU out of which
13.95% had prior history of DM and 4.99% detected diabetic
after admission.
EPIDEMIOLOG
Y. is estimated that 15-20% of adult admission to ICU has
It
prior DM and there was suboptimal glycemic control prior to
onset of acute illness as shown in a retrospective study
that found an HbA1C<6% in only 20% of known diabetic
patients.

Gornik et al assessed diabetes prevalence 4-6 weeks after

discharge from ICU and reported approximately 17% of
patients who suffered hyperglycemia during ICU stay actually
had unrecognised DM.
 Continued…..
In a recent prospective study by Godinjak
et al 100 patients were followed in a MICU, overall

prevalence of hyperglycemia was found to be 54% (35%

with DM ,19% with stress hyperglycemia) and 46%

were normoglycemic.

Patients with stress hyperglycemia

had higher mortality (52.6%)compare to patients with

previously diagnosed diabetes (48.6%) or normoglycemia(36%)

pathogenesis
Release of counter-regulatory stress hormones
(Corticosteroids,Glucagon, Catecholamine and GH) and
pro-inflammatory mediators (TNFα, IL1, IL6).

Increased counter-regulatory hormones contribute to

alteration in glucose metabolism including increased hepatic
glucose production and impaired peripheral utilisation.

Catecholamine inhibit insulin release and Cortisol increases

hepatic glucose production and stimulates protein
catabolism.
CONTINUED
….most important contributor to stress hyperglycemia seems
The
to be gluconeogenesis mediated primarily by glucagon and
supplemented by cortisol and epinephrine.

The whole picture is complicated by administration of

exogenous corticosteroids, Vasopressors and parenteral
solution containing dextrose.
PATHOGENESISPICTORIAL….
RECOMMENDEDTARGETBLOOD
GLUCOSE.
TRIALSFORGLYCEMICCONTROLINSTUDY
GRBelgian
In OUPS. clinical trial by Vendenberghe et.al,strict
glycemic control (B.S 80-110mg %) by IV insulin therapy in a
surgical ICU led to 32% reduction in mortality compared to
more flexible glucose control(B.S 180- 215mg%).

The same investigators in 2006 conducted a similar trial in

a medical ICU and found a reduction in mortality only among
patients who stayed in ICU for more than 3 days.
continued...
The NICE sugar trial,compared two insulin based glucose
control strategies(target B.S <180mg% in control group verses
a target range of 81-108 mg% in intervention group )in a
sample of 6104 patients.

In this trial intensive sugar control was associated with

increased CV mortality with an absolute difference of 5.8%.

A series of meta-analysis, were conducted after NICE sugar

trial and found no benefit for intensive control and
confirmed that this strategy was associated with increased
risk of hypoglycemia.
NOTEWORTHYTRIALS.
LEUVEN trial: Done in sx patient,found IIT improved
mortality.

SPECS trial:Done in cardiac surgical patients(no difference)

COIITSS trial: Corticosteroid and intensive insulin therapy

for septic shock(no difference)

VISEP trial: Volume substitution and insulin therapy in

severe sepsis(no difference)

GLUCONTROL trial: Terminated coz of protocol violation.

Listoftrials...
Listcontinued...
GUIDELINESFORGLYCEMICCONTROL.NONCRITICALLY
ILL BG target should be 110–130 mg/dL, and postmeal
Premeal
target should be 140–180 mg/dL. Targets should be less
stringent for the elderly and patients with significant
medical comorbidity.

Basal insulin to cover the basal and correctional need, and

prandial rapid-acting insulin to cover the nutritional need
are preferred choice. SSI is not recommended.

Insulin analogs should be preferred in indoor patients as

they are associated with less hypoglycemia, better
therapeutic outcomes, and are more flexible to use.
CRITICALLYILL...
Maintain BG level at a range of 140–180 mg/dL for majority
of patients with medical morbidity, and 110–140 mg/dL for
those with surgical morbidity.

Only IV insulin is recommended.Regular insulin or

rapid-acting insulin analogs (aspart, lispro, glulisine) can
be used as IV infusion.

Transition to subcutaneous insulin from IV insulin should

have an overlapping period of 1–2 hour. The overlap can be
reduced to 15–30 min if rapid analogs are used.
Monitoringofbloodglucose...
In patients receiving IV insulin, hourly blood sugar
estimation is done till blood sugar is stable followed by
testing every 2 hourly.

Patients with or without history of diabetes receiving

enteral or parenteral nutrition support should undergo
glucose testing every 4 to 6 hours.

Patients on oral feed are measured 4 times a day,before

Meals and at bedtime.More frequent measurements are

indicated after a medication change,abrupt discontinuation

nutrition or episodes of hypoglycemia.
Monitoringcontinued...
Glycated hemoglobin should be obtained in patient with
hyperglycemia without prior history of DM and with
persistent hyperglycemia of uncertain etiology.

Point of care monitoring of blood glucose is to be done

preferably with capillary method.In cases of hypotension,
hypothermia, shock, use of vasoconstrictors and
vasopressors, use venous sampling instead.

If logistics permit, CGMS should be used while monitoring

glycemic status in critically ill patients.
Monitoringinspecialpopulation..
PERIOPERATIVE POPULATIONS:

Tight glycemic control with insulin is advocated for a

better surgical outcome, with targets of BG between 110
mg/dL and 140 mg/dL.

Glucose and insulin should be given through separate IV

routes. Serum potassium should be monitored and maintained
through supplementation.

Relatively minor procedure where patients need not remain

nil per orally for prolonged periods may continue on oral
hypoglycemic agents if they are well controlled.
SPECIAL
POPULATINFARCTION:
MYOCARDIAL IONS.
Hyperglycemia and hypoglycemia both should be avoided in
patients with AMI to decrease morbidity and mortality.

Optimal glycemic control insulin,preferably analogs during

and after the episode, decreases the risk of complications
associated with AMI.
SPECIAL
POPULATIONUSE:
GLUCOCORTICOID S.
For patients already on insulin, 20% increment in total
daily insulin dose at time of high-dose glucocorticoid
initiation is a reasonable step.

ENTERAL FEED:

Insulin analogs should be preferred to control hyperglycemia

in indoor patients on enteral nutrition.Basal plus multiple
SC prandial boluses are to be preferred over SSI.
SPECIAL
POPULATIPATIENTS:
PERIPARTUM ONS.
Rapid-acting insulin analogs—aspart and lispro are preferred
for use in pregnancy. Detemir is a preferred choice as basal
insulin.

Patients in active labor should be on glucose, IV insulin

plus potassium infusion to prevent hypokalemia, hypoglycemia
as well as ketosis.

Incremental insulin dose is required for pregnant ladies

receiving long-acting glucocorticoid for fetal maturity.
Specialattentionwhilemonitoring..
Type of glucose analyser used(Blood gas,core lab,glucose
oxidase).

Clinical condition of the patient(anemia,hypoxia).

Medications taken(acetaminophen,ascorbic acid,IV

Ig,Peritoneal dialysis)

Arterial blood measured by POC glucometers are far accurate

than capillary one and should be used.
Glycemictargets..
AACE and ADA task force recommended a blood
glucose level between 140-180mg/dl for majority of

ICU patients and a lower target between 110-140mg/

dl in selected ICU patients (i.e.cardiac

surgical patients,patients with stable glycemic control

without hypoglycemia).

Glucose targets of >180mg/dl and <110mg/dl are not

recommended in ICU patients.
Glycemictargets...tables
SETTINGINSULININFUSION.
CHANGINGINSULININFUSIONRATE.
Changinginsulininfusionrate..
Patients being discharged from the hospital may be
prescribed basal-bolus or premixed insulin regimen as
required•

Education regarding insulin technique, self-monitoring of

blood glucose (SMBG), hypoglycemia, and self adjustment of
doses should be provided before discharge and on an ongoing
basis.
continued..
Make adjustments based on carbohydrates intake.
Consider multiple source of carbohydrate intake.

Assess calorie intake every 12 hourly

Special attention to RENAL,HEPATIC,CNS patients.

When improved IV insulin should be changed to SC.

Better to use LA insulin with SA insulin.

continued...
While calculating dose consider pre existing DM,stress,drug
use.

LAI should be used in overlaping fashion with

discontinuation of iv drip to prevent hyperglycemia.

In general SAI is given 2 times the drip plus LAI.

If SAI not given the drip should overlap 2 to 3 hours for

LAI to be effective.
TAKEHOMEMESSAGE.
Still controversial….??

Patient likely to be in ICU for more than 5 days target a

lower range avoiding hypoglycemia.

Give IV INSULIN, with regular RBS monitoring.

Keep in mind the nutritional status,previous glycemic

control,underlying disease.

Use a standardised glucose monitoring technique...

THANKS