Intervention
Indications
Cautions
Side effects
Protocol
Notes
Intensive insulin therapy (or tight glycemic control)
Critically ill patients with stress-induced hyperglycemia (sepsis, stroke, traumatic brain injury, myocardial infarction, trauma, burns, cardiothoracic surgery, and major noncardiac surgery)
Adequate caloric support must be provided
Diabetic patients are more prone to develop hypoglycemia, hypokalemia, and electrocardiographic alterations
Severe hypoglycemia
Still debated. A general blood glucose target of 110–140 mg/dL for both nondiabetic and diabetic patients in good metabolic control; unclear for poorly controlled diabetic patients
Intensive insulin therapy (blood glucose target of 81–110 mg/dL) is associated with higher mortality due to a greater incidence of severe hypoglycemia, especially in diabetic patients
Furthermore, glucose variability rather than stable hyperglycemia is associated with worse outcomes in critically ill and surgical patients, and glucose stability should be sought whenever treating these patients
The effect of nutrition and insulin coadministration may be particularly beneficial for previously nondiabetic patients
References
1.
Mazeraud A, Polito A, Annane D et al (2014) Experimental and clinical evidences for glucose control in intensive care: is infused glucose the key point for study interpretation? Crit Care 18(4):232PubMedCentralPubMed
2.
Marik PE, Bellomo R (2013) Stress hyperglycemia: an essential survival response! Crit Care 17(2):305PubMedCentralPubMed
3.
Schulman RC, Mechanick JI (2012) Metabolic and nutrition support in the chronic critical illness syndrome. Respir Care 57(6):958–977PubMed
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Qi C, Pekala PH (2000) Tumor necrosis factor-alpha-induced insulin resistance in adipocytes. Proc Soc Exp Biol Med 223(2):128–135PubMed
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Salim A, Hadjizacharia P, Dubose J et al (2009) Persistent hyperglycemia in severe traumatic brain injury: an independent predictor of outcome. Am Surg 75(1):25–29PubMed
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Capes SE, Hunt D, Malmberg K et al (2000) Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 355(9206):773–778PubMed
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Krinsley JS (2003) Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc 78(12):1471–1478PubMed
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Parsons MW, Barber PA, Desmond PM et al (2002) Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol 52(1):20–28PubMed
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Iwakura K, Ito H, Ikushima M et al (2003) Association between hyperglycemia and the no-reflow phenomenon in patients with acute myocardial infarction. J Am Coll Cardiol 41(1):1–7PubMed
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Bochicchio GV, Sung J, Joshi M et al (2005) Persistent hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma 58(5):921–924PubMed
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Jones KW, Cain AS, Mitchell JH et al (2008) Hyperglycemia predicts mortality after CABG: postoperative hyperglycemia predicts dramatic increases in mortality after coronary artery bypass graft surgery. J Diabetes Complications 22(6):365–370PubMed
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