Glycaemic control in intensive care: Everything in moderation

Abstract

Introduction: Glycaemic control is an important predictor of mortality in sepsis. Various international organizations including the Surviving Sepsis campaign recommend glycaemic control in critical illness with a glucose target between 6.1-10 mmol/L. The NICE-SUGARTrial in 2009 was a landmark in the debate over tight versus liberal glycaemic control in the critically ill and subsequent guidelines have been adjusted to reflect a move towards moderate glycaemic control. Methods: We conducted a nationwide study comparing glucose targets used in intensive care units in the United Kingdom in 2007 with those used in 2014 to 2015 to see the impact of the NICE-SUGAR study and subsequent guideline changes. Results: We received a combined response from 81% of intensive care units in the UK. There was an increase in the average median glucose target in 2014/2015 compared with 2007 (7.8 versus 7.2; p < 0.01). However, there is still much variability in glucose targets used in critical care in the UK. Conclusions: There is an overall trend towards using a more moderate glucose target in critical care in the UK reflecting changes in international guidelines. However, it is likely that controversies, which still exist in the literature, are reflected in the variability of glycaemic control targets. It is possible that the advent of closed-loop or continuous glucose monitoring may have a further impact on this.

Position statement: surgery and diabetes mellitus (Update 2023)

“…Eine rezente Metaanalyse zeigte reduzierte postoperative Wundinfektionen bei strikteren Glukosezielbereichen für kardiochirurgische und allgemeinchirurgische Populationen, jedoch war dies einhergehend mit zunehmenden Hypoglykämien und erhöhter Mortalität [ 85 ]. Eine zu strikte normnahe perioperative Glukoseeinstellung ist möglicherweise wegen iatrogen bedingter Hypoglykämien nachteilig, da diese intramural wie perioperativ mit erhöhter Mortalität assoziiert sind [ 86 , 87 ]. Für isolierte herzchirurgische Eingriffe hingegen scheinen günstige Ergebnisse (inklusive einer verringerten postoperativen Frühmortalität) für eine strikte perioperative Glukosekontrolle nachweisbar, solange diese ohne signifikant erhöhte Hypoglykämierate erzielt werden kann [ 25 , 88 , 89 ].…”

Managing Patients with Insulin Pumps and Continuous Glucose Monitors in the Hospital: to Wear or Not to Wear

“…In the critically ill, hyperglycemia occurs not only in patients formally diagnosed with diabetes but can also be seen in patients without known diabetes; this group includes patients with undiagnosed type 2 diabetes and those with so-called stress hyperglycemia [13,14]. At the same time, hypoglycemia and glucose variability have identified as strong predictors of increased morbidity and mortality in the ICU [15]. It is often more difficult to detect hypoglycemia through the usual symptomatic signs or complaints in the ICU setting.…”

Glucose Management Technologies for the Critically Ill

“…7-10 These results prompted wide adoption of intensive insulin therapy and tight glycemic control protocols for the management of hyperglycemia in the ICU. However, since the NICE-SUGAR trial and several other studies that showed increased mortality risk associated with intensive glucose control (likely due to hypoglycemia), 11,12 the approach of strict glycemic control in the ICU for all patients has been discouraged, and moderate control allowing for a certain degree of hyperglycemia has been promoted instead. 13,14 To this date, challenges for achieving adequate glycemic control still exist.…”