Glycemic control in non-diabetic critically ill patients

Abstract

Hyperglycemia is a common and costly health care problem in hospitalized patients. In hospital hyperglycemia is defined as any glucose value >7.8 mmol/l (140 mg/dl). Hyperglycemia is present in 40% of critically ill patients and in up to 80% of patients after cardiac surgery, with ~ 80% of ICU patients with hyperglycemia having no history of diabetes prior to admission. The risk of hospital complications relates to the severity of hyperglycemia, with a higher risk observed in patients without a history of diabetes compared to those with known diabetes. Improvement in glycemic control reduces hospital complications and mortality; however, the ideal glycemic target has not been determined. A target glucose level between 7.8 and 10.0 mmol/l (140 and 180 mg/dl) is recommended for the majority of ICU patients. This review aims to present updated recommendations for the inpatient management of hyperglycemia in critically ill patients with and without a history of diabetes.

Diabetes and its negative impact on outcomes in orthopaedic surgery

“…Stress hyperglycemia can occur in hospitalized patients without a previous history of DM and is defined as any serum glucose > 140 mg/dL. Although this hyperglycemic state typically resolves with abatement of the heightened stress, approximately 60% of patients may ultimately develop DM [7] . Surgery, trauma and infection stimulate release of counter regulatory hormones such as glucagon, epinephrine, cortisol, and growth hormone, resulting in derangement in normal carbohydrate metabolism.…”

“…Surgery, trauma and infection stimulate release of counter regulatory hormones such as glucagon, epinephrine, cortisol, and growth hormone, resulting in derangement in normal carbohydrate metabolism. This dysfunction may result in a decrease in peripheral tissue insulin uptake (i.e., resistance), gluconeogenesis in the liver, decreased efficiency of tissue glucose utilization and relative insulin deficiency [7] . Both observational studies and prospective studies in intensive care unit (ICU) patients have demonstrated a correlation between hyperglycemia and adverse outcomes during the hospitalization [8,9] .…”

“…Regardless of the clinical setting (ICU vs non-ICU), hypoglycemia is to be avoided (blood glucose ≤ 70 mg/dL) [4,13,14] . Hyperglycemia is very common in ICU patients, and up to 80% of these patients may not have been diagnosed with DM prior to the ICU admission [7] . Stress induced hyperglycemia may manifest in orthopaedic surgery patients after major surgery, sepsis or trauma.…”

Hyperglycaemia in criticaly ill patients

“…В настоящее время именно адекватный контроль глюкозы считается первостепенно важным [42]. Известно, что контроль ГГ уменьшает стационарные осложнения и летальность; однако оптимальный целевой уровень гликемии до сих пор обсуждается [43], а протоколы введения инсулина отличаются по целевым показателям и пороговым зна-чениям, при которых нужно начинать инсулинотерапию. Принципиально существует два лагеря, один из которых придерживается необходимости «жесткого контроля», другой ориентирован на менее интенсивную коррекцию.…”

“…Принципиально существует два лагеря, один из которых придерживается необходимости «жесткого контроля», другой ориентирован на менее интенсивную коррекцию. «Жесткий» протокол контроля предполагает поддержа-ние уровня глюкозы крови в интервале 4,5-6 ммоль/л, инфузию инсулина рекомендовано начинать при уровне более 6 ммоль/л, менее интенсивный протокол реко-мендует интервал 8-10 ммоль/л, инфузию начинают при уровне более 10 ммоль/л [43].…”