Glycemic targets in critically ill adults: A mini-review

Abstract

Illness-induced hyperglycemia impairs neutrophil function, increases pro-inflammatory cytokines, inhibits fibrinolysis, and promotes cellular damage. In turn, these mechanisms lead to pneumonia and surgical site infections, prolonged mechanical ventilation, prolonged hospitalization, and increased mortality. For optimal glucose control, blood glucose measurements need to be done accurately, frequently, and promptly. When choosing glycemic targets, one should keep the glycemic variability < 4 mmol/L and avoid targeting a lower limit of blood glucose < 4.4 mmol/L. The upper limit of blood glucose should be set according to casemix and the quality of glucose control. A lower glycemic target range ( i.e. , blood glucose 4.5-7.8 mmol/L) would be favored for patients without diabetes mellitus, with traumatic brain injury, or who are at risk of surgical site infection. To avoid harm from hypoglycemia, strict adherence to glycemic control protocols and timely glucose measurements are required. In contrast, a higher glycemic target range ( i.e. , blood glucose 7.8-10 mmol/L) would be favored as a default choice for medical-surgical patients and patients with diabetes mellitus. These targets may be modified if technical advances for blood glucose measurement and control can be achieved.

Association of Blood Glucose Variability with Sepsis-Related Disseminated Intravascular Coagulation Morbidity and Mortality

“…However, hyperglycemia was not associated with more complications and worse outcomes in patients with diabetes having sepsis, which may be the result of high mean BG tolerance in the diabetes group. 62,63 In contrast, in the group with sepsis not having diabetes, no differences were observed between the outcomes of the HBG2 and LBG2 groups. Notably, patients who maintained moderate BG for 72 h achieved better outcomes, including significantly lower DIC morbidity and 90-day mortality.…”

“…However, hyperglycemia was not associated with more complications and worse outcomes in patients with diabetes having sepsis, which may be the result of high mean BG tolerance in the diabetes group. 62 , 63 …”

Acute management of pneumonia in adult patients

“…Poorly controlled diabetes mellitus requires glucose control while avoiding hypoglycaemia, and a glucose target range of 7.8–10 mmol/L is reasonable in critically ill diabetic patients with pneumonia. [ 32 ] Acquired immunodeficiency syndrome requires early institution of antiretroviral therapy. Leucopenia may be reversed using granulocyte colony-stimulating factor, while immunoglobulin deficiency may be overcome with immunoglobulin infusion.…”

Acute glycemic variability and mortality of patients with acute stroke: a meta-analysis

“…Accumulating evidence suggests that dysglycemia, including stress-induced hyperglycemia [ 8 ], persistent hyperglycemia [ 9 ], as well as hypoglycemia [ 10 ], are all associated with poor prognosis in patients with acute stroke, which suggests the possible role of glucose fluctuation as a predictor of poor outcomes in patients with acute stroke [ 11 ]. Recently, acute glycemic variability (GV), which reflects the extent of glucose fluctuation within days, has been related to poor prognosis in patients with critical illnesses [ 12 – 14 ]. Although no consensus has been reached regarding the optimal measuring method and cutoff of GV in an acute setting, some parameters have been well applied in previous researches, including the coefficient of variation of blood glucose (CVBG), the standard deviation of blood glucose (SDBG), and the mean amplitude of glycemic excursion (MAGE) [ 15 – 19 ].…”