Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients

Abstract

While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infusion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy.

Strict glycemic control to prevent surgical site infections in gastroenterological surgery

“…Important processes of care for insulin therapy include use of a validated insulin titration program, frequent BG monitoring, and avoidance of finger‐stick glucose testing through the use of arterial or venous glucose samples 35. Furnary et al 36.…”

Management of hospitalized type 2 diabetes mellitus patients

“…[30,37] Subcutaneous and intravenous insulins are valid options for managing hyperglycemia. The use of intravenous infusion of insulin is reserved for critical patients where exist the possibility for a tighter control, [30,38] and patients with marked hyperglycemia because is achieves better control. [4,39] For more stable patients and patients in non-ICU, the insulin can be administered by mixing it in nutritional parenteral bag safely.…”

2014 ESC/ESA Guidelines on Non-cardiac Surgery: Cardiovascular Assessment and Management

“…240 More recently, the emphasis has shifted from diabetes to hyperglycaemia, where new-onset hyperglycaemia (compared with hyperglycaemia in known diabetics) may hold a much higher risk of adverse outcome. 240,241 Studies in the field of critical care have demonstrated the detrimental effect of hyperglycaemia, due to an adverse effect on renal and hepatic function, endothelial function, and immune response, particularly in patients without underlying diabetes. Oxidative stress (a major cause of macrovascular disease) is triggered by swings in blood glucose, more than by sustained and persistent hyperglycaemia.…”

“…Minimization of the degree of glucose variability may be cardioprotective, and mortality may correlate more closely with blood glucose variability than mean blood glucose per se. 240,241 A significant number of surgical patients will have previously undiagnosed pre-diabetes, and are at increased risk of unrecognised perioperative hyperglycaemia and the attendant adverse outcomes. Although there is no evidence that screening low-or moderate-risk adults for diabetes improves outcomes, it may reduce complications in high-risk adults.…”

“…For non-cardiac surgery patients without known diabetes, evidence for strict blood glucose control is derived largely from studies in critically ill patients, and is disputed. 240,241 Early randomized controlled trials of intensive insulin therapy maintaining strict glycaemic control showed morbidity benefits in medical patients in ICUs, and reduced mortality and morbidity in surgical patients in ICUs. Subsequent studies, however, found a reduction in mortality in those whose blood glucose control was less strict [7.8-10 mmol/L (140 -180 mg/dL)] than in those in whom it was tightly controlled [4.5 -6 mmol/L (81 -108 mg/dL)], as well as fewer incidents of severe hypoglycaemia.…”