Insulin Infusion For The Management Of Hyperglycemia In Critically Ill Patients
Publication Date: December 1, 2012
Last Updated: March 14, 2022
Recommendations
We suggest that a BG ≥ 150 mg/dL should trigger initiation of insulin therapy, titrated to keep BG < 150 mg/dL for most adult ICU patients and to maintain BG values absolutely <180 mg/dL using a protocol that achieves a low rate of hypoglycemia (BG ≤ 70 mg/dL) despite limited impact on patient mortality. (2-VL)
699
We suggest that maintaining BG < 150 mg/dL has not consistently demonstrated a difference in several morbidity measures (renal failure, transfusion, bacteremia, polyneuropathy, and ICU length of stay [LOS]) when evaluated in the general adult ICU population.
699
We suggest implementation of moderate GC (BG < 150 mg/dL) in the postoperative period following cardiac surgery to achieve a reduced risk of deep sternal wound infection and mortality. (2-VL)
699
In the population of critically ill injured (trauma) ICU patients, we suggest that BG ≥ 150 mg/dL should trigger initiation of insulin therapy, titrated to keep BG < 150 mg/dL for most adult trauma patients and to maintain BG values absolutely < 180 mg/dL, using a protocol that achieves a low rate of hypoglycemia (BG ≤ 70 mg/dL) to achieve lower rates of infection and shorter ICU stays in trauma patients. (2-VL)
699
We suggest that a BG ≥ 150 mg/dL triggers initiation of insulin therapy for most patients admitted to an ICU with the diagnoses of ischemic stroke, intraparenchymal hemorrhage, aneurysmal subarachnoid hemorrhage, or TBI, titrated to achieve BG values absolutely < 180 mg/dL with minimal BG excursions <100 mg/dL, to minimize the adverse effects of hyperglycemia. (2-VL)
699
We further suggest that BG < 100 mg/dL be avoided during insulin infusion for patients with brain injury. (2-VL)
699
We suggest that BG ≤ 70 mg/dL are associated with an increase in mortality, and that even brief SH (BG ≤ 40 mg/dL) is independently associated with a greater risk of mortality and that the risk increases with prolonged or frequent episodes. (2-L)
699
We suggest that BG < 70 mg/dL (<100 mg/dL in neurologic injury patients) be treated immediately by stopping the insulin infusion and administering 10–20 g of hypertonic (50%) dextrose, titrated based on the initial hypoglycemic value to avoid overcorrection. The BG should be repeated in 15 mins with further dextrose administration as needed to achieve BG > 70 mg/dL with a goal to avoid iatrogenic hyperglycemia. (2-VL)
699
We suggest that BG be monitored every 1–2 hrs for most patients receiving an insulin infusion. (2-VL)
699
We suggest that most POC glucose meters are acceptable but not optimal for routine BG testing during insulin infusion therapy. Clinicians must be aware of potential limitations in accuracy of glucose meters for patients with concurrent anemia, hypoxia, and interfering drugs. (2-VL)
699
We suggest arterial or venous whole blood sampling instead of finger-stick capillary BG testing for patients in shock, on vasopressor therapy, or with severe peripheral edema, and for any patient on a prolonged insulin infusion. (2-M)
699
In the absence of compelling data, no recommendation can be made for or against the use of continuous glucose sensors in critical care patients. (-)
(No recommendation/very low Quality of Evidence)
699
We suggest continuous insulin infusion (1 unit/mL) therapy be initiated after priming new tubing with a 20-mL waste volume. (2-M)
699
Subcutaneous insulin may be an alternative treatment for selected ICU patients.
(No recommendation/very low Quality of Evidence)
699
We suggest that stable ICU patients should be transitioned to a protocol-driven basal/bolus insulin regimen before the insulin infusion is stopped to avoid a significant loss of GC. (2-VL)
699
We suggest that calculation of basal and bolus insulin dosing requirements should be based on the patient’s IV insulin infusion history and carbohydrate intake. (2-VL)
699
We suggest that the amount and timing of carbohydrate intake should be evaluated when calculating insulin requirements. (2-L)
699
We also suggest that GC protocols should include instructions to address unplanned discontinuance of any form of carbohydrate infusion. (2-L)
699
We suggest that insulin is a high-risk medication, and that a systems-based approach is needed to reduce errors. (2-VL)
699
We suggest that ICUs develop a protocolized approach to manage GC. Components include a validated insulin administration protocol, appropriate staffing resources, use of accurate monitoring technologies, and a robust data platform to monitor protocol performance and clinical outcome measures. (2-VL)
- A standard insulin infusion protocol should include a requirement for continuous glucose intake, standardized IV insulin infusion preparation, a dosing format requiring minimal bedside decision-making, frequent BG monitoring, provisions for dextrose replacement if feedings are interrupted, and protocolized dextrose dosing for prompt treatment of hypoglycemia.
699
Glycemic variability has been independently associated with mortality in several cohorts of critically ill patients; however, there is no consensus regarding the appropriate metric for mathematically defining GV. We suggest that the simplest tools––SD of each patient’s mean BG and coefficient of variation (SD/mean)––be reported in all published interventional studies. (2-VL)
699
Measures of overall glucose control should include mean (SD) and median (IQR) BG levels as well as ICU-level run charts of percentage BG < 150 mg/dL and 180 mg/dL. We suggest that hypoglycemic events should be monitored regularly and reported as events per patient, as a percentage of all BG values, and events per 100 hrs of insulin infusion. (2-VL)
699
We recommend that programs to monitor and treat hyperglycemia in critically ill patients be implemented to reduce hospital costs. (1-M)
699
We suggest implementation of programs to monitor and treat hyperglycemia in diabetic patients following cardiovascular surgery to reduce hospital costs. (2-L)
699
In the absence of compelling data, no recommendations could be made for or against the use of tight GC in pediatric critical care patients.
Recommendation Grading
Overview
Title
Insulin Infusion For The Management Of Hyperglycemia In Critically Ill Patients
Authoring Organization
Society of Critical Care Medicine
Publication Month/Year
December 1, 2012
Last Updated Month/Year
May 16, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point.
Target Patient Population
Critical ill patients with hyperglycemia
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Emergency care, Home health, Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D003422 - Critical Care, D016638 - Critical Illness, D061385 - Insulins, D007328 - Insulin, D006943 - Hyperglycemia, D020158 - Hyperglycinemia, Nonketotic
Keywords
insulin, hyperglycemia, critical care, critical illness
Source Citation
Critical Care Medicine: December 2012 - Volume 40 - Issue 12 - p 3251-3276
doi: 10.1097/CCM.0b013e3182653269