Glycemic Control for Critically Ill Children and Adults

Publication Date: January 18, 2024
Last Updated: January 24, 2024

Summary of Recommendations

Adults

Clinicians should initiate glycemic management protocols and procedures to treat persistent hyperglycemia, ≥ 10 mmol/L (180 mg/dL) in critically ill adults. (U, CC)
620
Clinicians should use glycemic management protocols and procedures that demonstrate a low risk of hypoglycemia among critically ill adults and should treat hypoglycemia without delay. (U, CC)
620
Based on available randomized controlled trial data, in critically ill adults, we suggest against titrating an insulin infusion to a lower BG target INT: 4.4–7.7 mmol/L (80–139 mg/dL) as compared with a higher BG target range, CONV: 7.8–11.1 mmol/L (140–200 mg/dL) to reduce the risk of hypoglycemia. (C, M )
620
Observational data suggest a potential benefit of personalized glucose targets that more closely match chronic prehospital glycemic control. We recommend high-quality interventional trials of individualized glycemic targets in critically ill adults, stratified by prior glycemic control (such as indicated by glycosylated hemoglobin A1c). (C, U)
620
We suggest using continuous IV insulin infusion rather than intermittent subcutaneous insulin in the acute management of hyperglycemia in critically ill adults. (C, VL )
620
We suggest frequent (≤ 1 hr, continuous or near-continuous) glucose monitoring compared with monitoring at intervals greater than hourly in the management of hyperglycemia in critically ill adults on IV insulin during periods of glycemic instability. (C, L )
620
We suggest use of a protocol that includes explicit decision support tools (tools) over a protocol with no such tools in critically ill adults receiving IV insulin infusions for the management of hyperglycemia. (C, M )
620

Pediatrics

Clinicians should initiate glycemic management protocols and procedures to treat persistent hyperglycemia, ≥ 10 mmol/L (180 mg/dL) in critically ill children. (U, CC)
620
Clinicians should use glycemic management protocols and procedures that demonstrate a low risk of hypoglycemia among critically ill children and should treat hypoglycemia without delay. (U, CC)
620
We recommend against INT BG control, 4.4–7.7 mmol/L (80–139 mg/dL) as compared with CONV BG control, 7.8–11.1 mmol/L (140–200 mg/dL) in critically ill children. (S, M )
620
We make no recommendation regarding the use of continuous IV infusion for insulin therapy over intermittent subcutaneous insulin, in the acute management of hyperglycemia in critically ill pediatric patients in whom insulin therapy is indicated. However, “in our practice,” our pediatric-expert panel members use continuous IV infusion over intermittent subcutaneous insulin in critically ill pediatric patients with hyperglycemia. (U, U)
620
We make no recommendation regarding frequent BG monitoring (interval ≤ 1 hr, continuous or near-continuous) or less frequent (> 1 hr) in pediatric critically ill patients on insulin infusion therapy. However, “in our practice,” we almost always use frequent (interval ≤ 1 hr) or continuous/near-continuous monitoring systems (if available) in children being treated with insulin infusion therapy. (U, U)
620
We suggest use of explicit decision support tools over no such tools in critically ill pediatric patients receiving IV insulin infusions for the management of hyperglycemia. (C, VL )
620
We strongly recommend high-quality research on the use of explicit decision support tools for insulin infusion titration in pediatric patients.

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Glycemic Control for Critically Ill Children and Adults

Authoring Organization

Society of Critical Care Medicine

Publication Month/Year

January 18, 2024

Last Updated Month/Year

April 1, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

The purpose was to update the 2012 Society of Critical Care Medicine and American College of Critical Care Medicine (ACCM) guidelines with a new systematic review of the literature and provide actionable guidance for clinicians.

Target Patient Population

Critically Ill children and adults in need of glycemic control

Target Provider Population

Critical care, endocrinology, internal medicine and allied providers caring for critically Ill children and adults in need of glycemic control

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D000085002 - Glycemic Control

Keywords

glycemic control, critically ill

Source Citation

Honarmand, Kimia MD, MSc, FRCPC1,2; Sirimaturos, Michael PharmD, FCCM3; Hirshberg, Eliotte L. MD, MS, FCCM4; Bircher, Nicholas G. MD, FCCM5; Agus, Michael S. D. MD, FCCM6; Carpenter, David L. PA-C, JM, FCCM7; Downs, Claudia R.8; Farrington, Elizabeth A. PharmD, FCCM9; Freire, Amado X. MD, MPH, FCCM10; Grow, Amanda11; Irving, Sharon Y. CRNP, MSN, PhD, PNP FCCM12; Krinsley, James S. MD, FCCM13; Lanspa, Michael J. MD, MS, FCCM14; Long, Micah T. MD15; Nagpal, David MD, MSc, FRCSC, FCCS16; Preiser, Jean-Charles MD, PhD17; Srinivasan, Vijay MD, MBBS, FCCM18,19; Umpierrez, Guillermo E. MD, CDE20; Jacobi, Judith PharmD, MCCM21. Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024. Critical Care Medicine ():10.1097/CCM.0000000000006174, January 19, 2024. | DOI: 10.1097/CCM.0000000000006174

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
145
Literature Search Start Date
December 31, 1999
Literature Search End Date
December 31, 2022