Glycemic Management in Critically Ill Patients

Introduction to Glycemic Control

The American College of Physicians guidelines provide strong recommendations against using intensive insulin therapy in ICU patients, with a target blood glucose of 140-200 mg/dL (7.8-11.1 mmol/L) for patients with cirrhosis and pancreatitis, based on moderate-quality evidence 1
Avoid strict glycemic control (<140 mg/dL) as it increases risk of hypoglycemia without mortality benefit in ICU patients with cirrhosis and pancreatitis, as supported by evidence from the American College of Physicians 1 and Clinical Nutrition 2

A basal-bolus insulin regimen is recommended for patients with cirrhosis and pancreatitis in the ICU, targeting blood glucose levels of 140-200 mg/dL (7.8-11.1 mmol/L), according to the American College of Physicians guidelines 1 and the American Diabetes Association 3
For patients who are eating, implement a basal-bolus-correction insulin regimen, with 50% as basal insulin (long-acting) and 50% as prandial insulin (rapid-acting) 3
For patients with poor oral intake or NPO, use basal insulin with correction doses, and consider continuous IV insulin infusion for severe hyperglycemia or unstable patients, as suggested by the American Diabetes Association 3
Total daily dose of insulin for insulin-naive patients is 0.3-0.5 units/kg/day, with 50% basal insulin and 50% prandial aspart, according to the American College of Clinical Endocrinologists 4, 5

Check blood glucose every 4-6 hours for NPO patients, and before meals and at bedtime for patients who are eating, as recommended by the American Diabetes Association 3 and the American Association of Clinical Endocrinologists 5
For IV insulin, monitor every 30 minutes to 2 hours until stable, according to the American Diabetes Association 3
Insulin doses should be adjusted based on patterns of glycemic control, with the goal of achieving a target blood glucose range 3, 5
If fasting blood glucose is consistently >140 mg/dL, the basal insulin dose should be increased by 10-20%, according to the Endocrine Society 5

Pancreatitis may cause fluctuating insulin requirements due to beta-cell dysfunction, stress-induced hyperglycemia, and potential hypertriglyceridemia, as noted by the American College of Gastroenterology
Premixed insulin formulations are not recommended for hospital use due to an unacceptably high rate of hypoglycemia, as stated by the American Association of Clinical Endocrinologists and the American Diabetes Association 5
Continuous IV insulin infusion is preferred over subcutaneous aspart for critically ill patients, targeting a blood glucose range of 140-180 mg/dL, as recommended by the Society of Critical Care Medicine and the American College of Critical Care Medicine 3, 5
Euglycemia (80-110 mg/dL) should not be targeted due to the increased risk of hypoglycemia, as advised by the American College of Critical Care Medicine 5
Hypoglycemia should be treated promptly with oral carbohydrates or IV glucose if the patient is NPO, and the regimen should be reviewed and modified after hypoglycemic episodes, according to the American College of Endocrinology 6