Last updated March 14, 2022

Insulin Infusion For The Management Of Hyperglycemia In Critically Ill Patients

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

Publication Month/Year

December 1, 2012

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