Glucose Management in Critically Ill Patients
Hyperglycemia Hypoglycemia
Goal: Maintain blood glucose <180 mg/dL in critically ill patients
Consider insulin if 2 or more blood glucoses above >150 mg/dL
Why it’s Uncontrolled hyperglycemia leads to increased length of stay,
important: increased risk of surgical complications, infection, and mortality
Medications: Bolus Insulin
Rapid: (Onset: <15 min - Peak: 1-2 hrs - Duration: 4-6 hrs)
Humalog (lispro), Novolog (aspart), Apidra (glulisine)
Short:(Onset: 0.5 -1 hr - Peak 2-4 hrs - Duration: 6-8 hrs)
Humulin/Novolin R (regular)
Basal Insulin
Intermediate:(Onset: 1-2 hrs - Peak: 6-10 hrs - Duration: ~12 hrs)
Humulin N (NPH)
Long (Onset: 1 hr - Peak: Minimal Peak - Duration: Up to 24 hrs)
Levemir (detemir), Lantus (glargine)
Management: 1) Insulin IV 1 unit / 1mL Drip (100 insulin regular units / 100mL)
a) Once Endotool or provider orders subcutaneously insulin, do not
stop insulin drip immediately
b) First give basal insulin. Stop drip 2-4 hours after subcutaneous
injection to avoid rebound hyperglycemia
2) Basal +/- Bolus Insulin
-Mimics healthy pancreas to provide a steady dose of basal insulin
throughout the day and bolus insulin before meals to cover increase
in glucose
3) Insulin Sliding Scale
-Reactively corrects blood sugar using rapid/short acting insulin
Avoid blood glucose < 70 mg
Correct to > 100 mg/dL if hypoglycemic
Hypoglycemia symptoms range from mild to severe:
Mild: Shakiness, sweating, dizziness, irritability, nausea
Moderate: Blurred vision, slurred speech, confusion
Severe: Loss of consciousness, seizure, coma, death
Medications: Carbohydrates, Dextrose IV, Glucagon IM
- If responsive and able to eat → 15-30g of carbs
- If unresponsive or NPO with IV access → dextrose 50% IV
kit
- If unresponsive or NPO without IV access → glucagon 1mg
IM kit
- If glucagon given twice without response, give dextrose
(glycogen stores may be exhausted)
1) If hypoglycemic, correct blood glucose to > 100 mg/dL
2) Administer appropriate medications and notify provider
3) Repeat fingerstick in 15 minutes after administration
4) If <100 mg/dL, repeat step 2 and 3 until >100 mg/dL
 a.

2. Management Goal:
 a. NICE-SUGAR
i. Increased mortality and hypoglycemic events in ICU patients with intensive targets (81-108) vs conventional control <180
b. VISEP Trial
i. Increased hypoglycemia events in intensive arm 80-110 vs 180-200 in ICU patients with sepsis

c. BG > 150 mg/dL should warrant insulin therapy

d. Maintain BG below 180 absolutely

3. Preparation:
a. 1 unit regular insulin / mL IV infusion
i. Bioavailability due to leaching is approximately 50-60 percent

b. When to use IV drip?

i. Type 1 DM, hemodynamically unstable with hyperglycemia, and long acting is not appropriate due to changing clinical
status (food intake,)

c. When to use SubQ?

i. After stabilization of BG with IV insulin

d. How to transition?
i. Initiate basal 2-4 hours before insulin infusion stops to prevent rebound hyperglycemia

e. What dose when transitioning?

i. 60-80% TDD due to leaching
ii. Consider patient changes

4. Monitoring
a. Monitor blood glucose q1-2h with insulin infusion
i. POC may not be accurate especially in patients:
1. Poor peripheral perfusion may underestimate blood glucose

5. Hypoglycemia Management:
a. If <70 or <100 in neurologic injury patients, stop insulin and adminster 10-20g of IV dextrose; repeat smaller dextrose doses in 15
minutes if necessary. Goal >70 mg/dL
i. (100-BG)*0.2 = grams of dextrose