PULMONARY & CRITICAL CARE MEDICINE- DR. HEMANT KUMAR AGARWAL

1. HYPERGLYCEMIA IN ICU
Dr. Hemant Kumar
DM Fellow
Pulmonary & Critical Care Medicine, KGMU
Date: 03/08/2021
1

2. IN HOSPITALIZED PATIENT
 Hyperglycemia in hospitalized patients is defined as
blood glucose levels >140 mg/dL
 Hypoglycemia in hospitalized patients has been
defined as blood glucose <54mg/dL (3.0mmol/L)
 Blood glucose level of <70 mg/dL is considered an
alert value and may be used as a threshold for
further titration of insulin regimens.
2

3. ETIOLOGY OF HYPERGLYCEMIA/ HYPOGLYCEMIA
3

4. LINK BETWEEN HIGH BLOOD GLUCOSE AND
POOR OUTCOMES?
1. Hyperglycemia and impaired immune function
(impaired phagocyte function of leucocytes, increased
ROS ,inc. cytosolic calcium and dec. ATP)
2. Hyperglycemia and the cardiovascular system-
(increased catecholamines, increased bp, blood
viscosity, reduced coronary collateral blood supply and
impairs protective mechanism for ischemic insult to
heart)
3. Hyperglycemia and thrombosis-
(platelet hyperactivity and inc. thromboxane
biosynthesis and inc. fibrinogen.)
4

5. 4. Hyperglycemia and inflammation-
(inc. IL-6 & TNF-A)
5. Hyperglycemia and the brain
(acute hyperglycemia is associated with enhanced
neuronal damage following induced brain ishchemia,
major portion of brain is sensitive to injury from
hyperglycemia is the ischemic penumbra)
5. Hyperglycemia and oxidative stress
5

6. HYPERGLYCEMIA:ANINDEPENDENT MARKER OF
IN-HOSPITAL MORTALITY IN PATIENTS WITH UNDIAGNOSED
DIABETES
TotalIn-patient Mortality
Normoglycemia
* P<0.01
Known
Diabetes
New
Hyperglycemia
1.7% 3.0%
16.0%*
Mortality
(%)
UmpierrezGEet al, JClinEndocrinolMetabol 87:978, 2002
0
10
20
30
7

7. HYPERGLYCEMIAAND PNEUMONIA OUTCOMES
0
BG(mg/dl) <
110
110 -
<198
198 -
<250
≥25
0
* *
*
* p:<0.05 vsBG<198 mg/dl (11 mmol/L)
N=2,471 patientswith CAP
McAllister et al, Diabetes Care28:810-815, 2005
%
5
10
15
20
25
30 * Admission
glucose
(mg/dl)
Mortality
Hospital
C
omplications
8

8. HYPERGLYCEMIAIN HOSPITALIZED
PATIENTS
• Hyperglycemia (>200 mg/dLx2) occurredin 38%of
hospitalizedpatients
– 26%hadknownhistoryof diabetes
– 12%hadnohistoryof diabetes
• Newly discoveredhyperglycemiawasassociated with:
– Longerhospital stays
– higheradmissionrates to intensive care units
– Lesschanceto bedischargedto home(required more
transitional or nursinghome care)
Umpierrez GE,et al. JClin Endocrinol Metab.2002;87:978–982.
9

9. DIAGNOSISOF DIABETESAND HYPERGLYCEMIA
IN HOSPITAL SETTING
• Patients with known historyof diabetes canbe
admitted in hospital
• Hyperglycemia detected in the hospital
it could be newly detected diabetes
it couldbestresshyperglycemia
• Abovetwo canbe differentiated bythe
measurementof HBA1C 10

10. NICE-SUGAR STUDY OUTCOMES
Outcome
Measure
Intensive
Group
Convention
al Group
MorningBG (mg/dL) 118+ 25 145+ 26
Hypoglycemia 206/3016 15/3014
(≤ 40mg/dL) (6.8%) (0.5%)
28DayMortality (p=0.17)
22.3% 20.8%
90DayMortality (p=0.02)
27.5% 24.9%
11

11. 12

12. 13

13. AACE-ADAConsensusStatement on
Inpatient GlycaemicTargets
Recommendsusinginsulintherapy if bloodglucoselevels
exceed180 mg/dL
Moghissi E,et al. DiabetesCare2009; 32 (6):1119-1131
14

14. Moghissi et al. EndocrPract2009;15:353–69
Inpatient glycaemictargets
• Insulininfusionto controlhyperglycaemia
• Startingthresholdnohigherthan 180 mg/dL
• Maintain BGbetween 140 and180 mg/dL
– Possiblegreaterbenefit at lower endof range
• Somewhatlower targetsmaybeappropriate in selected patients
• Targets<110mg/dLare not recommended
Not recommended
<110mg/dL
May beappropriate
110–140 mg/dL
Recommended
140–180mg/dL
Not recommended
>180 mg/dL
15

15. In critical care settings continuous IV
insulin infusion is the most effective
method to achieving specific
glycemic targets
YALE Insulin Drip Protocol
16

16. YALEProtocol Benefits
 Eliminates the need for multipleinjections
 Allows for more accurate doseadministration
 Hasmore predictable kinetics
 Provides aquick responseto rapidlychanging glucoselevels
 Accomplish adequate control with smallerinsulin doses
17

17. YALE Protocol Not to beUsed
•Diabetic Ketoacidosis(DKA)
•Hyperglycemic Hyperosmolar
Syndrome(HHS)
•BG≥500 mg/dL
18

18. YaleInsulinInfusion Protocol
• Insulininfusion:
– Mix 1 U regular human insulin per 1 mL 0.9%
Administervia infusionpumpin incrementsof 0.5 U/h
NaCl.
• Bolusandinitial infusion rate:
– Divideinitial BGby100, roundto nearest0.5 Ufor bolusandinitial
infusionrates
• Example:Initial BG=325 mg/dL:325/100 =3.25, round
upto 3.5, IV bolus=3.5 U+start infusionat 3.5 U/h
• Subsequentrate adjustments:
– Changesin infusionrate are determined bythe current infusionrate and
the hourlyrate of changefrom the prior BGlevel
Goldberg PA,et al. Diabetes Care.2004;27:461-467. 26
19

19. Blood Glucose
Monitoring
Check RBS Hourly until stable
(3 consecutive values in target range)
20

20. Blood GlucoseMonitoring
Oncestable check RBS every 2 hours
Stable for 12-24 hours
No significant change in clinical condition
No significant change in nutritional intake
Every 4 hours
21

21. Blood GlucoseMonitoring
Consider resumption of hourly RBSmonitoring:
•Any change in insulin drip rate
•Significant changesin clinical
condition
•Initiation/cessation of pressor/
steroid therapy, dialysis, nutritional
support
22

22. BG<50 mg/dL BG 50-69 mg/dL
Discontinue Drip
Dextrose 1 amp (25g) Symptomatic: 1 amp (25 g)
Asymptomatic: ½amp (12.5 g)
or 8 ozjuice PO
Check
BG
q 15min Symptomatic: q 15min
Asymptomatic: q 15-30min
Restarting Drip
When BG≥ 90 mg/dL wait 1hour
RecheckBGif still ≥ 90 mg/dL restartdrip
New
Rate
50%of recent rate 75%of recent rate
Changing the Insulin DripRate
23

23. Changing the Insulin DripRate
IFBG≥70 mg/dL
Determine the Current BGLEVEL
70-89
mg/dL
90-119 mg/dL 120-179
mg/dL
≥ 180 mg/dL
Identify aCOLUMNin the table
24

24. Determine RATEOFCHANGEfrom prior BGlevel
25

25. Conversion from IV to SCInsulin
 T
ocalculateTDD:
1. Units of insulin given in last 6 hours x4
2. Use80%of that value ( x0.8)
OR
1. Uselast 7 insulin drip rates and omit the 2highest
2. Sumof the lowest 5 drip rates x4
 Apply Basal-Bolus Insulin Model
26

26. Basal-BolusInsulin Model
Total Daily Dose
Basal(50%) Bolus (50%)
Breakfast
Lunch
Dinner
Correctional
Insulin
27

27. Insulin Options
Bas
al
Glargine
Detemir
NPH
Lispro
Aspart
Glulisine
Regular
Bolus
Correction
al
Lispro
Regular
28

28. ADVICEAT HOSPITAL DISCHARGE
Umpierrez GE.ClevelandClinic JournalOf Medicine 2011; 78(6):379-384
29

29. CONCLUSION
Glucoseconcentrations should be closely
monitored in critically illpatients
IV insulin infusion is preferred for optimum
blood glucosecontrol
 Maintains blood glucose within desiredrange
Basal-Bolus insulin model once patient is
stabilized
30

30.  THANKS
31