This document discusses glycemic control in ICU patients. It defines hyperglycemia as blood glucose above 140 mg/dL and recommends treating levels above 180 mg/dL, with a target range of 140-180 mg/dL. For patients on insulin infusions, it recommends hourly blood glucose monitoring initially, extending to every 2 hours once stable, and potentially every 4 hours if two consecutive readings are in target range. It also provides guidance on transitioning patients from intravenous to subcutaneous insulin and treating hypoglycemia.

1. Glycemic control
Ni’ma bader

2. DM
 Definition: is a group of metabolic disorders
characterized by hyperglycemia and abnormalities
in carbohydrate, fat, and protein metabolism.
 Complications: microvascular and macrovascular
complications.

3. Type 1 DM Type 2 DM
Speed of onset Abrupt Gradual
Age of onset Mostly young Mostly adults
Body type Thin or normal Often obese
Autoantibodies Present Absent
Endogenous insulin Absent Decrease gradually
Symptoms Symptomatic Often asymptomatic

5. Treatment approach
 Patients with HbAlc of 7.5% or less are usually treated with an
antihyperglycemic agent which is unlikely to cause
hypoglycemia.
 Those with HbAlc more than 7.5% but less than 8.5% could
be initially treated with a single agent, or combination therapy.
 Patients with higher initial HbAlc will require two agents or
insulin.

6. • Insulin should be particularly considered in A1C >9.5 percent
,fasting plasma glucose >250 mg/dL random glucose consistently
>300 mg/dL.
 Symptomatic patients may initially require treatment with insulin
or combination therapy.
 if the individualized A1C target is not reached after 3 months
of dual-drug therapy, a third drug may be added.

8. ICU patients

9. BG target range
 Definition of hyperglycemia: BG>140mg/Dl
 Treat if BG>180mg/dL
 Target BG: 140–180 mg/ dL
 Patients with trauma, traumatic brain injury,
cardiothoracic surgery, and thermal injury may
benefit from tighter BG (e.g., less than 140–150
mg/ dL) control if it can be done safely without
hypoglycemia.

10. BG monitoring frequency
 With insulin infusions:
◦ Monitor BG every hour then extend it to every 2 hours once
there is stability in BG control and the intravenous insulin
infusion rate is demonstrated.
◦ BG monitoring could be extended to every 4 hours once two
consecutive BG concentrations in the target range are
achieved.
◦ If the patient stable enough to warrant BG monitoring every 4
hours, the EN-fed patient is transitioned to intermediate- or
long acting subcutaneous insulin therapy

11. Point-of-care meters
 Point-of-care meters with capillary BG testing may be
reasonable for most critically ill patients and still in use by
many institutions as long as the patient’s BG concentrations
are greater than 80 mg/dL the vast majority of the time.
 For low BG concentrations, point-of-care meters may
erroneously report BG concentrations higher than measured.
Patients with significant peripheral edema may also have
erroneous BG concentrations

12. Transitioning from a continuous
intravenous insulin infusion
i. Give 30%–50% of the daily required intravenous regular human
insulin, divided into two separate doses and given every 12 hours.
Continue the graduated intravenous insulin infusion according to the
algorithm.
ii. BG measurements are continued every 1–2 hours and are mapped
to the timing of the subcutaneous NPH therapy to ascertain its
pharmacokinetic peak and duration.
iii. The NPH dosage and interval are adjusted accordingly daily until the
intravenous regular human insulin infusion is “auto-weaned” to 1–2
units/hour.
iv. The regular human insulin infusion is then discontinued with BG
determinations, with slidingscale regular human insulin coverage
every 3–4 hours. The NPH is further titrated daily according to the
required amount of corrective regular human insulin required to
maintain BG within the target BG range.
v. Frequency of BG measurements is decreased because the patient
has stability in glycemic control.

13. Case:
Patient Case 14. A 55-year-old woman (weight 75 kg)
without diabetes is given PN after a major GI resection. She
has been weaned from mechanical ventilation and is being
transferred from the ICU to the floor. Her current PN
formulation is 200 g of dextrose (1.8 mg/kg/minute), 110 g of
amino acids, and 80 g of lipids (1.1 g/kg/day), which meets
her goal requirements of protein at 26 kcal/kg/day and 1.5
g/kg/day. It contains regular human insulin at 20 units/day.
During the past 24 hours, her fingerstick BG measurements
have been 170–210 mg/ dL, and her serum glucose
concentration is 182 mg/dL. She has received 14 units of
sliding-scale regular human insulin coverage. Which would
be best to suggest for optimal glycemic control?
A. Increase regular insulin to 30 units/day.
B. Decrease dextrose to 100 g/day.
C. Increase regular insulin to 50 units/day.
D. Do not change the current regimen

14. Diabetic emergencies
 Diabetic ketoacidosis (DKA)
 Hyperosmolar hyperglycemic state
(HHS)

15. Causes:
 Typically caused by an insufficiency of
insulin in patients with diabetes
combined with another potential
trigger such as infection, pancreatitis,
and certain drugs (steroids, diuretics,
vasopressors, antipsychotics,
cocaine).

17. Management:
1. Fluid replacement:
1. 0.9% sodium chloride at a rate of 15–20 mL/kg for the first
hour.
2. Thereafter, fluid administration is titrated to hemodynamic
parameters and urine output.
3. Patients with mild dehydration and normal or high sodium
concentrations can be changed to 0.45% sodium chloride
infused at a rate of 250–500 mL/hour.
4. Maintenance fluids can be switched to a dextrose-containing
fluid (often 5% dextrose with 0.45% sodium chloride) once
BG concentrations have dropped to less than 200 mg/dL in
DKA and less than 300 mg/dL in HHS.

18. 2. Insulin therapy
◦ Intravenous regular insulin is preferred to subcutaneous
insulin because of its short half-life and ease of titration.
◦ The insulin infusion should subsequently be titrated on an
hourly basis to decrease BG concentrations by 50–75
mg/dL/hour.

19. Potassium
 should be replaced aggressively (assuming
adequate renal function) with a goal serum
potassium of 4–5 mEq/L.
i. Patients with initial serum potassium less than 3.3 mEq/L should
have insulin withheld and potassium administered until their serum
potassium is above 3.3 mEq/L.
ii. Patients with serum potassium of 3.3–5.2 mEq/L should have 20–30
mEq of potassium added to each liter of intravenous fluid
administered.
iii. Patients with initial serum potassium greater than 5.2 mEq/L should
not receive potassium, but they should be monitored closely (with
potassium administered if the patient’s serum falls below 4 mEq/L).
iv. Patients with DKA and initial hyperkalemia should not receive
therapy directed toward total body potassium removal (e.g.,
sodium polystyrene sulfonate or furosemide). The patient’s
serum potassium will typically decrease as insulin is
administered.

20. Acidemia:
 Administer sodium bicarbonate if PH<6.9

21. Hypoglycemia
 Definition:
◦ BG less than 70 mg/dL
◦ Mild to moderate hypoglycemia: BG concentration of 40–60
mg/dL (because autonomic symptoms often appear)
◦ Severe (life-threatening) hypoglycemia as less than 40
mg/dL.
 Occurs commonly in the ICU, both with and without intensive
glucose control.
 Symptoms:
 In the early stages: sweating, anxiety, hunger,
palpitations, tremor.
 Confusion, dizziness, and difficulty speaking develop.
 Severe hypoglycemia leads to seizures and

22.  Most common risk factors for hypoglycemia during
insulin therapy
i. Excessive insulin dose
ii. Abrupt discontinuation of EN or PN without an adjustment in
the insulin therapy
iii. Renal failure (half-life of insulin is prolonged, impaired renal
gluconeogenesis in response to hypoglycemia)
iv. Advanced age
v. Inotropes, vasopressor agents, octreotide with insulin
therapy
vi. Sepsis

23. Management
a. For conscious patients without severe symptoms,
oral glucose should be ingested (milk, juice, or
dextrose tablets).
i. The typical initial glucose dose is 20 g, which should
be repeated in 15–20 minutes if symptoms have not
improved or if BG remains low.
ii. Because the response to this “rescue glucose” is
transient (less than 2 hours), it should be followed by
more substantial glucose intake as a snack or meal.

24.  Parenteral therapy is necessary for patients unable to
take glucose orally or hospitalized patients with
moderate or severe hypoglycemia.

25.  Hospitalized patients with severe hypoglycemia
(either severe symptoms or BG less than 40 mg/dL)
or those receiving an insulin infusion with BG less
than 70 mg/dL (less than 100 mg/ dL in neurologic
injured patients) should be treated with intravenous
dextrose:
(a) Insulin infusion should be discontinued, as appropriate.
(b) Administer 10–20 g of 50% dextrose solution (20–40 mL of 50%
dextrose in water).
(c) The BG measurement should be repeated in 15 minutes, with
additional dextrose doses administered to achieve a BG greater
than 70 mg/dL.
(d) Care should be taken to avoid excessive dextrose
administration in order to avoid iatrogenic hyperglycemia and
because glucose variability has been associated with adverse
outcomes.