What is the recommended glucose goal for patients in the Intensive Care Unit (ICU)?

From the Guidelines

The recommended glucose goal for patients in the Intensive Care Unit (ICU) is to maintain blood glucose levels between 140-180 mg/dL (7.8-10.0 mmol/L). This moderate glycemic control approach has become the standard of care for most critically ill patients, as supported by the most recent and highest quality study 1. Insulin therapy, typically administered as an intravenous infusion in the ICU setting, is the primary method for achieving these targets. Regular insulin is commonly used, starting with a weight-based infusion protocol and titrated according to frequent blood glucose monitoring.

Key Considerations

• Hypoglycemia (blood glucose <70 mg/dL) should be avoided as it carries significant risks in critically ill patients.
• The moderate target range balances the risks of hyperglycemia against the dangers of hypoglycemia.
• Special considerations may apply for specific patient populations, such as those with diabetic ketoacidosis or neurological injuries.
• The findings from the NICE-SUGAR trial, as well as several meta-analyses, support the use of moderate glycemic targets, as they have been shown to reduce the risk of hypoglycemia and mortality compared to more intensive targets 1.

Implementation

• Insulin therapy should be initiated for the treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L).
• Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for most critically ill and non-critically ill patients.
• More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L), may be appropriate for selected patients if they can be achieved without significant hypoglycemia.

From the Research

Glucose Goal for Patients in the ICU

The recommended glucose goal for patients in the Intensive Care Unit (ICU) is a topic of ongoing discussion and research. Based on the available evidence, the following points can be made:

• The target range of 7.8-10 mmol/L (140-180 mg/dL) is proposed by specialty societies for hospitalized patients with diabetes, as it seems to be the best compromise for optimizing clinical outcomes while avoiding hypoglycemia 2, 3, 4, 5.
• Meta-analyses have shown that an upper blood sugar limit of 10 mmol/L (180 mg/dL) is associated with better outcomes for diabetic patients than an upper limit of less than this value 2.
• The method of choice for achieving this goal in intensive care medicine is the continuous intravenous administration of insulin, requiring standardized, high-quality monitoring conditions 2.
• Avoiding hypoglycemia is a primary therapeutic strategy in the perioperative setting, as neurotoxic effects and the promotion of wound-healing disturbances are among the adverse consequences of hyperglycemia 2.
• The use of intensive insulin therapy (IIT) can reduce the variability of blood glucose, but the 140-180 mg/dL range may be more secure in terms of presenting greater variability and hyperglycemia 6.
• Newly updated national guidelines call for a blood glucose target for critically ill patients of 140-180 mg/dL, using a continuous insulin infusion if needed 3, 5.

Key Considerations

• The ideal glycemic target has not been determined, but a target glucose level between 7.8 and 10.0 mmol/l (140 and 180 mg/dl) is recommended for the majority of ICU patients 4.
• Hyperglycemia is present in 40% of critically ill patients and in up to 80% of patients after cardiac surgery, with ∼ 80% of ICU patients with hyperglycemia having no history of diabetes prior to admission 4.
• Improvement in glycemic control reduces hospital complications and mortality, but overly stringent control may result in hypoglycemia, which is itself a risk factor for adverse clinical outcome 3, 5.