What are the target blood glucose ranges for inpatients and why?

Target Blood Glucose Ranges for Inpatients

For most hospitalized patients, the recommended blood glucose target range is 140-180 mg/dL (7.8-10.0 mmol/L) for both critically ill and non-critically ill patients. 1

Different Patient Populations and Target Ranges

Critically Ill Patients

• Standard target: 140-180 mg/dL (7.8-10.0 mmol/L) 1
• Selected ICU patients: More stringent goals of 110-140 mg/dL (6.1-7.8 mmol/L) may be appropriate for specific patients (e.g., post-surgical or cardiac surgery patients) if achievable without significant hypoglycemia 1
• Implementation: Continuous insulin infusion is the preferred regimen for ICU patients 1
• Avoid: Targets below 110 mg/dL due to increased risk of hypoglycemia and mortality as demonstrated in the NICE-SUGAR trial 1

Non-Critically Ill Patients

• Standard target: 140-180 mg/dL (7.8-10.0 mmol/L) 1
• Treatment threshold: Insulin therapy should be initiated when blood glucose is ≥180 mg/dL (checked on two occasions) 1
• Implementation: Basal-bolus insulin regimens are preferred over sliding scale insulin alone 1

Special Populations

• Elderly patients: 100-180 mg/dL, with emphasis on avoiding hypoglycemia 2
• Patients with severe comorbidities: Higher targets up to 200-250 mg/dL may be acceptable 1
• Terminally ill patients: Targets up to 250 mg/dL (13.9 mmol/L) may be acceptable to minimize glucosuria, dehydration, and electrolyte disturbances 1
• Settings with limited monitoring: Higher targets up to 200 mg/dL may be appropriate where frequent glucose monitoring or close nursing supervision is not feasible 1

Rationale for These Targets

1. Balance of benefits and risks:

   • Hyperglycemia is associated with increased morbidity and mortality in hospitalized patients 3
   • However, strict glycemic control (80-110 mg/dL) increases risk of hypoglycemia without improving outcomes 1

2. Evidence from clinical trials:

   • The NICE-SUGAR trial showed increased mortality with intensive insulin therapy targeting euglycemia in critically ill patients 1
   • Multiple meta-analyses support more moderate glycemic targets 1

3. Hypoglycemia prevention:

   • Hypoglycemia is associated with increased mortality, especially in elderly patients 2
   • Fasting glucose levels <100 mg/dL are predictors of hypoglycemia within 24 hours 2

Monitoring Recommendations

• Critically ill patients: Frequent monitoring with continuous insulin infusion protocols 4
• Non-critically ill patients who are eating: Check blood glucose before meals 1
• Non-critically ill patients not eating: Check blood glucose every 4-6 hours 1
• Warning signs requiring more frequent monitoring:
  • Fasting glucose trending below 100 mg/dL
  • Irregular meal consumption
  • New medications affecting glucose levels 2

Common Pitfalls and How to Avoid Them

1. Relying solely on sliding scale insulin:

   • Sliding scale insulin alone is strongly discouraged 1, 2
   • Use basal-bolus regimens for non-critically ill patients 1

2. Delayed insulin adjustments:

   • Review blood glucose daily until stabilized 2
   • Adjust insulin doses every 2-3 days based on patterns 2

3. Failure to consider nutritional status:

   • Match insulin dosing to carbohydrate intake 2
   • Consider nutritional changes when adjusting insulin 1

4. Overly aggressive targets:

   • Avoid targets below 110 mg/dL due to hypoglycemia risk 1
   • Consider relaxing targets for patients with severe comorbidities 1

5. Poor transition planning:

   • Begin discharge planning at admission 2
   • Provide clear written and oral instructions for post-discharge management 2

By maintaining appropriate blood glucose targets based on patient characteristics and clinical setting, healthcare providers can optimize outcomes while minimizing the risks of both hyperglycemia and hypoglycemia in hospitalized patients.