Basal-Bolus Insulin Regimen is Preferred Over Sliding Scale in Sepsis Management
For patients with sepsis requiring glucose control, use a scheduled basal-bolus insulin regimen rather than sliding scale insulin alone, as basal-bolus provides superior glycemic control with better outcomes in hospitalized patients. 1
Why Basal-Bolus is Superior
The evidence strongly favors structured insulin regimens over reactive sliding scale approaches:
Basal-bolus insulin strategy achieves better glycemic control than sliding scale insulin in non-critically ill hospitalized patients, which is the appropriate approach for most septic patients not requiring ICU-level continuous IV insulin infusion 1
Sliding scale insulin (SSI) regimens are not effective and should not be used, especially as monotherapy, because they exclude the critical basal insulin component needed for consistent glucose control 2
The basal-bolus approach uses long-acting basal insulin analogs (glargine or detemir) for baseline coverage, combined with rapid-acting insulin analogs (aspart, lispro, or glulisine) for bolus and correction doses, which more closely mimics physiological insulin secretion 2
When to Initiate Insulin Therapy in Sepsis
Follow this algorithmic approach based on current guidelines:
Start protocolized insulin therapy when two consecutive blood glucose levels are >180 mg/dL 3, 4, 5
Target an upper blood glucose limit of ≤180 mg/dL (NOT the more stringent ≤110 mg/dL target, which increases harm and hypoglycemia risk) 3, 6, 4, 5
A target glucose range of 110-180 mg/dL is appropriate for most critically ill patients, with values >180 mg/dL increasing risk of hospital complications 1
Critical Care vs. Non-Critical Care Settings
The insulin delivery method differs based on illness severity:
For critically ill septic patients in the ICU: Continuous intravenous insulin infusion is the best method for achieving glycemic targets and allows for rapid titration 1
For non-critically ill septic patients on the ward: Scheduled subcutaneous basal-bolus insulin regimens are the preferred modality 1, 2
Monitoring Requirements
Implement strict glucose monitoring protocols:
Monitor blood glucose every 1-2 hours initially until glucose values and insulin infusion rates are stable 3, 6, 4
Use arterial blood samples for glucose measurement in critically ill patients with invasive vascular monitoring, as capillary blood glucose measurements may not accurately estimate arterial or plasma glucose values, especially in hypoperfusion states 6
Common Pitfalls to Avoid
Never use tight glycemic control targeting <110 mg/dL in sepsis patients, as this significantly increases the risk of hypoglycemic events and mortality 6, 4, 5
Do not rely on sliding scale insulin as monotherapy, as it is reactive rather than proactive and fails to provide basal insulin coverage 2
Avoid using capillary blood glucose measurements alone in critically ill septic patients with hypoperfusion, as these readings can be inaccurate 3, 6
Special Considerations in Sepsis
Septic patients have unique metabolic derangements:
Sepsis creates a catabolic state with increased counter-regulatory hormones, leading to elevated glucose, amino acids, and free fatty acids 7
Hyperglycemia itself has distinct proinflammatory effects that worsen endothelial and neutrophil dysfunction in sepsis 7
Insulin therapy may serve a dual purpose: controlling hyperglycemia while also modulating inflammatory pathways 7
Patients with septic shock are at higher risk for hypoglycemia, making the moderate glucose target of ≤180 mg/dL (rather than normalization) particularly important 8