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498 Hyperglycemia & Glycemic Control In ICU

ductions among surgical ICU patients supported by • Increased hepatic gluconeogenesis and glycog-
mechanical ventilation. (1) enolysis

• Impaired peripheral glucose uptake
Three Types of Hyperglycemic Patient • And higher circulating levels of insulin
• Known history of diabetes Counter regulatory hormones, such as glucagon,
cortisol, growth hormone, and catecholamine, as
• Existing, but unrecognized, diabetes
well as elevated levels of cytokines play an import-
• Stress hyperglycemia ant role in up-regulating hepatic glucose production.
Some of these hormones and cytokines have also
HBA1C IS THE KEY FOR ASSESSING THE been shown to directly oppose insulin, resulting in
CONTROL OF DIABETES increased lipolysis and proteolysis, which serve to
Guidelines From Professional Organizations on the provide substrates for further gluconeogenesis
Management of Glucose Levels in the ICU (Table 1) As patients become bed-bound in the ICU, exer-
cise-stimulated uptake in skeletal muscle disap-
AACE - Consensus Conference - Blood pears.The increased counter regulatory environment
Glucose Targets of critical illness and the impairments in glycogen
synthase activity compromise glucose uptake in
Upper Limit Inpatient Glycemic Targets: the heart, skeletal muscle, and adipose tissue. In-
• Critical Care: 110 mg/dl (6.1 mmol/L) (Fasting ) sulin-stimulated uptake by carriers such as GLUT-4
(Glucose transporter type 4 a solute carrier family 2,
• Non-critical care (limited data)
facilitated glucose transporter member 4) is also de-
• Pre-prandial: 110 mg/dl (6.1 mmol/L) creased,leading to Hyperglycemic state.
• Post-Prandial : 180 mg/dL (10 mmol/L) Hyperglycemia and Its Biologic Effects: The higher
risk of organ failure seen in patients with hyperglyce-
The current ADA guideline for pre-prandial plasma mia, likely in part arises from alterations in microcir-
glucose is now < 126 mg/dL (2)
culation that lead to inadequate oxygen delivery as a
result of endothelial dysfunction. Even when oxygen
Pathophysiology delivery is adequate, certain types of tissue appear
Hyperglycemia during critical illness can be best to be at risk for bioenergetic failure and cellular death
characterized as a state of insulin resistance that resulting from mitochondrial dysfunction when faced
develops in the context of: with persistent hyperglycemia.

Year Organization Patient Treatment Target Glucose Definition of Updated Since
Population Threshold Level Hypoglycemia NICE_SUGAR
Trial, 2009
2009 American Association ICU patients 180 140-180 <70 Yes
of Clinical Endocrinol-
ogists and American
Diabetes Association
2009 Surviving Sepsis Cam- ICU patients 180 150 Not stated Yes
paign
2009 Institute for Health- ICU patients 180 <180 <40 Yes
care Improvement
2008 American Heart Asso- ICU patients with 180 90-140 Not stated No
ciation acute coronary
syndromes
2007 European Society of ICU patients with Not stated “Strict” Not stated No
Cardiology and Euro- cardiac disorders
pean Association for
the Study of Diabetes
Table 1: Guidelines From Professional Organizations on the Management of Glucose Levels in the ICU

GCDC 2017