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Cardio Diabetes Medicine 2017 503

10% if the IIT discontinued prematurely. GLYCEMIC VARIABILITY
No significant difference in the primary outcome, Wide fluctuations in glucose levels induce apopto-
death. sis, endothelial activation, and oxidative stress more
than sustained hyperglycemia Glycemic variability
Inclusion criteria,i.e., length of stay is a subjective has been shown to be a more powerful predictor of
parameter.
mortality than mean BG values among a heteroge-
The study was not blinded to the treating personnel nous group of ICU patients
In one study, for the same degree of glucose control
CONCLUSION OF TRAILS (mean BG ranging between 80 and 110 mg/dL), mor-
Intensive Insulin Therapy (IIT) trail concluded that tality ranged from 4.2% to 27.5% depending on the de-
Blood glucose control at or below 110mg/dl reduced gree of glucose variability. Krinsley JS. Glycemic vari-
morbidity and mortality in Critical care patients in ability: a strong independent predictor of mortality in
SICU critically ill patients. Crit Care Med. 2008;36(11):3008-
3013
NICE SUGAR study said moderate glycemic control
at 127-179mg/dl was superior to tight glycemic con- Glycemic variability is usually expressed as the stan-
trol with decreased mortality and morbidity and major dard deviation around the mean glucose value as
complications for patients mean amplitude of excursionsGlycemic variability is
also associated with outcome in critically ill patients
MANAGEMENT OF HYPERGLYCEMIA IN ;specifically ,greater glycemic variability is associated
THE CRITICAL CARE SETTING with significant higher mortality rate.The mortality rate
SAMPLING among non-diabetic patients with a mean glucose
level of 70-99 mg/dL during the ICU stay was 10.2%
Blood (vascular catheter) – danger of contamination for patients with a glucose GV of < 15% vs 58.3% for
with IV fluids patients with a glucose GV above 50%
Finger stick – inaccurate in patients with edema or
anemia Increased glycemic variability not only
increased the mortality rate, but also
MEASUREMENTS
morbidities, such as nosocomial infections
• Glucometer – fastest, least accurate and hospital length of stay
• Blood gas machine – fast, accurate ADA 2016 Recommendations : critically ill patient
• Laboratory analysis – slowest, most accurate
• Inpatient glycemic Mx – Definition of Terms

Hospital hyperglycemia Any BG>140 mg/dl
Stress hyperglycemia Elevations in blood glucose
levels that occur in patients
with no prior History of diabe-
tes and A1c Levels that are not
significantly elevated(6.5%)
A1c Value>6.5% Suggestive of prior history of
diabetes
Hypoglycemia Any BG<70mg/dl IV insulin protocol with demonstrated efficacy, safety
in achieving desired glucose range without increas-
Severe hypoglycaemia Any BG<40mg/dl
ing risk for severe hypoglycemia
INTERPRETATION : Glycemic management in ICU
< 140 mg/dL - monitoring less frequent
In critically ill patients, initial treatment of hyperglyce-
140 – 180 mg/dL -  HA1C – frequent monitoring mia typically is accomplished with IV insulin therapy.
The ideal protocol should quickly reach and maintain
> 180 mg/dL -  HA1C , consider insulin – monitor
per algorithm target blood glucose, account for the current blood
glucose and rate of change in blood glucose values,

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