3.3.0.0 Moderate Versus Tight Glycemic Control
A meta-analysis of over 26 studies, including the Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study, showed increased rates of “severe hypoglycemia” (defined in the analysis as blood glucose <40 mg/dL [2.2 mmol/L]) and mortality in cohorts with tight versus moderate glycemic control (22). Recent randomized controlled studies and metaanalyses in surgical patients have also reported that targeting perioperative blood glucose levels to <180 mg/dL (10 mmol/L) is associated with lower rates of mortality and stroke compared with a target glucose <200 mg/dL (11.1 mmol/L), whereas no significant additional benefit was found with more strict glycemic control (<140 mg/dL [7.8 mmol/L]) (23,24). Insulin therapy should be initiated for 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 the majority of critically ill and noncritically ill patients (2). More stringent goals, such as <140 mg/dL (7.8 mmol/L), may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia. Conversely, higher glucose ranges may be acceptable in terminally ill patients, in patients with severe comorbidities, and in inpatient care settings where frequent glucose monitoring or close nursing supervision is not feasible.
Clinical judgment combined with ongoing assessment of the patient’s clinical status, including changes in the trajectory of glucose measures, illness severity, nutritional status, or concomitant medications that might affect glucose levels (e.g., glucocorticoids), should be incorporated into the day-to-day decisions regarding insulin dosing (2).