SpringerLink
Log in

Updates in Glycemic Management in the Hospital

  • Hospital Management of Diabetes (A Wallia and JJ Seley, Section Editors)
  • Published:
Current Diabetes Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

To provide an update of glycemic management during metabolic stress related to surgery or critical illness.

Recent Findings

There is a clear association between severe hyperglycemia, hypoglycemia, and high glycemic variability and poor outcomes of postoperative or critically ill patients. However, the impressive beneficial effects of tight glycemic management (TGM) by intensive insulin therapy reported in one study were never reproduced. Hence, the recommendation of TGM is now replaced by more liberal blood glucose (BG) targets (< 180 mg/dL or 10 mM). Recent data support the concept of targeting individualized blood glucose (BG) values according to the presence of diabetes mellitus/chronic hyperglycemia, the presence of brain injury, and the time from injury.

Summary

A more liberal glycemic management goal is currently advised during metabolic stress and could be switched to individualized glycemic management once validated by prospective trials.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (Germany)

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Dungan KM, Braithwaite SS, Preiser JC. Stress hyperglycaemia. Lancet. 2009;373:1798–807.

    CAS  PubMed  PubMed Central  Google Scholar 

  2. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:1007–21.

    CAS  PubMed  Google Scholar 

  3. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359–67.

    Google Scholar 

  4. Preiser J (2010) 72 - Should Blood Glucose Be Tightly Controlled in the Intensive Care Unit? In: Deutschman CS, Neligan PJ (eds) Evidence-Based Practice of Critical Care. Saunders, Philadelphia, an imprint of Elsevier Inc., pp 505–508

    Google Scholar 

  5. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283–97.

    Google Scholar 

  6. Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006;354:449–61.

    PubMed  Google Scholar 

  7. De La Rosa GD, Donado JH, Restrepo AH, et al. Strict glycaemic control in patients hospitalised in a mixed medical and surgical intensive care unit: a randomised clinical trial. Crit Care. 2008;12:R120.

    Google Scholar 

  8. Arabi Y, Dabbagh OC, Tamim HM, et al. Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients. Crit Care Med. 2008;36:3190–7.

    CAS  PubMed  Google Scholar 

  9. Kalfon P, Giraudeau B, Ichai C, et al. Tight computerized versus conventional glucose control in the ICU: a randomized controlled trial. Intensive Care Med. 2014;40:171–81.

    CAS  PubMed  Google Scholar 

  10. COIITSS Study Investigators, Annane D, Cariou A, Maxime V, et al. Corticosteroid treatment and intensive insulin therapy for septic shock in adults: a randomized controlled trial. JAMA. 2010;303:341–8.

    Google Scholar 

  11. Brunkhorst FM, Engel C, Bloos F, German competence network Sepsis (SepNet), et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358:125–39.

    CAS  PubMed  Google Scholar 

  12. Preiser JC, Devos P, Ruiz-Santana S, et al. A prospective randomized multi-Centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Intensive Care Med. 2009;35:1738–48.

    CAS  PubMed  Google Scholar 

  13. Rosso C, Corvol JC, Pires C, Crozier S, Attal Y, Jacqueminet S, et al. Intensive versus subcutaneous insulin in patients with hyperacute stroke: results from the randomized INSULINFARCT trial. Stroke. 2012;43:2343–9.

    PubMed  Google Scholar 

  14. Bilotta F, Spinelli A, Giovannini F, et al. The effect of intensive insulin therapy on infection rate, vasospasm, neurologic outcome, and mortality in neurointensive care unit after intracranial aneurysm clip** in patients with acute subarachnoid hemorrhage: a randomized prospective pilot trial. J Neurosurg Anesthesiol. 2007;19:156–60.

    PubMed  Google Scholar 

  15. Bilotta F, Caramia R, Paoloni FP, et al. Safety and efcacy of intensive insulin therapy in critical neurosurgical patients. Anesthesiology. 2009;110:611–9.

    CAS  PubMed  Google Scholar 

  16. de Mulder M, Umans VA, Cornel JH, et al. Intensive glucose regulation in hyperglycemic acute coronary syndrome: results of the randomized BIOMarker study to identify the acute risk of a coronary syndrome-2 (BIOMArCS-2) glucose trial. JAMA Intern Med. 2013;173:1896–904.

    PubMed  Google Scholar 

  17. Wallia A, Schmidt K, Oakes DJ, et al. Glycemic control reduces infections in post-liver transplant patients: results of a prospective, Randomized Study. J Clin Endocrinol Metab. 2017;102:451–9.

    PubMed  Google Scholar 

  18. The NICE-SUGAR. Study investigators hypoglycemia and risk of death in critically ill patients. N Engl J Med. 2012;367:1108–18.

    Google Scholar 

  19. • Wang YY, Hu SF, Ying HM, Chen L, Li HL, Tian F, et al. Postoperative tight glycemic control significantly reduces postoperative infection rates in patients undergoing surgery: a meta-analysis. BMC Endocr Disord. 2018;18:42. An updated systematic review on the effect of tight glycemic control on postoperative infections.

    PubMed  PubMed Central  Google Scholar 

  20. • Kang ZQ, Huo JL, Zhai XJ. Effects of perioperative tight glycemic control on postoperative outcomes: a meta-analysis. Endocr Connect. 2018;7:R316–27. An updated systematic review on the effect of tight glycemic control on postoperative complications.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. • Yamada T, Shojima N, Noma H, Yamauchi T, Kadowaki T. Glycemic control, mortality, and hypoglycemia in critically ill patients: a systematic review and network meta-analysis of randomized controlled trials. Intensive Care Med. 2017;43:1–15. An important comprehensive analysis of the available clinical data on tight glycemic control in intensive care medicine.

    CAS  PubMed  Google Scholar 

  22. Kao LS, Meeks D, Moyer VA, Lally KP. Peri-operative glycaemic control regimens for preventing surgical site infections in adults. Cochrane Database Syst Rev. 2009;3:CD006806.

    Google Scholar 

  23. Preiser JC, Chase JG, Hovorka R, et al. Glucose control in the ICU: a continuing story. J Diabetes Sci Technol. 2016;10:1372–81.

    PubMed  PubMed Central  Google Scholar 

  24. • Olariu E, Pooley N, Danel A, Miret M, Preiser JC. A systematic sco** review on the consequences of stress-related hyperglycaemia. PLoS One. 2018;13:e0194952. A systematic review of the available data on the associations between hyperglycemia and outcomes in the critically ill.

    PubMed  PubMed Central  Google Scholar 

  25. American Diabetes Association. Classification and Diagnosis of Diabetes. Diabetes Care. 2017;40(Suppl. 1):S11–24.

    Google Scholar 

  26. • Cheisson G, Jacqueminet S, Cosson E, et al. Perioperative management of adult diabetic patients. Review of hyperglycaemia: definitions and pathophysiology. Anaesth Crit Care Pain Med. 2018;37(Suppl 1):S5–8. A practical and updated approach of the management of diabetes before and after surgery.

    PubMed  Google Scholar 

  27. Preiser JC, Ichai C, Orban JC, Groeneveld AB. Metabolic response to the stress of critical illness. Br J Anaesth. 2014;113:945–54.

    CAS  PubMed  Google Scholar 

  28. Preiser JC. Restoring normoglycaemia: not so harmless. Crit Care. 2008;12:116.

    PubMed  PubMed Central  Google Scholar 

  29. Lena D, Kalfon P, Preiser JC, Ichai C. Glycemic control in the intensive care unit and during the postoperative period. Anesthesiology. 2011;114:438–44.

    PubMed  Google Scholar 

  30. Uyttendaele V, Dickson JL, Shaw GM, Desaive T, Chase JG. Untangling glycaemia and mortality in critical care. Crit Care. 2017;21:152.

    PubMed  PubMed Central  Google Scholar 

  31. Soeters MR, Soeters PB. The evolutionary benefit of insulin resistance. Clin Nutr. 2012;31:1002–7.

    CAS  PubMed  Google Scholar 

  32. Harp JB, Yancopoulos GD, Gromada J. Glucagon orchestrates stress-induced hyperglycaemia. Diabetes Obes Metab. 2016;18:648–53.

    CAS  PubMed  PubMed Central  Google Scholar 

  33. Nielsen ST, Janum S, Krogh-Madsen R, Solomon TP, Møller K. The incretin effect in critically ill patients: a case-control study. Crit Care. 2015;19:402.

    PubMed  PubMed Central  Google Scholar 

  34. Jamaludin UK, Docherty PD, Chase JC, et al. Observation of incretin effects during enteral feed transitions of critically ill patients. e-SPEN J. 2012;7:e154–9.

    Google Scholar 

  35. • Ding W, Xu L, Zhang L, et al. Meta-analysis of association between TCF7L2 polymorphism rs7903146 and type 2 diabetes mellitus. BMC Med Genet. 2018;19:38. A systematic review of the association studies confirming the presence of a single polymorphism as a risk factor for type 2 diabetes mellitus across all ethnicities.

    PubMed  PubMed Central  Google Scholar 

  36. • Ben Hamou A, Kipnis E, Elbaz A, et al. Association of transcription factor 7-like 2 gene (TCF7L2) polymorphisms with stress-related hyperglycaemia (SRH) in intensive care and resulting outcomes: The READIAB study. Diabetes Metab. 2019; A large-scale study assessing the presence of a single polymorphism as a risk factor for stress hyperglycemia. https://doi.org/10.1016/j.diabet.2019.05.001.

  37. Badawi O, Waite MD, Fuhrman SA, Zuckerman IH. Association between intensive care unit-acquired dysglycemia and in-hospital mortality. Crit Care Med. 2012;40:3180–8.

    PubMed  Google Scholar 

  38. Falciglia M, et al. Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med. 2009;37:3001–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  39. Krinsley JS, Egi M, Kiss A, et al. Diabetic status and the relation of the three domains of glycemic control to mortality in critically ill patients: an international multicenter cohort study. Crit Care. 2013;17:R37.

    PubMed  PubMed Central  Google Scholar 

  40. Green JP, Berger T, Garg N, et al. Hyperlactatemia affects the association of hyperglycemia with mortality in nondiabetic adults with sepsis. Acad Emerg Med. 2012;19:1268–75.

    PubMed  PubMed Central  Google Scholar 

  41. Kaukonen KM, Bailey M, Egi M, Orford N, Glassford NJ, Marik PE, et al. Stress hyperlactatemia modifies the relationship between stress hyperglycemia and outcome: a retrospective observational study. Crit Care Med. 2014;42(6):1379–85.

    CAS  PubMed  Google Scholar 

  42. Freire Jorge P, Wieringa N, de Felice E, van der Horst ICC, Oude Lansink A, Nijsten MW. The association of early combined lactate and glucose levels with subsequent renal and liver dysfunction and hospital mortality in critically ill patients. Crit Care. 2017;21:218.

    PubMed  PubMed Central  Google Scholar 

  43. Egi M, Bellomo R, Stachowski E. Etal. Blood glucose concentration and outcome of critical illness: the impact of diabetes. Crit Care Med. 2008;36:2249–55.

    CAS  PubMed  Google Scholar 

  44. Sechterberger MK, Bosman RJ, Oudemans-van Straaten HM, et al. The effect of diabetes mellitus on the association between measures of glycaemic control and ICU mortality: a retrospective cohort study. Crit Care. 2013;17:R52.

    PubMed  PubMed Central  Google Scholar 

  45. • van Vught LA, Holman R, de Jonge E, et al. Diabetes is not associated with increased 90-day mortality risk in critically ill patients with sepsis. Crit Care Med. 2017;45:e1026–35. Analysis of a national database showing differences between the associations of dysglycemia and outcomes according to the presence of diabetes.

    PubMed  Google Scholar 

  46. Van den Berghe G, Wilmer A, Milants I. Intensive insulin therapy in mixed medical/surgical intensive care units: benefit versus harm. Diabetes. 2006;55:3151–9.

    PubMed  Google Scholar 

  47. Kosiborod M, Rathore SS, Inzucchi SE, Masoudi FA, Wang Y, Havranek EP, et al. Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction: implications for patients with and without recognized diabetes. Circulation. 2005;111:3078–86.

    CAS  PubMed  Google Scholar 

  48. Mesotten D, Preiser JC, Kosiborod M. Glucose management in critically ill adults and children. Lancet Diabetes Endocrinol. 2015;3:723–33.

    CAS  PubMed  Google Scholar 

  49. • Egi M, Krinsley JS, Maurer P, et al. Pre-morbid glycemic control modifies the interaction between acute hypoglycemia and mortality. Intensive Care Med. 2016;42:562–71. Multinational multicenter observational study showing differences between the associations of dysglycemia and outcomes according to the admission HbA1c level.

    CAS  PubMed  Google Scholar 

  50. • Magee F, Bailey M, Pilcher DV, Mårtensson J, Bellomo R. Early glycemia and mortality in critically ill septic patients: Interaction with insulin-treated diabetes. J Crit Care. 2018;45:170–7. Analysis of a large database of septic patients showing different relationship between hospital mortality and highest glucose levels and glycemic variability in the first 24 h, according to the presence of insulin-treated diabetes.

    CAS  PubMed  Google Scholar 

  51. Egi M, Bellomo R, Stachowski E, et al. The interaction of chronic and acute glycemia with mortality in critically ill patients with diabetes. Crit Care Med. 2011;39:105–11.

    PubMed  Google Scholar 

  52. Roberts GW, Quinn SJ, Valentine N. Relative hyperglycemia, a marker of critical illness: introducing the stress hyperglycemia ratio. J Clin Endocrinol Metab. 2015;100:4490–7.

    CAS  PubMed  Google Scholar 

  53. Preiser JC, Lheureux O, Prevedello D. A step toward personalized glycemic control. Crit Care Med. 2018;46:1019–20.

    PubMed  Google Scholar 

  54. Plummer MP, Bellomo R, Cousins CE, et al. Dysglycaemia in the critically ill and the interaction of chronic and acute glycaemia with mortality. Intensive Care Med. 2014;40:973–80.

    CAS  PubMed  Google Scholar 

  55. • Krinsley JS, Preiser JC, Hirsch IB. Safety and efficacy of personalized glycemic control in critically ill patients: a 2-year before and after interventional trial. Endocr Pract. 2017;23:318–30. A proof-of concept clinical investigation showing an improvement of survival when a higher blood glucose target was applied in patients with chronic hyperglycemia.

    PubMed  Google Scholar 

  56. Bosarge PL, Shoultz TH, Griffin RL, Kerby JD. Stress-induced hyperglycemia is associated with higher mortality in severe traumatic brain injury. J Trauma Acute Care Surg. 2015;79:289–94.

    CAS  PubMed  Google Scholar 

  57. • Saxena A, Anderson CS, Wang X, et al. Prognostic Significance of Hyperglycemia in Acute Intracerebral Hemorrhage: The INTERACT2 Study. Stroke. 2016;47:682–8. Analysis of a large cohort of patients with intracerebral hemorrhage enrolled in an interventional trial on blood pressure management, showing an association between admission hyperglycemia, diabetes mellitus and poor nerological outcome.

    CAS  PubMed  Google Scholar 

  58. Green DM, O'Phelan KH, Bassin SL, Chang CW, Stern TS, Asai SM. Intensive versus conventional insulin therapy in critically ill neurologic patients. Neurocrit Care. 2010;13:299–306.

    CAS  PubMed  Google Scholar 

  59. Bilotta F, Caramia R, Paoloni FP, Delfini R, Rosa G. Safety and efficacy of intensive insulin therapy in critical neurosurgical patients. Anesthesiology. 2009;110:611–9.

    CAS  PubMed  Google Scholar 

  60. Meier R, Béchir M, Ludwig S, et al. Differential temporal profile of lowered blood glucose levels (3.5 to 6.5 mmol/l versus 5 to 8 mmol/l) in patients with severe traumatic brain injury. Crit Care. 2008;12:R98.

    PubMed  PubMed Central  Google Scholar 

  61. Lheureux O, Prevedello D, Preiser JC. Update on glucose in critical care. Nutrition. 2019;59:14–20. https://doi.org/10.1016/j.nut.2018.06.027.

    Article  CAS  PubMed  Google Scholar 

  62. American Diabetes Association. 15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2019;42(Supplement 1):S173–81.

    Google Scholar 

  63. • Cosson E, Catargi B, Cheisson G, Jacqueminet S, Ichai C, Leguerrier AM, et al. Practical management of diabetes patients before, during and after surgery: A joint French diabetology and anaesthesiology position statement. Diabetes Metab. 2018;44(3):200–16. A practical and updated approach of the management of diabetes before and after surgery.

    CAS  PubMed  Google Scholar 

  64. Ichai C, Preiser JC, Société Française d'Anesthésie-Réanimation, Société de Réanimation de langue Française, & Experts group. International recommendations for glucose control in adult non diabetic critically ill patients. Crit Care. 2010;14(5):R166.

    PubMed  PubMed Central  Google Scholar 

  65. Leelarathna L, English SW, Thabit H, et al. Feasibility of fully automated closed-loop glucose control using continuous subcutaneous glucose measurements in critical illness: a randomized controlled trial. Crit Care. 2013;17:R159.

    PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium

    Wasineenart Mongkolpun, Bruna Provenzano & Jean-Charles Preiser

Authors
  1. Wasineenart Mongkolpun
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bruna Provenzano
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jean-Charles Preiser
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jean-Charles Preiser.

Ethics declarations

Conflict of Interest

Wasineenart Mongkolpun and Bruna Provenzano declare that they have no conflict of interest.

Jean-Charles Preiser reports personal fees from Optiscan, Edwards Lifesciences, and Medtronic.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Hospital Management of Diabetes

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mongkolpun, W., Provenzano, B. & Preiser, JC. Updates in Glycemic Management in the Hospital. Curr Diab Rep 19, 133 (2019). https://doi.org/10.1007/s11892-019-1274-7

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11892-019-1274-7

Keywords

Search

Navigation