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Glucose Management

Glucose management is relevant to ALL critically unwell, whether they are diabetic or not.

  • Patients may be on altered feeding regimes

    • For example, continuous enteral (NG) or parenteral (IV) feeds ​

  • Critical illness is associated with both hyper- and hypoglycaemia

    • Systemic inflammation and stress response, increased metabolic demands, hepatic dysfunction, etc.​

  • Various pharmacological agents (eg. sedatives) may mask signs and symptoms of hypoglycaemia

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Standard glucose target = 6 - 12 mmol/L

  • Tight glucose targets in intensive patients are associated with worse outcomes (NICE-SUGAR trial)

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Generally, on admission to ICU, all oral hypoglycaemic agents should be ceased and sugars should be managed with short-acting insulin therapy.

As the patient improves, long acting insulin will be added and/or re-introduction of regular oral hypoglycaemic agents will occur

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Patients with new or increased insulin requirements should be referred for endocrine follow-up on discharge from ICU

Hyperglycaemia

Sliding Scale Insulin Regime

  • Interval insulin boluses titrated to target BSL

  • Agent - Novorapid

  • Route - subcutaneous

  • Timing:

    • QID for continuous feeding regimes​

    • TDS with meals for ward diet

  • Dose

    • Regime:​

      • ​​BSL 12.1 - 15 --> 2 - 4 units​

      • BSL 15.1 - 18 --> 4 - 6 units

      • BSL > 18 --> 8 - 10 units AND medical team should be notified​

    • In insulin naive patients, start low

    • In patients with pre-existing insulin resistance, larger dosing regimes may be required

      • Always err on side of caution; additional insulin may be given if required​

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Long Acting Insulin

  • Basal insulin regime

    • Provides 24 hour background insulin​

    • Often used to transition from insulin infusion in the critically ill​

  • Agent - Lantus

  • Route - subcutaneous

  • Dose:

    • 30 - 60% of 24 hour total dose of short acting insulin

    • Start low and up-titrate as necessary

    • Short-acting insulin doses should be adjusted down accordingly

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Insulin Infusion

  • Allows rapid and fine control of plasma glucose levels

  • Commence infusion if 2 consecutive BSLs > 12

    • Check with ICU registrar prior to commencing insulin infusion​

  • Agent - Actrapid

  • Route - Intravenous

  • Dose:

    • Titrated to target BSL as per protocol​

    • Must always be run concurrently with dextrose infusion unless patient is receiving continuous enteral feeds or TPN

  • Cessation of an infusion may require transition to alternative insulin therapy

    • In patients with T1DM, ​long acting insulin should be commenced 2 - 4 hours PRIOR to cessation of infusion to avoid development of DKA

    • In patients without T1DM:​

      • Commencement of PRN sliding scale following cessation may be adequate​

      • If insulin requirements are high (> 4 units/hr) or patient is normally on some form of insulin, long acting insulin may also be necessary

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Hypoglycaemia

Hypoglycaemia is considered a BSL < 3.5 - 4 mmol/L (although there is no strict cut-off)

  • Severe hypoglycaemia = BSL < 3.0 mmol/L

  • In patients with chronic hyperglycaemia, relative hypoglycaemia may even occur at levels in the 4s and 5s

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New altered conscious state or delirium should always prompt a check of blood sugar levels

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Management:

  • If conscious and able to swallow:

    • Glucogel 15 - 20g AND/OR 150ml juice (make sure it is not sugar free!)​

    • Slow release complex carbohydrate; eg. sandwhich

      • In addition to the fast-acting sugar​

  • If not able to swallow or severe hypoglycaemia:

    • 25 - 50ml 50% dextrose IV (12.5 - 25g glucose) +/- commence dextrose infusion​

    • Glucagon 1 - 2 mg IM, if no intravenous access​

  • BSL should be checked at 15 minutes, 1 hour and 4 hours

    • Repeat treatment if BSL remains < 4​ mmol/L

  • Ensure patient is receiving ongoing source of glucose to prevent recurrence

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       Author: Ryan Slack, Peer Reviewer: Irma Bilgrami Date: 02/04/20

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