Management of critically ill patients with diabetes

Table 1 Factors leading to hyperglycemia and hypoglycemia in critically ill patients

Hyperglycemia[65]	Hypoglycemia[66]
Release of stress hormones (glucagon, epinephrine, cortisol, and TNF-α)	Severe sepsis
Certain medications (exogenous glucocorticoids, vasopressors, lithium, and β-blockers)	Trauma
Overfeeding	DM
Intravenous dextrose	Prior insulin treatment
Parenteral nutrition	Prior glucocorticoid treatment
Persistent bed rest	Cardiovascular failure
Increased insulin resistance (DM type 2)	Intensive glucose control
Deficient insulin secretion (DM type 1)

DM: Diabetes mellitus; TNF: Tumor necrosis factor.

Table 2 Glycemic control recommendation based on patient condition

Condition	Glucose control recommendation	Studies with patient number	Ref.
Non-diabetic ICU patients	140-180 mg/dL	29 studies with 8432 total patients and 26 studies with 13567 total patients	Wiener et al[30] (2008) and Griesdale et al[31] (2009), respectively
Diabetic ICU patients	If HbA1c < 7%: 140-180 mg/dL	1 retrospective study with 415 total patients	Egi et al[34] (2011)
	If HbA1c > 7%: > 200 mg/dL
Surgical ICU	If ICU stay is for more than 3 d, ventilator dependent, on dialysis, or with cardiac comorbidities: < 150 mg/dL	1 prospective study with 4864 total patients across 17 yr	Furnary et al[40] (2004)
Neurocritical ICU patients	If not: < 180 mg/dL	16 studies with 1258 total patients	Kramer et al[43] (2012)
	If hypoglycemia can be prevented: 110-140 mg/dL
	If not: 140-180 mg/dL
STEMI ICU patients	< 200 mg/dL	No high quality studies available Consensus by NICE	Nice Guidelines[47] (2011)
Sepsis ICU patients	< 180 mg/dL	1 randomized control trial with 6104 patients	Based of NICE-SUGAR study[17]
Pregnant ICU patients	No consensus	N/A	Van de Velde et al[55] (2013)

ICU: Intensive care unit; N/A: Not applicable; HbA1c: Glycosylated hemoglobin; NICE-SUGAR: Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation.

Table 3 Strict glycemic control vs moderate glycemic control in critically ill patients with diabetes

Ref.	Study design/cohort	Sample size	Control group	Therapies employed	Conclusion	Favored therapy
Lecomte et al[57] (2011)	Diabetics undergoing off-pump cardiac bypass surgery	60	Matched 60 non-diabetics	Strict glycemic control (80-110 mg/dL)	Strict glycemic control was feasible and efficient	Strict glycemic control
					Minimal risks for hypo- or hyperglycemia
Yuan et al[58] (2015)	Diabetic patients receiving enteral nutrition after gastrectomy	212	None	Strict glycemic control (80-110 mg/dL) and moderate glycemic control (< 200 mg/dL)	Strict glycemic control lead to higher rates of severe hypoglycemia but lower rates of severe hyperglycemia	Strict glycemic control
					Surgical site infection rate was higher with moderate glycemic control
					Rates of other complications were similar in the two groups
Umpierrez et al[59] (2015)	Diabetic patients after coronary artery bypass surgery	152	150 non-diabetics	Strict glycemic control (100-140 mg/dL) and moderate glycemic control (141-180 mg/dL)	No significant differences between the two in the rate and severity of complications	Neither
Kar et al[9] (2016)	Diabetic ICU patients with HbA1c ≥ 7.0% admission	83	None	Moderate glycemic control (< 180 mg/dL) and Loose glycemic control (< 250 mg/dL)	Loose glycemic control reduces glycemic variability and moderate to severe hypoglycemia	Loose glycemic control

ICU: Intensive care unit; HbA1c: Glycosylated hemoglobin.