Professor University of Minnesota Medical School Minneapolis, Minnesota
Disclosure(s):
Douglas B. Coursin, MD: No relevant financial relationship(s) to disclose.
Dysglycemia, including hyperglycemia, hypoglycemia, and glycemic variability, develops in most critically ill patients. Management can significantly impact outcomes and hinges on frequent, accurate glucose monitoring and effective insulin therapeutic strategies. Since the publication of the NICE-SUGAR and GLUCONTROL trials, glucose goals have been standardized for nearly all patients to intermediate levels (130-180 mg/dL). This one-size-fits-all approach has been increasingly challenged. For those without diabetes, even moderate hyperglycemia is associated with harm, including mortality. For those with poorly controlled diabetes, typical glucose targets may result in relative hypoglycemia and subsequent metabolic stress and potential harm. The move toward individualized patient glucose goals has been tempered by the risk of absolute hyperglycemia (with liberal goals), hypoglycemia (with tighter goals), and prior failures in achieving stated goals with current insulin algorithms. New technology may mitigate these risks and improve glycemic control. This session will address the physiologic rationale for, and unique risks of, individualized glucose goals, including liberalizing glucose goals in those with diabetes, and targeting tight physiologic glucose goals in those without diabetes who develop hyperglycemia. Speakers will compare and contrast the risk of acute/stress hyperglycemia with chronic hyperglycemia. The impact of relative hypoglycemia and glycemic variability will be integrated into a holistic approach to glucose targets in critically ill patients. Speakers will review newer technology including continuous glucose monitors and artificial pancreas devices in both outpatient and critical care settings for potential safe, individualized glycemic control.
Learning Objectives:
List glucose measurement technologies used in the ICU, describe their strengths, weaknesses, and risks, and describe clinical situations that decrease the accuracy of each approach
Recognize which clinical scenarios decrease accuracy or directly cause inaccuracy of continuous glucose monitors
Describe how continuous glucose meters work, how they integrate into an artificial pancreas device, and their potential benefits in the ICU, specifically their impact on hyperglycemia, hypoglycemia, and glycemic variability
Define relative hypoglycemia, list its potential negative clinical impacts in the ICU, and contrast the risk of relative hypoglycemia with that of hyperglycemia to determine an individualized glucose goal for a patient with poorly controlled diabetes
Define stress hyperglycemia in patients with and without diabetes, describe the stress hyperglycemia ratio and glycemic gap, list the risks of acute or acute-on-chronic hyperglycemia and the physiology that underlies these injuries, and contrast these risks with those of chronic hyperglycemia
