Leave Them Alone! Liberal Glucose Goals for Patients With Chronic Hyperglycemia

Standardized, intermediate glucose targets in the critically seek to balance the risk of hyperglycemic injury, including infections and multi-organ system dysfunction, to the risk of treatment-induced hypoglycemia, reported to be associate with increased mortality. The “optimal” glucose target, however, remains ill-defined and is likely patient- and time-specific.  Patients who have chronic hyperglycemia and poorly controlled diabetes have been found to have metabolic markers of stress with relative hypoglycemia – glucose more than 30% below their baseline glycemia.  Meanwhile, hyperglycemic injury appears to occur less frequently in this cohort.  Accordingly, several trials have investigated liberalized glucose targets in the critically ill.  These efforts have shown a lower incidence of hypoglycemia, decreased relative hypoglycemia, and no other difference in outcome, suggesting that the strategy is safer and without harm.  Guidance will be offered towards consideration of this therapeutic strategy including patient selection by medical history and by current illness state.