ABSTRACT
David
C. Klonoff, M.D., FACP
Intensive insulin therapy (IIT) for
hyperglycemia in critically ill patients has become a standard practice. Target
levels for glycemia have fluctuated since 2000, as evidence initially indicated
that tight glycemic control to so-called normoglycemia (80–110 mg/dl) leads to
the lowest morbidity and mortality without hypoglycemic
complications. Subsequent studies have
demonstrated minimal clinical benefit combined with greater hypoglycemic
morbidity and mortality with tight glycemic control in this population. The
consensus glycemic targets were then liberalized to the mid 100s (mg/dl).
Handheld POC blood glucose (BG) monitors have
migrated from the outpatient setting to the hospital environment because they
save time and money for managing critically ill patients who require IIT. These
devices are less accurate than hospital-grade POC blood analyzers or central
laboratory analyzers.
Three questions must be answered to understand
the role of IIT for defined populations of critically ill patients: (1) How
safe is IIT, with various glycemic targets, from the risk of hypoglycemia? (2)
How tightly must BG be controlled for this approach to be effective? (3) What
role does the accuracy of BG measurements play in affecting the safety of this
method? For each state of impaired glucose regulation seen in the hospital,
such as hyperglycemia, hypoglycemia, or glucose variability, the benefits,
risks, and goals of treatment, including IIT, might differ.
With improved accuracy of BG monitors, IIT
might be rendered even more intensive than at present, because patients will be
less likely to receive inadvertent overdosages of insulin. Greater doses of
insulin, but with dosing based on more accurate glucose levels, might result in
less hypoglycemia, less hyperglycemia, and less glycemic variability. (J Diabetes Sci Technol 2011;5(3):755-767)
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