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Guidelines on Glycemic Control for Critically Ill Children and Adults
Citation: Honarmand K, Sirimaturos M, Hirshberg E, et al. Society of Critical Care Medicine guidelines on glycemic control for critically ill children and adults 2024. Crit Care Med. Online special article. January 19, 2024. doi: 10.1097/CCM.0000000000006174.
RATIONALE: Maintaining glycemic control of critically ill patients may impact outcomes such as survival, infection, and neuromuscular recovery, but there is equipoise on the target blood levels, monitoring frequency, and methods.
OBJECTIVES: To update the 2012 Society of Critical Care Medicine (SCCM) and American College of Critical Care Medicine (ACCM) guidelines with a new systematic review of the literature and provide actionable guidance for clinicians.
PANEL DESIGN: The 22-member multiprofessional panel, consisting of clinicians, patient/family advocates, and a methodologist, applied the processes described in the ACCM guidelines standard operating procedure manual to develop evidence-based recommendations in alignment with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach methodology. Conflict-of-Interest policies were strictly followed in all phases of guidelines development, including panel selection and voting.
METHODS: The panel conducted a systematic review for each population, intervention, comparison, outcome (PICO) question related to glycemic management in critically ill children (aged ≥ 42 week adjusted gestational age to 18 years) and adults, including triggers for initiation of insulin therapy, route of administration, monitoring frequency, role of an explicit decision support tool for protocol maintenance, and methodology for glucose testing. The panel identified the best available evidence, statistically summarized the evidence, and assessed the quality of evidence using the GRADE approach. The panel used the evidence-to-decision framework to formulate recommendations as strong or weak or as a best practice statement. In addition, “in our practice” statements were included when the available evidence was insufficient to support a recommendation but the panel members felt that describing their practice patterns may be appropriate. Additional topics were identified for future research.
RESULTS: This guideline is an update of the guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. It is intended for adult and pediatric practitioners to reassess current practices and direct research into areas for which literature is inadequate. The panel issued seven statements related to glycemic control in unselected adults (two best practice statements, four conditional recommendations, one research statement) and seven statements for pediatric patients (two best practice statements, one strong recommendation, one conditional recommendation, two “in our practice” statements, and one research statement), with additional detail on specific subset populations, where available.
CONCLUSION: The panel achieved consensus for adults and children regarding a preference for an insulin infusion for the acute management of hyperglycemia with titration guided by an explicit clinical decision support tool and frequent (≤ 1 hour) monitoring intervals during glycemic instability to minimize hypoglycemia and against targeting intensive glucose levels. These recommendations are intended for consideration within the framework of the patient’s existing clinical status. Further research is required to evaluate the role of individualized glycemic targets, continuous glucose monitoring systems, explicit decision support tools, and standardized glycemic control metrics.
KEYWORDS: adult; continuous glucose monitoring; critical illness; decision support; diabetes mellitus; glucose; hyperglycemia; hypoglycemia; insulin; pediatric
Guideline Type: Administrative
Section:
Strength:
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Clinicians should initiate glycemic management protocols and procedures to treat persistent hyperglycemia ≥ 10 mmol/L (180 mg/dL) in critically ill adults.
Clinicians should use glycemic management protocols and procedures that demonstrate a low risk of hypoglycemia among critically ill adults and should treat hypoglycemia without delay.
Based on available RCT data, in critically ill adults, we suggest against titrating an insulin infusion to a lower BG target INT: 4.4-7.7 mmol/L (80-139 mg/dL) as compared to a higher BG target range, CONV: 7.8-11.1 mmol/L (140-200 mg/dL) to reduce the risk of hypoglycemia.
Quality of evidence: Moderate
Observational data suggest a potential benefit of personalized glucose targets that more closely match chronic prehospital glycemic control. We recommend high-quality interventional trials of individualized glycemic targets in critically ill adults, stratified by prior glycemic control.
We suggest using continuous IV insulin infusion rather than intermittent subcutaneous insulin in the acute management of hyperglycemia in critically ill adults.
Quality of evidence: Very low
We suggest frequent (≤ 1 hour, continuous or near-continuous) glucose monitoring compared with monitoring at intervals greater than hourly in the management of hyperglycemia in critically ill adults on IV insulin during periods of glycemic instability.
Quality of evidence: Low
We suggest use of a protocol that includes explicit decision support tools over a protocol with no such tools in critically ill adults receiving IV insulin infusions for the management of hyperglycemia.
Quality of evidence: Moderate
Clinicians should initiate glycemic management protocols and procedures to treat persistent hyperglycemia, ≥ 10 mmol/L (180 mg/dL) in critically ill children.
Clinicians should use glycemic management protocols and procedures that demonstrate a low risk of hypoglycemia among critically ill children and should treat hypoglycemia without delay.
We recommend against intensive (INT) BG control, 4.4-7.7 mmol/L (80-139 mg/dL) as compared to conventional (CONV) BG control, 7.8-11.1 mmol/L (140-200 mg/dL) in critically ill children (defined by the pediatric panel as ≥ 42 weeks adjusted gestational age).
Quality of evidence: Moderate
We make no recommendation regarding the use of continuous IV infusion for insulin therapy over intermittent subcutaneous insulin in the acute management of hyperglycemia in critically ill pediatric patients in whom insulin therapy is indicated. However, in our practice, our pediatric expert panel members use continuous IV infusion over intermittent subcutaneous insulin in critically ill pediatric patients with hyperglycemia.
We make no recommendation regarding frequent BG monitoring (interval ≤ 1 hour, continuous or near-continuous) or less frequent (> 1 hour) in pediatric critically ill patients on insulin infusion therapy. However, in our practice we almost always use frequent (interval ≤ 1 hour) or continuous or near-continuous monitoring systems (if available) in children being treated with insulin infusion therapy.
We suggest the use of explicit decision support tools over no such tools in critically ill pediatric patients receiving IV insulin infusions for the management of hyperglycemia.
Quality of evidence: Low
We strongly recommend high-quality research on the use of explicit decision support tools for insulin infusion titration in pediatric patients.
The panel is unable to provide a specific statement due to inconsistent methodologies and reporting among comparative studies, but we recognize the need for timely results in a clinical setting.
Quality of evidence: Very low
A complete list of the guidelines authors and contributors is available within the published manuscript.
