The Society of Critical Care Medicine on January 19th released its updated guidelines for the management of blood glucose levels in critically ill children and adults. These guidelines are the first update since the society’s 2012 recommendations.
Below, Dr. Erik Van Eaton, a surgical intensivist at the University of Washington, provides TransformativeMed’s take on the key recommendations and provides additional commentary in support of using an electronic glycemic management system with appropriate features to achieve better outcomes.
Specific questions addressed by the Society in this review include:
When to initiate insulin therapy
The guidelines recommend initiating your glycemic management strategy when a critically ill patient’s blood glucose persists at or above 180 mg/dL. The guidelines specifically emphasize using glycemic management protocols and procedures that demonstrate a low risk of hypoglycemia among critically ill adults.
Our take: High-reliability healthcare systems should use multiple methods for blood glucose surveillance to promptly intervene on persistent hyperglycemia. The EHR should provide easy-to-use, customizable views of patient blood glucose levels across multiple types of groups: dashboards for entire facilities, geographical units, service lines, provider teams, as well as individual patient data.
Whether to pursue an intensive or conventional glucose target
These guidelines reflect the ongoing, national efforts to reduce hypoglycemia events. Some prior randomized trials demonstrated improved outcomes among specific populations of critically ill adults when intensive insulin protocols were used to target lower blood glucose levels. These 2024 guidelines “suggest against” titrating insulin infusions among unselected or mixed critically ill adults to lower blood glucose targets (80-139 mg/dL) in favor of more conventional goals (140-200 mg/dL).
Our take: Good adherence with these guidelines emphasizes the need for tools that support organizations in adjusting their protocols in such a way that they can minimize hypoglycemia. Different protocols might work better for different patient populations. In addition, the flexibility to pursue tighter glycemic ranges in carefully monitored patient populations also requires protocol flexibility. High-reliability healthcare organizations should implement a system that provides this flexibility.
For acute management, should insulin be initiated as a continuous IV infusion or as intermittent subcutaneous dosing?
The evidence here is lacking, as studies in support of starting with an insulin infusion had very small sample sizes. The guidelines “suggest” starting with an IV insulin infusion. The support for this leans heavily on the assumption that in the ICU, the resource cost of either method is similar and that IV insulin is probably more predictable in critically ill patients who are likely to have poor peripheral circulation and varying levels of anasarca that can confound reliable subcutaneous uptake.
Our take: The best practice for glycemic control in the acute care setting is to use a system that reliably supports either continuous insulin infusions or subcutaneous basal-bolus therapy so selection can depend on the patient and not on the system. A single system with a familiar design across both therapy modalities is easier to teach, easier to use, and more reliable when patient volumes stretch bedside resources.
How often to monitor blood glucose levels
This question also did not have enough high-quality evidence for a strong recommendation. They “suggest” using continuous or near-continuous (≤ 1 hour intervals) monitoring during periods of glycemic instability. The interval between blood glucose checks for critically ill patients with stable blood sugar levels can probably be longer, but again the guidelines warn about the risk of undetected hypoglycemia if longer intervals between testing are used. The ADA and AACE suggest monitoring patients with stable glucose levels every 30 minutes to 2 hours while on insulin infusions. The panel specifically points out that Continuous Glucose Monitoring, while quickly gaining acceptance among ambulatory diabetic patients, is not ready for routine use among hospitalized patients as this requires regulatory approval, training, and system integration.
Our take: One of the important considerations when updating or creating a holistic management plan for glycemic control in the hospital is minimizing steps. To free bedside resources for intensive monitoring, we advise health systems reject processes and tools that require additional data entry, or any additional work outside the EHR environment. Fully embedded functionality that aggregates data is critical.
Whether to use explicit clinical decision support tools
The panel included a table in the guidelines that sets out the minimum requirements for “Explicit Decision Support Tools for Glycemic Management.” The key criteria include the following: that the bedside clinician knows exactly what to do with each blood glucose level and that those actions are reproducible across patients with the same situation; that the system uses two or more patient-specific input variables and produces two or more output variables; and that the system allows the clinician to agree or disagree with the system’s recommendation.
Our take: The last of these five minimum requirements is critical. When health systems evaluate their glycemic management strategy, they should critically evaluate the EHR tools they provide to their front-line workers. Because conditions may exist outside the collection of data in the EHR that trained bedside clinicians recognize, there must be affordances in the decision support system to permit full visibility to the reasoning behind a dose recommendation and the ability to adjust or override that recommendation.
