Key Principles

• Avoidance of hypoglycaemia is of paramount importance as this has been associated with worse outcomes in critically ill patients.

• Hyperglycaemia in critically ill patients is very common and may be associated with a pre-existing diagnosis of Diabetes Mellitus or may represent a stress response to critical illness.

• Avoidance of hyperglycaemia is desirable and the treatment of blood glucose above which insulin should commence is 10 mmol/L with a target range of 6.0-10 mmol/L.

• Minimising glucose variability and increasing time in target range are important secondary targets.

INFO

It is likely that patients should have an individualised glucose target according to their history of diabetes, chronic glucose control and the nature of their presenting critical illness. However, until future randomised controlled trials are available, the best evidence supports using a “conventional” rather than intensive treatment strategy with a focus on avoiding hypoglycaemia and glycaemic variability.

• Treatment with insulin infusions is often required to treat hyperglycaemia. These infusions are associated with a risk of hypoglycaemia and are a common cause of reported drug errors. The use of a dynamic insulin infusion calculator is recommended to minimise the risk of error and reduce the incidence of hypoglycaemia.

• All patients should have their HBA1c checked on admission to Critical Care.

• There is an increasing prevalence of type 2 diabetes in the population and with it recent advances in novel antidiabetic agents that may have specific risks and benefits for the critically ill patient. For instance, the use of sodium–glucose-co-transporter 2 (SGLT-2) has an associated risk of euglycaemic ketoacidosis. These guidelines aim to provide guidance on the use of these agents in critical care.

• Critically ill patients have unpredictable absorption of subcutaneous insulin and this may pose a risk of both under- and over-dosing of insulin.