1. Glycemic Control in the ICU
Steven Podnos MD

2. Hyperglycemia
• Occurs in up to 50% of ICU patients due to
underlying DM , steroids, and/or stress of
illness
• Is a MARKER of worse outcomes in many
different ICU illnesses

3. Control of Glucose in ICU
• One early study (van den Berghe) found a
decreased mortality with intensive control of
glucose (IIT), but was limited to Cardiac
Surgery patients , often on TPN
• Two large recent trials of IIT were stopped due
to 1) lack of benefit with IIT and 2) increased
hypoglycemia

4. Stress Hormones and Hyperglycemia
• Glucagon,Glucocorticoids,Norepinephrine
• Epinephrine
• Tumor Necrosis factor
• All these hormones are secreted with stress
of illness and produce elevated glucose
through various methods

5. Ill Effects of Hyperglycemia
• Direct Immune suppression
• Excess insulin causes cellular damage
• Direct cellular toxicity and release of
inflammatory mediators in presence of
hyperglycemia

6. Hypoglycemia
• Brain requires adequate glucose levels or
coma/death results in minutes

7. Why is Consensus Changing?
• Early studies suggested benefit to Intensive
Insulin Therapy (IIT)
• Later studies do not-some show harm from
hypoglycemia and no mortality benefit
• Studies differ in many variables: SICU vs
MICU, parenteral vs enteral nutrition, degree
of illness (APACHE 2 scores), intensity of
control
• More studies pending

8. Recommendations
• Current consensus seems to be liberalizing
glucose control to 140-180.
• Evidence weak of benefit
• Some suggest it is swings in glucose levels that
may be harmful rather than absolute levels.
• May be more appropriate to use constant
insulin drip to keep levels higher than sliding
scale which has more glucose fluctuations
(unproven)