Perioperative glycemic management in 2011: paradigm shifts

The publication of Van den Berghe's landmark study in 2001 supported the use of intensive insulin therapy (IIT) to target normoglycemia in the critically ill and triggered a new era in glycemic management in the perioperative period and in the ICU. In 2009, the normoglycemia in intensive care evaluation-survival using glucose algorithm regulation (NICE-SUGAR) trial demonstrated increased mortality and incidence of hypoglycemia in patients managed with IIT, resulting in a shift toward higher blood glucose targets in this patient population. This review distills clinically pertinent principles from the related literature published in the months since the NICE-SUGAR trial.

A target blood glucose level in the acute care setting supported by many of the pertinent societies and frequently quoted in the literature is 140-180 mg/dl. Hyperglycemia, hypoglycemia, and glucose variability are detrimental. Accurate and efficient glucose monitoring devices are essential. Insulin infusion protocols (IIPs) employed to achieve desired blood glucose targets must be individualized and validated for the ICU and institution in which they are being implemented.

Appropriate glycemic management in the acute care setting can be achieved by targeting a reasonable blood glucose range and employing specific and institutionally validated IIPs.