Glucose management in critically ill adults and children

Blood glucose management in people with acute myocardial infarction and critical illness has always attracted controversy. Compared with the era before 2001 when no attention was given to blood glucose management, DIGAMI-1 in 1995 and the first Leuven study in 2001 showed improved outcomes with strict control of blood glucose, thereby suggesting a causal association between hyperglycaemia and mortality risk. These landmark trials have set the standard in clinical practice that excessive hyperglycaemia is not acceptable. Multicentre trials contradicted the benefits of tight control of patients' blood glucose and results showed that different standard operating procedures for blood glucose control (eg, blood glucose meters or algorithms), divergent concomitant feeding strategies, and varying patient populations are important confounders. The general consensus now is that excessive hyperglycaemia (>10 mmol/L) and severe hypoglycaemia (<2·2 mmol/L) should be avoided in critically ill adults. If adequate blood glucose meters and clinically validated protocols for insulin-dosing are available, targeting of blood glucose concentrations to less than 8 mmol/L (moderate glycaemic control), while avoiding mild hypoglycaemia (<3·9 mmol/L), is a reasonable strategy in adult patients who are critically ill. This recommendation is not based on findings from randomised controlled trials, but merely represents a very common, pragmatic approach by physicians at the bedside. As a result of the few properly validated technologies for tighter blood glucose control, targeting blood glucose concentrations to less than 6 mmol/L is not recommended, because its risk-to-benefit ratio becomes questionable. Because blood glucose control in the target of adult ranges does not improve patient outcomes for children in the intensive care unit, glucose management in this patient population should be limited to avoid excessive hyperglycaemia (>10 mmol/L).