Start an insulin protocol when glucose is persistently ≥ 180 mg/dL, titrate to 140-200 mg/dL (not 80-139), monitor at least hourly while unstable, and treat hypoglycaemia immediately.
At the bedside
Timed steps- 1
≥ 180 mg/dL twice
TriggerTwo consecutive values ≥ 180 mg/dL (10 mmol/L): review glucose sources (dextrose, feeds, steroids) and start an IV insulin protocol.
- 2
140-200 mg/dL
TargetSCCM 2024 suggests against an 80-139 mg/dL target because of hypoglycaemia. NICE-SUGAR (81-108 mg/dL) increased 90-day mortality (27.5% vs 24.9%).
- 3
IV infusion
RouteContinuous IV insulin with an explicit decision-support protocol rather than SC sliding scales in unstable patients.
- 4
≤ 1 hourly
MonitorHourly checks during instability; arterial or venous samples on a blood-gas analyser are more accurate than capillary meters in shock or oedema.
- 5
When stable and eating
TransitionBasal-bolus SC insulin, ~60-80% of the stable 24-h IV requirement, basal overlapping 1-2 h before stopping infusion.
References
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ICU hyperglycaemia
Step 1 of ~3
Decision: Persistent on repeat?
Based on Honarmand K, Sirimaturos M, Hirshberg EL, et al. Educational use; follow local protocol.
Evidence
- NICE-SUGAR 2009 (n = 6104): intensive 81-108 mg/dL increased mortality and severe hypoglycaemia.
- TGC-fast 2023 (n = 9230): tight control without early parenteral nutrition: no difference in ICU dependency or mortality.
- SCCM 2024: suggest against 80-139 mg/dL; target 140-200 mg/dL.
Controversies
- Individualised targets based on HbA1c (higher targets in chronic poor control) are promising but unproven.
🇮🇳 India notes
- Nursing workload and cost of strips limit hourly checks; a written nurse-driven protocol with blood-gas glucose is a practical compromise.
References
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Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.