A 65-year-old woman with a history of chronic obstructive pulmonary disease (COPD) is brought to the intensive care unit after being intubated for respiratory failure. She initially presented to the emergency department with severe respiratory distress, fever, chills, and productive cough. She smokes 1 pack of cigarettes per day and has been intubated in the past for COPD exacerbation. Her other medical problems include hypertension, coronary artery disease, congestive heart failure, and colonic diverticulosis. She has no history of diabetes mellitus.
Her leukocyte count is 15,000 cells/µL and her serum creatinine is 1.2 mg/dL. Liver function tests are within normal limits. Chest x-ray shows bilateral lower lobe infiltrates. She is started on high-dose methylprednisolone, inhaled bronchodilators, and antibiotics. Over the following 12 hours, her fingerstick blood glucose levels ranged from 210 to 280 mg/dL.
Which of the following is the most appropriate next step in management?

Question

A 65-year-old woman with a history of chronic obstructive pulmonary disease (COPD) is brought to the intensive care unit after being intubated for respiratory failure.  She initially presented to the emergency department with severe respiratory distress, fever, chills, and productive cough.  She smokes 1 pack of cigarettes per day and has been intubated in the past for COPD exacerbation.  Her other medical problems include hypertension, coronary artery disease, congestive heart failure, and colonic diverticulosis.  She has no history of diabetes mellitus.
Her leukocyte count is 15,000 cells/µL and her serum creatinine is 1.2 mg/dL.  Liver function tests are within normal limits.  Chest x-ray shows bilateral lower lobe infiltrates.  She is started on high-dose methylprednisolone, inhaled bronchodilators, and antibiotics.  Over the following 12 hours, her fingerstick blood glucose levels ranged from 210 to 280 mg/dL.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

Hyperglycemia is common in critically ill, non-diabetic patients in the intensive care unit (ICU), and is associated with poor clinical outcomes in medical, surgical, and trauma patients. Uncontrolled hyperglycemia (glucose > 180-200 mg/dL) should be controlled in the ICU setting, but the exact levels for optimal glucose control are unknown. Intensive glucose control (glucose 80-110 mg/dL) has not consistently improved mortality and morbidity, and may be associated with severe hypoglycemia. Current guidelines recommend using insulin infusions to achieve a target blood glucose level of 140-180 mg/dL along with frequent blood glucose monitoring to avoid marked hyperglycemia and/or hypoglycemia. (Choice A) Intensive glucose control (target blood glucose level of 80-110 mg/dL) is associated with an increased incidence of severe hypoglycemia without added survival benefit when compared to a target blood glucose level of 140-180 mg/dL. (Choice C) Hyperglycemia in the course of acute illness was previously thought to be the result of an adaptive response and was not routinely treated in ICU patients. However, recent evidence suggests that blood glucose levels exceeding 180 mg/dL are associated with poor clinical outcomes (e.g., infections, critical illness myopathy) in critically ill patients. (Choice D) Oral agents are contraindicated in patients who are not eating. Metformin should also be used cautiously in patients with impaired or borderline renal function, which is common in critically ill ICU patients. (Choice E) Insulin infusion allows the most accurate titration of blood glucose and can be quickly discontinued in cases of hypoglycemia. Subcutaneous insulin in ICU patients may be associated with wide swings in glucose levels and increases the risk of hypoglycemic and hyperglycemic events. Educational objective: Hyperglycemia in critically ill ICU patients is associated with poor outcomes. Glucose levels of 140-180 mg/dL are currently recommended to avoid extremes of hyperglycemia or hypoglycemia, and are only achievable with insulin infusions and frequent glucose checks. __________ References: Glucose control in the intensive care unit: a roller coaster ride or a swinging pendulum (http://www.ncbi.nlm.nih.gov/pubmed/19487715) Blood glucose control in the intensive care unit: benefits and risks (http://www.ncbi.nlm.nih.gov/pubmed/20525106)

A 65-Year-Old Woman with a History of Chronic Obstructive Pulmonary