RATIONALE: Maintaining glycemic control of critically ill patients may impact outcomes such as survival, infection, and neuromuscular recovery, but there is equipoise on the target blood levels, monitoring frequency, and methods.

OBJECTIVES: The purpose was to update the 2012 Society of Critical Care Medicine and American College of Critical Care Medicine (ACCM) guidelines with a new systematic review of the literature and provide actionable guidance for clinicians.

PANEL DESIGN: The total multiprofessional task force of 22, consisting of clinicians and patient/family advocates, and a methodologist applied the processes described in the ACCM guidelines standard operating procedure manual to develop evidence-based recommendations in alignment with the Grading of Recommendations Assessment, Development, and Evaluation Approach (GRADE) methodology. Conflict of interest policies were strictly followed in all phases of the guidelines, including panel selection and voting.

METHODS: We conducted a systematic review for each Population, Intervention, Comparator, and Outcomes question related to glycemic management in critically ill children (≥ 42wk old adjusted gestational age to 18 yr old) and adults, including triggers for initiation of insulin therapy, route of administration, monitoring frequency, role of an explicit decision support tool for protocol maintenance, and methodology for glucose testing. We identified the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as a good practice statement. In addition, “In our practice” statements were included when the available evidence was insufficient to support a recommendation, but the panel felt that describing their practice patterns may be appropriate. Additional topics were identified for future research.

RESULTS: This guideline is an update of the guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. It is intended for adult and pediatric practitioners to reassess current practices and direct research into areas with inadequate literature. The panel issued seven statements related to glycemic control in unselected adults (two good practice statements, four conditional recommendations, one research statement) and seven statements for pediatric patients (two good practice statements, one strong recommendation, one conditional recommendation, two “In our practice” statements, and one research statement), with additional detail on specific subset populations where available.

CONCLUSIONS: The guidelines panel achieved consensus for adults and children regarding a preference for an insulin infusion for the acute management of hyperglycemia with titration guided by an explicit clinical decision support tool and frequent (≤ 1hr) monitoring intervals during glycemic instability to minimize hypoglycemia and against targeting intensive glucose levels. These recommendations are intended for consideration within the framework of the patient’s existing clinical status. Further research is required to evaluate the role of individualized glycemic targets, continuous glucose monitoring systems, explicit decision support tools, and standardized glycemic control metrics.

依据：维持重症患者的血糖控制可能会影响结局，如生存期、感染和神经肌肉恢复，但在目标血液水平、监测频率和方法方面存在平衡。

目的：目的是使用新的文献系统综述更新2012年重症医学学会和美国重症医学学会(ACCM)指南，并为临床医生提供可操作的指导。

小组设计：由临床医生和患者/家属倡导者以及一名方法学家组成的22名多专业工作组应用ACCM指南标准操作规程手册中描述的过程，根据推荐分级评估、开发和评价方法(GRADE)方法制定基于证据的建议。准则的所有阶段都严格遵守利益冲突政策，包括小组选择和投票。

方法：我们对危重儿童（≥42周龄，调整胎龄至18岁）和成人的血糖管理相关的每个人群、干预、对照和结局问题进行了系统回顾，包括胰岛素治疗的启动诱因、给药途径、监测频率、明确的作用方案维护的决策支持工具和血糖测试方法。我们确定了最佳可用证据，对证据进行了统计学总结，然后使用GRADE方法评估了证据的质量。我们使用证据到决策框架来提出强弱或良好做法声明的建议。此外，当现有证据不足以支持建议时，纳入了“在我们的实践中”声明，但小组认为描述其实践模式可能是适当的。确定了用于未来研究的其他主题。

结果：本指南是对使用胰岛素输注管理重症患者高血糖症的指南的更新。预期供成人和儿科执业医师重新评估当前实践，并指导对文献不足领域的研究。专家小组发布了7项关于非选择性成人血糖控制的声明（2项良好实践声明、4项条件性建议、1项研究声明）和7项关于儿科患者的声明（2项良好实践声明、1项强烈建议、1项条件性建议、2项“在实践中”声明和1项研究声明），并提供了特定亚组人群的更多详细信息（如可用）。

结论：在成人和儿童中达成了共识，即在急性高血糖管理中首选胰岛素输注，在明确的临床决策支持工具指导下进行滴定，并在血糖不稳定期间频繁(≤1h)监测间隔，以尽量减少低血糖，并针对强化血糖水平。这些建议预期在患者现有临床状态的框架内考虑。需要进一步的研究来评估个体化血糖目标、动态血糖监测系统、明确的决策支持工具和标准化血糖控制指标的作用。