Management of dysglycemia in critically ill adults: current evidence, clinical practice and future directions

Hyperglycemia is among the most common metabolic disturbances in critically ill patients, affecting up to 50% of adults admitted to intensive care units (ICUs), regardless of pre-existing diabetes. Both diabetes and stress-induced hyperglycemia are associated with increased risk of organ dysfunction, healthcare-associated infections, prolonged mechanical ventilation, longer ICU and hospital length of stay, and mortality. Clinical guidelines recommend initiating intravenous insulin therapy when blood glucose remains ≥180 mg/dL (10.0 mmol/L) and targeting 140–180 mg/dL (7.8–10.0 mmol/L) for most critically ill adults. Recent advances in continuous glucose monitoring, computerized insulin dosing algorithms, automated insulin delivery systems and artificial intelligence-enabled clinical decision support are transforming glucose management in the ICU and have the potential to improve safety and efficiency. This review summarizes current understanding of the pathophysiology of stress hyperglycemia, the clinical consequences of dysglycemia, contemporary glucose targets, insulin therapy and glucose monitoring strategies. We also highlight emerging technologies, special patient populations and future directions expected to shape precision glycemic management for critically ill adults.