Critical Care Scenarios Lightning rounds 60: The nuances of insulin, with Melissa Nestor
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Feb 11, 2026 Melissa Nestor, a clinical pharmacist in neurocritical care, explains glucose and insulin management in the ICU. She covers who needs monitoring and the role of A1C on admission. Topics include when to escalate to infusions, pros and cons of sliding scale versus scheduled or basal insulin, and safety-first tactics to prevent hypoglycemia.
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Why Non‑Diabetics Get Fingersticks In The ICU
- Many non-diabetic ICU patients still need glucose monitoring because stress, steroids, and altered feeding commonly cause hyperglycemia.
- Melissa Nestor cites steroids, cortisol response, and continuous tube feeds as routine ICU drivers of new hyperglycemia.
Order A1C Early To Guide Acute And Outpatient Plans
- Get an A1C on admission when starting insulin to distinguish chronic hyperglycemia from acute stress hyperglycemia.
- A1C helps decide intensity, need for endocrine follow-up, and whether high sugars are baseline (eg A1C 11% suggests outpatient insulin needs).
ICU Targets Are More Permissive After NICE‑SUGAR
- ICU glycemic targets shifted from tight control (80–110) to more permissive ranges due to hypoglycemia risk.
- Melissa references NICE-SUGAR guidance and suggests 140–180 as the common ICU target window now.