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OBJECTIVE -In a recent randomized controlled trial, lowering blood glucose levels to 80 -110 mg/dl improved clinical outcomes in critically ill patients. In that study, the insulin infusion protocol (IIP) used to normalize blood glucose levels provided valuable guidelines for adjusting insulin therapy. In our hands, however, ongoing expert supervision was required to effectively manage the insulin infusions. This work describes our early experience with a safe, effective, nurse-implemented IIP that provides detailed insulin dosing instructions and requires minimal physician input.RESEARCH DESIGN AND METHODS -We collected data from 52 medical intensive care unit (MICU) patients who were placed on the IIP. Blood glucose levels were the primary outcome measurement. Relevant clinical variables and insulin requirements were also recorded. MICU nurses were surveyed regarding their experience with the IIP.RESULTS -To date, our IIP has been employed 69 times in 52 patients admitted to an MICU. Using the IIP, the median time to reach target blood glucose levels (100 -139 mg/dl) was 9 h. Once blood glucose levels fell below 140 mg/dl, 52% of 5,808 subsequent hourly blood glucose values fell within our narrow target range; 66% within a "clinically desirable" range of 80 -139 mg/dl; and 93% within a "clinically acceptable" range of 80 -199 mg/dl. Only 20 (0.3%) blood glucose values were Ͻ60 mg/dl, none of which resulted in clinically significant adverse events. In general, the IIP was readily accepted by our MICU nursing staff, most of whom rated the protocol as both clinically effective and easy to use. CONCLUSIONS -Our nurse-implemented IIP is safe and effective in improving glycemic control in critically ill patients. Diabetes Care 27:461-467, 2004I n 2001, a large randomized controlled trial from Leuven, Belgium, demonstrated that normalization of blood glucose levels using an intensive insulin infusion protocol (IIP) improved clinical outcomes in patients admitted to a surgical intensive care unit (ICU) (1). In the Leuven study, intensive insulin therapy (to maintain blood glucose levels between 80 and 110 mg/dl) reduced ICU mortality by 42% and also reduced the incidence of bloodstream infections, the incidence of acute renal failure, the need for prolonged ventilatory support, and the duration of ICU stay. Strict glycemic control appears to be beneficial in other intensive care settings as well. In the DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) study (2,3), an intravenous insulin-glucose infusion (followed by an outpatient multidose subcutaneous insulin regimen) improved long-term prognosis in diabetic patients following acute myocardial infarction. In patients undergoing open heart surgery, the use of a perioperative IIP dramatically reduced the incidence of deep sternal wound infections (4).Based on this emerging clinical evidence, there are increasing efforts worldwide to maintain strict glycemic control in critically ill patients. However, achieving this goal requires exte...

Strict glycemic control improves clinical outcomes in critically ill patients. However, practical tools for frequent monitoring of blood glucose (BG) levels in the intensive care unit (ICU) are limited. The Continuous Glucose Monitoring System (CGMS, Medtronic MiniMed, Northridge, CA) is currently approved for detecting glycemic excursions in outpatients with diabetes mellitus. The use of this device has never been carefully examined in the inpatient setting. This preliminary study was designed to investigate the accuracy of the CGMS in critically ill patients admitted to a medical ICU (MICU). Subjects at risk for hyperglycemia were recruited from among all patients admitted to our MICU. CGMS sensors were implanted for up to 72 h. Study subjects wore between one and five consecutive sensors. Four or more standard capillary BG readings were recorded per 24 h. All paired meter-sensor (M-S) readings were used both for CGMS calibration and for data analysis. Twenty-two MICU patients wore 41 CGMS sensors, yielding 546 M-S BG pairs. Overall, the Pearson correlation coefficient ( r ) was 0.88, with a mean M-S difference of 3.3 +/- 26.7 mg/dL (0.6 +/- 17.4%) and a mean absolute M-S difference of 19.7 +/- 18.3 mg/dL (12.8 +/- 11.9%). Clarke Error Grid analysis categorized 98.7% of the M-S pairs within "clinically acceptable" zones A and B. The CGMS is promising for potential use in critically ill patients. If validated in larger studies, the device could serve as a useful research tool for investigating the role of hyperglycemia (and strict glycemic control) in ICU patients. If further developed as a "real-time" glucose sensor, CGMS technology could ultimately prove clinically useful in the ICU, by decreasing nursing workload and/or by providing alarm signals for impending glycemic excursions.