Description and Evaluation of a Glycemic Management Protocol for Patients with Diabetes Undergoing Heart Surgery

Markovitz, Lawrence J.; Wiechmann, Robert J.; Harris, Natalie; Hayden, Vicky; Cooper, Joseph B.; Johnson, Gilbert H.; Harelstad, Randy; Calkins, Lu; Braithwaite, Susan S.

doi:10.4158/ep.8.1.10

Cited by 139 publications

(59 citation statements)

References 11 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Not surprisingly, it is the intravenous drip orders from which Glucommander was developed. A close match is the intravenous insulin protocol of Markovitz et al (16).…”

Section: Figure 3-the Means and Sds Of The Data From All Glucommandermentioning

confidence: 99%

See 1 more Smart Citation

Glucommander

2005

View full text Add to dashboard Cite

OBJECTIVE -Intravenous insulin is now the recommended method of diabetes management in critically ill persons in the hospital. The published methods for administering the insulin are complex and are usually limited to intensive care units with a low patient-to-nurse ratio. RESEARCH DESIGN AND METHODS-A computer-directed algorithm for advice on the delivery of intravenous insulin that is flexible in blood glucose timing and advises insulin dosing in a graduated manner has been developed. This software program, known as the Glucommander, has been used extensively by our group. The data were analyzed for this study.RESULTS -The data from 5,080 intravenous insulin runs over 120,683 h show that blood glucose levels can be safely stabilized in a target range without significant hypoglycemia by nonspecialized nurses working on any unit of a general hospital. The mean glucose level reached Ͻ150 mg/dl in 3 h. Only 0.6% of all glucose values were Ͻ50 mg/dl. The prevalence of hypoglycemia Ͻ40 mg/dl was 2.6% of all runs. No hypoglycemia was severe.CONCLUSIONS -This computer-directed algorithm is a simple, safe, effective, and robust method for maintaining glycemic control. It has been extensively studied and is applicable in a wide variety of conditions. In contrast to other published intravenous insulin protocols, which have been limited to intensive care units, Glucommander can be used in all units of any hospital. Diabetes Care 28:2418 -2423, 2005A large, randomized, controlled trial of patients admitted to a surgical intensive care unit in Leuven, Belgium, and reported by Van den Berghe et al. (1) showed that regulation of blood glucose levels to Ͻ110 mg/dl using an intravenous insulin protocol improved clinical outcomes. In the Leuven study, intensive insulin therapy reduced intensive care unit (ICU) mortality by 34% and also reduced sepsis, the need for dialysis, prolonged ventilator support, and the duration of ICU stay.Strict glycemic control has been demonstrated to be beneficial in other settings as well, with intravenous insulin in preference to the subcutaneous route in many clinical situations, including diabetic ketoacidosis and the nonketotic hyperosmolar state (2), critical care illness (1), myocardial infarction or cardiogenic shock (3-5), and the postoperative period after cardiac surgical procedures (6). Other indications for intravenous insulin infusion therapy include use in patients with diabetes who are receiving nothing by mouth, general perioperative care, total parental nutrition, or high-dose corticosteroid therapy; in patients who have had a stroke; in women during labor and delivery; as a dose-finding strategy in anticipation of initiation of subcutaneous insulin; and in prevention or treatment of infection.Based on the emerging clinical evidence, there are widespread efforts to maintain very strict glycemic control in critically ill patients. However, achieving this goal requires extensive nursing efforts, including frequent bedside capillary glucose monitoring and the implementation of compl...

show abstract

“…Not surprisingly, it is the intravenous drip orders from which Glucommander was developed. A close match is the intravenous insulin protocol of Markovitz et al (16).…”

Section: Figure 3-the Means and Sds Of The Data From All Glucommandermentioning

confidence: 99%

“…With Glucommander as the standard, the set of other protocols show little agreement during the first 5 h in the treatment of a patient who is very hyperglycemic and is typical of patients seen clinically (1,3,6,8,(12)(13)(14)(15)(16)(17)(18)(19)(20). This analysis is presented as Fig.…”

Section: Figure 3-the Means and Sds Of The Data From All Glucommandermentioning

confidence: 99%

Glucommander

2005

View full text Add to dashboard Cite

show abstract

“…The intravenous insulin therapy protocol was a modified version of the Markovitz protocol (13), and the subcutaneous insulin protocol incorporated basal, nutritional, and corrective insulin (14). In the TRIUMPH units, intravenous insulin infusion was initiated when the measured glucose was Ͼ140 mg/dl.…”

mentioning

confidence: 99%

Economic Benefits of Intensive Insulin Therapy in Critically Ill Patients

Sadhu¹,

Ang²,

Ingram‐Drake³

et al. 2008

Diabetes Care

View full text Add to dashboard Cite

OBJECTIVE -The purpose of this study was to analyze the economic outcomes of a clinical program implemented to achieve strict glycemic control with intensive insulin therapy in patients admitted to the intensive care unit (ICU). RESEARCH DESIGN AND METHODS-A difference-in-differences (quasiexperimental) study design was used to examine the associations of an intensive insulin therapy intervention with changes in hospital length of stay (ICU and total), costs (ICU and total), and mortality. Hospital administrative data were obtained for 6,719 adult patients admitted between 2003 and 2005 to one of five intervention or four comparison ICUs in a large academic medical center. Linear regression models with log transformations and appropriate retransformations were used to estimate length of stay (LOS) and costs; logistic regressions were used to estimate mortality.RESULTS -After adjustment for observable patient characteristics and secular time trends, the intervention was consistently associated with lower average glucose levels and a trend toward shorter LOS, lower costs, and lower mortality. However, associations with resource use and outcomes were statistically significant in only ICU LOS, with an average reduction of 1.19 days of ICU care per admission. Other associations, although large in magnitude and in the hypothesized directions, were not estimated with sufficient precision to rule out other net effects. The associations with ICU days and costs were larger in magnitude than total days and costs.CONCLUSIONS -A clinical team focused on hyperglycemia management for ICU patients can be a valuable investment with significant economic benefits for hospitals.

show abstract

“…Each service had their own protocol, but in July of 2002 the insulin infusion algorithms were all standardized to a protocol adapted from the Markovitz report (see Appendix 1) [68]. Instead of introducing the protocol throughout the entire hospital at the same time, each nursing unit was transitioned sequentially until they were comfortable with the new protocol.…”

Section: The Use Of Intravenous Insulin In the Hospitalmentioning

confidence: 99%

“…Next, the protocol should include some mechanism for changing infusion rate if there have been significant alterations in blood glucose. Some of the most widely used protocols have this feature [68,69].…”

Section: The Use Of Intravenous Insulin In the Hospitalmentioning

confidence: 99%

Hospital Management of Diabetes

Moghissi

Hirsch

2005

Endocrinology and Metabolism Clinics of North America

View full text Add to dashboard Cite

Diabetes remains a major cause of death and disability and is a growing global concern. The age-adjusted prevalence of type 2 diabetes in the United States increased by more than 55% from 1990 to 2000 [1]. It is estimated that one out of three individuals born in 2000 will develop diabetes in their lifetime [2].Chronic complications of diabetes, especially cardiovascular disease, result in hospitalization in many patients with diabetes. In 2001, more than 4.6 million hospitalizations were associated with diabetes, accounting for nearly 17 million hospital days at a cost of over $40 billion [3].Mounting observational and interventional evidence consistently indicates that hyperglycemia in the hospital setting is associated with increased mortality and morbidity and that meticulous glycemic control can improve clinical outcomes [4][5][6][7]. The purpose of this article is to review the evidence, discuss the importance of striving for good glycemic control in the hospital setting, and emphasize the need for additional outcome research studies to further examine the currently recommended in-hospital glycemic guidelines.

show abstract

Description and Evaluation of a Glycemic Management Protocol for Patients with Diabetes Undergoing Heart Surgery

Cited by 139 publications

References 11 publications

Glucommander

Glucommander

Economic Benefits of Intensive Insulin Therapy in Critically Ill Patients

Hospital Management of Diabetes

Contact Info

Product

Resources

About