Hyperglycemia During Acute Coronary Syndrome: A Nurse-Managed Insulin Infusion Protocol for Stricter and Safer Control

Abstract

The nurse-managed DDD IIP was easily implemented in our CCU and permitted strict and safe glycemic control in hyperglycemic patients with ACS.

Compliance with Surgical Care Improvement Project Blood Glucose—A Marker for Euglycemia, but Does It Put our Patients at Risk?

“…Coincident with these findings regarding BG and postoperative wound infections, it has become apparent that protocols and checklists that ''force'' physician behavior reduce medical errors and improve quality of care, [20][21][22][23] and many hospitals have instituted insulinglucose algorithms to good effect. [24][25][26][27][28][29][30][31][32][33] However, our experience in instituting an IIP was less successful; in particular, as evidenced by our inability to consistently meet the SCIP metric of BG £ 200 mg/dL on POD 1 and 2 at 6 am. We initially hypothesized that erratic implementation of our IIP, which aimed for a BG of < 140 mg/dL, was responsible for our inability to dependably prevent hyperglycemia.…”

Conventional insulinvsinsulin infusion therapy in acute coronary syndrome diabetic patients

“…Also, a major risk of intensive insulin treatment is the greater appearance of hypoglycaemic episodes which are mainly related to diabetes life span, frequency of previous hypoglycaemic attacks and pre-existing coronary artery disease [29,30] with worsening of prognosis and prolongation of in-hospital stay. Several insulin-infused operational protocols to be adopted in ICUs have been proposed so far [15][16][17][18][19][20][21][22] but no specific guidelines with validate protocols in day-to-day clinical practice and definite glycaemic target values have been provided. Furthermore, an additional concern is represented by a recurrence of hyperglycaemic states during the transition from intravenous to subcutaneous treatment regimen.…”

“…The frequency of blood glucose determinations was guided by the infusion protocol as previously suggested [21] ; usually blood samples were withdrawn every 2 h during day-time and every three hours during nighttime. Blood glucose was checked at fixed times (i.e., 07:00 am; 10:00 am; 12:00 am; 04:00 am; 06:00 pm; 10:00 pm) in the case of subcutaneous insulin treatment.…”

“…We adopted the nurse-implemented continuous intravenous insulin infusion protocol as proposed by Avanzini et al [21] developed also to drive the optimal transition to subsequent subcutaneous insulin therapy [22] , with little modifications. In particular targeting glycemic values were 120-180 mg/dL (i.e., 6.6-10 mmol/L) instead of 100-139 mg/dL (i.e., 5.5-7.7 mmol/L), and infusion treatment was stopped in presence of glycemic values below 120 mg/dL (i.e., 6.7 mmol/L) instead of 100 mg/dL (i.e., 5.5 mmol/L) To facilitate acceptance, during year 2012 all nurses involved in the study were previously trained by a weeklong series of 1-h in-service training sessions and all experienced very good compliance with the infusion protocol at the time of the study.…”

“…For the above reasons, the European Society of Cardiology/European Association for the Study of Diabetes recommends blood glucose control by intensive insulin treatment (Class Ⅰ recommendation) in patients with AMI (Class Ⅱ, level of evidence B) [14] . Some schemes of insulin infusion therapy have been proposed for critically ill patients [15][16][17][18][19][20][21][22] ; however, among the nurseimplemented insulin infusion protocols available none was specifically tested in patients with ACS during the day-today clinical activity of a coronary care unit [21] .…”