Implementation of a Safe and Effective Insulin Infusion Protocol in a Medical Intensive Care Unit

Abstract

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...

Evaluation of hospital glycemic control at US Academic Medical Centers

“…[16][17][18] Though intravenous insulin use was associated with better overall glucose control in our study; only about 50% of ICU patients received it on measurement day 1. A recent prospective randomized clinical trial demonstrated superior glycemic control in non-critically ill hospitalized patients with type 2 diabetes with basal/bolus insulin therapy compared to sliding scale insulin alone.…”

“…15 There is now emerging consensus that use of continuous insulin infusion given through a standardized protocol is the standard of care to control hyperglycemia in critically ill patients. [16][17][18] Likewise, use of specific hospital insulin regimens that include basal and short-acting insulin with appropriate bedside glucose monitoring and avoiding use of ''sliding scale'' short-acting insulin alone has become recognized as the most effective approach for glucose management in hospitalized patients not requiring intravenous insulin. 4,[19][20][21] The University HealthSystem Consortium (UHC) is an alliance of 97 academic health centers and 153 of their associated hospitals that conducts benchmarking studies on clinical and operational topics with member academic medical centers and develops new programs to improve quality of care, patient safety, and operational, clinical, and financial performance.…”

Management of Hyperglycemia in Critical Illness: Review of Targets and Strategies

“…Insulin can be started either as insulin and glucose infused separately or glucose insulin potassium (GIK) combined solution. While a number of validated and effective protocols for insulin infusion are in use [6,20,27,29], we suggest the following as a simplified method.…”

“…Alternatively, a supplemental subcutaneous bolus of regular insulin may be administered if patient is haemodynarnically stable. [29]: Prepare insulin drip by adding 50 units of human regular insulin to 500 ml of normal saline. Infusion set should be flushed with 30 ml of solution to saturate binding sites in the tubing.…”

The Future is Now: Software-Guided Intensive Insulin Therapy in the Critically Ill

“…45-50, GlucoCare (Pronia Medical Systems, Louisville, KY), EndoTool (Hospira, Lake Forest, IL), and GlucoStabilizer (Alere Informatics Solutions, formerly Medical Automation Systems, Charlottesville, VA) are other industrial SG protocols with documented efficacy. [51][52][53][54]46 The newest algorithms fall into the category of model predictive controls (MPCs). By incorporating dextrose administration, insulin sensitivity, age, diabetes diagnosis, and several other patient-specific parameters, these protocols attempt to predict a patient's response to hyperglycemia and IIT.…”