Inpatient Management of Hyperglycemia: The Northwestern Experience

Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
Endocrine Practice (Impact Factor: 2.81). 09/2006; 12(5):491-505. DOI: 10.4158/EP.12.5.491
Source: PubMed


To describe a novel method of safe and effective intensive management of inpatient hyperglycemia with use of cost-effective protocols directed by a glucose management service (GMS).
An intravenous insulin protocol was designed to achieve a glycemic target of 80 to 110 mg/dL. When stable inpatients were transferred from the intravenous protocol to a subcutaneous insulin protocol, which consisted of basal long-acting and prandial and supplemental rapid-acting insulins, the blood glucose target was 80 to 150 mg/dL. Glucose levels were reviewed by the GMS at least daily for protocol adjustments, when necessary.
The intravenous insulin protocol was used in 276 patients, and 4,058 capillary blood glucose levels were recorded. Glycemic target levels (80 to 110 mg/dL) were achieved, on average, 10.6 +/- 5.2 hours after initiation of insulin drip therapy. The mean capillary blood glucose level during the study interval was 135.3 +/- 49.9 mg/dL. Hypoglycemia (< or = 60 mg/dL) was recorded in 1.5% of glucose values, and hyperglycemia (> or = 400 mg/dL) was recorded in only 0.06%. The subcutaneous insulin protocol was used in 922 patients, and 18,067 capillary glucose levels were documented. The mean blood glucose level was 145.6 +/- 55.8 mg/dL during the study period. The blood glucose target of 80 to 150 mg/dL was achieved in 58.6%, whereas 74.3% of glycemic values were in the clinically acceptable range (80 to 180 mg/dL). Hypoglycemia (< or = 60 mg/dL) occurred in 1.3% of capillary blood glucose values, and hyperglycemia (> or = 400 mg/dL) occurred in 0.4% of values.
Validated protocols dedicated to the achievement of strict glycemic goals were implemented by a GMS and resulted in substantial improvements in glycemic control on the surgical inpatient services, with a reduced frequency of hypoglycemia. The protocols and the GMS have been well received by the inpatient nursing and surgical staff members, and all of this has been done in a cost-effective manner.

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Available from: Lowell Schmeltz, Sep 30, 2015
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    • "Many factors are suggested to contribute to the disturbed glucose metabolism. Although insulin is infused during CPB to maintain blood glucose level, the counter regulatory hormones secreted, as a result of stress, lead to insulin resistance and hence a high blood glucose level.[1516] Non-esterified fatty acids produced as a result of high level of heparin infusion during CPB, are suggested to have a role in hyperglycemia.[17] "
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    ABSTRACT: Cardiopulmonary bypass (CPB) during coronary artery bypass grafting is thought to contribute significantly to increased blood glucose level and altered blood electrolytes balance during the operation. In this (CABG) study, blood electrolytes and glucose during CPB in insulin-dependent diabetic and non-diabetic patients were assessed with special emphasis on the trend of the changes. Blood glucose and electrolytes were assessed in 30 insulin-dependent diabetic and 30 non-diabetic patients, classified as class II and III American Society of Anesthesiologist, before, during, and after CPB. Repeated-measures analysis of variance (ANOVA) was used to compare the trend of the changes during CPB for the two groups. The trend in blood glucose level did not show any significant difference between two groups (P = 0.59). For other blood factors, no significant between-group difference was detected except for PaCO2 (P = 0.002). The study suggested that the changes in blood electrolytes and the increase in blood glucose level do not differ between insulin dependent diabetic and non-diabetic patients.
    Journal of research in medical sciences 04/2013; 18(4):322-325. · 0.65 Impact Factor
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    • "Recently, computer-based algorithms have become commercially available to assist the nursing staff in adjusting insulin infusion rates [85] [86]. Although studies have shown that computer-based algorithms have been associated with tighter glucose control, there have been no reported differences in the frequency of hypoglycemic events, length of ICU and hospital stay, or mortality with these algorithms; their use depends on physicians' preferences and cost considerations [87] [88] [89]. The following are the current recommendations of the Society of Thoracic Surgery regarding blood glucose management during adult cardiac surgery [81]. "
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    ABSTRACT: Hyperglycemia, which occurs in the perioperative period during cardiac surgery, has been shown to be associated with increased morbidity and mortality. The management of perioperative hyperglycemia during coronary artery bypass graft surgery and all cardiac surgical procedures has been the focus of intensive study in recent years. This report will paper the pathophysiology responsible for the detrimental effects of perioperative hyperglycemia during cardiac surgery, show how continuous insulin infusions in the perioperative period have improved outcomes, and discuss the results of trials designed to determine what level of a glycemic control is necessary to achieve optimal clinical outcomes.
    11/2012; 2012:292490. DOI:10.5402/2012/292490
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    • "Hyperglycemia commonly occurs during hospitalization and is of particular concern in intensive care units (ICUs).1,2,3,4,5,6,7,8 Hyperglycemia can result from administration of medications such as glucocorticoids, parenteral feeding, or as a natural response to critical illness with increased release of stress hormones. "
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    ABSTRACT: The benefits of controlling blood glucose levels in intensive care units (ICUs) are well documented. This study determined the effectiveness and safety of a standardized transition order set for converting a continuous insulin infusion to a subcutaneous insulin regimen in non-cardiovascular surgery ICUs patient population. A retrospective study was conducted. Patients presenting with diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome were excluded. One hundred patients were included prior to and 100 patients were included after initiating the transition order set. Blood glucose control was reviewed for up to 72 hours following the transition. A total of 115 patients were included in data analysis: 85 prior to and 30 after transition protocol. All patients transitioned using the protocol were transitioned to basal insulin, compared to only 40% of the prior to protocol group. Patients transitioned correctly per the transition order set, "per protocol," had 54% of blood sugars within the desired range, no increase in hypoglycemic events, and on average 5.56 hyperglycemic events (blood glucose >180 mg/dL) per person during the 72 hours compared to 6.68 and 9.00 for the prior to protocol group and the "off protocol" group (transitioned different than the protocol recommended), respectively (p= 0.05). There were significant differences in blood sugar control at 48 and 72 hours between the "per protocol" and "off protocol" groups (p= 0.01) and a 40% reduction in sliding scale or correctional insulin coverage. The addition of basal insulin to transition regimens resulted in fewer hyperglycemic events with no increase in hypoglycemic events. Patients transitioned "per protocol" had better glucose control demonstrated by: less hyperglycemic events, lower mean blood glucose levels at 48 and 72 hours, and lower need for correctional insulin. These findings showed benefits of glycemic control in the ICU by following a standardized transition protocol.
    03/2012; 10(1):45-51. DOI:10.4321/S1886-36552012000100008
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