Achieving durable glucose control in the intensive care unit without hypoglycaemia: A new practical IV insulin protocol

Department of Medicine, Huntington Hospital, Huntington, NY 11743, USA.
Diabetes/Metabolism Research and Reviews (Impact Factor: 2.97). 01/2007; 23(1):49-55. DOI: 10.1002/dmrr.673
Source: PubMed

ABSTRACT Hyperglycaemia occurs in a substantial portion of critically ill patients in our intensive care units. Near normalization of elevated blood glucose levels with IV insulin may improve outcome. However, currently published IV insulin protocol are not ideal; most are relatively complex and often result in hypoglycaemia. We designed a protocol that would be practical to use while incorporating the necessary complexities required to achieve good glucose control, coupled with a low incidence hypoglycaemia.
The essential part of the protocol is a matrix specifying the amount by which an insulin flow rate is to be changed. The intersection of the current and the previous blood glucose values on the matrix locates the appropriate cell containing the required change in insulin flow rate. No additional calculations or tables are required.
The initial glucose level obtained by blood glucose meter (BGM) averaged 253.5 +/- 95.6 mg/dL and fell below 140 within 9.3 h on the protocol. The average BGM on the protocol was 133.5 +/- 43.9 mg/dL. Only 0.09% of all glucose values were <40 mg/dL and insulin had to be held only 2.2% of the time on the protocol. Physician input was not required and nursing accuracy in applying the protocol was greater than 94%. This protocol has been adopted as the default IV insulin protocol for the NorthShore-LIJ Health System and several other medical centers.
A practical IV insulin protocol that has been extensively tested is presented. The protocol has been implemented at multiple institutions indicating its ease of use and excellent results.

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    • "Lonergan et al. [18] modeled these dynamics and limited infusion rates accordingly. In contrast, glycaemic control protocols have been published that utilise maximum insulin infusion rates of 10 or 20 units per hour [2] [19] or have no limit [9]. "
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    ABSTRACT: Consistent tight blood sugar control in critically ill patients has proven elusive. Properly accounting for the saturation of insulin action and reducing the need for frequent measurements are important aspects in intensive insulin therapy. This paper presents a composite metabolic model, 'Glucosafe', that integrates models and parameters from normal physiology and accounts for the reduced rate of glucose gut absorption and saturation of insulin action in patients with reduced insulin sensitivity. Particularly, two different sites of reduced insulin sensitivity, before and after the non-linearity of insulin action, are explored with this model. These approaches are assessed based on the model's accuracy in retrospectively predicting blood glucose measurements of 10 randomly chosen, hyperglycemic intensive care patients. For each patient, median absolute percent error is <25% for prediction times < or = 270min and modelling reduced insulin sensitivity after the non-linearity, compared to <29% for modelling reduced insulin sensitivity before the non-linearity. Scaling the insulin effect (after the non-linearity) is a suitable assumption in this model structure. These results are preliminary and subject to further and more extensive validation of the model's capability to predict the longer term (>2h) blood glucose excursion in critically ill patients.
    Computer methods and programs in biomedicine 07/2009; 97(3):211-22. DOI:10.1016/j.cmpb.2009.06.004 · 1.09 Impact Factor
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    • "De par, les fluctuations de l'état glucométabolique du patient d'anesthésie-réanimation, le risque d'hypoglycémie est constant quel que soit le protocole utilisé dans la littérature. Son incidence varie entre 1 et 7 % selon les auteurs [19] [27]. Les facteurs favorisants sont les grandes augmentations de débit de pompe d'insuline, les diminutions rapides de la glycémie sur les dernières heures, les diminutions des apports d'hydrate de carbone sans adaptation de l'insulinothérapie, la maladie diabétique préexistante, l'épuration extra-rénale, le sepsis et l'utilisation de catécholamines [27]. "
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