Improving glycemic control in the cardiothoracic intensive care unit: Clinical experience in two hospital settings

Yale University, New Haven, Connecticut, United States
Journal of Cardiothoracic and Vascular Anesthesia (Impact Factor: 1.46). 01/2005; 18(6):690-7. DOI: 10.1053/j.jvca.2004.08.003
Source: PubMed


Recent studies suggest that strict perioperative glycemic control improves clinical outcomes after cardiothoracic surgery. However, optimal methods and targets for controlling blood glucose (BG) levels in this setting have not been established. Currently published intensive insulin infusion protocols (IIPs) have important practical limitations, which may affect their utility. In this article, the authors present their experience with a safe, effective, nurse-driven IIP, which was implemented simultaneously in 2 cardiothoracic intensive care units (CTICUs).
Prospective cohort study.
Tertiary referral hospital and community teaching hospital.
CTICU patients.
A standardized, intensive IIP was used for all patients admitted to both CTICUs. Hourly BG levels, relevant baseline variables, and clinical interventions were collected prospectively from the active hospital chart and CTICU nursing records.
The IIP was used 137 times in 118 patients. The median time required to reach target BG levels (100-139 mg/dL) was 5 hours. Once BG levels decreased below 140 mg/dL, 58% of 2,242 subsequent hourly BG values fell within the narrow target range, 73% within a "clinically desirable" range of 80 to 139 mg/dL, and 94% within a "clinically acceptable" range of 80 to 199 mg/dL. Only 5 (0.2%) BG values were less than 60 mg/dL, with no associated adverse clinical events.
The IIP safely and effectively improved glycemic control in 2 CTICUs, with minimal hypoglycemia. Based on prior studies showing the benefits of strict glycemic control, the implementation of this IIP should help to reduce morbidity and mortality in CTICU patients.

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    • "In designing the protocol, three data elements are used by experienced endocrinologists to adjust intravenous insulin infusions: (1) the current BG value, (2) the previous BG value, and (3) the current insulin infusion rate. That means this IIP was based primarily on the velocity of glycemic change, rather than on absolute BG levels [29]. "
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    ABSTRACT: Good glycemic control through insulin administration among intensive care unit (ICU) patients can reduce mortality significantly; however, it remains a big challenge because of scarcity of individualized models for ICU patients. To deal with this challenge, a new combination of particle swarm optimization (PSO) and model predictive control (MPC) has been proposed to identify the model online as well as to optimally design the input, i.e., the insulin delivery rate automatically. According to the population distribution, ten typical linear dynamic models were selected such that any patient's model could be approximated by a linear combination of these ten typical models. PSO was used to update the weight coefficients while MPC was used to design the insulin delivery rate based on the combination model identified by using PSO. The proposed strategy was compared with the Yale protocol on 30 virtual subjects. According to the control-variability grid analysis, the percentage values in A + B zone were, respectively, 100% under the proposed strategy and while 51% under the Yale protocol, which demonstrates the superior performance of the proposed strategy. As a good candidate for the full closed-loop insulin delivery method, this new combination can control the glucose level by bringing it to a safe range promptly thereby reducing the risk of death.
    01/2014; 18(1):290-299. DOI:10.1109/JBHI.2013.2269699
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    • "Three studies that were carried out without the use of controls were those of Goldberg et al. [24], Lecomte et al. [25] and Studer et al. [26]. Although no controls were used, insulin infusion protocols were used to obtain target blood glucose levels of 100 to 139 mg/dl (5.6 to 7.7 mmol/l), 80 to 110 mg/dl (4.4 to 6.1 mmol/l) and 100 to 139 mg/dl (5.6 to 7.7 mmol/l), respectively. "
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    ABSTRACT: Perioperative hyperglycaemia is associated with poor outcomes in patients undergoing cardiac surgery. Frequent postoperative hyperglycaemia in cardiac surgery patients has led to the initiation of an insulin infusion sliding scale for quality improvement. A systematic review was conducted to determine whether a protocol-directed insulin infusion sliding scale is as safe and effective as a conventional practitioner-directed insulin infusion sliding scale, within target blood glucose ranges. A literature survey was conducted to identify reports on the effectiveness and safety of an insulin infusion protocol, using seven electronic databases from 2000 to 2012: MEDLINE, CINAHL, EMBASE, the Cochrane Library, the Joanna Briggs Institute Library and SIGLE. Data were extracted using pre-determined systematic review and meta-analysis criteria. Seven research studies met the inclusion criteria. There was an improvement in overall glycaemic control in five of these studies. The implementation of protocols led to the achievement of blood glucose concentration targets more rapidly and the maintenance of a specified target blood glucose range for a longer time, without any increased frequency of hyperglycaemia. Of the seven studies, four used controls and three had no controls. In terms of the meta-analysis carried out, four studies revealed a failure of patients reaching target blood glucose levels (P < 0.0005) in the control group compared with patients in the protocol group. The risk of hypoglycaemia was significantly reduced (P <0.00001) between studies. It can be concluded that the protocol-directed insulin infusion sliding scale is safe and improves blood glucose control when compared with the conventional practitioner-directed insulin infusion sliding scale. This study supports the adoption of a protocol-directed insulin infusion sliding scale as a standard of care for post-cardiac surgery patients.
    10/2012; 1(1). DOI:10.1186/2047-0525-1-7
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    • "- In spite of multiple blood-glucose control protocols [39,40,41,42,43,44], there is a paucity of clinical evidence on the effect of stress-induced hyperglycemia control in diabetic and non-diabetic patients undergoing cardiac and vascular   surgery. "
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    ABSTRACT: During the past few years, it has become evident that metabolic control is a major determinant of postoperative outcomes, not only for diabetic patients but for all patients undergoing surgery. In cardiac and vascular surgery, myocardial ischemia is a common challenge and the management of hyperglycemia should be part of the strategy aimed at optimizing cardiac protection during these types of surgery, since performed in high risk patients. Little informations are available on the relation between glucose substrate and the type of anesthesia and few studies have been performed on glucose metabolism in the perioperative risk assessment as well as on intraoperative and post surgical management of hyperglycemia in patients submitted to cardiac and vascular surgery. Evidence exists that even slight increased in glycemia are detrimental for patients (diabetic and non) elective for cardiac and vascular surgery, though the precise details of the timing of insulin therapy, the desired target serum glucose level, and the duration of therapy are so far to be completely elucidated. Anesthestiologists can therefore affect outcome by simply preserving a normal blood glucose concentration initiating in the operating room. The challenge to optimize glucose control should begin during preoperative evaluation.
    04/2010; 2(1):19-26.
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