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Rapid restoration of normoglycaemia using intravenous insulin boluses
Abstract
The reduction of elevated fasting plasma glucose levels to near normal by repeated intravenous bolus insulin doses, given according to a simple algorithm, has been studied in 17 Type I and 23 Type II, healthy diabetic patients. Using a formula based on the patient's plasma glucose, height and bodyweight with insulin boluses given every 30 min if the plasma glucose remained above 6 mmol/1, plasma glucose levels were reduced to less than 7.5 mmol/1 in 28 (70%) patients by 60 min at which time the mean (+/- 1 SD) plasma glucose level in the Type I diabetic patients had reduced from 18.2 +/- 4.9 to 8.9 +/- 3.5 mmol/1 and in the Type II diabetic patients from 12.3 +/- 3.1 to 5.9 +/- 1.4 mmol/1. None of the patients had symptomatic hypoglycaemia although in one Type I patient the plasma glucose level fell to 2.2 mmol/1. The rate of fall of glucose in the less insulin sensitive patients was not increased by giving more insulin. The regimen allows a reproducible and prompt glycaemic reduction in fasting diabetic patients.
Hyperglycemia in critical care patients is a common and costly problem with serious medical consequences. There is a complex host of endocrinologic features associated with critical illness. Insulin resistance in the liver, skeletal muscle, and heart causes stress-induced hyperglycemia. The optimal means for achieving tight glycemic control in a critical care setting is with insulin therapy, preferably intravenous insulin. There are studies that indicate that morbidity, mortality, clinical outcomes and cost can be improved in certain patients in the critical care setting. Some of the benefits from intensive insulin therapy are associated with improvements in inflammation and immunity. The benefits of insulin treatment are associated with blood glucose (BG) control and the glucose-independent mechanisms of insulin therapy. It appears that insulin infusion linked to glucose lowering must occur to show beneficial outcomes. The importance of good glycemic control has been demonstrated in medical and surgical patients, acute myocardial infarction, cardiac surgery, infection, and patients in the medical-surgical intensive care unit (ICU). This article reviews data which are supportive of intensive glycemic control in the ICU, discusses recommendations from national guidelines concerning tight glycemic control, and provides examples of different protocols to achieve good metabolic control in an ICU setting.
To improve control of blood glucose concentrations in critically ill patients through use of a bedside, nurse-managed, intravenous insulin nomogram.
Retrospective, before-after cohort study.
Fifteen-bed mixed medical/surgical intensive care unit in a tertiary, teaching hospital.
A total of 167 intensive care unit patients requiring intravenous insulin infusions during two 9-month periods.
The sliding scale group was treated using ad hoc sliding scale infusion therapy. The intervention group was treated using a dosing nomogram that allowed the nurse to adjust the insulin infusion rate based on current glucose concentration and concurrent insulin infusion rates. The adjustments were made independent of physician input.
Time from initiating the insulin infusion to initial control of glucose concentration (<11.5 mmol/L) was determined. Effectiveness of glucose control was determined retrospectively by measuring the area under the curve of blood concentrations >11.5 mmol/L versus time of insulin infusion, divided by total duration of insulin infusion. The median time to initial control of glucose (<11.5 mmol/L) was 4 hr (range 1-38 hr) for the baseline and 2 hr (range 1-22 hr) for nomogram group (p =.0004). The median area under the curve of glucose concentration divided by duration of insulin infusion was 0.9 (range 0.0-5.9) for sliding scale group and 0.3 (range 0.0-11.1) for nomogram (p =.0001), without any increase in the frequency of episodes of hypoglycemia.
Use of an insulin nomogram in critically ill patients improves control of blood glucose concentrations and is safe.
Diabetes increases the risk for disorders that predispose individuals to hospitalization, including coronary artery, cerebrovascular and peripheral vascular disease, nephropathy, infection, and lower-extremity amputations. The management of diabetes in the hospital is generally considered secondary in importance compared with the condition that prompted admission. Recent studies (1,2) have focused attention to the possibility that hyperglycemia in the hospital is not necessarily a benign condition and that aggressive treatment of diabetes and hyperglycemia results in reduced mortality and morbidity. The purpose of this technical review is to evaluate the evidence relating to the management of hyperglycemia in hospitals, with particular focus on the issue of glycemic control and its possible impact on hospital outcomes. The scope of this review encompasses adult nonpregnant patients who do not have diabetic ketoacidosis or hyperglycemic crises.
For the purposes of this review, the following terms are defined (adapted from the American Diabetes Association [ADA] Expert Committee on the Diagnosis and Classification of Diabetes Mellitus) (3):
The prevalence of diabetes in hospitalized adult patients is not known. In the year 2000, 12.4% of hospital discharges in the U.S. listed diabetes as a diagnosis. The average length of stay was 5.4 days (4). Diabetes was the principal diagnosis in only 8% of these hospitalizations. The accuracy of using hospital discharge diagnosis codes for identifying patients with …
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