Effects of outcome on in-hospital transition from intravenous insulin infusion to subcutaneous therapy

Challenges in hyperglycemia management in critically ill patients with COVID-19

Hyperglycemia is commonly associated with adverse outcomes especially in patients requiring intensive care unit stay. Data from the corona virus disease 2019 (COVID-19) pandemic indicates that individuals with diabetes appear to be at similar risk for COVID-19 infection to those without diabetes but are more likely to experience increased morbidity and mortality. The proposed hypothesis for hyperglycemia in COVID-19 include insulin resistance, critical illness hyperglycemia (stress- induced hyperglycemia) secondary to high levels of hormones like cortisol and catecholamines that counteract insulin action, acute cytokine storm and pancreatic cell dysfunction. Diabetic patients are more likely to have severe hyperglycemic complications including diabetic ketoacidosis and hyperosmolar hyperglycemic state. Management of hyperglycemia in COVID-19 is often complicated by use of steroids, prolonged total parenteral or enteral nutrition, frequent acute hyperglycemic events, and restrictions with fluid management due to acute respiratory distress syndrome. While managing hyperglycemia special attention should be paid to mode of insulin delivery, frequency of glucose monitoring based on patient and caregiver safety thereby minimizing exposure and conserving personal protective equipment. In this article we describe the pathophysiology of hyperglycemia, challenges encountered in managing hyperglycemia, and review some potential solutions to address them.

Effect of the Concomitant Use of Subcutaneous Basal Insulin and Intravenous Insulin Infusion in the Treatment of Severe Hyperglycemic Patients

BACKGRUOUND

No consensus exists regarding the early use of subcutaneous (SC) basal insulin facilitating the transition from continuous intravenous insulin infusion (CIII) to multiple SC insulin injections in patients with severe hyperglycemia other than diabetic ketoacidosis. This study evaluated the effect of early co-administration of SC basal insulin with CIII on glucose control in patients with severe hyperglycemia.

METHODS

Patients who received CIII for the management of severe hyperglycemia were divided into two groups: the early basal insulin group (n=86) if they received the first SC basal insulin 0.25 U/kg body weight within 24 hours of CIII initiation and ≥4 hours before discontinuation, and the delayed basal insulin group (n=79) if they were not classified as the early basal insulin group. Rebound hyperglycemia was defined as blood glucose level of >250 mg/dL in 24 hours following CIII discontinuation. Propensity score matching (PSM) methods were additionally employed for adjusting the confounding factors (n=108).

RESULTS

The rebound hyperglycemia incidence was significantly lower in the early basal insulin group than in the delayed basal insulin group (54.7% vs. 86.1%), despite using PSM methods (51.9%, 85.2%). The length of hospital stay was shorter in the early basal insulin group than in the delayed basal insulin group (8.5 days vs. 9.6 days, P=0.027). The hypoglycemia incidence did not differ between the groups.

CONCLUSION

Early co-administration of basal insulin with CIII prevents rebound hyperglycemia and shorten hospital stay without increasing the hypoglycemic events in patients with severe hyperglycemia.

Hypoglycemia Reduction Strategies in the ICU

PURPOSE OF REVIEW

We reviewed the strategies associated with hypoglycemia risk reduction among critically ill non-pregnant adult patients.

RECENT FINDINGS

Hypoglycemia in the ICU has been associated with increased mortality in a number of studies. Insulin dosing and glucose monitoring rules, response to impending hypoglycemia, use of computerization, and attention to modifiable factors extrinsic to insulin algorithms may affect the risk for hypoglycemia. Recurring use of intravenous (IV) bolus doses of insulin in insulin-resistant cases may reduce reliance upon higher IV infusion rates. In order to reduce the risk for hypoglycemia in the ICU, caregivers should define responses to interruption of continuous carbohydrate exposure, incorporate transitioning strategies upon initiation and interruption of IV insulin, define modifications of antihyperglycemic therapy in the presence of worsening renal function or chronic kidney disease, and anticipate the effects traceable to other medications and substances. Institutional and system-wide quality improvement efforts should assign priority to hypoglycemia prevention.

Hospital Guidelines for Diabetes Management and the Joint Commission-American Diabetes Association Inpatient Diabetes Certification

BACKGROUND

The Joint Commission Advanced Inpatient Diabetes Certification Program is founded on the American Diabetes Association's Clinical Practice Recommendations and is linked to the Joint Commission Standards. Diabetes currently affects 29.1 million people in the USA and another 86 million Americans are estimated to have pre-diabetes. On a daily basis at the Medical University of South Carolina (MUSC) Medical Center, there are approximately 130-150 inpatients with a diagnosis of diabetes.

METHODS

The program encompasses all service lines at MUSC. Some important features of the program include: a program champion or champion team, written blood glucose monitoring protocols, staff education in diabetes management, medical record identification of diabetes, a plan coordinating insulin and meal delivery, plans for treatment of hypoglycemia and hyperglycemia, data collection for incidence of hypoglycemia, and patient education on self-management of diabetes.

RESULTS

The major clinical components to develop, implement, and evaluate an inpatient diabetes care program are: I. Program management, II. Delivering or facilitating clinical care, III. Supporting self-management, IV. Clinical information management and V. performance measurement. The standards receive guidance from a Disease-Specific Care Certification Advisory Committee, and the Standards and Survey Procedures Committee of the Joint Commission Board of Commissioners.

CONCLUSIONS

The Joint Commission-ADA Advanced Inpatient Diabetes Certification represents a clinical program of excellence, improved processes of care, means to enhance contract negotiations with providers, ability to create an environment of teamwork, and heightened communication within the organization.

Effectiveness of regular versus glargine insulin in stable critical care patients receiving parenteral nutrition: a randomized controlled trial

STUDY OBJECTIVE

To compare the effectiveness and safety of two glycemic control regimens in stable critical care patients receiving parenteral nutrition (PN).

DESIGN

Prospective, randomized open-label clinical trial.

METHODS

Eligible postoperative critical care patients in the ICU began PN on the first to the seventh day of ICU admission. The PN admixture included regular insulin, in doses sufficient to maintain 3 or more goal blood glucose (BG) levels between 110 and 180 mg/dl. After 3 to 5 days of PN containing regular insulin, patients were randomized to 3 more days of regular insulin at the same dose or 80% of their total daily regular insulin dose provided in PN solution as glargine insulin. Capillary BG monitoring was performed every 6 hours.

RESULTS

Twenty one patients were randomized to each treatment group. Median APACHE II scores were not significantly different between the two groups within the first 24-hour of ICU admission. There were no significant differences between the two groups at day 3 for mean daily dextrose (306.9 ± 46.2 vs. 305.2 ± 52.2 g; p=0.913) or insulin (18.3 ± 8.8 vs. 19.5 ± 10.0 units; p=0.696) doses. The percentage of BG values in the goal (110-180 mg/dl), hyperglycemic (> 180 mg/dl), and hypoglycemic (< 70 mg/dl) BG levels were similar between the two groups (69.0% vs. 66.7%, p=0.567; 11.9% vs. 11.1%, p=0.780; 0% vs. 1.6%, p=0.124, respectively). Mean daily BG levels were not significantly different between the two groups on each of the 3 study days (day 1: 140 ± 20 vs. 131 ± 25 mg/dl, p=0.194; day 2: 136 ± 20 vs. 140 ± 18 mg/dl, p=0.498; day 3: 142 ± 15 vs. 140 ± 19 mg/dl; p=0.741).

CONCLUSION

These data suggest that, compared with regular insulin added to PN, glargine insulin results in similar glycemic control and rates of hyperglycemia and hypoglycemia in stable critical care patients.

Transitioning safely from intravenous to subcutaneous insulin

The transition from intravenous (IV) to subcutaneous (SQ) insulin in the hospitalized patient with diabetes or hyperglycemia is a key step in patient care. This review article suggests a stepwise approach to the transition in order to promote safety and euglycemia. Important components of the transition include evaluating the patient and clinical situation for appropriateness, recognizing factors that influence a safe transition, calculation of proper SQ insulin doses, and deciding the appropriate type of SQ insulin. This article addresses other clinical situations including the management of patients previously on insulin pumps and recommendations for patients requiring glucocorticoids and enteral tube feedings. The use of institutional and computerized protocols is discussed. Further research is needed regarding the transition management of subgroups of patients such as those with type 1 diabetes and end-stage renal disease.

Inpatient hyperglycaemia improvement quality program

BACKGROUND

Poorly controlled hyperglycaemia is associated with increased morbidity and mortality in hospitalised patients. Based on the view that hospitalisation provides a window of opportunity to improve patient quality of care and health status, a comprehensive program for treating hospitalised diabetic patients was initiated. This study assessed the effectiveness of the Inpatient Hyperglycaemia Improvement Quality Program (IHIQP) over a 4-year period.

METHODS

Pre-test post-test design. In the pre-intervention period (August-December 2007), an institution-wide blood glucose monitoring system was introduced in August 2007. The remaining program components were introduced in January 2008, including implementing a hospital care protocol based on the 2007 American Diabetes Association Standards, a multidisciplinary team that participates in patient care and arranges continuing care after discharge and comprehensive patient education prior to discharge. Program results from January 2008 through October 2011 were evaluated.

RESULTS

During follow-up, more than 600,000 blood glucose tests were performed. Blood glucose values declined from 196.4 ± 98.4 mg/dl pre-IHIQP (August-December 2007) to 174.5 ± 82.0 mg/dl post-IHIQP (January-October 2011) (p < 0.0001). Prevalence of glucose values lower than 60 mg/dl declined from 2% to 1.3% (p < 0.004). Prevalence of glucose values ≥ 300 mg/dl declined from 13.6% to 8.4% (p < 0.0001). Concomitantly, the proportion of in-target values of 80-180 mg/dl increased from 47.7% to 58.1% (p < 0.0001).

CONCLUSION

This in-patient hyperglycaemia quality improvement program led to improvements in-patient glycaemic control, which continued over time. The effect of this improvement on in-patient mortality and morbidity needs additional follow-up.

Practical approach to management of inpatient hyperglycemia in select patient populations

Hospitalized patients frequently transition between various levels of care and changing clinical situations. Optimal management of hospitalized patients with hyperglycemia includes awareness of situations that may significantly affect glucose and/or insulin metabolism. A review of published clinical trials reveals practical approaches to the management of hyperglycemia in select patient populations that may prove useful for the hospital clinician. We outline approaches to the management of hyperglycemia in hospitalized patients receiving glucocorticoids, patients with severe or end-stage renal disease undergoing hemo- or peritoneal dialysis, and patients receiving total parenteral or enteral feeding, in addition to patients transitioning from intravenous insulin infusion to subcutaneously administered insulin. Key considerations underlying these management methods include a proactive approach, frequent blood glucose monitoring, daily review of blood glucose patterns, and daily reassessment of the insulin regimen and associated orders.

Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients

OBJECTIVE

To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point.

METHODS

Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear.

RECOMMENDATIONS

The article is focused on a suggested glycemic control end point such that a blood glucose ≥ 150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤ 70 mg/dL) and to minimize glycemic variability.Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate monitoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients.

CONCLUSIONS

While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infusion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy.

Converting continuous insulin infusion to subcutaneous insulin glargine after cardiac surgery using percentage-based versus weight-based dosing: a pilot trial

BACKGROUND

Most studies report using percentage of total daily insulin (TDI) for converting therapy from continuous insulin infusion to subcutaneous insulin in cardiac surgery patients. Few studies have evaluated the efficacy of using body weight to calculate the basal insulin dose.

OBJECTIVE

To compare the efficacy and safety of dosing insulin glargine by weight versus percentage of TDI in cardiac surgery patients transitioning from continuous insulin infusion to subcutaneous insulin.

METHODS

We conducted a prospective, randomized, open-label, pilot study. Study patients who had a preoperative weight less than 100 kg and were receiving at least 6 hours of a continuous insulin infusion were randomized to receive either 50% of their TDI requirement or 0.5 units/kg of glargine as a one-time dose 2 hours before stopping the continuous insulin infusion. All patients were administered subcutaneous corrective insulin. Blood glucose monitoring occurred before each meal, at bedtime, and with morning laboratory tests for 24 hours after administration of the glargine dose.

RESULTS

A total of 200 blood glucose measurements were performed in each group. The percentage of blood glucose measurements in target range (80-140 mg/dL) was similar between the weight-based group and the percentage-based group (66% vs 64%, p = 0.75). Median blood glucose after transition was 120 mg/dL (interquartile range [IQR] 99-147) in the weight-based group compared to 127 mg/dL (IQR 107-149; p = 0.03) in the percentage-based group. The median glargine dose was higher in the weight-based group (41 units; IQR 36-44) than in the weight-based group (24 units; IQR 14-30, p < 0.001). The rate of hypoglycemia (blood glucose <60 mg/dL) was 2.5% in each group.

CONCLUSIONS

In this small cohort, dosing insulin glargine by weight proved to be safe, but larger scale studies are needed before adopting weight-based dosing in this patient population.

Subcutaneous administration of glargine to diabetic patients receiving insulin infusion prevents rebound hyperglycemia

CONTEXT

Transition of diabetic patients from iv insulin infusion to s.c. insulin frequently results in rebound hyperglycemia.

OBJECTIVES

We hypothesized that initiation of a long-acting insulin therapy concurrently with i.v. insulin infusion would decrease the rate of rebound hyperglycemia after discontinuation of the insulin infusion.

DESIGN AND INTERVENTION

Sixty-one diabetic patients receiving i.v. insulin therapy participated in this prospective randomized study. Subjects in the intervention group received daily injections of glargine s.c. (0.25 U/kg body weight) starting within 12 h of initiation of i.v. insulin infusion. Capillary blood glucose measurements were obtained up to 12 h after discontinuation of insulin infusion. Rebound hyperglycemia was defined as a blood glucose level greater than 180 mg/dl.

SETTING

The study was conducted at the University of Colorado Hospital.

PATIENTS

Sixty-one hospitalized patients with known type 1 or type 2 diabetes receiving i.v. insulin infusion participated in the study.

MAIN OUTCOME

The primary outcome of this study was to compare the rates of rebound hyperglycemia between the control and the intervention groups after i.v. insulin infusion is discontinued.

RESULTS

Overall, 29 subjects in the control group (93.5%) had at least one glucose value above 180 mg/dl during the 12-h follow-up period. This was significantly greater than the rate of rebound hyperglycemia in the intervention group (10 subjects or 33.3%, P < 0.001). The effect of the intervention was apparent in subjects who presented with diabetic ketoacidosis, after solid organ transplantation, and in patients with other surgical and medical diagnoses. There were three hypoglycemic measurements in two control subjects (68, 62, and 58 mg/dl) and none in the intervention group.

CONCLUSIONS

Once-daily s.c. insulin glargine administered during i.v. insulin infusion is a safe method for preventing future rebound hyperglycemia, without increased risk of hypoglycemia.

Glycemic variability and glycemic control in the acutely ill cardiac patient

The mechanisms for hyperglycemia-mediated harm in the hospitalized cardiac patient are poorly understood. Potential obstacles in the inpatient management of hyperglycemia in cardiac patients include rapidly changing clinical status, frequent procedures and interruptions in carbohydrate exposure, and short hospital length of stay. A patient's preadmission regimen is rarely suitable for inpatient glycemic control. Instead, an approach to a flexible, physiologic insulin regimen is described, which is intended to minimize glycemic excursions. When diabetes or hyperglycemia is addressed early and consistently, the hospital stay can serve as a potential window of opportunity for reinforcing self-care behaviors that reduce long-term complications.

Comparison of 3 algorithms for Basal insulin in transitioning from intravenous to subcutaneous insulin in stable patients after cardiothoracic surgery

OBJECTIVE

To determine the effectiveness of an algorithm containing 1 of 3 initial subcutaneous doses of insulin detemir and flexible prandial and supplemental insulin aspart in stable patients who have undergone cardiac surgery and are being transitioned off intravenous insulin infusion.

METHODS

Patients were extubated, were not taking vasopressors, and were otherwise stable, requiring at least 1 unit per hour of intravenous insulin at least 48 hours after surgery. Patients were randomly assigned to once-daily insulin detemir at 50%, 65%, or 80% of intravenous basal insulin requirements and received insulin aspart according to carbohydrate intake. The dose of insulin detemir was adjusted daily over 72 hours.

RESULTS

Eighty-two patients were included. The percentages of patients with an initial morning glucose concentration of 80 to 130 mg/dL were 36%, 63%, and 56% of patients at the 50%, 65%, and 80% doses, respectively (P = .12). However, the mean overall glucose value at 24 and 72 hours was similar between groups, and 86%, 93%, and 92% of patients in each group, respectively, achieved a mean glucose concentration of 80 to 180 mg/dL at 72 hours (P = .60). Hypoglycemia (glucose <65 mg/dL) only occurred in the 65% group (21%) and the 80% group (12%) over the first 72 hours (P = .02 in the 50% group compared with the 65% and 80% groups combined) with 1 event of a glucose concentration less than 40 mg/dL in the 80% group. There was no loss of glycemic control by the end of the once-daily dosing interval.

CONCLUSIONS

Glycemic targets can be achieved without hypoglycemia by 72 hours in most patients who have undergone cardiac surgery and require intravenous insulin with a regimen consisting of an initial insulin detemir dose of 50% of basal intravenous insulin requirements and prandial and supplemental insulin.

Evaluation of an intensive insulin transition protocol in the intensive care unit setting: a before and after study

The benefits of controlling blood glucose levels in intensive care units (ICUs) are well documented.

Objective

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.

Methods

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.

Results

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.

Conclusions

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.

Differential response between diabetes and stress-induced hyperglycaemia to algorithmic use of detemir and flexible mealtime aspart among stable postcardiac surgery patients requiring intravenous insulin

AIM

To determine whether an insulin algorithm could be used in a similar manner in the setting of diabetes and stress hyperglycaemia following cessation of intravenous (IV) insulin after cardiac surgery.

METHODS

Subjects who were clinically stable, requiring ≥ 1 unit/h of IV insulin 48 h after surgery, were randomized to once daily detemir at 50, 65 or 80% of IV insulin requirements and received aspart according to carbohydrate intake. Diabetes was defined as any history of diabetes or preoperative HbA1c 6.5%.

RESULTS

The morning glucose in patients with diabetes was 143 mg/dl (n = 61) vs. 124 mg/dl in those with stress hyperglycaemia (n = 21,p = 0.05) on day 1 and 127 vs. 110 mg/dl over 72 h (p = 0.01). This was unaffected by adjustment for initial dosing group. At 72 h, 56% of patients with stress hyperglycaemia reached AM (80-130 mg/dl) and 87% reached overall (80-180 mg/dl) glucose targets, compared to 90 and 100% of patients with stress hyperglycaemia, respectively. There was no difference in hypoglycaemia in patients with stress hyperglycaemia or diabetes. The percentage of patients with diabetes receiving insulin was 46% on admission and 77% at discharge, compared to 0 and 42% of patients with stress hyperglycaemia.

CONCLUSIONS

Following cardiac surgery, patients with stress hyperglycaemia may be converted from IV insulin to detemir with a 50% conversion factor, while patients with diabetes may require a higher conversion factor. Stress hyperglycaemia may be prolonged; the intensity and duration of insulin therapy required for optimal outcomes warrants further examination.

Management of hyperglycemia in the non-intensive care patient: featuring subcutaneous insulin protocols

OBJECTIVE

To provide insulin protocols and adjustment guidance for management of hyperglycemia in common inpatient clinical scenarios.

METHODS

We performed a PubMed search of pertinent existing literature from 1980 to 2010.

RESULTS

Hyperglycemia is frequently encountered in general medical and surgical wards and has been linked to adverse clinical outcomes, prolonged hospital length of stay, and increased institutional care needs after discharge. No randomized controlled trial has been conducted to define optimal glycemic goals or to investigate the effects of intensive glycemic control in the non-intensive care unit (ICU) setting. Nonetheless, it is advocated by the American Association of Clinical Endocrinologists and the American Diabetes Association, in their 2009 Consensus Statement on Inpatient Glycemic Control, that optimization of glycemia in hospitalized patients with diabetes and hyperglycemia be judiciously offered. This approach is clinically sound, in light of the known deleterious consequences of hyperglycemia in critically and noncritically ill patients and the benefits observed with improved glycemic control in intensive care settings. The approach to hyperglycemia in non-ICU inpatients should follow the principles of provision of basal-nutritional-supplemental insulin. Herein we provide insulin protocols and adjustment guidance for management of hyperglycemia in common clinical scenarios. Recommendations reflect the opinion of national experts in the field and our departmental consensus at Penn State Institute for Diabetes and Obesity.

CONCLUSION

Glycemic control in the non-ICU setting is a relevant clinical situation that should be addressed and managed effectively and prudently. We present a practical guide for management of hyperglycemia individualized to various clinical scenarios encountered in the general hospital wards.

Hospital Strategies for Insulin Therapy with Rapid-Acting Insulin Analogs

This article presents strategies on how to meet the challenges presented by the use of insulin in the hospital setting and describes trends seen in current hospital practice. Insulin provides the greatest flexibility in the hospital setting to achieve optimal blood glycemic control in patients with known type 2 diabetes, thereby reducing complications and death. Important challenges include implementing protocols for use of subcutaneous insulin injection (including optimal use of insulin pens), conversion from continuous subcutaneous insulin infusion or intravenous infusion to subcutaneous administration by multiple injections, and dosing of insulin in patients receiving corticosteroids. One important trend is a move away from the use of sliding-scale insulin to the use of correction-dose insulin as an adjunct to basal/bolus insulin. In this approach, insulin treatment is closely tailored to changing levels of glycemia, and a protocol is put in place for administration of a correction dose of rapid-acting insulin in response to a glycemic excursion. Insulin analogs can more closely mimic physiological insulin profiles than regular insulin, and rapid-acting analogs are invaluable agents as correction insulin administered by pump or in transition to multiple daily injections and as part of basal/bolus therapy. Good glycemic control can improve outcomes of hospital patients in several ways, including facilitating more rapid recovery from infections, shortening intensive care stays, and minimizing costs. Strategies employed to meet the challenges of insulin use in the hospital setting include the increasing use of continuous glucose monitoring systems and the development of insulin dosing algorithms.

Visceral obesity is a better predictor than generalized obesity for basal insulin requirement at the initiation of insulin therapy in patients with type 2 diabetes

AIMS

Basal insulin requirement in patients with type 2 diabetes is difficult to determine because of individual variability in insulin sensitivity and secretion. We aimed to identify factors that influence basal insulin requirement in insulin-naïve patients with type 2 diabetes.

METHODS

We studied 50 insulin-naïve patients with type 2 diabetes. Their basal insulin requirement was calculated by 8h overnight intravenous insulin infusion. Patients underwent abdominal computed tomography; subcutaneous and visceral fat areas were measured.

RESULTS

The basal insulin requirement was 31.3 ± 16.9 units/day, and it varied widely from 0.2 to 1.4 units/kg. It was positively correlated with visceral fat area (γ=0.485, P<0.001), body mass index (BMI, γ=0.339, P=0.008), glycated hemoglobin (HbA1C, γ=0.327, P=0.019), alanine aminotransferase (ALT, γ=0.310, P=0.027), and triglyceride (γ=0.305, P=0.032). However, body weight, waist circumference and total fat mass were not related to basal insulin requirement. Multiple linear regression analysis showed that visceral fat area, HbA1C, and ALT are independent predictors of basal insulin requirement.

CONCLUSIONS

Visceral obesity was a better predictor than generalized obesity for basal insulin requirement at the initiation of insulin therapy in patients with type 2 diabetes.

Transition from intravenous to subcutaneous insulin: effectiveness and safety of a standardized protocol and predictors of outcome in patients with acute coronary syndrome

OBJECTIVE

The study objectives were 1) to assess the effectiveness and safety of a standardized protocol for the transition to subcutaneous insulin and oral feeding in diabetic or hyperglycemic patients with acute coronary syndrome (ACS) who were receiving intravenous insulin and glucose at the time of the transfer from the intensive cardiac care unit to a general ward and 2) to identify predictors of transition outcome.

RESEARCH DESIGN AND METHODS

This was a prospective observational study. The protocol specifies that patients receive a 100% of their daily subcutaneous insulin requirement from the first day of oral feeding, calculated from the intravenous insulin rate during the final 12 h divided into two: 50% basal and 50% prandial.

RESULTS

In 142 patients (93 male, 49 female, age range 47-88 years, 135 with known diabetes) the first day after transition, 44.8% of blood glucose (BG) measurements were within the strict range of 100-140 mg/dL before meals and 100-180 mg/dL after meals, and 70.8% were within the broader ranges of 80-160 mg/dL and 80-200 mg/dL, respectively. Pre- or postprandial hypoglycemia (BG<70 mg/dL) occurred in 11 patients (7.7%) on the first day and in 38 patients (26.8%) on the first 3 days after transition. Old age, high doses of intravenous insulin, and wide BG variations in the 24 h before insulin infusion was stopped were predictive of poor BG control after transition.

CONCLUSIONS

This study shows the effectiveness and safety of a standardized protocol for the transition from intravenous to subcutaneous insulin in patients with ACS when regular oral feeding was resumed.

Glycemic control and nutritional strategies in the cardiothoracic surgical intensive care unit--2010: state of the art

Patients in the cardiothoracic surgical intensive care unit are generally critically ill and undergoing a systemic inflammatory response to cardiopulmonary bypass, ischemia/reperfusion, and hypothermia. This presents several metabolic challenges: hyperglycemia in need of intensive insulin therapy, catabolism, and uncertain gastrointestinal tract function in need of nutritional strategies. Currently, there are controversies surrounding the standard use of intensive insulin therapy and appropriate glycemic targets as well as the use of early enteral nutrition ± parenteral nutrition. In this review, an approach for intensive metabolic support in the cardiothoracic surgical intensive care unit is presented incorporating the most recent clinical evidence. This approach advocates an IIT blood glucose target of 80-110 mg/dL if, it can be implemented safely, with early nutrition support (using parenteral nutrition as needed) to prevent a critical energy debt.

Conversion from intravenous insulin to subcutaneous insulin after cardiovascular surgery: transition to target study

BACKGROUND

No study of transition from intravenous to subcutaneous insulin after cardiac surgery with dose based on percentage of intravenous total daily insulin (TDI) has reported a clearly superior regimen for achieving target blood glucose. We compared three first-dose transition strategies for insulin glargine: two based on TDI alone and one that also took body weight into account.

METHODS

Mostly obese, type 1 and type 2 diabetes patients (n = 223) undergoing cardiac surgery were randomized to receive insulin glargine subcutaneously at 60% or 80% of TDI or in a dose based on TDI and body weight.

RESULTS

Transition to subcutaneous insulin occurred 27.4 ± 6.6 h after surgery. Over the study period, mean proportion of blood glucose values within target range (80-140 mg/dL) were 0.34 ± 0.24, 0.35 ± 0.24, and 0.36 ± 0.22 in the 60% TDI, 80% TDI, and weight-based groups, respectively. This difference was not significant. Significantly more insulin corrections were needed in the 60% TDI group than in the weight-based group. There was only one incidence of hypoglycemia (blood glucose < 40 mg/dL).

CONCLUSIONS

No subcutaneous insulin regimen implemented approximately 1 day after cardiac surgery showed significantly better control of blood glucose over the 3-day study period. Further studies are needed to determine optimal formulae for effecting an early transition to subcutaneous insulin after cardiac surgery or whether it is preferable and/or necessary to continue intravenous insulin therapy for an additional period of time.

Superiority of moderate control of hyperglycemia to tight control in patients undergoing coronary artery bypass grafting

OBJECTIVE

Although consensus in cardiac surgery supports tight control of perioperative hyperglycemia (glucose<120 mg/dL), recent studies in critical care suggest moderate glycemic control may be superior. We sought to determine whether tight control or moderate glycemic control is optimal after coronary artery bypass grafting.

METHODS

From 1995 to 2008, a total of 4658 patients with known diabetes or perioperative hyperglycemia (preoperative glycosylated hemoglobin≥8 or postoperative serum glucose>126 mg/dL) underwent isolated coronary artery bypass grafting at our institution. Patients were stratified into 3 postoperative glycemic groups: tight (≤126 mg/dL), moderate (127-179 mg/dL), and liberal (≥180 mg/dL). Preoperative risk factors, glycemic management, and postoperative outcomes were analyzed.

RESULTS

Operative mortality was 2.5% (119/4658); major complication rate was 12.5% (581/4658). Relative to moderate group, more patients in tight group had preoperative renal failure (tight 16.4%, 22/134, moderate 8.3%, 232/2785, P=.001) and underwent emergent operations (tight 5.2%, 7/134, moderate 1.9%, 52/2785, P=.007); however, Society of Thoracic Surgeons predicted mortality risk was lower in tight group (P<.001). Moderate group had lowest mortality (tight 2.9%, 4/134, moderate 2.0%, 56/2785, liberal 3.4%, 59/1739, P=.02) and incidence of major complications (tight 19.4%, 26/134, moderate 11.1%, 308/2785, liberate 14.2%, 247/1739, P<.001). Risk-adjusted major complication incidence (adjusted odds ratio 0.7, 95% confidence interval 0.58-0.87) and mortality (adjusted odds ratio 0.6, 95% confidence interval 0.37-0.83) were lower with moderate glucose control than with tight or liberal management.

CONCLUSIONS

Moderate glycemic control was superior to tight glycemic control, with decreased mortality and major complications, and may be ideal for patients undergoing isolated coronary artery bypass grafting.

[Impairment of cardiac autonomic nervous system and incidence of arrhythmias in severe hyperglycemia]

BACKGROUND AND PURPOSE

Deterioration of cardiac autonomic nervous system in diabetics is associated with increased cardiac and arrhythmogenic mortality. Therefore, the present study engaged in the question how heart rate variability is acutely changed in diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome. Moreover was evaluated how blood pressure, heart rate and incidence of arrhythmias can be explained by figures of heart rate variability.

PATIENTS AND METHODS

In a prospective observation of time course we investigated in 4 years consecutively 12 intensive care patients with DKA and 2 with HHS (10 male, 4 female, 19-62 years, initial plasma glucose 404-1192 mg/dl). All patients received a standardized treatment to international current guidelines. In addition to hemodynamic and clinical-chemical monitoring HRV analysis was performed continuously for at least 48 hours. Simultaneously, we determined supraventricular and ventricular arrhythmic episodes.

RESULTS

HRV was diminished over the whole spectrum in dependence on blood glucose concentration. Thus, sympathovagal balance (LF/HF ratio) was initially sympathetic predominated in blood glucose levels < 600 mg/dl (relatively prevailing LF power) and vagal predominated in blood glucose levels > 600 mg/dl (relatively prevailing HF power). In correlation analysis of HRV parameters with blood glucose rS-coefficients from -0.934 to -0.821 were achieved (p < 0.001). Further, the initial mean blood pressure correlated with the LF/HF ratio in HRV minimum (rS = 0.711, p = 0.004). The initial heart rate in relation to assumed intrinsic frequency correlated with minimal found Total Power (rS = -0.656, p = 0.011). In the period of whole 48 hours, more arrhythmic events occurred in consequence to initial glucose levels (rS = 0.693, p = 0.006). But the maximum of arrhythmic episodes was usually later ascertained than the minimum of HRV (p < 0.001). At the time of each arrhythmic maximum the sympathovagal balance (LF/HF) showed no uniform figures. Only similar in all cases was that the LF/HF ratio was found either > 4 or < 1.

CONCLUSION

Clinical complications in high glucose levels must be seen in the context of a nearly complete blockade of sympathetic and parasympathetic activity. Basically to extreme autonomic restriction, sympathetic and vagal predominance can change rapidly into each other. This retarded vulnerable predisposition may declare the arrhythmic potential. An important progress in the monitoring of patients could be achieved by implementation of a continuous HRV measurement because hereby the actual risk potential can be ascertained timely and reliably.

Ensuring optimal insulin utilization in the hospital setting: role of the pharmacist

PURPOSE

To summarize essential information for the hospital pharmacist to support the safe and effective use of insulin for the treatment of inpatient hyperglycemia.

SUMMARY

Ensuring optimal insulin utilization in the hospital setting requires collaboration of a multidisciplinary team, including physicians (and endocrinologists specifically), nurses, pharmacists, dieticians, diabetes educators, laboratory staff, quality management staff, and others. The role of pharmacists in this multidisciplinary team is to assist in the standardization of insulin therapy via selection of appropriate insulin treatment protocols, participate in formulary management of insulin products, and contribute to the development of order sets and policies and procedures to minimize the risk of medication errors and misadventures. In addition, pharmacists can provide guidelines or treatment recommendations in special situations, such as those involving patients receiving enteral or parenteral nutrition or high-dose corticosteroids and the transition from i.v. to subcutaneous insulin therapy. Education of patients and providers is another key role for pharmacists. Nurses are important allies in the effort to ensure safe insulin use, as they are at the bedside of patients administering and adjusting insulin therapy. Recommendations are provided for the safe and effective use of insulin for the treatment of inpatient hyperglycemia.

CONCLUSION

Pharmacists are an integral part of the multidisciplinary team ensuring the safe and effective implementation of inpatient hyperglycemic control and insulin usage.

Analysis of institutional blood glucose surveillance

In an article by Anderson and colleagues in this issue of Journal of Diabetes Science and Technology, the 2009 Remote Automated Laboratory System Report describes the use of a proprietary software application in 576 United States hospital benchmark subscribers, permitting blood glucose surveillance. The Program for the Treatment of the Hospitalized Diabetic Patient was initiated at Edith Wolfson Medical Center in 2007 and included an automated glucometer in each inpatient department. Results are transmitted automatically to a central database. Importantly, these data interface with the patient electronic medical record, permitting accurate patient follow-up within and between hospitalizations; the patient response-to-treatment evaluation; identification of secular glucose trends; and interdepartmental and interinstitutional comparisons. The data have been associated with a significant reduction in random blood glucose values. In Israel, the National Diabetes Council has recommended the use of automated institutional glucometers in all hospitals.

Maintaining glycemic control when transitioning from infusion insulin: a protocol-driven, multidisciplinary approach

BACKGROUND

An observational pilot study of 41 medical and surgical intensive care patients on infusion insulin at our own institution found that glycemic control rapidly deteriorated within 48 hours of stopping infusion insulin. This prompted the design and testing of a transition protocol.

METHODS

The transition protocol identified appropriate patients for subcutaneous (SC) insulin along with the insulin dose and schedule. A pharmacist-hospitalist improvement team offered protocol guidance but adherence was left to the discretion of the provider. The primary endpoints were mean blood glucose the first and second day after stopping the insulin infusion and the number of patients with hypoglycemia (41-70 mg/dL) and severe hypoglycemia (<40 mg/dL) during the 48-hour transition. Secondary endpoints include severe hyperglycemia (>300 mg/dL), length of stay (LOS), re-initiation of the infusion insulin, day-weighted glucose mean 12 days following transition for patients with diabetes, and identification of a new diagnosis of diabetes.

RESULTS

Patients with diabetes transitioned by protocol (n = 33) had better glycemic control than those (n = 39) transitioned without the protocol (Day 1 population glucose mean of 168 mg/dL vs. 211 mg/dL [P<0.001], Day 2 means of 176 mg/dL vs 218 mg/dL [P<0.001]). Severe hypoglycemia occurred once in each group. There were 14 patients newly diagnosed with diabetes based on an A1c ≥6%. Patients with stress hyperglycemia maintained good glycemic control with correctional insulin only.

CONCLUSION

Protocol adherence improved glycemic control, reduced unnecessary use of insulin, and identified patients with previously undiagnosed diabetes, without any increase in hypoglycemia.

Addressing hyperglycemia from hospital admission to discharge

BACKGROUND

This review examines glycemia management practices in hospitalized patients. Optimal glycemic control remains a challenge among hospitalized patients. Recent studies have questioned the benefit of tight glycemic control and have raised concerns regarding the safety of this approach. As a result, medical societies have updated glycemic targets and have published new consensus guidelines for management of glycemia in hospitalized patients. This review highlights recent inpatient glycemic trials, the new glycemic targets and recommended strategies for management of glycemia in hospitalized patients.

METHODS

Medline and PubMed searches (diabetes, hyperglycemia, hypoglycemia, intensive therapy insulin, tight glycemic control, and hospital patients) were performed for English-language articles on treatment of diabetes, insulin therapy, hyperglycemia or hypoglycemia in hospitalized patients published from 2004 to present. Earlier works cited in these papers were surveyed. Clinical studies, reviews, consensus/guidelines statements, and meta-analyses relevant to the identification and management of diabetes and hyperglycemia in hospitalized patients were included and selected. This is not an exhaustive review of the published literature.

RESULTS

Insulin remains the most appropriate agent for a majority of hospitalized patients. In critically ill patients insulin is given as a continuous intravenous (IV) infusion and in non-critically ill inpatients hyperglycemia is best managed using scheduled subcutaneous (SC) basal-bolus insulin regimens supplemented with correction doses as needed and adjusted daily with the guidance of frequent blood glucose monitoring. Prevention of hypoglycemia is equally as important to patient outcomes and is an equally necessary part of any effective glucose control program. Modern insulin analogs offer advantages over the older human insulins (e.g., regular and neutral protamine Hagedorn [NPH] insulin) because their time-action profiles more closely correspond to physiological basal and prandial insulin requirements, and have a lower propensity for inducing hypoglycemia than human insulin formulations. Long-acting basal insulin analogs (glargine, detemir) are suitable and preferred for the basal component of therapy; rapid-acting insulin analogs (aspart, lispro, glulisine) are recommended for bolus and correction doses. Sliding-scale insulin (SSI) regimens are not effective and should not be used, especially as this excludes a basal insulin component from the therapy.

CONCLUSIONS

Optimal glycemic management in the hospital setting requires judicious treatment of hyperglycemia while avoiding hypoglycemia. Insulin is the most appropriate agent for management of hyperglycemia for the majority of hospitalized patients. Intravenous insulin infusion is still preferred during and immediately after surgery, but s.c. basal insulin analogs with prandial or correction doses should be used after the immediate post-operative period, and also should be used in non-critically ill patients. Frequent and effective glucose monitoring is critical for avoiding wide deviations from acceptable glucose levels, which under a recently promulgated consensus guideline currently range between 140 mg/dL and 180 mg/dL. Glucose targets near 140 mg/dL are recommended as being the most appropriate for all hospitalized patients.

Institutional blood glucose monitoring system for hospitalized patients: an integral component of the inpatient glucose control program

BACKGROUND

The ability to measure patient blood glucose levels at bedside in hospitalized patients and to transmit those values to a central database enables and facilitates glucose control and follow-up and is an integral component in the care of the hospitalized diabetic patient.

OBJECTIVE

The goal of this study was to evaluate the performance of an institutional glucometer employed in the framework of the Program for the Treatment of the Hospitalized Diabetic Patient (PTHDP) at E. Wolfson Medical Center, Holon, Israel.

METHODS

As part of the program to facilitate glucose control in hospitalized diabetic patients, an institutional glucometer was employed that permits uploading of data from stands located in each inpatient department and downloading of that data to a central hospital-wide database. Blood glucose values from hospitalized diabetic patients were collected from August 2007 to October 2008. The inpatient glucose control program was introduced gradually beginning January 2008.

RESULTS

During the follow-up period, more than 150,000 blood glucose measures were taken. Mean glucose was 195.7 +/- 99.12 mg/dl during the follow-up period. Blood glucose values declined from 206 +/- 105 prior to PTHDP (August 2007-December 2007) to 186 +/- 92 after its inception (January 2008-October 2008). The decline was associated significantly with time (r = 0.11, p < 0.0001). The prevalence of blood glucose values lower than 60 mg/dl was 1.48% [95% confidence interval (CI) 0.36%] prior to vs 1.55% (95% CI 0.37%) following implementation of the PTHDP. Concomitantly, a significant increase in the proportion of blood glucose values between 80 and 200 mg/dl was observed, from 55.5% prior to program initiation vs 61.6% after program initiation (p < 0.0001).

CONCLUSIONS

The present study was designed to observe changes in institution-wide glucose values following implementation of the PTHDP. Information was extracted from the glucometer system itself. Because the aforementioned study was not a clinical trial, we cannot rule out that factors other than introduction of the program could explain some of the variability observed. With these limitations in mind, it nevertheless appears that the PTHDP, of which the institutional glucometer is an integral, essential component, was associated with improved blood glucose values in the hospitalized diabetic patient.

Hyperglycemia Management in the Hospital: The Pharmacists Role

Hyperglycemia is prevalent in the inpatient setting and is associated with increased morbidity and mortality in patients with diabetes and in those without diabetes. Too often hyperglycemia is underrecognized, under-reported, and undermanaged. Insulin is the treatment of choice for most patients who have hyperglycemia and are hospitalized, and pharmacists are often responsible for ensuring its safe and effective use. Improving hyperglycemia management in patients who are hospitalized provides pharmacists with an opportunity to positively affect patient outcomes and health care costs. This article discusses the pharmacist's role in managing blood glucose levels; current recommendations for target blood glucose concentrations; the evolution of insulin treatment from sliding scale to algorithms/protocols to computer-guided decision-support systems; discharge planning; and patient education.

Cleveland Clinic cardiovascular intensive care unit insulin conversion protocol

BACKGROUND

The importance of near-normal blood glucose in the immediate postoperative period is generally accepted and is best achieved in the perioperative period with a constant intravenous (IV) infusion of insulin. This requires intensive nursing only achievable in an intensive care unit (ICU) setting. Glucose management after transfer to a regular nursing floor (RNF) has not been studied systematically. In August 2006, the Cleveland Clinic began using long-acting insulin glargine as the insulin infusion was terminated in the ICU.

METHODS

This prospective analysis examined all patients receiving IV insulin infusion after cardiothoracic surgery in a 1 month period. The analyses evaluated the safety and efficacy of a protocol using a transition to subcutaneous insulin glargine of 50% of the calculated 24 h requirement at the end of the ICU insulin infusion protocol in preparation for transfer to the RNF.

RESULTS

Only 1 patient in 99 developed hypoglycemia, and no patient suffered severe hypoglycemia (glucose < 40 mg/dl), while the majority (70%) had euglycemia (glucose between 70 and 150 mg/dl).

CONCLUSIONS

This approach was both safe-as there was very little hypoglycemia (1 patient in 99)-and effective, as blood sugar was well controlled in most subjects. Efficacy for achieving euglycemia was 70%. Efficacy was likely reduced because of the upper limit of insulin glargine dosage imposed by some providers as a safety consideration. Although there was a physician option to override, the maximum protocol dose of 30 U was rarely exceeded, leading to inadequate dosing in some subjects who required high insulin infusion rates in the ICU.

Conversion from Continuous Insulin Infusions to Subcutaneous Insulin in Critically III Patients

Background:

Continuous insulin infusions have become a standard of care in many intensive care units (ICUs); however, methods for transitioning patients from continuous infusions to other insulin therapies have not been extensively evaluated.

Objective:

To determine the most effective method for transitioning ICU patients from continuous insulin infusions to subcutaneous insulin therapy.

Methods:

A searchable pharmacy database at the University of North Carolina Hospitals was used to retrospectively identify adults admitted to the neurosurgery ICU and prescribed a continuous insulin infusion between May 2007 and February 2008, All patients were transitioned to subcutaneous insulin upon floor transfer. Patients were stratified according to the dose of subcutaneous insulin as a percentage of their prior 24-hour continuous insulin requirement and then analyzed on the rate of achievement of goal blood glucose values (80–150 mg/dL) within the first 48 hours after transition.

Results:

A total of 769 blood glucose values from 79 patients were recorded during the study. Data analysis demonstrated significantly lower median blood glucose values with the use of subcutaneous insulin doses that were 60–70% of insulin infusion requirements when compared with all other groups. For patients without a history of diabetes mellitus, the use of a subcutaneous dose that was 60–70% of the insulin infusion requirement resulted in a significantly greater percentage of patients within the target range compared with other groups (78%; p < 0.05). For those with a history of diabetes, subcutaneous doses higher than 70% of the insulin infusion requirement yielded the most frequent achievement of target values, although there was substantial variability within this group. No significant difference was noted in the incidence of hypoglycemia (blood glucose <80 mg/dL) between groups, although the frequency of hypoglycemia was almost twice as high in the group with diabetes as in those without it (4.2% vs 2.2%).

Conclusions:

Methods currently used to transition patients off insulin infusions vary widely. Initial data suggest that utilizing 60–70% of the 24-hour insulin infusion requirement as a subcutaneous dose would result in blood glucose values of 80–150 mg/dL 70% of the time. Further study is necessary to adequately assess the optimal insulin infusion transition protocol for critically ill patients to ensure both safety and efficacy.

Evaluation of glycemic control following discontinuation of an intensive insulin protocol

BACKGROUND

Intensive insulin protocols (IIPs) have been demonstrated to reduce morbidity and mortality in critically ill patients. Currently, there are no published studies evaluating glycemic control after discontinuation of an IIP.

OBJECTIVE

The purpose of this study was to compare blood glucose (BG) control during an IIP and for 5 days following its discontinuation (follow-up period).

METHODS

The study was a retrospective review of intensive care unit patients who received an IIP for >or=24 hours. Data were collected during the last 12 hours of the IIP and subsequent follow-up period.

RESULTS

For all 65 included patients, the mean +/- standard deviation for BG on the IIP was 123 +/- 26 mg/dL versus 168 +/- 50 mg/dL following discontinuation of the IIP (P < 0.001). The median (interquartile range) insulin that was administered decreased from 40 (22-65) units on the IIP to 8 (0-18) units after the IIP was stopped (P < 0.001). The mean daily BG during the follow-up period was significantly higher than that during the IIP (P < 0.001). Additionally, an insulin requirement of >20 units during the last 12 hours of the IIP was identified as a risk factor for poor glycemic control during the follow-up period (odds ratio: 4.62; 95% confidence interval: 1.17-18.17).

CONCLUSIONS

This study demonstrates a significant increase in BG following discontinuation of an IIP. Higher insulin requirements during the last 12 hours of an IIP were identified as an independent risk factor for poor glycemic control following the IIP. A standardized insulin transition protocol may help better control BG after discontinuation of an IIP.

Surgical Resident and Attending Physician Attitudes toward Glucose Control in the Surgical Patient

Hyperglycemia is a common occurrence in postoperative surgical patients and has been related to adverse outcomes, including increased infections, delayed wound healing, and increased postoperative mortality. Therefore, the management of hyperglycemia has become an increasingly important part of surgical practice. A 16-point questionnaire was distributed to general surgery housestaff and attending physicians at three teaching hospitals in southern California. The survey was scaled 1 to 5 (1, strongly disagree; 5, strongly agree). Answers of 1 and 2 were considered a negative response, whereas 4 and 5 were considered affirmative responses. There were 105 survey respondents (60 surgical residents, 45 surgical attendings). Only half of respondents were confident in their ability to adequately control blood sugar in their hospitalized patients. Approximately 60 per cent of attendings rely on residents to manage glucose control. Less than half of the attendings (49%) and less than one-third of residents (27%) stated they were current with the latest guidelines for glucose control. Only one-third of the attendings would consult an internist or endocrinologist to assist in glycemic management. This study reveals an important knowledge deficit among surgical resident and attending physicians. Focused education on glycemic control in the perioperative patient should be a mandatory component of surgical training.

Practical aspects of intensive insulinization in the intensive care unit

PURPOSE OF REVIEW

Strategies used for intensive insulin therapy of critically ill patients and differences of approach according to medical condition are reviewed.

RECENT FINDINGS

Acceptance of proposed glycemic targets for critically ill patients has been tempered by uncertainties about benefit of strict glycemic control for specific target subpopulations, differences between treatment centers, optimal timing and duration of intervention, and safety. Present-day intravenous insulin infusion protocols may perform well only for restricted populations. Assessment of protocol performance requires knowledge of algorithm behavior on or near the narrow target range and, using the patient as unit of observation, examination of glycemic variability. Systems of the future will permit adjustment of algorithm parameters to meet individual- or population-specific targets and match carbohydrate exposure.

SUMMARY

Attainment and preservation of glycemic control among critically ill patients are best attempted with intravenous insulin infusion. Advances in the design of decision support and insulin delivery systems, and progress in the technology of continuous blood glucose monitoring, are likely to reduce the risk of hypoglycemia, without compromise of target range control, such that the patient outcomes enjoyed by experienced centers in the future will prove generalizable to others through the extension of new technologies.