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Rovida S, Bruni A, Pelaia C, Bosco V, Saraco G, Galluzzo E, Froio A, Auletta G, Garofalo E, Longhini F. Nurse led protocols for control of glycaemia in critically ill patients: A systematic review. Intensive Crit Care Nurs 2022; 71:103247. [PMID: 35437186 DOI: 10.1016/j.iccn.2022.103247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Blood glucose control in critically ill patients is challenging and can affect clinical outcomes. Several manual as well as automated approaches have been proposed over the time, however nursing staff still covers the key-role for optimization of glycemia throughout adjustment of insulin infusion and administration. AIM Systematic review to compare the efficacy/the effects of nurse led insulin infusion protocols versus standard approaches in patients admitted in the intensive care unit. METHODS All relevant studies evaluating nurse directed protocols for insulin administration in critically ill adults. Data was independently extracted and collected through a dedicated electronic form. The following outcomes have been recorded: the number (or percentage) of glycaemia measurements within the target range; the number of hypo- and hyper-glycaemic events, separately; the mean glycaemia; the lowest and highest glycemia values recorded; the time to reach the glycaemia target; the ICU length of stay and the ICU and the long-term (>30 days) mortality. Statistical analysis was conducted on the summary statistics of the selected articles (eg, means, medians, proportions). Unpaired nonparametric continuous data were compared through the Mann-Whitney U-test. RESULTS Glycaemic control as well as ICU length of stay and mortality are similar in both patients' groups. Specifically, the group of patients treated with standard modalities include those treated with doctors led protocols, paper charts or software-based approaches. CONCLUSION Overall, nurse led insulin protocols can effectively control blood glucose level among critically ill patients.
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Affiliation(s)
- Serena Rovida
- Department of Emergency Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Andrea Bruni
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Corrado Pelaia
- Department of Health Sciences, Magna Graecia University, Catanzaro, Italy
| | - Vincenzo Bosco
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Giuseppe Saraco
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Erika Galluzzo
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Annamaria Froio
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Gaetano Auletta
- School of Nursing, Department of Translational Medicine, Eastern Piedmont University, Novara, Italy
| | - Eugenio Garofalo
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.
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Rodriguez-Calero MA, Barceló Llodrá E, Cruces Cuberos M, Blanco-Mavillard I, Pérez Axartell MA. Effectiveness of an evidence-based protocol for the control of stress-induced hyperglycaemia in critical care. ENFERMERIA INTENSIVA 2018; 30:4-12. [PMID: 29935968 DOI: 10.1016/j.enfi.2018.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 11/17/2022]
Abstract
AIM To assess the effectiveness of the implementation of a protocol for glycaemic control in critical care, in terms of maintenance of a pre-established target of blood glucose level, reduction of hyperglycaemia and prevention of severe hypoglycaemia. METHOD Prospective "pre-post" quasi-experimental study carried out in a general critical care unit. Adult patients treated with intravenous insulin were included. We recorded all glycaemic tests performed from November 2014 to August 2015 (pre-intervention) and from November 2015 to August 2016 (post-intervention). The intervention consisted of the implementation of an evidence-based glycaemic control protocol to achieve glycaemic levels in a range of 140-180mg/dl. Main variables analysed were: proportion of glycaemic tests in the target range, proportions of severe hypoglycaemia (under 40mg/dl) and hyperglycaemia over 200mg/dl. RESULTS We analysed 7864 glycaemic tests from 125 patients, 66 pre-intervention and 59 post-intervention. Average age was 66.24±13.99 years, 64% of patients were male. The proportion of tests within the target range was higher in the intervention group (38.82 vs. 44.34 p<.001). Only one case of severe hypoglycaemia was identified, which happened in the pre-intervention period. The rate of severe hyperglycaemia was lower in the post-intervention group (19.19 vs. 16.28 p=.001). CONCLUSIONS Our experience shows that implementation of evidence-based interventions can improve glycaemic control during critical illness. We found higher glycaemia levels in the target range. The protocol proved useful in the prevention of severe hypoglycaemia. Nurse-led interventions based on clinical data improved health results in our patients.
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Affiliation(s)
- M A Rodriguez-Calero
- Unidad de Calidad, Docencia e Investigación, Hospital de Manacor, Manacor, Mallorca, España.
| | - E Barceló Llodrá
- Área del Paciente Crítico, Hospital de Manacor, Manacor, Mallorca, España
| | - M Cruces Cuberos
- Unidad de Cuidados Intensivos, Hospital de Manacor, Manacor, Mallorca, España
| | - I Blanco-Mavillard
- Unidad de Calidad, Docencia e Investigación, Hospital de Manacor, Manacor, Mallorca, España
| | - M A Pérez Axartell
- Unidad de Cuidados Intensivos, Hospital de Manacor, Manacor, Mallorca, España
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Forlenza GP, Chinnakotla S, Schwarzenberg SJ, Cook M, Radosevich DM, Manchester C, Gupta S, Nathan B, Bellin MD. Near-euglycemia can be achieved safely in pediatric total pancreatectomy islet autotransplant recipients using an adapted intravenous insulin infusion protocol. Diabetes Technol Ther 2014; 16:706-13. [PMID: 25068208 PMCID: PMC4201245 DOI: 10.1089/dia.2014.0061] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Children with severe chronic pancreatitis may undergo total pancreatectomy with islet autotransplantation (TPIAT) to relieve pain while minimizing the risk of postsurgical diabetes. Because overstimulation of transplanted islets by hyperglycemia can result in β-cell loss, we developed a specialized intravenous insulin infusion protocol (IIP) for pediatric TPIAT recipients to maintain euglycemia or near-euglycemia posttransplant. SUBJECTS AND METHODS Our objective was to review glucose control using an IIP specific for TPIAT recipients at a single institution. We reviewed postoperative blood glucose (BG) levels for 32 children 4-18 years old with chronic pancreatitis who underwent TPIAT between July 2011 and June 2013. We analyzed the proportion of BG values in the range of 70-140 mg/dL, mean glucose, glucose variability, and occurrence of hypoglycemia during the IIP; we also evaluated the transition to subcutaneous therapy (first 72 h with multiple daily injections [MDI]). RESULTS During IIP, the mean patient BG level was 116±27 mg/dL, with 83.1% of all values in the range of 70-140 mg/dL. Hypoglycemia was rare, with only 2.5% of values <70 mg/dL. The more recent era (n=16) had a lower mean BG and less variability than the early era (first 16 patients) (P≤0.004). Mean glucose level (116 vs. 128 mg/dL) and glucose variability were significantly lower during the IIP compared with MDI therapy (P<0.0001). CONCLUSIONS Tight glycemic control without excessive severe hypoglycemia was achieved in children undergoing TPIAT using an IIP specifically designed for this population; the ability to maintain BG in target range improved with experience with the protocol.
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Affiliation(s)
- Gregory P. Forlenza
- Department of Pediatrics, University of Minnesota Medical Center and Amplatz Children's Hospital, Minneapolis, Minnesota
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical Center and Amplatz Children's Hospital, Minneapolis, Minnesota
| | - Sarah J. Schwarzenberg
- Department of Pediatrics, University of Minnesota Medical Center and Amplatz Children's Hospital, Minneapolis, Minnesota
| | - Marie Cook
- Department of Surgery, University of Minnesota Medical Center and Amplatz Children's Hospital, Minneapolis, Minnesota
| | - David M. Radosevich
- Department of Surgery, University of Minnesota Medical Center and Amplatz Children's Hospital, Minneapolis, Minnesota
| | | | - Sameer Gupta
- Department of Pediatrics, University of Minnesota Medical Center and Amplatz Children's Hospital, Minneapolis, Minnesota
| | - Brandon Nathan
- Department of Pediatrics, University of Minnesota Medical Center and Amplatz Children's Hospital, Minneapolis, Minnesota
| | - Melena D. Bellin
- Department of Pediatrics, University of Minnesota Medical Center and Amplatz Children's Hospital, Minneapolis, Minnesota
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Krikorian A, Ismail-Beigi F, Moghissi ES. Comparisons of different insulin infusion protocols: a review of recent literature. Curr Opin Clin Nutr Metab Care 2010; 13:198-204. [PMID: 20040862 DOI: 10.1097/mco.0b013e32833571db] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To provide an update on the currently available insulin infusion protocols for treatment of hyperglycemia in critically ill patients and to discuss the major differences and similarities among them. RECENT FINDINGS We identified a total of 26 protocols, 20 of which used manual blood-glucose calculations, and six that used computerized algorithms. The major differences and similarities among the insulin infusion protocols were in the following areas: patient characteristics, target glucose level, time to achieve target glucose level, incidence of hypoglycemia, rationale for adjusting the rates of insulin infusion, and methods of blood-glucose measurements. Several computerized protocols hold promise for safer achievement of glycemic targets. SUMMARY Insulin infusion is the most effective method for controlling hyperglycemia in critically ill patients. Clinicians should utilize a validated insulin infusion protocol that is well tolerated, and is most appropriate and practical for their institution based on the resources that are available.
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Affiliation(s)
- Armand Krikorian
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, USA.
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Szumita PM. The hospital pharmacist: an integral part of the hyperglycaemic management team. J Clin Pharm Ther 2009; 34:613-21. [DOI: 10.1111/j.1365-2710.2009.01040.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Adams G, Hunter J, Langley J. Is nurse-managed blood glucose control in critical care as safe and effective as the traditional sliding scale method? Intensive Crit Care Nurs 2009; 25:294-305. [DOI: 10.1016/j.iccn.2009.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Revised: 09/15/2009] [Accepted: 09/19/2009] [Indexed: 12/01/2022]
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Eslami S, de Keizer NF, de Jonge E, Schultz MJ, Abu-Hanna A. A systematic review on quality indicators for tight glycaemic control in critically ill patients: need for an unambiguous indicator reference subset. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R139. [PMID: 19014427 PMCID: PMC2646350 DOI: 10.1186/cc7114] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 10/14/2008] [Accepted: 11/11/2008] [Indexed: 01/08/2023]
Abstract
Introduction The objectives of this study were to systematically identify and summarize quality indicators of tight glycaemic control in critically ill patients, and to inspect the applicability of their definitions. Methods We searched in MEDLINE® for all studies evaluating a tight glycaemic control protocol and/or quality of glucose control that reported original data from a clinical trial or observational study on critically ill adult patients. Results Forty-nine studies met the inclusion criteria; 30 different indicators were extracted and categorized into four nonorthogonal categories: blood glucose zones (for example, 'hypoglycaemia'); blood glucose levels (for example, 'mean blood glucose level'); time intervals (for example, 'time to occurrence of an event'); and protocol characteristics (for example, 'blood glucose sampling frequency'). Hypoglycaemia-related indicators were used in 43 out of 49 studies, acting as a proxy for safety, but they employed many different definitions. Blood glucose level summaries were used in 41 out of 49 studies, reported as means and/or medians during the study period or at a certain time point (for example, the morning blood glucose level or blood glucose level upon starting insulin therapy). Time spent in the predefined blood glucose level range, time needed to reach the defined blood glucose level target, hyperglycaemia-related indicators and protocol-related indicators were other frequently used indicators. Most indicators differ in their definitions even when they are meant to measure the same underlying concept. More importantly, many definitions are not precise, prohibiting their applicability and hence the reproducibility and comparability of research results. Conclusions An unambiguous indicator reference subset is necessary. The result of this systematic review can be used as a starting point from which to develop a standard list of well defined indicators that are associated with clinical outcomes or that concur with clinicians' subjective views on the quality of the regulatory process.
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Affiliation(s)
- Saeid Eslami
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Meibergdreef, 1105 AZ Amsterdam, The Netherlands.
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Dickerson RN, Swiggart CE, Morgan LM, Maish GO, Croce MA, Minard G, Brown RO. Safety and efficacy of a graduated intravenous insulin infusion protocol in critically ill trauma patients receiving specialized nutritional support. Nutrition 2008; 24:536-45. [DOI: 10.1016/j.nut.2008.02.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2007] [Revised: 02/10/2008] [Accepted: 02/12/2008] [Indexed: 12/31/2022]
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Abstract
The role of hyperglycaemia in critical illness, and its corresponding treatment, has been an area of controversy, fuelled by conflicting research findings. The aims of this study were to critically evaluate the literature and present an historical review of the sequence of published papers relating to blood glucose control in critical care. Their subsequent impact together with the implications for patient care is discussed. This article is based on a systematic review of papers relating to glycaemic control in critical care patients. The review was conducted using the MedLine, CINAHL and EMBASE databases using key search terms (details of the search terms can be found after the conclusion of the paper) for the period 1950-2006. The searches resulted in 4863 papers being screened for relevance to the historic progression of glycaemic management in critical care patients, by title and then abstract. Of these, 209 were accessed, and their reference lists were snowballed for further papers. Papers that were repeatedly quoted throughout the literature and were therefore considered important in the historical development of accepted critical care practice were finally subjected to rigorous appraisal. These totalled 91 papers and included 18 randomized controlled trials, an additional 28 research papers, 25 editorials and 20 reviews. This critical evaluation of published work indicates that the evidence for the benefit of this therapy may not be as compelling as previously indicated, and its widespread use may have been premature. From a nursing perspective, this demonstrates the importance of maintaining a questioning attitude to new therapies and reviewing best practice in the light of evolving evidence.
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Affiliation(s)
- Penny Parsons
- Intensive Care Society Trials Group, Nuffield Department of Anaesthetics, University of Oxford, Oxford, UK.
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de Graaff MJ, Spronk PE, Schultz MJ. Strict Glycemic Control: Not If and When, but Who and How? YEARBOOK OF INTENSIVE CARE AND EMERGENCY MEDICINE 2008. [DOI: 10.1007/978-3-540-77290-3_47] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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de Graaff MJ, Spronk PE, Schultz MJ. Strict Glycemic Control: Not If and When, but Who and How? Intensive Care Med 2008. [DOI: 10.1007/978-0-387-77383-4_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Oeyen SG, Hoste EA, Roosens CD, Decruyenaere JM, Blot SI. Adherence to and Efficacy and Safety of an Insulin Protocol in the Critically Ill: A Prospective Observational Study. Am J Crit Care 2007. [DOI: 10.4037/ajcc2007.16.6.599] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Blood glucose control during acute illness has been associated with improved outcomes.
Objectives To evaluate adherence to and efficacy and safety of an insulin protocol for critically ill patients with target blood glucose levels between 81 and 110 mg/dL and to determine factors associated with adequate daily blood glucose control.
Methods In a prospective observational study, blood glucose levels were determined in 30 patients in intensive care units of a tertiary care university hospital during a 2-month period. All glucose measurements and corresponding insulin infusion rates were evaluated for adherence to and efficacy and safety of the insulin protocol. Linear regression analysis was used to determine factors associated with adequate daily blood glucose control, defined as time in the target range.
Results A total of 6016 blood glucose measurements were obtained during 352 protocol implementation days. Adherence to the protocol was 71%. Blood glucose levels were in the desired range 42% of the total protocol implementation time. Sixty percent of the patients experienced at least one hypoglycemic event. Adherence to the protocol (P < .001), high bilirubin level (P < .001), low daily insulin dose (P = .002), and low C-reactive protein level (P = .048) were independently associated with adequate daily blood glucose control.
Conclusions Protocol adherence was positively associated with daily time in the target range, but efficacy during the total protocol implementation time remained poor. Because of the frequency of hypoglycemia, protocols to maintain blood glucose levels between 81 and 110 mg/dL in critically ill patients may not be recommended.
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Affiliation(s)
- Sandra G. Oeyen
- Sandra Oeyen, Eric Hoste, and Carl Roosens are intensivists and work as staff members, Johan Decruyenaere is an intensivist and department head, and Stijn Blot is a research worker in the Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Eric A. Hoste
- Sandra Oeyen, Eric Hoste, and Carl Roosens are intensivists and work as staff members, Johan Decruyenaere is an intensivist and department head, and Stijn Blot is a research worker in the Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Carl D. Roosens
- Sandra Oeyen, Eric Hoste, and Carl Roosens are intensivists and work as staff members, Johan Decruyenaere is an intensivist and department head, and Stijn Blot is a research worker in the Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Johan M. Decruyenaere
- Sandra Oeyen, Eric Hoste, and Carl Roosens are intensivists and work as staff members, Johan Decruyenaere is an intensivist and department head, and Stijn Blot is a research worker in the Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Stijn I. Blot
- Sandra Oeyen, Eric Hoste, and Carl Roosens are intensivists and work as staff members, Johan Decruyenaere is an intensivist and department head, and Stijn Blot is a research worker in the Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
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Barth MM, Oyen LJ, Warfield KT, Elmer JL, Evenson LK, Tescher AN, Kuper PJ, Bannon MP, Gajic O, Farmer JC. Comparison of a nurse initiated insulin infusion protocol for intensive insulin therapy between adult surgical trauma, medical and coronary care intensive care patients. BMC Emerg Med 2007; 7:14. [PMID: 17727725 PMCID: PMC2064915 DOI: 10.1186/1471-227x-7-14] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Accepted: 08/29/2007] [Indexed: 01/08/2023] Open
Abstract
Background Sustained hyperglycemia is a known risk factor for adverse outcomes in critically ill patients. The specific aim was to determine if a nurse initiated insulin infusion protocol (IIP) was effective in maintaining blood glucose values (BG) within a target goal of 100–150 mg/dL across different intensive care units (ICUs) and to describe glycemic control during the 48 hours after protocol discontinuation. Methods A descriptive, retrospective review of 366 patients having 28,192 blood glucose values in three intensive care units, Surgical Trauma Intensive Care Unit (STICU), Medical (MICU) and Coronary Care Unit (CCU) in a quaternary care hospital was conducted. Patients were > 15 years of age, admitted to STICU (n = 162), MICU (n = 110) or CCU (n = 94) over 8 months; October 2003-June 2004 and who had an initial blood glucose level > 150 mg/dL. We summarized the effectiveness and safety of a nurse initiated IIP, and compared these endpoints among STICU, MICU and CCU patients. Results The median blood glucose values (mg/dL) at initiation of insulin infusion protocol were lower in STICU (188; IQR, 162–217) than in MICU, (201; IQR, 170–268) and CCU (227; IQR, 178–313); p < 0.0001. Mean time to achieving a target glucose level (100–150 mg/dL) was similar between the three units: 4.6 hours in STICU, 4.7 hours in MICU and 4.9 hours in CCU (p = 0.27). Hypoglycemia (BG < 60 mg/dL) occurred in 7% of STICU, 5% of MICU, and 5% of CCU patients (p = 0.85). Protocol violations were uncommon in all three ICUs. Mean blood glucose 48 hours following IIP discontinuation was significantly different for each population: 142 mg/dL in STICU, 167 mg/dL in MICU, and 160 mg/dL in CCU (p < 0.0001). Conclusion The safety and effectiveness of nurse initiated IIP was similar across different ICUs in our hospital. Marked variability in glucose control after the protocol discontinuation suggests the need for further research regarding glucose control in patients transitioning out of the ICU.
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Affiliation(s)
- Melissa M Barth
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Lance J Oyen
- Pharmacy Services, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Laura K Evenson
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Ann N Tescher
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - Philip J Kuper
- Pharmacy Services, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ognjen Gajic
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Nazer LH, Chow SL, Moghissi ES. Insulin infusion protocols for critically ill patients: a highlight of differences and similarities. Endocr Pract 2007; 13:137-46. [PMID: 17490927 DOI: 10.4158/ep.13.2.137] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To discuss the major differences and similarities among the currently published insulin infusion protocols (IIPs) for critically ill patients. METHODS IIPs were identified by searching MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. The reference lists for all retrieved protocols were also reviewed to identify any IIPs that were not surfaced with use of our initial search strategies. The major differences and similarities among the IIPs were identified and examined. In addition, strategies for successful implementation of IIPs were outlined. RESULTS Our search strategies retrieved 17 IIPs. Currently, no published studies have compared one insulin protocol with another. The major differences or similarities among the published IIPs were in the following areas: patient characteristics, target glucose level, time to achieve target glucose level, incidence of hypoglycemia, rationale for adjusting the rates of insulin infusion, and methods of blood glucose measurements. Because of variations in the definition of hypoglycemia, methods of blood glucose measurement, and types of blood samples used, some comparisons across the protocols were difficult. Use of a multidisciplinary team and gaining administrative support are crucial for addressing issues and provision of necessary resources for implementing a protocol for "tight" glycemic control in critically ill patients. CONCLUSION Clinicians should evaluate the type of patients in their critical care units, the mean baseline glucose levels, and the available resources to determine the most appropriate and practical IIP for their institution.
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Affiliation(s)
- Lama H Nazer
- Western University of Health Sciences, Pomona, California 91766-1854, USA
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Abstract
OBJECTIVE To review performance characteristics of 12 insulin infusion protocols. RESEARCH DESIGN AND METHODS We systematically identify and compare 12 protocols and then apply the protocols to generate insulin recommendations in the management of a patient with hyperglycemia. The main focus involves a comparison of insulin doses and patterns of insulin administration. RESULTS There is great variability in protocols. Areas of variation include differences in initiation and titration of insulin, use of bolus dosing, requirements for calculation in adjustment of the insulin infusion, and method of insulin protocol adjustments. Insulin recommendations for a sample patient are calculated to highlight differences between protocols, including the patterns and ranges of insulin dose recommended (range 27-115 units [mean +/- SD 66.7 +/- 27.9]), amount recommended for glucose readings >200 mg/dl, and adjustments nearing target glucose. CONCLUSIONS The lack of consensus in the delivery of intravenous insulin infusions is reflected in the wide variability of practice noted in this survey. This mandates close attention to the choice of a protocol. One protocol may not suffice for all patients.
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Affiliation(s)
- Mark Wilson
- Endocrine Section, West Los Angeles Healthcare Center, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, California 90073, USA
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Rea RS, Donihi AC, Bobeck M, Herout P, McKaveney TP, Kane-Gill SL, Korytkowski MT. Implementing an intravenous insulin infusion protocol in the intensive care unit. Am J Health Syst Pharm 2007; 64:385-95. [PMID: 17299178 DOI: 10.2146/ajhp060014] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The implementation of three different insulin protocols in intensive care unit (ICU) settings in two community hospitals and one academic hospital is described. SUMMARY Each institution possessed a commitment to improve the existing insulin protocols in order to achieve tighter glycemic control for ICU patients. Studies have shown that the maintenance of tight glycemic control provides improved patient outcomes. Obstacles to implementation of the insulin protocols at the institutions were increased staff workload, difficulties in interpreting algorithms, and lack of perceived benefit. In comparing details of the insulin protocols at the academic and community hospitals, it was found that differences were influenced by the type of institution. The differences among the institutions in the implementation of the protocols included the initial physician response to the protocol, the details of each protocol, nursing staff autonomy, and the involvement of the nursing staff in early protocol development. All three institutions had a dedicated pharmacist in the ICU who committed time toward insulin protocol implementation. For an increased likelihood of successful insulin protocol implementation, a full-time dedicated ICU pharmacist should be assigned to participate on multidisciplinary rounds, provide nursing support and education, and collect process measures to monitor and improve the protocol. CONCLUSION The i.v. insulin infusion protocols developed and implemented in the ICUs at three institutions successfully achieved acceptance and compliance by physicians and nurses. The factors attributed to the success were multidisciplinary involvement, the continuous education of nursing staff, the vigilant involvement of a pharmacist, and flexibility in revising the protocol.
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Affiliation(s)
- Rhonda S Rea
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, PA 15213, USA.
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Implementing Glucose Control Protocols in Critically Ill Patients. AACN Adv Crit Care 2007. [DOI: 10.1097/01256961-200701000-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kajbaf F, Mojtahedzadeh M, Abdollahi M. Mechanisms underlying stress-induced hyperglycemia in critically ill patients. ACTA ACUST UNITED AC 2007. [DOI: 10.2217/14750708.4.1.97] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Meynaar IA, Dawson L, Tangkau PL, Salm EF, Rijks L. Introduction and evaluation of a computerised insulin protocol. Intensive Care Med 2006; 33:591-6. [PMID: 17177048 DOI: 10.1007/s00134-006-0484-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Accepted: 11/13/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To lower glucose levels in all patients in the intensive care unit (ICU) to the target range of 4.5-7.5 mmol/l using a nurse-driven computerised insulin protocol in combination with bedside glucose measurement. DESIGN Cohort study. SETTING Mixed adult ICU. PATIENTS AND PARTICIPANTS All 182 patients admitted to the ICU during a 3-month period were studied, except for 3 patients admitted for diabetic keto-acidosis. INTERVENTIONS Five steps were taken to improve glucose regulation: (1) Nurses were authorised to adjust insulin dosage using a protocol. (2) Glucose was measured more often. (3) Glucose was measured at the bedside. (4) Consecutive protocols aimed for successively lower glucose levels; the final protocol had a target range of 4.5-7.5 mmol/l. (5) The protocol was computerised. MEASUREMENTS AND RESULT: Mean glucose decreased from 9.23 mmol/l without protocol to 7.68 mmol/l with the final protocol. This final protocol with the target of 4.5-7.5 mmol/l was evaluated more extensively. Glucose levels were measured a total of 1854 times in 179 ICU admissions during 552 ICU treatment days. The median glucose level was 7.0 mmol/l, and 53.1% of glucose measurements were within the target range of 4.5-7.5 mmol/l. One episode of hypoglycaemia (glucose </= 2.2 mmol/l) occurred, representing 0.5% of patients or 0.05% of glucose measurements. CONCLUSIONS The combined strategy of successively more ambitious nurse-driven (computerised) insulin protocols and bedside glucose measurement resulted in acceptably low glucose levels with very few episodes of hypoglycaemia.
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Affiliation(s)
- Iwan A Meynaar
- Intensive Care Unit, Reinier de Graaf Hospital, PO Box 5011, 2600 GA, Delft, Netherlands.
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