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Takahashi Y, Matsuura H, Domi H, Yamamura H. A continuous intravenous insulin infusion protocol to manage high-dose methylprednisolone-induced hyperglycemia in patients with severe COVID-19. Clin Diabetes Endocrinol 2022; 8:4. [PMID: 35477646 PMCID: PMC9044380 DOI: 10.1186/s40842-022-00141-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background Many patients with severe COVID-19 have impaired glucose tolerance, and steroid therapy is a standard treatment. Thus, good glycemic control is important and correlates with better patient outcomes. We began using a continuous intravenous insulin infusion protocol for glycemic control whose infusion rate changes based on the currently measured value and previous value. This study aimed to evaluate this protocol for COVID-19 patients requiring mechanical ventilation. Methods This single-center, retrospective, case control study was conducted on all adult patients who required mechanical ventilation for severe COVID-19 pneumonia admitted to our critical care center from April 1, 2020 through June 20, 2021. Blood glucose levels were measured in all patients every 4 h after admission. We started using the insulin infusion protocol from August 1, 2020. Patients before starting the protocol comprised the non-protocol group and those after starting the protocol comprised the protocol group. Blood glucose levels and hypo- or hyperglycemia events were compared between groups. We also surveyed ICU nurses about their experience using the protocol. Results During the study period, 173 patients with COVID-19 were admitted. After 15 patients were excluded for several reasons, the study included 158 patients: non-protocol group (n = 14) and protocol group (n = 144). In the initial phase (days 1–2), blood glucose levels of the protocol group were higher compared with the non-protocol group, and as the number of measurements increased, blood glucose levels were gradually brought under control within the target range in the protocol group. Almost no hypoglycemic events (blood glucose < 80 mg/dL) were detected in either group. The rate of hyperglycemia (blood glucose > 300 mg/dL) was about 5–10% in the initial phase in the protocol group and about 10–15% in the early phase (days 3–4) in the non-protocol group. The questionnaire survey revealed that 80% of ICU nurses responded favorably. Conclusions This insulin protocol gradually brought the blood glucose level within target levels in severe COVID-19 patients treated with high-dose steroid. Some hyperglycemia events were detected despite patients being under the protocol in the initial phase, and thus, minor modifications of the protocol might be required in the initial phase.
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Affiliation(s)
- Yoshihito Takahashi
- Osaka Prefectural Nakakawachi Emergency and Critical Care Center, 3-4-13 Nishiiwata, Higashiosaka, Osaka, 578-0947, Japan
| | - Hiroshi Matsuura
- Osaka Prefectural Nakakawachi Emergency and Critical Care Center, 3-4-13 Nishiiwata, Higashiosaka, Osaka, 578-0947, Japan.
| | - Hisaya Domi
- Osaka Prefectural Nakakawachi Emergency and Critical Care Center, 3-4-13 Nishiiwata, Higashiosaka, Osaka, 578-0947, Japan
| | - Hitoshi Yamamura
- Osaka Prefectural Nakakawachi Emergency and Critical Care Center, 3-4-13 Nishiiwata, Higashiosaka, Osaka, 578-0947, Japan
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Korytkowski M, Antinori-Lent K, Drincic A, Hirsch IB, McDonnell ME, Rushakoff R, Muniyappa R. A Pragmatic Approach to Inpatient Diabetes Management during the COVID-19 Pandemic. J Clin Endocrinol Metab 2020; 105:5851514. [PMID: 32498085 PMCID: PMC7313952 DOI: 10.1210/clinem/dgaa342] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/27/2020] [Indexed: 12/13/2022]
Abstract
The pandemic of COVID-19 has presented new challenges to hospital personnel providing care for infected patients with diabetes who represent more than 20% of critically ill patients in intensive care units. Appropriate glycemic management contributes to a reduction in adverse clinical outcomes in acute illness but also requires intensive patient interactions for bedside glucose monitoring, intravenous and subcutaneous insulin administration, as well as rapid intervention for hypoglycemia events. These tasks are required at a time when minimizing patient interactions is recommended as a way of avoiding prolonged exposure to COVID-19 by health care personnel who often practice in settings with limited supplies of personal protective equipment. The purpose of this manuscript is to provide guidance for clinicians for reconciling recommended standards of care for infected hospitalized patients with diabetes while also addressing the daily realities of an overwhelmed health care system in many areas of the country. The use of modified protocols for insulin administration, bedside glucose monitoring, and medications such as glucocorticoids and hydroxychloroquine that may affect glycemic control are discussed. Continuous glucose monitoring systems have been proposed as an option for reducing time spent with patients, but there are important issues that need to be addressed if these are used in hospitalized patients. On-site and remote glucose management teams have potential to provide guidance in areas where there are shortages of personnel who have expertise in inpatient glycemic management.
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Affiliation(s)
- Mary Korytkowski
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Address Reprint Requests to: Mary T. Korytkowski, MD, Professor of Medicine, Division of Endocrinology and Metabolism, University of Pittsburgh, 3601 Fifth Avenue, Suite 3B, Pittsburgh PA 15213, Phone: 412 586 9714, Fax: 412 586 9726,
| | | | | | | | | | | | - Ranganath Muniyappa
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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Braithwaite SS, Clark LP, Idrees T, Qureshi F, Soetan OT. Hypoglycemia Prevention by Algorithm Design During Intravenous Insulin Infusion. Curr Diab Rep 2018; 18:26. [PMID: 29582176 DOI: 10.1007/s11892-018-0994-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW This review examines algorithm design features that may reduce risk for hypoglycemia while preserving glycemic control during intravenous insulin infusion. We focus principally upon algorithms in which the assignment of the insulin infusion rate (IR) depends upon maintenance rate of insulin infusion (MR) or a multiplier. RECENT FINDINGS Design features that may mitigate risk for hypoglycemia include use of a mid-protocol bolus feature and establishment of a low BG threshold for temporary interruption of infusion. Computer-guided dosing may improve target attainment without exacerbating risk for hypoglycemia. Column assignment (MR) within a tabular user-interpreted algorithm or multiplier may be specified initially according to patient characteristics and medical condition with revision during treatment based on patient response. We hypothesize that a strictly increasing sigmoidal relationship between MR-dependent IR and BG may reduce risk for hypoglycemia, in comparison to a linear relationship between multiplier-dependent IR and BG. Guidelines are needed that curb excessive up-titration of MR and recommend periodic pre-emptive trials of MR reduction. Future research should foster development of recommendations for "protocol maxima" of IR appropriate to patient condition.
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Affiliation(s)
- Susan Shapiro Braithwaite
- , 1135 Ridge Road, Wilmette, IL, 60091, USA.
- Endocrinology Consults and Care, S.C, 3048 West Peterson Ave, Chicago, IL, 60659, USA.
| | - Lisa P Clark
- Presence Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Thaer Idrees
- Presence Saint Joseph Hospital, 2900 N. Lakeshore Dr, Chicago, IL, 60657, USA
| | - Faisal Qureshi
- Presence Saint Joseph Hospital, 2800 N Sheridan Road Suite 309, Chicago, IL, 60657, USA
| | - Oluwakemi T Soetan
- Presence Saint Joseph Hospital, 2900 N. Lakeshore Dr, Chicago, IL, 60657, USA
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5
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Rabinovich M, Grahl J, Durr E, Gayed R, Chester K, McFarland R, McLean B. Risk of Hypoglycemia During Insulin Infusion Directed by Paper Protocol Versus Electronic Glycemic Management System in Critically Ill Patients at a Large Academic Medical Center. J Diabetes Sci Technol 2018; 12:47-52. [PMID: 29251064 PMCID: PMC5761992 DOI: 10.1177/1932296817747617] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Insulin infusions are commonly utilized to control hyperglycemia in critically ill patients and decrease hyperglycemia associated complications. Safety concerns have been raised in trials evaluating methods of glycemic control regarding the incidence of hypoglycemia and its relationship to increased mortality. Electronic glycemic management systems (eGMS) may result in less variable blood glucose (BG) control and less hypoglycemia. This study aimed to compare BG control, time in target BG range, and the rate of hypoglycemia when critically ill patients were managed with an insulin infusion guided by paper-based protocol (PBP) versus eGMS. METHODS This retrospective review compared critically ill patients ≥ 18 years old that received insulin infusion from March to May 2015 (PBP group) and October to January 2017 (eGMS group). The primary outcome was the incidence of hypoglycemia. Secondary outcomes included frequency and severity of hypoglycemia, duration in glycemic target, length of insulin therapy, as well as ICU and hospital length of stay. RESULTS Fifty-four patients were evaluated, 27 in each group. Percentage of days with BG <70 mg/dL was significantly reduced after eGMS implementation (21.5% v 1.3%, P < .0001) including the frequency of severe hypoglycemia (BG < 40 mg/dL) (5.4% v 0.01%, P < .0001). Patients in the eGMS group spent a greater amount of time in target BG range (31.5% v 63.7%, P < .0001). CONCLUSIONS An eGMS has the potential to address many of the unmet needs of an optimal glycemic control strategy, minimizing hypoglycemia, and glycemic variability in a heterogeneous critically ill population.
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Affiliation(s)
- Marina Rabinovich
- Grady Health System, Atlanta, GA, USA
- Marina Rabinovich, PharmD, Grady Health System, 80 Jesse Hill Jr. Dr SE, Atlanta, GA 30303, USA.
| | - Jessica Grahl
- Vanderbilt University Medical Center, Nashville, TN, USA
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Poppy A, Retamal-Munoz C, Cree-Green M, Wood C, Davis S, Clements SA, Majidi S, Steck AK, Alonso GT, Chambers C, Rewers A. Reduction of Insulin Related Preventable Severe Hypoglycemic Events in Hospitalized Children. Pediatrics 2016; 138:peds.2015-1404. [PMID: 27317577 PMCID: PMC5901907 DOI: 10.1542/peds.2015-1404] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Insulin is a commonly used, high-risk medication in the inpatient setting. Incorrect insulin administration can lead to preventable hypoglycemic events, which are a significant morbidity in inpatient diabetes care. The goal of this intervention was to decrease preventable insulin-related hypoglycemic events in an inpatient setting in a tertiary care pediatric hospital. METHODS Methods included the institution of several interventions such as nursing and physician education, electronic medical record order sets, electronic communication note templates, and the development of new care guidelines. RESULTS After the institution of multiple interventions, the rate of preventable hypoglycemic events decreased from 1.4 preventable events per 100 insulin days to 0.4 preventable events per 100 insulin days. CONCLUSIONS Through the use of a multi-interventional approach with oversight of a multidisciplinary insulin safety committee, a sustained decreased rate of severe preventable hypoglycemic events in hospitalized pediatric patients receiving insulin was achieved.
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Affiliation(s)
- Amy Poppy
- Quality and Patient Safety, Children's Hospital Colorado, Aurora, Colorado;
| | | | - Melanie Cree-Green
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Colleen Wood
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Shanlee Davis
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Scott A. Clements
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and,Division of Endocrinology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Shideh Majidi
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Andrea K. Steck
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - G. Todd Alonso
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Christina Chambers
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Arleta Rewers
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz, Aurora, Colorado; and
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Duggan EW, Klopman MA, Berry AJ, Umpierrez G. The Emory University Perioperative Algorithm for the Management of Hyperglycemia and Diabetes in Non-cardiac Surgery Patients. Curr Diab Rep 2016; 16:34. [PMID: 26971119 DOI: 10.1007/s11892-016-0720-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hyperglycemia is a frequent manifestation of critical and surgical illness, resulting from the acute metabolic and hormonal changes associated with the response to injury and stress (Umpierrez and Kitabchi, Curr Opin Endocrinol. 11:75-81, 2004; McCowen et al., Crit Care Clin. 17(1):107-24, 2001). The exact prevalence of hospital hyperglycemia is not known, but observational studies have reported a prevalence of hyperglycemia ranging from 32 to 60 % in community hospitals (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Cook et al., J Hosp Med. 4(9):E7-14, 2009; Farrokhi et al., Best Pract Res Clin Endocrinol Metab. 25(5):813-24, 2011), and 80 % of patients after cardiac surgery (Schmeltz et al., Diabetes Care 30(4):823-8, 2007; van den Berghe et al., N Engl J Med. 345(19):1359-67, 2001). Retrospective and randomized controlled trials in surgical populations have reported that hyperglycemia and diabetes are associated with increased length of stay, hospital complications, resource utilization, and mortality (Frisch et al., Diabetes Care 33(8):1783-8, 2010; Kwon et al., Ann Surg. 257(1):8-14, 2013; Bower et al., Surgery 147(5):670-5, 2010; Noordzij et al., Eur J Endocrinol. 156(1):137-42, 2007; Mraovic et al., J Arthroplasty 25(1):64-70, 2010). Substantial evidence indicates that correction of hyperglycemia reduces complications in critically ill, as well as in general surgery patients (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Clement et al., Diabetes Care 27(2):553-97, 2004; Pomposelli et al., JPEN J Parented Enteral Nutr. 22(2):77-81, 1998). This manuscript reviews the pathophysiology of stress hyperglycemia during anesthesia and the perioperative period. We provide a practical outline for the diagnosis and management of preoperative, intraoperative, and postoperative care of patients with diabetes and hyperglycemia.
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Affiliation(s)
| | - Matthew A Klopman
- Department of Anesthesiology, Emory University Hospital, Atlanta, USA
| | - Arnold J Berry
- Department of Anesthesiology, Emory University Hospital, Atlanta, USA
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8
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Detection of adverse drug reactions by medication antidote signals and comparison of their sensitivity with common methods of ADR detection. Saudi Pharm J 2015; 23:515-22. [PMID: 26594117 PMCID: PMC4605900 DOI: 10.1016/j.jsps.2014.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 10/23/2014] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To determine the PPVs of selected ten medication antidote signals in recognizing potential ADRs and comparison of their sensitivity with manual chart analysis, and voluntary reporting recognizing the same ADRs. METHOD The inpatient EMR database of internal medicine department was utilized for a period of one year, adult patients prescribed at least one of the ten signals, were included in the study, recipient patients of antidote signals were assessed for the occurrence of an ADR by Naranjo's tool of ADR evaluation. PPVs of each antidote signal were verified. RESULT PPV of Methylprednisolone and Phytonadione was 0.28, Metoclopramide and Potassium Chloride - 0.29, Dextrose 50%, Promethazine, Sodium Polystyrene and Loperamide - 0.30, Protamine and Acetylcysteine - 0.33. In comparison of confirmed ADRs of antidote signals with other methods, Dextrose 50%, Metoclopramide, Sodium Polystyrene, Potassium Chloride, Methylprednisolone and Promethazine seem to be extremely significant (P value > 0.0001), while ADRs of Phytonadione, Protamine, Acetylcysteine and Loperamide were insignificant. CONCLUSION Antidote medication signals have definitive discerning evaluation value of ADRs over routine methods of ADR detection with a high detection rate with a minimum cost; Their integration with hospital EMR database and routine patient safety surveillance enhances transparency, time-saving and facilitates ADR detection.
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9
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Nair BG, Grunzweig K, Peterson GN, Horibe M, Neradilek MB, Newman SF, Van Norman G, Schwid HA, Hao W, Hirsch IB, Patchen Dellinger E. Intraoperative blood glucose management: impact of a real-time decision support system on adherence to institutional protocol. J Clin Monit Comput 2015; 30:301-12. [DOI: 10.1007/s10877-015-9718-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 06/05/2015] [Indexed: 11/28/2022]
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10
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The 2012 SEMDSA Guideline for the Management of Type 2 Diabetes (Revised). JOURNAL OF ENDOCRINOLOGY, METABOLISM AND DIABETES OF SOUTH AFRICA 2014. [DOI: 10.1080/22201009.2012.10872287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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11
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The 2012 SEMDSA Guideline for the Management of type 2 Diabetes. JOURNAL OF ENDOCRINOLOGY METABOLISM AND DIABETES OF SOUTH AFRICA 2014. [DOI: 10.1080/22201009.2012.10872277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
This research was conducted to (1) determine the relationship between nurses' confidence levels using an endocrine order set after educational interventions and experience and (2) measure glycemic control after cardiac surgery with the use of order sets. Findings showed that nurses' confidence increased with ongoing education and experience. Furthermore, tighter glycemic control was achieved on postoperative days 1 and 2, as the protocol was refined, and as the nurses became more comfortable with its use.
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13
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Destree L, Ludwig-Beymer P, Vercellino M, Rowe A. Effects of Education on Nurse Confidence and Cardiac Surgical Glycemic Control. AACN Adv Crit Care 2013. [DOI: 10.4037/nci.0b013e31829c1dbe] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
This research was conducted to (1) determine the relationship between nurses’ confidence levels using an endocrine order set after educational interventions and experience and (2) measure glycemic control after cardiac surgery with the use of order sets. Findings showed that nurses’ confidence increased with ongoing education and experience. Furthermore, tighter glycemic control was achieved on postoperative days 1 and 2, as the protocol was refined, and as the nurses became more comfortable with its use.
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Affiliation(s)
- Lani Destree
- Lani Destree is Clinical Nurse Specialist—Diabetes, Clinical Education, Edward Hospital and Health Services, 801 S Washington St, Naperville, IL 60540
| | - Patti Ludwig-Beymer
- Patti Ludwig-Beymer is Vice President and Chief Nursing Officer, Administration, Edward Hospital and Health Services, Naperville, Illinois
| | - Mary Vercellino
- Mary Vercellino is Clinical Nurse Specialist—Wound Care/Diabetes, Clinical Education, Edward Hospital and Health Services, Naperville, Illinois
| | - Amy Rowe
- Amy Rowe is Clinical Educator—Cardiac/Neuro ICU, Clinical Education, Edward Hospital and Health Services, Naperville, Illinois
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14
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Dombrowski NC, Karounos DG. Pathophysiology and management strategies for hyperglycemia for patients with acute illness during and following a hospital stay. Metabolism 2013; 62:326-36. [PMID: 22999713 DOI: 10.1016/j.metabol.2012.07.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 07/26/2012] [Accepted: 07/26/2012] [Indexed: 01/15/2023]
Abstract
Hyperglycemia in the inpatient setting is associated with poor clinical outcomes and is often suboptimally managed. This review addresses the pathophysiology of hyperglycemia, current recommendations for management of inpatient hyperglycemia in the general medical and surgical care setting, the transition between different diabetes treatments, and the transition from inpatient to outpatient therapy. The preferred drug for management of inpatient hyperglycemia is insulin. Successful use of intravenous and subcutaneous insulin in the hospital is based on the implementation of standardized protocols. Current guidelines recommend basal-bolus subcutaneous insulin in non-critically ill patients. The methods of switching from intravenous to subcutaneous, sliding-scale to basal-bolus, and biphasic to basal-bolus are discussed. Transition from an inpatient to an outpatient insulin regimen, especially in patients new to insulin therapy, requires special attention to ensure that patients have the knowledge to administer insulin safely and effectively. The optimal regimen at discharge must be individualized. Patients with acute infections may benefit from insulin therapy until the infection is resolved. Strategies to optimize diabetes therapy after discharge are discussed. Prompt outpatient follow-up is crucial to ensure optimal glycemic control. Despite the challenges, improved glycemic control in individuals with acute illness has the potential to reduce morbidity and mortality in individuals with this widespread metabolic illness.
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Affiliation(s)
- Nicole C Dombrowski
- Division of Endocrinology and Molecular Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
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15
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Rendell M, Saiprasad S, Trepp-Carrasco AG, Drincic A. The future of inpatient diabetes management: glucose as the sixth vital sign. Expert Rev Endocrinol Metab 2013; 8:195-205. [PMID: 30736179 DOI: 10.1586/eem.13.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Diabetes is an ever increasing health problem in our society. Due to associated small and large vessel conditions, patients with diabetes are two- to four-fold more likely to require hospitalization than nondiabetic individuals. Furthermore, hyperglycemia in hospitalized patients results in increased susceptibility to wound infections, worse outcomes postcardiac and cerebrovascular events, longer hospital length of stay and increased inpatient mortality. Several studies suggest that tight control of glucose levels yields improvement in these factors. Conversely, other studies have suggested increased mortality after tight glucose management, perhaps as a result of an increased incidence of hypoglycemic events. The most reasonable approach to control of hyperglycemia is to normalize glucose levels as much as possible without triggering hypoglycemia. In the hospital, insulin therapy of hyperglycemia is preferred due to the ability to flexibly manage glucose levels without side effects associated with many alternative antidiabetic agents. Due to the increasing burden of inpatient diabetes, and the detrimental effects of both hyper and hypoglycemia, the authors predict that blood-glucose levels will become the sixth vital sign to be frequently monitored in hospitalized patients and controlled in a narrow range. The future is in the use of insulin pumps controlled by continuous glucose monitors. This technology is complex and has not yet become standard. The development of future inpatient diabetes care will depend on adaptation of hospital systems to advance the new technology.
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Affiliation(s)
- Marc Rendell
- a Creighton Diabetes Center, 601 North 30th Street, Omaha, NE 68131, USA.
- b The Rose Salter Medical Research Foundation, 660 South 85th Street, Omaha, NE 68114, USA
| | - Saraswathi Saiprasad
- c Department of Internal Medicine, Creighton University School of Medicine, 601 North 30th Street, Omaha, NE 68131, USA
| | - Alejandro G Trepp-Carrasco
- d Department of Endocrinology and Metabolism, Creighton University School of Medicine, 601 North 30th Street, Omaha, NE 68131, USA
| | - Andjela Drincic
- e Department of Endocrinology, The University of Nebraska School of Medicine, Nebraska Medical Center, Omaha, NE 68198-5527, USA
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Lazar HL. Glycemic Control during Coronary Artery Bypass Graft Surgery. ISRN CARDIOLOGY 2012; 2012:292490. [PMID: 23209941 PMCID: PMC3504366 DOI: 10.5402/2012/292490] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 08/26/2012] [Indexed: 01/08/2023]
Abstract
Hyperglycemia, which occurs in the perioperative period during cardiac surgery, has been shown to be associated with increased morbidity and mortality. The management of perioperative hyperglycemia during coronary artery bypass graft surgery and all cardiac surgical procedures has been the focus of intensive study in recent years. This report will paper the pathophysiology responsible for the detrimental effects of perioperative hyperglycemia during cardiac surgery, show how continuous insulin infusions in the perioperative period have improved outcomes, and discuss the results of trials designed to determine what level of a glycemic control is necessary to achieve optimal clinical outcomes.
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Affiliation(s)
- Harold L Lazar
- Department of Cardiothoracic Surgery, The Boston Medical Center and The Boston University School of Medicine, 88 East Newton Street, Boston, MA 02118, USA
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McDonnell ME, Alexanian SM, White L, Lazar HL. A primer for achieving glycemic control in the cardiac surgical patient. J Card Surg 2012; 27:470-7. [PMID: 22640228 DOI: 10.1111/j.1540-8191.2012.01471.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Maintaining glycemic control (blood glucose <180 mg/dL) has been shown to reduce morbidity and enhance long-term survival in patients with diabetes mellitus following coronary artery bypass graft (CABG) surgery. In this review we present a management strategy to achieve perioperative glycemic control in all patients undergoing CABG surgery, with and without diabetes mellitus, designed to achieve compliance with current Surgical Care Improvement Project (SCIP) and Society of Thoracic Surgeons (STS) guidelines.
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Affiliation(s)
- Marie E McDonnell
- Section of Endocrinology, Diabetes, Nutrition and Weight Management, the Boston University, School of Medicine, Boston, Massachusetts, USA.
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18
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Özden D, Görgülü RS. Development of standard practice guidelines for open and closed system suctioning. J Clin Nurs 2012; 21:1327-38. [DOI: 10.1111/j.1365-2702.2011.03997.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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McDonnell ME, Umpierrez GE. Insulin therapy for the management of hyperglycemia in hospitalized patients. Endocrinol Metab Clin North Am 2012; 41:175-201. [PMID: 22575413 PMCID: PMC3738170 DOI: 10.1016/j.ecl.2012.01.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
It has long been established that hyperglycemia with or without a prior diagnosis of diabetes increases both mortality and disease-specific morbidity in hospitalized patients and that goal-directed insulin therapy can improve outcomes. This article reviews the pathophysiology of hyperglycemia during illness, the mechanisms for increased complications and mortality due to hyperglycemia and hypoglycemia, and beneficial mechanistic effects of insulin therapy and provides updated recommendations for the inpatient management of diabetes in the critical care setting and in the general medicine and surgical settings.
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Affiliation(s)
- Marie E. McDonnell
- Department of Medicine, Boston University School of Medicine, 88 East Newton Street, Boston, MA 02118, USA
| | - Guillermo E. Umpierrez
- Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta, GA 30303, USA
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20
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Creating a perioperative glycemic control program. Anesthesiol Res Pract 2011; 2011:465974. [PMID: 21912542 PMCID: PMC3168770 DOI: 10.1155/2011/465974] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 06/15/2011] [Accepted: 07/06/2011] [Indexed: 01/23/2023] Open
Abstract
Hyperglycemia in the surgical population is a recognized risk factor for postoperative complications; however, there is little literature to date regarding the management of hyperglycemia in the perioperative period. Here, we detail the strategies that our institutions have employed to identify and treat hyperglycemia in patients with diabetes who present for surgery. Our approach focuses on the recognition of hyperglycemia and metabolic abnormalities, control of glucose levels via insulin infusion when needed, monitoring for hypoglycemia and a comprehensive multidisciplinary approach that provides standardized recommendations for patients at all points in care as they transition from the preoperative clinic into the operating room, and then into the hospital.
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Kane-Gill SL, Bellamy CJ, Verrico MM, Handler SM, Weber RJ. Evaluating the positive predictive values of antidote signals to detect potential adverse drug reactions (ADRs) in the medical intensive care unit (ICU). Pharmacoepidemiol Drug Saf 2010; 18:1185-91. [PMID: 19728294 DOI: 10.1002/pds.1837] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE Signals are used to alert clinicians of potential ADRs. Positive predictive values (PPVs) of antidote signals in ICUs are unknown. The primary purpose was to determine PPVs of six signals. The secondary objective was to determine the sensitivity of various ADR detection strategies including manual chart review, administrative data review, and voluntary reporting at identifying the same ADRs discovered using antidotes as a signal. METHODS Adult patients admitted to a medical ICU from July 1, 2005 to June 30, 2006 who were prescribed select signals were eligible. Evaluated antidote signals included injectable diphenhydramine, protamine, phytonadione, dextrose 50%, injectable methylprednisolone, and sodium polystyrene. For each signal, a random sample of 50 patients was evaluated for the presence of an ADR. ADR occurrences were determined using two objective causality instruments through retrospective chart review. Agreement between the instruments was required for ADR consideration. PPVs were determined for each signal. RESULTS Two hundred and twenty three patients (52% male) were evaluated, with a mean +/- SD age of 60 +/- 17 years, and a median simplified acute physiology score (SAPSII) of 48. PPVs were 0.64, 0.50, 0.38, 0.26, 0.24, and 0.02 for protamine, sodium polystyrene, dextrose 50%, diphenhydramine, phytonadione, and methylprednisolone, respectively. Sensitivity of other detection strategies from highest to lowest was chart review for explicit documentation, administrative database review, and voluntary reporting. CONCLUSIONS Protamine and sodium polystyrene performed the best by detecting ADRs in at least one out of two evaluations. Detection strategies other than signals were not as sensitive at identifying the same ADRs as antidote signals.
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Affiliation(s)
- Sandra L Kane-Gill
- School of Pharmacy, Center for Pharmacoinformatics and Outcomes Research, University of Pittsburgh, Pittsburgh, PA, USA.
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Keene A, Hailpern S, Anees S, Sandhu J, Harris M, Ashton L, Bellin E. Glycemic control in critically ill patients before and after institution of an intensive insulin infusion protocol: circadian rhythm and the quality duration calculator. J Intensive Care Med 2009; 25:31-8. [PMID: 20034953 DOI: 10.1177/0885066609351393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION A circadian rhythm of blood glucose values has been recently reported in critically ill patients, but there are no reports of how this rhythm is altered by a continuous intensive insulin infusion therapy protocol (IIT). We wished to examine the effect of IIT on this rhythm as well as to describe the use of the quality duration calculator (QDC) for the evaluation of glycemic control before and after IIT. METHODS This was a retrospective multihospital observational study that took place in the medical and surgical intensive care units (ICUs) of 2 tertiary care hospitals. Cohorts of consecutively admitted critically ill patients from 2-year periods before and after institution of an IIT protocol were examined. Laboratory, demographic, and outcome data were extracted from hospital databases. RESULTS We studied 167,645 blood glucose measurements from 8,327 patients. We observed a circadian rhythm of blood glucose control in the pre-IIT cohort that was greatly attenuated in the post-IIT cohort. The difference between the morning and the average daily blood glucose in the pre-IIT cohort was 3.53 mg/dL (P < .001), and the difference between these values in the post-IIT cohort was 1.10 mg/dL (P = .031). In addition, the circadian nature of hyperglycemia incidence observed in the pre-IIT cohort was not seen in the post-IIT cohort. The amount of time spent in goal glycemic range increased from 23.69% (95% CI 23.01-24.38) in the pre-IIT cohort to 29.67% (95% CI 29.04-30.31) in the post-IIT cohort as estimated by the QDC. The amount of time spent in the hyperglycemic decreased from 20.17% (95% CI 19.33-20.99) in the pre-IIT cohort to 14.80% (95% CI 14.15-15.39) in the post-IIT cohort. CONCLUSIONS The circadian rhythm of blood glucose control confirmed in our pre-IIT cohort was lost after institution of IIT. The morning blood glucose value appears to be a reasonable surrogate of overall glycemic control in a critically ill population on IIT, although this may vary based on the degree of control achieved. The QDC method is useful for analyzing glycemic control in patients on IIT.
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Affiliation(s)
- Adam Keene
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10467, 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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Campion TR, Waitman LR, May AK, Ozdas A, Lorenzi NM, Gadd CS. Social, organizational, and contextual characteristics of clinical decision support systems for intensive insulin therapy: a literature review and case study. Int J Med Inform 2009; 79:31-43. [PMID: 19815452 DOI: 10.1016/j.ijmedinf.2009.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Revised: 09/07/2009] [Accepted: 09/11/2009] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Evaluations of computerized clinical decision support systems (CDSS) typically focus on clinical performance changes and do not include social, organizational, and contextual characteristics explaining use and effectiveness. Studies of CDSS for intensive insulin therapy (IIT) are no exception, and the literature lacks an understanding of effective computer-based IIT implementation and operation. RESULTS This paper presents (1) a literature review of computer-based IIT evaluations through the lens of institutional theory, a discipline from sociology and organization studies, to demonstrate the inconsistent reporting of workflow and care process execution and (2) a single-site case study to illustrate how computer-based IIT requires substantial organizational change and creates additional complexity with unintended consequences including error. DISCUSSION Computer-based IIT requires organizational commitment and attention to site-specific technology, workflow, and care processes to achieve intensive insulin therapy goals. The complex interaction between clinicians, blood glucose testing devices, and CDSS may contribute to workflow inefficiency and error. Evaluations rarely focus on the perspective of nurses, the primary users of computer-based IIT whose knowledge can potentially lead to process and care improvements. CONCLUSION This paper addresses a gap in the literature concerning the social, organizational, and contextual characteristics of CDSS in general and for intensive insulin therapy specifically. Additionally, this paper identifies areas for future research to define optimal computer-based IIT process execution: the frequency and effect of manual data entry error of blood glucose values, the frequency and effect of nurse overrides of CDSS insulin dosing recommendations, and comprehensive ethnographic study of CDSS for IIT.
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Affiliation(s)
- Thomas R Campion
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA.
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Computerized Model of Bedside Glucose Monitoring Contributes to the Successful Implementation of an Inpatient Diabetes Management Program in a University Hospital. POINT OF CARE 2009. [DOI: 10.1097/poc.0b013e3181b315b1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, Inzucchi SE, Ismail-Beigi F, Kirkman MS, Umpierrez GE. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract 2009; 15:353-69. [PMID: 19454396 DOI: 10.4158/ep09102.ra] [Citation(s) in RCA: 425] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Etie S Moghissi
- Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
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Cyrus RM, Szumita PM, Greenwood BC, Pendergrass ML. Evaluation of Compliance with a Paper-based, Multiplication-factor, Intravenous Insulin Protocol. Ann Pharmacother 2009; 43:1413-8. [DOI: 10.1345/aph.1m060] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Hyperglycemia is common in critically ill patients and is an independent risk factor for in-hospital morbidity and mortality. Objective: To assess compliance with a paper-based, multiplication-factor, intravenous insulin protocol. Methods: A retrospective chart review was conducted in a 720-bed urban, academic medical center in Boston, Massachusetts. During a 1-month period, compliance with and the consequent safety and efficacy of the Brigham and Women's Hospital paper-based, multiplication-factor, intravenous insulin protocol was evaluated. Results: The primary endpoint of protocol compliance, defined as correct adjustment to insulin infusion rate and correct timing of bedside blood glucose concentration (BBGC) checks ±10 minutes of prespecified BBGC check according to the Brigham and Women's Hospital Intravenous Insulin Protocol (BHIP), was 47.2%. Seventy-two patients met inclusion criteria. Appropriate adjustment of infusion rates occurred 68.2% (1206/1768) of the time. Compliance with the timing of BBGC checks was found to be the majority of protocol violations. BBGCs were monitored ±5 minutes of indicated time per the protocol 26.2% (463/1768) of the time. Blood glucose concentration checks within extended timing of ±10 minutes of indicated time per the protocol occurred 793 (44.8%) times. Blood glucose concentration monitoring took place greater than 20 minutes past indicated time 450 (25.5%) times. In 1768 measurements, blood glucose concentrations between 40 and 60 mg/dL occurred 23 (1.3%) times in 12 (16.7%) patients. Blood glucose concentrations 40 mg/dL or less were detected 3 (0.17%) times in 2 (2.7%) patients. None of these hypoglycemic events led to documented complications. Conclusions: Overall, a rather low level of compliance with a paper-based, multiplication-factor, intravenous insulin protocol was observed, which warrants further investigation. Compliance rates in this evaluation were found to be similar to the rates observed in previously evaluated fixed-dose intravenous insulin protocols. Protocol noncompliance may be associated with hypo- and hyperglycemia.
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Affiliation(s)
- Rachel M Cyrus
- Department of Pharmacy, Pharmacy Administration; L-2, Brigham and Women's Hospital, Boston, MA
| | - Paul M Szumita
- Department of Pharmacy, Pharmacy Administration; L-2, Brigham and Women's Hospital
| | - Bonnie C Greenwood
- Department of Pharmacy, Pharmacy Administration; L-2, Brigham and Women's Hospital
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Garg R, Jarry A, Pendergrass M. Delay in blood glucose monitoring during an insulin infusion protocol is associated with increased risk of hypoglycemia in intensive care units. J Hosp Med 2009; 4:E5-7. [PMID: 19670374 DOI: 10.1002/jhm.436] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hypoglycemia during insulin infusion therapy is a major problem. We investigated whether a delay in blood glucose (BG) monitoring during an insulin infusion protocol (IIP) in the intensive care unit (ICU) is associated with hypoglycemia. METHODS Data were collected for 50 consecutive patients treated with Brigham and Women's Hospital's IIP. Point-of-care BG values were obtained from the bedside paper flow sheets and the exact times of individual measurements were ascertained from an internet-based glucose meter download program. Data were carefully studied for protocol time violations, defined as a delay of >10 minutes after the recommended time for BG measurement. RESULTS A total of 2309 BG values were evaluated for time violation. A total of 1474 (63.9%) measurements had been obtained at the recommended time or earlier; 835 (36.1%) measurements had been obtained >10 minutes after the recommended time for measurement. There were a significantly higher proportion of BG values <80 mg/dL following the time violation as compared to no time violation (17.8% versus 11.6%; P < 0.001). CONCLUSION We conclude that the risk of hypoglycemia during insulin infusion therapy is higher after a delay in BG measurement.
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Affiliation(s)
- Rajesh Garg
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, Inzucchi SE, Ismail-Beigi F, Kirkman MS, Umpierrez GE. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009; 32:1119-31. [PMID: 19429873 PMCID: PMC2681039 DOI: 10.2337/dc09-9029] [Citation(s) in RCA: 842] [Impact Index Per Article: 56.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Etie S Moghissi
- Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA.
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Abstract
The intensive care unit (ICU) continues to be a major focus of decentralized pharmacy activities in health systems that care for critically ill patients. This is not surprising, given the need for rapid decision-making involving unstable patients, the large number of powerful medications typically used per patient, the high cost of many drugs used in the ICU and, most importantly, the evidence demonstrating the benefits of having a pharmacist as part of an interdisciplinary team. The purpose of this paper is to highlight important issues to consider when introducing or developing critical care pharmacy services beginning with the establishment of basic services and continuing through practitioner development, guideline/protocol development and implementation, patient safety, residency training, and research.
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Affiliation(s)
- Brian L Erstad
- College of Pharmacy, The University of Arizona, 1295 N. Martin - Pulido, PO Box 210207, Tucson, AZ 85721, USA.
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Abstract
Influential trials and guidelines supporting the value of glucose control in hospital settings, particularly in the intensive care and postoperative settings, has led to the widespread adoption of intravenous infusions of human regular insulin. As groups have attempted to study the outcomes or to explore improved methods for improved glucose control, a number of insulin infusion protocols (IIPs) have been reported and validated. Now, many institutions are attempting to translate this experience into clinical practice in a systematic manner. The intent of this discussion is to highlight the authors' practical view of best practices in development and use of IIPs. As the implementation of IIPs has progressed, it has become apparent that this is not a simple process. It requires a carefully planned, inclusive, and continuous effort striving to attain effective glucose control while avoiding severe hypoglycemia. Whereas there are limitations in the literature comparing the IIPs, we identify design elements and implementation methods that increase the chances for staff acceptance and safe attainment of glycemic goals. Most importantly, this must be a team effort with attention to the numerous potential pitfalls that can disrupt the process and place patients at risk. In many cases, it is best to start more conservatively and methodically intensify the protocol. Continuous assessment of protocol errors, adverse events, staff satisfaction, and outcomes is vital to overall success.
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Affiliation(s)
- Andrew J Ahmann
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, Oregon 97239-3098, USA.
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Abstract
PURPOSE OF REVIEW In a 2001 report from a surgical intensive care unit in Leuven, Belgium, intravenous insulin infusion targeting blood glucose 80-110 mg/dl reduced patient mortality and morbidities. Subsequent research has failed to define glycemic targets necessary or sufficient for attainment of desired health outcomes in other inpatient settings, but a large body of evidence suggests hospital outcomes are related to hyperglycemia. RECENT FINDINGS Recent literature describes observational evidence for hypoglycemia as an independent predictor of mortality in a general medical intensive care unit; superiority of performance of computerized intravenous insulin algorithms in comparison to earlier manual algorithms; acceptability of early transition to scheduled basal prandial correction subcutaneous insulin analog therapy for maintenance of glycemic targets after induction of euglycemia by intravenous insulin infusion, among cardiothoracic surgery patients; inferiority of sliding scale insulin compared to basal prandial correction therapy; and feasibility of diabetes patient self-management in the hospital setting. SUMMARY With development of improved insulin administration strategies problems of hypoglycemia and variability of glycemic control are reduced. Investigators and care providers need to achieve glycemic targets to optimize patient outcomes.
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Affiliation(s)
- Susan Shapiro Braithwaite
- Division of Endocrinology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina 27599-7172, USA.
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Reversing oversedation in the intensive care unit: the role of pharmacists in energizing guideline efforts and overcoming protocol fatigue. Crit Care Med 2008; 36:626-8. [PMID: 18216617 DOI: 10.1097/01.ccm.0000299844.38883.5e] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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