Effect of Adding Insulin Glargine on Glycemic Control in Critically Ill Patients Admitted to Intensive Care Units: A Prospective Randomized Controlled Study

Evaluation of Basal Plus Versus Sliding Scale Insulin Therapy on Glucose Variability in Critically Ill Patients Without Preexisting Diabetes

BACKGROUND

There is limited evidence evaluating the impact of insulin treatment strategies on glucose variability in critically ill patients without preexisting diabetes.

OBJECTIVE

Compare basal plus insulin (BPI) and sliding scale insulin (SSI) impact on glycemic control outcomes in critically ill patients without preexisting diabetes experiencing hyperglycemia.

METHODS

This multicenter, retrospective review analyzed critically ill patients with hyperglycemia who received either BPI or SSI. Patients with a hemoglobin A1C >6.5% during the admission of interest or in the previous 3 months, or a diagnosis of diabetes at the time of discharge were excluded. The primary outcome was glucose variability during the intensive care unit (ICU) admission. Secondary outcomes included hypoglycemia frequency, frequency of goal glucose levels, mortality, and length of stay.

RESULTS

The analysis included 228 patients (39 in BPI, 189 in SSI). Average glucose variability was higher in the BPI group compared with the SSI group (85.8 mg/dL ± 33.1 vs 70.2 mg/dL ± 30.7; P = 0.009), which remained when controlling for baseline confounding (-12.1 [5.6], 95% CI -23.2 to -0.99; P = 0.033). Hypoglycemia incidence was similar between groups. BPI patients had a lower incidence of glucose values within goal range than SSI patients (P = 0.046). There was no difference in length of stay or hospital mortality.

CONCLUSIONS AND RELEVANCE

The use of SSI compared with a BPI regimen may result in reduced glycemic variability in critically ill patients without preexisting diabetes. Future prospective studies, with a larger sample size, are warranted to confirm our exploratory findings and characterize clinically significant benefits.

Insulin therapy and blood glucose management in critically ill patients: a 1-day cross-sectional observational study in 69 French intensive care units

BACKGROUND

Hyperglycaemia is common in critically ill patients, but blood glucose and insulin management may differ widely among intensive care units (ICUs). We aimed to describe insulin use practices and the resulting glycaemic control in French ICUs. We conducted a multicentre 1-day observational study on November 23, 2021, in 69 French ICUs. Adult patients hospitalized for an acute organ failure, severe infection or post-operative care were included. Data were recorded from midnight to 11:59 p.m. the day of the study by 4-h periods.

RESULTS

Two ICUs declared to have no insulin protocol. There was a wide disparity in blood glucose targets between ICUs with 35 different target ranges recorded. In 893 included patients we collected 4823 blood glucose values whose distribution varied significantly across ICUs (P < 0.0001). We observed 1135 hyperglycaemias (> 1.8 g/L) in 402 (45.0%) patients, 35 hypoglycaemias (≤ 0.7 g/L) in 26 (2.9%) patients, and one instance of severe hypoglycaemia (≤ 0.4 g/L). Four hundred eight (45.7%) patients received either IV insulin (255 [62.5%]), subcutaneous (SC) insulin (126 [30.9%]), or both (27 [6.6%]). Among patients under protocolized intravenous (IV) insulin, 767/1681 (45.6%) of glycaemias were above the target range. Among patients receiving insulin, short- and long-acting SC insulin use were associated with higher counts of hyperglycaemias as assessed by multivariable negative binomial regression adjusted for the propensity to receive SC insulin: incidence rate ratio of 3.45 (95% confidence interval [CI] 2.97-4.00) (P < 0.0001) and 3.58 (95% CI 2.84-4.52) (P < 0.0001), respectively.

CONCLUSIONS

Practices regarding blood glucose management varied widely among French ICUs. Administration of short or long-acting SC insulin was not unusual and associated with more frequent hyperglycaemia. The protocolized insulin algorithms used failed to prevent hyperglycaemic events.

Application of the PDCA Cycle for Managing Hyperglycemia in Critically Ill Patients

Introduction

Stress hyperglycemia is a common symptom in critically ill patients, and is not only a marker indicating the severity of illness but is also related to worsening outcomes. Managing stress hyperglycemia without increasing the likelihood of hypoglycemia is one of the most pressing challenges to be urgently addressed in clinics. The Plan-Do-Check-Act (PDCA) cycle management has been put forward in various surgical management scenarios, and has proven to be effective in the diagnosis and treatment of different diseases. It possesses dynamic characteristics and can be updated according to the results of glycemic control and feedback. This study focused on the use of PDCA to manage glucose levels in critically ill patients.

Methods

Based on the glucose level of 1003 critically ill patients admitted to the emergency intensive care unit (EICU) from 1 October 2019 to 31 December 2020, we collected and matched the prevalence of hyperglycemia, hypoglycemia, and glucose variability on a quarterly basis. According to the PDCA management method, we analyzed the possible causes, supervised the implementation of measures, summarized the feedback on improvements, and then proposed new improvement measures for implementation in the next quarter.

Results

Three measures were proposed and applied to enhance the management of hyperglycemia: (I) Updating and formulating three editions of the insulin infusion protocol and increasing the initial and maintenance doses of insulin on a case-by-case basis; (II) reducing the use of parenteral nutrition and ensuring that enteral nutrition is consumed at a uniform and slow rate; and (III) forming a training method during the COVID-19 pandemic and improving implementation of the insulin infusion protocol. Following PDCA management, the prevalence of hyperglycemia fell from 43.18% to 32.61%, the incidence of hypoglycemia was below 1.00%, and there was no significant fluctuation in blood glucose variability.

Conclusion

The PDCA method is helpful in developing a superior insulin infusion protocol for critically ill patients and lowering the prevalence of hyperglycemia in critically ill patients.

A randomized trial to investigate the efficacy and safety of insulin glargine in hyperglycemic acute stroke patients receiving intensive care

This pilot, randomized, open-label controlled study compared the basal–bolus regimens of insulin glargine (IG) and neutral protamine Hagedorn (NPH) insulin in stroke patients with hyperglycemia receiving intensive care. The study recruited acute stroke patients requiring intensive care within 72 h (h) of onset and had blood glucose > 200 mg/dL. 50 patients received IG (n = 26) or NPH (n = 24) with added short-acting prandial regular insulin over a 72-h period. The primary end point was the percentage of glucose within 80–180 mg/dL assessed through continuous glucose monitoring. The baseline characteristics were comparable, except the IG had higher glucose pre-randomization than the NPH (290.69 ± 82.31 vs. 246.04 ± 41.76 mg/dL, P = 0.021). The percentage of time with glucose between 80 and 180 mg/dL was 45.88 ± 27.04% in the IG and 53.56 ± 22.89% in the NPH (P = 0.341) and the percentage of glucose reduction was 31.47 ± 17.52% in the IG and 27.28 ± 14.56% in the NPH (P = 0.374). The percentage of time with glucose < 60 mg/dL was 0.14 ± 0.49% in the IG and 0.47 ± 1.74% in the NPH. Poststroke outcomes were not significantly different. In conclusion, IG is safe and equally effective as an NPH-based basal-bolus regimen for acute stroke patients with hyperglycemia receiving intensive care.

Trial registration ClinicalTrials.gov, NCT02607943. Registered 18/11/2015, https://clinicaltrials.gov/ct2/show/NCT02607943.

Incidence and Prediction of Unstable Blood Glucose Level among Critically Ill Patients: A Cohort Study

PURPOSE

To evaluate the incidence and the prediction of unstable blood glucose level among critically ill patients hospitalized in an intensive care unit.

METHODS

A cohort study was conducted with 62 adult patients hospitalized at an intensive care unit of a hospital located in Minas Gerais, Brazil, between March and July of 2017. Patient's demographic information, along with scores for Simplified Acute Physiology Score III, primary medical diagnosis, discharge status, diagnosis of diabetes and/or sepsis, length of stay, glycemic variability, type of nutrition, types of medications and treatments, and oxygen therapy were collected daily. A daily venous blood sample was collected to measure blood glucose levels during the patient's hospitalization period. Bivariate analysis was used to explore the association among the potential diagnostic indicators and the outcome of unstable blood glucose levels. Multivariate Cox regression was used to identify the potential predictors for the outcome.

FINDINGS

Of the total of 62 participants, 45.1% (n=28) had unstable blood glucose level. Among the 28 patients with unstable blood glucose levels, half of them (n=14, 50%) had hypoglycemia and the other half had hyperglycemia (n=14, 50%). Decreased number of days hospitalized and the use of intensive glucose control with regular insulin were associated with decreased odds of developing hyperglycemia. The presence of mechanical ventilation was associated with a higher risk for the development of hypoglycemia.

CONCLUSIONS

This study provides knowledge and evidence of diagnostic indicators for unstable blood glucose levels that are not currently included in the NANDA-International terminology for the nursing diagnosis Risk for unstable blood glucose level (00179).

IMPLICATIONS FOR NURSING PRACTICE

This study identified important diagnostic indicators that nurses can observe during the assessment to identify patients that are at risk for developing unstable blood glucose level and provide the appropriate care.