Original ArticleAdapting To the New Consensus Guidelines for Managing Hyperglycemia During Critical Illness: the Updated Yale Insulin Infusion Protocol
Section snippets
INTRODUCTION
Over the past decade there has been a great deal of controversy regarding the optimal management of hyperglycemia in the intensive care unit (ICU). In 2001, Van den Berghe et al (1) demonstrated the benefits of intensive glucose control (80-110 mg/dL) in a single-center, prospective randomized controlled trial among surgical ICU patients. As a result of this compelling evidence, institutions around the world adopted insulin infusion protocols (IIPs) to achieve stringent blood glucose (BG)
Setting
The Yale New Haven Hospital Medical ICU (MICU) consists of 28 beds in a 966-bed tertiary care referral center located in New Haven, Connecticut. Internal medicine residents, under the supervision of critical care fellows and board-certified pulmonary and critical care physicians and hospitalist physicians, care for these patients. The nurse-topatient ratio in the MICU is 1:1 or 1:2.
IIP Implementation and Overview
Our MICU nursing staff was already skilled in the implementation of previous Yale IIPs. Accordingly, minimal
Patients
Data collection occurred from September 2009 to January 2010. The new IIP was used 115 times in 90 patients. Baseline characteristics are shown in Table 1. Fifty-eight patients (76 drips, 66.1%) had known diabetes, 40 patients (52 drips, 45.2%) were on insulin before hospital admission, and 22 patients (32 drips, 27.8%) were using oral hypoglycemic agents. The most frequent admitting diagnosis was acute respiratory failure. The mean Acute Physiology and Chronic Health Evaluation II score was
DISCUSSION
The importance of avoiding hyperglycemia in critically ill patients has been well established (1,11., 12., 13.). The Leuven study in 2001 (1) reported a 42% relative reduction in mortality with intensive insulin therapy aimed at maintaining BG in the 80 to 110-mg/dL range when compared with conventional therapy (BG goal 180-200 mg/dL) among 1548 patients in the surgical ICU. After this, the same investigators implemented a similar study in their MICU (14). Although their results revealed no
CONCLUSION
In summary, this study describes our experience with the implementation of a safe, effective IIP with revised targets. Our IIP protocol is well established. To our knowledge, there are no published data regarding safety and efficacy of IIPs in a real-world, nonresearch setting in the post-NICE-SUGAR era that are in line with the latest national recommendations for glycemic control in critically ill patients. Our revised protocol had low rates of hypoglycemia, was effective at maintaining good
DISCLOSURE
The authors have no multiplicity of interest to disclose.
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