Elsevier

Endocrine Practice

Volume 18, Issue 3, May–June 2012, Pages 363-370
Endocrine Practice

Original Article
Adapting To the New Consensus Guidelines for Managing Hyperglycemia During Critical Illness: the Updated Yale Insulin Infusion Protocol

https://doi.org/10.4158/EP11260.ORGet rights and content

ABSTRACT

Objective

To report our preliminary experience with the revised, more conservative Yale insulin infusion protocol (IIP) that targets blood glucose concentrations of 120 to 160 mg/dL.

Methods

We prospectively tracked clinical responses to the new IIP in our medical intensive care unit (ICU) by recording data on the first 115 consecutive insulin infusions that were initiated. All blood glucose values; insulin doses; nutritional support including intravenous dextrose infusions; caloric values for enteral and parenteral nutrition; and use of vasopressors, corticosteroids, and hemodialysis or continuous venovenous hemodialysis were collected from the hospital record.

Results

The IIP was used 115 times in 90 patients (mean age, 62 [± 14 years]; 51% male; 35% ethnic minorities; 66.1% with history of diabetes). The mean admission Acute Physiology and Chronic Health Evaluation II score was 24.4 (± 7.5). The median duration of insulin infusion was 59 hours. The mean baseline blood glucose concentration was 306.1 (± 89.8) mg/dL, with the blood glucose target achieved after a median of 7 hours. Once the target was reached, the mean IIP blood glucose concentration was 155.9 (± 22.9) mg/dL (median, 150 mg/dL). The median insulin infusion rate required to reach and maintain the target range was 3.5 units/h. Hypoglycemia was rare, with 0.3% of blood glucose values recorded being less than 70 mg/dL and only 0.02% being less than 40 mg/dL. In all cases, hypoglycemia was rapidly corrected using intravenous dextrose with no evident untoward outcomes.

Conclusions

The updated Yale IIP provides effective and safe targeted blood glucose control in critically ill patients, in compliance with recent national guidelines. It can be easily implemented by hospitals now using the original Yale IIP. (Endocr Pract. 2012;18:363-370)

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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