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An Intensive Insulin Protocol for Critically Ill Patients

Upstate Medical University, Syracuse, NY

PURPOSE: Hyperglycemia in critically ill patients predisposes to complications even in nondiabetic patients. Tight glycemic control has been shown to improve mortality and morbidity. Published intensive insulin protocols are few, complex and labor intensive. We propose an intensive insulin protocol that overcomes these technical difficulties.

METHODS: We tested the following insulin protocol 14 times on 10 patients who were admitted to our medical and surgical intensive care unit (ICU) at Crouse Hospital aiming for a blood glucose (BG) level between 80 and 110 mg% measured by fingersticks (FS). The ICU bedside nurse, without additional assistance, performed the protocol. All FS on protocol were recorded in a database as pre-control or post-initial control. Protocol: •Regular insulin drip started at 2 or 4 units/hour (decided by physician) •Fingersticks checked every 2 hours or as need •Insulin drip to be adjusted no more than every 4 hour as follows (unless hypoglycemic): FS < 70: drip held for 1 hour then decreased by 2 units/hour FS rechecked after 1 hour from restarting drip FS 71-80: drip decreased by 1 unit/hour FS 81-110: drip continued at current rate FS 111-200: drip increased by 1 unit/hour or restated at 1 unit/hour FS 201-300: drip increased by 2 units/hour Physician to be called for FS<60 or >300 .

RESULTS: There were 1195 blood glucose determinations, 1102 after reaching initial control. The mean (+ SD) initial glucose was 243.3 (+ 87.1) mg%. The mean (+ SD) post-initial control FS was 100.9 (+ 24.4) mg%. The average time (+ SD) to reach target glycemic control was 11.1 (+ 5.2) hours. The table
% Fingerstick Glucoses in Range After Reaching Glycemic Control

FS Range (mg%) % of Determinations < 60 1.5% < 110 68.6% < 130 80.4% < 150 93.6%

shows the distribution of the determinations and the graph illustrates the FS control over the first 120 hours of protocol.

CONCLUSION: This is a less labor-intensive insulin protocol that provides tight glycemic control in the ICU with minimal hypoglycemic episodes.

CLINICAL IMPLICATIONS: This protocol could facilitate the implementation of intensive glycemic control in the ICU.

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