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IMPLEMENTATION OF TIGHT GLYCEMIC CONTROL IN THE INTENSIVE CARE UNIT

Crouse Hospital, Syracuse, NY

PURPOSE: To assess the effectiveness of a comprehensive glucose management protocol in reducing hyperglycemia in ICU patients.

METHODS: All ICU patients with glucose > 120 mg/dl were treated on protocol. If the patient was critically ill, or had an extremely high glucose, they were treated with the Intensive Insulin Drip Protocol. If they were NPO, on TPN, or continuous tube feedings, they were placed on a "progressive" Q6h Regular Insulin Sliding Scale Protocol, where the dose progressively escalates if the glucose is out of range. For those eating regular meals, they were treated with a weight based AC Sliding Scale Protocol. The NPO protocol was initiated if the patient received long acting insulin and subsequently became NPO. The ICU team ordered Glargine daily after reviewing the prior day's insulin requirement. Subsequent Glargine doses were increased by 50% of regular insulin administered the prior day. Glucometer readings of all ICU patients were downloaded into a database.

RESULTS: 24,424 glucose values between 7/1/2004 and 3/31/2006 were analyzed. The average daily glucose for all ICU patients decreased from 158.6 mg/dl to 131.2 mg/dl (p<0.0001). The standard deviation decreased from 20.0 to 13.8 (p<0.0003). There was a 53.0% reduction in glucose values > 200 mg/dl, a 24.1% increase in values between 80-110 gm/dl, (both p<0.0001) and an increase in values < 50 gm/dl from 1.9% to 2.3%(p=NS). ICU mortality decreased from 14.5% to 11.9% (p=NS). Severity adjusted length of stay decreased from 5.6 to 4.6 days for all ICU patients and from 13.0 to 10.7 days for patients in the "extreme" category (p=NS). Rates of nosocomial MRSA, VRE and C. difficle infections decreased from 4.61, 4.61 and 6.91 per 1,000 patient days to 2.75, 0, and 2.75 per 1,000 patient days respectively (p=NS).

CONCLUSION: Tight glycemic control in all ICU patients is achievable, with minimal increases in hypoglycemia, utilizing insulin protocols.

CLINICAL IMPLICATIONS: Protocols to manage hyperglycemia in all ICU populations should be utilized to reduce mortality and morbidity.

DISCLOSURE: Russell Acevedo, None.