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TRANSITION FROM A CONTINUOUS INTRAVENOUS INFUSION TO A SUBCUTANEOUS INSULIN REGIMEN IN CRITICALLY ILL PATIENTS

Intermountain Healthcare - LDS Hospital, Salt Lake City, UT

PURPOSE: Intravenous insulin protocols to control blood glucose (BG) in critically ill patients have been successfully developed. Less attention has been paid to BG control when the patient leaves the intensive care unit or begins to eat. We adopted a technique recommended for outpatient glucose control in a subcutaneous transition program. Our objective was to transition intensive care patients on a 80 –110 mg/dL range intravenous protocol to a subcutaneous insulin regimen to maintain BG < 140 mg/dL.

METHODS: Data was collected prospectively from July 2005 through February 2006. Shock Trauma Respiratory Intensive Care Unit patients on our electronic continuous infusion insulin protocol (80 –110 range) were eligible to transition to the subcutaneous protocol. Patients were transitioned if they were stable on the insulin drip protocol, were anticipated to leave the unit within one to three days, or were beginning oral caloric intake. The subcutaneous transition was based on a total daily dose (TDD) calculation. Basal insulin was calculated as 50% of the TDD. The carbohydrate ratio and correction factor were calculated using the 2.8 and 1700 rules respectively. Daily insulin orders were written by critical care clinical pharmacists after review of the glucose values from the previous day.

RESULTS: Eighty-four patients transitioned to the subcutaneous protocol representing 2267 blood glucose values. The average infusion rate at the time of transition was 3.9 units/hour. After transition the average of all glucose values was 125 mg/dL and 85.7% of the patients had an average BG 140 mg/dL. Hypoglycemia ( 40 mg/dL) occurred in 1.2% of patients and 0.044% of all glucose measurements.

CONCLUSION: Intensive care patients were safely and effectively transitioned from an intravenous to a subcutaneous insulin regimen.

CLINICAL IMPLICATIONS: Tight glycemic control applied to patients in the intensive care unit has been shown to improve morbidity and mortality. Glucose control that begins in the ICU and extends to the floor may further improve patient outcome.

DISCLOSURE: Rick Carlson, None.