University of Minnesota – University of Minnesota – School of Nursing Spring School of Nursing Spring Research DayResearch Day

Glycemic Control of Critically Ill Glycemic Control of Critically Ill PatientsPatients

Lynn Jensen, RN; Jessica Swearingen, BCPS, PharmD; Lynn Jensen, RN; Jessica Swearingen, BCPS, PharmD; Peggy Hoeft, RN; Pam Richardson, RN; Robert Miner, MDPeggy Hoeft, RN; Pam Richardson, RN; Robert Miner, MD

Abbott Northwestern Hospital Abbott Northwestern Hospital

ObjectivesObjectives

Understand benefits of intensive Understand benefits of intensive (“tight”) glycemic control in critically ill (“tight”) glycemic control in critically ill patientspatients

Describe the Intensive Insulin ICU Describe the Intensive Insulin ICU protocol implementation experience at protocol implementation experience at Abbott Northwestern (ANW) Hospital Abbott Northwestern (ANW) Hospital

Share patient outcome data associated Share patient outcome data associated with ANW Intensive Insulin ICU protocol with ANW Intensive Insulin ICU protocol utilizationutilization

Hyperglycemia in the Hyperglycemia in the Critically Ill Patient Critically Ill Patient PopulationPopulation

Hyperglycemia occurs in >50% in ICU Hyperglycemia occurs in >50% in ICU patientspatients

Multiple etiologies (e.g., counterregulatory Multiple etiologies (e.g., counterregulatory hormone release, medications)hormone release, medications)

Historically, hyperglycemia treated only at Historically, hyperglycemia treated only at very high blood glucose levelsvery high blood glucose levels

Hyperglycemia-related adverse effects (e.g., Hyperglycemia-related adverse effects (e.g., osmotic diuresis, impaired immune function) osmotic diuresis, impaired immune function) well establishedwell established

More recent evidence suggests close More recent evidence suggests close correlation between hyperglycemia & clinical correlation between hyperglycemia & clinical outcomeoutcome

Hyperglycemia Clinical Hyperglycemia Clinical Trials in Critically Ill Trials in Critically Ill PatientsPatients

Open heart surgery patients with history of DM Open heart surgery patients with history of DM & mean BG >206 mg/dL post-op had increased & mean BG >206 mg/dL post-op had increased risk for:risk for:– leg & chest wound infectionsleg & chest wound infections– pneumoniapneumonia– urinary tract infectionsurinary tract infections

AMI patients with history of DM or AMI patients with history of DM or hyperglycemia on hospital admission hyperglycemia on hospital admission randomized to tight control (BG 126-200 randomized to tight control (BG 126-200 mg/dL) for mg/dL) for 3 months or usual care 3 months or usual care – mortality at 1 yr & 3.4 yrs mortality at 1 yr & 3.4 yrs by 7.5% & 11%, by 7.5% & 11%,

respectively respectively – reinfarction & new cases of CHF decreasedreinfarction & new cases of CHF decreasedGolden et al. Diabetes Care 1999;22(9):1408-14;

Malmberg et al. J Am Coll Cardiol 1995;26(1):57-65

Hyperglycemia Clinical Hyperglycemia Clinical Trials in Critically Ill Trials in Critically Ill PatientsPatients

Mechanically ventilated, surgical ICU Mechanically ventilated, surgical ICU patientspatients– majority of patients had no history of DMmajority of patients had no history of DM– randomized to tight control or standard care randomized to tight control or standard care – after transfer from ICU both groups received after transfer from ICU both groups received

standard care standard care ResultsResults

– mortality mortality by 3.4% for tight control group by 3.4% for tight control group– mortality in patients with ICU stay >5 days mortality in patients with ICU stay >5 days by 9.6% by 9.6%

– significant significant in deaths due to sepsis & MODS in deaths due to sepsis & MODS – tight control tight control blood transfusions (28.6% vs. 31%); blood transfusions (28.6% vs. 31%);

dialysis (4.8% vs. 8.2%); mechanical ventilation >14 dialysis (4.8% vs. 8.2%); mechanical ventilation >14 days (7.5% vs. 11.9%); or ICU stay >14 days (11.4% days (7.5% vs. 11.9%); or ICU stay >14 days (11.4% vs. 15.7%)vs. 15.7%)Van den Berghe et al. NEJM 2001;345(19):1359-67.

Observational trial in Med/Surg/Neuro/Cardiac Observational trial in Med/Surg/Neuro/Cardiac ICU ICU

Before & after designBefore & after design– historical controls vs. consecutive protocol patientshistorical controls vs. consecutive protocol patients– protocol group received insulin infusion after 2 protocol group received insulin infusion after 2

successive BG levels >200 mg/dLsuccessive BG levels >200 mg/dL– BG goal <140 mg/dLBG goal <140 mg/dL

ResultsResults– mean BG mean BG from 152.3 mg/dL to 130.7 mg/dL from 152.3 mg/dL to 130.7 mg/dL– protocol significantly protocol significantly mortality from 20.9% to 14.8% mortality from 20.9% to 14.8%– most striking most striking in mortality for septic shock, neurologic in mortality for septic shock, neurologic

& surgical patients& surgical patients– BG>200 mg/dL BG>200 mg/dL from 16.7% to 7.1% from 16.7% to 7.1% – hypoglycemia did not increase (0.35% vs. 0.34%)hypoglycemia did not increase (0.35% vs. 0.34%)

Hyperglycemia Clinical Trials in Critically Ill Patients

Krinsley et al. Mayo Clin Proc 2004;79(8)992-1000

ANW Intensive Insulin Protocol ANW Intensive Insulin Protocol Implementation ExperienceImplementation Experience Multidisciplinary team of physicians, Multidisciplinary team of physicians,

pharmacists & nurses from each ICU pharmacists & nurses from each ICU Revision of existing Med/Surg/Neuro ICU Revision of existing Med/Surg/Neuro ICU

protocolprotocol Desktop computer protocol developedDesktop computer protocol developed New protocol implemented in all ICUs New protocol implemented in all ICUs

May 2004May 2004 Nurses in all ICUs educated Nurses in all ICUs educated Additional resources available during first Additional resources available during first

5 days of protocol implementation5 days of protocol implementation

ANW blood glucose goal range: 90-ANW blood glucose goal range: 90-120 mg/dL120 mg/dL

All protocol patients received:All protocol patients received:– insulin infusioninsulin infusion– hourly blood glucose checks until within goal range, hourly blood glucose checks until within goal range,

then every two hours then every two hours Data collected on:Data collected on:

– mean blood glucosemean blood glucose– efficacy attaining goal rangeefficacy attaining goal range– episodes of hypoglycemiaepisodes of hypoglycemia– patient outcomespatient outcomes

ANW Intensive Insulin ANW Intensive Insulin Protocol Implementation Protocol Implementation ExperienceExperience

Continued to make changes to Continued to make changes to protocol & provide feedbackprotocol & provide feedback

Challenges during implementationChallenges during implementation– physician (surgeon) acceptancephysician (surgeon) acceptance– limited glucometer availabilitylimited glucometer availability– multiple patient sticks/blood drawsmultiple patient sticks/blood draws– nursing acceptance due to nursing acceptance due to workload workload– computer dosing based on last 2 BG computer dosing based on last 2 BG

valuesvalues

ANW Intensive Insulin ANW Intensive Insulin Protocol Implementation Protocol Implementation ExperienceExperience

Protocol ExampleProtocol Example

ANW Intensive Insulin ANW Intensive Insulin Protocol Implementation Protocol Implementation ExperienceExperience

What is the rationale for using this intensive regular insulin infusion protocol?Research in critically ill patients has demonstrated decreased morbidity (sepsis, ventilator days, ICU LOS, dialysis, etc.) and mortality when glucose concentrations are kept below 110 mg/ dL. van den Berghe G, Wouters P, Weekers F, et al. Intensive Insulin Therapy in Critically Ill Patients. N Engl J Med 2001; 345(19):1359-67

How does the intensive regular insulin infusion protocol improve morbidity and mortality?Intense control of glucose concentration may improve immune function since white blood cell function is more effective when the glucose concentration is normal rather than when it is greater than 200 mg/ dL.

Can the intensive regular insulin infusion protocol be used in all critically ill patients?No. The protocol may be beneficial in most critically ill patients with acute hyperglycemia, even those with no prior diagnosis of diabetes. However, the protocol IS NOT to be used in patients with diabetic ketoacidosis or in women who are pregnant.

What are some side effects of an insulin infusion?Hypokalemia: insulin and glucose cause potassium to shift out of the blood and into cells. The end result may be to excessively lower the concentration of potassium in the blood. To avoid this, monitor potassium concentrations and implement the potassiu

Hypoglycemia: Because the glucose target range is narrow and lower than that of the past, the risk for hypoglycemia a concern. The insulin infusion rate may be too high for a specific patient and excessively lower his/ her blood glucose concentration. T

Neurologic events: Severe hypoglycemia may cause seizures or obtundation. Again, close monitoring of glucose concentrations is indicated to minimize the risk of these occurring.

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ANW Intensive Insulin ANW Intensive Insulin Protocol DataProtocol Data

CVICU CCU

Pre-protocol(81

patients; 5227 BG values)

Post-protocol (139

patients; 14192 BG values)

Pre-protocol

(25 patients; 1639 BG values)

Post-protocol (65 patients;

8141 BG values)

BG in goal range (90–120 mg/dL)

22% 36% 20% 33%

Mean BG (mg/dL)

158 133 162 138

BG ≥ 200 mg/dL

18% 7% 23% 10%

BG < 60 mg/dL

0.6% 0.6% 1.1% 0.6%

ANW Intensive Insulin ANW Intensive Insulin Protocol DataProtocol Data

Patient Demographics Pre-Protocol (n = 50)

Post-Protocol (n = 50)

Mean Age (years) 66.8 65.6

Sex (% male) 59 67

Ventilated (%) 76 80

History of Diabetes (%) 84 74

High Risk for Hyperglycemia (%)

70 61

Admit Diagnosis (%)

-Cardiovascular 69 75

-Renal 10 5

-Pulmonary 6 10

-Other 15 10

ANW Intensive Insulin ANW Intensive Insulin Protocol DataProtocol Data

Outcomes Pre-Protocol (n = 50)

Post-Protocol (n = 50)

Mean Blood Glucose (mg/dL) 168 133

Hypoglycemic Events (%) 0.22 0.23

Hospital Mortality (%) 14 11

New Onset Renal Dysfunction (%) 44 31

Mean Hospital Length of Stay (days)

17 13

Blood Product Administration (%) 61 52

ConclusionsConclusions

Tight glycemic control can Tight glycemic control can significantly improve morbidity & significantly improve morbidity & mortality in critically ill surgical mortality in critically ill surgical patientspatients

Barriers to implementation can be Barriers to implementation can be overcomeovercome

Nurses can significantly impact Nurses can significantly impact mortality & patient outcome by mortality & patient outcome by managing blood glucose more tightlymanaging blood glucose more tightly

Any Questions?Any Questions?