Transcript Intensive Insulin Therapy: The Critical Facts
University of Minnesota – School of Nursing Spring Research Day
Glycemic Control of Critically Ill Patients
Lynn Jensen, RN; Jessica Swearingen, BCPS, PharmD; Peggy Hoeft, RN; Pam Richardson, RN; Robert Miner, MD Abbott Northwestern Hospital
Objectives
Understand benefits of intensive (“tight”) glycemic control in critically ill patients Describe the Intensive Insulin ICU protocol implementation experience at Abbott Northwestern (ANW) Hospital Share patient outcome data associated with ANW Intensive Insulin ICU protocol utilization
Hyperglycemia in the Critically Ill Patient Population
Hyperglycemia occurs in >50% in ICU patients Multiple etiologies (e.g., counterregulatory hormone release, medications) Historically, hyperglycemia treated only at very high blood glucose levels Hyperglycemia-related adverse effects (e.g., osmotic diuresis, impaired immune function) well established More recent evidence suggests close correlation between hyperglycemia & clinical outcome
Hyperglycemia Clinical Trials in Critically Ill Patients
Open heart surgery patients with history of DM & mean BG >206 mg/dL post-op had increased risk for: – leg & chest wound infections – pneumonia – urinary tract infections AMI patients with history of DM or hyperglycemia on hospital admission randomized to tight control (BG 126-200 mg/dL) for 3 months or usual care – mortality at 1 yr & 3.4 yrs by 7.5% & 11%, respectively – reinfarction & new cases of CHF decreased Golden et al. Diabetes Care Malmberg et al. 1999;22(9):1408-14; J Am Coll Cardiol 1995;26(1):57-65
Hyperglycemia Clinical Trials in Critically Ill Patients
Mechanically ventilated, surgical ICU patients – majority of patients had no history of DM – randomized to tight control or standard care – after transfer from ICU both groups received standard care Results – mortality by 3.4% for tight control group – mortality in patients with ICU stay >5 days by 9.6% – significant in deaths due to sepsis & MODS – tight control blood transfusions (28.6% vs. 31%); dialysis (4.8% vs. 8.2%); mechanical ventilation >14 days (7.5% vs. 11.9%); or ICU stay >14 days (11.4% vs. 15.7%) Van den Berghe et al. NEJM 2001;345(19):1359-67.
Hyperglycemia Clinical Trials in Critically Ill Patients
Observational trial in Med/Surg/Neuro/Cardiac ICU Before & after design – historical controls vs. consecutive protocol patients – protocol group received insulin infusion after 2 successive BG levels >200 mg/dL – BG goal <140 mg/dL Results – mean BG from 152.3 mg/dL to 130.7 mg/dL – protocol significantly mortality from 20.9% to 14.8% – most striking in mortality for septic shock, neurologic & surgical patients – BG>200 mg/dL from 16.7% to 7.1% – hypoglycemia did not increase (0.35% vs. 0.34%) Krinsley et al. Mayo Clin Proc 2004;79(8)992-1000
ANW Intensive Insulin Protocol Implementation Experience
Multidisciplinary team of physicians, pharmacists & nurses from each ICU Revision of existing Med/Surg/Neuro ICU protocol Desktop computer protocol developed New protocol implemented in all ICUs May 2004 Nurses in all ICUs educated Additional resources available during first 5 days of protocol implementation
ANW Intensive Insulin Protocol Implementation Experience
ANW blood glucose goal range: 90-120 mg/dL All protocol patients received: – insulin infusion – hourly blood glucose checks until within goal range, then every two hours Data collected on: – mean blood glucose – efficacy attaining goal range – episodes of hypoglycemia – patient outcomes
ANW Intensive Insulin Protocol Implementation Experience
Continued to make changes to protocol & provide feedback Challenges during implementation – physician (surgeon) acceptance – limited glucometer availability – multiple patient sticks/blood draws – nursing acceptance due to workload – computer dosing based on last 2 BG values
ANW Intensive Insulin Protocol Implementation Experience
Protocol Example
What is the rationale for using this intensive regular insulin infusion protocol?
R e t urn t o T o p 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.
R e t urn t o T o p 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.
R e t urn t o T o p 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.
R e t urn t o T o p
ANW Intensive Insulin Protocol Data
CVICU CCU BG in goal range (90– 120 mg/dL) Mean BG (mg/dL) BG ≥ 200 mg/dL BG < 60 mg/dL Pre-protocol (81 patients; 5227 BG values)
22%
Post-protocol (139 patients; 14192 BG values)
36%
Pre-protocol (25 patients; 1639 BG values)
20%
Post-protocol (65 patients; 8141 BG values)
33% 158 18% 0.6% 133 7% 0.6% 162 23% 1.1% 138 10% 0.6%
ANW Intensive Insulin Protocol Data
Patient Demographics
Mean Age (years) Sex (% male) Ventilated (%) History of Diabetes (%) High Risk for Hyperglycemia (%) Admit Diagnosis (%) -Cardiovascular -Renal -Pulmonary -Other
Pre-Protocol (n = 50)
66.8
59 76 84 70 69 10 6 15
Post-Protocol (n = 50)
65.6
67 80 74 61 75 5 10 10
ANW Intensive Insulin Protocol Data
Outcomes
Mean Blood Glucose (mg/dL)
Pre-Protocol (n = 50)
168 Hypoglycemic Events (%) Hospital Mortality (%) New Onset Renal Dysfunction (%) Mean Hospital Length of Stay (days) Blood Product Administration (%) 0.22
14 44 17 61
Post-Protocol (n = 50)
133 0.23
11 31 13 52
Conclusions
Tight glycemic control can significantly improve morbidity & mortality in critically ill surgical patients Barriers to implementation can be overcome Nurses can significantly impact mortality & patient outcome by managing blood glucose more tightly