Hyperglycemia Control of theNil Per OsPatient in the Intensive Care Unit: Introduction of a Simple Subcutaneous Insulin Algorithm

Abstract

Abbreviations: (BG) blood glucose, (ICU) intensive care unit, (IV) intravenous, (IVI) intravenous insulin, (NPO) nil per os, (SQ) subcutaneous, (SQIA) subcutaneous insulin algorithm

Automated Self-Adjusting Subcutaneous Insulin Algorithm for Patients NPO or on TPN or Enteral Feedings

“…As published in 2012, we previously demonstrated the feasibility of implementing a paper-based self-titrating SQIA and that it maintains the majority of glucose levels within the target range of 80-180 mg/dL. 25 In that study, where we compared the SQIA to use of an IV insulin infusion, the SQIA resulted in similar glucose levels, but only required nursing intervention every 4 hours instead of every hour. As we prepared to launch this paper-based protocol into use throughout the medical center, inpatient use of EPIC began.…”

“…This SQIA maintained the majority of glucoses within the target range with very low rates of hypoglycemia and was effective in surgical patients with and without diabetes. As we have previously highlighted, 25 inpatient diabetes management using sliding-scale insulin, where a fixed dose of insulin is given based on the current glucose level, can lead to a "rollercoaster" effect on glucose levels. When the glucose is at goal, no insulin is given; then the glucose increases and insulin is given, lowering the glucose, and the cycle begins again.…”

“…This algorithm is a variation on a simple protocol that was first described by Pezzarossa et al in 1988, 24 and then modified as part of a Quality Improvement (QI) project at the University of California, San Francisco (UCSF) using a shorter-acting insulin analog, aspart (NovoLog, Novo Nordisk Pharmaceuticals Inc.). 25 Based on our experience with the algorithm during the QI project, a new multidisciplinary team composed of endocrinologists, pharmacists, nurses, and programmers was formed. The SQIA underwent further refinement and details are shown in Supplemental Figure S1.…”

“…Prior studies have shown that simple subcutaneous (SQ) insulin algorithms used in the ICU or perioperative setting can have adequate glycemic control as compared to the labor-intensive IV insulin algorithms in patients who are nil per os (NPO). 24,25 These algorithms can be applied to other hospitalized populations, particularly in patients who are receiving calories in a controlled and continuous fashion, such as those who are NPO or receiving continuous enteral or parenteral nutrition.…”

Prednosti in slabosti različnih protokolov vodenja vrednosti glukoze v krvi pri kritično bolnih pacientih

“…Glede na namen raziskave ugotoviti prednosti in slabosti najbolj pogostih protokolov vodenja vrednosti glukoze v krvi pri kritično bolnih pacientih ugotavljamo, da imajo medicinske sestre pri vzdrževanju ustrezne ravni koncentracije glukoze v krvi pomembno vlogo. Zdravljenje kritično bolnih pacientov v enoti intenzivne terapije pogosto poteka z inzulinsko infuzijsko mešanico, kar od medicinskih sester zahteva večkratne meritve koncentracije glukoze v krvi in prilagajanje doze inzulina (Kim, et al, 2012). Pri kritično bolnih pacientih so kot najprimernejša oblika vzdrževanja ciljnih glikemičnih vrednosti uveljavljeni kontiunirani protokoli vodenja vrednosti glukoze v krvi (Kelly, 2014).…”