Intensive Insulin Therapy in Critical Care

Abstract

OBJECTIVE -To review performance characteristics of 12 insulin infusion protocols.RESEARCH DESIGN AND METHODS -We systematically identify and compare 12 protocols and then apply the protocols to generate insulin recommendations in the management of a patient with hyperglycemia. The main focus involves a comparison of insulin doses and patterns of insulin administration.RESULTS -There is great variability in protocols. Areas of variation include differences in initiation and titration of insulin, use of bolus dosing, requirements for calculation in adjustment of the insulin infusion, and method of insulin protocol adjustments. Insulin recommendations for a sample patient are calculated to highlight differences between protocols, including the patterns and ranges of insulin dose recommended (range 27-115 units [mean Ϯ SD 66.7 Ϯ 27.9]), amount recommended for glucose readings Ͼ200 mg/dl, and adjustments nearing target glucose.CONCLUSIONS -The lack of consensus in the delivery of intravenous insulin infusions is reflected in the wide variability of practice noted in this survey. This mandates close attention to the choice of a protocol. One protocol may not suffice for all patients.

Tight glycemic control in critical care – The leading role of insulin sensitivity and patient variability: A review and model-based analysis

“…This result also requires a level of adaptability from the TGC protocol that is not available in most published cases [66,[76][77][78].…”

“…• Insulin sensitivity (S I hereafter) and its variability, which controls the balance between the first two factors (insulin and nutritional inputs) and outcome glycemia for a given set of these two interventions A typical TGC control protocol controls only insulin dosing [42,66,77,81], excepting SPRINT, which (uniquely) controls both insulin and nutrition individually. Many studies leave nutritional inputs to unit specific standards and don't specify or report them.…”

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

“…A review of 12 published insulin infusion protocols for critically ill patients showed wide variability in dose recommendations and variable glucose control [485]. This lack of consensus about optimal dosing of IV insulin may reflect variability in patient factors (severity of illness, surgical versus medical settings), or practice patterns (e.g., approaches to feeding, IV dextrose) in the environments in which these protocols were developed and tested.…”

Perioperative glucose control: living in uncertain times—Continuing Professional Development

“…Les protocoles d'insuline 22,23 Standardisation La standardisation de l'insulinothérapie intraveineuse améliore l'efficacité et l'innocuité des stratégies de contrôle de la glycémie comparativement à une titration dirigée par le médecin. 24 Bien qu'il n'existe que peu de données qui permettent de comparer la performance de différents protocoles, un indice de pénalité glycémique 25 récemment mis au point pourrait faciliter de telles évaluations.…”

“…Insulin protocols 22,23 Standardization Standardization of intravenous insulin therapy improves the efficiency and safety of glucose control strategies when compared with physician-directed titration. 24 While little data exist to compare the performance of different protocols, a recently developed glycemic penalty index 25 may facilitate such evaluations.…”