Reducing the Risk of Hypoglycemia Associated With Intravenous Insulin

Abstract

SymposiumThe level of glycemic control needed to improve outcomes without increasing the risk of hypoglycemia in hospitalized patients with critical illness is controversial. Achieving reasonable control of blood glucose without causing an excess risk of hypoglycemia is especially challenging in patients with ESRD, a condition commonly encountered in the critically ill.In 2001, Van den Berghe and colleague's landmark study in a surgical intensive care unit (ICU) suggested that strict blood glucose (BG) control (mean 103 mg/dL) was associated with a mortality and morbidity benefit in comparison to standard therapy (mean 153 mg/dL).1 A subsequent study of patients in the medical ICU however failed to show similar benefits and hypoglycemia was a frequent complication.2 Meta-analysis of multiple studies shows an inconsistent mortality benefit with intensive glycemic control and highlights the increased risk of hypoglycemia.3 More recently, the NICE-SUGAR study compared all-cause and cause-specific mortality and morbidity (new organ failure, bacteremia, redcell transfusion, and volume resuscitation) in over 6100 surgical and medical ICU patients treated either with an intensive insulin regimen (target BG 81-108 mg/dL) or a standard insulin regimen (target BG less than 180 mg/dL). 4 This trial concluded that intensive BG control was associated with a significant increase in the incidence of both moderate hypoglycemia (BG 41-70 mg/dL), and severe hypoglycemia (BG ≤ 40 mg/dL). Both degrees of hypoglycemia were associated with increased all-cause mortality, and particularly cardiovascular mortality. 5The cumulative effect of repeated hypoglycemia-related stress responses increases the risk of cardiac arrhythmias, neurological impairment, seizures, and death. [5][6] In light of AbstractComputerized insulin infusion protocols have facilitated more effective blood glucose (BG) control in intensive care units (ICUs). This is particularly important in light of the risks associated with hypoglycemia. End stage renal disease (ESRD) increases the risk of insulin-induced hypoglycemia. We evaluated BG control in 210 patients in 2 medical ICUs and in 2 surgical ICUs who were treated with a computerized insulin infusion program (CIIP). Our CIIP was programmed for a BG target of 140-180 mg/dL for medical ICU patients or 120-160 mg/dL for surgical ICU patients. In addition, we focused on BG control in the 11% of our patients with ESRD. Mean BG was 147 ± 20 mg/dL for surgical ICU patients and 171 ± 26 mg/ dL for medical ICU patients. Of both surgical and medical ICU patients, 17% had 1 or more BG 60-79 mg/dL, while 3% of surgical ICU and 8% of medical ICU patients had 1 or more BG < 60 mg/dL. Mean BG in ESRD patients was 147 ± 16 mg/dL similar to 152 ± 23 mg/dL in patients without ESRD. Of ESRD patients, 41% had 1 or more BG < 79 mg/dL as compared with 17.8% of non-ESRD patients (P < .01). A higher BG target for medical ICU patients as compared with surgical ICU patients yielded comparably low rates of moderate or severe hypoglycemia....

S3-Leitlinie Sepsis – Prävention, Diagnose, Therapie und Nachsorge

“…Eine Hyperglykämie und Glukosevariabilität scheint nicht im Zusammenhang mit erhöhten Mortalitätsraten bei Diabetespatienten im Vergleich zu Nichtdiabetespatienten zu stehen [468][469][470]. Patienten mit Diabetes, chronischer Hyperglykämie und Niereninsuffizienz im Endstadium könnten höhere Blutzuckerwertebereiche benötigen [471,472]. Begründung.…”

Hypoglycemia minimizing technologies used in adult patients undergoing continuous infusion of insulin

“…According to the studies carried out, the computerized protocols that are used for intensive glycemic control, are considered expensive, but effective in preventing hypoglycemia, in addition to optimizing the time spent by the nursing professionals. 16,17 The studies carried out comparing paper protocols and computerized protocols, unanimously highlighted the occurrence of decreased hypoglycemic events in intensive care units and even non-intensive ones that adopted computerized protocols. The computer alert system concerning the behavior of the nursing team, where it has numerous demands and in a tense sector, allows the team to establish priority in care when the alert goes off.…”

“…Among them, the calculations that must be made hourly at the bedside, delays or failure to perform blood glucose measurements and the difficulty in interpreting the protocols, these factors increased the variability of glycemic values and hypoglycemic events occurred more frequently. 16 In another study that evaluated nursing satisfaction with the use of paper protocols and computerized protocols, obtained a result of nurses' satisfaction using computerized protocols. Still in this study, it was observed that the nursing team deviated from what was required by the protocols, this could be assessed when comparing the insulin infusion doses that were found in the medical records and the doses that should really be included according to what was requested in protocols, so when compared to paper protocols, the computerized protocols suffered less deviation by the nursing team.…”

Hypoglycemia Reduction Strategies in the ICU

“…It is recommended that during IV insulin infusion, in the presence of chronic kidney disease (CKD), there should be conservative BG goals and insulin infusion rates [17,36,100,101]. Exogenous insulin bypasses first pass hepatic extraction, which is normally responsible for removal of about 40-60% of endogenously secreted insulin.…”

“…The renal contribution to gluconeogenesis may be compromised. In the critical care setting, renal failure increases the risk for hypoglycemia during insulin therapy [5,17,22,36].…”