Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients

Jacobi, Judith PharmD, FCCM; Bircher, Nicholas MD, FCCM; Krinsley, James MD, FCCM; Agus, Michael MD; Braithwaite, Susan S. MD; Deutschman, Clifford MD, FCCM; Freire, Amado X. MD, MPH, FCCM; Geehan, Douglas MD, FCCM; Kohl, Benjamin MD, FCCM; Nasraway, Stanley A. MD, FCCM; Rigby, Mark MD, PhD, FCCM; Sands, Karen APRN-BC, ANP, MSN, CCRN; Schallom, Lynn RN, MSN, CCNS, FCCM; Taylor, Beth MS, RD, CNSD, FCCM; Umpierrez, Guillermo MD; Mazuski, John MD, PhD, FCCM; Schunemann, Holger MD

doi: 10.1097/CCM.0b013e3182653269
Special Article

Objective: To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point.

Methods: Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear.

Recommendations: The article is focused on a suggested glycemic control end point such that a blood glucose ≥150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤70 mg/dL) and to minimize glycemic variability.

Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate monitoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients.

Conclusions: While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infusion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy.

From the Indiana University Health Methodist Hospital, Indianapolis, IN (JJ); University of Pittsburgh Medical Center, Pittsburgh, PA (NB); Stamford Hospital, Stamford, CT (JK); Intermediate Care Unit, Children’s Hospital Boston, Boston, MA (MA); Endocrine Consults and Care, Evanston, IL (SSB); Critical Care and Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (CD); PCC and Sleep Medicine, University of Tennessee Health Science Center, Memphis, TN (AXF); University of Missouri Kansas City, Kansas City, MO (DG); University of Pennsylvania, Philadelphia, PA (BK); SICU, Tufts/New England Medical Center, Boston, MA (SAN); Pediatric Critical Care, Riley Hospital For Children, Indianapolis, IN (MR); Novant Health, Winston Salem, NC (KS); Barnes-Jewish Hosptial, St. Louis, MO (LS); Barnes Jewish Hospital, St. Louis, MO (BT); Emory University School of Medicine, Atlanta, GA (GU); Washington University St. Louis, St. Louis, MO (JM); McMaster University, Hamilton, Ontario, Canada (HS).

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Dr. Agus has consulted for the Diabetes Technology Society. He also has a pending patent on an ECMO-based glucose, sensor, which is not connected to idea discussed in this article. Dr. Braithwaite has a U.S. patent. Dr. Kohl has received grant support from Amylin and Eli Lilly. Dr. Krinsley has performed consulting work for Medtronic Inc., Edwards Life Sciences, Baxter, Roche Diagnostics, and Optiscan Biomedical and has received speaker’s fees from Edwards Life Sciences, Roche Diagnostics and Sanofi-Aventis. Dr. Nasraway has consulted for Optiscan, Echo Therapeutics. Dr. Geehan has received grant support from the Department of Defense Research. Dr. Rigby has received consulting fees from Medtronic. Dr. Schallom has received honoraria/speaking fees from Roche Laboratories Speakers Bureau on Glycemic Control. The remaining authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: jjacobi@iuhealth.org

The American College of Critical Care Medicine (ACCM), which honors individuals for their achievements and contributions to multidisciplinary critical care medicine, is the consultative body of the Society of Critical Care Medicine (SCCM) that possesses recognized expertise in the practice of critical care. The College has developed administrative guidelines and clinical practice parameters for the critical care practitioner. New guidelines and practice parameters are continually developed, and current ones are systematically reviewed and revised.

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