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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 4  |  Page : 215-219

Glycemic control in intensive care unit: Experience of a tertiary care center


1 Department of Internal Medicine, University Hospital of Sharjah, Sharjah, UAE
2 Department of Pharmacy Services, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
3 Department of Critical Care, King Khalid University Hospital, King Saud University Medical City, Riyadh, Saudi Arabia

Date of Web Publication4-Oct-2019

Correspondence Address:
Hadil A Alotair
Department of Internal Medicine, University Hospital of Sharjah, PO Box 72272, Sharjah
UAE
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JNSM.JNSM_20_19

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  Abstract 


Background: Hyperglycemia complicates the course of illness of many critically ill patients and contributes to the increased morbidity and mortality in adult intensive care units (ICUs). Objective: The objective of this study is to compare the effectiveness of a modified nurse-implemented insulin infusion protocol (NIIP) against the original protocol used in the adult ICUs, in terms of controlling hyperglycemia while averting significant hypoglycemia. Methodology: Blood glucose (BG) readings that were collected over 3 months in medical and surgical ICUs (SICUs) while on the original insulin infusion protocol were retrospectively reviewed. A modified insulin infusion protocol was prepared by a dedicated adult ICU quality focus group composed of physicians, nurses, clinical pharmacists, and quality representative. The rate of insulin infusion was increased by 10%–20% for the BG ranges above 13.1 mmol/L, allowing early transition from a mild-to-moderate scale. The new protocol was implemented for 2 months, and BG readings were compared to the results of the original insulin infusion protocol. Results: A total of 3490 BG readings in the medical ICU and 3006 in SICU were analyzed. Hyperglycemia was found in 1743 readings (26.83%) while on the original insulin protocol. When the modified insulin infusion protocol was applied, hyperglycemia was significantly less (19.83%, P < 0.0001) and significantly more readings were in the range of 7.8–10 mmol/L (52.57% vs. 46.54%, P= 0.0001). The reduction in hyperglycemia was more significant in SICU patients (19.20% vs. 31.27%, P < 0.0001). Meanwhile, severe hypoglycemia remained within the benchmark. Conclusions: The modified NIIP achieved fewer episodes of hyperglycemia in critically ill patients while avoiding the deleterious effects of hypoglycemia. This affirms the value of periodic monitoring and adjustment of ongoing protocols in ICUs.

Keywords: Hyperglycemia, hypoglycemia, insulin infusion, intensive care unit


How to cite this article:
Alotair HA, Aldasoqi SA, Baldove JP, Abdou MA. Glycemic control in intensive care unit: Experience of a tertiary care center. J Nat Sci Med 2019;2:215-9

How to cite this URL:
Alotair HA, Aldasoqi SA, Baldove JP, Abdou MA. Glycemic control in intensive care unit: Experience of a tertiary care center. J Nat Sci Med [serial online] 2019 [cited 2019 Oct 22];2:215-9. Available from: http://www.jnsmonline.org/text.asp?2019/2/4/215/266074




  Introduction Top


Hyperglycemia is a prevalent complication and a noted manifestation in up to 90% of patients with a critical illness.[1] Common risk factors include sepsis, severe trauma, extensive surgery, and myocardial infarction.[2] Possible underlying mechanisms include insulin resistance, even in nondiabetic persons, and the release of stress hormones.[2] Recent evidence demonstrated increased mortality and morbidity associated with hyperglycemia.[3],[4],[5],[6],[7],[8]

The revised clinical practice guidelines for the management of patients with sepsis and septic shock recommended a protocolized approach for the control of hyperglycemia.[9] However, the design of insulin infusion protocols continues to pose a challenge for clinicians, as most are unsuccessful in achieving target blood glucose (BG) without increasing the rate of hypoglycemia.[10]

The critical care nurses play a fundamental role in the assessment and monitoring of insulin therapy. This allows them to make a sound clinical judgment and proactively support quality improvement in lessening the repercussions of hypoglycemia and hyperglycemia in the intensive care unit (ICU) while still providing safety margins where a physician consultation is still essential.

In this study, we describe the insulin infusion protocol used in a university hospital ICUs both medical and surgical in 2016 and compare it to the modified nurse-implemented insulin infusion protocol initiated in 2017 as a quality improvement project in ICU. We used an upper target of BG of ≤10 mmol/L and hypoglycemia was defined as BG <4 mmol/L.


  Methodology Top


BG readings were taken in medical ICU (MICU)(10 beds) and surgical ICU (SICU) (14 beds) of King Khalid University Hospital, Riyadh, Saudi Arabia. Point of care glucometer (STAT-STRIP GLU/KET Meter, Nova Bio Medical, UK) was used for the measurement of BG. Most of the SICU beds were occupied by postoperative patients. One bed in SICU was occupied by a medical patient at times of bed shortage in MICU. The original protocol used in ICU in the year 2016 is shown in [Figure 1]. It was initiated in 2014 to control BG below 10 mmol/L. It included mild, moderate, and individualized scales, and patients were moved from one scale to the other according to the results of consecutive BG readings [Figure 1], guidelines]. All patients were started initially on a mild scale. The results of BG readings recorded over 3 months were analyzed by a dedicated focus group consisting of ICU nurse specialist, ICU physicians, clinical pharmacist, quality coordinator, and quality specialist. The protocol was modified by increasing the rate of insulin infusion by 10%–20% for the ranges of blood sugar with a higher frequency of high readings in both the mild and moderate ranges and the shift from one scale to the other was made sooner [Figure 2], changes underlined]. Education for the modified NIIP was given to ICU nurses by the nurse educator and head nurses 2 weeks prior to the start of the modified protocol. BG readings taken by the same glucometer were recorded for 2 months. BG readings were compared in the two protocols in terms of hyperglycemia, defined as BG more than 10 mmol/L, mild hypoglycemia (BG 2.2–3.9 mmol/L), and severe hypoglycemia (BG <2.2 mmol/L). The institutional review board approval for this paper was under a waiver for retrospective studies as this insulin protocol was the standard of care in ICU patients.
Figure 1: Adult intensive care unit insulin infusion protocol-2016

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Figure 2: Adult intensive care unit insulin infusion protocol-2017

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Statistical method

Statistical analysis was performed using Statistical Package for the Social Sciences version 22.0 software (SPSS Inc., Chicago, IL, USA) which was used for statistical analysis.

We calculated the frequencies and percentages for all nominal variables.

We used the Chi-square test or Fisher's exact test to compare the results of 2016 and 2017 after modifying the insulin infusion protocol.

We assumed that there was a statistically significant difference when P < 0.05.


  Results Top


A total of 6496 (3490 in MICU and 3006 from SICU) BG readings were recorded while the patients were receiving the original 2016 insulin infusion protocol and 2728 readings were recorded following the implementation of the modified 2017 insulin infusion protocol [Table 1]. Hyperglycemia was found in 1743 readings (26.83%) while on the original protocol and 541 readings (19.8%) with the modified protocol. Significantly less hyperglycemia was found with the modified protocol (19.83%, vs. 26.83%, P < 0.0001). Similarly, there were significantly more readings in the desirable range of 7.8–10 mmol/L after implementing the modified protocol (52.57% vs. 46.54%, P= 0.0001). On the other hand, BG readings in the mild hypoglycemia range (2.2–3.9 mmol/L) were more with the modified protocol; however, only one reading of severe hypoglycemia (<2.2 mmol/L) was recorded with the modified protocol [Table 1]. There were 3915 BG readings recorded from diabetic patients receiving the original insulin infusion protocol in 2016 and 1767 readings recorded from diabetic patients on the modified protocol. During the implementation of the original protocol, 3851 readings were for patients who received steroids compared to 1098 readings for patients on steroids with the modified protocol.
Table 1: Comparison between the blood glucose readings of all patients following the insulin infusion protocol implemented in 2016 and 2017

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In SICU, the hyperglycemia readings above 10 mmol/L were significantly less after using the modified protocol (19.2% vs. 31.27%, P < 0.0001) [Table 2], but there were more readings in the mild hypoglycemia range with the modified protocol (0.7% vs. 0.2%. P= 0.01). However, there was no difference in the readings of severe hypoglycemia between the two protocols (one reading in the modified protocol versus none in the original protocol).
Table 2: Comparison between the blood glucose readings of patients in surgical intensive care unit and surgical intensive care unit following the insulin infusion protocol implemented in 2016 and 2017

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Similarly, in the MICU, BG readings in the hyperglycemia range were lower with the modified protocol, but this did not reach statistical significance [Table 3]. Mild hypoglycemia was also more frequent with the modified protocol (0.95 vs. 0.11, P < 0.0001), but no readings of severe hypoglycemia were recorded with either protocol [Table 3].
Table 3: Comparison between the blood glucose readings of patients in medical intensive care unit and medical intensive care unit following the insulin infusion protocol implemented in 2016 and 2017

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Comparing possible factors that can affect BG control, the percentage of BG readings recorded from diabetic patients (64.77%) and patients on total parenteral nutrition (9.93%) was statistically higher in the modified protocol compared to the original protocol (60.27% and 5.56% respectively, P < 0.0001). However, there were more frequent readings from patients on steroids in the original protocol (59.2% vs. 40.25%, P < 0.0001).

Limitations

This is a single-center pre/post-implementation observational study and no separate analysis was made for diabetic patients and nondiabetics.


  Discussion Top


In this paper, we describe a new insulin infusion protocol that was modified after the analysis of the glucose readings obtained while following an existing protocol. This was part of a quality improvement project to control hyperglycemia in critically ill patients in both MICU and SICUs. The modified protocol achieved better control of hyperglycemia while avoiding severe hypoglycemia. Important elements that contributed to the success of this protocol include adjustments based on the analysis of glucose readings while using a previous protocol, the gradual rate of change in insulin infusion rate, and the increase in the frequency of glucose checks. The use of protocols in the ICUs, in general, decreases variability of practice and improves outcomes. This is particularly true of insulin infusion protocols when compared to the sliding scale of intravenous insulin and physician-directed titration.[10]

When compared to other insulin infusion protocols, this modified protocol is much simpler as it does not require boluses or mathematical calculation of the rate or velocity of change in BG to adjust the insulin infusion rate.[10]

The Society of Critical Care Medicine (SCCM) stressed the importance of controlling hyperglycemia in critically ill (ICU) patients. Active measures need to be taken to maintain BG below 150 mg/dl (8.3 mmol/L) and absolutely below 180 mg/dl (10 mmol/L).[11]

NICE-SUGAR study, which is the largest study on glucose control in ICU patients, suggests a target BG level between 7.8 and 10.0 mmol/L (140 and 180 mg/dl) for the majority of ICU patients and a lower glucose targets between 6.1 and 7.8 mmol/L (110 and 140 mg/dl) in selected ICU patients.[9],[10],[11] Other studies recommended at 9–11 mmol/L (162–198 mg/dl) to maximize cellular uptake of glucose without the risk of hyperosmolar effects.[6],[11],[12],[13],[14] Our target for BG control (<10 mmol/L) is in agreement with the new recommendations of American Diabetes Association, American Heart Association, and SCCM.[11],[15],[16]

Using the modified ICU protocol, the rate of hyperglycemia was significantly reduced (down to 19.8%) among all ICU patients, though more significantly in SICU. Several studies have demonstrated increased morbidity and mortality and poorer prognosis associated with hyperglycemia.[17],[18] Hyperglycemia in diabetic surgical patients has been associated with a high prevalence of postoperative infections as well as poor prognosis after stroke and head injury. In cardiac patients, plasma glucose at admission was an independent risk factor for long-term prognosis after myocardial infarction and following coronary artery bypass graft surgery.[17],[18] Recent evidence suggests that even mild hyperglycemia can aggravate ischemia/reperfusion damage to the heart and brain. Myocardial infarct size in humans, with or without diabetes, is greater in the presence of hyperglycemia.[2],[19],[20],[21] These poor clinical outcomes could be due to the proinflammatory, prothrombotic, and pro-oxidant adverse effects of hyperglycemia.[19],[20],[21] Hyperglycemic state may reduce intracellular bactericidal activity, thus increasing the risk of infection,[22],[23] and in the same way, increase oxidative stress leading to increased risk for thrombotic events.[22],[23],[24],[25],[26],[27] This is particularly true during the acute phase of sepsis where hyperglycemia can intensifying the risk of cardiac and hemodynamic complications, including acute kidney failure and death.[28],[29],[30] However, this is not applicable to all patients and, in particular, to those who are already diabetic probably due to adaptive mechanisms to chronic hyperglycemia.[29],[30],[31]

On the other hand, hypoglycemia is independently associated with increased risk of mortality among patients with diabetes as well as among those without diabetes admitted in ICU.[31]

In the two protocols we used in ICU, hypoglycemia (BG <4 mmol/L) was considered the lower cutoff for glycemic control. After implementing the modified protocol, there were more readings in the mild hypoglycemia range (2.2–3.9 mmol/L) compared to the original protocol; however, these were <1% [Table 1] which is within acceptable benchmark (<2% Institute of Healthcare Improvement (IHI) (0.5% – internal benchmark).[16]

Similarly, BG readings of severe hypoglycemia (BG <2.2 mmol/L) were 0% in MICU and 0.07% in SICU with the modified protocol [Table 2] and [Table 3].

Meanwhile, the use of hydrocortisone in the treatment of critically ill patients admitted in ICU may induce hyperglycemia. It is contemplated that dexamethasone increases postoperative glucose levels and therefore increase insulin requirements.[32],[33],[34] In this study, we found that there were more readings taken from patients receiving steroids with the original protocol than the modified protocol (59.28% vs. 40.25%). This could have contributed to the increased rate of hyperglycemia observed with the original protocol.

Another factor that could affect glucose control in ICU patients is parenteral nutrition. The prevalence of hyperglycemia is higher in patients receiving parenteral nutrition than those receiving enteral nutrition.[35],[36],[37],[38] Many studies have confirmed that hyperglycemia is a frequent complication of parenteral nutrition in both patients with and without diabetes and that the development of hyperglycemia during nutrition support increases the risk of complications and mortality.[39],[40],[41],[42],[43] In our report, we found more patients on parenteral nutrition receiving the modified protocol, but this did not affect the rate of hyperglycemia probably due to their small percentage (9.93%).


  Conclusions Top


It is most important to be vigilant in monitoring and reducing hyperglycemia in ICU patients while at the same time avoiding an increase in hypoglycemic episodes. Periodic revision of ongoing insulin infusion protocol used in ICU along with attentive education is highly recommended. Followed strictly, the modified nurse-implemented insulin infusion protocol (NIIP) can control BG levels in ICU patients effectively and safely.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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