Glycemic control in the Intensive Care Units

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  • First I would like to talk about patient case that I came across during the ICU rotation and I will focus only on Insulin therapy that patient received. I think the regimen patient was on can be applied to majority of ICU patients.
  • According to the Med Rec.
  • After the surgery patient was admitted to the surgical ICU and started on YALE insulin drip protocol
  • FAST HUG is a mnemonic used in the intensive care unit (ICU) to aide healthcare professionals in maximize therapeutic interventions.FAST HUG is a mental ―checklist that highlights key aspects in the general care of the critically ill
  • Landmark trials in Leuven, Belgium suggested that targeting BS concentrations 80-110 reduced mortality and morbidity in ICU patients. But other trials such as Glucontrol, NICE-SUGAR trials were not able to replicate these findings. In contrast they reported increased mortality with this approach, and recent meta-analyses do not support intensive glucose control for critically ill patients. Recommendations from the ACE ( American college of endocrinology) and the ADA generally endorsed tight glycemic control in critical care units. Indeed, recent trials in critically ill patients have failed to show a significant improvement in mortality with intensive glycemic control (12,13) or have even shown increased mortality risk (14). Moreover, these recent RCTs have highlighted the risk of severe hypoglycemia resulting from such efforts (12–17).
  • Because of very short half-life of circulating insulin, IV delivery allows rapid dosing adjustments to address alterations in the status of patients
  • ICU patients experience changes in volume and subcutaneous tissue perfusion that could dramatically affect absorption kineticsIV insulin protocols should incorporate insulin sensitivity as the basis for adjustments in IV drip rates. Rate of change is the parameter that best facilitates evaluation of insulin sensitivity. When given intravenously, insulin has a rapid onset and short duration of action, allowing for precise titration. 
  • It is one unit per one ml concentration. Regular insulin is used mixed in 0.9% of normal saline
  • . In hypotensive patients, capillary blood glucose (i.e.,fingersticks)may be inaccurate and obtaining a blood sample from an indwelling vascular catheter may be preferable.
  • At 6 am it was 141 with drip rate 2. at 7 am it was 118. change is 23, decrease by 0.5. New drip rate is 1.5
  • Overlap with infusion 2-3 hours
  • Since patient was NPO
  • Glycemic control in the Intensive Care Units

    1. 1. Glycemic Control in the Intensive Care Unit Hanna Yudchyts, Pharm.D. PGY-1 Pharmacy Resident NSLIJ Lenox Hill Hospital
    2. 2.  Introduce patient case  Describe YALE Insulin Drip Protocol  Discuss benefits of insulin drip in the ICU  Review Basal- Bolus Insulin Model  Apply learned material to patient case and evaluate therapy chosen by medical team
    3. 3. Patient Case
    4. 4. History of Present Illness  GS is a 52 year old male  Patient experienced episode of midsternal chest pain while at work  He presented at Jersey City Medical Center ED  Angiogram revealed a three-vessel disease  Patient was instructed to follow up with CT surgery for further management and evaluation  He presented to Lenox Hill Hospital for surgical consultation
    5. 5. Past Medical History Diabetes Mellitus Type 1 HbA1c 10.2 Hypertension Hyperlipidemia Coronary Artery Disease Angina
    6. 6. Medications Prior to Admission Insulin Glargine 14 units at bedtime Lisinopril 40 mg daily Rosuvastatin 20 mg daily Metoprolol ER 25 mg daily Aspirin 81 mg daily Ranolazine 1000 mg daily Ticagrelor 90 mg daily Amiodarone 300 mg twice daily
    7. 7. Treatment Course  On 09/11/2013 patient underwent Off-Pump Coronary Artery Bypass Grafting (OPCABG)  After surgery was started on insulin infusion as per YALE insulin drip protocol – Insulin Regular Sliding Scale IV – 250 units in 250 mg NS IV Continuous Infusion – Titrate per protocol
    8. 8. Give Your Patient FAST HUG Once a Day Feeding Analgesia Sedation Thromboembolic prophylaxis Head-of-bed elevation Ulcer prevention Glucose control
    9. 9. 140-180 mg/dL 2009 ACE/ADA Guidelines Target Blood Glucose 90-119 mg/dL YALE Insulin Drip Protocol
    10. 10. In critical care settings continuous IV insulin infusion is the most effective method to achieving specific glycemic targets YALE Insulin Drip Protocol
    11. 11. YALE Protocol Benefits Eliminates the need for multiple injections Allows for more accurate dose administration Has more predictable kinetics Provides a quick response to rapidly changing glucose levels Accomplish adequate control with smaller insulin doses Incorporate current and previous blood glucose levels, current infusion rate and rate of change
    12. 12. YALE Protocol Not to be Used •Diabetic Ketoacidosis (DKA) •Hyperglycemic Hyperosmolar Syndrome (HHS) •BG≥ 500 mg/dL
    13. 13. Initiating an Insulin Drip Insulin infusion Mix 1 unit Regular Human Insulin per 1 ml 0.9% NaCl Administration Via infusion pump in increments of 0.5 units/hr Priming Flush 50 ml of Insulin/NS drip through all IV tubing
    14. 14. Calculating Initial Insulin Rate Blood Glucose divide by 100, then round to nearest 0.5 units for bolus and initial drip rate Example – Initial BG 325 mg/dL 325: 100=3.25 rounded up to 3.5 3.5 units IV bolus + 3.5 units/h start drip
    15. 15. Blood Glucose Monitoring Check FS hourly until stable (3 consecutive values in target range)
    16. 16. Blood Glucose Monitoring Once stable check FS every 2 hours Stable for 12-24 hours No significant change in clinical condition No significant change in nutritional intake Every 4 hours
    17. 17. Blood Glucose Monitoring Consider resumption of hourly FS monitoring: •Any change in insulin drip rate • Significant changes in clinical condition • Initiation/cessation of pressor/ steroid therapy, dialysis, nutritional support
    18. 18. BG<50 mg/dL BG 50-69 mg/dL Discontinue Drip Dextrose 1 amp (25g) Symptomatic: 1 amp (25 g) Asymptomatic: ½ amp (12.5 g) or 8 oz juice PO Check BG q 15 min Symptomatic: q 15 min Asymptomatic: q 15-30 min Restarting Drip When BG ≥ 90 mg/dL wait 1 hour Recheck BG if still ≥ 90 mg/dL restart drip New Rate 50% of recent rate 75% of recent rate Changing the Insulin Drip Rate
    19. 19. Changing the Insulin Drip Rate IF BG≥ 70 mg/dL Determine the Current BG LEVEL 70-89 mg/dL 90-119 mg/dL 120-179 mg/dL ≥ 180 mg/dL Identify a COLUMN in the tablet
    20. 20. Determine RATE OF CHANGE from prior BG level
    21. 21. Conversion from IV to SQ Insulin  To calculate TDD: 1. Units of insulin given in last 6 hours x 4 2. Use 80% of that value ( x 0.8) OR 1. Use last 7 insulin drip rates and omit the 2 highest 2. Sum of the lowest 5 drip rates x 4  Apply Basal- Bolus Insulin Model
    22. 22. Basal-Bolus Insulin Model Total Daily Dose Basal (50%) Bolus (50%) Breakfast Lunch Dinner Correctional Insulin
    23. 23. Insulin Options Basal Glargine Detemir NPH Bolus Lispro Aspart Glulisine Regular Correctional Lispro Regular
    24. 24. Duration of action of different insulin formulations
    25. 25. Back to Patient Case
    26. 26. Insulin Infusion Administration Record 2-8 AM Before Discontinuation Time BG RESULT (mg/dL) CHANGE in BG (mg/dL) NEW HOURLY RATE (units/h) 2 AM 108 0 1 3 AM 116 8 1 4 AM 109 7 1 5 AM 121 11 1.5 6 AM 141 20 2 7 AM 118 23 1.5 8 AM 138 20 2 Insulin administered in last 6 hours: 9 units
    27. 27. Transition from IV to SQ Calculating TDD  9 units x 4= 36 units  36 units x 0.8= 28.8 units Implementing Basal- Bolus regimen  28.8 x 0.5= 14.25≈ 14 units of basal insulin  14.25 : 3= 4.75 ≈ 5 units of bolus insulin before each meal  Insulin Correctional Scale
    28. 28. Transition from IV to SQ Patient was started on  Insulin Glargine 17 units once daily  Insulin Lispro 6 units three times a day with each meal  Insulin Correctional Scale (Lispro) Monitoring  BG monitoring before meals and at bedtime
    29. 29. Conclusion  Glucose concentrations should be closely monitored in critically ill patients  IV insulin infusion is preferred for optimum blood glucose control  Maintains blood glucose within desired range  Basal- Bolus insulin model once patient is stabilized
    30. 30. References • American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Diabetes Care. 2009 June; 32(6): 1119–1131. • http://www.istockphoto.com • Goldberg PA et al (2004). Implementation of a Safe and Effective Insulin Infusion Protocol in a Medical Intensive Care Unit. Diabetes Care 27(2):461-7. • Improving Care of the Hospitalized Patient with Hyperglycemia and Diabetes from the SHM Glycemic Control Task Force. Supplement to Journal of Hospital Medicine Volume 3 Issue S5 , Pages 1 - 83 (September/October 2008). • Armahizer M., PharmD, Benedict N., PharmD. FAST HUG: ICU Prophylaxis. Last updated: June 1, 2011. • Egi M. MD, Finfer S. MD, Bellomo R. MD. Glycemic Control in the ICU. CHEST; June 2010.

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