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Clinical Results of an Updated Insulin Infusion Protocol in Critically Ill Patients

The first 20% of the full text of this article appears below.

Strict glycemic control has recently been shown to improve clinical outcomes in critically ill patients. In the February 2004 issue of Diabetes Care, we reported our early experience implementing an insulin infusion protocol (IIP) in a medical intensive care unit (MICU).¹ To facilitate early acceptance by our critical care physicians and nurses, we initially selected a conservative blood glucose target of 100–139 mg/dl. We subsequently published similar (indeed, slightly better) results using this same IIP in two cardiothoracic intensive units (CTICUs).²

Following this work, based on the primary literature,³ a position statement from the American College of Endocrinology (ACE),⁴ and a technical review by the American Diabetes Association (ADA),⁵ we decided to lower our target further into the normal range. Rather than abruptly drop to the 80–110 mg/dl target espoused by both the ACE and ADA, we elected to gradually lower our blood glucose target range in order to carefully study the impact of lowering the target on both glycemic control and rates of hypoglycemia.

To this end, we present here our updated experience with a new, more stringent IIP, which differs from our old protocol in three fundamental ways:

1. Target blood glucose levels are lowered to 90–119 mg/dl,
   
2. To facilitate more rapid glycemic control, the initial insulin bolus is increased by 40%, and,
   
3. The protocol language is now in compliance with the Joint Commission on Accreditation of Healthcare Organizations.
   

The complete, updated IIP is shown in Figure 1.

View larger version (50K): [in this window] [in a new window]   Figure 1. The new Yale IIP.

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				S. G. Oeyen, E. A. Hoste, C. D. Roosens, J. M. Decruyenaere, and S. I. Blot Adherence to and Efficacy and Safety of an Insulin Protocol in the Critically Ill: A Prospective Observational Study Am. J. Crit. Care., November 1, 2007; 16(6): 599 - 608. [Abstract] [Full Text] [PDF]