University of Minnesota School of Nursing Spring Research Day

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University of Minnesota School of Nursing
Spring Research Day

• Glycemic Control of Critically Ill Patients
• Lynn Jensen, RN Jessica Swearingen, BCPS,
  PharmD Peggy Hoeft, RN Pam Richardson, RN
  Robert Miner, MD
• Abbott Northwestern Hospital

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Objectives

• Understand benefits of intensive (tight)
  glycemic control in critically ill patients
• Describe the Intensive Insulin ICU protocol
  implementation experience at Abbott Northwestern
  (ANW) Hospital
• Share patient outcome data associated with ANW
  Intensive Insulin ICU protocol utilization

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Hyperglycemia in the Critically Ill Patient
Population

• Hyperglycemia occurs in gt50 in ICU patients
• Multiple etiologies (e.g., counterregulatory
  hormone release, medications)
• Historically, hyperglycemia treated only at very
  high blood glucose levels
• Hyperglycemia-related adverse effects (e.g.,
  osmotic diuresis, impaired immune function) well
  established
• More recent evidence suggests close correlation
  between hyperglycemia clinical outcome

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Hyperglycemia Clinical Trials in Critically Ill
Patients

• Open heart surgery patients with history of DM
  mean BG gt206 mg/dL post-op had increased risk
  for
• leg chest wound infections
• pneumonia
• urinary tract infections
• AMI patients with history of DM or hyperglycemia
  on hospital admission randomized to tight control
  (BG 126-200 mg/dL) for ?3 months or usual care
• mortality at 1 yr 3.4 yrs ? by 7.5 11,
  respectively
• reinfarction new cases of CHF decreased

Golden et al. Diabetes Care 199922(9)1408-14
Malmberg et al. J Am Coll Cardiol
199526(1)57-65
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Hyperglycemia Clinical Trials in Critically Ill
Patients

• Mechanically ventilated, surgical ICU patients
• majority of patients had no history of DM
• randomized to tight control or standard care
• after transfer from ICU both groups received
  standard care
• Results
• mortality ? by 3.4 for tight control group
• mortality in patients with ICU stay gt5 days ? by
  9.6
• significant ? in deaths due to sepsis MODS
• tight control ? blood transfusions (28.6 vs.
  31) dialysis (4.8 vs. 8.2) mechanical
  ventilation gt14 days (7.5 vs. 11.9) or ICU
  stay gt14 days (11.4 vs. 15.7)

Van den Berghe et al. NEJM 2001345(19)1359-67.
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Hyperglycemia Clinical Trials in Critically Ill
Patients

• Observational trial in Med/Surg/Neuro/Cardiac ICU
  
• Before after design
• historical controls vs. consecutive protocol
  patients
• protocol group received insulin infusion after 2
  successive BG levels gt200 mg/dL
• BG goal lt140 mg/dL
• Results
• mean BG ? from 152.3 mg/dL to 130.7 mg/dL
• protocol significantly ? mortality from 20.9 to
  14.8
• most striking ? in mortality for septic shock,
  neurologic surgical patients
• BGgt200 mg/dL ? from 16.7 to 7.1
• hypoglycemia did not increase (0.35 vs. 0.34)

Krinsley et al. Mayo Clin Proc 200479(8)992-1000
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ANW Intensive Insulin Protocol Implementation
Experience

• Multidisciplinary team of physicians, pharmacists
  nurses from each ICU
• Revision of existing Med/Surg/Neuro ICU protocol
• Desktop computer protocol developed
• New protocol implemented in all ICUs May 2004
• Nurses in all ICUs educated
• Additional resources available during first 5
  days of protocol implementation

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ANW Intensive Insulin Protocol Implementation
Experience

• ANW blood glucose goal range 90-120
  mg/dL
• All protocol patients received
• insulin infusion
• hourly blood glucose checks until within goal
  range, then every two hours
• Data collected on
• mean blood glucose
• efficacy attaining goal range
• episodes of hypoglycemia
• patient outcomes

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ANW Intensive Insulin Protocol Implementation
Experience

• Continued to make changes to protocol provide
  feedback
• Challenges during implementation
• physician (surgeon) acceptance
• limited glucometer availability
• multiple patient sticks/blood draws
• nursing acceptance due to ? workload
• computer dosing based on last 2 BG values

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ANW Intensive Insulin Protocol Implementation
Experience

• Protocol Example

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ANW Intensive Insulin Protocol Data
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ANW Intensive Insulin Protocol Data
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ANW Intensive Insulin Protocol Data
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Conclusions

• Tight glycemic control can significantly improve
  morbidity mortality in critically ill surgical
  patients
• Barriers to implementation can be overcome
• Nurses can significantly impact mortality
  patient outcome by managing blood glucose more
  tightly

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Any Questions?