Improving Patient OutcomesImproving Patient OutcomesGLYCEMIC CONTROL IN PERI-OPERATIVE GLYCEMIC CONTROL IN PERI-OPERATIVE

PATIENTSPATIENTSUTILIZING INSULIN INFUSION PROTOCOLSUTILIZING INSULIN INFUSION PROTOCOLS

The ProblemThe Problem

Hyperglycemia is common in critically ill surgical patients, Hyperglycemia is common in critically ill surgical patients, regardless of whether they had diabetes before hospital admission.regardless of whether they had diabetes before hospital admission.Control of blood glucose has been shifting toward progressively Control of blood glucose has been shifting toward progressively tighter glucose control in diabetics, a paradigm shift also reflected in tighter glucose control in diabetics, a paradigm shift also reflected in the care of critically ill patients. the care of critically ill patients. Elevated blood glucose (BG) is associated with increased mortality Elevated blood glucose (BG) is associated with increased mortality in the ICU setting.in the ICU setting.Hyperglycemia also causes substantial morbidity in critical illness, Hyperglycemia also causes substantial morbidity in critical illness, including increased risk of nosocomial infection, increased infarct including increased risk of nosocomial infection, increased infarct size with worsened outcomes in myocardial infarction and ischemic size with worsened outcomes in myocardial infarction and ischemic cerebrovascular accident, and increased protein catabolism after cerebrovascular accident, and increased protein catabolism after burn injury. burn injury. Hyperglycemia affects immune function Hyperglycemia affects immune function Clinicians have also observed that elevated glucose promotes Clinicians have also observed that elevated glucose promotes dehydration and inflammation.dehydration and inflammation.Post-operative patients are relatively Post-operative patients are relatively insulin resistantinsulin resistant

The StudiesThe StudiesVan den Berghe and associates examined whether the control of Van den Berghe and associates examined whether the control of hyperglycemia in critically ill patients can lead to improved outcomes in a hyperglycemia in critically ill patients can lead to improved outcomes in a prospective randomized trial. Study patients were admitted to the ICU for prospective randomized trial. Study patients were admitted to the ICU for mechanical ventilation. Patients were randomly assigned to one of two mechanical ventilation. Patients were randomly assigned to one of two groups: the first group received groups: the first group received intensive insulin therapyintensive insulin therapy with the goal of with the goal of trying to maintain glucose at between 80 and 110 mg/dL (ie, trying to maintain glucose at between 80 and 110 mg/dL (ie, normoglycemia), while in the normoglycemia), while in the conventional treatment armconventional treatment arm the goal glucose the goal glucose was kept between 180 and 200 mg/dL. was kept between 180 and 200 mg/dL.

This study showed that intensive insulin control This study showed that intensive insulin control lowered mortalitylowered mortality by > 40%. by > 40%. It also showed that there was a It also showed that there was a decreased requirement for ventilatordecreased requirement for ventilator supportsupport. Interestingly, a decreased need for renal replacement therapy was . Interestingly, a decreased need for renal replacement therapy was also demonstrated. Control of hyperglycemia also also demonstrated. Control of hyperglycemia also decreased septicdecreased septic episodesepisodes in the patients randomized to intensive insulin therapy by > 40%. in the patients randomized to intensive insulin therapy by > 40%. In totality, these studies make a compelling case that normoglycemia should In totality, these studies make a compelling case that normoglycemia should be the rule rather than the exception in surgical patients in the ICU. be the rule rather than the exception in surgical patients in the ICU.

(from Schwartz Principles of Surgery, (from Schwartz Principles of Surgery,

Diabetes mellitus (DM):Diabetes mellitus (DM): decreased insulin decreased insulin production (type I) and/or increased insulin production (type I) and/or increased insulin resistance (type II).resistance (type II).

InsulinInsulin: -inhibits hepatic production of glucose: -inhibits hepatic production of glucose - facilitates glucose transportation into - facilitates glucose transportation into

cellscells - inhibits breakdown of fatty acids (thus - inhibits breakdown of fatty acids (thus

decreasing ketone formation)decreasing ketone formation) - protein synthesis stimulation - protein synthesis stimulation

UNCONTROLLED DMUNCONTROLLED DM: : - reduction in inflammatory response- reduction in inflammatory response- reduction in angiogenesis- reduction in angiogenesis- reduction in collagen synthesis- reduction in collagen synthesis

Adapted from: Adapted from: Insulin delivery during surgery in the diabetic Insulin delivery during surgery in the diabetic

patient.patient. Diabetes Care 1982;5(Suppl 1):65–77Diabetes Care 1982;5(Suppl 1):65–77

Diabetes mellitus and cardiothoracic surgical site infectionsDiabetes mellitus and cardiothoracic surgical site infectionsAmerican Journal of Infectious Control, Volume 33(6), August 2005, p American Journal of Infectious Control, Volume 33(6), August 2005, p

353–359353–359

Continuous Intravenous Insulin Infusion Reduces the Continuous Intravenous Insulin Infusion Reduces the Incidence of Deep Sternal Wound Infection in Diabetic Incidence of Deep Sternal Wound Infection in Diabetic

Patients after Cardiac Surgical Procedures.Patients after Cardiac Surgical Procedures. In Annals of Thoracic Surgery 1999; 67: 352-62.In Annals of Thoracic Surgery 1999; 67: 352-62.

- Q4 hour CBG and RISS (goal <200)- Q4 hour CBG and RISS (goal <200) VSVS Insulin Infusion utilizing the Portland Insulin Infusion utilizing the Portland CII ProtocolCII Protocol

(goal between 150-200)(goal between 150-200)- 2467 patients evaluated- 2467 patients evaluated

ResultResult: : Significant reduction (2% in RISS patients vs 0.8% in Insulin infusion Significant reduction (2% in RISS patients vs 0.8% in Insulin infusion patients) in major infectious morbidity and its socioeconomic costspatients) in major infectious morbidity and its socioeconomic costs

Common concerns about intensive insulin infusion therapyCommon concerns about intensive insulin infusion therapy::

1. 1. CostCost: A randomized controlled trial in mechanically ventilated patients admitted to a surgical ICU ( (Analysis of healthcare resource utilization with intensive insulin Analysis of healthcare resource utilization with intensive insulin therapy in critically ill patients, Crit Care Med 2006; 34:3: 612-616)therapy in critically ill patients, Crit Care Med 2006; 34:3: 612-616) showed that intensive insulin therapy (goal of 80 and 100 mg/dl) significantly reduced hospital costs by reducing morbidity and mortality (vs conventional therapy of 180 and 200 mg/dl)

.

Table 5. Per patient costs of health care resources in [Euro sign] (interquartile range) consumed in the intensive and conventional treatment groups From:   Van den Berghe: Crit Care Med, Volume 34(3).March 2006.612-616

                                                                                                                                            

2. 2. support personnel availabilitysupport personnel availability: : Intensive insulin infusion therapy initially requires glucose finger sticks (CBG’s) Intensive insulin infusion therapy initially requires glucose finger sticks (CBG’s) every 1 hour. However, a study performed at Yale University every 1 hour. However, a study performed at Yale University (Clinical Results of an

Updated Insulin Infusion Protocol in Critically Ill Patients Diabetes Spectrum 18:188-191, 2005) has shown that the target glucose level was reached within about 6 hours. has shown that the target glucose level was reached within about 6 hours. Once the serum glucose level stabilizes, the frequency of CBG’s can be Once the serum glucose level stabilizes, the frequency of CBG’s can be decreased. Also, the protocols are followed by nurses. Thus, less time is spent decreased. Also, the protocols are followed by nurses. Thus, less time is spent on getting insulin orders from physicians. on getting insulin orders from physicians. 3. 3. Why the goal of 80-119 mg/dl?:Why the goal of 80-119 mg/dl?: The American Diabetes Association The American Diabetes Association recommends pre-prandial glucose levels between 90-130 mg/dl.recommends pre-prandial glucose levels between 90-130 mg/dl.Also, the study mentioned above showed improved morbidity Also, the study mentioned above showed improved morbidity (Analysis of healthcare (Analysis of healthcare resource utilization with intensive insulin therapy in critically ill patients, Crit Care Med 2006; 34:3: resource utilization with intensive insulin therapy in critically ill patients, Crit Care Med 2006; 34:3: 612-616).612-616).

4. 4. Concerns about hypoglycemiaConcerns about hypoglycemia: a study at Yale University showed that : a study at Yale University showed that even with a serum glucose goal of 80-119 mg/dl, the rate of hypoglycemic even with a serum glucose goal of 80-119 mg/dl, the rate of hypoglycemic events increased from 0.2 to 0.3% in the CTICU and 0.3 to 0.4 %.events increased from 0.2 to 0.3% in the CTICU and 0.3 to 0.4 %.

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

Diabetes SpectrumDiabetes Spectrum 18:188-191, 2005 18:188-191, 2005in Cardiothoracic ICUin Cardiothoracic ICU

(Old target glucose levels: 100-139 mg/dl(Old target glucose levels: 100-139 mg/dlNew target glucose levels: 90-119 mg/dl)New target glucose levels: 90-119 mg/dl)

(IIP: Insulin Infusion Protocol)(IIP: Insulin Infusion Protocol)

Clinical Results of an Updated Insulin Infusion Clinical Results of an Updated Insulin Infusion

Protocol in Critically Ill PatientsProtocol in Critically Ill Patients Diabetes SpectrumDiabetes Spectrum 18:188-191, 2005 18:188-191, 2005

in Medical ICUin Medical ICU (Old target glucose levels: 100-139 mg/dl (Old target glucose levels: 100-139 mg/dlNew target glucose levels: 90-119 mg/dl)New target glucose levels: 90-119 mg/dl)

Implementation of insulin infusion therapy in peri-operativeImplementation of insulin infusion therapy in peri-operativepatientspatients

1.1. Intensive insulin infusion therapy to be available in D1 Intensive insulin infusion therapy to be available in D1 – D3.– D3.

2.2. Goal serum glucose levels between 80 and 120 mg/dl.Goal serum glucose levels between 80 and 120 mg/dl.

3.3. Increased awareness of the need for tight glucose Increased awareness of the need for tight glucose controlcontrol

4.4. Increased awareness that hyperglycemia occurs in Increased awareness that hyperglycemia occurs in non-diabetic patientsnon-diabetic patients