Glycemic Control in the Intensive Care
Unit
Hanna Yudchyts, Pharm.D.PGY-1 Pharmacy ResidentNSLIJ Lenox Hill Hospital
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
Patient Case
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
Past Medical History
Diabetes Mellitus Type 1
HbA1c 10.2
Hypertension
Hyperlipidemia
Coronary Artery Disease
Angina
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
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
Give Your Patient FAST HUG Once a Day
Feeding
Analgesia
Sedation
Thromboembolic prophylaxis
Head-of-bed elevation
Ulcer prevention
Glucose control
140-180 mg/dL2009 ACE/ADA Guidelines
Target Blood Glucose
90-119 mg/dLYALE Insulin Drip Protocol
In critical care settings continuous IV insulin infusion is the most effective method to
achieving specific glycemic targets
YALE Insulin Drip Protocol
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
YALE Protocol Not to be Used
•Diabetic Ketoacidosis (DKA)
•Hyperglycemic Hyperosmolar Syndrome (HHS)
•BG≥ 500 mg/dL
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
PrimingFlush 50 ml of Insulin/NS drip through all IV tubing
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=3.25rounded up to 3.5
3.5 units IV bolus + 3.5 units/h start drip
Blood Glucose Monitoring
Check FS hourly until stable(3 consecutive values in target range)
Blood Glucose Monitoring
Once stable check FS every 2 hours
Stable for 12-24 hoursNo significant change in clinical condition No significant change in nutritional intake
Every 4 hours
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
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 minAsymptomatic: q 15-30 min
Restarting DripWhen 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
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
Determine RATE OF CHANGE from prior BG level
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
Basal-Bolus Insulin Model
Total Daily Dose
Basal (50%) Bolus (50%)
Breakfast
Lunch
Dinner
Correctional Insulin
Insulin Options
Basal
Glargine
Detemir
NPH
Bolus
Lispro
Aspart
Glulisine
Regular
Correctional
Lispro
Regular
Duration of action of different insulin formulations
Back to Patient Case
Insulin Infusion Administration Record 2-8 AM Before Discontinuation
Time BG RESULT(mg/dL)
CHANGE in BG(mg/dL)
NEW HOURLYRATE (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
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
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
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
References
• American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient GlycemicControl. 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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