Improving Patient Outcomes GLYCEMIC CONTROL IN PERIOPERATIVE PATIENTS UTILIZING INSULIN INFUSION PRO

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Improving Patient OutcomesGLYCEMIC CONTROL IN
PERI-OPERATIVE PATIENTSUTILIZING INSULIN
INFUSION PROTOCOLSPeter Baik, D.O.PGY-2,
Department of SurgerySt. Barnabas Hospital
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The Problem

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

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The Studies

• Van den Berghe and associates examined whether
  the control of hyperglycemia in critically ill
  patients can lead to improved outcomes in a
  prospective randomized trial. Study patients were
  admitted to the ICU for mechanical ventilation.
  Patients were randomly assigned to one of two
  groups the first group received intensive
  insulin therapy with the goal of trying to
  maintain glucose at between 80 and 110 mg/dL (ie,
  normoglycemia), while in the conventional
  treatment arm the goal glucose was kept between
  180 and 200 mg/dL.
• This study showed that intensive insulin control
  lowered mortality by gt 40. It also showed that
  there was a decreased requirement for ventilator
  support. Interestingly, a decreased need for
  renal replacement therapy was also demonstrated.
  Control of hyperglycemia also decreased septic
  episodes in the patients randomized to intensive
  insulin therapy by gt 40.
• In totality, these studies make a compelling case
  that normoglycemia should be the rule rather than
  the exception in surgical patients in the ICU.

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(from Schwartz Principles of Surgery, Diabetes
mellitus (DM) decreased insulin production (type
I) and/or increased insulin resistance (type
II).Insulin -inhibits hepatic production of
glucose - facilitates glucose transportation
into cells - inhibits breakdown of fatty
acids (thus decreasing ketone formation)
- protein synthesis stimulationUNCONTROLLED DM
- reduction in inflammatory response -
reduction in angiogenesis - reduction in
collagen synthesis
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Adapted from Insulin delivery during surgery in
the diabetic patient. Diabetes Care 19825(Suppl
1)6577
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Diabetes mellitus and cardiothoracic surgical
site infectionsAmerican Journal of Infectious
Control, Volume 33(6), August 2005, p 353359
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Continuous Intravenous Insulin Infusion Reduces
the Incidence of Deep Sternal Wound Infection in
Diabetic Patients after Cardiac Surgical
Procedures. In Annals of Thoracic Surgery 1999
67 352-62.- Q4 hour CBG and RISS (goal lt200)
VS Insulin Infusion utilizing the Portland CII
Protocol(goal between 150-200)- 2467 patients
evaluatedResult Significant reduction (2 in
RISS patients vs 0.8 in Insulin infusion
patients) in major infectious morbidity and its
socioeconomic costs
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Common concerns about intensive insulin infusion
therapy

• 1. Cost A randomized controlled trial in
  mechanically ventilated patients admitted to a
  surgical ICU (Analysis of healthcare resource
  utilization with intensive insulin therapy in
  critically ill patients, Crit Care Med 2006
  343 612-616) 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)
• .

                                                
                                                  
                                          
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2. support personnel availability Intensive
insulin infusion therapy initially requires
glucose finger sticks (CBGs) every 1 hour.
However, a study performed at Yale University
(Clinical Results of an Updated Insulin Infusion
Protocol in Critically Ill Patients Diabetes
Spectrum 18188-191, 2005) has shown that the
target glucose level was reached within about 6
hours. Once the serum glucose level stabilizes,
the frequency of CBGs can be decreased. Also,
the protocols are followed by nurses. Thus, less
time is spent on getting insulin orders from
physicians. 3. Why the goal of 80-119 mg/dl?
The American Diabetes Association recommends
pre-prandial glucose levels between 90-130
mg/dl.Also, the study mentioned above showed
improved morbidity (Analysis of healthcare
resource utilization with intensive insulin
therapy in critically ill patients, Crit Care Med
2006 343 612-616).4. Concerns about
hypoglycemia a study at Yale University showed
that 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 .
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Clinical Results of an Updated Insulin Infusion
Protocol in Critically Ill Patients Diabetes
Spectrum 18188-191, 2005in Cardiothoracic
ICU(Old target glucose levels 100-139 mg/dlNew
target glucose levels 90-119 mg/dl)(IIP
Insulin Infusion Protocol)
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Clinical Results of an Updated Insulin Infusion
Protocol in Critically Ill Patients Diabetes
Spectrum 18188-191, 2005in Medical ICU (Old
target glucose levels 100-139 mg/dlNew target
glucose levels 90-119 mg/dl)
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Implementation of insulin infusion therapy in
peri-operativepatients

• Intensive insulin infusion therapy to be
  available in D1 D3.
• Goal serum glucose levels between 80 and 120
  mg/dl.
• Increased awareness of the need for tight glucose
  control
• Increased awareness that hyperglycemia occurs in
  non-diabetic patients