Keywords
How to Cite
Abstract
Two sliding scale regular human insulin (RHI) algorithms (SSI) were retrospectively evaluated to identify those who develop severe hyperglycemia (blood glucose (BG) > 180 mg/dL) and for glycemic management of continuously-fed, critically ill trauma patients with mild to moderate hyperglycemia (BG 126 to 179 mg/dL). Assignment of low or high SSI was based upon anticipated severity of difficulty in glycemic control. BG was obtained every 3 to 6 hours. Target BG range was 70 to 149 mg/dL. Patients who were unable to achieve a BG < 150 mg/dL with SSI and who required a continuous intravenous RHI infusion were identified. Twenty-five of 121 patients (21%) failed SSI necessitating more intensive insulin therapy. The low and high intensity SSI groups exhibited a baseline BG of 123 + 33 mg/dL and 164 + 20 mg/dL (P = 0.001). Average BG for each group was 129 ± 14 mg/dL and 145 ± 21 mg/dL (P = 0.001). Each group spent 20 ± 4 and 16 ± 5 hours/day within the target BG range (P = 0.001), respectively. Mild hypoglycemia (BG 40 - 60 mg/dL) occurred in 11% and 7% of patients from each group (P = N.S.). Severe hypoglycemia (BG < 40 mg/dL) occurred in zero and two (5%) patients, respectively (P = N.S). SSI served as a useful technique to identify those requiring more intensive insulin therapy and was safe and efficacious for continuously-fed, critically ill trauma patients with mild to moderate hyperglycemia.
References
Black PR, Brooks DC, Bessey PQ, Wolfe RR, Wilmore DW. Mechanisms of insulin resistance following injury. Ann Surg 1982; 196: 420-35. https://doi.org/10.1097/00000658-198210000-00005
Bochicchio GV, Sung J, Joshi M, Bochicchio K, Johnson SB, Meyer W, Scalea TM. Persistent hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma 2005; 58: 921-4. https://doi.org/10.1097/01.TA.0000162141.26392.07
Collier B, Diaz J, Jr., Forbes R, et al. The impact of a normoglycemic management protocol on clinical outcomes in the trauma intensive care unit. JPEN J Parenter Enteral Nutr 2005; 29: 353-9. https://doi.org/10.1177/0148607105029005353
Scalea TM, Bochicchio GV, Bochicchio KM, Johnson SB, Joshi M, Pyle A. Tight glycemic control in critically injured trauma patients. Ann Surg 2007; 246: 605-12. https://doi.org/10.1097/SLA.0b013e318155a789
van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345: 1359-67. https://doi.org/10.1056/NEJMoa011300
Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360: 1283-97. https://doi.org/10.1056/NEJMoa0810625
American Diabetes Association. Standards of medical care in diabetes- 2016. Diabetes Care 2016; 39: S1-S112.
McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2016; 40: 159-211. https://doi.org/10.1177/0148607115621863
McMahon MM, Nystrom E, Braunschweig C, et al. A.S.P.E.N. clinical guidelines: nutrition support of adult patients with hyperglycemia. JPEN J Parenter Enteral Nutr 2013; 37: 23-36. https://doi.org/10.1177/0148607112452001
Bochicchio GV, Joshi M, Bochicchio KM, et al. Early hyperglycemic control is important in critically injured trauma patients. J Trauma 2007; 63: 1353-9. https://doi.org/10.1097/TA.0b013e31815b83c4
Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med 2012; 40: 3251-76. https://doi.org/10.1097/CCM.0b013e3182653269
Anon. Joint Commission IDs five high-alert meds. ED Manag 2000; 12: 21-2.
Dickerson RN, Lynch AM, Maish GO, 3rd, Croce MA, Minard G, Brown RO. Improved safety with intravenous insulin therapy for critically ill patients with renal failure. Nutrition 2014; 30: 557-62. https://doi.org/10.1016/j.nut.2013.10.010
Dickerson RN, Swiggart CE, Morgan LM, Maish III GO, Croce MA, Minard G, Brown RO. Safety and efficacy of a graduated intravenous insulin infusion protocol in critically ill trauma patients receiving specialized nutritional support. Nutrition 2008; 24: 536-45. https://doi.org/10.1016/j.nut.2008.02.008
Dickerson RN, Hamilton LA, Connor KA, Maish GO, 3rd, Croce MA, Minard G, Brown RO. Increased hypoglycemia associated with renal failure during continuous intravenous insulin infusion and specialized nutritional support. Nutrition 2011; 27: 766-72. https://doi.org/10.1016/j.nut.2010.08.009
Dickerson RN, Maish GO, 3rd, Minard G, Brown RO. Nutrition support team-led glycemic control program for critically ill patients. Nutr Clin Pract 2014; 29: 534-41. https://doi.org/10.1177/0884533614530763
Baldwin D, Villanueva G, McNutt R, Bhatnagar S. Eliminating inpatient sliding-scale insulin: a reeducation project with medical house staff. Diabetes Care 2005; 28: 1008-11. https://doi.org/10.2337/diacare.28.5.1008
Hirsch IB. Sliding scale insulin--time to stop sliding. JAMA 2009; 301: 213-4. https://doi.org/10.1001/jama.2008.943
Umpierrez GE, Palacio A, Smiley D. Sliding scale insulin use: myth or insanity? Am J Med 2007; 120: 563-7. https://doi.org/10.1016/j.amjmed.2006.05.070
Kudsk KA, Minard G, Croce MA, et al. A randomized trial of isonitrogenous enteral diets after severe trauma. An immune-enhancing diet reduces septic complications. Ann Surg 1996; 224: 531-43. https://doi.org/10.1097/00000658-199610000-00011
Rosmarin DK, Wardlaw GM, Mirtallo J. Hyperglycemia associated with high, continuous infusion rates of total parenteral nutrition dextrose. Nutr Clin Pract 1996; 11: 151-6. https://doi.org/10.1177/0115426596011004151
Baker SP, O'Neill B, Haddon W, Jr., Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14: 187-96. https://doi.org/10.1097/00005373-197403000-00001
Dickerson RN, Wilson VC, Maish GO, 3rd, Croce MA, Minard G, Brown RO. Transitional NPH insulin therapy for critically ill patients receiving continuous enteral nutrition and intravenous regular human insulin. JPEN J Parenter Enteral Nutr 2013; 37: 506-16. https://doi.org/10.1177/0148607112458526
Krinsley JS. Glycemic variability: a strong independent predictor of mortality in critically ill patients. Crit Care Med 2008; 36: 3008-13. https://doi.org/10.1097/CCM.0b013e31818b38d2
Meyfroidt G, Keenan DM, Wang X, Wouters PJ, Veldhuis JD, Van den Berghe G. Dynamic characteristics of blood glucose time series during the course of critical illness: effects of intensive insulin therapy and relative association with mortality. Crit Care Med 2010; 38: 1021-9. https://doi.org/10.1097/CCM.0b013e3181cf710e
Shaw JH, Wolfe RR. An integrated analysis of glucose, fat, and protein metabolism in severely traumatized patients. Studies in the basal state and the response to total parenteral nutrition. Ann Surg 1989; 209: 63-72. https://doi.org/10.1097/00000658-198901000-00010
Dickerson RN, Johnson JL, Maish GO, 3rd, Minard G, Brown RO. Evaluation of nursing adherence to a paper-based graduated continuous intravenous regular human insulin infusion algorithm. Nutrition 2012; 28: 1008-11. https://doi.org/10.1016/j.nut.2012.01.010
Preiser JC, Devos P, Ruiz-Santana S, et al. A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Inten Care Med 2009; 35: 1738-48. https://doi.org/10.1007/s00134-009-1585-2
Dickerson LM, Ye X, Sack JL, Hueston WJ. Glycemic control in medical inpatients with type 2 diabetes mellitus receiving sliding scale insulin regimens versus routine diabetes medications: a multicenter randomized controlled trial. Ann Fam Med 2003; 1: 29-35. https://doi.org/10.1370/afm.2
Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med 1997; 157: 545-52. https://doi.org/10.1001/archinte.1997.00440260101014
Alfonso A, Koops MK, Mong DP, Vigersky RA. Glycemic control with regular versus lispro insulin sliding scales in hospitalized Type 2 diabetics. J Diabetes Complications 2006; 20: 153-7. https://doi.org/10.1016/j.jdiacomp.2005.06.009
Umpierrez GE, Smiley D, Jacobs S, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care 2011; 34: 256-61. https://doi.org/10.2337/dc10-1407
Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care 2007; 30: 2181-6. https://doi.org/10.2337/dc07-0295
Golightly LK, Jones MA, Hamamura DH, Stolpman NM, McDermott MT. Management of diabetes mellitus in hospitalized patients: efficiency and effectiveness of sliding-scale insulin therapy. Pharmacotherapy 2006; 26: 1421-32. https://doi.org/10.1592/phco.26.10.1421
Emam IA, Allan A, Eskander K, et al. Our experience of controlling diabetes in the peri-operative period of patients who underwent cardiac surgery. Diabetes Res Clin Pract 2010; 88: 242-6. https://doi.org/10.1016/j.diabres.2010.03.002
Korytkowski MT, Salata RJ, Koerbel GL, et al. Insulin therapy and glycemic control in hospitalized patients with diabetes during enteral nutrition therapy: a randomized controlled clinical trial. Diabetes Care 2009; 32: 594-6. https://doi.org/10.2337/dc08-1436
Cook A, Burkitt D, McDonald L, Sublett L. Evaluation of glycemic control using NPH insulin sliding scale versus insulin aspart sliding scale in continuously tube-fed patients. Nutr Clin Pract 2009; 24: 718-22. https://doi.org/10.1177/0884533609351531
Datta S, Qaadir A, Villanueva G, Baldwin D. Once-daily insulin glargine versus 6-hour sliding scale regular insulin for control of hyperglycemia after a bariatric surgical procedure: a randomized clinical trial. Endocr Pract 2007; 13: 225-31. https://doi.org/10.4158/EP.13.3.225
Schroeder JE, Liebergall M, Raz I, Egleston R, Ben Sussan G, Peyser A, Eldor R. Benefits of a simple glycaemic protocol in an orthopaedic surgery ward: a randomized prospective study. Diabetes Metab Res Rev 2012; 28: 71-5. https://doi.org/10.1002/dmrr.1217
Becker T, Moldoveanu A, Cukierman T, Gerstein HC. Clinical outcomes associated with the use of subcutaneous insulin-by-glucose sliding scales to manage hyperglycemia in hospitalized patients with pneumonia. Diabetes Res Clin Pract 2007; 78: 392-7. https://doi.org/10.1016/j.diabres.2007.05.003
Hagelberg A, Ivert T, Efendic S, Ohrvik J, Anderson RE. Insulin glargine improves glycaemic control after coronary surgery in patients with diabetes or pre-diabetes. Scand Cardiovasc J 2008; 42: 71-6. https://doi.org/10.1080/14017430701721756
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright (c) 2017 Sarah V. Cogle , Susan E. Smith , George O. Maish III , Gayle Minard , Martin A. Croce , Roland N. Dickerson