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.