Finding the Sweet Spot with Glycemic Management in ICU

Roberts, Melanie

Saturday, 29 October 2011

Melanie Roberts, MSN, APRN, CCRN
CICU and SICU, Medical Center of the Rockies, Loveland, CO

Learning Objective 1: state the appropriate target glucose range for critically ill patients based on the current evidenced based practice in literature.

Learning Objective 2: explain the associated morbidity and mortality associated with hypoglycemic events for critically ill patients and discuss the strategies developed to achieve zero severe hypoglycemia events.

INTRODUCTION: Glycemic management in ICU has been a moving target since the Van de Berghe study was published in 2001 introducing the concept of tight glycemic control. Later studies demonstrated a single hypoglycemic event contributes to mortality risk, negating the benefit of tight glycemic control.

PURPOSE: This evidence-based practice project is focused on developing an insulin protocol to maintain blood glucose within a specified target range and eliminating severe hypoglycemia.

DESCRIPTION: In 2008, order sets were developed to drive the practice and insulin protocol. There are two protocols, IV and subcutaneous, which are used in the ICUs. The original target was 90mg/dL-140mg/dL based on the current literature at the time and the concern of the physicians for hypoglycemia. Data is reviewed to determine the patients mean glucose level, percent of patients within the target range and episodes of hypoglycemia. In 2009, each hypoglycemic event was reviewed in detail for learning opportunities and common causes. Order sets were changed based on information found in the chart reviews to standardize care. In 2010, the order sets were changed to reflect the most recent evidence for the target range (120mg/dL-180mg/dL) and standardized insulin infusion titration.

EVALUATION and OUTCOMES: Evaluation of this project is based on the monthly review of glucose data. Data is analyzed for the following: percent of patients within the target range, percent of patients with mean blood glucose greater than 200 mg/dL, percent of patients with mild-to-moderate hypoglycemia (50-69mg/dL), percent of patients with severe hypoglycemia (<50mg/dL), and each hypoglycemic event is reviewed in detail. The Cardiac ICU had zero severe hypoglycemia from October 2010-March 2011, previously the rate was 3%-5%. The Surgical ICU had a decrease in the rate of severe hypoglycemia, from a rate of 5% to 4% , 3 of the last 6 months having zero hypoglycemia.

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