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What is needed to help improve implementation of intensive insulin therapy in the ICU?
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A universally accepted protocol may be helpful
IV insulin is underutilized but is the safest way to give patients insulin because the half life is short, and provided appropriate monitoring, patients should be safe. There are now several protocols that account for rate of change in glucose. These protocols are user friendly and can accurately maintain glucose in a tight range.
Obviously, the down-side is more frequent glucose monitoring that is labor intensive and some patients are adverse to the finger sticks. In the ICU setting where the nurse-to-patient ratio is more manageable, this is less of an issue. An often missed point regarding IV insulin is that subcutaneous boluses of prandial insulin still have to be given if patients are receiving boluses of enteral nutrition or eating meals. Retrospective increases in the insulin drip rate to account for mealtime or TEN excursions can lead to hypoglycemia.
 Mark H. Schutta |
There is somewhat unwarranted fear of hypoglycemia in the hospital on the part of the physicians and nursing staff who have little experience in treating diabetes with insulin. There is also a lack of understanding about how to treat hypoglycemia, and the staff tends to overreact to perceived hypoglycemia and give excessive amounts of dextrose to patients. We should figure out the appropriate treatment for these patients to reduce their risk for sepsis, nosocomial infections, morbidity and mortality, and their length of stay in the ICU. Most institutions derive their protocols from other well-known protocols, but every institution has their own singular protocol that they use. In fact, in some large institutions there may be an IV insulin protocol in the surgical ICU that is different from the neuro-ICU.
It might be a good idea to try to find the most efficient, user-friendly protocol that is safest for patients and that yields the best results in terms of changes in insulin concentration. Perhaps there could and should be a universally accepted protocol.
Mark H. Schutta, MD, is an Assistant Professor and the Medical Director of the Rodebaugh Diabetes Center at the Hospital of the University of Pennsylvania.
Better brain glucose measures are needed
 John C. Murphy |
An intensive insulin therapy guideline was introduced in the neuroscience ICU five years ago. With some trepidation, we adopted the euglycemic goal of 80 mg/dL to 120 mg/dL and quickly found that nurses were able to use the guideline to lower many of our patients’ glucose levels to within range. However, the challenge of maintaining the patient within this desired range can be difficult, and there remains a population of patients who are significantly slower in responding.
Despite the research concerning maintenance of patients within the tightly defined range, many of the same clinicians who implement the intensive insulin therapy guideline daily are not convinced that glucose measurements translate directly with the glucose levels in the patient’s brain. Some clinicians interpret the guideline more loosely and prefer to err towards the higher side of the desired range rather than risk hypoglycemia.
Although the goal of intensive insulin therapy is to more quickly stabilize and maintain the patient’s blood glucose levels, the ICU patient’s condition is ever changing. Many of the patients are receiving varying amounts of IV or enteral glucose, are spiking fevers or are being tapered from steroid treatments. These same patients are traveling to tests and procedures where intensive insulin therapy and IV infusions are being interrupted despite our best efforts to maintain stable insulin treatments.
Despite having confidence in our intensive insulin therapy guideline for stabilizing and maintaining most patients’ blood glucose levels, a better measure of brain glucose levels and more confidence in our ability to more evenly maintain patient’s euglycemic state is needed to avoid the negative effects of hypoglycemic episodes.
John C. Murphy, RN, MS, is a Nurse Director of the Neuroscience Intensive Care Unit at Massachusetts General Hospital.