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University of Minnesota – School of Nursing Spring Research Day

University of Minnesota – School of Nursing Spring Research Day. Glycemic Control of Critically Ill Patients Lynn Jensen, RN; Jessica Swearingen, BCPS, PharmD; Peggy Hoeft, RN; Pam Richardson, RN; Robert Miner, MD Abbott Northwestern Hospital . Objectives.

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University of Minnesota – School of Nursing Spring Research Day

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  1. University of Minnesota – School of Nursing Spring Research Day Glycemic Control of Critically Ill Patients Lynn Jensen, RN; Jessica Swearingen, BCPS, PharmD; Peggy Hoeft, RN; Pam Richardson, RN; Robert Miner, MD Abbott Northwestern Hospital

  2. Objectives • Understand benefits of intensive (“tight”) glycemic control in critically ill patients • Describe the Intensive Insulin ICU protocol implementation experience at Abbott Northwestern (ANW) Hospital • Share patient outcome data associated with ANW Intensive Insulin ICU protocol utilization

  3. Hyperglycemia in the Critically Ill Patient Population • Hyperglycemia occurs in >50% in ICU patients • Multiple etiologies (e.g., counterregulatory hormone release, medications) • Historically, hyperglycemia treated only at very high blood glucose levels • Hyperglycemia-related adverse effects (e.g., osmotic diuresis, impaired immune function) well established • More recent evidence suggests close correlation between hyperglycemia & clinical outcome

  4. Hyperglycemia Clinical Trials in Critically Ill Patients • Open heart surgery patients with history of DM & mean BG >206 mg/dL post-op had increased risk for: • leg & chest wound infections • pneumonia • urinary tract infections • AMI patients with history of DM or hyperglycemia on hospital admission randomized to tight control (BG 126-200 mg/dL) for 3 months or usual care • mortality at 1 yr & 3.4 yrs  by 7.5% & 11%, respectively • reinfarction & new cases of CHF decreased Golden et al. Diabetes Care 1999;22(9):1408-14; Malmberg et al. J Am Coll Cardiol 1995;26(1):57-65

  5. Hyperglycemia Clinical Trials in Critically Ill Patients • Mechanically ventilated, surgical ICU patients • majority of patients had no history of DM • randomized to tight control or standard care • after transfer from ICU both groups received standard care • Results • mortality  by 3.4% for tight control group • mortality in patients with ICU stay >5 days  by 9.6% • significant  in deaths due to sepsis & MODS • tight control blood transfusions (28.6% vs. 31%); dialysis (4.8% vs. 8.2%); mechanical ventilation >14 days (7.5% vs. 11.9%); or ICU stay >14 days (11.4% vs. 15.7%) Van den Berghe et al. NEJM 2001;345(19):1359-67.

  6. Hyperglycemia Clinical Trials in Critically Ill Patients • Observational trial in Med/Surg/Neuro/Cardiac ICU • Before & after design • historical controls vs. consecutive protocol patients • protocol group received insulin infusion after 2 successive BG levels >200 mg/dL • BG goal <140 mg/dL • Results • mean BG  from 152.3 mg/dL to 130.7 mg/dL • protocol significantly  mortality from 20.9% to 14.8% • most striking  in mortality for septic shock, neurologic & surgical patients • BG>200 mg/dL  from 16.7% to 7.1% • hypoglycemia did not increase (0.35% vs. 0.34%) Krinsley et al. Mayo Clin Proc 2004;79(8)992-1000

  7. ANW Intensive Insulin Protocol Implementation Experience • Multidisciplinary team of physicians, pharmacists & nurses from each ICU • Revision of existing Med/Surg/Neuro ICU protocol • Desktop computer protocol developed • New protocol implemented in all ICUs May 2004 • Nurses in all ICUs educated • Additional resources available during first 5 days of protocol implementation

  8. ANW Intensive Insulin Protocol Implementation Experience • ANW blood glucose goal range: 90-120 mg/dL • All protocol patients received: • insulin infusion • hourly blood glucose checks until within goal range, then every two hours • Data collected on: • mean blood glucose • efficacy attaining goal range • episodes of hypoglycemia • patient outcomes

  9. ANW Intensive Insulin Protocol Implementation Experience • Continued to make changes to protocol & provide feedback • Challenges during implementation • physician (surgeon) acceptance • limited glucometer availability • multiple patient sticks/blood draws • nursing acceptance due to  workload • computer dosing based on last 2 BG values

  10. ANW Intensive Insulin Protocol Implementation Experience Protocol Example

  11. ANW Intensive Insulin Protocol Data

  12. ANW Intensive Insulin Protocol Data

  13. ANW Intensive Insulin Protocol Data

  14. Conclusions • Tight glycemic control can significantly improve morbidity & mortality in critically ill surgical patients • Barriers to implementation can be overcome • Nurses can significantly impact mortality & patient outcome by managing blood glucose more tightly

  15. Any Questions?

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