Efficacy and Safety of Insulin Protocol among Medical and Surgical Patients Admitted in the Medical City Hospital
Objectives. The general objective was to compare the efficacy and safety of the Markovitz insulin protocol (MIP) with physician directed insulin infusion (PDI). Specific objectives were to compare the rate of change to normal glucose levels between MIP and PDP, time to achieve normal glucose levels and to determine the number of hypoglycemic episodes between MIP and PDI.
Methodology. This is a retrospective study examining the medical records of critically ill patients admitted from 2001-2009. Efficacy outcome was measured as the time to achieve normal glucose level and the mean difference of percentage change towards normal blood glucose level. Safety outcome was measured in terms of frequency of hypoglycemic episodes.
Results. One hundred and one patients met the inclusion criteria. The mean time required to achieve target blood glucose levels was 24 hrs (SD=19.5) for MIP compared to PDI. The mean drop in blood glucose levels was -235.49 (SD=113.4), with mean percent difference of -57.5% (SD=20.72) (p-value = 0.919) for MIP compared to physician directed. The MIP resulted in a higher percentage of blood glucose within target (19.57% vs 9.86 %) compared to PID (p= 0.005). Patients in MIP had shorter ICU stay (p=0.049). In addition, MIP was associated with a significantly lower rate of hypoglycemia at 4.2%, compared to PID at 30% (p<0.001).
Conclusions. Markovitz insulin protocol appeared to be significant to physician directed insulin infusion in terms of its greater percentage of glucose measurements maintained within target range, without an increased risk of severe hypoglycemia.
Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE: Hyperglycemia: An independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002; 87:978-982. http://dx.doi.org/10.1210/jcem.87.3.8341.
Krinsley JS. Effect of intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004; 79:992–1000 [erratum in Mayo Clin Proc 2005; 80:1101].
Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures [with discussion]. Ann Thorac Surg. 1999;67:352-362. http://dx.doi.org/10.1016/S0003-4975(99)00014-4.
Malmberg K, Ryden L, Efendic S, et al. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): Effects on mortality at 1 year. J Am Coll Cardiol. 1995;26:57-65. http://dx.doi.org/10.1016/0735-1097(95)00126-K.
Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006; 354:449-461. http://dx.doi.org/10.1056/ NEJMoa052521.
Finfer S, Chittock DR, Su SY, et al. NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283-1297. http://dx.doi.org/ 10.1056/NEJMoa0810625.
Markovitz LJ, Wiechmann RJ, Harris N, Hayden V, Cooper J, Johnson G, et al: Description and evaluation of a glycemic management protocol for patients with diabetes undergoing heart surgery. Endocr Pract. 2002 Jan-Feb;8(1):10-8.
American Diabetes Association. Standards of Medical Care in Diabetes-2013. Diabetes Care. 2013; 36 (Suppl. 1):S11-66.
Bode BW, Braithwaite SS, Steed RD, Davidson PC: Intravenous insulin infusion therapy: Indications, methods, and transition to subcutaneous insulin therapy. Endocr Pract. 2004; 10 (Suppl. 2):71– 80.
Kanji S, Singh A, Tierney M, Meggison H, McIntyre L, Hebert PC. Standardization of intravenous insulin therapy improves the efficiency and safety of blood glucose control in critically ill adults. Intensive Care Med. 2004 May; 30(5):804-10.
Reynolds R. Insulin use in the hospital: An evolving therapeutic paradigm. Lab Medicine. August 2008; 39: 491-495. http://dx.doi.org/10.1309/87FW3DAAQFCEUU9.
Balfe D. Implementation of a safe glycemic control protocol in hospitalized intensive care unit patients. ICU Director. 2010; 1(5):271-276. http://dx.doi.org/10.1177/1944451610384357.
Wilson M, Weinreb J, Soo Hoo G. Intensive insulin therapy in critical care: A review of 12 protocols. Diabetes Care. 2007; 30:1005–1011. doi: 10.2337/dc06-1964. http://dx.doi.org/10.2337/dc06-1964.
Ku SY, Sayre CA, Hirsch IB, Kelly JL. New insulin infusion protocol improves blood glucose control in hospitalized patients without increasing hypoglycemia. Jt Comm J Qual Patient Saf. March 2005; 31- 141-147.
Trence D, Kelly J, et al. The rationale and management of hyperglycemia for in patients with cardiovascular disease: Time for change. JCEM. June 2003; 88 (6): 2430-2437.
Finney SJ, Zekveld C, Elia A, Evans TW: Glucose control and mortality in critically ill patients. JAMA. 2003; 290:2041–2047. http://dx.doi.org/10.1001/jama.290.15.2041.
Goldberg PA, Siegel MD, Sherwin RS, et al. Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care. 2007;27: 461-467. http://dx.doi.org/ 10.2337/diacare.27.2.461.
Goldberg PA, Siegel MD, Sherwin RS, Halickman JI, Lee M, Bailey VA, Lee SL, Dziura JD, Inzucchi SE. Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care. 2004;27:461–467. http://dx.doi.org/10.2337/ diacare.27.2.461.
Malesker MA, Foral PA, McPhillips AC, Christensen KJ, Chang JA, Hilleman DE. An efficiency evaluation of protocols for tight glycemic control in intensive care units. Am J Crit Care. 2007;16:589-598.
Newton CA, Smiley D, Bode BW, et al. A comparison study of continuous insulin infusion protocols in the medical intensive care unit: computer-guided vs. standard column-based algorithms. J Hosp Med. 2010 October; 5(8):432–437. http://dx.doi.org/10.1002/jhm.816.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985 Oct;13(10):818-29.
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