Hospital related hyperglycemia and diabetes mellitus in the intensive care unit (ICU) – two “down-to-earth“ protocols

Introduction: Hyperglycemia is a common problem in the ICU due to stress activation of insulin counter regulatory hormones. Optimal control of hyperglycemia in the ICU has been shown to significantly decrease mortality and morbidity of severely ill patients.

Study aim: To develop and implement two undemanding protocols and algorithm to reach the targets of near normal capillary blood glucose (CBG) levels on our ICU city hospital.

Methods: A s.c. protocol was developed for hyperglycemic patients with relatively stable circulation, like myocardial infarction or apoplexy. A long acting insulin analogue, glargine, was immediately given after an elevated CBG had been measured. In addition, short acting insulin was given pre- and two hours postprandially to reach the target CBG levels of 80–129mg/dl. An i.v. insulin protocol was used for severely ill patients with sepsis, cardiogenic shock, etc. with enteral/parenteral nutrition and catecholamine infusion, etc. The s.c. protocol was also used for transition from the ICU to a peripheral ward in the i.v. patient group, i.e. two hours before insulin infusion was discontinued, glargine was injected. The personal of the ICU was motivated and trained before the beginning of the program, and a questionnaire was given after 6 months. Daily quality control was carried out by the diabetes team.

Results: 137 consecutive patients were evaluated. After 6 months, the percentage of CBG measurements (CBGM) >140mg/dl decreased from 49% to 25%, whereas the percentage of CBGM <100mg/dl increased from 8% to 30%, respectively. No severe hypoglycemia occurred. After 9 months, in the i.v. and s.c protocol, 60% and 53% of CBGM reached the target range, respectively. Frequency of CBGM per day and patient increased from 4 before to 12. The practicability of the protocols was graded as good by the ICU personnel.

Summary: The protocols allow a satisfying control of CBG in ICU patients and can be implemented in the working flow on the ICU after motivation and training of the personnel.