intensive insulin therapy

TraumaNurse · Aug 15, 2003

The most recent research suggests patient outcomes are greatly improved if blood glucose levels are kept within a tight range. Our facility keeps glucose levels between 80 - 120. We use Insulin gtts on almost every patient and check glucose levels every 1-2 hours or more frequently if needed.

zambezi, BSN, RN · Aug 24, 2003

In our CCU we have strict blood sugar controls after heart surgery. If BS >150, pt gets started on an insulin gtt...we have a whole long protocol on how to titrate (by percentages) and how often to do cbs checks, as often and q1hr (q.5 hr is dramatic drop) depending on how frequently we are titrating the insulin gtt. Our goal is to keep cbs 90-120 but anything less than 150 is acceptable. Now that we are used to it, it is not too bad, but can get busy if you have two pts on q1hr cbs checks.

helix · Sep 11, 2003

That is interesting. We don't have anything like that and could probably use it. Who initiated the protocols for your institutions? Was it nursing or physicians or both? Did you have certain physicians that began doing this and then others followed? Could you refer me to some research so that maybe I could get it started at our facility?

Thanks,

Helix

Vadillo · Sep 20, 2003

The text that you are looking for is in http://content.nejm.org/cgi/content/abstract/345/19/1359

NEJM Volume 345:1359-1367 November 8, 2001 Number 19

The protocol was initiated by physicians but its a nurse work.

morta

gwenith, BSN, RN · Sep 20, 2003

Thank-you Morta and welcome to the board!!

pghfoxfan · Sep 23, 2003

When our patients are on Insulin drips, we do blood sugars every 1 hour.

Just a reminder that Insulin will adhere to the IV tubing so remember to waste about 30 or so cc's before starting the drip.

We tried to keep the blood sugars below 150.

Chttynurs · Sep 23, 2003

All diabetics on our unit go in insulin gtts post op and we have a written protocol, every one hour, half hour when they go too low until they come up again. Big improvement in post op infection and healing rates! :)

pghfoxfan · Sep 23, 2003

Ditto with us...but what a freekin pain in the ass!

Tenesma · Oct 5, 2003

some of the initial studies were done at my institution (MGH) in conjunction w/ the european groups --- and now in our ICU we are moving away from the 80-120 BS parameters towards 110-150 - primarily due to the higher incidence of hypoglycemic episodes with such tight control.... and we find that the infection/comorbidities are just as good with the slightly higher range, minus the worry for hypoglycemia

ethelbsnrn · Oct 13, 2003

I wonder if somebody ( Morta, Zambezi or Trauma Nurse) could post here the insulin titration protocol you are using in your unit. We don't have objective basis (by percentages) in our titration. Your input would be a great help in our unit, my nurse manager would appreciate it.

Ethel

zambezi, BSN, RN · Oct 18, 2003

This is what we use as our insulin infusion guideline. Our goal is to keep the BG level between 100-150. This is only used as a guideline, we are allowed to use our nursing judgement based on patients response, gtts, etc.

Frequency of BG Checks

NonDiabetic: Q2hrs x2, then Q4 x2

Diabetic: Q2 hrs until taking PO, then AC/HS (sliding scale)

While on Insulin Gtt: Q1 hr x3, then per algorithm/prn

Check Q1 during insulin titration/titration of inotropes

Start Insulin Gtt if:

DIABETIC: 1st BG >150 NONDIABETIC: 2nd BG >150

BG 121-150: 1unit/hr

BG 151-200: 1.5unit/hr

BG 201-250 2unit/hr

BG 251-300 3unit/hr

BG 301-350 4unit/hr

BG >350 6unit/hr

Insulin Gtt Titration Algorithm (sorry, can't fit nice table here)

BG

recheck 30 minutes

60-99 -STOP insulin gtt. recheck BG in 30 minutes

If Current BG is 100-119

-And current BG is higher than previous BG

-No change in insulin rate Check BG in 1 hour

-And current BG is less than 10% lower than previous test

-Decrease rate by 0.5 u/hr Check BG in 1 hr

-And current BG is 10% lower than previous BG

-No change in rate Check in 1 hour

-And current BG is more than 10% lower than previous BG

-Decrease rate by 50% Check in 1 hour

If Current BG is 120-150

-And if previous BG was below 100

-No change in insulin rate Check in 2 hours

-And if previous BG was 100-150

-No change in insulin rate Check in 2 hours

-And if previous BG was 151-200

-Decrease rate by 25% Check in 1 hour

-And if previous BG was >201

-Decrease rate by 50% Check in 1 hour

If Current BG is 151-200

-And if previous BG was more than 40mg/dl higher

-Decrease rate by 25% Check 1 hour

-And if previous BG was 0-39 mg/dl higher

-No change in rate Check in 1 hour

-And if previous BG was 0-39 mg/dl lower

-Increase rate by 20% Check in 1 hour

-And if previous BG was more than 40 mg/dl lower

-Increase rate by 40% Check in 1 hour

In Current BG is 201-250

-And if previous BG was below 201

-Increase rate by 40% Check in 1 hour

-And if previous BG was greater by 201

-Increase rate by 20% Check in 1 hour

If Current BG is above 250

-And if previous BG was below current reading

-Increase rate by 50% Check in 1 hour

-And if previous BG was 0-60 mg/dl higher

-Increase rate by 25% Check in 1 hour

-And if previous BG was more than 60 mg/dl higher

-Increase rate by 10% Check in 1 hour

Whew, long post sorry :rolleyes: Anyway..to be honest, I start with the guideline for the first couple of sugars, but I am a round number type of person unless it is not in the patients best interest, so I usually deviate a bit from the protocol to keep my units is round numbers....it seems to work just as well, I look at how their sugars have been running, if they are resistant, how fast the changes are, what gtts I am titrating...We usually take patients off gtts as soon as they are PO...If we are using double stregnth insulin we use the same types of titrations...I think that we have been controlling sugars well with this scale thus far (even though the table is painful to look at!):kiss