530763
research-article2014
NCPXXX10.1177/0884533614530763Nutrition in Clinical PracticeDickerson et al
Techniques & Procedures
Nutrition Support Team-Led Glycemic Control Program for Critically Ill Patients
Nutrition in Clinical Practice Volume XX Number X Month 201X 1–8 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614530763 ncp.sagepub.com hosted at online.sagepub.com
Roland N. Dickerson, PharmD1; George O. Maish III, MD2; Gayle Minard, MD2; and Rex O. Brown, PharmD1
Abstract Glycemic control is an important component of the metabolic management of the critically ill patient. Nutrition support teams are frequently challenged by complicated patients who exhibit multiple concurrent etiologies for hyperglycemia. Nutrition support teams can serve in a pivotal role in the development and evaluation of safe and effective techniques for achieving glycemic control. This review describes the efforts of a nutrition support team in achieving safe and effective glycemic control at their institution. Identification of target blood glucose concentration range, development, initiation, monitoring of a continuous intravenous insulin infusion algorithm, nursing adherence to the algorithm, modification of the algorithm based on the presence of conditions that alter insulin metabolism and glucose homeostasis, and transition of the patient who receives continuous enteral nutrition from a continuous intravenous insulin infusion to intermittent subcutaneous insulin therapy are discussed. (Nutr Clin Pract. XXXX;xx:xx-xx)
Keywords nutritional support; hyperglycemia; insulin; critical care; trauma; endocrinology; enteral nutrition; parenteral nutrition
Introduction Since 2001, use of a continuous intravenous (IV) insulin infusion for glycemic control in the intensive care unit (ICU) has been emphasized.1-3 The Joint Commission4 and the Institute of Safe Medication Practices5 list insulin as one of the top “high-alert” medications that have the highest risk for causing injury when misused. Recent trends toward an increasing prevalence of hypoglycemia with continuous IV insulin therapy2,6,7 have prompted clinicians to critically evaluate their current management of hyperglycemia. The risk of severe hypoglycemia leading to seizures, coma, and death mandates that a chosen or developed continuous IV insulin infusion algorithm be not only therapeutic but also safe. Nutrition support teams are actively engaged in the management of patients who are among those at high risk for hyperglycemia8 due to concurrent critical illness-associated increased gluconeogenesis and insulin resistance,9 carbohydrate or glucose-containing nutrition therapy, and potential receipt of medications such as corticosteroids, vasopressors, and inotropic agents that can further exacerbate hyperglycemia.10 Nutrition support teams can be instrumental in developing and/or evaluating institutional procedures and protocols for the safe and effective use of insulin therapy. The intent of this article is to describe the efforts of our nutrition support service to achieve safe and effective glycemic control for critically ill patients who receive enteral nutrition (EN) or parenteral nutrition (PN) as well as to provide guidance to other nutrition support teams seeking similar glycemic control outcomes for their patients. The importance of defining
an appropriate target blood glucose concentration (BG) range, nutrition efforts to reduce hyperglycemia, provision of safe and efficacious IV insulin therapy, recognition of conditions that predispose patients to developing hypoglycemia, and development of a transition plan to subcutaneous intermediate or longacting insulin therapy are discussed.
Identification of an Appropriate Target BG Range The first step to develop a glycemic control program for critically ill patients is to identify the “best” target BG range. Although most guidelines recommend a desired BG target range within 140–180 mg/dL,11-13 certain subpopulations (eg, trauma,14-16 thermal injury,17-19 and cardiothoracic surgery3,20 patients) may benefit from tighter glycemic control if it can be done safely without hypoglycemia.11,12 Most patients referred to the nutrition support service at the Regional Medical Center at Memphis are critically ill, multiple trauma, or thermally From the 1Department of Clinical Pharmacy; and 2Department of Surgery, University of Tennessee College of Medicine, Memphis. Financial disclosure: None declared. Corresponding Author: Roland N. Dickerson, PharmD, Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, 881 Madison Ave, Suite 345, Memphis, TN 38163, USA. Email: [email protected]
Downloaded from ncp.sagepub.com at University of Otago Library on March 13, 2015
2
Nutrition in Clinical Practice XX(X)
injured patients. Patients with traumatic injuries demonstrate improved clinical outcomes when BG is kept 125 mg/dL, restart RHI infusion at ½ last infusion rate. BG may be repeated in 30 minutes following administration of rescue IV glucose.
therapy. Since the vast majority of BG measurements during concurrent nutrition and glycemic control therapy are >80 mg/ dL at our institution27,31,32 and because patients experience anemia secondary to blood loss from traumatic injuries and surgical procedures, we prefer the use of capillary point-of-care blood glucose systems for glycemic control. However, pointof-care BG determinations may overestimate serum glucose concentrations by about 10%, thereby missing potential hypoglycemic episodes.28 Sending blood samples to the hospital core laboratory every 1–4 hours for determination of a serum glucose concentration and the process of obtaining venous or arterial blood samples, which may include minor blood volume waste, may not be practical or appropriate for some patients or institutions.
Selection or Development of an Insulin Infusion Algorithm When we undertook the means for providing safe and effective glycemic control for our critically ill patients with traumatic injuries who received EN or PN several years ago, no published algorithms or commercially available software designed to achieve our desired target BG range for critically ill trauma patients (ie, 70–149 mg/dL) were available. Working closely with the trauma physicians and nursing staff in the ICU of the Presley Memorial Trauma Center, we developed an IV insulin infusion algorithm for trauma patients without renal failure and who received continuous EN or PN (Table 2).27 This development process occurred over an approximate 2.5-year period. There are numerous published continuous IV insulin infusion algorithms as well as commercial software-based insulin infusion programs from which to choose. We recommend that,
whatever insulin infusion algorithm or software program is selected for use at your institution, the methodology be closely evaluated to ensure that hypoglycemia is avoided and the method effectively achieves BG concentrations within the desired target BG range for your institution’s population.
Evaluation of the Safety and Efficacy of the Insulin Infusion Algorithm To evaluate the safety and efficacy of an insulin infusion algorithm, the target BG range and the criteria for hypoglycemia must be defined. For most ICUs, especially mixed medicalsurgical ICUs, the current guideline recommendation is a BG range within 140–180 mg/dL.12,13 Specialized ICUs for patients with traumatic injuries, thermal injuries, and cardiothoracic surgery may benefit from tighter glycemic control (eg, BG
research-article2014
NCPXXX10.1177/0884533614530763Nutrition in Clinical PracticeDickerson et al
Techniques & Procedures
Nutrition Support Team-Led Glycemic Control Program for Critically Ill Patients
Nutrition in Clinical Practice Volume XX Number X Month 201X 1–8 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614530763 ncp.sagepub.com hosted at online.sagepub.com
Roland N. Dickerson, PharmD1; George O. Maish III, MD2; Gayle Minard, MD2; and Rex O. Brown, PharmD1
Abstract Glycemic control is an important component of the metabolic management of the critically ill patient. Nutrition support teams are frequently challenged by complicated patients who exhibit multiple concurrent etiologies for hyperglycemia. Nutrition support teams can serve in a pivotal role in the development and evaluation of safe and effective techniques for achieving glycemic control. This review describes the efforts of a nutrition support team in achieving safe and effective glycemic control at their institution. Identification of target blood glucose concentration range, development, initiation, monitoring of a continuous intravenous insulin infusion algorithm, nursing adherence to the algorithm, modification of the algorithm based on the presence of conditions that alter insulin metabolism and glucose homeostasis, and transition of the patient who receives continuous enteral nutrition from a continuous intravenous insulin infusion to intermittent subcutaneous insulin therapy are discussed. (Nutr Clin Pract. XXXX;xx:xx-xx)
Keywords nutritional support; hyperglycemia; insulin; critical care; trauma; endocrinology; enteral nutrition; parenteral nutrition
Introduction Since 2001, use of a continuous intravenous (IV) insulin infusion for glycemic control in the intensive care unit (ICU) has been emphasized.1-3 The Joint Commission4 and the Institute of Safe Medication Practices5 list insulin as one of the top “high-alert” medications that have the highest risk for causing injury when misused. Recent trends toward an increasing prevalence of hypoglycemia with continuous IV insulin therapy2,6,7 have prompted clinicians to critically evaluate their current management of hyperglycemia. The risk of severe hypoglycemia leading to seizures, coma, and death mandates that a chosen or developed continuous IV insulin infusion algorithm be not only therapeutic but also safe. Nutrition support teams are actively engaged in the management of patients who are among those at high risk for hyperglycemia8 due to concurrent critical illness-associated increased gluconeogenesis and insulin resistance,9 carbohydrate or glucose-containing nutrition therapy, and potential receipt of medications such as corticosteroids, vasopressors, and inotropic agents that can further exacerbate hyperglycemia.10 Nutrition support teams can be instrumental in developing and/or evaluating institutional procedures and protocols for the safe and effective use of insulin therapy. The intent of this article is to describe the efforts of our nutrition support service to achieve safe and effective glycemic control for critically ill patients who receive enteral nutrition (EN) or parenteral nutrition (PN) as well as to provide guidance to other nutrition support teams seeking similar glycemic control outcomes for their patients. The importance of defining
an appropriate target blood glucose concentration (BG) range, nutrition efforts to reduce hyperglycemia, provision of safe and efficacious IV insulin therapy, recognition of conditions that predispose patients to developing hypoglycemia, and development of a transition plan to subcutaneous intermediate or longacting insulin therapy are discussed.
Identification of an Appropriate Target BG Range The first step to develop a glycemic control program for critically ill patients is to identify the “best” target BG range. Although most guidelines recommend a desired BG target range within 140–180 mg/dL,11-13 certain subpopulations (eg, trauma,14-16 thermal injury,17-19 and cardiothoracic surgery3,20 patients) may benefit from tighter glycemic control if it can be done safely without hypoglycemia.11,12 Most patients referred to the nutrition support service at the Regional Medical Center at Memphis are critically ill, multiple trauma, or thermally From the 1Department of Clinical Pharmacy; and 2Department of Surgery, University of Tennessee College of Medicine, Memphis. Financial disclosure: None declared. Corresponding Author: Roland N. Dickerson, PharmD, Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, 881 Madison Ave, Suite 345, Memphis, TN 38163, USA. Email: [email protected]
Downloaded from ncp.sagepub.com at University of Otago Library on March 13, 2015
2
Nutrition in Clinical Practice XX(X)
injured patients. Patients with traumatic injuries demonstrate improved clinical outcomes when BG is kept 125 mg/dL, restart RHI infusion at ½ last infusion rate. BG may be repeated in 30 minutes following administration of rescue IV glucose.
therapy. Since the vast majority of BG measurements during concurrent nutrition and glycemic control therapy are >80 mg/ dL at our institution27,31,32 and because patients experience anemia secondary to blood loss from traumatic injuries and surgical procedures, we prefer the use of capillary point-of-care blood glucose systems for glycemic control. However, pointof-care BG determinations may overestimate serum glucose concentrations by about 10%, thereby missing potential hypoglycemic episodes.28 Sending blood samples to the hospital core laboratory every 1–4 hours for determination of a serum glucose concentration and the process of obtaining venous or arterial blood samples, which may include minor blood volume waste, may not be practical or appropriate for some patients or institutions.
Selection or Development of an Insulin Infusion Algorithm When we undertook the means for providing safe and effective glycemic control for our critically ill patients with traumatic injuries who received EN or PN several years ago, no published algorithms or commercially available software designed to achieve our desired target BG range for critically ill trauma patients (ie, 70–149 mg/dL) were available. Working closely with the trauma physicians and nursing staff in the ICU of the Presley Memorial Trauma Center, we developed an IV insulin infusion algorithm for trauma patients without renal failure and who received continuous EN or PN (Table 2).27 This development process occurred over an approximate 2.5-year period. There are numerous published continuous IV insulin infusion algorithms as well as commercial software-based insulin infusion programs from which to choose. We recommend that,
whatever insulin infusion algorithm or software program is selected for use at your institution, the methodology be closely evaluated to ensure that hypoglycemia is avoided and the method effectively achieves BG concentrations within the desired target BG range for your institution’s population.
Evaluation of the Safety and Efficacy of the Insulin Infusion Algorithm To evaluate the safety and efficacy of an insulin infusion algorithm, the target BG range and the criteria for hypoglycemia must be defined. For most ICUs, especially mixed medicalsurgical ICUs, the current guideline recommendation is a BG range within 140–180 mg/dL.12,13 Specialized ICUs for patients with traumatic injuries, thermal injuries, and cardiothoracic surgery may benefit from tighter glycemic control (eg, BG
