Evaluation of Efficacy, Safety, Frequency of Protocol Deviations and Clinical Outcomes of an ICU Insulin Infusion Protocol

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SUN 807-838-Diabetes - Diagnosis, Complications & Outcomes
Sunday, June 16, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SUN-820
Queenie Guinto Ngalob*1, Cecilia A. Jimeno2 and Iris Thiele Isip-Tan2
1University of Philippines, Manila, Philippines, 2University of the Philippines, Manila, Philippines
Introduction. The recommended strategy for glycemic control in the ICU is through intravenous insulin adjusted based on a standardized protocol. In 2009, we adapted the Yale Insulin infusion protocol and modified it to target 140-180 mg/dl. Since then, this protocol has been used in the ICU of the hospital at the discretion of attending physicians but an evaluation of its performance has not yet been done.

 Objectives.  The aim of the study is to evaluate the effectiveness of the Modified Yale Insulin Infusion Protocol (IIP) in achieving glycemic control.  Specifically, we aim to first, compare the efficacy, safety and clinical outcomes of patients managed using the IIP compared with usual care.  Secondly, we aim to assess adherence to the protocol by determining the frequency of protocol deviations.

 Methodology. A retrospective chart review was done on all admissions of the Medical and Central ICUs during the period of January 2010 to December 2011. Patients eligible for intensive glycemic control were identified.  Charts in which IIP was employed as well as those managed differently were reviewed.   Demographic and clinical outcomes  were extracted.  Charts managed using the IIP were reviewed for protocol deviations.

Results.  Eighty one patients met the inclusion criteria. Twenty eight patients (34.6%) were managed using the Modified Yale IIP. In one patient, the IIP was used twice. Baseline characteristics were comparable between the two groups except for a higher percentage of diabetes and sepsis in the IIP group. Patients on the IIP achieved a significantly lower mean blood glucose (BG) (182.3 vs 212.1 mg/dl, p=<0.05) during the entire duration of treatment.  However, once normoglycemia was reached, the median BG was already similar (155.2 vs 159.6 mg/dl, p=0.14).  The IIP group reached normoglycemia (5 vs 12 hours, p=<0.05) and target glucose range (8.4 vs 18.3 hours, p=<0.05) at a shorter time.  A significantly higher proportion of BG measurements were in normoglycemia (58.3 vs 32.9%, p=<0.05) and a lower proportion in out of target range (41.7 vs 66.9%) in the IIP group. Proportion of BG within target range was similar (22.9 vs 17.9%, p=<0.05).  Hypoglycemia was rare regardless of methods of glycemic control.  No difference in mortality or morbidity was seen.  Duration of hospital stay  (12.7 vs 8.1 days, p=0.03) and ICU stay (5.7 vs 3.0 days, p<0.05) were longer in the IIP group. Majority of protocol deviations were on insulin dose administered (66.6%) followed by timing of blood glucose determination (23.4%).  Errors on hypoglycemia protocol was least common at 10.1%.  A mean of 11 deviations per patient occurred.

Conclusion: The Modified Yale IIP is efficaceous and safe for ICU patients. Compared with other methods of glycemic control, use of the protocol yielded better glycemic profiles. A significant amount of protocol deviations occurred with errors in insulin dose adjustment as most common.

Nothing to Disclose: QGN, CAJ, ITI

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