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Validation of an Insulin Infusion Nomogram for Intensive Glucose Control in Critically Ill Patients
Author(s) -
Chant Clarence,
Wilson Gail,
Friedrich Jan O.
Publication year - 2005
Publication title -
pharmacotherapy: the journal of human pharmacology and drug therapy
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.227
H-Index - 109
eISSN - 1875-9114
pISSN - 0277-0008
DOI - 10.1592/phco.25.3.352.61594
Subject(s) - critically ill , nomogram , insulin , intensive care medicine , medicine
Study Objective . To evaluate the effectiveness, safety, and associated patient outcomes of a simplified, nurse‐directed insulin nomogram designed to achieve intensive blood glucose level control (target range 90–144 mg/dl). Design . Prospective study with a retrospective control group. Setting . A medical‐surgical intensive care unit (ICU) in a quaternary care, university‐affiliated hospital in an urban center. Patients . Eighty‐six critically ill adult patients (aged ≥ 18 yrs) requiring blood glucose control, with 42 in the retrospective control group and 44 in the prospective nomogram group. Intervention . Control patients received insulin subcutaneously or intravenously based on ad hoc insulin sliding scales; nomogram patients received intravenous insulin at a rate specified by the nomogram, based on capillary blood glucose levels measured at the bedside. Measurements and Main Results . Insulin infusion in the prospective patient group was titrated by the bedside nurse based on a predefined nomogram to attain the target blood glucose level. The retrospective control group was used as a comparison to assess the safety and effectiveness of the nomogram. Fewer patients in the nomogram (32%) than control (67%) group had a diagnosis of diabetes mellitus on admission. Overall, blood glucose levels in the nomogram group were within the target range 52% of the time versus 20% in the control group (p<0.001). Morning blood glucose levels were significantly lower compared with the control group (mean + SD 128 + 32 vs 176 + 50 mg/dl, p<0.001). Nomogram patients achieved target blood glucose levels faster than control patients (median 15 vs 66 hrs, p<0.0001). This improved blood glucose control remained statistically significant after adjusting for baseline differences in diabetes status. Hyperglycemia occurred less often in the nomogram than the control group (14% vs 53%, p<0.0001), and hypoglycemia occurred more often (3.8% vs 2.2%, p=0.004). The frequency of severe hypoglycemia was similar in both groups (0.2% vs 0.4%, p=NS). Such control required slightly more blood glucose checks/day in the nomogram group (7.1 + 1.5 vs 5.8 + 1.1, p<0.001). No significant reduction was observed in duration of vasopressor or antibiotic therapy or in length of stay in the ICU. Conclusion . This study demonstrated that intensive blood glucose control is achievable using a nurse‐directed nomogram. This improved control was achieved, regardless of diabetes status of the patient, without substantially compromising safety or increasing resource use.