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Implementation of tight glucose control for critically ill surgical patients: a process improvement analysis.
Surg Infect (Larchmt). 2009 Dec; 10(6):523-31.SI

Abstract

BACKGROUND

Tight glucose control has been advocated as a method to improve outcomes of surgical critical care. However, continuous infusion of insulin has potential morbidity (e.g., neurologic consequences of hypoglycemia), and it remains unclear to what degree the glucose concentration must be controlled. We examined our performance in instituting a protocol for tight glucose control in our surgical intensive care unit (ICU).

METHODS

Prospective study of 220 consecutive patients (February, 2003-March, 2006) who received an infusion of insulin for glucose control for >24 h by protocol. Data collected included age, acuity (Acute Physiology and Chronic Health Evaluation [APACHE] III) score, sex, history of diabetes mellitus, organ dysfunction (Marshall), and death or survival. Infusion-related data included initial glucose concentration, time to glucose <120 mg/dL, h/day of glucose <110 mg/dL and <140 mg/dL, duration of infusion (days), insulin units/day, year of therapy, and complications. Analysis was performed by chi(2), analysis of variance, and logistic regression, with p < 0.05 considered significant.

RESULTS

Insulin drips were required by 10.2% of patients (287/2,804); 29 of these (10.1%) had diabetes mellitus. The mean APACHE III score for the treated patients was 77 +/- 2 (standard deviation), and the mortality rate was 24%. Hypoglycemia (<60 mg/dL) occurred in 4.2% of patients. The trigger insulin concentration decreased over time (2003 vs. 2005) from 249 +/- 14 to 160 +/- 5 mg/dL, and the h/day of glucose <140 increased from 11 +/- 1 to 16 +/- 1. However, age, acuity, APACHE III, days of insulin, time to achieve glucose <120, h/day of glucose <110, and mortality rate were unchanged. By logistic regression, only the year of treatment (odds ratio [OR] 1.871; 95% confidence interval [CI] 1.177, 2.972; p = 0.008] predicted success in controlling the blood glucose concentration to <140 mg/dL; age, illness severity, diabetes history, and trigger glucose concentration [OR 0.996; 95% CI 0.992, 1.001; p = 0.11] did not.

CONCLUSIONS

Success in implementing tight glucose control was modest, albeit improving, despite a specific protocol for administration. No medical reason could be identified for inability to achieve tight glucose control; therefore, successful implementation must be volitional. Education, particularly regarding hypoglycemia, and possible refinement of our protocol may improve our ability to control blood glucose in our ICU.

Authors+Show Affiliations

Department of Surgery, Weill Cornell Medical College, New York, New York, USA. sre2003@med.cornell.eduNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

20001333

Citation

Eachempati, Soumitra R., et al. "Implementation of Tight Glucose Control for Critically Ill Surgical Patients: a Process Improvement Analysis." Surgical Infections, vol. 10, no. 6, 2009, pp. 523-31.
Eachempati SR, Hydo LJ, Shou J, et al. Implementation of tight glucose control for critically ill surgical patients: a process improvement analysis. Surg Infect (Larchmt). 2009;10(6):523-31.
Eachempati, S. R., Hydo, L. J., Shou, J., & Barie, P. S. (2009). Implementation of tight glucose control for critically ill surgical patients: a process improvement analysis. Surgical Infections, 10(6), 523-31. https://doi.org/10.1089/sur.2009.003
Eachempati SR, et al. Implementation of Tight Glucose Control for Critically Ill Surgical Patients: a Process Improvement Analysis. Surg Infect (Larchmt). 2009;10(6):523-31. PubMed PMID: 20001333.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Implementation of tight glucose control for critically ill surgical patients: a process improvement analysis. AU - Eachempati,Soumitra R, AU - Hydo,Lynn J, AU - Shou,Jian, AU - Barie,Philip S, PY - 2009/12/17/entrez PY - 2009/12/17/pubmed PY - 2010/2/27/medline SP - 523 EP - 31 JF - Surgical infections JO - Surg Infect (Larchmt) VL - 10 IS - 6 N2 - BACKGROUND: Tight glucose control has been advocated as a method to improve outcomes of surgical critical care. However, continuous infusion of insulin has potential morbidity (e.g., neurologic consequences of hypoglycemia), and it remains unclear to what degree the glucose concentration must be controlled. We examined our performance in instituting a protocol for tight glucose control in our surgical intensive care unit (ICU). METHODS: Prospective study of 220 consecutive patients (February, 2003-March, 2006) who received an infusion of insulin for glucose control for >24 h by protocol. Data collected included age, acuity (Acute Physiology and Chronic Health Evaluation [APACHE] III) score, sex, history of diabetes mellitus, organ dysfunction (Marshall), and death or survival. Infusion-related data included initial glucose concentration, time to glucose <120 mg/dL, h/day of glucose <110 mg/dL and <140 mg/dL, duration of infusion (days), insulin units/day, year of therapy, and complications. Analysis was performed by chi(2), analysis of variance, and logistic regression, with p < 0.05 considered significant. RESULTS: Insulin drips were required by 10.2% of patients (287/2,804); 29 of these (10.1%) had diabetes mellitus. The mean APACHE III score for the treated patients was 77 +/- 2 (standard deviation), and the mortality rate was 24%. Hypoglycemia (<60 mg/dL) occurred in 4.2% of patients. The trigger insulin concentration decreased over time (2003 vs. 2005) from 249 +/- 14 to 160 +/- 5 mg/dL, and the h/day of glucose <140 increased from 11 +/- 1 to 16 +/- 1. However, age, acuity, APACHE III, days of insulin, time to achieve glucose <120, h/day of glucose <110, and mortality rate were unchanged. By logistic regression, only the year of treatment (odds ratio [OR] 1.871; 95% confidence interval [CI] 1.177, 2.972; p = 0.008] predicted success in controlling the blood glucose concentration to <140 mg/dL; age, illness severity, diabetes history, and trigger glucose concentration [OR 0.996; 95% CI 0.992, 1.001; p = 0.11] did not. CONCLUSIONS: Success in implementing tight glucose control was modest, albeit improving, despite a specific protocol for administration. No medical reason could be identified for inability to achieve tight glucose control; therefore, successful implementation must be volitional. Education, particularly regarding hypoglycemia, and possible refinement of our protocol may improve our ability to control blood glucose in our ICU. SN - 1557-8674 UR - https://www.unboundmedicine.com/medline/citation/20001333/Implementation_of_tight_glucose_control_for_critically_ill_surgical_patients:_a_process_improvement_analysis_ L2 - https://www.liebertpub.com/doi/10.1089/sur.2009.003?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -