What is the Purpose of Continuous Sodium Infusion

Diabetes Spectr. 2014 Aug; 27(3): 218–223.

Continuous Insulin Infusion: When, Where, and How?

The association between inpatient hyperglycemia and adverse patient outcomes is well documented.^1–7 Thus, focus on inpatient glycemic control has increased in the past decade. However, optimal glycemic targets remain controversial, and significant barriers to optimal glycemic control persist.

Inpatient Glycemic Targets

After publication of the initial van den Berghe trial in surgical intensive care patients,¹ several professional organizations published guidelines supporting near-normal glycemic targets.^8,9 Subsequent trials documented an increased risk for hypoglycemia with tight glycemic control, suggesting that more modest glycemic targets may be optimal.^10–13 The Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study,¹⁴ a large, randomized trial involving > 6,100 medical and surgical patients, documented higher 90-day mortality rates in patients managed with tight glycemic control than in those receiving conventional glucose management. Although hypoglycemia was more common among patients in the intensive treatment group, the association of hypoglycemia with an increased hazard ratio for death was similar in the two groups, suggesting that hypoglycemia contributed to the excess mortality in the intensively treated group.¹⁵

The increased risk for hypoglycemia and mortality with tight glycemic control does not justify ignoring glycemic control, but it does justify setting more moderate targets. The American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Surviving Sepsis Campaign, and the Institute for Healthcare Improvement all updated their guidelines for glycemic control in 2009 in response to data from NICE-SUGAR.^16-18 All four sets of guidelines recommend initiating insulin therapy in patients with persistent hyperglycemia (blood glucose > 180 mg/dl). After insulin is initiated, the target blood glucose range should be 140-180 mg/dl for the majority of patients. However, a more stringent goal of 110-140 mg/dl may be appropriate for certain patients, provided it can be achieved without causing significant hypoglycemia. The Society of Critical Care Medicine recommends a slightly different target of 100-150 mg/dl, while still focusing on minimizing the risk for hypoglycemia.¹⁹

Rationale for Continuous Insulin Infusion

Insulin is the preferred treatment modality in the hospital setting because it is the most potent agent to lower blood glucose, is rapidly effective, is easily titrated, and has no absolute contraindications.^18,20 However, insulin is a high-alert medication that is consistently implicated in reports of preventable patient harm (from hypoglycemia) and thus requires accurate monitoring and standardized protocols to minimize risks while maximizing benefits.^21–24

Intravenous (IV) infusion is the preferred route of insulin delivery in critical care, labor and delivery, and perioperative inpatient settings because the rapid onset and short duration of action associated with IV infusion allow for matching insulin requirements to rapidly changing glucose levels. Table 1 provides additional potential indications for IV insulin infusion.²⁰ Sliding-scale or correction algorithms with regular or rapid-acting insulin administered as needed for hyperglycemia without scheduled basal insulin or prandial insulin (for patients who are eating) are outdated treatment modalities that should be abandoned. Data are lacking to support the benefit of sliding-scale insulin or correction insulin algorithms without basal insulin, and these practices are associated with wide fluctuations in blood glucose, which have been linked to higher hospital mortality rates.²⁵

Table 1.

Potential Indications for IV Insulin Therapy²⁰

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Insulin infusion may be an alternative to a basal-bolus insulin regimen outside of the critical care setting for perioperative and other patients who are not eating (NPO status) and patients whose glycemia is poorly controlled with subcutaneous insulin. Insulin infusion can be safely administered outside of the critical care setting provided staff education, nurse-to-patient ratios, and blood glucose monitoring are adequate.^20,26 In addition, setting more moderate glycemic targets for patients outside of the critical care setting may minimize nursing time for blood glucose monitoring and titration of the insulin infusion. For patients starting parenteral or enteral nutrition, the use of IV insulin infusion with appropriate monitoring may allow for more rapid titration and determination of patients' insulin requirements than one could expect from either a subcutaneous insulin regimen or from the practice of including insulin in the parenteral nutrition solution. The use of IV insulin infusion in patients who are eating or are receiving intermittent enteral/parenteral nutrition requires proactive increases in infusion rate with the start of nutritional intake and decreases when nutritional intake is stopped, and thus, in most situations, conversion to subcutaneous insulin is appropriate because it is less labor intensive.

Barriers to Implementing a Continuous Insulin Infusion Protocol

Potential barriers to implementing an insulin infusion protocol include fear of hypoglycemia, confusion regarding appropriate glycemic targets, insufficient nurse-to-patient ratios, insufficient availability or convenience of glucose-monitoring devices, lack of administrative support, various system and procedural issues, and resistance to change. Before implementing an IV insulin infusion protocol, it is imperative to evaluate the current glycemic-related practices within the institution and address the following crucial questions: What is the current level of glycemic control? Who is checking patients' blood glucose and how often? How interested is the staff in optimizing glycemic control, and do they have the support they need to achieve this goal?

Key steps to overcoming these barriers include building support with multidisciplinary champions, involving key staff members in the process, educating staff and administrators about the benefits of optimizing glycemic control, and internally marketing the clinical success of the protocol. Descriptions of several models of implementation have been published, including endocrinologist consultation models, glycemic control teams, and system-wide models.^27–32 It is important to adapt whichever model is selected to meet the needs of the specific institution.

Selecting an Insulin Infusion Protocol

Numerous insulin infusion protocols have been published. However, head-to-head comparisons are rare, and efficacy and safety are difficult to determine because of differing patient populations, glycemic targets, metrics for evaluation, and definitions of hypoglycemia used in the various protocols.^26,33–37 Selecting a validated protocol allows for more rapid implementation but does not eliminate the need for ongoing safety and effectiveness monitoring and continuous quality improvement.

Some paper protocols are table-based, whereas others require mathematical calculations. The level of clinical judgment and physician oversight also varies among the available protocols. Computerized protocols allow for more complex mathematical calculations and can provide alerts or alarms to remind staff members to check patients' blood glucose level and adjust infusion rates.

Several studies comparing computerized and paper-based protocols have found improved protocol adherence, improved glycemic control, and less hypoglycemia with computerized protocols.^38–49 It is worth noting that evaluations of computerized glucose control programs have used glycemic targets that are tighter than currently recommended, and although the percentages of blood glucose readings within the target range were higher than with paper protocols, they still were not optimal in most studies. It is not clear how computerized glucose control programs compare to paper-based protocols when currently recommended targets are used.

Several computerized decision-support systems for insulin infusion management are commercially available; however, licensing fees and compatibility with institutional computer systems may limit their use. An institution's culture, finances, computer/technical support, and patient populations will dictate the best type of protocol for that specific setting. Table 2 lists characteristics to consider when selecting an insulin infusion protocol.

Table 2.

Components of a Safe and Effective Insulin Infusion Protocol

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Successful implementation of an insulin infusion protocol requires multidisciplinary interaction and ongoing staff education to ensure optimal patient outcomes. An ideal protocol achieves the desired target blood glucose quickly (within 3-12 hours in published protocols) and maintains blood glucose in the target range.⁴⁰ The protocol should have a clear algorithm for dose titration, which includes not only a patient's current blood glucose, but also the rate of change in the patient's blood glucose. The rate of change is calculated based on the slope of the blood glucose trend line. It is frequently incorporated into table-based protocols by movement to a more aggressive algorithm/column if blood glucose is above the target range and not declining rapidly enough or movement to a less aggressive algorithm if blood glucose is declining too rapidly or approaching the target range. Finally and most importantly, the protocol should minimize hypoglycemia and provide specific instructions for prompt treatment of hypoglycemia should it occur. The reported incidence of hypoglycemia with insulin infusion is highly variable (< 1 to >20%) and dependent on multiple factors.^40,46 Minimizing the risk of hypoglycemia with any insulin infusion protocol requires ongoing evaluation of hypoglycemia episodes and the contributing factors such that the protocol can be revised to address and minimize the risk.

Hypoglycemia Prevention and Treatment

Recent data have brought renewed appreciation of the risk for hypoglycemia.^{10,13–15,50} Historically, hypoglycemia has been variably defined as a blood glucose level of anywhere from < 40 to < 70 mg/dl. The ADA currently defines hypoglycemia as a blood glucose level < 70 mg/dl. The most effective strategies to prevent hypoglycemia include frequent blood glucose monitoring and proactive adjustment of the infusion rate if the blood glucose level decreases too rapidly. In addition, more frequent blood glucose monitoring (every 15-20 minutes) should be implemented until blood glucose is consistently > 100 mg/dl. Some hypoglycemia protocols temporarily stop the insulin infusion for hypoglycemia and restart it at a lower rate once hypoglycemia has resolved. However, failure to restart the infusion can result in profound hyperglycemia and ultimately diabetic ketoacidosis (DKA) in patients with type 1 diabetes. Thus, some hypoglycemia protocols do not stop the infusion, but significantly reduce the rate.

The ADA and AACE recommend hourly blood glucose monitoring for patients receiving IV insulin therapy except for patients with stable blood glucose within the target range, for whom monitoring can be performed every 2 hours. Some protocols have used a monitoring schedule of every 4 hours. However, the incidence of hypoglycemia exceeds 10% with many of these protocols.^11–13 In practice, monitoring blood glucose every 1-2 hours can be difficult, especially outside of the critical care setting. Additional strategies that may improve safety include targeting higher blood glucose levels, titrating the insulin infusion rate less aggressively, and providing staff education and policies regarding when a patient must be transferred and additional nursing resources must be allocated.

An embedded hypoglycemia treatment protocol is imperative for the safety of insulin infusion therapy. A hypoglycemia protocol allows bedside nurses to immediately implement treatment without additional orders. Key components of a hypoglycemia protocol include specific instructions regarding temporarily turning off or reducing the infusion rate, treating with dextrose or other glucose sources, and monitoring more frequently, as well as when the insulin infusion, if temporarily stopped, should be restarted and at what rate.

Point-of-Care Glucose Monitoring

Although point-of-care (POC) blood glucose monitoring is the most practical option for bedside blood testing, there are limitations to its accuracy, and thus a strong quality control program is necessary. Some situations may render capillary blood glucose monitoring inaccurate, including shock, hypoxia, dehydration, extremes in hematocrit, elevated bilirubin and triglycerides, and the use of some medications (e.g., mannitol, icodextrin/maltose, and acetaminophen). The degree of interference and thus inaccuracy of the blood glucose measurement varies depending on the concentration of the interfering substance and the POC methodology (e.g., glucose oxidase vs. glucose dehydrogenase).⁵¹ Thus, it is important to carefully assess the specific device limitations and patient populations to optimize quality control policies and procedures. There is concern that the safety and effectiveness of POC blood glucose monitoring systems are not sufficiently evaluated in hospitalized acutely ill patient populations before marketing. The U.S. Food and Drug Administration has issued draft recommendations requiring additional testing of POC blood glucose monitoring devices for use in the hospital setting before approval.⁵²

Arterial or venous whole blood sampling is recommended instead of finger-stick capillary testing for patients in shock, receiving vasopressor therapy, or with severe peripheral edema.¹⁹ In these situations, samples from an arterial or venous site should be used. Bedside POC blood gas analyzers are frequently use in the operative and critical care settings and can be used to monitor blood glucose, as well as electrolytes and blood gases. However, they require a larger volume of blood, are substantially more expensive, and utilize the same methodology (glucose oxidase) as many of the available POC blood glucose meters. Any time a POC blood glucose value does not match the clinical situation, it should be verified with a repeat test or laboratory blood glucose determination.

Continuous glucose sensors are available for ambulatory patients and have demonstrated benefits in select patients over intermittent POC testing. However, data are mixed regarding the performance of these U.S. Food and Drug Administration-approved ambulatory devices in the critical care setting.^53-55 Preclinical testing of an intravascular continuous glucose monitoring sensor has been promising.⁵⁶ Perhaps in the future, the use of continuous glucose sensors in combination with a computerized decision-support system for insulin therapy will improve the safety of insulin infusion therapy for critically ill patients, allowing for the achievement of tighter glycemic goals without hypoglycemia.

Staff Education

The safety of any insulin infusion protocol is tied to the ability of staff members to understand and follow the protocol; thus, ongoing education and competence assessment are crucial. The best educational approach is a varied one that allows for differing learning styles and differing work schedules and that can be repeated at frequent intervals. Each institution will have unique educational needs; thus, the education plan will differ from site to site. However, education is a key component of successful insulin infusion protocols in all settings.

Metrics for Evaluating Insulin Infusion Protocols

Ongoing evaluation of efficacy and safety is also crucially important to the successful implementation of an insulin infusion protocol. Such evaluation facilitates continuous improvement and staff education and builds momentum to support expansion of the protocol into additional patient populations or additional settings within the institution. Evaluation metrics can be as simple as tracking 1) mean or median blood glucose with standard deviations or interquartile ranges by unit or patient population and 2) incidence of hypoglycemia. It is also important to evaluate glucose variability because increased variability is also associated with poor patient outcomes.⁵⁷ Depending on the institution's specific goals and barriers, metrics can include more advanced evaluation, including financial analysis. Several institutions have published their metrics and financial impact assessments.^58-60 Similar to staff education, evaluation metrics will differ from one institution to another but remain a crucial tool for safe and effective insulin infusion programs in all institutions.

Transition from IV to Subcutaneous Insulin

To avoid loss of glycemic control and optimize patient outcomes, it is important that patients are appropriately transitioned from IV to subcutaneous insulin. This is especially important for patients with type 1 diabetes, because they can develop DKA if scheduled basal insulin and prandial insulin (for patients who are eating) are not initiated before stopping the insulin infusion. A transition protocol provides guidance regarding which patients are likely to require transition to subcutaneous insulin and when and how to make the transition. Patients with type 1 diabetes and most patients with type 2 diabetes who were treated with insulin before hospitalization will require such a transition. In addition, patients receiving > 2 units/hour of insulin on the infusion protocol will likely require subcutaneous insulin unless there is a significant change in their clinical situation, such as discontinuation of parenteral/enteral nutrition, tapering of steroids, or gastric bypass surgery.⁶¹

The appropriate timing for the transition from IV to subcutaneous insulin depends on institutional policies regarding where and when insulin infusion can be used. Ideally, the transition occurs when patients begin an oral diet and their blood glucose levels are stable within the target range. IV insulin has a very short duration of action (minutes), and the onset of basal subcutaneous insulin is 1-2 hours. Thus, IV insulin should be continued for 1-2 hours after the first administration of subcutaneous basal insulin.

Once a patient has been identified as needing to transition to subcutaneous insulin, the patient's 24-hour insulin requirement can be calculated by extrapolating from the average IV dose required over the previous 6-8 hours in a stable patient. Most authorities recommend using 60-80% of the total daily insulin requirement calculated from the insulin infusion rate to minimize the risk of hypoglycemia. An additional factor to consider is the caloric intake of the patient while on the insulin infusion protocol. If intake is minimal, the calculated daily insulin dose reflects primarily the patient's basal insulin requirement. If the caloric intake is more substantial (e.g., parenteral or enteral nutrition), the calculated insulin requirement reflects both basal and nutritional insulin requirements. Patients who will be eating will require both basal and prandial insulin, with correction doses as needed. For patients who will be on NPO status or eating very little, basal insulin with correction doses can be used. Several authors have published protocols for the transition from IV to subcutaneous insulin.^62-67

Conclusion

Although the past decade has seen great controversy regarding optimal glycemic targets for inpatients, it is clear that extremes of blood glucose lead to poor outcomes, and continuous IV protocols are the preferred treatment modality for glycemic control in the critical care setting. In addition, insulin infusion can be an effective treatment modality in other acute care settings with appropriate glycemic targets, monitoring, and education. The safety of insulin infusion protocols hinges on appropriate blood glucose monitoring and titration. Using a computerized infusion protocol and a continuous blood glucose sensor may allow for tighter glycemic control without increasing hypoglycemia and mortality rates.

References

van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R: Intensive insulin therapy in critically ill patients. N Engl J Med 345:1359–1367, 2001 [PubMed] [Google Scholar]
Bagshaw SM, Egi M, George C, Bellomo R; Australia New Zealand Intensive Care Society Database Management Committee: Early blood glucose control and mortality in critically ill patients in Australia. Crit Care Med 37:463–470, 2009 [PubMed] [Google Scholar]
Falciglia M, Freyberg RW, Almenoff PL, D'Alessio DA, Render ML: Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med 37:3001–3009, 2009 [PMC free article] [PubMed] [Google Scholar]
Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE: Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 87:978–982, 2002 [PubMed] [Google Scholar]
Finney SJ, Zekveld C, Elia A, Evans TW: Glucose control and mortality in critically ill patients. JAMA 290:2041–2047, 2003 [PubMed] [Google Scholar]
Freire AX, Bridges L, Umpierrez GE, Kuhl D, Kitabchi AE: Admission hyperglycemia and other risk factors as predictors of hospital mortality in a medical ICU population. Chest 128:3109–3116, 2005 [PubMed] [Google Scholar]
Krinsley JS: Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clinic Proc 78:1471–1478, 2003 [PubMed] [Google Scholar]
Garber AJ, Moghissi ES, Bransome ED, Jr, Clark NG, Clement S, Cobin RH, Furnary AP, Hirsch IB, Levy P, Roberts R, Van den Berghe G, Zamudio V; American College of Endocrinology Task Force on Inpatient Diabetes Metabolic Control: American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract 10:77–82, 2004 [PubMed] [Google Scholar]
Deedwania P, Kosiborod M, Barrett E, Ceriello A, Isley W, Mazzone T, Raskin P; American Heart Association Diabetes Committee of the Council on Nutrition, Physical Activity, and Metabolism: Hyperglycemia and acute coronary syndrome: a scientific statement from the American Heart Association Diabetes Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation 117:1610–1619, 2008 [PubMed] [Google Scholar]
Arabi YM, Dabbagh OC, Tamim HM, Al-Shimemeri AA, Memish ZA, Haddad SH, Syed SJ, Giridhar HR, Rishu AH, Al-Daker MO, Kahoul SH, Britts RJ, Sakkijha MH: Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients. Crit Care Med 36:3190–3197, 2008 [PubMed] [Google Scholar]
Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, Moerer O, Gruendling M, Oppert M, Grond S, Olthoff D, Jaschinski U, John S, Rossaint R, Welte T, Schaefer M, Kern P, Kuhnt E, Kiehntopf M, Hartog C, Natanson C, Loeffler M, Reinhart K, German Competence Network Sepsis (SepNet): Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 358:125–139, 2008 [PubMed] [Google Scholar]
Preiser JC, Devos P, Ruiz-Santana S, Melot C, Annane D, Groeneveld J, Iapichino G, Leverve X, Nitenberg G, Singer P, Wernerman J, Joannidis M, Stecher A, Chiolero R: A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Intensive Care Med 35:1738–1748, 2009 [PubMed] [Google Scholar]
van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R: Intensive insulin therapy in the medical ICU. N Engl J Med 354:449–461, 2006 [PubMed] [Google Scholar]
NICE-SUGAR Study Investigators; Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hebert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ: Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360:1283–1297, 2009 [PubMed] [Google Scholar]
NICE-SUGAR Study Investigators; Finfer S, Liu B, Chittock DR, Norton R, Myburgh JA, McArthur C, Mitchell I, Foster D, Dhingra V, Henderson WR, Ronco JJ, Bellomo R, Cook D, McDonald E, Dodek P, Hebert PC, Heyland DK, Robinson BG: Hypoglycemia and risk of death in critically ill patients. N Engl J Med 367:1108–1118, 2012 [PubMed] [Google Scholar]
de Miguel-Yanes JM, Munoz-Gonzalez J, Andueza-Lillo JA, Moyano-Villaseca B, Gonzalez-Ramallo VJ, Bustamante-Fermosel A: Implementation of a bundle of actions to improve adherence to the Surviving Sepsis Campaign guidelines at the ED. Am J Emerg Med 27:668–674, 2009 [PubMed] [Google Scholar]
Kavanagh BP, McCowen KC: Clinical practice: glycemic control in the ICU. N Engl J Med 363:2540–2546, 2010 [PubMed] [Google Scholar]
Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, Inzucchi SE, Ismail-Beigi F, Kirkman MS, Umpierrez GE, American Association of Clinical Endocrinology, American Diabetes Association: American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract 15:353–369, 2009 [PubMed] [Google Scholar]
Jacobi J, Bircher N, Krinsley J, Agus M, Braithwaite SS, Deutschman C, Freire AX, Geehan D, Kohl B, Nasraway SA, Rigby M, Sands K, Schallom L, Taylor B, Umpierrez G, Mazuski J, Schunemann H: Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med 40:3251–3276, 2012 [PubMed] [Google Scholar]
Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, Hirsch IB, American Diabetes Association Diabetes in Hospitals Writing Committee: Management of diabetes and hyperglycemia in hospitals. Diabetes Care 27:553–591, 2004 [PubMed] [Google Scholar]
Cohen MR: Pharmacists' role in ensuring safe and effective hospital use of insulin. Am J Health Syst Pharm 67:S17–S21, 2010 [PubMed] [Google Scholar]
Institute for Safe Medication Practices: ISMP's list of high-alert medications. Available from www.ismp.org/Tools/highalertmedications.pdf. Accessed 13 April 2014
Hellman R: A systems approach to reducing errors in insulin therapy in the inpatient setting. Endocr Pract 10 (Suppl. 2):100–108, 2004 [PubMed] [Google Scholar]
Joint Commission: High-alert medications and patient safety. Available from www.jointcommission.org/sentinel_event_alert_issue_11_high-alert_medications_and_patient_safety. Accessed 13 April 2014
Browning LA, Dumo P: Sliding-scale insulin: an antiquated approach to glycemic control in hospitalized patients. Am J Health Syst Pharm 61:1611–1614, 2004 [PubMed] [Google Scholar]
Ku SY, Sayre CA, Hirsch IB, Kelly JL: New insulin infusion protocol improves blood glucose control in hospitalized patients without increasing hypoglycemia. Jt Comm J Qual Patient Saf 31:141–147, 2005 [PubMed] [Google Scholar]
DeSantis AJ, Schmeltz LR, Schmidt K, O'Shea-Mahler E, Rhee C, Wells A, Brandt S, Peterson S, Molitch ME: Inpatient management of hyperglycemia: the Northwestern experience. Endocr Pract 12:491–505, 2006 [PubMed] [Google Scholar]
Munoz M, Pronovost P, Dintzis J, Kemmerer T, Wang NY, Chang YT, Efird L, Berenholtz SM, Golden SH: Implementing and evaluating a multicomponent inpatient diabetes management program: putting research into practice. Jt Comm J Qual Patient Saf 38:195–206, 2012 [PMC free article] [PubMed] [Google Scholar]
Newton CA, Young S: Financial implications of glycemic control: results of an inpatient diabetes management program. Endocr Pract 12 (Suppl. 3):43–48, 2003 [PubMed] [Google Scholar]
Olson L, Muchmore J, Lawrence CB: The benefits of inpatient diabetes care: improving quality of care and the bottom line. Endocr Pract 12 (Suppl. 3):35–42, 2006 [PubMed] [Google Scholar]
Osburne RC, Cook CB, Stockton L, Baird M, Harmon V, Keddo A, Pounds T, Lowey L, Reid J, McGowan KA, Davidson PC: Improving hyperglycemia management in the intensive care unit: preliminary report of a nurse-driven quality improvement project using a redesigned insulin infusion algorithm. Diabetes Educ 32:394–403, 2006 [PubMed] [Google Scholar]
Reynolds LR, Cook AM, Lewis DA, Colliver MC, Legg SS, Barnes NG, Conigliaro J, Lofgren RP: An institutional process to improve inpatient glycemic control. Qual Manag Health Care 16:239–249, 2007 [PubMed] [Google Scholar]
Furnary AP: Insulin infusions for cardiac surgery patients with diabetes: a call to reason. Endocr Pract 8:71–72, 2002 [PubMed] [Google Scholar]
Krinsley JS: Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clinic Proc 79:992–1000, 2004 [PubMed] [Google Scholar]
Markovitz LJ, Wiechmann RJ, Harris N, Hayden V, Cooper J, Johnson G, Harelstad R, Calkins L, Braithwaite SS: Description and evaluation of a glycemic management protocol for patients with diabetes undergoing heart surgery. Endocr Pract 8:10–18, 2002 [PubMed] [Google Scholar]
Shetty S, Inzucchi SE, Goldberg PA, Cooper D, Siegel MD, Honiden S: Adapting to the new consensus guidelines for managing hyperglycemia during critical illness: the updated Yale insulin infusion protocol. Endocr Pract 18:363–370, 2012 [PubMed] [Google Scholar]
Wilson M, Weinreb J, Hoo GW: Intensive insulin therapy in critical care: a review of 12 protocols. Diabetes Care 30:1005–1011, 2007 [PubMed] [Google Scholar]
Bouw JW, Campbell N, Hull MA, Juneja R, Guzman O, Overholser BR: A retrospective cohort study of a nurse-driven computerized insulin infusion program versus a paper-based protocol in critically ill patients. Diabetes Technol Ther 14:125–130, 2012 [PubMed] [Google Scholar]
Dortch MJ, Mowery NT, Ozdas A, Dossett L, Cao H, Collier B, Holder G, Miller RA, May AK: A computerized insulin infusion titration protocol improves glucose control with less hypoglycemia compared to a manual titration protocol in a trauma intensive care unit. JPEN J Parenter Enteral Nutr 32:18–27, 2008 [PubMed] [Google Scholar]
Hoekstra M, Vogelzang M, Verbitskiy E, Nijsten MW: Health technology assessment review: computerized glucose regulation in the intensive care unit: how to create artificial control. Crit Care 13:223, 2009. (doi:10.1186/cc8023) [PMC free article] [PubMed] [Google Scholar]
Lee J, Fortlage D, Box K, Sakarafus L, Bhavsar D, Coimbra R, Potenza B: Computerized insulin infusion programs are safe and effective in the burn intensive care unit. J Burn Care Res 33:e114–e119, 2012 [PubMed] [Google Scholar]
Magee MC: Improving IV insulin administration in a community hospital. J Vis Exp 64:e3705, 2012. (doi: 10.3791/3705) [PMC free article] [PubMed] [Google Scholar]
Marvin MR, Inzucchi SE, Besterman BJ: Computerization of the Yale insulin infusion protocol and potential insights into causes of hypoglycemia with intravenous insulin. Diabetes Technol Ther 15:246–252, 2013 [PMC free article] [PubMed] [Google Scholar]
Olinghouse C: Development of a computerized intravenous insulin application (AutoCal) at Kaiser Permanente Northwest, integrated into Kaiser Permanente HealthConnect: impact on safety and nursing workload. Perm J 16:67–70, 2012 [PMC free article] [PubMed] [Google Scholar]
Faraon-Pogaceanu C, Banasiak KJ, Hirshberg EL, Faustino EV: Comparison of the effectiveness and safety of two insulin infusion protocols in the management of hyperglycemia in critically ill children. Pediatr Crit Care Med 11:741–749, 2010 [PubMed] [Google Scholar]
Krikorian A, Ismail-Beigi F, Moghissi ES: Comparisons of different insulin infusion protocols: a review of recent literature. Curr Opin Clin Nutr Metab Care 13:198–204, 2010 [PubMed] [Google Scholar]
Juneja R, Roudebush CP, Nasraway SA, Golas AA, Jacobi J, Carroll J, Nelson D, Abad VJ, Flanders SJ: Computerized intensive insulin dosing can mitigate hypoglycemia and achieve tight glycemic control when glucose measurement is performed frequently and on time. Crit Care 13:R163, 2009. (doi: 10.1186/cc8129) [PMC free article] [PubMed] [Google Scholar]
Newton CA, Smiley D, Bode BW, Kitabchi AE, Davidson PC, Jacobs S, Steed RD, Stentz F, Peng L, Mulligan P, Freire AX, Temponi A, Umpierrez GE: A comparison study of continuous insulin infusion protocols in the medical intensive care unit: computer-guided vs. standard column-based algorithms. J Hosp Med 5:432–437, 2010 [PMC free article] [PubMed] [Google Scholar]
Sood R, Zieger M, Roggy D, Nazim M, Henderson SR, Hartman B: The effectiveness of a computerized IV infusion protocol to treat hyperglycemia in burn patients. J Burn Care Res 33:638–641, 2012 [PubMed] [Google Scholar]
Wiener RS, Wiener DC, Larson RJ: Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA 300:933–944, 2008 [PubMed] [Google Scholar]
Dungan K, Chapman J, Braithwaite SS, Buse J: Glucose measurement: confounding issues in setting targets for inpatient management. Diabetes Care 30:403–409, 2007 [PubMed] [Google Scholar]
U.S. Food and Drug Administration: Blood glucose monitoring test systems for prescription point-of-care use: draft guidance for industry and Food and Drug Administration staff. Available from http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM380325.pdf. Accessed 5 June 2014
Goldberg PA, Siegel MD, Russell RR, Sherwin RS, Halickman JI, Cooper DA, Dziura JD, Inzucchi SE: Experience with the continuous glucose monitoring system in a medical intensive care unit. Diabetes Technol Ther 6:339–347, 2004 [PubMed] [Google Scholar]
Rabiee A, Andreasik V, Abu-Hamdah R, Galiatsatos P, Khouri Z, Gibson BR, Andersen DK, Elahi D: Numerical and clinical accuracy of a continuous glucose monitoring system during intravenous insulin therapy in the surgical and burn intensive care units. J Diabetes Sci Technol 3:951–959, 2009 [PMC free article] [PubMed] [Google Scholar]
Yamashita K, Okabayashi T, Yokoyama T, Yatabe T, Maeda H, Manabe M, Hanazaki K: Accuracy and reliability of continuous blood glucose monitor in post-surgical patients. Acta Anaesthesiol Scand 53:66–71, 2009 [PubMed] [Google Scholar]
Skjaervold NK, Solligard E, Hjelme DR, Aadahl P: Continuous measurement of blood glucose: validation of a new intravascular sensor. Anesthesiology 114:120–125, 2011 [PubMed] [Google Scholar]
Mendez CE, Mok KT, Ata A, Tanenberg RJ, Calles-Escandon J, Umpierrez GE: Increased glycemic variability is independently associated with length of stay and mortality in noncritically ill hospitalized patients. Diabetes Care 36:4091–4097, 2013 [PMC free article] [PubMed] [Google Scholar]
Hoofnagle AN, Peterson GN, Kelly JL, Sayre CA, Chou D, Hirsch IB: Use of serum and plasma glucose measurements as a benchmark for improved hospital-wide glycemic control. Endocr Pract 14:556–563, 2008 [PubMed] [Google Scholar]
Krinsley JS, Jones RL: Cost analysis of intensive glycemic control in critically ill adult patients. Chest 129:644–650, 2006 [PubMed] [Google Scholar]
van den Berghe G, Wouters PJ, Kesteloot K, Hilleman DE: Analysis of healthcare resource utilization with intensive insulin therapy in critically ill patients. Crit Care Med 34:612–616, 2006 [PubMed] [Google Scholar]
Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, Seley JJ, van den Berghe G, Endocrine Society: Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 97:16–38, 2012 [PubMed] [Google Scholar]
Bode BW, Braithwaite SS, Steed RD, Davidson PC: Intravenous insulin infusion therapy: indications, methods, and transition to subcutaneous insulin therapy. Endocr Pract 10 (Suppl. 2):71–80, 2004 [PubMed] [Google Scholar]
Furnary AP, Braithwaite SS: Effects of outcome on in-hospital transition from intravenous insulin infusion to subcutaneous therapy. Am J Cardiol 98:557–564, 2006 [PubMed] [Google Scholar]
Olansky L, Sam S, Lober C, Yared JP, Hoogwerf B: Cleveland Clinic cardiovascular intensive care unit insulin conversion protocol. J Diabetes Sci Technol 3:478–486, 2009 [PMC free article] [PubMed] [Google Scholar]
Schmeltz LR, DeSantis AJ, Schmidt K, O'Shea-Mahler E, Rhee C, Brandt S, Peterson S, Molitch ME: Conversion of intravenous insulin infusions to subcutaneously administered insulin glargine in patients with hyperglycemia. Endocr Pract 12:641–650, 2006 [PubMed] [Google Scholar]
Larsen J, Goldner W: Approach to the hospitalized patient with severe insulin resistance. J Clin Endocrinol Metab 96:2652–2662, 2011 [PubMed] [Google Scholar]
Kelly JL: Ensuring optimal insulin utilization in the hospital setting: role of the pharmacist. Am J Health Syst Pharm 67:S9–S16, 2010 [PubMed] [Google Scholar]

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4523736/