Intensive insulin therapy has been shown to reduce mortality in adult patients receiving mechanical ventilation admitted to the intensive care unit. The use of exogenous insulin to maintain the blood glucose level at no higher than 110 mg/dL was found to reduce morbidity and mortality regardless of whether the patients had diabetes. We studied the safety and feasibility of widespread implementation of a standardized intensive insulin therpay protocol targeted to this range as part of a mechanical ventilation bundle on a trauma service.
50 patients admitted to the ICU on the trauma service and requiring mechanical ventilation were treated with insulin infusions per a standardized protocol to keep the blood glucose between 80 and 110 mg/dL. Compliance with the protocol, mortality, frequency of hypoglycemia, rate of infusion and duration of insulin required, and cause of mortality were measured and recorded.
Physician compliance in ordering the protocol was 90%. Only 5 did not receive the protocol. Of the other 45 patients who had intensive insulin therapy ordered, 42 actually required insulin administration (93.3%). Three patients died (6.0%) during the ICU stay. Hypoglycemia (glucose 40 mg/dL or less) only occured in 2 patients (4.0%)without adverse sequelae. The mean duration of intensive insulin therapy was 6.5 days. The range of insulin required was from 0 to 15 units/h. The causes of death were MODS from sepsis, a fatal cervical spine injury, and severe traumatic brain injury.
Intensive insulin therapy with a continuous infusion of insulin according to a standardized protocol can easily be performed in critically ill trauma patients requiring mechanical ventilation. A determined approach to glucose control can be taken with minimal fear of hypoglycemia.
Intensive insulin therapy has been recommended for implementation as standard therapy as part of a mechanical ventilation bundle. Unfamiliarity, lack of real world data, and fear of hypoglycemia have been barriers to implementation. This study shows that intensive insulin therapy with tight glucose contol is feasible in a critically ill population.
John Kepros, None.