Although tight glucose control in the ICU has been shown to significantly impact outcomes, it remains a labor intensive intervention to apply broadly. We developed a protocol which allows the nurse to control an insulin infusion to maintain tight glucose control with only minimal input from the physician.
Our insulin drip protocol is included in Figure 1. The protocol is initiated when blood glucose measurements on a sliding scale insulin regimen were > 140 for 24 hours. The physician writes the order to initiate the insulin drip protocol and the starting infusion rate. The numbers on the left side of the chart refer to the previous glucose measurement; those on the bottom refer to the current reading. The nurse matches up previous reading with the current reading and follows the instructions in the table. Blood glucose is monitored Q1 hour for 4 hours, then Q2 hours thereafter if blood sugar stabilizes to less than 140. For any rate change, the blood glucose readings are rechecked Q1 hour x 2 hours and then resumed at Q2 hour checks.
From May 2004 to May 2005 94 patients were started on the protocol. The average time to achieve a blood glucose of < 140 was approximately 10 hours (r 5-21), with an average length of stay on the protocol of 3.4 days (r 5-21). 3(3.2%) patients developed hypoglycemia (blood glucose < 40). Blood glucose levels of < 140 were acheived in 95% of patients.
Our nurse directed insulin infusion protocol for the tight control of blood glucose in the ICU is a safe and effective means of achieving goal glucose levels in critically ill patients. Once stabilized the patient can have glucose monitoring as inferequently as every 2 hours which significantly decreases the workload on the bedside nurse.
Utilization of a nurse directed protocolized insulin infusion can afford safe and effective blood glucose control in the ICU without causing a significant increase in nursing workload.
Leo Rotello, None.