title: Achieving durable glucose control in the intensive care unit without hypoglycaemia: a new practical IV insulin protocol.
abstract: BACKGROUND
  Hyperglycaemia occurs in a substantial portion of critically ill patients in our intensive care units. Near normalization of elevated blood glucose levels with IV insulin may improve outcome. However, currently published IV insulin protocol are not ideal; most are relatively complex and often result in hypoglycaemia. We designed a protocol that would be practical to use while incorporating the necessary complexities required to achieve good glucose control, coupled with a low incidence hypoglycaemia.
  
  
  METHODS
  The essential part of the protocol is a matrix specifying the amount by which an insulin flow rate is to be changed. The intersection of the current and the previous blood glucose values on the matrix locates the appropriate cell containing the required change in insulin flow rate. No additional calculations or tables are required.
  
  
  RESULTS
  The initial glucose level obtained by blood glucose meter (BGM) averaged 253.5 +/- 95.6 mg/dL and fell below 140 within 9.3 h on the protocol. The average BGM on the protocol was 133.5 +/- 43.9 mg/dL. Only 0.09% of all glucose values were <40 mg/dL and insulin had to be held only 2.2% of the time on the protocol. Physician input was not required and nursing accuracy in applying the protocol was greater than 94%. This protocol has been adopted as the default IV insulin protocol for the NorthShore-LIJ Health System and several other medical centers.
  
  
  CONCLUSIONS
  A practical IV insulin protocol that has been extensively tested is presented. The protocol has been implemented at multiple institutions indicating its ease of use and excellent results.
authors.affiliation: Department of Medicine, Huntington Hospital, Huntington, NY 11743, USA. mbalkin@mac.com
authors.forename: Michael
authors.initials: M
authors.lastname: Balkin
authors.forename: Charles
authors.initials: C
authors.lastname: Mascioli
authors.forename: Virginia
authors.initials: V
authors.lastname: Smith
authors.forename: Hicham
authors.initials: H
authors.lastname: Alnachawati
authors.forename: Sandeep
authors.initials: S
authors.lastname: Mehrishi
authors.forename: Ghulam
authors.initials: G
authors.lastname: Saydain
authors.forename: Helen
authors.initials: H
authors.lastname: Slone
authors.forename: Joseph
authors.initials: J
authors.lastname: Alessandrini
authors.forename: Lawrence
authors.initials: L
authors.lastname: Brown
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001786:Blood Glucose / Q000378:metabolism*; D002985:Clinical Protocols; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D007003:Hypoglycemia / Q000517:prevention & control*; D007262:Infusions, Intravenous; D007328:Insulin / Q000008:administration & dosage*; D007362:Intensive Care Units / Q000592:standards*; D008297:Male; D008875:Middle Aged
chemical_list: D001786:Blood Glucose; D007328:Insulin