Cleveland Clinic cardiovascular intensive care unit insulin conversion protocol.
BACKGROUND
The importance of near-normal blood glucose in the immediate postoperative period is generally accepted and is best achieved in the perioperative period with a constant intravenous (IV) infusion of insulin. This requires intensive nursing only achievable in an intensive care unit (ICU) setting. Glucose management after transfer to a regular nursing floor (RNF) has not been studied systematically. In August 2006, the Cleveland Clinic began using long-acting insulin glargine as the insulin infusion was terminated in the ICU.


METHODS
This prospective analysis examined all patients receiving IV insulin infusion after cardiothoracic surgery in a 1 month period. The analyses evaluated the safety and efficacy of a protocol using a transition to subcutaneous insulin glargine of 50% of the calculated 24 h requirement at the end of the ICU insulin infusion protocol in preparation for transfer to the RNF.


RESULTS
Only 1 patient in 99 developed hypoglycemia, and no patient suffered severe hypoglycemia (glucose < 40 mg/dl), while the majority (70%) had euglycemia (glucose between 70 and 150 mg/dl).


CONCLUSIONS
This approach was both safe-as there was very little hypoglycemia (1 patient in 99)-and effective, as blood sugar was well controlled in most subjects. Efficacy for achieving euglycemia was 70%. Efficacy was likely reduced because of the upper limit of insulin glargine dosage imposed by some providers as a safety consideration. Although there was a physician option to override, the maximum protocol dose of 30 U was rarely exceeded, leading to inadequate dosing in some subjects who required high insulin infusion rates in the ICU.
Olansky
Leann
L
Department of Endocrinology, Cleveland Clinic and Outcomes Research, Cleveland, OH 44195, USA. olanskl@ccf.org
Sam
Sharon
S
Lober
Cheryl
C
Yared
Jean-Pierre
JP
Hoogwerf
Byron
B
D000368:Aged; D001786:Blood Glucose / Q000187:drug effects; D002318:Cardiovascular Diseases / Q000601:surgery*; D002985:Clinical Protocols; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000097:blood / Q000517:prevention & control*; D007004:Hypoglycemic Agents / Q000008:administration & dosage / Q000494:pharmacology / Q000627:therapeutic use*; D007262:Infusions, Intravenous; D007328:Insulin / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000494:pharmacology / Q000627:therapeutic use*; D000069036:Insulin Glargine; D049528:Insulin, Long-Acting; D007362:Intensive Care Units / Q000639:trends*; D008297:Male; D008875:Middle Aged; D009820:Ohio; D011184:Postoperative Period; D011446:Prospective Studies; D012189:Retrospective Studies
D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin; D049528:Insulin, Long-Acting; D000069036:Insulin Glargine