title: A unified Hyperglycemia and Diabetic ketoacidosis (DKA) insulin infusion protocol based on an Excel algorithm and implemented via Electronic Medical Record (EMR) in Intensive Care Units.
abstract: BACKGROUND
  To assess the efficacy of a unified hyperglycemia and diabetic ketoacidosis (DKA) insulin infusion protocol (IIP), based on an Excel algorithm and implemented as an electronic order set, in achieving glycemic targets and minimizing hypoglycemia.
  
  
  METHODS
  An IIP was instituted in medical and surgical intensive care units for post-cardiac surgery (PCS) and other stress hyperglycemia (SH), diabetes hyperglycemia (DH), and DKA. The IIP initiated therapeutic insulin rates at elevated blood glucose (BG), and decreased insulin when target range was achieved. A convenience sample (n=62) was studied; 20 PCS, 15 with DH, 9 with SH, 8 with diabetes on vasopressors, 7 with diabetes on glucocorticoids and 3 with DKA were assessed.
  
  
  RESULTS
  The protocol maintained BG at 144±24.7mg/dL for PCS and 167±36mg/dL for patients with diabetes mellitus. It maintained acceptable target range (ATR) (100mg/dL-180mg/dL) 89% of the time for PCS and 67% of the time for patients with diabetes mellitus. There were no measurements of BG<70mg/dL. The protocol lowered the BG at a similar rate and time period in those with diabetes, DKA and those with or without vasopressors or glucocorticoids. To determine long-term efficacy, a retrospective review of Point of Care (POC) RALS (Remote Automated Data System) BG data 2 years post implementation demonstrated fewer episodes of hypoglycemia<70mg/dL and hyperglycemia>240mg/dL and more BG values within ATR.
  
  
  CONCLUSIONS
  This IIP maintained ATR without hypoglycemia for patients in the ICU setting without requiring complex nursing calculations.
authors.affiliation: Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States. Electronic address: dgupta4@slu.edu.
authors.forename: Deepashree
authors.initials: D
authors.lastname: Gupta
authors.affiliation: Department of Pharmacy, St. Luke's Hospital, St. Louis, MO, United States.
authors.forename: Meredith
authors.initials: M
authors.lastname: Kirn
authors.affiliation: Division of Pulmonary, Critical Care and Sleep Medicine, Saint Louis University School of Medicine, United States.
authors.forename: Zafar A
authors.initials: ZA
authors.lastname: Jamkhana
authors.affiliation: Department of Cardiovascular Medicine, Division of Comprehensive Cardiovascular Care, Saint Louis University School of Medicine, United States.
authors.forename: Richard
authors.initials: R
authors.lastname: Lee
authors.affiliation: Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States.
authors.forename: Stewart G
authors.initials: SG
authors.lastname: Albert
authors.affiliation: SSM Saint Louis University Hospital.
authors.forename: Kimberly M
authors.initials: KM
authors.lastname: Rollins
mesh_terms: D000368:Aged; D000465:Algorithms; D001786:Blood Glucose / Q000032:analysis / Q000378:metabolism; D016883:Diabetic Ketoacidosis / Q000097:blood / Q000188:drug therapy*; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000097:blood / Q000188:drug therapy*; D007003:Hypoglycemia / Q000139:chemically induced / Q000517:prevention & control; D007328:Insulin / Q000008:administration & dosage*; D007332:Insulin Infusion Systems; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D019095:Point-of-Care Systems; D012189:Retrospective Studies
chemical_list: D001786:Blood Glucose; D007328:Insulin
keywords: Diabetic ketoacidosis; ICU; Insulin infusion