Diabetes management in ICU

Leuven Surgical Trial (2001)

Intensive glycemic control was not a high priority in most ICU patients, till 2001, when a landmark trial (Leuven Surgical Trial) by Van Den Berghe & colleagues demonstrated 42% mortality benefit when maintaining BG= 80-110, compared to conventional glycemic control.

NICE-SUGAR Trial (2009)

Are we increasing the risk of hypoglycemia by intensive measures? Yes. Risk of hyperglycaemia increases with intensive therapy, especially with advanced age, reduced oral intake, chronic renal failure, liver disease, beta blockers. Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR) trial showed higher mortality in intensive treatment group.

Present Guidelines:

NICE-SUGAR trial contradicted and overrode intensive glycemic control of the earlier Leuven trials. As a result, intensive glycemic control in the ICU to a target <110 mg/dL is no longer recommended. The ideal target glucose remains unclear. Standard ICU target is 140-180 mg/dL & is supported by several guideline-issuing bodies.

Insulin Protocols: IV infusion or sc sliding scale

Protocols vary greatly. Optimal glycemic target is debatable. There can be different targets for different patient groups. IV infusion protocol should be chosen on patients who are NPO, continuous tube fed, on TPN, on non-caloric fluids.

Subcutaneous sliding scale:

1. Check BSugar 4hrly.
2. Initiate SENSITIVE sliding scale:

BSugar	Insulin Units
below 120	Nil
120-150	2
151-200	4
201-250	6
251-300	8
above 300	10

3. For any subsequent BSugar is more than 150, switch to RESISTANT sliding scale:

BSugar	Insulin Units
below 120	Nil
120-150	4
151-200	6
201-250	10
251-300	15
above 300	20

4. If BSugar drops below 80 on RESISTANT sliding scale for 2 readings, revert to SENSITIVE sliding scale.
5. If no insulin is required for 72 hrs, check BSugar 12hrly

Infusion protocol:

It should be a printed protocol for nursing Staff. It should be effective, safe & easily implementable. I will outline an example of infusion protocol (download pdf), which you can download and practice. Following is Trauma / SICU Glycemia control orders for adults 18 years old or greater :
1. Start Insulin infusion for any BSugar above 150 on RESISTANT sliding scale.
2. Start insulin drip at 3 units/hr.
3. Start with BSugar check every hour.

BSugar	Rate
above 220	incr by 1ml/hr
155-220	incr by 0.5ml/hr
101-150	no change
below 100	Stop infusion

4. If infusion stopped because of BSugar below 100, check BSugar every 30 minutes for 2 hours. If BSugar remains below 150, discontinue insulin infusion and revert to RESISTANT sliding scale, but if BSugar goes above 150, restart insulin infusion by reducing infusion rate by 1ml/hr.
5. If BSugar is less than 250, change IVF to 5%DNS.
6. If BSugar is less than 60 during insulin infusion - give 25ml of 50% Dextrose slow IV push over 2 minutes, followed immediately by BSugar check. Repeat this step if BSugar remain below 60.But if BSugar goes above 60, check BSugar every 30 minutes for 2 hrs.
6. If BSugar remains between 100-150 for more than 6hrs, check BSugar 2hrly.
7. Note: Above Infusion protocol is for Trauma/Surgical ICU. This protocol is not for non-ICU patients or diabetic emergencies.
8. If patient is on Vitamin-C drip, BSugar should be checked by serum at Lab.