HOSPITAL INSULIN PROTOCOL AIMS FOR GLUCOSE CONTROL IN GLUCOCORTICOID-INDUCED HYPERGLYCEMIA.

OBJECTIVE: To compare the effectiveness of 2 insulin protocols to treat glucocorticoid-induced hyperglycemia in the nonintensive care hospital setting. METHODS: A randomized, open-label, parallel-arm study was conducted comparing standard recommended care of complete insulin orders (CIO) (i.e., 3-part insulin regimen of long-acting basal [background], rapid-acting bolus [mealtime], and rapid-acting correction factor) to an experimental group following a regimen of Neutral Protamine Hagedorn (NPH) plus CIO (NPH-CIO). The primary outcome was mean blood glucose (BG), and the secondary outcome was percent of BG in target range of 70 to 180 mg/dL. Hypoglycemia was also evaluated. RESULTS: Sixty-one patients completed 2 to 5 consecutive inpatient days (31 CIO; 30 NPH-CIO). Baseline mean BG results were 237.2 ± 50.2 and 221.9 ± 35.8 mg/dL (P = .30) in the CIO and NPH-CIO groups, respectively. No significant difference in overall mean BG between the 2 groups was detected; however, a significant difference arose on day 3: mean BG 181.8 ± 32.6 mg/dL (CIO) versus 157.2 ± 6.1 mg/dL (NPH-CIO) (P = .03). Moreover, the total daily doses (TDDs) of insulin did not differ: 34.8 ± 43.0 units (CIO) versus 35.8 ± 25.0 units (NPH-CIO) (P = .13). Percent of BG in target was 54.6% (CIO) and 62% (NPH-CIO) (P = .24). Incidence of severe hypoglycemia (<50 mg/dL) was the same in both groups (0.1%). CONCLUSION: NPH added to 3-part insulin regimen (CIO) may be an effective way to a combat glucocorticoid-induced hyperglycemia, though further research is needed in a larger population.

Evaluation of admission blood glucose levels in the intensive care unit.

OBJECTIVE: To assess the availability and clinical value of blood glucose (BG) testing at the time of admission to the intensive care unit (ICU) after such testing was implemented as routine care in the ICU. METHODS: We studied ICU admission BG testing rates and the prevalence of hyperglycemia. In this effort, we assessed the frequency of baseline BG testing in 330 consecutive patients during a period of 3 months and then implemented routine BG monitoring in 1,147 consecutive ICU patients during a 7-month period. RESULTS: Of the total study population, 25% had previously diagnosed diabetes (PDD). At baseline, 70% had BG measured within 4 hours before or after ICU admission (99% of patients with and 60% of patients without PDD). After implementation of routine BG monitoring, there was a significant increase in testing (70% before versus 87% after, P<0.001; 70% during the baseline 3-month period versus 93% in the final 3 months of the study, P<0.001). In patients without PDD, 41% had BG levels < or =140 mg/dL, and 8% had BG concentrations < or =200 mg/dL. Overall in the ICU setting, 57% of BG values < or =140 mg/dL and 33% of BG levels < or =200 mg/dL were in patients without PDD. Frequencies of BG testing by admission diagnosis included the following (at baseline and during the final 3 months after implementation of routine BG tests): postsurgical status (46%, 85%), peripheral vascular disease (51%, 90%), neurologic disease (52%, 83%), gastrointestinal disease (58%, 91%), infection (69%, 100%), and diabetes (100%, 100%). CONCLUSION: Rates of routine BG testing are low in ICU patients without PDD. Elevations in BG levels were detected in 41% of our study patients without PDD, suggesting that routine implementation of BG monitoring in an ICU will identify patients at increased risk for hyperglycemia-associated higher morbidity and mortality.

Diabetic ketoacidosis.

Preview Patients with diabetic ketoacidosis require immediate and aggressive therapy, but they may have confusing signs and symptoms. Patients are often warm and flushed despite having profound fluid depletion; they are seldom feverish but often have underlying infection. Dr Fish summarizes the clinical presentation of these patients, the four components of primary therapy, laboratory values to be monitored in tracking progress, and important details of follow-up.