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Glucose Control: What, Why, When, and How. Terry P. Clemmer, MD Salt Lake City, Utah. What Are The Options?. No Glucose Control Some Glucose Control with Target <250 mg/dl (14 mMol) Moderate Glucose Control with Target <150 mg/dl (8.3 mMol)

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glucose control what why when and how

Glucose Control:What, Why, When, and How

Terry P. Clemmer, MD

Salt Lake City, Utah

Glucose Control NYNY

what are the options
What Are The Options?
  • No Glucose Control
  • Some Glucose Control with Target <250 mg/dl (14 mMol)
  • Moderate Glucose Control with Target <150 mg/dl (8.3 mMol)
  • Tight Glucose Control with Target 80-110 mg/dl (4.4 - 6.1 mMol)

Glucose Control NYNY

slide3
What:

Define Tight Glucose Control

  • Blood Glucose Is Controlled with > 40% of the Values Between 80-110 mg/dl
  • Over 80% of Values Are Between 60-150 mg/dl
  • The Hypoglycemia Rate (<60) Is Acceptable and Near Routine Practice
  • The Severe Hyperglycemia Rate (>250) is Acceptable and Below Routine Practice

Glucose Control NYNY

slide6
Why:

The Evidence

  • Van den Berghe. N Engl J Med 2001;345:1359- 67
  • Van den Berghe, Crit Care Med 2003
  • Finney et al. JAMA 2003
  • Krinsley. Mayo Clin Proc 2004
  • Van den Berghe. N Engl J Med 2006
  • Brunkhorst et al. 2008

Glucose Control NYNY

hypothesis
Hypothesis
  • Hyperglycemia, Relative Insulin Deficiency or Both During Critical Illness May Confer a Predisposition to Complications:
      • Severe Infections
      • Polyneuropathy
      • Multi-organ Failure
      • Death

Glucose Control NYNY

entrance criteria
Entrance Criteria
  • ICU Admission Requiring a Ventilator
  • Written Informed Consent
  • Dates Feb 2, 2000 - Jan 18, 2001

Glucose Control NYNY

enrollment
Enrollment
  • 1548 Patients Enrolled
    • 783 Conventional Rx
    • 765 Intensive Insulin Rx
  • 14 Excluded
    • 5 Participating in Other Trials
    • 9 Moribund on Admission With DNR Orders

Glucose Control NYNY

randomization
Randomization
  • Sealed Envelopes
  • Stratification According to Type of Critical Illness
  • Balance With Permuted Blocks of 10

Glucose Control NYNY

study design
Study Design
  • Conventional Group
    • Insulin Started Only If Serum Glucose > 215 mg/dl
    • Insulin Adjusted to Keep Gluucose @ 180-200 mg/dl
    • Feed 20-30 NPKcal / day with 20-40% Fat

Glucose Control NYNY

study design1
Study Design
  • Intensive Rx Group
    • Insulin Started If Serum Glu. > 110 mg/dl
    • Insulin Adjusted to Keep Glu. @ 80-110 mg/dl
    • Max Insulin Dose 50 Units Per Hour
    • Whole Blood Glu. Measure Q1-4 Hours

Glucose Control NYNY

study design2
Study Design
  • Intensive Rx Group
    • Adjustments Made Using an Algorithm by a Team of CC Nurses Assisted by a Study Physician Not Caring For the Patients
    • Upon Unit Discharge Study Patients Were Rx According to Conventional Protocol (180-200)
    • Feed 20-30 NP-Kcal / day with 20-40% Fat

Glucose Control NYNY

population demographics

Characteristic

Conventional

Intensive

Number

783

765

Gender Male

557 (71%)

554 (71%)

Age

62.2

63.4

BMI

25.8

26.2

Reason for ICU Care

Cardiac Surg

493 (63%)

477 (62%)

Non-Cardiac Surg.

290 (37%)

288 (38%)

Neuo/Neuro Surg

30 (4%)

33 (4%)

Resp. Fail / Thor. Surg

56 (7%)

66 (9%)

Abdominal Surg.

58 (7%)

45 (6%)

Vasc. Surg.

32 (4%)

30 (4%)

Trauma/Burns

35 (4%)

33 (4%)

Transplantation

44 (6%)

46 (6%)

Other

35 (4%)

35 (5%)

Population Demographics

Glucose Control NYNY

population demographics1

Characteristic

Conventional

Intensive

APACHE II

9

9

TISS-28

43

43

Tertiary Referral

135 (17%)

126 (16%)

Hx of Cancer

119 (15%)

122 (16%)

Hx of Diabetes

103 (13%)

101 (13%)

Rx with Insulin

33 (4%)

39 (5%)

Rx w/o Insulin

70 (9%)

62 (8%)

FBG > 110

598 (76%)

557 (73%)

FBG > 200

110 (13%)

81 (11%)

Population Demographics

Glucose Control NYNY

control of blood glucose

Variable

Conventional

Intensive

Adm of Insulin

307 (39.2%)

755 (98.7%)

Insulin Dose

Median

33 u/day

71 u/day

Duration of Insulin

Median

67% of days

100% of days

AM Blood Glucose

All Patients

153+33 mg%

103+19 mg%

Rx with Insulin

173+33 mg%

103+18 mg%

Incidence of Glu. < 40 mg%

6 (0.78%)

39 (5%)

P-value for all variables <0.001

Control of Blood Glucose

Glucose Control NYNY

mortality

p- value

Variable

Conventional

Intensive

0.04

All ICU Deaths

63/783 (8%)

35/765 (4.6%)

0.9

During 1st 5 days

14/783 (1.8%)

13/765 (1.7%)

49/243 (20.2%)

22/208 (10.6%)

0.005

> 5 days ICU care

Hosp. Deaths

0.01

All Patients

85/783 (10.9%)

55/765(7.2%)

0.01

64/243 (26.3%)

35/208 (16.8%)

> 5 days ICU care

10/477 (2.1%)

Cardiac Surg.

25/493 (5.1%)

Non-Cardiac

Neuo/Neuro Surg

7/30 (23.3%)

6/33 (18.2%)

Resp. Fail / Thor. Surg

10/56 (17.9%)

5/66 (7.6%)

Abdominal Surg.

9/58 (15.5%)

6/45 (13.3%)

Vasc. Surg.

2/32 (6.2%)

2/30 (6.7%)

Trauma/Burns

3/35(8.6%)

4/33 (12.1%)

Transplantation

1/44 (2.3%)

2/46 (4.4%)

Other

6/35 (17.1%)

0/35

Mortality

Glucose Control NYNY

morbidity

Conventional

Intensive

Variable

Rx

Rx

p-value

ICU - LOS

All Pts

3 (2-9)

3 (2-6)

0.2

<5 days

2 (2-3)

2 (2-3)

0.2

> 5 days

15 (9-27)

12 (8-20)

0.003

> 14 days

126 (15%)

87 (11%)

0.01

Vent. Days

All Pts

2 (1-6)

2 (1-4)

0.06

<5 days

1 (1-2)

1 (1-2)

0.9

> 5 days

12 (7-23)

10 (6-16)

0.006

> 14 days

93 (11.9%)

57 (7.5%)

0.003

Renal Failure

Creat. > 2.5

96 (12.3%)

69 (9%)

0.04

BUN > 54

88 (11..2%)

59 (7.7%)

0.02

Dialysis

64 (8.2%)

37 (4.8%)

0.007

Sepsis

Pos. Culture

61 (7.8%)

32 (4.2%)

0.003

Abx > 10 d

134 (17.1%)

86 (11.2%)

0.001

Polyneuropathy

Any

107/206 (51.9%)

45/157 (11.2%)

0.001

Twice

39/206 (18.9%)

11/157 (7%)

0.001

Morbidity

Glucose Control NYNY

not all evidence is created equal
Not All Evidence is Created Equal...

Population

  • Med/Surgical ICU patients

Methods

  • Prospective observational study (n= 531)

Analysis

  • Logistic regression
  • Exposure: insulin dose and glucose range
  • Adjustment: APACHE II, SOFA score, age, sex, BMI, admission dx, ICU LOS

Outcome: mortality

Finney et al. JAMA 2003

Glucose Control NYNY

outcomes
Outcomes

Conclusion: Target blood glucose < 145 mg/dl

Finney et al. JAMA 2003

Glucose Control NYNY

intensive glucose management in critically ill adult patients
Intensive Glucose Management in Critically Ill Adult Patients

Population

  • 14-bed Med/surg ICU at a university-affiliated community teaching hospital

Intervention: protocol (target < 140 mg/dl)

  • Before protocol (n= 800)
    • glucose mean = 152.3
  • After protocol (n= 800)
    • glucose mean = 130.7
    • 56% reduction in % glucose >200 mg/dl

Krinsley. Mayo Clin Proc 2004

Glucose Control NYNY

intensive glucose management in critically ill adult patients1
Intensive Glucose Management in Critically Ill Adult Patients

Outcomes

  • Decreased new renal failure: 75% (p=0.03)
  • Decreased ICU LOS: 11% (p=0.01)
  • Decreased hospital mortality: 29% (p=0.002)
  • Hypoglycemia (< 60 mg/dl): 0.54 to 1.02%
  • Hypoglycemia (< 40 mg/dl): 0.34 to 0.35%

Krinsley. Mayo Clin Proc 2004

Glucose Control NYNY

entrance criteria1
Entrance Criteria
  • Patient Expected to Be in ICU > 3-days
  • Patients Expected to Be NPO > 3-days

Glucose Control NYNY

slide26

64%

Glucose Control NYNY

slide32

P=0.31

P=0.005

P=0.31

P=0.05

Glucose Control NYNY

hypoglycemia
Hypoglycemia

Glucose Control NYNY

slide38

Intermountain Computer Controlled

Tight Glucose Control

Glucose Control NYNY

if the hypoglycemia rate is unacceptable is the definition of tight glucose control fulfilled
If The Hypoglycemia Rate Is Unacceptable, Is the Definition of Tight Glucose Control Fulfilled?

Glucose Control NYNY

when and at what level is tight control appropriate
When:And At What Level Is Tight Control Appropriate
  • What Are The Units Resources
    • How often can glucose monitoring be done
    • How skilled are the nurses at using the glucose protocol
    • How unstable are the patients glucoses
  • Should It Only Be After 3-days in the ICU
  • Is < 150 as Beneficial as 80-110
  • What Are the Hypoglycemia Risks

Glucose Control NYNY

conclusions
Conclusions
  • Glucose Should Be Controlled at Some Level
  • The Leuven Protocol Used Blindly and Broadly Results In Unacceptable Hypoglycemia
  • The Leuven Protocol Should Not Be Used Unless Modified and Tested for safety and Effectiveness In the Local Environment

Glucose Control NYNY

conclusions1
Conclusions
  • Exact Range for Maximal Benefit at Lowest Risk Should Be Determined
    • It Depends Upon Units Resources
    • It is Dependent on Local Protocol Implementation
  • Glucose Control Should Be Done at the Local Level

Glucose Control NYNY

slide43
How:

The Science of Implementation

  • Do It At The Front Line
  • Create a Protocol
  • Rapid Cycle Test the Protocol
  • Find the Problems and Learn

Glucose Control NYNY

slide44
How

The Science of Implementation

  • Modify the Protocol
  • Repeat the Process Until Protocol Is
          • Safe
          • Effective
          • Doable
          • Acceptable

Glucose Control NYNY

slide45

AIM:What are we trying to accomplish.

  • MEASURE:How will we know the change is an improvement?
  • CHANGE CONCEPT: What change can we make that will result in an improvement?
  • TEST:

Langley, Nolan, Nolan, Norman & Provost

‘ The Improvement Guide’

Act

Plan

Study

Do

IHI Model for Improvement

Glucose Control NYNY

slide46

Example:

AIM:

Use an insulin drip protocol to achieve tight glucose control

Glucose Control NYNY

slide47

Glucose

Drip Rate of 1 - 3 u/h

Drip Rate of 4 - 6 u/h

Drip Rate of 7-10 u/h

Drip Rate of 11-14 u/h

Drip Rate of 15-18 u/h

Drip Rate of >18 u/h

< 41 mg/dl

D/C Drip and Give

1 amp D/50

D/C Drip and Give

1 amp D/50

D/C Drip and Give

1 amp D/50

D/C Drip and Give

1 amp D/50

D/C Drip and Give

1 amp D/50

D/C Drip and Give

1 amp D/50

41-60 mg/dl

D/C Drip and Give

1/2 amp D/50

D/C Drip and Give

1/2 amp D/50

D/C Drip and Give

1/2 amp D/50

D/C Drip and Give

1/2 amp D/50

D/C Drip and Give

1/2 amp D/50

D/C Drip and Give

1/2 amp D/50

61-80 mg/dl

D/C Drip

Decrease Drip Rate by one half

Decrease Drip Rate by one half

Decrease Drip Rate by one half

Decrease Drip Rate by two thirds

Decrease Drip Rate by two thirds

81-115 mg/dl

Do Nothing / Don\'t tamper with success

Do Nothing / Don\'t tamper with success

Do Nothing / Don\'t tamper with success

Do Nothing / Don\'t tamper with success

Do Nothing / Don\'t tamper with success

 Do Nothing / Don\'t tamper with success

Glucose

Drip Rate of 1 - 3 u/h

Drip Rate of 4 - 6 u/h

Drip Rate of 7-10 u/h

Drip Rate of 11-14 u/h

Drip Rate of 15-18 u/h

Drip Rate of > 18

116-140 mg/dl

Give 1 u insulin IV push and increase Drip Rate by 1 unit/hour

Give 1 u insulin IV push and increase Drip Rate by 2 unit/hour

Give1 u insulin IV push and increase Drip Rate by 3 unit/hour

Give1 u insulin IV push and increase Drip Rate by 4 unit/hour

Give1 u insulin IV push and increase Drip Rate by 5 unit/hour

Call Physician for New Order

141-180 mg/dl

Give 2 u insulin IV push and increase Drip Rate by 1 unit/hour

Give 2 u insulin IV push and increase Drip Rate by 2 unit/hour

Give 2 u insulin IV push and increase Drip Rate by 3 unit/hour

Give 2 u insulin IV push and increase Drip Rate by 4 unit/hour

Give 2 u insulin IV push and increase Drip Rate by 5 unit/hour

Call Physician for New Order

 181-240 mg/dl

Give 3 u insulin IV push and increase Drip Rate by 1 unit/hour

 Give 3 u insulin IV push and increase Drip Rate by 2 unit/hour

 Give 3 u insulin IV push and increase Drip Rate by 3 unit/hour

Give 3 u insulin IV push and increase Drip Rate by 4 unit/hour

Give 3 u insulin IV push and increase Drip Rate by 5 unit/hour

Call Physician for New Order

241-300 mg/dl

Give 5 u insulin IV push and increase Drip Rate by 1 unit/hour

 Give 5 u insulin IV push and increase Drip Rate by 2 unit/hour

 Give 5 u insulin IV push and increase Drip Rate by 3 unit/hour

Give 5 u insulin IV push and increase Drip Rate by 4 unit/hour

Give 5 u insulin IV push and increase Drip Rate by 5 unit/hour

 Call Physician for New Order

301-360 mg/dl

Give 8 u insulin IV push and increase Drip Rate by 2 unit/hour

 Give 8 u insulin IV push and increase Drip Rate by 3 unit/hour

 Give 8 u insulin IV push and increase Drip Rate by 4 unit/hour

Give 8 u insulin IV push and increase Drip Rate by 5 unit/hour

Give 8 u insulin IV push and increase Drip Rate by 6 unit/hour

 Call Physician for New Order

361-420 mg/dl

Give 10 u insulin IV push and increase Drip Rate by 2 unit/hour

 Give 10 u insulin IV push and increase Drip Rate by 3 unit/hour

 Give 10 u insulin IV push and increase Drip Rate by 4 unit/hour

Give 10 u insulin IV push and increase Drip Rate by 5 unit/hour

Give 10 u insulin IV push and increase Drip Rate by 6 unit/hour

 Call Physician for New Order

>420 mg/dl

Call Physician for New Order

 Call Physician for New Order

 Call Physician for New Order

Call Physician for New Order

Call Physician for New Order

 Call Physician for New Order

LOOK UP TABLES FOR "AGGRESSIVE" INSULIN DRIP PROTOCOL

Give 3 u insulin IV push and increase Drip Rate by 3 unit/hour

Glucose Control NYNY

slide48

Plan

Use an ‘adopted’ insulin drip protocol to control the glucose in ‘one’ hyperglycemic patient for “one” shift keeping the level between 60 and 150 mg/dl as measured at the bedside.

Glucose Control NYNY

slide49

Do

  • Use the protocol on one patient
  • for one Shift
  • Record
      • insulin drip changes
      • amount and timing of insulin boluses
      • the blood glucose levels
      • the time the glucoses were done
  • Document whenever the protocol was not followed and the time and reason for the protocol violation.

Glucose Control NYNY

slide50
Study
  • The protocol resulted in two incidents of mild hypoglycemia.
  • After the hypoglycemia the nurse violated the protocol when the glucose was dropping rapidly by reducing the incremental drip change and omitted bolus to avoid this complication.
  • The protocol was ambiguous in a few places that the nurse felt could lead to mistakes.
  • The protocol was very effective at reducing the glucose to below the 150 mg/dl range.

Glucose Control NYNY

slide51

Act

  • After discussion the protocol was modified to be less aggressive
  • The areas of ambiguity in the protocol were removed
  • Team is ready to plan next small test

Glucose Control NYNY

slide52

Plan

Use the ‘modified’ insulin drip protocol to control the glucose in ‘two more’ hyperglycemic septic patient keeping the level between 60 and 150 mg/dl as measured at the bedside.

Glucose Control NYNY

slide54

1. Frontline

Engagement

6. Clear

Communication

2. Scripted

Processes

Requisite for

Sustainable

Improvement

3. Reliable

Execution

5. Scientific

Change Process

4. Organizational

Learning

Terry P. Clemmer, MD

LDS Hospital

glucose control taking it beyond the icu

Glucose Control:Taking It Beyond the ICU

Bruno DiGiovine, MD

Henry Ford Hospital

Detroit, MI

Terry P. Clemmer, MD

Intermountain Healthcare

Salt Lake City, UT 84143

Glucose Control NYNY

overview
Overview
  • Review General Thinking about Insulin Delivery
  • Review a Protocol from Georgetown University
  • Review Protocol from Intermountain Health

Glucose Control NYNY

new thinking
New Thinking
  • Hospitalized Patients are constantly changing.
    • Changing Levels of Stress Hormones & Cytokines
    • Changing Medications that Influence Glucose
    • Changing Glucose Intake
    • Changing Organ Function
  • One Size Does Not Fit All or Even the Same Patient From Day to Day

Glucose Control NYNY

slide60

87 year old 100 kg male admitted with colo-rectal adenocarcinoma for elective surgery

46 year old 53 kg female admitted for worsening pneumonia and sepsis

Glucose Control NYNY

new thinking1
New Thinking
  • Traditional Sliding Scales are Inadequate and Even Dangerous
  • Different Scenarios Require Different Regimens of Insulin
    • NPO/D5W only patient
    • TPN Patient
    • Enteral Feeding Patient
    • Oral Feeding Patient
    • Diabetic Versus Non-Diabetic

Glucose Control NYNY

new thinking2
New Thinking
  • Patient Must Be Evaluated and Insulin Needs Assessed and Reordered Daily
  • This Can Be a Stopper Because It Adds Burden to Physician Work Load and Many Physicians Do Not Know How to Do This
  • New Ways to Accomplish This Task Will Need to Be Found
    • Computer Aided Ordering
    • Use Special Glucose Control Teams
    • Use Clinical Pharmacy as the Specialists

Glucose Control NYNY

new thinking3
New Thinking
  • Do Away with the Term Sliding Scale Insulin
  • Use Basal Insulin To Meet Patients Intrinsic Glucose Needs
  • Use Carbohydrate Ratio to Cover Extrinsic (Ingested, IV or Enteral) Carbohydrates
  • UseaCorrection Factor To Cover Hyperglycemia Problems

Glucose Control NYNY

definition of insulin needs
Definition of Insulin Needs
  • Basal Insulin
    • Insulin required per unit time to prevent unchecked gluconeogenesis and ketogenesis
  • Nutritional Insulin
    • Insulin required to cover ingested/infused glucose
  • Correction-dose (“supplemental”) Insulin
    • Insulin used to treat hyperglycemia

Clement et al. Diabetes Care 2004; 27(2): 553.

Glucose Control NYNY

total daily dose
Total Daily Dose
  • Total amount the patient received the day before. (Best Way). It Takes Into Account the Patient’s Changing Stress Factors

or

  • Amount the patient takes as an outpatient

or

  • Weight based. (least accurate)
    • Type I: 0.5 – 0.7 units/kg/day
    • Type II: 0.4 – 1.0 units/kg/day

Clement et al. Diabetes Care 2004; 27(2): 553.

Glucose Control NYNY

basal insulin
Basal Insulin
  • It Represents the Basal Needs That Covers Glucose Made Intrinsically By the Liver
  • Every Hyperglycemic Patient Needs Basal Insulin
  • Determine Patients Total Daily Dose (TDD) from:
  • Basal Dose Is 40-50 % of Total Daily Dose Should Be Given as Long Acting Insulin (Lantus) once daily

1Davidson PC, et al. Statistically based CSII parameters: correction factor, CF (1700 rule), carbohydrate-insulin ratio, CIR (2.8 rule), and basal to total ratio [abstract]. Diabetes Technol Ther 2003; 5: 237.

Glucose Control NYNY

carbohydrate ratio
Carbohydrate Ratio
  • The Grams of Carbohydrate Covered By “ONE” Unit of Insulin(If the CHO Ratio is 15 then ideally 1 unit of insulin would cover 15 grams of carbohydrate)
  • Formula for Calculation of Carbohydrate Ratio 6.16 times Patient Wt. In Kg divided By TDD
  • Used to Cover Enteral Feedings as Regular Insulin Given q6h In Case Feedings Get Stopped
  • Used to Cover Meals By Doing Carbohydrate Counting. In this Case Aspart Insulin Is Used.

1Davidson PC, et al. Statistically based CSII parameters: correction factor, CF (1700 rule), carbohydrate-insulin ratio, CIR (2.8 rule), and basal to total ratio [abstract]. Diabetes Technol Ther 2003; 5: 237.

Glucose Control NYNY

correction factor
Correction Factor
  • The Term “ Sliding Scale” Should Disappear
  • The New Term Is “Correction Factor”
  • Calculation: Correction Factor = 1700/TDD
  • This Factor Is Used to Construct a Correction Factor Table That Changes With Patients Insulin Sensitivity

1Davidson PC, et al. Statistically based CSII parameters: correction factor, CF (1700 rule), carbohydrate-insulin ratio, CIR (2.8 rule), and basal to total ratio [abstract]. Diabetes Technol Ther 2003; 5: 237.

Glucose Control NYNY

pump groove formulae 1
Pump – Groove Formulae1

Basal

40-50% of TDD

Total Daily

Dose

(TDD)

Carb/Insulin

Ratio

6.16 x BW(kg)/TDD

Correction

Factor

1Davidson PC, et al. Statistically based CSII parameters: correction factor, CF (1700 rule), carbohydrate-insulin ratio, CIR (2.8 rule), and basal to total ratio [abstract]. Diabetes Technol Ther 2003; 5: 237.

1700/TDD

Glucose Control NYNY

basic rules
Basic Rules
  • Write Orders Daily
  • Standardize Process
  • Avoid Trailing Zeros & Write Out “Units”
  • Methods To Avoid Confusing Regular Insulin With Glargine (Lantus)
  • Investigation And Tracking Of Hypoglycemic Cases

Glucose Control NYNY

sample orders
Sample Orders

Glucose Control NYNY

sample orders1
Sample Orders

Yesterday, TDD was 50 units of insulin. Patient Eating.

25

X

X

10

10

10

X

Glucose Control NYNY

sample orders2
Sample Orders

Yesterday, TDD was 50 units of insulin.

Patient On Continuous Feeds.

25

X

X

6

X

X

Glucose Control NYNY

supplemental insulin
Supplemental Insulin

Glucose Control NYNY

special circumstances
Special Circumstances
  • NPO
    • Type I: Continue Basal Insulin
    • Type II: May be able to do without Basal I.
  • TPN
    • Add Regular insulin to bags to cover Basal and Prandial Needs
    • Each Day add 2/3 of supplemental insulin to daily bag

Glucose Control NYNY

special circumstances cont
Special Circumstances (cont)
  • Transitioning from IV to SQ
    • Give 40 -50% of TDD as Lantus
    • Turn off drip once glucose less than 70 mg/dl
  • Patients who are at risk for Hypoglycemia
    • Renal dysfunction
    • Cardiac dysfunction
    • Hepatic dysfunction
    • Elderly

Glucose Control NYNY

study of transitioning protocol versus using sliding scale
Study of Transitioning Protocol Versus Using Sliding Scale

Carlson R, Crit Care Med (Suppl) 2006; 34:A64 abst.

Glucose Control NYNY

demographics
Demographics

Glucose Control NYNY

capillary glucose values
Capillary Glucose Values

Glucose Control NYNY

average glucose values
Average Glucose Values

Glucose Control NYNY

results
Results

Glucose Control NYNY

patient transition example tube feeds
Patient Transition ExampleTube Feeds

Transition Day #13

Insulin Drip Protocol

Subcutaneous Insulin Protocol

Glucose Control NYNY

intensive insulin rx in critically ill patients

Intensive Insulin Rx in Critically Ill Patients

Van Den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinalde P, Lauwere P, Bouillon R.

Catholic University of Leuven,

Leuven Belgium

NEJM 2001; 345:1359-1367

Glucose Control NYNY

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