Abstract 3738: A Novel Critical Pathway for the Management of Hyperglycemia Facilitates a Rapid Intensive Glycemic Control in Critical Care Patients Without Causing any Hypoglycemic Episodes
Background: We have developed a simplified, novel pathway for the management of hyperglycemia for critical care patients. Our study aim was to show that implementation of this pathway would lead to rapid achievement of target blood glucose (BG) control without the risk of hypoglycemia.
Methods: This pathway incorporates two new concepts the “WHEEL” concept for insulin dosing, complemented by the notion of “Catch-up Insulin”. The WHEEL which serves as a treatment guideline is made up of four circles depicting the range of blood glucose; the innermost circle and three tiers of intravenous insulin infusion rates on the outer circles. The graphic WHEEL is then translated into a nursing work sheet, where critical care nurses are able to follow the protocol without any further assistance. 50 patients who were admitted to the cardiac care unit and intensive care unit were included in this study aiming for tight BG control ranging between 80 to 120 mg/dl for cardiac intensive care patients and 100 to 150 mg/dl for non-cardiac intensive patients.
Results: 29 patients were on the study Protocol (PG) (67±13 years, 51% males) and 21 patients served as control group (CG) (59±14 years, 42% males), managed with “standard” insulin drips adjusted based on physician determination prior to the pathway implementation, p=0.06. The mean initial BG was 318±120 mg/dl and 270±75 mg/dl, p=0.47, in the CG and PG respectively. The mean BG during treatment in the CG was 184±63 mg/dl compared to 133±18 mg/dl in the PG, p=0.001. Target blood glucose levels were reached within 11±8 hours in the CG and 6±1 hours in the PG p<0.007. The mean lowest BG readings in the CG were 58±24 mg/dl vs. 90±14 mg/dl in PG, p=0.0003. The incidence of symptomatic hypoglycemia was 0% in the PG compared to 61% in the CG, p<0.0001. Insulin drip had to be stopped in 71% of the CG patients Vs 17% of the PG, p<0.0002.
Conclusion: This study shows that our concept and implementation of the WHEEL is an easily applicable IV insulin protocol that can be managed by a Critical Care nurse and will facilitate the accomplishment of intensive glycemic control in all critical care patients without causing a significant number of hypoglycemic episodes.