Hyperglycemia During Acute Coronary Syndrome: A Nurse-Managed Insulin Infusion Protocol for Stricter and Safer Control

Background: Diabetic patients with acute coronary syndromes (ACS) might benefit from tight glycemic control by means of insulin infusion. Nurse-implemented insulin infusion protocols (IIP) are available but none validated in patients with ACS admitted to a coronary care unit (CCU). Aims: To assess feasibility, effectiveness and safety of a new nurse-managed IIP (Desio Diabetes Diagram, DDD) for intensive glucose control in patients with suspected ACS and known diabetes or blood glucose (BG) > 200 mg/dL. Methods and results: To reach and maintain a target BG level of 100–139 mg/dL we adopted a nomogram based on the percent changes in the insulin infusion rate according to the current BG value and the percent change from previous BG level. Ninety-one consecutive patients (53 men, mean age 69.7 ± 11.2 years) were treated with DDD IIP. Baseline BG was 202.2 ± 86.8 mg/dL. The median time to achieve the target was 3 h (Q1–Q3 2–5 h). Afterwards target BG levels were maintained for 70.4 ± 15.9% of the time. During 5004 h of insulin infusion BG never fell below 40 mg/dL. Conclusions: The nurse-managed DDD IIP was easily implemented in our CCU and permitted strict and safe glycemic control in hyperglycemic patients with ACS.

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Abstract 3529: Feasibility, Effectiveness and Safety of Intensive Glucose Control in Critically Ill Hyperglycemic Patients Hospitalized With Acute Coronary Syndromes

Circulation ◽

10.1161/circ.116.suppl_16.ii_799 ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Mikhail Kosiborod ◽

Silvio Inzucchi ◽

Mitchell Hamburg ◽

Lisa Riggs ◽

Sindhu Koshy ◽

...

Keyword(s):

Critically Ill ◽

Insulin Infusion ◽

Laboratory Data ◽

Female Gender ◽

Intensive Glucose Control ◽

Post Intervention ◽

Intravenous Insulin ◽

Coronary Syndromes ◽

Insulin Infusion Protocol ◽

Infusion Protocol

Background: Elevated blood glucose (BG) is associated with higher mortality and complications in patients (pts) hospitalized with AMI. While current ACC/AHA guidelines recommend “normalization” of BG in critically ill AMI pts, experience with implementation of intensive BG control protocols in this population is extremely limited. Methods: We implemented an intensive BG control protocol at the Mid America Heart Institute (MAHI) CCU beginning 08/2006, with the purpose of evaluating its feasibility, safety and effectiveness. All ACS patients with admission BG >140 mg/dL received a modified Yale-MAHI intravenous insulin infusion protocol, with a target BG range of 90–120 mg/dL. Demographic, clinical and laboratory data were abstracted from medical records of 94 consecutive pts that received the protocol (post-intervention), and compared with data on 138 consecutive ACS pts with admission BG >140 mg/dL hospitalized in CCU immediately prior to the protocol implementation (pre-intervention). Results: There were no significant differences between pre and post-intervention pts in age (64 vs. 66, p=0.2), female gender (40 vs. 39%, p=0.8), known diabetes (57 vs. 51%, p=0.3), or admission BG (218 vs. 203 mg/dL, p=0.13). Mean 24 hour BG was markedly reduced in post-intervention vs. pre-intervention pts (132 vs. 181 mg/dL, p<0.001). The protocol was very effective in both rapid attainment and maintenance of BG targets (Figure ). The rate of hypoglycemia (BG <60 mg/dL) was 0.72%, and none of the hypoglycemic events were symptomatic. Conclusions: Intensive BG control in critically ill ACS patients with the modified Yale-MAHI protocol is feasible, effective and safe.

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