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Background: Three trials of tight glucose control (TGC) found clinical benefit of normalization of blood glucose levels in the intensive care unit (ICU). Implementation of TGC was imperfect in subsequent trials, since attained blood glucose levels (BGLs) never reached the targets as in the original trials of TGC. We investigated whether implementation of the TGC guideline as used in the original trials of TGC is feasible and safe., Methods: In this study 3 ICUs adopted and implemented the TGC guideline as used in the original trials of TGC using a multifaceted practice change strategy; 3 ICUs that did not change their blood glucose control guideline served as controls. TGC was practiced by physicians and nurses during the first 12-month (period-2), thereafter exclusively by nurses (period-3). Blood glucose metrics 12-month before (period-1) and 24-month after implementation of the guideline were compared., Results: The analysis included 1321 in period-1, 1169 and 1006 patients in period-2, and -3, respectively, in the intervention ICUs, and 3110 patients in the control ICUs. After implementation of the new TGC guideline, patients in intervention ICUs had lower median BGLs (105 [IQR: 85-130] mg/dL vs. 119 [99-150] mg/dL in period-1, P<0.001; and vs. 113 [95-141] mg/dL in control ICUs, P<0.001). The incidence of severe hypoglycemia initially increased, but again decreased when exclusively nurses practiced TGC, and was not associated with increased mortality or morbidity., Conclusions: Implementation of the original TGC guideline is feasible and safe. Our study suggests a learning effect over time.

Background: Hyperglycemia and glycemic variabilities are associated with adverse outcomes in critically ill patients. Blood glucose control with insulin mandates an adequate and precise assessment of blood glucose levels. Blood glucose levels, however, can change ex vivo after sampling. The aim of this study was to determine whether this phenomenon affects the practice of blood glucose control., Methods: We performed an observational study in a mixed medical-surgical intensive care unit (ICU). ICU nurses were the primary healthcare workers involved in the practice of blood glucose control, and they used an insulin-titration method and blood-sampling algorithm aimed at maintaining blood glucose levels between 5 to 8 mmol/L., Results: Blood glucose levels were measured directly after sampling, as well as after 30 and 60 minutes using the same samples. Blood glucose control algorithm recommendations were scored for each measurement. We collected 450 blood samples from 74 patients (median of 3 [2-8] samples per patient). The mean ex vivo changes in the blood glucose level were rather small (-0.1±1.6 mmol/L (range -1.4 to 0.7) and -0.2±1.6 mmol/L (range -1.3 to 0.5) at 30 and 60 minutes after sampling, respectively; P<0.05). An ex-vivo change in the blood glucose level hardly ever resulted in a change in algorithm recommendation (4% and 6% at 30 and 60 minutes after sampling, respectively). In most cases the algorithm advised a lower insulin infusion speed., Conclusion: Ex vivo changes in blood glucose levels, although statistically significant, seem clinically irrelevant.