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Objectives:We present the case of a 66-year-old woman who developed hypoglycemia following the prolonged infiltration of a high dose continuous peripheral IV insulin infusion.Study Selection:Case report.Data Sources and Extraction:PubMed was searched for relevant literature on exogenous hyperinsulin

This article describes the unique practice of nurse-driven titration of continuous insulin infusion in post-cardiac surgery patients in the intensive care unit at a tertiary care teaching hospital. A prospective quality assurance study was conducted to support our innovative practice.

To provide an update on the currently available insulin infusion protocols for treatment of hyperglycemia in critically ill patients and to discuss the major differences and similarities among them.We identified a total of 26 protocols, 20 of which used manual blood-glucose calculations, and six that used computerized algorithms. The major differences and similarities among the insulin infusion protocols were in the following areas: patient characteristics, target glucose level, time to achieve target glucose level, incidence of hypoglycemia, rationale for adjusting the rates of insulin infusion, and methods of blood-glucose measurements. Several computerized protocols hold promise for safer achievement of glycemic targets.Insulin infusion is the most effective method for controlling hyperglycemia in critically ill patients. Clinicians should utilize a validated insulin infusion protocol that is well tolerated, and is most appropriate and practical for their institution based on the resources that are available.

The objective of the quality assessment was to develop and evaluate a modified nurse-driven insulin infusion protocol for intensive care unit patients and compare the hours needed to achieve a targeted glycemic range and duration within a goal range (80-110 mg/dL) to that of our traditional protocol. With our modified nurse-driven protocol, the median time to reach the goal for patients with diabetes was 11.5 hours versus 21.5 hours with the traditional protocol. Patients without diabetes reached the goal in 8 hours with the modified-nurse driven protocol versus 12 hours with the traditional protocol. Percentage of time within the goal improved from 14.6% to 20.7% for patients with diabetes and from 7% to 24.3% for patients without diabetes.

Inhospital morbidity and mortality are increased in hyperglycemia. Normalization of blood glucose levels using intensive insulin infusion protocols improves clinical outcomes. Insulin infusion algorithms have been shown to be safe and effective; however, a major obstacle in their implementation is their complexity. We have developed a novel pathway for the management of hyperglycemia, which introduces the "wheel" concept for insulin dosing complemented by "catchup" insulin dosing. The "wheel" serves as a treatment guide. It is made up of 4 concentric circles. The inner circle features blood glucose ranges and the 3 outer circles correspond to increasing rates of insulin infusion. Simple guidelines are provided to facilitate conversion from insulin infusion to a subcutaneous insulin-delivery regimen in preparation for transfer from the critical care unit setting. Our protocols eliminate reliance on the familiar "sliding scale" insulin administration schemes with the introduction of "catchup" insulin dosing to supplement the basic regimen. This pathway is comprehensive yet simple and provides guidelines for treatment of hyperglycemia for all patients screened to a critical care unit or to a stepdown unit.

Hyperglycemia is associated with complications in the surgical intensive care unit. The purpose of this study was to determine the efficacy and safety of nurse-driven insulin infusion protocols in lowering blood glucose (BG) in critical illness.All patients in a 24-bed surgical intensive care unit who required i.v. insulin infusions during 3 noncontiguous 6-month periods from 2002 to 2004 were evaluated. In the preintervention phase, 71 patients received a physician-initiated insulin infusion without a developed protocol. They were compared with 95 patients who received a nurse-driven insulin infusion protocol with a target BG of 120 to 150 mg/dL and to 119 patients who received a more stringent protocol with a target BG of 80 to 110 mg/dL.There was a stepwise decrease in average daily BG levels, from 190 to 163 to 132 mg/dL (p0.001). The less stringent protocol decreased the time to achieve a BG level150 mg/dL from 14.1 to 7.4 hours compared with physician-driven management (p0.05) resulting in similar time on an insulin infusion (53 versus 48 hours). The more intensive protocol brought BG levels150 mg/dL in 7.2 hours and111 mg/dL in 13.6 hours, but increased the length of time a patient was on an insulin infusion to 77 hours. The incidence of severe hypoglycemia (BG40 mg/dL) was statistically similar between the groups, ranging between 1.1% and 3.4%.Implementation of a nurse-driven protocol led to more rapid and more effective BG control in critically ill surgical patients compared with physician management. Tighter BG control can be obtained without a significant increase in hypoglycemia, although this is associated with increased time on an insulin infusion.

Because maternal hyperglycemia during labor foretells neonatal hypoglycemia and subsequent neurodevelopmental impairment, aggressive control of intrapartum maternal plasma glucose levels has been proposed. Current guidelines recommend continuous low-dose insulin infusion for women with insul

Abstract This study evaluated both cardiac hemodynamic and metabolic effects of a graded intracoronary artery infusion of insulin in four normal and five obese anesthetized dogs. Dogs were anesthetized with isoflurane, a catheter was advanced under fluoroscopic guidance into the coronary sinus and great cardiac vein, and a 20-MHz 3F coronary Doppler catheter was advanced into either the mid left anterior descending or circumflex coronary artery. A graded intracoronary insulin infusion was administered (starting at 0.3 mU/min and doubling every 40 minutes until a maximum dose of 2.4 mU/min was achieved). Coronary glucose extraction, coronary blood flow velocity, and coronary artery size were measured at each infusion rate. An intracoronary artery infusion of insulin stimulated myocardial glucose uptake in normal dogs. However, in high-fat–fed dogs, weight gain was associated with a reduction in the ability of insulin to promote glucose uptake by cardiac muscle and a rightward shift in the dose-response curve. In normal dogs, an intracoronary insulin infusion resulted in an increase in coronary blood flow and coronary vasodilation (with insulin coronary vascular resistance index decreases to 0.72±0.06, P

Glycemic control is important not only in the antepartum period but in the intrapartum period as well. Nursing management of the patient receiving insulin infusion therapy can assist in prevention of maternal and newborn morbidity. Careful glucose monitoring, insulin infusion therapy, and skilled nursing management of these complex patients result in the prevention of maternal and fetal injury and ensure a positive childbirth experience.

Purpose The performance of an updated insulin infusion protocol was evaluated at a large, academic medical center. Methods A retrospective medical record review was performed after a one-month run-in period for all patients at a large, academic, tertiary care medical center in whom the insulin infusion per protocol was administered from January 1 through February 28, 2014. Data were evaluated to determine the median blood glucose (BG) level, time to achieve BG in the target range, number of BG checks per patient per day, time elapsed between each BG check, and the frequency of hypoglycemia (BG concentration of ≤70 mg/dL). Results A total of 170 patients were included. The median preinfusion BG was 244 mg/dL (interquartile range [IQR], 204–304 mg/dL), which decreased to a median of 168 mg/dL (IQR, 147.5–199.5 mg/dL) when the protocol was utilized. However, 70 patients (41%) had a median BG concentration of ≥180 mg/dL, and 25 patients’ (15%) BG value remained above 180 mg/dL. The median time to achieve the goal BG value was 4.2 hours (95% confidence interval, 3.2–5.1 hours). BG checks were performed a median of every 2.1 hours (IQR, 1.4–2.3 hours). Hypoglycemia was rare, occurring in only 2 (1.2%) patients. Conclusion The median BG with an updated insulin infusion protocol approached the upper limit of the target BG range, and 41% of patients had a median BG above the goal range. Protocol specifications for the frequency of BG monitoring were not commonly followed, but the frequency of hypoglycemia was extremely low.

PURPOSE OF REVIEW The publication of Van den Berghe's landmark study in 2001 supported the use of intensive insulin therapy (IIT) to target normoglycemia in the critically ill and triggered a new era in glycemic management in the perioperative period and in the ICU. In 2009, the normoglycemia in intensive care evaluation-survival using glucose algorithm regulation (NICE-SUGAR) trial demonstrated increased mortality and incidence of hypoglycemia in patients managed with IIT, resulting in a shift toward higher blood glucose targets in this patient population. This review distills clinically pertinent principles from the related literature published in the months since the NICE-SUGAR trial. RECENT FINDINGS A target blood glucose level in the acute care setting supported by many of the pertinent societies and frequently quoted in the literature is 140-180 mg/dl. Hyperglycemia, hypoglycemia, and glucose variability are detrimental. Accurate and efficient glucose monitoring devices are essential. Insulin infusion protocols (IIPs) employed to achieve desired blood glucose targets must be individualized and validated for the ICU and institution in which they are being implemented. SUMMARY Appropriate glycemic management in the acute care setting can be achieved by targeting a reasonable blood glucose range and employing specific and institutionally validated IIPs.

During 15 labours in diabetic women blood glucose concentrations were controlled with simultaneous infusion of insulin and glucose. The mean insulin infusion rate was between 1 and 2 U/h. No infant showed evidence of neonatal hypoglycaemia. The procedure is simple to use and may be carried out in any labour ward.