Original articles
Improving glycemic control in the cardiothoracic intensive care unit: Clinical experience in two hospital settings

Presented in part as a poster at the American Diabetes Association’s 64th Scientific Sessions, Orlando, FL, June 4–8, 2004.
https://doi.org/10.1053/j.jvca.2004.08.003Get rights and content

Abstract

Objective: Recent studies suggest that strict perioperative glycemic control improves clinical outcomes after cardiothoracic surgery. However, optimal methods and targets for controlling blood glucose (BG) levels in this setting have not been established. Currently published intensive insulin infusion protocols (IIPs) have important practical limitations, which may affect their utility. In this article, the authors present their experience with a safe, effective, nurse-driven IIP, which was implemented simultaneously in 2 cardiothoracic intensive care units (CTICUs).

Design: Prospective cohort study.

Setting: Tertiary referral hospital and community teaching hospital.

Participants: CTICU patients.

Interventions: A standardized, intensive IIP was used for all patients admitted to both CTICUs. Hourly BG levels, relevant baseline variables, and clinical interventions were collected prospectively from the active hospital chart and CTICU nursing records.

Measurements and Main Results: The IIP was used 137 times in 118 patients. The median time required to reach target BG levels (100–139 mg/dL) was 5 hours. Once BG levels decreased below 140 mg/dL, 58% of 2,242 subsequent hourly BG values fell within the narrow target range, 73% within a “clinically desirable” range of 80 to 139 mg/dL, and 94% within a “clinically acceptable” range of 80 to 199 mg/dL. Only 5 (0.2%) BG values were less than 60 mg/dL, with no associated adverse clinical events.

Conclusions: The IIP safely and effectively improved glycemic control in 2 CTICUs, with minimal hypoglycemia. Based on prior studies showing the benefits of strict glycemic control, the implementation of this IIP should help to reduce morbidity and mortality in CTICU patients.

Section snippets

Methods

The Yale New Haven Hospital (YNHH) CTICU is an 18-bed unit located in a 944-bed tertiary care referral center in New Haven, CT. Sixty-three percent of YNHH CTICU patients are admitted for coronary artery bypass grafting (CABG), 18% for cardiac valve surgery, and 12% for a combined CABG-valve procedure. Thirty-one percent of patients admitted to the YNHH CTICU remain for less than 24 hours; 44% stay longer than 48 hours.

The Hospital of Saint Raphael’s (HSR) CTICU is a 16-bed unit located in a

Results

At the time of data analysis, the IIP had been used 137 times in 118 patients (YNHH, 81 infusions in 71 patients; HSR, 56 infusions in 47 patients). Baseline characteristics of the 118 IIP patients are shown in Table 1, including their primary reason for CTICU admission. Notably, YNHH and HSR patients were similar in most respects. YNHH patients had a somewhat greater severity of illness (APACHE II score), which was expected, given that YNHH is a tertiary care referral center. For all 118

Discussion

The authors’ intensive IIP was successful in improving BG levels in 2 CTICUs, with rare and clinically insignificant hypoglycemia. Importantly, the authors’ protocol was equally effective in a tertiary referral center and in a community teaching hospital. Additionally, because the IIP has previously been proven effective in medical ICU patients,5 the authors suspect that it could be applied in a variety of clinical settings. The generalizability of the IIP is one if its important strengths.

Acknowledgements

IIP implementation, data collection, data analysis, and manuscript review were assisted by Robert Sherwin, MD, Mark Siegel, MD, James Dziura, PhD, James McCabe, BS, Daniel Prince, BS, Surani Fernando, MD, Amy Nuernberg, MD, John Aversa Jr, DO, Odile Anderson, MSN., APRN, Jennifer Doward, MSN, RN, and Joshua Halickman. The authors are also indebted to the following cardiothoracic surgeons involved in this project: Peter Barrett, MD, Charles Beckman, MD, Michael Dewar, MD, John Elefteriades, MD,

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    Supported by fellowship training grants from the Juvenile Diabetes Research Foundation (File #3-2003-95) and from Eli Lilly and Company (Indianapolis, IN), and NIH General Clinical Research Center Grant RR125.

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