Outcome of cardiothoracic Intensive Care Web Based Online Intravenous Insulin Infusion Calculator Study at a Medical University Hospital Ppt Powerpoint Presentation slides Hermayer M.D., Kathie L Medical Slideshow Calculator Study at a Medical University Hospital

Outcome of cardiothoracic Intensive Care Web Based Online Intravenous Insulin Infusion Calculator Study at a Medical University Hospital

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Notes

Show Notes

Slide 1 :

Slide 2 :

Purpose of MUSC IVIIC Study To examine whether a web-based, on-line intravenous insulin infusion calculator (IVIIC) program for delivery of IV insulin therapy in coronary artery bypass graft (CABG) patients was superior to a prior intravenous insulin (IVI) protocol used in the cardiothoracic intensive care unit (CTICU) at our institution.

Slide 3 :

Background

Slide 4 :

Improved patient outcomes and survival from tight control with intravenous insulin (IVI) Clement S, Braithwaite SS, Magee MF, Ahmann A,Smith EP, Schafer RG, Hirsch IB: Management of diabetes and hyperglycemia in hospitals. Diabetes Care.2004;27:553–591. Garber AJ, Moghissi ES, Bransome ED Jr, Clark NG,Clement S, Cobin RH, Furnary AP, Hirsch IB, Levy P, Roberts R, Van den Berghe G, Zamudio V: American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract 2004;10:77–82. Krinsley JS: Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc 2003;78:1471–1478. Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R: Intensive insulin therapy in the medical ICU. N Engl J Med 2006;354:449–461. Van den Berghe G, Wouters P, Weekers F, VerwaestC, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R: Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345:1359–1367. Zerr KJ, Furnary AP, Grunkemeier GL, Bookin S, Kanhere V, Starr A: Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg 1997;63:356–361.

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Portland Diabetic Project (n=5510) goal 150-200mg/dL (1992) with a gradual decrease to 70-110mg/dL at the end of the study IVI protocol until morning day 3 postop 75% reduction in cardiac related mortality for diabetic patients undergoing CABG 77% reduction in deep sternal wound infection (p<0.0001) Furnary, AP et al, Ann Thorac Surg 1997;63:356-361

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DIGAMI Diabetes and Insulin Glucose Infusion in Acute Myocardial Infarction Study (n=620) Insulin-glucose infusion to achieve goal of <200mg/dL, followed by subcutaneous insulin therapy for 3 or more months Increased long term survival after average of 3.4 years 28% mortality risk reduction Malmberg K. BMJ 1997;314:1512–1515 Malmberg K, et. al, J Am Coll Cardiol 1995;26:57–65

Slide 7 :

Methods

Slide 8 :

Medical University of SC MUSC Hospital Diabetes Task Force (HDTF) January 2005 Multidisciplinary team: physicians, nurses, pharmacists, dieticians, etc. Goal: to improve insulin infusion protocol in CT ICU for CABG patients to maintain BG 80-120mg/dL Objective: compare outcomes from on-line web-based IVIIC with previous IVI nomogram protocol* in same unit *developed after the initial intensive insulin study by: Van den Berghe et al, NEJM 2001;345:1359-1367 Ref: Clayton SB, et. al, Crit Care Med 2006;34:2974–2978

Slide 9 :

Desirable protocol characteristics identified by MUSC HDTF Easy physician ordering: requiring only a signature Ability to reach and maintain target BG quickly Minimal risk for hypoglycemic events Adaptability for various hospital settings Acceptance and implementation by nursing staff Minimal complexity of calculations for nursing, ultimately reducing errors in rate adjustments Davidson PC, et. al, Diabetes Care 2005;28:2418–2423

Slide 10 :

“Multiplier” protocol used for the MUSC on-line IVIIC Originator White et al. and used by Amarillo Medical Specialists (TX), Dr. Joseph B. Hawkins (Fresno, CA), and the Georgia Hospital Association (all based on the Atlanta Diabetes Associates Protocol) White NH, et. al, Ann Intern Med 1982;97:210–213 Davidson P, et. al, [abstract]. Diabetes 1986;35:126 Bode B, et. al, [abstract]. Diabetes 1999;48:A0519

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“Multiplier” IVI protocol IVI rate is changed based on a formula that uses a “multiplier”: a surrogate for an insulin sensitivity factor and the difference between a measured blood glucose (BG) and a target blood glucose (TBG) Rate of insulin infusion/hour = (current BG – 60 mg/dL) x 0.03 (multiplier)

Slide 12 :

“Multiplier” protocol cont’ allows enough insulin be infused to address severe hyperglycemia at initiation with a rapid reduction in infusion rate as BG normalizes. permit adjustment of insulin infusion rate by 0.1 units/hr to maintain BG in the center of target range differences in protocols is starting multiplier

Slide 13 :

Calculator and Order Set Parameters TBG: 80–120 mg/dL • Start infusion for a random BG 120 mg/dL • Infusion is 250 units of regular insulin/250mL of 0.9% NaCl • Use a multiplier of 0.03

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BG is checked hourly to every 2 h (or more frequently), and the IVIIC recalculates the infusion rate as follows:

Slide 15 :

Hypoglycemia treatment directed by IVIIC

Slide 16 :

IVIIC directs nurse to set infusion rate to zero at a BG of 65mg/dL MUSC IVIIC

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Slide 18 :

Figure 2, page 529. Image of the web interface for the IVIIC

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Study Inclusion 97 CABG patients studied: 10/04-2/05 pre-protocol (T2DM) 10/05-2/06 post-protocol (+/- T2DM)

Slide 20 :

Results of MUSC IVIIC Study

Slide 21 :

TABLE 1. DEMOGRAPHIC DATA FOR THREE COHORTS PRE- AND POST-PROTOCOL IVIIC

Slide 22 :

TABLE 2. COMPARISON OF BG OUTCOMES FOR THREE COHORTS PRE- AND POST-PROTOCOL IVIIC DURING THE FIRST 48 H POSTOPERATIVELY

Slide 23 :

TABLE 2 (cont’). COMPARISON OF BG OUTCOMES FOR THREE COHORTS PRE- ANDPOST-PROTOCOL IVIIC DURING THE FIRST 48 H POSTOPERATIVELY

Slide 24 :

TABLE 2 (cont’). COMPARISON OF BG OUTCOMES FOR THREE COHORTS PRE- ANDPOST-PROTOCOL IVIIC DURING THE FIRST 48 H POSTOPERATIVELY *HGI – hyperglycemic index, measurement of mean glucose level above120mg/dL

Slide 25 :

FIG. 3. TBG achievement. Comparison of percentage reaching TBG per hour during the first 24 h postoperatively between IVI pre-protocol (with type 2 diabetes) and web-based on-line IVIIC program (©2005 MUSC) post-protocol (with types diabetes and without type 2 diabetes): pre-protocol, type 2 diabetes, on infusion (?); post-protocol, types2 diabetes (¦); and post-protocol, no history of type 2 diabetes (?). pre-protocol, type 2 diabetes post-protocol type 2 diabetes post-protocol, no history of diabetes

Slide 26 :

Summary successful implementation of web based on line IVIIC at MUSC for CTICU CABG patients to maintain BG 80-120mg/dL efficient and significant improvement in overall in-hospital glycemic control w/o significantly increasing hypoglycemia validation of MUSC protocol’s success based on safe BG control outcomes

Slide 27 :

Conclusions The IVIIC is a safe nurse-driven protocol with excellent BG outcomes

Slide 28 :

Acknowledgements Although this article does not include a discussion of any investigational or unlabeled use of a product associated with the following pharmaceutical companies, K.L.H. is participating in a clinical drug trial of Rimonabant with Sanofi-aventis and is on the speaker’s bureau for Eli Lilly, Sanofi-aventis, and Novartis, T.V.H. is on the speaker’s bureau for Sanofi-aventis, and P.C.A. is on the speaker’s bureau for Sanofi-aventis, Pfizer, and NovoNordisk.

	hermayer 1 Years ago. Category: Cardiology

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