Trauma Service Line Insulin Protocols

Original Date: 05/2011 | Supersedes: 08/2017 | Last Review Date: 08/2021
Purpose: To optimize the control of blood glucose

Background

Hyperglycemia, as part of the stress response, is a commonly seen in the ICU. However, hyperglycemia, has been associated with ICU complications. In 2001, maintaining tight glucose control (BG 80-110 mg/dL)9 was shown to decrease mortality and many intensive care complications, however these results could not be duplicated. The incidence of hypoglycemia also was higher. Recently, conventional glucose control (BG < 180 mg/dL) was shown to have a significantly lower mortality and hypoglycemic rate compared to tight glucose control.10 The target BG value of 180 mg/dl was selected based upon common practices.

In critically ill trauma patients, admission blood glucose (BG) values > 200 mg/dL have been shown to be independent predictors of increased infections and mortality.1-3 BG values > 200 mg/dL during the initial week of ICU stay also have been shown to be independent predictors of infections, increased ventilator and ICU LOS and mortality.4-6 In patients with traumatic brain injuries, BG > 200 mg/dL, acidosis and hypercapnia are associated with a prolonged ICU stay, whereas BG > 200 mg/dL, hypothermia and hypotension are associated with increased mortality.8

High glucose variability has been associated with increased infections, prolonged ventilator and ICU LOS4-6 and increased mortality.4-7 Glucose variability in 4th quartile has been associated with significantly increased mortality whereas the 1st quartile had a significantly lower mortality.7

Using the NICE-SUGAR data, moderate (BG 41-70 mg/dL) and severe (BG ≤ 40 mg/dL) had significantly higher mortalities compared to patients without hypoglycemia. Also, the more times a patient experienced hypoglycemia increased the mortality risk.11

Basal insulin use has been shown to improve glucose control better than sliding scales alone in the non-critically ill diabetic patients. The use of basal insulin in the critically ill patient is common in order to wean insulin drips and/or decrease the use of sliding scales.

Management

Sliding Scale Monitoring

  1. Check FSBS Q4H.
  2. If FSBS < 60 mg/dL and patient has received any insulin in the past 24 hours, check FSBS Q2H until FSBS ³ 80 mg/dL, then resume Q4H FSBS.
  3. If FSBS > 60 and  £ 140 mg/dL and NO insulin has been administered x 48 hours, change FSBS to Q8H.
  4. If the patient requires insulin administration for 2 consecutive checks during the Q8H FSBS, change FSBS Q4H.
  5. Check FSBS q 30 minutes after administering D50W until FSBG >80 x 2 consecutive checks

Sliding Scale

FSBS 0-39 mg/dL = 1 amp D50W (50 ml) & call MD
FSBS 40-60 mg/dL = 0.5 amp D50W (25 ml) & call MD
61-149 mg/dL = 0 units Regular Insulin SQ
150-174 mg/dL = 5 units Regular Insulin SQ
175-199 mg/dL = 8 units Regular Insulin SQ
³ 200 mg/dL = 12 units Regular Insulin SQ*
*If 3 consecutive FSBS ³ 200 mg/dL, call MD & start insulin drip.

Insulin Drip

  1. Begin at 4 units/hr and titrate to maintain FSBS 150-199 mg/dL.
  2. Check FSBS Q1H.
  3. Discontinue drip if FSBS £ 140 mg/dL.
  4. Once drip rate is stable x 4 hrs, begin Q2H FSBS.

Basal Insulin

Patients requiring basal insulin, either to wean from insulin infusion or to decrease sliding scale requirements, NPH every 8 hours is be preferred.

***If patient experiences hypoglycemia consider discontinuing all insulin***

References

  1. Yendamuri, Saikrishma, et al. Admission Hyperglycemia as a Prognostic Indicator in Trauma. J Trauma 2003; 55:33-38.
  2. Laird, Amanda M, et al. Relationship of Early Hyperglycemia to Mortality in Trauma Patients. J Trauma 2004; 56:1058-1062.
  3. Sung, Jin et al. Admission Hyperglycemia is Predictive of Outcome in Critically Ill Trauma Patients. J Trauma 2005; 59:80-83.
  4. Bochicchio, Grant, et al. Persistent Hyperglycemia is Predictive of Outcome in Critically Ill Trauma Patients. J Trauma 2005; 58:921-924.
  5. Bochicchio, Grant, et al. Early Hyperglycemic Control is Important in Critically injured Trauma Patients. J Trauma 2007; 63:1353-1359.
  6. Scalea, Thomas, et al. Tight Glycemic Control in Critically Injured Trauma Patients. Ann Surg 2007; 246:605-612.
  7. Krinsely, James S, et al. Glycemic variability: A Strong Predictor of Mortality in Critically Ill Patients. Crit Care Med 2008; 36:3008-3013.
  8. Jeremitsky, Elan, et al. The Impact of Hyperglycemia on Patients with Severe Brain Injury. J of Trauma 2005; 58:47-50.
  9. Van Den Berghe, Greet, et al. Intensive Insulin Therapy in Critically Ill Patients. NEJM 2001; 345:1359-67.
  10. NICE-SUGAR: Intensive verses Conventional Glucose Control in Critically Ill Patients. NEJM 2009; 360:1283-97.
  11. NICE-SUGAR: Hypoglycemia and Risk of Death in Critically Ill Patients. NEJM 2012; 367:1108-18.