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Intensive Insulin Therapy for Tight Glycemic Control Research Therapy Monitoring Nursing Proceedings from The Seventh Conference The CareFusion Center for Safety and Clinical Excellence June 7-8, 2007, San Diego, CA Philip J. Schneider, MS, FASHP, Editor Intensive Insulin Therapy for Tight Glycemic Control Research Therapy Monitoring Nursing Conference Report Published by The CareFusion Center for Safety and Clinical Excellence www.cardinalhealth.com/clinicalcenter International Conference on Intensive Insulin Therapy for Tight Glycemic Control The seventh invitational conference at the CareFusion Center for Safety and Clinical Excellence in San Diego, held June 7-8, 2007, brought together a distinguished faculty from clinical practice, academia, and organizations. Judith Jacobi, PharmD, FCCM, FCCP, BCPS, Critical Care Pharmacist, Methodist Hospital/Clarian Health, Indianapolis, IN and Timothy S. Bailey, MD, FACE, CPI, Advanced Metabolic Care and Research, Escondido, CA chaired the conference. Internationally recognized experts on research, current issues and opportunities in the use of intensive insulin therapy for tight glycemic control (TGC IIT) presented. This conference report summarizes the information presented on TGC IIT with regard to research findings, safety concerns, emerging practices, monitoring, and nursing issues as researchers and clinicians seek to optimize insulin therapy to help maintain normoglycemia in critically ill patients. The proceedings were edited by Philip J. Schneider, MS, FASHP, Clinical Professor and Director, Latiolais Leadership Program, College of Pharmacy, The Ohio State University, Columbus, OH. 7th Invited Conference: Intensive Insulin Therapy for Tight Glycemic Control Content Introduction p3 Tight Glycemic Control: Judith Jacobi, PharmD, FCCM, FCCP, BCPS An Overview Methodist Hospital/Clarian Health, Indianapolis, IN Timothy S. Bailey, MD, FACE, CPI Advanced Metabolic Care and Research Escondido, CA Research p4 A Brief History of Tight Glycemic Control: Tony Furnary, MD What We Know in 2007; and How We Got Here Starr-Wood Cardiac Group, Portland, OR p10 Intensive Insulin Therapy and the Simon Finfer, MBBS NICE-SUGAR Study Royal North Shore Hospital of Sydney, Australia p13 European Multi-center Trials with Tight Glucose Philippe Devos, MD Control by Intensive Insulin Therapy The George Institute of Liege, Belgium p17 Implementation of Tight Glycemic Control James Krinsley, MD at Stamford Hospital Stamford Hospital, Stamford, CT p21 Meta-analysis of Randomized Trials Anastassios G. Pittas, MD, MS of Tight Glycemic Control Tufts/New England Medical Center, Boston, MA p23 Perioperative Glucose Management Richard Prielipp, MD and IIT in The Operating Room University of Minnesota, Minneapolis, MN Douglas Coursin, MD Univertisty of Wisconsin, Madison,WI p26 Economic Advantages of Judi Jacobi, PharmD Tight Glycemic Control Methodist Hospital/Clarian Health, Indianapolis, IN Therapy p29 Intensive Insulin Therapy in the Robert Osburne, MD Intensive Care Unit Atlanta Medical Center, Atlanta, GA p33 Use of Computerized Algorithm in Patients Bruce Bode, MD Undergoing Cardiovascular Surgery: Atlanta Diabetes Associates, Atlanta, GA A Protocol for Tight Glycemic Control p36 Computerized Management of Pat Burgess, MD, PhD Tight Glycemic Control Carolinas Medical Center, Charlotte, NC p39 Analysis of Variation in Guy Soo Hoo, MD Insulin Protocols VA Hospital, Los Angeles, CA p43 Improving ICU Quality and Safety: Sean Berenholtz, MD Implications for Tight Glycemic Control Johns Hopkins, Baltimore, MD p47 Specialized Nutrition Support Kalman Holdy, MD and Glycemic Control Sharp Healthcare, San Diego, CA Executive Summary Conference Report 1 7th Invited Conference: Intensive Insulin Therapy for Tight Glycemic Control p50 Examining Medication Errors John Santell, MS Associated with Intravenous Insulin US Pharmacopeia, Washington, DC p53 The Portland-Vancouver Regional Chris Hogness, MD, MPH Inpatient Glycemic Control Collaborative Southwest Washington Medical Center Vancouver, WA p56 Building Transitions from the ICU to the Ward Greg Maynard, MD for the Hyperglycemic Patient: UCSD, San Diego, CA One Piece of the Puzzle Monitoring p59 Glucose Control and (Continuous) Christophe De Block, MD Glucose Monitoring in Critical Illness Antwerp University Hospital, Belgium p62 Glucose Sensor Technology: Timothy Bailey, MD Current State and Future Trends Advanced Metabolic Care and Research Escondido, CA p64 Assessing the Accuracy and Confounding Nam Tran, PhD (Candidate) Factors in Critical Care Glucose Monitoring UC Davis, Davis, CA p68 Glucose Sensor Augmented Insulin Delivery Jeffrey Joseph, DO in the Hospital: Open and Closed-Loop Methods T. Jefferson University, Philadelphia, PA Nursing p73 The Impact of Intensive Insulin Therapy Daleen Aragon, PhD, CCRN, FCCM on Nursing Orlando Regional, Orlando, FL p76 Nursing Education and Intensive Insulin Therapy Carol Manchester, MSN, APRN, BC-ADM, CDE University of Minnesota, Minneapolis, MN p79 Applying Glucometrics to Tight Jacqueline Thompson, MAS,RN,CDE Glycemic Control Sharp Healthcare, San Diego, CA Roundtable p81 Impact on Hospital Costs p81 Reasonable Target p82 Factors that Complicate Glycemic Control p82 Administrative Aspects of IIT p83 Risk of Hypoglycemia p84 Blood Glucose Measurement Appendix p85 Table. Major Published Randomized Controlled Anastassios G. Pittas, MD, MS Trials with Insulin Therapy in Critically Ill Patients Tufts/New England Medical Center, Boston, MA 2 Executive Summary Conference Report 7th Invited Conference: Tight Glycemic Control : An Overview INTRODUCTION Tight Glycemic Control: An Overview Judith Jacobi, PharmD, FCCM, FCCP, BCPS, Critical Care Pharmacist, Methodist Hospital/Clarian Health, Indianapolis, IN; Timothy S. Bailey, MD, FACE, CPI, Advanced Metabolic Care and Research, Escondido, CA More than five years ago the publication There is significant workload associated will no longer ignore blood glucose values of a landmark trial of intensive insulin therapy with frequent glucose monitoring. Point-of- as a mere epiphenomenon of critical illness. (IIT) that demonstrated a reduction in surgi- care (POC) testing is a component of nurse- Glycemic control is essential, although the cal critical care mortality led clinicians to seek titrated protocols. Current POC methodolo- optimal target remains a topic of discussion. to evaluate and improve glycemic control in gies are less precise and more expensive The IIT process will need to be computer- their practice. Many protocols were devel- than standard central laboratory methods. ized to provide the most consistent ability oped and implemented in critical care units Potential errors arise from faulty operator to follow complex dosing algorithms, and with varying degrees of effectiveness. The technique, inadequate sample volume and glucose monitoring will need to be far more first protocols were paper-based and varied artifacts due to the altered physiology in ICU automated. Closed-loop insulin titration and greatly in complexity. Computer support is patients (e.g., hypoxia or low hematocrit). continuous monitoring would be most desir- now being developed to make intravenous Subcutaneous continuous glucose monitor- able. (IV) insulin (considered a high-risk drug) safer ing technology is only approved for use in The CareFusion Center for Safety and and easier to use. outpatients. Research with glucose sensors Clinical Excellence hosted an international that may be used in critically ill patients is The benefits of insulin and glucose con- conference that brought together some ongoing. trol were not surprising to endocrinologists of the world’s leaders in glycemic control or cardiovascular surgeons. Early reports Although single-center clinical trials have research, therapy and monitoring to discuss showed that the use of insulin infusions to suggested a benefit to lowering glucose to the latest findings in this area. Summaries of improve glucose control was associated with 80-110 mg/dL, a recent multi-center trial was their presentations and the spirited roundta- prevention of deep sternal wound infections stopped well before the target enrollment ble discussion that concluded the conference and lower mortality. Subsequent studies have because of safety concerns. A large, multi- are compiled in this monograph. added evidence to support the use of IIT center trial (NICE-SUGAR) is underway by the We hope that our readers will recognize to reduce morbidity and mortality in criti- Australia-New Zealand Critical Care Clinical the value of this information and experi- cally ill patients, including a subset of medi- Trials group with results expected in 2008. ence with IIT and that future systems can be cal patients who remain in the intensive care Without more large, prospective trials, ques- designed to achieve optimal safety and effi- unit (ICU) more than three days. Clinicians tions will remain about the optimal (both safe cacy. We wish to express our sincere thanks still struggle to provide IIT to achieve and effective) glucose endpoint. to CareFusion for their commitment to medi- near-euglycemia without causing hypogly- With regard to the future it is clear that cation safety and their sponsorship of this cemia. no matter what research will reveal, clinicians program. Executive Summary Conference Report 3 7th Invited Conference: A Brief History of Tight Glycemic Control: What We Know in 2007; and How We Got Here PROCEEDINGS A Brief History of Tight Glycemic Control: What We Know in 2007, and How We Got Here Tony Furnary, MD, Starr-Wood Cardiac Group, Portland, OR patient)
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