|The Dec 2003 Clinical Practice Guidelines of the Canadian Diabetes Association have recognized the crucial importance of tight glycemic control in times of severe stress such as in the immediate post heart attack (myocardial infarction) or post operative period in which intensive medical and nursing care is needed. The reductions in morbidity and mortality are so dramatic that it behooves us to implement tight glycemic control during these periods. The most effective way of achieving the glycemic control needed for improved outcomes is to use the continuous intravenous insulin infusion. Most acute cardiac events are initially treated in community hospitals. In large tertiary care hospitals, intensive insulin therapy in the management of acute coronary syndromes is standard of care. It is unacceptable for smaller community hospitals not to provide this evidence based standard. We; the front line soldiers, have to set up mechanisms by which we can render care to the standards of the CPG in our smaller communities.
Since we do not have full time ICU residents on site we need to develop simplified protocols that can be followed by nursing staff and will allow us to provide acceptable levels of care to our communities. Most community hospitals have protocols in place for treatment of hypoglycemia, heparin protocols or post clot lysis for the patient with MI. The implementation of a peri-ACS or peri-Operative Glycemic control protocol is no more complicated than what we are already doing in other areas.
Elements of a Successful Insulin Infusion Protocol
- Frequent monitoring: Blood glucose monitoring every hour initially and after an infusion rate changes, this can generally be progressively decreased to every 4 hours if and once blood glucose levels are stable.
- Set a standard starting dose (units per hour) with a standard insulin dilution (usually 10 units of regular insulin in 100 cc of normal saline) alternatively 1u/cc.
- Set target goals: these can be as tight as 4 7 mmol/L to 6 12 mmol/L depending on local staff’s availability and familiarity with the protocol and patients characteristics.
- Set procedures for either hypoglycemia or hyperglycemia. For hypoglycemia this should include prompt treatment with 15 grams of glucose for mild hypoglycemia either oral or IV and 25 grams of IV glucose or glucagon 1 mg for severe episodes. To avoid recurrence a decreased or suspension of insulin perfusion should be done. (See CDA CPG on treatment of hypoglycemia).
- Education of staff responsible for the application of the protocol. This is a major factor in the safety and efficacy of a successful protocol. Many hospitals already have such protocols each with their pro and cons. If developing a new protocol, individuals are encouraged to consult as many protocols as possible and adjust based on local resources and needs.
J. Robin Conway May 05