Pathway for the management of hyperglycemia in critical care units

Inhospital morbidity and mortality are increased in hyperglycemia. Normalization of blood glucose levels using intensive insulin infusion protocols improves clinical outcomes. Insulin infusion algorithms have been shown to be safe and effective; however, a major obstacle in their implementation is their complexity. We have developed a novel pathway for the management of hyperglycemia, which introduces the "wheel" concept for insulin dosing complemented by "catchup" insulin dosing. The "wheel" serves as a treatment guide. It is made up of 4 concentric circles. The inner circle features blood glucose ranges and the 3 outer circles correspond to increasing rates of insulin infusion. Simple guidelines are provided to facilitate conversion from insulin infusion to a subcutaneous insulin-delivery regimen in preparation for transfer from the critical care unit setting. Our protocols eliminate reliance on the familiar "sliding scale" insulin administration schemes with the introduction of "catchup" insulin dosing to supplement the basic regimen. This pathway is comprehensive yet simple and provides guidelines for treatment of hyperglycemia for all patients screened to a critical care unit or to a stepdown unit.