Pathway for the management of hyperglycemia in the cardiac care unit

Inpatient hyperglycemia has been associated with increased morbidity and mortality in critically ill patients. Optimal control of blood glucose (BG) levels using insulin infusion protocols has been shown to improve clinical outcomes. Protocols have been developed to prescribe a safe and effective rate of insulin infusion for optimal control of BG levels; however, a major obstacle in their implementation is their complexity. We have revised and updated our previously published pathway for the management of hyperglycemia, which introduces the "wheel" concept for insulin dosing. The "wheel" serves as a treatment guide. It is made up of 6 concentric circles. The core circle represents the goal of BG in critically ill patients, with inner circle showing the actual BG range of the patient. The 4 outer circles correspond to increasing rates of insulin infusion from tier 1 to tier 4. Simple guidelines are provided to facilitate conversion from insulin infusion to a subcutaneous insulin-delivery regimen in preparation for transfer from the cardiac care unit (CCU) setting. Our protocols also provide guidelines for management of diabetic ketoacidosis and hyperosmolar hyperglycemic states while at the same time creates a flowchart for activation of diabetes care team and their involvement in the multidisciplinary care of a patient in CCU with hyperglycemia and/or diabetes mellitus. This pathway provides a comprehensive and detailed, yet simple and practical algorithm for management of hyperglycemia in the CCU.