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The Impact of a Normoglycemic Management Protocol on Clinical Outcomes in the Trauma Intensive Care Unit

Bryan Collier, DO, Jose Diaz, Jr, MD, Rachel Forbes, BS, John Morris, Jr, MD, Addison May, MD, Jeffrey Guy, MD, Asli Ozdas, PhD^,||, William Dupont, PhD^*, Richard Miller, MD and Gordon Jensen, MD, PhD

^* Departments of Biostatistics and Medicine-Gastroenterology, Hepatology and Nutrition–Center for Human Nutrition, Section of Surgical Sciences, Division of Trauma and Surgical Critical Care, and ^|| Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee; and Vanderbilt University School of Medicine, Nashville, Tennessee

Correspondence: Bryan Collier, DO, Trauma Patient Care Center, Vanderbilt University Medical Center, 243 Medical Center South, 2100 Pierce Avenue, Nashville, TN 37212. Electronic mail may be sent to bryan.collier{at}vanderbilt.edu.

Background: The purpose of this study was to determine if protocol-driven normoglycemic management in trauma patients affected glucose control, ventilator-associated pneumonia, surgical-site infection, and inpatient mortality. Methods: A prospective, consecutive-series, historically controlled study design evaluated protocol-driven normoglycemic management among trauma patients at Vanderbilt University Medical Center. Those mechanically ventilated 24 hours and 15 years of age were included. A glycemic-control protocol required insulin infusion therapy for glucose >110 mg/dL. Control patients included those who met criteria, were admitted the year preceding protocol implementation, and had hyperglycemia treated at the physician's discretion. Results: Eight hundred eighteen patients met study criteria; 383 were managed without protocol; 435 underwent protocol. The protocol group had lower glucose levels 7 of 14 days measured. After admission, both groups had mean daily glucose levels <150 mg/dL. No difference in pneumonia (31.6% vs 34.5%; p = .413), surgical infection (5.0% vs 5.7%; p = .645) or mortality (12.3% vs 13.1%; p = .722) occurred between groups. If one episode of blood glucose level was 150 mg/dL (n = 638; 78.0%), outcomes were worse: higher daily glucose levels for 14 days after admission (p < .001), pneumonia rates (35.9% vs 23.3%; p = .002), and mortality (14.6% vs 6.1%; p = .002). One or more days of glucose 150 mg/dL had a 2- to 3-fold increase in the odds of death. Protocol use in these patients was not associated with outcome improvement. Conclusions: Protocol-driven management decreased glucose levels 7 of 14 days after admission without outcome change. One or more glucose levels 150 mg/dL were associated with worse outcome.

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Journal of Parenteral and Enteral Nutrition, Vol. 29, No. 5, 353-359 (2005)
DOI: 10.1177/0148607105029005353


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