Hospital Pharmacy - April 2018 - 121

746418
research-article2017

HPXXXX10.1177/0018578717746418Hospital PharmacyHill et al

Article
Hospital Pharmacy
2018, Vol. 53(2) 121-124
© The Author(s) 2017
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https://doi.org/10.1177/0018578717746418
DOI: 10.1177/0018578717746418
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Incidence of Hypoglycemia in
Burn Patients: A Focus for
Process Improvement
David M. Hill1,2, Sean Lloyd2, and William L. Hickerson1,2

Abstract
Background: Glycemic control in burn patients is critical for reducing infection and mortality. Objective: This study was
conducted to assess the incidence and outcomes of hypoglycemia during continuous insulin infusions (CII). Methods: This
institutional review board-approved study was a retrospective, single burn center, electronic chart review. Patients admitted
between January 1, 2013, and October 31, 2014, who received a CII were included. Patients with incomplete data or who
received <24 hours of CII were excluded. Results: Thirty-eight patients met inclusion criteria; 6 were excluded. The average
patient was a 52-year-old Caucasian male with a 33% total body surface area burn and an acute physiology and chronic
health evaluation (APACHE) II score of 20.Hypoglycemia was present for 87 of 6540 hours of CII therapy (1.1%). Two-thirds
experienced a serum glucose <70 mg/dL and half <60 mg/dL. The most commonly assessed reasons for the hypoglycemic
episodes were protocol violations (47%) and glucose variability (30%). After multivariable logistic regression, only history
of diabetes remained a statistically significant risk factor with an odds ratio of 15.4 (95% confidence interval: 2.5-95.1). Four
different CII protocols were prescribed. All protocols had a high glucose variability, as assessed by hours / day within goal
range (13.1 ± 2.5, 14.1 ± 3.1, 14.3 ± 2.4, 9.8; P = .282). Conclusion: The amount of different protocols likely contributed
to protocol violations and glucose variability. Our data demonstrate the need to create and consolidate usage to a single
protocol in attempts to improve glycemic control.
Keywords
hypoglycemia, burns, insulin, blood glucose

Introduction
Adequate glycemic control is critical, yet difficult to
achieve after thermal injury. Burn patients have altered processes, physiological responses, and increased resistance to
insulin.1,2 Recommendations for blood glucose targets have
changed over time for intensive care patients, and evidence
exists to suggest benefit for a different target in thermal
injury. Intensive insulin therapy, targeting blood glucoses
between 81 and 108 mg/dL, was previously shown to
improve morbidity and mortality.3 However, subsequent
studies have correlated intensive insulin therapy with a
lower probability of survival due to more severe hypoglycemic (<40 mg/dL) events as compared with more conservative goals (<180 mg/dL).4
The role of intensive insulin therapy may best serve select
intensive care unit populations, such as cardiothoracic surgery, trauma, and burn.1,4-6 A target blood glucose less than
150 mg/dL in burn patients has been shown to achieve
desired reductions in infection mortality balanced with a
decreased incidence of hypoglycemia.1,5,7 Additional evidence exists on the timing of attaining adequate glycemic

control in burn patients with early control resulting in reductions in infectious complications and improved mortality.5,8
The purpose of this study is to assess and characterize the
glycemic control of critically ill burn patients at our institution and to determine whether further action needs to be
taken to better manage continuous insulin infusions (CII) in
these patients.

Materials and Methods
This study was a retrospective, single-center study and
received approval from 2 institutional review boards. Patients
were initially included if they were admitted to the burn
center between January 1, 2013, and October 31, 2014, and
1

Regional One Health, Memphis, TN, USA
The University of Tennessee, Memphis, TN, USA

Corresponding Author:
David M. Hill, Director of Burn Research, Firefighters Burn Center,
Clinical Pharmacist, Department of Pharmacy, Regional One Health,
877 Jefferson Avenue, Memphis, TN 38103, USA.
Email: dmhill@regionalonehealth.org

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