A prospective randomized trial comparing computerized columnar insulin dosing chart (the Atlanta protocol) versus the joint British diabetes societies for inpatient care protocol in management of hyperglycemia in patients with acute coronary syndrome admitted to cardiac care unit in Alexandria, Egypt

Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024

“…The use of tools had no effect on critical patient outcomes including hospital mortality or ICU LOS (moderate certainty), ICU mortality or quality of life at 90 days (low certainty), or other important clinical outcomes, although certainty in these outcomes was downgraded due to inconsistency and imprecision. These findings were consistent across the five RCTs (85, 98–101) evaluating cardiac surgery patients (SDC 9-5 B , http://links.lww.com/CCM/H476).…”

“…We defined explicit clinical decision support tools as those that provide all the elements listed in Table 5 preferably with computerized support and interoperability of the tool with the EHR. We identified 13 RCTs (85, 90–101) (including five [85, 98–101] among cardiac surgery patients) that compared tools to conventional glycemic management protocols without tools ( SDC 9-5 , http://links.lww.com/CCM/H476). The addition of tools was associated with reduced episodes of moderate hypoglycemia, less than 3.3 mmol/L (60 mg/dL) (five RCTs [94–97, 101]; RR, 0.74; 95% CI, 0.57–0.98; moderate certainty), and more time within target range (MD, 14%; 95% CI, 8.85–19.06; 10 RCTs [85, 91, 92, 94–99]; moderate certainty).…”

“…The two most robust trials in critically ill children used adjunctive subcutaneous CGM monitoring for safety reasons (106, 109, 120). For comparison, in “adult” data, more frequent BG monitoring was associated with reduced frequency of hypoglycemia, < 2.2 to < 4.0 mmol/L (40–72 mg/dL) variably defined by the author (five RCTs [95–97, 101, 121]; moderate certainty), less time in hyperglycemic range (three RCTs; low certainty), and possibly reduced glycemic variability (three RCTs; moderate certainty). For these reasons, our panel members always employ frequent or continuous/near-continuous BG monitoring in pediatric patients on an insulin infusion.…”

“…Overall, the processes to manage hyperglycemia with an insulin infusion are similar between pediatrics and adults. On the basis of data from the adult ICU literature, in which use of clinical decision support tools reduced frequency of hypoglycemia (five RCTs [95–97, 101, 121]; moderate certainty) and increased time within target BG range (10 RCTs [85, 91, 92, 95–99, 121]; moderate certainty), the panel suggests the use of such tools where available and feasible (SDC 9-5 C , http://links.lww.com/CCM/H476). The key elements of an explicit decision support tool are listed in Table 5 and are discussed further in the adult section.…”

Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024: Executive Summary

“…While patient outcomes were prioritized for this guideline, the panel acknowledges that insulin titration protocols add to bedside caregiver cognitive burden and workload and could be minimized with a well-designed explicit decision support tool that directs treatment (65,66). Protocols incorporating these tools were associated with reduced frequency of moderate hypoglycemia less than 3.3 mmol/L (60 mg/dL) and greater proportion of BG values within the target range (45,50,(67)(68)(69)(70)(71)(72)(73)(74)(75)(76). There were no effects on other critical outcomes such as hospital mortality or ICU LOS (moderate certainty), ICU mortality or quality of life at 90 days (low certainty).…”