Computer-assisted glucose control in critically ill patients

Abstract

Objective: Intensive insulin therapy is associated with the risk of hypoglycemia and increased costs of material and personnel. We therefore evaluated the safety and efficiency of a computer-assisted glucose control protocol in a large population of critically ill patients. Design and setting: Observational cohort study in three intensive care units (32 beds) in a 1,300-bed university teaching hospital. Patients: All 2,800 patients admitted to the surgical, neurosurgical, and cardiothoracic units; the study period started at each ICU after implementation of Glucose Regulation for Intensive Care Patients (GRIP), a freely available computer-assisted glucose control protocol. Measurements and results:We analysed compliance in relation to recommended insulin pump rates and glucose measurement frequency. Patients were on GRIP-ordered pump rates 97% of time. Median measurement time was 5 min late (IQR 20 min early to 34 min late). Hypoglycemia was uncommon (7% of patients for mild hypoglycemia, < 3.5 mmol/l; 0.86% for severe hypoglycemia, < 2.2 mmol/l). Our predefined target range (4.0-7.5 mmol/l) was reached after a median of 5.6 h (IQR 0.2-11.8) and maintained for 89% (70-100%) of the remaining stay at the ICU. The number of measurements needed was 5.9 (4.8-7.3) per patient per day. In-hospital mortality was 10.1%. Conclusions: Our computer-assisted glucose control protocol provides safe and efficient glucose regulation in routine intensive care practice. A low rate of hypoglycemic episodes was achieved with a considerably lower number of glucose measurements than used in most other schemes.

Computerization of the Yale Insulin Infusion Protocol and Potential Insights into Causes of Hypoglycemia with Intravenous Insulin

“…[18][19][20][21][22][23]26 These have revealed less hypoglycemia and improved adherence to the protocol. Other studies have demonstrated that even experienced clinicians following complex paper protocols often make critical mistakes that lead to unwarranted hypo-or hyperglycemic excursions.…”

“…[13][14][15][16][17][18][19] Several investigations have demonstrated that automation of ''paper'' protocols via insulin-dosing calculators can enhance compliance, reduce errors, and improve glucose control. [18][19][20][21][22][23] In the original Yale protocol articles, adherence to the published algorithm was not assessed. Accordingly, its reported metrics of glycemic control could never be assessed in the context of how precisely the protocol was actually followed.…”

Glycemic Control in the Burn Intensive Care Unit: Focus on the Role of Anemia in Glucose Measurement

“…Development of CGM technology 74,77 is underway to provide realtime near-continuous BG quantification, minimizing a concomitant increase in nursing workload requirements. 78 Several CDSS applications for insulin management are currently commercially available, [79][80][81][82] demonstrating reduced glycemic excursion and significantly fewer hypoglycemic events.…”

Effectiveness of the computerization of a YALE insulin infusion modified protocol in reducing the nursing workload in an Internal Medicine Department

“…At the same time, it reduces nursing workload, thereby improving efficacy and safety. [8][9][10][11] To our knowledge there is no evidence of these improvements in an internal medicine setting. This, Article in spite of the lack of appropriate nursing resources being the main limitation on the use of intravenous insulin protocols, which are therefore underused.…”