Computerized intensive insulin dosing can mitigate hypoglycemia and achieve tight glycemic control when glucose measurement is performed frequently and on time

Abstract

IntroductionControl of blood glucose (BG) in critically ill patients is considered important, but is difficult to achieve, and often associated with increased risk of hypoglycemia. We examined the use of a computerized insulin dosing algorithm to manage hyperglycemia with particular attention to frequency and conditions surrounding hypoglycemic events.MethodsThis is a retrospective analysis of adult patients with hyperglycemia receiving intravenous (IV) insulin therapy from March 2006 to December 2007 in the intensive care units of 2 tertiary care teaching hospitals. Patients placed on a glycemic control protocol using the Clarian GlucoStabilizer™ IV insulin dosing calculator with a target range of 4.4-6.1 mmol/L were analyzed. Metrics included time to target, time in target, mean blood glucose ± standard deviation, % measures in hypoglycemic ranges <3.9 mmol/L, per-patient hypoglycemia, and BG testing interval.Results4,588 ICU patients were treated with the GlucoStabilizer to a BG target range of 4.4-6.1 mmol/L. We observed 254 severe hypoglycemia episodes (BG <2.2 mmol/L) in 195 patients, representing 0.1% of all measurements, and in 4.25% of patients or 0.6 episodes per 1000 hours on insulin infusion. The most common contributing cause for hypoglycemia was measurement delay (n = 170, 66.9%). The median (interquartile range) time to achieve the target range was 5.9 (3.8 - 8.9) hours. Nearly all (97.5%) of patients achieved target and remained in target 73.4% of the time. The mean BG (± SD) after achieving target was 5.4 (± 0.52) mmol/L. Targeted blood glucose levels were achieved at similar rates with low incidence of severe hypoglycemia in patients with and without diabetes, sepsis, renal, and cardiovascular disease.ConclusionsGlycemic control to a lower glucose target range can be achieved using a computerized insulin dosing protocol. With particular attention to timely measurement and adjustment of insulin doses the risk of hypoglycemia experienced can be minimized.

Efficacy of an Insulin Infusion Treatment Protocol Administered in a Medical Intensive Care Unit

“…Son zamanlarda yapılan çalışmalar sık ve zamanında kan şekeri ölçümünün kan şekeri seviyesinin ayarlanmasının güvenliğini ve kalitesini iyileştirdiğini göstermiştir (27,28). Sürekli kan şekeri monitörizasyo-nu zamanında kan şekerini ölçmeyi sağlar.…”

Glucose management in the intensive care unit: are we looking for the right sweet spot?

“…Most studies of intensive insulin therapy are unblinded, and use protocols that allow considerable unnecessary variation in clinician management. The largest trial of intensive insulin therapy had high rates of clinician error contributing to hypoglycemia (10). Consequently, even studies that implement the same protocol are often limited by the high amount of clinician variation, which again limits generalizability.…”

The Future is Now: Software-Guided Intensive Insulin Therapy in the Critically Ill

“…These algorithms require little patient-specific information to initiate and allow for real-time adjustments, but they are intensive and may require 18 or more measurements a day. 23,37,38 One open-loop example of this type is the eProtocol-insulin algorithm. 39 Alternatively, the Glucose Regulation for Intensive Care Patients (GRIP) incorporates the derivate aspect of PID controls by using not only the glucose levels and insulin rates, but the change in those values over time.…”

“…Though a nascent field of study with few outcomes data, SG IIT appears to be tighter, faster, and less variable, with less hypoglycemia compared with paper-based IIT protocols. [23][24][25][26][27][28][29][30] Software algorithms can be divided into three groups. The simplest type of software is heuristic, converting paperbased protocols into a software program.…”