Target Attainment Through Algorithm Design During Intravenous Insulin Infusion

Devi, Radha; Zohra, Tatheer; Howard, Bradley S.; Braithwaite, Susan S.

doi:10.1089/dia.2013.0287

Cited by 10 publications

(18 citation statements)

References 29 publications

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“…Limited evidence suggests that the use of a protocol, whether based on national guidelines or individual institution-formed guidelines leads to a better adherence to key treatment principles and improved patient outcome (4, 12, 46, 72–77). …”

Section: Resultsmentioning

confidence: 99%

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

et al. 2017

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BackgroundDiabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs).ObjectiveTo review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes.MethodsOvid Medline searches were conducted with limits “all adult” and published between “1973 to current” applied. National consensus statements were also reviewed. Eligibility was determined by two reviewers’ assessment of title, abstract, and availability.ResultsA total of 85 eligible articles published between 1973 and 2016 were reviewed. The salient findings were (i) Crystalloids are favoured over colloids though evidence is lacking. The preferred crystalloid and hydration rates remain contentious. (ii) IV infusion of regular human insulin is preferred over the subcutaneous route or rapid acting insulin analogues. Administering an initial IV insulin bolus before low-dose insulin infusions obviates the need for supplemental insulin. Consensus-statements recommend fixed weight-based over “sliding scale” insulin infusions although evidence is weak. (iii) Potassium replacement is imperative although no trials compare replacement rates. (iv) Bicarbonate replacement offers no benefit in DKA with pH > 6.9. In severe metabolic acidosis with pH < 6.9, there is lack of both data and consensus regarding bicarbonate administration. (v) There is no evidence that phosphate replacement offers outcome benefits. Guidelines consider replacement appropriate in patients with cardiac dysfunction, anaemia, respiratory depression, or phosphate levels <0.32 mmol/L. (vi) Upon resolution of DKA, subcutaneous insulin is recommended with IV insulin infusions ceased with an overlap of 1–2 h. (vii) DKA resolution rates are often used as end points in studies, despite a lack of evidence that rapid resolution improves outcome. (viii) Implementation of DKA protocols lacks strong evidence for adherence but may lead to improved clinical outcomes.ConclusionThere are major deficiencies in evidence for optimal management of DKA. Current practice is guided by weak evidence and consensus opinion. All aspects of DKA management require RCTs to affirm or redirect management and formulate consensus evidence-based practice to improve patient outcomes.

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Section: Resultsmentioning

confidence: 99%

Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols

et al. 2017

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“…For a given MR, in a published method of assigning IR which we will call the "three segment method," the IR function utilized a different rule on each of three BG domains [23][24][25][26]. Additionally, there were rules for response to hypoglycemia with BG < 70 mg/dL.…”

Section: Insulin Infusion Rate (Ir) Under Progenitor Algorithmsmentioning

confidence: 99%

“…The three segments of the IR function were demarcated by two possible values for the variable BG, at which the function was not differentiable: the BG values marking the lower and upper limits of the target range. In the present work, the terms BG target_minus and BG target_plus replace terminology of earlier publications, in which the limits of the target range were designated as BG true_target and BG upper_target [25,26].…”

Section: Insulin Infusion Rate (Ir) Under Progenitor Algorithmsmentioning

confidence: 99%

“…A sigmoidal relationship between IR and BG may help achieve these goals. A prototype for the present work, developed as a set of three tabular algorithms, each having a different target range but created from a single mathematical design, has been implemented in clinical practice [23][24][25]. The specific objective of this paper is to address an essential step necessary to computerization.…”

Section: Introductionmentioning

confidence: 99%

“…"IR" will refer to the insulin infusion rate in units/hr for the next iteration of the algorithm. Previous publications referred to these values as BG current and IR next , respectively [24][25][26].…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

A Quadruply‐Asymmetric Sigmoid to Describe the Insulin‐Glucose Relationship during Intravenous Insulin Infusion

Braithwaite

Umpiérrez

Braithwaite

2014

Journal of Healthcare Engineering

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For hospitalized patients requiring intravenous insulin therapy, an objective is to quantify the intravenous insulin infusion rate (IR) across the domain of blood glucose (BG) values at a single timepoint. The algorithm parameters include low BG (70 mg/dL), critical high BG, target range BG limits, and maintenance rate (MR) of insulin infusion, which, after initialization, depends on rate of change of blood glucose, previous IR, and other inputs. The restraining rate (RR) is a function of fractional completeness of ascent of BG (FCABG) from BG 70 mg/dL to target. The correction rate (CR) is a function of fractional elevation of BG (FEBG), in comparison to elevation of a critical high BG, above target. IR = RR + CR. The proposed mathematical model describing a sigmoidal relationship between IR and BG may offer a safety advantage over the linear relationship currently employed in some intravenous glucose management systems.

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