Use of Continuous Glucose Monitor in Critically Ill COVID-19 Patients Requiring Insulin Infusion: An Observational Study

Abstract

Context The coronavirus disease 2019 (COVID-19) pandemic has created a need for remote blood glucose (BG) monitoring in the intensive care unit (ICU). Objective To evaluate feasibility and patient safety of a hybrid monitoring strategy of point of care (POC) BG plus continuous glucose monitor (CGM) in the ICU. Design Retrospective analysis. Setting ICU of an academic medical center. Patients Patients with COVID-19 on intravenous (IV) insulin. Intervention After meeting initial validation criteria, CGM was used for IV insulin titration and POC BG was performed every 6 hours or as needed. Main Outcome Measures Outcomes included frequency of POC BG, workflow, safety, and accuracy measures. Results The study included 19 patients, 18 with CGM data, mean age 58 years, 89% on mechanical ventilation, 37% on vasopressors, and 42% on dialysis. The median time to CGM validation was 137 minutes (interquartile range [IQR] 114-206). During IV insulin, the median number of POC values was 7 (IQR 6-16) on day 1, and declined slightly thereafter ( 71% reduction compared to standard of 24 /day). The median number of CGM values used nonadjunctively to titrate IV insulin was 11.5 (IQR 0, 15) on day 1 and increased thereafter. Time in range 70-180mg/dl was 64+/-23% on day 1 and 72+/-16% on day 2-7 while time <70 mg/dl was 1.5 +/-4.1% on day 1 and <1% on days 2-7. Conclusions This study provides data to support that CGM using a hybrid protocol is feasible, accurate, safe, and has potential to reduce nursing and staff workload.

Continuous glucose monitoring in the hospital: an update in the era of COVID-19

“…Authors enrolled a total of 19 medical ICU patients requiring intravenous insulin managed by this protocol showing feasibility of this hybrid approach. Overall MARD was 13.9% ± 7.8% on day 1 and 13.5% ± 8.1% on days 2 through 7 with a 71% reduction in POC use [ 38 ▪▪ ].…”

“…Sensor insertion was done by a trained nurse, nurse practitioner or healthcare professional in most of the studies [ 35 – 37 , 38 ▪▪ , 39 , 42 , 43 ]. For the studies using Dexcom G6 system, glucose data was transmitted to Dexcom receivers [ 36 , 42 ], Android phones [ 38 ▪▪ ] or both iPad and iPhones [ 35 ] and were placed close to the patient's room. These receiving devices were within 10–20 feet from the transmitter to ensure Bluetooth transmission.…”

“…Other studies noted reduction in POC ranging between 50 and 63% [ 36 , 42 , 44 ▪ ]. While implementation of a hybrid CGM and POC protocol by Faulds et al was well received by nursing staff, there was unanimous consensus amongst them that the protocol was excessively lengthy [ 38 ▪▪ ]. Nursing staff also commented components for CGM use (i.e., receiver, phone, cords) and training materials were crowding their workstations.…”

Effect of Hyperglycemia on COVID-19 Outcomes: Vaccination Efficacy, Disease Severity, and Molecular Mechanisms

“…While insulin infusion has been shown to reduce mortality in COVID-19 patients [ 10 ], the use of continuous glucose monitoring (CGM) should also improve glucose variability, a phenomenon linked to an increased risk of death in ICU settings, also independently of COVID-19 and diabetes [ 8 , 47 ]. At least three studies have substantiated the usefulness of CGM in terms of feasibility, accuracy, meaningful reduction in the frequency of glucose testing, and possibly also in terms of increased time-in-range in COVID-19 patients in the ICU [ 48 , 49 , 50 ]. However, whether CGM improves hard outcomes in COVID-19 patients is unknown.…”

A continuous intravenous insulin infusion protocol to manage high-dose methylprednisolone-induced hyperglycemia in patients with severe COVID-19

“…Many patients with severe COVID-19 have impaired glucose tolerance [ 5 , 6 ], and steroid therapy is one of the standard treatments [ 7 ], thus making control of blood glucose important in the ICU. A glycemic control protocol for COVID-19 has been reported as a sliding scale for subcutaneous injection of insulin [ 8 ], and continuous insulin infusion adjustments were also reported in some studies of small numbers of patients undergoing continuous glucose monitoring [ 9 , 10 ]. Continuous intravenous insulin infusion is the best method for achieving glycemic targets in the critically ill patient [ 11 ], and several infusion protocols for ICU patients that included computer-guided management were reported previously [ 12 – 17 ].…”