1
|
Lalani B, Gosselin K, Penno R, Puryear B, Rilo H, Lalani A. A Retrospective Cohort Analysis of Two Computerized Insulin Infusion Protocols. J Diabetes Sci Technol 2023; 17:635-641. [PMID: 36946553 PMCID: PMC10210128 DOI: 10.1177/19322968231163584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVE The primary objective of this analysis was to compare the safety and efficacy of a novel computerized insulin infusion protocol (CIIP), the Lalani Insulin Infusion Protocol (LIIP), with an established CIIP, Glucommander. METHODS We conducted a 10-month retrospective analysis of 778 patients in whom LIIP was used (August 18, 2020 to June 25, 2021) at six HonorHealth Hospitals in the Phoenix metropolitan area. These data were compared with Glucommander that was used at those same hospitals from January 1, 2018 to August 17, 2020, n = 4700. Primary end points of the project included average time to euglycemia and average time in hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL). Additional subgroup analysis was done to evaluate CIIP performance in patients in whom maintenance of euglycemia was more challenging. RESULTS The LIIP had a faster time to euglycemia (191 vs 222 minutes, P < .001) and similar time in hypoglycemia (2.79 vs 2.76 minutes, P = .50) for all patients, when compared with Glucommander. Similar observations were made for the following subgroups: diabetic ketoacidosis/hyperosmolar hyperglycemic state (DKA/HHS) patients, COVID-19 patients, patients on steroids, patients with ≥60 glomerular filtration rate (GFR), patients with renal insufficiency, and patients with sepsis. CONCLUSIONS The LIIP is a safe and effective CIIP in managing intravenous insulin infusion rates. Utilization of LIIP resulted in reduced time to euglycemia, P < .001, when compared with Glucommander and did not cause increased hypoglycemia during the project period. Contributing factors to the success of LIIP may include improved clinical workflow, learnability and ease of use, compatibility with the Epic electronic health record (EHR), and its unique, dynamic and adaptive algorithm.
Collapse
Affiliation(s)
- Benjamin Lalani
- Johns Hopkins University, Baltimore, MD,
USA
- Pump Avenue Foundation, Scottsdale, AZ,
USA
| | - Kevin Gosselin
- HonorHealth Research Institute, Scottsdale,
AZ, USA
- AriTex, Chandler, AZ, USA
| | - Ruth Penno
- HonorHealth Hospitals, Scottsdale, AZ,
USA
| | | | - Horacio Rilo
- Advanced Biological Technologies, Long
Island, NY, USA
| | - Atul Lalani
- HonorHealth Hospitals, Scottsdale, AZ,
USA
- Endocrine Technologies, Scottsdale, AZ,
USA
- East Valley Endocrinology, Diabetes and
Metabolism, Scottsdale, AZ, USA
| |
Collapse
|
2
|
Faulds ER, Dungan KM, McNett M, Jones L, Poindexter N, Exline M, Pattison J, Pasquel FJ. Nursing Perspectives on the Use of Continuous Glucose Monitoring in the Intensive Care Unit. J Diabetes Sci Technol 2023; 17:649-655. [PMID: 37081831 PMCID: PMC10210097 DOI: 10.1177/19322968231170616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND The COVID-19 pandemic necessitated rapid implementation of continuous glucose monitoring (CGM) in the intensive care unit (ICU). Although rarely reported, perceptions from nursing staff who used the systems are critical for successful implementation and future expanded use of CGM in the inpatient setting. METHODS A 22-item survey focused on CGM use was distributed to ICU nurses at two large academic medical centers in the United States in 2022. Both institutions initiated inpatient CGM in the spring of 2020 using the same CGM+point of care (POC) hybrid protocol. The survey employed a 1- to 5-point Likert scale regarding CGM sensor insertion, accuracy, acceptability, usability, training, and perceptions on workload. RESULTS Of the 71 surveys completed, 68 (96%) nurses reported they cared for an ICU patient on CGM and 53% reported they had independently performed CGM sensor insertion. The ICU nurses overwhelmingly reported that CGM was accurate, reduced their workload, provided safer patient care, and was preferred over POC glucose testing alone. Interestingly, nearly half of nurses (49%) reported that they considered trend arrows in dosing decisions although trends were not included in the CGM+POC hybrid protocol. Nurses received training through multiple modalities, with the majority (80%) of nurses reporting that CGM training was sufficient and prepared them for its use. CONCLUSION These results confirm nursing acceptance and preference for CGM use within a hybrid glucose monitoring protocol in the ICU setting. These data lay a blueprint for successful implementation and training strategies for future widespread use.
Collapse
Affiliation(s)
- Eileen R. Faulds
- The Ohio State University College of Nursing,
Columbus, OH, USA
- The Ohio State University Wexner Medical
Center, Columbus, OH, USA
| | - Kathleen M. Dungan
- The Ohio State University Wexner Medical
Center, Columbus, OH, USA
- Division of Endocrinology, Diabetes and
Metabolism, Department of Internal Medicine, The Ohio State University College of Medicine,
Columbus, OH, USA
| | - Molly McNett
- The Ohio State University College of Nursing,
Columbus, OH, USA
- Implementation Science, Helene Fuld Health
Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio
State University College of Nursing, Columbus, OH, USA
| | - Laureen Jones
- Critical Care Nursing, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Norma Poindexter
- Division of Critical Care, Grady Health
System, Atlanta, GA, USA
| | - Matthew Exline
- Division of Critical Care Medicine, The Ohio
State University Medical Center, Columbus, OH, USA
| | | | - Francisco J. Pasquel
- Division of Endocrinology, Emory University
School of Medicine, Atlanta, GA, USA
| |
Collapse
|
3
|
Rovida S, Bruni A, Pelaia C, Bosco V, Saraco G, Galluzzo E, Froio A, Auletta G, Garofalo E, Longhini F. Nurse led protocols for control of glycaemia in critically ill patients: A systematic review. Intensive Crit Care Nurs 2022; 71:103247. [PMID: 35437186 DOI: 10.1016/j.iccn.2022.103247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Blood glucose control in critically ill patients is challenging and can affect clinical outcomes. Several manual as well as automated approaches have been proposed over the time, however nursing staff still covers the key-role for optimization of glycemia throughout adjustment of insulin infusion and administration. AIM Systematic review to compare the efficacy/the effects of nurse led insulin infusion protocols versus standard approaches in patients admitted in the intensive care unit. METHODS All relevant studies evaluating nurse directed protocols for insulin administration in critically ill adults. Data was independently extracted and collected through a dedicated electronic form. The following outcomes have been recorded: the number (or percentage) of glycaemia measurements within the target range; the number of hypo- and hyper-glycaemic events, separately; the mean glycaemia; the lowest and highest glycemia values recorded; the time to reach the glycaemia target; the ICU length of stay and the ICU and the long-term (>30 days) mortality. Statistical analysis was conducted on the summary statistics of the selected articles (eg, means, medians, proportions). Unpaired nonparametric continuous data were compared through the Mann-Whitney U-test. RESULTS Glycaemic control as well as ICU length of stay and mortality are similar in both patients' groups. Specifically, the group of patients treated with standard modalities include those treated with doctors led protocols, paper charts or software-based approaches. CONCLUSION Overall, nurse led insulin protocols can effectively control blood glucose level among critically ill patients.
Collapse
Affiliation(s)
- Serena Rovida
- Department of Emergency Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Andrea Bruni
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Corrado Pelaia
- Department of Health Sciences, Magna Graecia University, Catanzaro, Italy
| | - Vincenzo Bosco
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Giuseppe Saraco
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Erika Galluzzo
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Annamaria Froio
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Gaetano Auletta
- School of Nursing, Department of Translational Medicine, Eastern Piedmont University, Novara, Italy
| | - Eugenio Garofalo
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.
| |
Collapse
|
4
|
Efficacy and safety of a new insulin infusion protocol adapted for the target glycemic range of 140–180 mg/dl in adult critical care units: a tertiary care centre experience. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-020-00915-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
|
5
|
Zeitoun MH, Abdel-Rahim AA, Hasanin MM, El Hadidi AS, Shahin WA. 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. Diabetes Metab Syndr 2021; 15:711-718. [PMID: 33813246 DOI: 10.1016/j.dsx.2021.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Hyperglycemia in acute coronary syndrome (ACS) is linked to raised morbidity and mortality. Insulin administration using insulin infusion protocols (IIP) is the preferred strategy to control hyperglycemia in critically ill patients. To date, no specific IIP has been identified as the most efficient for achieving glycemic control. AIM to compare glycemic achievements (safety) (primary objective), and coronary and other clinical outcomes (efficacy) (secondary objective) by hyperglycemia management in Cardiac Care Unit (CCU) using computerized Atlanta Protocol (Group (I)) versus paper-based Joint British Diabetes Societies (JBDS) For Inpatient Care Protocol (Group (II)). PATIENTS AND METHODS The study was done on 100 ACS patients admitted to Alexandria Main University hospital CCU with RBG >180 mg/dL. They were randomized into the 2 groups in a 1:1 ratio. CBG was measured hourly for 72 hours and was managed by IV insulin infusion. RESULTS Group (I) showed statistically significant less mean time for target BG achievement (3.52 ± 1.53hours), lower incidence of Level 1 hypoglycemia (2%) than Group (II) (4.76 ± 2.33 hours, 22%, p = 0.013, 0.002 respectively) and statistically significant less mean number of episodes above the glycemic target after its achievement than Group (II) (p < 0.001). Regarding Level 2 hypoglycemia the difference was not significant statistically. CONCLUSION Both protocols successfully maintained target BG level with low incidence of clinically significant hypoglycemia, however, the computerized Atlanta protocol achieved better glycemic outcomes. We recommend the use of the computerized Atlanta protocol in CCU rather than JBDS for Inpatient Care Protocol whenever this is feasible.
Collapse
Affiliation(s)
- Mohamed H Zeitoun
- Department of Internal Medicine, Faculty of Medicine, University of Alexandria, Egypt
| | - Ali A Abdel-Rahim
- Department of Internal Medicine, Faculty of Medicine, University of Alexandria, Egypt
| | - Mahmoud M Hasanin
- Department of Cardiology and Angiology, Faculty of Medicine, University of Alexandria, Egypt
| | - Abeer S El Hadidi
- Department of Clinical and Chemical Pathology, Faculty of Medicine, University of Alexandria, Egypt
| | - Wafaa A Shahin
- Department of Internal Medicine, Faculty of Medicine, University of Alexandria, Egypt.
| |
Collapse
|
6
|
[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
7
|
Rao RH, Perreiah PL, Cunningham CA. Monitoring the Impact of Aggressive Glycemic Intervention during Critical Care after Cardiac Surgery with a Glycemic Expert System for Nurse-Implemented Euglycemia: The MAGIC GENIE Project. J Diabetes Sci Technol 2021; 15:251-264. [PMID: 33650454 PMCID: PMC8256075 DOI: 10.1177/1932296821995568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A novel, multi-dimensional protocol named GENIE has been in use for intensive insulin therapy (IIT, target glucose <140 mg/dL) in the surgical intensive care unit (SICU) after open heart surgery (OHS) at VA Pittsburgh since 2005. Despite concerns over increased mortality from IIT after the publication of the NICE-SUGAR Trial, it remains in use, with ongoing monitoring under the MAGIC GENIE Project showing that GENIE performance over 12 years (2005-2016) aligns with the current consensus that IIT with target blood glucose (BG) <140 mg/dL is advisable only if it does not provoke severe hypoglycemia (SH). Two studies have been conducted to monitor glucometrics and outcomes during GENIE use in the SICU. One compares GENIE (n = 382) with a traditional IIT protocol (FORMULA, n = 289) during four years of contemporaneous use (2005-2008). The other compares GENIE's impact overall (n = 1404) with a cohort of patients who maintained euglycemia after OHS (euglycemic no-insulin [ENo-I], n = 111) extending across 12 years (2005-2016). GENIE performed significantly better than FORMULA during contemporaneous use, maintaining lower time-averaged glucose, provoking less frequent, severe, prolonged, or repetitive hypoglycemia, and achieving 50% lower one-year mortality, with no deaths from mediastinitis (0 of 8 cases vs 4 of 9 on FORMULA). Those benefits were sustained over the subsequent eight years of exclusive use in OHS patients, with an overall one-year mortality rate (4.2%) equivalent to the ENo-I cohort (4.5%). The results of the MAGIC GENIE Project show that GENIE can maintain tight glycemic control without provoking SH in patients undergoing OHS, and may be associated with a durable survival benefit. The results, however, await confirmation in a randomized control trial.
Collapse
Affiliation(s)
- R. Harsha Rao
- Division of Endocrinology, Medicine
Service Line, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- R. Harsha Rao, MD, FRCP, Professor of
Medicine and Chief of Endocrinology, VA Pittsburgh Healthcare System, Room
7W-109 VAPHS, University Drive Division, Pittsburgh, PA 15240, USA. Emails:
;
| | - Peter L. Perreiah
- Division of Endocrinology, Medicine
Service Line, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Candace A. Cunningham
- Division of Endocrinology, Medicine
Service Line, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| |
Collapse
|
8
|
Kulasa K, Serences B, Nies M, El-Kareh R, Kurashige K, Box K. Insulin Infusion Computer Calculator Programmed Directly Into Electronic Health Record Medication Administration Record. J Diabetes Sci Technol 2021; 15:214-221. [PMID: 33118415 PMCID: PMC8256066 DOI: 10.1177/1932296820966616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Computerized insulin infusion protocols have demonstrated higher staff satisfaction, better compliance with protocols, and increased time with glucose in range compared to paper protocols. At University of California San Diego Health (UCSDH), we implemented an insulin infusion computer calculator (IICC) and transitioned it from a web-based platform directly into the electronic medication administration record (eMAR) of our primary electronic health record (EHR). METHODS This is a retrospective analysis of 6306 adult patients at UCSDH receiving intravenous (IV) insulin infusion from March 7, 2013 to May 30, 2019. We created three periods of the study-(1) the pre-eMAR integration period; (2) the eMAR integration period; and (3) the post-eMAR integration period-and looked at the percentage of readings within goal range (90-150 mg/dL for intensive care unit [ICU], 90-180 mg/dL for non-ICU) in patients with and without hyperglycemic emergencies. As our safety endpoints, we elected to look at incidence of blood glucose (BG) readings <70 mg/dL, <54 mg/dL, and <40 mg/dL. RESULTS Pre-eMAR 69.8% of readings were in the 90-150 mg/dL range compared to 70.2% post-eMAR (P = .03) and 82.7% of readings were in the 90-180 mg/dL range pre-eMAR versus 82.9% (P = .09) post-eMAR in patients without hyperglycemic emergencies. Rates of hypoglycemia with BG <70 mg/dL were 0.43%, <54 mg/dL were 0.07%, and <40 mg/dL were 0.01% of readings pre- and post-eMAR. CONCLUSIONS At UCSDH, our IICC has shown to be safe and effective in a wide variety of clinical situations and we were able to successfully transition it from a web-based platform directly into the eMAR of our primary EHR.
Collapse
Affiliation(s)
- Kristen Kulasa
- Division of Endocrinology, Diabetes and
Metabolism, University of California, San Diego, San Diego, CA, USA
- Kristen Kulasa, MD, University of California, San
Diego, 200 W Arbor Drive MC 8409, San Diego, CA 92103, USA.
| | - Brittany Serences
- Department of Nursing Education, Development
and Research, University of California, San Diego, San Diego, CA, USA
| | - Michael Nies
- Department of Information Services, University
of California San Diego Health, San Diego, CA, USA
| | - Robert El-Kareh
- Health Department of Biomedical Informatics,
University of California, San Diego, San Diego, CA, USA
| | - Kirk Kurashige
- Department of Information Services-Analytics,
University of California San Diego Health, San Diego, CA, USA
| | - Kevin Box
- Department of Pharmacy, University of
California, San Diego, San Diego, CA, USA
| |
Collapse
|
9
|
Shelden D, Ateya M, Jensen A, Arnold P, Bellomo T, Gianchandani R. Improving Hospital Glucometrics, Workflow, and Outcomes with a Computerized Intravenous Insulin Dose Calculator Built into the Electronic Health Record. J Diabetes Sci Technol 2021; 15:271-278. [PMID: 33355001 PMCID: PMC8256071 DOI: 10.1177/1932296820974767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To adjust for dynamic insulin requirements in critically ill patients, intravenous (IV) insulin infusions allow for titration of the dose according to a prespecified algorithm. Despite the adaptability of IV insulin protocols, human involvement in dose calculation allows for error. We integrated a previously validated IV insulin calculator into our electronic health record (Epic) and instituted it in the cardiovascular intensive care unit (CVICU). We aim to describe the design of the calculator, the implementation process, and evaluate the calculator's impact. METHOD Employing an aggressive training program and user acceptance testing prior to significant elbow support at the time of institution, we successfully integrated the insulin calculator in our CVICU. We evaluated the glucometrics before and after implementation as well as nursing satisfaction following calculator implementation. RESULTS Overall, our implementation led to increased frequency of blood sugar at various glycemic targets, a trend toward less hypoglycemia or hyperglycemia. For severe hypoglycemia, our preintervention cohort had 0.02% of blood sugars less than 40 mg/dL but no blood sugars less than 40 mg/dL were identified in our patient's postintervention. For the CVICU target blood glucose of 70-180 mg/dL, 87.97% blood sugars at baseline met goal compared to 91.39% at one month, 91.24% at three months, and 90.87% at six months postintervention. CONCLUSION By utilizing an aggressive education campaign championing superusers and making adjustments to the calculator based on early problems that were encountered, we were able to improve glycemic control and limit glucose variability at our institution.
Collapse
Affiliation(s)
- Daniel Shelden
- Metabolism Endocrinology and Diabetes,
University of Michigan, Ann Arbor, MI, USA
| | - Mohammed Ateya
- University of Michigan College of Pharmacy,
Ann Arbor, MI, USA
| | | | - Patrick Arnold
- Metabolism Endocrinology and Diabetes,
University of Michigan, Ann Arbor, MI, USA
| | | | - Roma Gianchandani
- Metabolism Endocrinology and Diabetes,
University of Michigan, Ann Arbor, MI, USA
- Roma Gianchandani, MD, University of Michigan Health
System, Metabolism Endocrinology and Diabetes, 4029 Ave Maria Dr, Lobby C, Ann Arbor, MI
48109, USA.
| |
Collapse
|
10
|
Lal A, Haque N, Lee J, Katta SR, Maranda L, George S, Trivedi N. Optimal Blood Glucose Monitoring Interval for Insulin Infusion in Critically Ill Non-Cardiothoracic Patients: A Pilot Study. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021036. [PMID: 33682835 PMCID: PMC7975947 DOI: 10.23750/abm.v92i1.9083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 01/05/2020] [Indexed: 11/29/2022]
Abstract
Objective: The American Diabetes Association and the Society of Critical Care Medicine recommend monitoring blood glucose (BG) every 1-2 hours in patients receiving insulin infusion to guide titration of insulin infusion to maintain serum glucose in the target range; however, this is based on weak evidence. We evaluated the compliance of hourly BG monitoring and relation of less frequent BG monitoring to glycemic status. Materials and Methods: Retrospective chart review performed on 56 consecutive adult patients who received intravenous insulin infusion for persistent hyperglycemia in the ICU at Saint Vincent Hospital, a tertiary care community hospital an urban setting in Northeast region of USA. The frequency of fingerstick blood glucose (FSBG) readings was reviewed for compliance with hourly FSBG monitoring per protocol and the impact of FSBG testing at different time intervals on the glycemic status. Depending on time interval of FSBG monitoring, the data was divided into three groups: Group A (<90 min), Group B (91-179 min) and Group C (≥180 min). Results: The mean age was 69 years (48% were males), 77% patients had preexisting type 2 diabetes mellitus (T2DM). The mean MPM II score was 41. Of the 1411 readings for BG monitoring on insulin infusion, 467 (33%) were in group A, 806 (57%) in group B and 138 (10%) in group C; hourly BG monitoring compliance was 12.6%. The overall glycemic status was similar among all groups. There were 14 (0.99%) hypoglycemic episodes observed. The rate of hypoglycemic episodes was similar in all three groups (p=0.55). Conclusion: In patients requiring insulin infusion for sustained hyperglycemia in ICU, the risk of hypoglycemic episodes was not significantly different with less frequent BG monitoring. The compliance to hourly blood glucose monitoring and ICU was variable, and hypoglycemic episodes were similar across the groups despite the variation in monitoring. Significance of the Study: The importance of glycemic control in ICU has been well established and it is a resource intensive venture. However, there are no major studies highlighting the most optimal time interval for blood glucose checks in critically ill patients on insulin infusion. With this study we hypothesize that time duration between blood glucose checks can be increased safely without any untoward effects. Our study provides evidence for effective resource management with reducing the time spent with every glucose check and directly translating into high value care.
Collapse
Affiliation(s)
| | - Nurul Haque
- Department of Medicine Merit Health River Region Hospital 2100 US-61, Vicksburg, MS 39183.
| | - Jennifer Lee
- Clinical Pharmacy Coordinator, Critical Care Department of Pharmacy 123 Summer Street Saint Vincent Hospital, Worcester, Massachusetts. USA 01608.
| | - Sai Ramya Katta
- Clinical Pharmacy Coordinator, Critical Care Department of Pharmacy 123 Summer Street Saint Vincent Hospital, Worcester, Massachusetts. USA 01608.
| | - Louise Maranda
- Department of Biostatistics University of Massachusetts Medical School.
| | - Susan George
- Clinical Associate Professor of Medicine University of Massachusetts Medical School Program Director, Internal Medicine Residency Chair, Department of Medicine Performance Improvement Committee 123 Summer Street Saint Vincent Hospital, Worcester, Massachusetts..
| | - Nitin Trivedi
- Director, Division of Endocrinology Associate Program Director, Internal Medicine Residency Department of Medicine, Saint Vincent Hospital Associate Professor of Medicine University of Massachusetts Medical School 123 Summer Street Saint Vincent Hospital, Worcester, Massachusetts.
| |
Collapse
|
11
|
Stress burden related to postreperfusion syndrome may aggravate hyperglycemia with insulin resistance during living donor liver transplantation: A propensity score-matching analysis. PLoS One 2020; 15:e0243873. [PMID: 33301501 PMCID: PMC7728193 DOI: 10.1371/journal.pone.0243873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
Background We investigated the impact of postreperfusion syndrome (PRS) on hyperglycemia occurrence and connecting (C) peptide release, which acts as a surrogate marker for insulin resistance, during the intraoperative period after graft reperfusion in patients undergoing living donor liver transplantation (LDLT) using propensity score (PS)-matching analysis. Patients and methods Medical records from 324 adult patients who underwent elective LDLT were retrospectively reviewed, and their data were analyzed according to PRS occurrence (PRS vs. non-PRS groups) using the PS-matching method. Intraoperative levels of blood glucose and C-peptide were measured through the arterial or venous line at each surgical phase. Hyperglycemia was defined as a peak glucose level >200 mg/dL, and normal plasma concentrations of C-peptide in the fasting state were taken to range between 0.5 and 2.0 ng/mL. Results After PS matching, there were no significant differences in pre- and intra-operative recipient findings and donor-graft findings between groups. Although glucose and C-peptide levels continuously increased through the surgical phases in both groups, glucose and C-peptide levels during the neohepatic phase were significantly higher in the PRS group than in the non-PRS group, and larger changes in levels were observed between the preanhepatic and neohepatic phases. There were higher incidences of C-peptide levels >2.0 ng/mL and peak glucose levels >200 mg/dL in the neohepatic phase in patients with PRS than in those without. PRS adjusted for PS with or without exogenous insulin infusion was significantly associated with hyperglycemia occurrence during the neohepatic phase. Conclusions Elucidating the association between PRS and hyperglycemia occurrence will help with establishing a standard protocol for intraoperative glycemic control in patients undergoing LDLT.
Collapse
|
12
|
Ekanayake PS, Juang PS, Kulasa K. Review of Intravenous and Subcutaneous Electronic Glucose Management Systems for Inpatient Glycemic Control. Curr Diab Rep 2020; 20:68. [PMID: 33165676 DOI: 10.1007/s11892-020-01364-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to summarize current literature on electronic glucose management systems (eGMS) and discuss their benefits and disadvantages in the inpatient setting. RECENT FINDINGS We review different versions of commercially available eGMS: Glucommander™ (Glytec, Greenville, SC), EndoToolR (MD Scientific LLC, Charlotte, NC), GlucoStabilizer™ (Medical Decision Network, Charlottesville, VA), GlucoCare™ (Pronia Medical Systems, KY), and discuss advantages such as reducing rates of hypoglycemia, hyperglycemia, and glycemic variability. In addition, eCGMs offer a uniform standard of care and may improve workflows across institutions as well reduce barriers. Despite ample literature on intravenous (IV) versions of eGMS, there is little published research on subcutaneous (SQ) insulin guidance. Although use of eGMS requires extensive training and institution-wide adoption, time spent on diabetes management is better facilitated by their use.
Collapse
Affiliation(s)
- Preethika S Ekanayake
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, San Diego, CA, USA.
| | - Patricia S Juang
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, San Diego, CA, USA
| | - Kristen Kulasa
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, San Diego, CA, USA
| |
Collapse
|
13
|
Yoo HJ, Suh EE, Shim J. Effectiveness of blood glucose control protocol for open heart surgery patients. J Adv Nurs 2020; 77:275-285. [PMID: 33016410 DOI: 10.1111/jan.14592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 07/30/2020] [Accepted: 08/07/2020] [Indexed: 12/01/2022]
Abstract
AIMS To evaluate the effectiveness of a tailored blood glucose control protocol for postoperative cardiac surgery patients treated in intensive care. DESIGN Retrospective study. METHODS Data for the control group (non-tailored protocol) were collected from medical records at a tertiary hospital in Seoul, Korea between April-July 2015. Data for the experimental group (tailored protocol) were obtained from medical records between April-July 2016. After adjusting the target blood glucose range, eliminating single-dose insulin administration and extending the blood glucose measurement time interval, data for blood glucose measurements, time for reaching and maintaining target blood glucose, mean number of daily blood glucose measurements and insulin dose adjustments for the experimental group were collected. RESULTS In the experimental group (where the target blood glucose rate was increased) the hypoglycaemia rate and the variation in blood glucose decreased significantly compared with the control group. In particular, the experimental group maintained relatively stable blood glucose levels by retaining a small variation range in glucose, regardless of the presence of diabetes. Time required for maintaining target blood glucose, mean number of daily blood glucose measurements and insulin dose adjustments per patient decreased. CONCLUSION The tailored protocol contributes to the safe and effective control of blood glucose in critical care patients after cardiac surgery and to the efficiency of nurses administering it. IMPACT This study has two significant impacts. The application of the tailored protocol has a positive impact on patients' blood glucose management, a critical component of treatment for postoperative cardiac patients in intensive care units. It also has a positive impact on the efficiency of nurses applying it. The results of this study are thus expected to facilitate successful implementation of clinical protocols for critical care after heart surgery.
Collapse
Affiliation(s)
- Hye Jin Yoo
- Department of Nursing, Asan Medical center, Seoul, South Korea
| | - Eunyoung E Suh
- College of Nursing and Research Institute of Nursing Science, Seoul National University, Seoul, South Korea
| | - JaeLan Shim
- College of Medicine, Department of Nursing, Dongguk University, Gyeongju, South Korea
| |
Collapse
|
14
|
Yi D. Letter: An Electronic Health Record-Integrated Computerized Intravenous Insulin Infusion Protocol: Clinical Outcomes and in Silico Adjustment ( Diabetes Metab J 2020;44:56-66). Diabetes Metab J 2020; 44:354-355. [PMID: 32347028 PMCID: PMC7188977 DOI: 10.4093/dmj.2020.0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Dongwon Yi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.
| |
Collapse
|
15
|
Canbolat O, Kapucu S, Kilickaya O. Comparison of Routine and Computer-Guided Glucose Management for Glycemic Control in Critically Ill Patients. Crit Care Nurse 2020; 39:20-27. [PMID: 31371364 DOI: 10.4037/ccn2019431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Glycemic control is crucial for reducing morbidity and mortality in critically ill patients. A standardized approach to glycemic control using a computer-guided protocol may help maintain blood glucose level within a target range and prevent human-induced medical errors. OBJECTIVE To determine the effectiveness of a computer-guided glucose management protocol for glycemic control in intensive care patients. METHODS This controlled, open-label implementation study involved 66 intensive care patients: 33 in the intervention group and 33 in the control group. The blood glucose level target range was established as 120 to 180 mg/dL. The control group received the clinic's routine glycemic monitoring approach, and the intervention group received monitoring using newly developed glycemic control software. At the end of the study, nurse perceptions and satisfaction were determined using a questionnaire. RESULTS The rates of hyperglycemia and hypoglycemia were lower and the blood glucose level was more successfully maintained in the target range in the intervention group than in the control group (P < .001). The time to achieve the target range was shorter and less insulin was used in the intervention group than in the control group (P < .05). Nurses reported higher levels of satisfaction with the computerized protocol, which they found to be more effective and reliable than routine clinical practice. CONCLUSIONS The computerized protocol was more effective than routine clinical practice in achieving glycemic control. It was also associated with higher nurse satisfaction levels.
Collapse
Affiliation(s)
- Ozlem Canbolat
- Ozlem Canbolat is an assistant professor, Faculty of Nursing, Necmettin Erbakan University, Selçuklu, Konya, Turkey. Sevgisun Kapucu is a professor, Faculty of Nursing, Hacettepe University, Ankara, Turkey. Oguz Kilickaya is an associate professor, Bahcelievler Medical Park Hospital, Istanbul, Turkey.
| | - Sevgisun Kapucu
- Ozlem Canbolat is an assistant professor, Faculty of Nursing, Necmettin Erbakan University, Selçuklu, Konya, Turkey. Sevgisun Kapucu is a professor, Faculty of Nursing, Hacettepe University, Ankara, Turkey. Oguz Kilickaya is an associate professor, Bahcelievler Medical Park Hospital, Istanbul, Turkey
| | - Oguz Kilickaya
- Ozlem Canbolat is an assistant professor, Faculty of Nursing, Necmettin Erbakan University, Selçuklu, Konya, Turkey. Sevgisun Kapucu is a professor, Faculty of Nursing, Hacettepe University, Ankara, Turkey. Oguz Kilickaya is an associate professor, Bahcelievler Medical Park Hospital, Istanbul, Turkey
| |
Collapse
|
16
|
Park SW, Lee S, Cha WC, Hur KY, Kim JH, Lee MK, Park SM, Jin SM. An Electronic Health Record-Integrated Computerized Intravenous Insulin Infusion Protocol: Clinical Outcomes and in Silico Adjustment. Diabetes Metab J 2020; 44:56-66. [PMID: 31701686 PMCID: PMC7043972 DOI: 10.4093/dmj.2018.0227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 03/30/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND We aimed to describe the outcome of a computerized intravenous insulin infusion (CII) protocol integrated to the electronic health record (EHR) system and to improve the CII protocol in silico using the EHR-based predictors of the outcome. METHODS Clinical outcomes of the patients who underwent the CII protocol between July 2016 and February 2017 and their matched controls were evaluated. In the CII protocol group (n=91), multivariable binary logistic regression analysis models were used to determine the independent associates with a delayed response (taking ≥6.0 hours for entering a glucose range of 70 to 180 mg/dL). The CII protocol was adjusted in silico according to the EHR-based parameters obtained in the first 3 hours of CII. RESULTS Use of the CII protocol was associated with fewer subjects with hypoglycemia alert values (P=0.003), earlier (P=0.002), and more stable (P=0.017) achievement of a glucose range of 70 to 180 mg/dL. Initial glucose level (P=0.001), change in glucose during the first 2 hours (P=0.026), and change in insulin infusion rate during the first 3 hours (P=0.029) were independently associated with delayed responses. Increasing the insulin infusion rate temporarily according to these parameters in silico significantly reduced delayed responses (P<0.0001) without hypoglycemia, especially in refractory patients. CONCLUSION Our CII protocol enabled faster and more stable glycemic control than conventional care with minimized risk of hypoglycemia. An EHR-based adjustment was simulated to reduce delayed responses without increased incidence of hypoglycemia.
Collapse
Affiliation(s)
- Sung Woon Park
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seunghyun Lee
- Department of Creative IT Engineering, Pohang University of Science and Technology (POSTECH), Pohang, Korea
| | - Won Chul Cha
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Korea
| | - Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Kyu Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Min Park
- Department of Creative IT Engineering, Pohang University of Science and Technology (POSTECH), Pohang, Korea.
| | - Sang Man Jin
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Korea.
| |
Collapse
|
17
|
Barasch N, Romig MC, Demko ZO, Dwyer C, Dietz A, Rosen M, Griffiths SM, Ravitz AD, Pronovost PJ, Sapirstein A. Automation and interoperability of a nurse-managed insulin infusion protocol as a model to improve safety and efficiency in the delivery of high-alert medications. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2019. [DOI: 10.1177/2516043519893228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Noah Barasch
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Mark C Romig
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Zoe O Demko
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Cindy Dwyer
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Aaron Dietz
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Michael Rosen
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Steven M Griffiths
- Applied Physics Laboratory, The Johns Hopkins University, Baltimore, MD, USA
| | - Alan D Ravitz
- Applied Physics Laboratory, The Johns Hopkins University, Baltimore, MD, USA
| | - Peter J Pronovost
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Adam Sapirstein
- The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
18
|
Majeste AC, Tatum E, Christian R, Palokas M. Glycemic control outcomes of manual and computerized insulin titration protocols: a systematic review protocol. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2019; 17:1626-1633. [PMID: 30964769 DOI: 10.11124/jbisrir-2017-003866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The object of this systematic review is to determine the effectiveness of computerized insulin titration protocols compared to manual insulin titration protocols for glycemic control in hospitalized adult patients. INTRODUCTION Hyperglycemia is common during acute illness, and current recommendations for patients with altered glucose metabolism is the use of intravenous insulin therapy. Due to the narrow therapeutic index of insulin, euglycemia is difficult to achieve and requires frequent dose titrations and blood glucose checks. Dose titrations can be accomplished through the use of manual or computerized insulin titration protocols. INCLUSION CRITERIA This review will consider studies that compare manual and computerized insulin titration protocols for hospitalized adult patients requiring intravenous insulin therapy for hyperglycemia. Studies must have considered one or more glycemic control outcomes. METHODS This systematic review will use the JBI methodology for evidence of effectiveness. The search will be limited to studies published in English from 1984, as this was the approximate year that the first pilot study of a computerized titration protocol was implemented. The databases to be searched include: Cochrane Central Register of Controlled Trials, CINAHL, PubMed, Embase, Health Technology Assessments and Ovid Healthstar. The trial registers to be searched include: US National Library of Medicine (ClinicalTrials.gov). The search for unpublished studies will include ProQuest Dissertations and Theses, and MedNar. Retrieval of full-text studies, assessment of methodological quality and data extraction will be performed independently by two reviewers. Meta-analysis will be performed if possible, and a Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Summary of Findings presented. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42019142776.
Collapse
Affiliation(s)
- Andrew C Majeste
- School of Nursing, University of Mississippi Medical Center, USA
- The UMMC SON Evidence-Based Practice & Research Team: an Affiliate Group of the Joanna Briggs Institute
| | - Eva Tatum
- School of Nursing, University of Mississippi Medical Center, USA
- The UMMC SON Evidence-Based Practice & Research Team: an Affiliate Group of the Joanna Briggs Institute
| | - Robin Christian
- School of Nursing, University of Mississippi Medical Center, USA
- The UMMC SON Evidence-Based Practice & Research Team: an Affiliate Group of the Joanna Briggs Institute
| | - Michelle Palokas
- School of Nursing, University of Mississippi Medical Center, USA
- The UMMC SON Evidence-Based Practice & Research Team: an Affiliate Group of the Joanna Briggs Institute
| |
Collapse
|
19
|
Salinas PD, Mendez CE. Response to Letter Concerning Comparison Between Different Electronic Glucose Management Technologies. J Diabetes Sci Technol 2019; 13:805-806. [PMID: 31079478 PMCID: PMC6610589 DOI: 10.1177/1932296819841070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Pedro D. Salinas
- Aurora Critical Care Services,
University of Wisconsin School of Medicine and Public Health, Milwaukee, WI,
USA
- Pedro D. Salinas, MD, FCCP, Aurora Critical
Care Service, University of Wisconsin School of Medicine and Public Health, 2901
W Kinnickinnic River Pkwy, Ste 305, Milwaukee, WI 53215-3268, USA.
| | - Carlos E. Mendez
- Froedtert and Medical College of
Wisconsin, Division of Diabetes and Endocrinology, Zablocki Veteran Affairs Medical
Center, Milwaukee, WI, USA
| |
Collapse
|
20
|
Abstract
Hyperglycemia is common in the intensive care unit (ICU) both in patients with and without a previous diagnosis of diabetes. The optimal glucose range in the ICU population is still a matter of debate. Given the risk of hypoglycemia associated with intensive insulin therapy, current recommendations include treating hyperglycemia after two consecutive glucose >180 mg/dL with target levels of 140-180 mg/dL for most patients. The optimal method of sampling glucose and delivery of insulin in critically ill patients remains elusive. While point of care glucose meters are not consistently accurate and have to be used with caution, continuous glucose monitoring (CGM) is not standard of care, nor is it generally recommended for inpatient use. Intravenous insulin therapy using paper or electronic protocols remains the preferred approach for critically ill patients. The advent of new technologies, such as electronic glucose management, CGM, and closed-loop systems, promises to improve inpatient glycemic control in the critically ill with lower rates of hypoglycemia.
Collapse
Affiliation(s)
- Pedro D. Salinas
- Aurora Critical Care Services,
University of Wisconsin School of Medicine and Public Health, Milwaukee, WI,
USA
| | - Carlos E. Mendez
- Froedtert and Medical College of
Wisconsin, Division of Diabetes and Endocrinology, Zablocki Veteran Affairs Medical
Center, Milwaukee, WI, USA
| |
Collapse
|
21
|
Chase JG, Desaive T, Bohe J, Cnop M, De Block C, Gunst J, Hovorka R, Kalfon P, Krinsley J, Renard E, Preiser JC. Improving glycemic control in critically ill patients: personalized care to mimic the endocrine pancreas. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:182. [PMID: 30071851 PMCID: PMC6091026 DOI: 10.1186/s13054-018-2110-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/29/2018] [Indexed: 02/06/2023]
Abstract
There is considerable physiological and clinical evidence of harm and increased risk of death associated with dysglycemia in critical care. However, glycemic control (GC) currently leads to increased hypoglycemia, independently associated with a greater risk of death. Indeed, recent evidence suggests GC is difficult to safely and effectively achieve for all patients. In this review, leading experts in the field discuss this evidence and relevant data in diabetology, including the artificial pancreas, and suggest how safe, effective GC can be achieved in critically ill patients in ways seeking to mimic normal islet cell function. The review is structured around the specific clinical hurdles of: understanding the patient’s metabolic state; designing GC to fit clinical practice, safety, efficacy, and workload; and the need for standardized metrics. These aspects are addressed by reviewing relevant recent advances in science and technology. Finally, we provide a set of concise recommendations to advance the safety, quality, consistency, and clinical uptake of GC in critical care. This review thus presents a roadmap toward better, more personalized metabolic care and improved patient outcomes.
Collapse
Affiliation(s)
- J Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA In-Silico Medicine, University of Liège, Liège, Belgium
| | - Julien Bohe
- Medical Intensive Care Unit, Lyon-Sud University Hospital, Pierre-Bénite, France
| | - Miriam Cnop
- ULB Center for Diabetes Research, and Division of Endocrinology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Edegem, Belgium
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Roman Hovorka
- University of Cambridge Metabolic Research Laboratories, Level 4, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
| | - Pierre Kalfon
- Service de Réanimation polyvalente, Hôpital Louis Pasteur, CH de Chartres, Chartres, France
| | - James Krinsley
- Division of Critical Care, Department of Medicine, Stamford Hospital, Columbia University College of Physicians and Surgeons, Stamford, CT, USA
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, and Institute of Functional Genomics, CNRS, INSERM, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, route de Lennik 808, 1070, Brussels, Belgium.
| |
Collapse
|
22
|
Rodriguez-Calero MA, Barceló Llodrá E, Cruces Cuberos M, Blanco-Mavillard I, Pérez Axartell MA. Effectiveness of an evidence-based protocol for the control of stress-induced hyperglycaemia in critical care. ENFERMERIA INTENSIVA 2018; 30:4-12. [PMID: 29935968 DOI: 10.1016/j.enfi.2018.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 11/17/2022]
Abstract
AIM To assess the effectiveness of the implementation of a protocol for glycaemic control in critical care, in terms of maintenance of a pre-established target of blood glucose level, reduction of hyperglycaemia and prevention of severe hypoglycaemia. METHOD Prospective "pre-post" quasi-experimental study carried out in a general critical care unit. Adult patients treated with intravenous insulin were included. We recorded all glycaemic tests performed from November 2014 to August 2015 (pre-intervention) and from November 2015 to August 2016 (post-intervention). The intervention consisted of the implementation of an evidence-based glycaemic control protocol to achieve glycaemic levels in a range of 140-180mg/dl. Main variables analysed were: proportion of glycaemic tests in the target range, proportions of severe hypoglycaemia (under 40mg/dl) and hyperglycaemia over 200mg/dl. RESULTS We analysed 7864 glycaemic tests from 125 patients, 66 pre-intervention and 59 post-intervention. Average age was 66.24±13.99 years, 64% of patients were male. The proportion of tests within the target range was higher in the intervention group (38.82 vs. 44.34 p<.001). Only one case of severe hypoglycaemia was identified, which happened in the pre-intervention period. The rate of severe hyperglycaemia was lower in the post-intervention group (19.19 vs. 16.28 p=.001). CONCLUSIONS Our experience shows that implementation of evidence-based interventions can improve glycaemic control during critical illness. We found higher glycaemia levels in the target range. The protocol proved useful in the prevention of severe hypoglycaemia. Nurse-led interventions based on clinical data improved health results in our patients.
Collapse
Affiliation(s)
- M A Rodriguez-Calero
- Unidad de Calidad, Docencia e Investigación, Hospital de Manacor, Manacor, Mallorca, España.
| | - E Barceló Llodrá
- Área del Paciente Crítico, Hospital de Manacor, Manacor, Mallorca, España
| | - M Cruces Cuberos
- Unidad de Cuidados Intensivos, Hospital de Manacor, Manacor, Mallorca, España
| | - I Blanco-Mavillard
- Unidad de Calidad, Docencia e Investigación, Hospital de Manacor, Manacor, Mallorca, España
| | - M A Pérez Axartell
- Unidad de Cuidados Intensivos, Hospital de Manacor, Manacor, Mallorca, España
| |
Collapse
|
23
|
Telford ED, Franck AJ, Hendrickson AL, Dietrich NM. A Bedside Computerized Decision-Support Tool for Intravenous Insulin Infusion Management in Critically Ill Patients. Jt Comm J Qual Patient Saf 2018; 44:299-303. [PMID: 29759263 DOI: 10.1016/j.jcjq.2017.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/30/2017] [Indexed: 12/26/2022]
Abstract
Intravenous (IV) insulin infusions using a validated protocol are the recommended method for blood glucose control in critically ill patients. Computerized decision-support tools improve quality over manual paper-based protocols. However, nonproprietary computerized tools targeting the recommended blood glucose range of 140-180 mg/dL are not readily available. A bedside computerized decision-support tool was developed at a US Department of Veterans Affairs health system to assist the nursing staff with the management of patients requiring IV insulin infusion. Initial evaluation showed that the tool was useful in the safe and effective management of an IV insulin infusion protocol for blood glucose control targeting the updated blood glucose range.
Collapse
|
24
|
Braithwaite SS, Clark LP, Idrees T, Qureshi F, Soetan OT. Hypoglycemia Prevention by Algorithm Design During Intravenous Insulin Infusion. Curr Diab Rep 2018; 18:26. [PMID: 29582176 DOI: 10.1007/s11892-018-0994-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW This review examines algorithm design features that may reduce risk for hypoglycemia while preserving glycemic control during intravenous insulin infusion. We focus principally upon algorithms in which the assignment of the insulin infusion rate (IR) depends upon maintenance rate of insulin infusion (MR) or a multiplier. RECENT FINDINGS Design features that may mitigate risk for hypoglycemia include use of a mid-protocol bolus feature and establishment of a low BG threshold for temporary interruption of infusion. Computer-guided dosing may improve target attainment without exacerbating risk for hypoglycemia. Column assignment (MR) within a tabular user-interpreted algorithm or multiplier may be specified initially according to patient characteristics and medical condition with revision during treatment based on patient response. We hypothesize that a strictly increasing sigmoidal relationship between MR-dependent IR and BG may reduce risk for hypoglycemia, in comparison to a linear relationship between multiplier-dependent IR and BG. Guidelines are needed that curb excessive up-titration of MR and recommend periodic pre-emptive trials of MR reduction. Future research should foster development of recommendations for "protocol maxima" of IR appropriate to patient condition.
Collapse
Affiliation(s)
- Susan Shapiro Braithwaite
- , 1135 Ridge Road, Wilmette, IL, 60091, USA.
- Endocrinology Consults and Care, S.C, 3048 West Peterson Ave, Chicago, IL, 60659, USA.
| | - Lisa P Clark
- Presence Saint Francis Hospital, 355 Ridge Ave, Evanston, IL, 60202, USA
| | - Thaer Idrees
- Presence Saint Joseph Hospital, 2900 N. Lakeshore Dr, Chicago, IL, 60657, USA
| | - Faisal Qureshi
- Presence Saint Joseph Hospital, 2800 N Sheridan Road Suite 309, Chicago, IL, 60657, USA
| | - Oluwakemi T Soetan
- Presence Saint Joseph Hospital, 2900 N. Lakeshore Dr, Chicago, IL, 60657, USA
| |
Collapse
|
25
|
Abstract
Advanced informatics systems can help improve health care delivery and the environment of care for critically ill patients. However, identifying, testing, and deploying advanced informatics systems can be quite challenging. These processes often require involvement from a collaborative group of health care professionals of varied disciplines with knowledge of the complexities related to designing the modern and "smart" intensive care unit (ICU). In this article, we explore the connectivity environment within the ICU, middleware technologies to address a host of patient care initiatives, and the core informatics concepts necessary for both the design and implementation of advanced informatics systems.
Collapse
|
26
|
Abstract
PURPOSE OF REVIEW We reviewed the strategies associated with hypoglycemia risk reduction among critically ill non-pregnant adult patients. RECENT FINDINGS Hypoglycemia in the ICU has been associated with increased mortality in a number of studies. Insulin dosing and glucose monitoring rules, response to impending hypoglycemia, use of computerization, and attention to modifiable factors extrinsic to insulin algorithms may affect the risk for hypoglycemia. Recurring use of intravenous (IV) bolus doses of insulin in insulin-resistant cases may reduce reliance upon higher IV infusion rates. In order to reduce the risk for hypoglycemia in the ICU, caregivers should define responses to interruption of continuous carbohydrate exposure, incorporate transitioning strategies upon initiation and interruption of IV insulin, define modifications of antihyperglycemic therapy in the presence of worsening renal function or chronic kidney disease, and anticipate the effects traceable to other medications and substances. Institutional and system-wide quality improvement efforts should assign priority to hypoglycemia prevention.
Collapse
Affiliation(s)
- Susan Shapiro Braithwaite
- , 1135 Ridge Road, Wilmette, IL, 60091, USA.
- Endocrinology Consults and Care, S.C, 3048 West Peterson Ave, Chicago, IL, 60659, USA.
| | - Dharmesh B Bavda
- Presence Saint Joseph Hospital-Chicago, 2900 N. Lake Shore Drive, Chicago, IL, 60657, USA
| | - Thaer Idrees
- Presence Saint Joseph Hospital-Chicago, 2900 N. Lake Shore Drive, Chicago, IL, 60657, USA
| | - Faisal Qureshi
- , 2800 N Sheridan Road Suite 309, Chicago, IL, 60657, USA
| | - Oluwakemi T Soetan
- Presence Saint Joseph Hospital-Chicago, 2900 N. Lake Shore Drive, Chicago, IL, 60657, USA
| |
Collapse
|
27
|
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45:486-552. [PMID: 28098591 DOI: 10.1097/ccm.0000000000002255] [Citation(s) in RCA: 1889] [Impact Index Per Article: 269.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
Collapse
|
28
|
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304-377. [PMID: 28101605 DOI: 10.1007/s00134-017-4683-6] [Citation(s) in RCA: 3716] [Impact Index Per Article: 530.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
Collapse
|
29
|
De Block CEM, Rogiers P, Jorens PG, Schepens T, Scuffi C, Van Gaal LF. A comparison of two insulin infusion protocols in the medical intensive care unit by continuous glucose monitoring. Ann Intensive Care 2016; 6:115. [PMID: 27878572 PMCID: PMC5120161 DOI: 10.1186/s13613-016-0214-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 11/05/2016] [Indexed: 12/12/2022] Open
Abstract
Background Achieving good glycemic control in intensive care units (ICU) requires a safe and efficient insulin infusion protocol (IIP). We aimed to compare the clinical performance of two IIPs (Leuven versus modified Yale protocol) in patients admitted to medical ICU, by using continuous glucose monitoring (CGM). This is a pooled data analysis of two published prospective randomized controlled trials. CGM monitoring was performed in 57 MICU patients (age 64 ± 12 years, APACHE-II score 28 ± 7, non-diabetic/diabetic: 36/21). The main outcome measures were percentage of time in normoglycemia (80–110 mg/dl) and in hypoglycemia (<60 mg/dl), and glycemic variability (standard deviation, coefficient of variation, mean amplitude of glucose excursions, mean of daily differences). Results Twenty-two subjects were treated using the Leuven protocol and 35 by the Yale protocol; >63,000 CGM measurements were available. The percentage of time in normoglycemia (80–110 mg/dl) was higher (37 ± 15 vs. 26 ± 11%, p = 0.001) and percentage of time spent in hypoglycemia was lower (0[0–2] vs. 5[1–8]%, p = 0.001) in the Yale group. Median glycemia did not differ between groups (118[108–128] vs. 128[106–154] mg/dl). Glycemic variability was less pronounced in the Yale group (median SD 28[21–37] vs. 47[31–71] mg/dl, p = 0.001; CV 23[19–31] vs. 36[26–50]%, p = 0.001; MODD 35[26–41] vs. 60[33–94] mg/dl, p = 0.001). However, logistic regression could not identify type of IIP, diabetes status, age, BMI, or APACHE-II score as independent parameters for strict glucose control. Conclusions The Yale protocol provided better average glycemia, more time spent in normoglycemia, less time in hypoglycemia, and less glycemic variability than the Leuven protocol, but was not independently associated with strict glycemic control. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0214-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Christophe E M De Block
- Department of Endocrinology, Diabetology and Metabolism, Faculty of Medicine, Antwerp University Hospital and University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium.
| | - Peter Rogiers
- Intensive Care Unit, ZNA, General Hospital Middelheim, Antwerp, Belgium
| | - Philippe G Jorens
- Intensive Care Unit, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Tom Schepens
- Intensive Care Unit, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Cosimo Scuffi
- A. Menarini Diagnostics, Scientific and Technology Affairs, Florence, Italy
| | - Luc F Van Gaal
- Department of Endocrinology, Diabetology and Metabolism, Faculty of Medicine, Antwerp University Hospital and University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium
| |
Collapse
|
30
|
Wallia A, Umpierrez GE, Nasraway SA, Klonoff DC. Round Table Discussion on Inpatient Use of Continuous Glucose Monitoring at the International Hospital Diabetes Meeting. J Diabetes Sci Technol 2016; 10:1174-81. [PMID: 27286715 PMCID: PMC5032965 DOI: 10.1177/1932296816656380] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In May 2015 the Diabetes Technology Society convened a panel of 27 experts in hospital medicine and endocrinology to discuss the current and potential future roles of continuous glucose monitoring (CGM) in delivering optimum health care to hospitalized patients in the United States. The panel focused on 3 potential settings for CGM in the hospital, including (1) the intensive care unit (ICU), (2) non-ICU, and (3) continuation of use of home CGM in the hospital. The group reviewed barriers to use and solutions to overcome the barriers. They concluded that CGM has the potential to improve the quality of patient care and can provide useful information to help health care providers learn more about glucose management. Widespread adoption of CGM by hospitals, however, has been limited by added costs and insufficient outcome data.
Collapse
Affiliation(s)
- Amisha Wallia
- Northwestern University, Feinberg School of Medicine, Division of Endocrinology, Metabolism, and Molecular Medicine, Chicago, IL, USA
| | | | | | - David C Klonoff
- Mills-Peninsula Health Services, Diabetes Research Institute, San Mateo, CA, USA
| |
Collapse
|
31
|
Marvin MR, Inzucchi SE, Besterman BJ. Minimization of Hypoglycemia as an Adverse Event During Insulin Infusion: Further Refinement of the Yale Protocol. Diabetes Technol Ther 2016; 18:480-6. [PMID: 27257910 PMCID: PMC4991569 DOI: 10.1089/dia.2016.0101] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The management of hyperglycemia in the intensive care unit has been a controversial topic for more than a decade, with target ranges varying from 80-110 mg/dL to <200 mg/dL. Multiple insulin infusion protocols exist, including several computerized protocols, which have attempted to achieve these targets. Importantly, compliance with these protocols has not been a focus of clinical studies. METHODS GlucoCare™, a Food and Drug Administration (FDA)-cleared insulin-dosing calculator, was originally designed based on the Yale Insulin Infusion Protocol to target 100-140 mg/dL and has undergone several modifications to reduce hypoglycemia. The original Yale protocol was modified from 100-140 mg/dL to a range of 120-140 mg/dL (GlucoCare 120-140) and then to 140 mg/dL (GlucoCare 140, not a range but a single blood glucose [BG] level target) in an iterative and evidence-based manner to eliminate hypoglycemia <70 mg/dL. The final modification [GlucoCare 140(B)] includes the addition of bolus insulin "midprotocol" during an insulin infusion to reduce peak insulin rates for insulin-resistant patients. This study examined the results of these protocol modifications and evaluated the role of compliance with the protocol in the incidence of hypoglycemia <70 mg/dL. RESULTS Protocol modifications resulted in mean BG levels of 133.4, 136.4, 143.8, and 146.4 mg/dL and hypoglycemic BG readings <70 mg/dL of 0.998%, 0.367%, 0.256%, and 0.04% for the 100-140, 120-140, 140, and 140(B) protocols, respectively (P < 0.001). Adherence to the glucose check interval significantly reduced the incidence of hypoglycemia (P < 0.001). Protocol modifications led to a reduction in peak insulin infusion rates (P < 0.001) and the need for dextrose-containing boluses (P < 0.001). CONCLUSION This study demonstrates that refinements in protocol design can improve glucose control in critically ill patients and that the use of GlucoCare 140(B) can eliminate all significant hypoglycemia while achieving mean glucose levels between 140 and 150 mg/dL. In addition, attention to the timely performance of glucose levels can also reduce hypoglycemic events.
Collapse
Affiliation(s)
| | - Silvio E. Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | | |
Collapse
|
32
|
Welsh N, Derby T, Gupta S, Fulkerson C, Oakes DJ, Schmidt K, Parikh ND, Norvell JP, Levitsky J, Rademaker A, Molitch ME, Wallia A. INPATIENT HYPOGLYCEMIC EVENTS IN A COMPARATIVE EFFECTIVENESS TRIAL FOR GLYCEMIC CONTROL IN A HIGH-RISK POPULATION. Endocr Pract 2016; 22:1040-7. [PMID: 27124695 DOI: 10.4158/ep151166.or] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Inpatient hypoglycemia (glucose ≤70 mg/dL) is a limitation of intensive control with insulin. Causes of hypoglycemia were evaluated in a randomized controlled trial examining intensive glycemic control (IG, target 140 mg/dL) versus moderate glycemic control (MG, target 180 mg/dL) on post-liver transplant outcomes. METHODS Hypoglycemic episodes were reviewed by a multidisciplinary team to calculate and identify contributing pathophysiologic and operational factors. A subsequent subgroup case control (1:1) analysis (with/without) hypoglycemia was completed to further delineate factors. A total of 164 participants were enrolled, and 155 patients were examined in depth. RESULTS Overall, insulin-related hypoglycemia was experienced in 24 of 82 patients in IG (episodes: 20 drip, 36 subcutaneous [SQ]) and 4 of 82 in MG (episodes: 2 drip, 2 SQ). Most episodes occurred at night (41 of 60), with high insulin amounts (44 of 60), and during a protocol deviation (51 of 60). Compared to those without hypoglycemia (n = 127 vs. n = 28), hypoglycemic patients had significantly longer hospital stays (13.6 ± 12.6 days vs. 7.4 ± 6.1 days; P = .002), higher peak insulin drip rates (17.4 ± 10.3 U/h vs. 13.1 ± 9.9 U/h; P = .044), and higher peak insulin glargine doses (36.8 ± 21.4 U vs. 26.2 ± 24.3 U; P = .035). In the case-matched analysis (24 cases, 24 controls), those with insulin-related hypoglycemia had higher median peak insulin drip rates (17 U/h vs. 11 U/h; P = .04) and protocol deviations (92% vs. 50%; P = .004). CONCLUSION Peak insulin requirements and protocol deviations were correlated with hypoglycemia. ABBREVIATIONS DM = diabetes mellitus ICU = intensive care unit IG = intensive glycemic control MELD = Model for End-stage Liver Disease MG = moderate glycemic control SQ = subcutaneous.
Collapse
|
33
|
Comparison of Intraoperative Changes in Blood Glucose According to Model for End-stage Liver Disease Score During Living Donor Liver Transplantation. Transplant Proc 2016; 47:1877-82. [PMID: 26293066 DOI: 10.1016/j.transproceed.2015.03.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/11/2015] [Accepted: 03/04/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recipients of liver transplantation (LT) may experience disturbance of blood glucose balance, which is aggravated by various exogenous factors. The Model for End-stage Liver Disease (MELD) score is an indicator of the severity of pretransplantation liver disease. In this study, we investigated the role of the MELD score in intraoperative changes in blood glucose in patients undergoing living donor LT (LDLT). METHODS Perioperative data from 280 patients undergoing LDLT were reviewed, including glucose-related data. Intraoperatively, blood glucose levels were checked every hour, and the mean values at each phase of LDLT were calculated. Patients were divided into high and low MELD groups. An unpaired t-test and repeated measures analysis of variance (RMANOVA) were used in intergroup and intragroup comparisons of perioperative blood glucose. RESULTS The high MELD group consisted of 79 patients. Both the time sequential change during LDLT and the interaction between perioperative blood glucose and MELD score were significant (RMANOVA with multivariate adjustment; P < .05). Pretransplant blood glucose levels did not differ between the 2 groups, but the mean levels of blood glucose were lower and the incidence of hypoglycemia was higher in the high compared with the low MELD group during all phases of LDLT (P < .05). CONCLUSIONS Blood glucose levels progressively increased during LDLT with an interaction with the MELD score. Patients with a high MELD score had low blood glucose levels and a greater incidence of intraoperative hypoglycemia. MELD score is a useful determinant of intraoperative blood glucose levels in LDLT patients.
Collapse
|
34
|
Blaha J, Barteczko-Grajek B, Berezowicz P, Charvat J, Chvojka J, Grau T, Holmgren J, Jaschinski U, Kopecky P, Manak J, Moehl M, Paddle J, Pasculli M, Petersson J, Petros S, Radrizzani D, Singh V, Starkopf J. Space GlucoseControl system for blood glucose control in intensive care patients--a European multicentre observational study. BMC Anesthesiol 2016; 16:8. [PMID: 26801983 PMCID: PMC4722682 DOI: 10.1186/s12871-016-0175-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 01/20/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Glycaemia control (GC) remains an important therapeutic goal in critically ill patients. The enhanced Model Predictive Control (eMPC) algorithm, which models the behaviour of blood glucose (BG) and insulin sensitivity in individual ICU patients with variable blood samples, is an effective, clinically proven computer based protocol successfully tested at multiple institutions on medical and surgical patients with different nutritional protocols. eMPC has been integrated into the B.Braun Space GlucoseControl system (SGC), which allows direct data communication between pumps and microprocessor. The present study was undertaken to assess the clinical performance and safety of the SGC for glycaemia control in critically ill patients under routine conditions in different ICU settings and with various nutritional protocols. METHODS The study endpoints were the percentage of time the BG was within the target range 4.4 - 8.3 mmol.l(-1), the frequency of hypoglycaemic episodes, adherence to the advice of the SGC and BG measurement intervals. BG was monitored, and insulin was given as a continuous infusion according to the advice of the SGC. Nutritional management (enteral, parenteral or both) was carried out at the discretion of each centre. RESULTS 17 centres from 9 European countries included a total of 508 patients, the median study time was 2.9 (1.9-6.1) days. The median (IQR) time-in-target was 83.0 (68.7-93.1) % of time with the mean proposed measurement interval 2.0 ± 0.5 hours. 99.6% of the SGC advices on insulin infusion rate were accepted by the user. Only 4 episodes (0.01% of all BG measurements) of severe hypoglycaemia <2.2 mmol.l(-1) in 4 patients occurred (0.8%; 95% CI 0.02-1.6%). CONCLUSION Under routine conditions and under different nutritional protocols the Space GlucoseControl system with integrated eMPC algorithm has exhibited its suitability for glycaemia control in critically ill patients. TRIAL REGISTRATION ClinicalTrials.gov NCT01523665.
Collapse
Affiliation(s)
- Jan Blaha
- Department of Anaesthesiology and Intensive Medicine, 1st Faculty of Medicine, Charles University and General University Hospital Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
| | - Barbara Barteczko-Grajek
- Department of Anaesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland.
| | - Pawel Berezowicz
- Department of Anaesthesiology and Intensive Care Medicine, Vejle Hospital, Vejle, Denmark.
| | - Jiri Charvat
- Internal Medicine Clinic, University Hospital in Motol, Prague, Czech Republic.
| | - Jiri Chvojka
- Medical Department I, Faculty of Medicine in Pilsen, Charles University in Prague and University Hospital in Pilsen, Pilsen, Czech Republic.
| | - Teodoro Grau
- Department of Anaesthesiology and Intensive Care Medicine, Capio Hospital Sur, Madrid, Spain.
| | - Jonathan Holmgren
- Department of Anaesthesiology and Intensive Care Medicine, County Hospital Ryhov, Jönköping, Sweden.
| | - Ulrich Jaschinski
- Department of Anaesthesiology and Surgical Intensive Care Medicine, Klinikum Augsburg, Augsburg, Germany.
| | - Petr Kopecky
- Department of Anaesthesiology and Intensive Medicine, 1st Faculty of Medicine, Charles University and General University Hospital Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
| | - Jan Manak
- Department of Internal Medicine III - Metabolism and Gerontology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Mette Moehl
- Department of Cardiothoracic Anaesthesia and Intensive Care Unit, University Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Jonathan Paddle
- Intensive Care Department, Royal Cornwall Hospital, Truro, UK.
| | - Marcello Pasculli
- Department of Surgical and Intensive Medicine, Siena University Hospital, Siena, Italy.
| | - Johan Petersson
- Department of Anesthesiology and Intensive Care, Karolinska University Hospital Solna, Stockholm, Sweden.
| | - Sirak Petros
- Medical ICU, University Hospital Leipzig, Leipzig, Germany.
| | - Danilo Radrizzani
- Department of Anesthesiology and Intensive Care, Legnano Hospital, Legnano, Italy.
| | - Vinodkumar Singh
- Critical Care Services, Department of Anaesthetics, West Suffollk Hospital NHS Trust, Bury St Edmunds, UK.
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.
| |
Collapse
|
35
|
Chung HS, Lee S, Kwon SJ, Park CS. Perioperative predictors for refractory hyperglycemia during the neohepatic phase of liver transplantation. Transplant Proc 2015; 46:3474-80. [PMID: 25498075 DOI: 10.1016/j.transproceed.2014.06.078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 06/17/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND Hyperglycemia in the neohepatic phase of liver transplantation (LT) tends to decrease toward completion of the surgical procedure. Refractory hyperglycemia in the neohepatic phase (RH) is influenced by multiple perioperative factors and may be connected to posttransplant outcomes. We attempted to demonstrate the relationship of RH to posttransplant outcomes and to establish a predictive model for RH in living donor liver transplantation (LDLT). METHODS Perioperative data of 211 patients who underwent LDLT from 2009 and 2012 were reviewed, including declines in the blood glucose levels during the neohepatic phase. Perioperative variables including the posttransplant model for end-stage liver disease (MELD) score until day 30 were compared between patients with normal declines in blood glucose and patients with RH. Selected variables after intergroup comparisons were examined by means of multivariate logistic regression to establish a predictive model for RH occurrence. RESULTS The mean blood glucose decline was 22.3 ± 31.5 mg/dL during the neohepatic phase, and 84 of 203 patients (41.4%) had no decline in blood glucose. In intergroup comparisons, preoperative factors associated with RH included sex, Child-Pugh-Turcotte class, MELD score, emergency, liver enzymes, and graft-to-recipient weight ratio. During surgery, surgical time, serum lactate, and arterial pH were associated with RH. After surgery, the RH group showed slower recovery of the MELD score (15.2 versus 11.9 days) and higher MELD scores until day 10 (P < .05). After the multivariate analysis, recipient sex, emergency, surgical time (≤9 h), and the final intraoperative serum lactate level (≥5.0 mmol/L) were included in the predictive model for RH. CONCLUSIONS RH was associated with delayed functional recovery of the liver graft in LT. Recipient sex, emergency, surgical time, and the final intraoperative serum lactate level were identified as predictors of RH. Close monitoring of intraoperative blood glucose in LDLT may be an early prognostic indicator.
Collapse
Affiliation(s)
- H S Chung
- Department of Anesthesiology and Pain Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - S Lee
- Department of Anesthesiology and Pain Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - S J Kwon
- Department of Anesthesiology and Pain Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - C S Park
- Department of Anesthesiology and Pain Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| |
Collapse
|
36
|
Boutin JM, Gauthier L. Insulin infusion therapy in critically ill patients. Can J Diabetes 2015; 38:144-50. [PMID: 24690510 DOI: 10.1016/j.jcjd.2014.01.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/28/2014] [Accepted: 01/29/2014] [Indexed: 12/20/2022]
Abstract
While dysglycemia (hyperglycemia, hypoglycemia and glucose variability) is clearly associated with increased mortality in critically ill patients, target range of blood glucose control remains controversial. Standardized insulin infusion protocols constitute the basis of treatment of these patients. The choice of protocol and its implementation is a great challenge. In this article, we review the published data to help define the essential elements that compose a good protocol and apply the right conditions to make it safe and effective.
Collapse
Affiliation(s)
- Jean-Marie Boutin
- Département de Médecine, Service d'endocrinologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
| | - Lyne Gauthier
- Département de Pharmacie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| |
Collapse
|
37
|
Shi Z, Tang S, Chen Y, Lee DTF, Chair SY, Jiang B, Zhu X, Pan X, Yang J, Qin Y. Application of a glycaemic control optimization programme in patients with stress hyperglycaemia. Nurs Crit Care 2014; 21:304-10. [PMID: 25348047 DOI: 10.1111/nicc.12121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 06/25/2014] [Accepted: 07/01/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Stress-induced hyperglycaemia (SHG) can be observed in as high as 75% of critically ill patients, which can induce severe complications or adverse events. However, conventional intensive insulin therapy (CIIT) tends to induce hypoglycaemia and glucose variability. AIMS This study investigated the clinical effects of a blood glycaemic control optimization programme (BGCOP) in patients with stress hyperglycaemia post hepatobiliary or pancreatic surgery. DESIGN This study is a randomized, controlled, prospective clinical observation. METHODS Eighty-six patients with postoperative SHG were randomly divided into a control and experimental groups. Participants in the control group underwent CIIT, while participants in the experimental group underwent blood glycaemic control optimization programme (BGCOP). A range of 7·8-10·0 mmol/L was designated as the target range for effective control of blood sugar. The validity index, adverse events and complications were compared between two groups. RESULTS Compared to participants treated with CIIT, participants treated with BGCOP reached the target range of blood sugar levels more quickly (p = 0·000). The high glycaemic index (p = 0·000), incidence of hypoglycaemia (p = 0·011), and other adverse events as well as the incidence of abdominal infection (p = 0·026), incision infection (p = 0·044), and lung infection (p = 0·047) were significantly lower in participants who underwent the BGCOP than in patients treated with CIIT. CONCLUSION BGCOP can more effectively control blood sugar levels compared with CIIT in patients with SHG after hepatobiliary or pancreatic surgery. RELEVANCE TO CLINICAL PRACTICE This study provides a direction for blood glycaemic control in patients with stress hyperglycaemia post hepatobiliary or pancreatic surgery.
Collapse
Affiliation(s)
- Zeya Shi
- Surgical Intensive Care Unit, People's Hospital of Hunan Province, Changsha, Hunan, China.,Central South University School of Nursing, Changsha, Hunan, China
| | - Siyuan Tang
- Department of Cummunity Nursing, Central South University School of Nursing, Changsha, Hunan, China
| | - Yuxiang Chen
- Department of Pharmacy, Biomedical Engineering Institute, Central South University, Changsha, Hunan, China
| | - Diana T-F Lee
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China
| | - Sek Y Chair
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, China
| | - Bo Jiang
- Hepatobiliary Surgery, People's Hospital of Hunan Province, Changsha, Hunan, China
| | - Xu Zhu
- Surgical Intensive Care Unit, People's Hospital of Hunan Province, Changsha, Hunan, China
| | - Xiaoji Pan
- Surgical Intensive Care Unit, People's Hospital of Hunan Province, Changsha, Hunan, China
| | - Jinxu Yang
- Department of Nursing, College of Medicine, Luohe, China
| | - Yuelan Qin
- Department of Nursing, People's Hospital of Hunan Province, Changsha, Hunan, China
| |
Collapse
|
38
|
Wilinska ME, Hovorka R. Glucose control in the intensive care unit by use of continuous glucose monitoring: what level of measurement error is acceptable? Clin Chem 2014; 60:1500-9. [PMID: 25294923 DOI: 10.1373/clinchem.2014.225326] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Accuracy and frequency of glucose measurement is essential to achieve safe and efficacious glucose control in the intensive care unit. Emerging continuous glucose monitors provide frequent measurements, trending information, and alarms. The objective of this study was to establish the level of accuracy of continuous glucose monitoring (CGM) associated with safe and efficacious glucose control in the intensive care unit. METHODS We evaluated 3 established glucose control protocols [Yale, University of Washington, and Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR)] by use of computer simulations. Insulin delivery was informed by intermittent blood glucose (BG) measurements or CGM levels with an increasing level of measurement error. Measures of glucose control included mean glucose, glucose variability, proportion of time glucose was in target range, and hypoglycemia episodes. RESULTS Apart from the Washington protocol, CGM with mean absolute relative deviation (MARD) ≤ 15% resulted in similar mean glucose as with the use of intermittent BG measurements. Glucose variability was also similar between CGM and BG-informed protocols. Frequency and duration of hypoglycemia were not worse by use of CGM with MARD ≤ 10%. Measures of glucose control varied more between protocols than at different levels of the CGM error. CONCLUSIONS The efficacy of CGM-informed and BG-informed commonly used glucose protocols is similar, but the risk of hypoglycemia may be reduced by use of CGM with MARD ≤ 10%. Protocol choice has greater influence on glucose control measures than the glucose measurement method.
Collapse
Affiliation(s)
- Malgorzata E Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science and Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science and Department of Paediatrics, University of Cambridge, Cambridge, UK.
| |
Collapse
|
39
|
Sandler V, Misiasz MR, Jones J, Baldwin D. Reducing the risk of hypoglycemia associated with intravenous insulin: experience with a computerized insulin infusion program in 4 adult intensive care units. J Diabetes Sci Technol 2014; 8:923-9. [PMID: 25172875 PMCID: PMC4455385 DOI: 10.1177/1932296814540870] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Computerized insulin infusion protocols have facilitated more effective blood glucose (BG) control in intensive care units (ICUs). This is particularly important in light of the risks associated with hypoglycemia. End stage renal disease (ESRD) increases the risk of insulin-induced hypoglycemia. We evaluated BG control in 210 patients in 2 medical ICUs and in 2 surgical ICUs who were treated with a computerized insulin infusion program (CIIP). Our CIIP was programmed for a BG target of 140-180 mg/dL for medical ICU patients or 120-160 mg/dL for surgical ICU patients. In addition, we focused on BG control in the 11% of our patients with ESRD. Mean BG was 147 ± 20 mg/dL for surgical ICU patients and 171 ± 26 mg/dL for medical ICU patients. Of both surgical and medical ICU patients, 17% had 1 or more BG 60-79 mg/dL, while 3% of surgical ICU and 8% of medical ICU patients had 1 or more BG < 60 mg/dL. Mean BG in ESRD patients was 147 ± 16 mg/dL similar to 152 ± 23 mg/dL in patients without ESRD. Of ESRD patients, 41% had 1 or more BG < 79 mg/dL as compared with 17.8% of non-ESRD patients (P < .01). A higher BG target for medical ICU patients as compared with surgical ICU patients yielded comparably low rates of moderate or severe hypoglycemia. However, hypoglycemia among ESRD patients was more common compared to non-ESRD patients, suggesting a need for a higher BG target specific to ESRD patients.
Collapse
|
40
|
|
41
|
Amrein K, Kachel N, Fries H, Hovorka R, Pieber TR, Plank J, Wenger U, Lienhardt B, Maggiorini M. Glucose control in intensive care: usability, efficacy and safety of Space GlucoseControl in two medical European intensive care units. BMC Endocr Disord 2014; 14:62. [PMID: 25074071 PMCID: PMC4118658 DOI: 10.1186/1472-6823-14-62] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/15/2014] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The Space GlucoseControl system (SGC) is a nurse-driven, computer-assisted device for glycemic control combining infusion pumps with the enhanced Model Predictive Control algorithm (B. Braun, Melsungen, Germany). We aimed to investigate the performance of the SGC in medical critically ill patients. METHODS Two open clinical investigations in tertiary centers in Graz, Austria and Zurich, Switzerland were performed. Efficacy was assessed by percentage of time within the target range (4.4-8.3 mmol/L; primary end point), mean blood glucose, and sampling interval. Safety was assessed by the number of hypoglycemic episodes (≤2.2 mmol/L) and the percentage of time spent below this cutoff level. Usability was analyzed with a standardized questionnaire given to involved nursing staff after the trial. RESULTS Forty medical critically ill patients (age, 62 ± 15 years; body mass index, 30.0 ± 8.9 kg/m2; APACHE II score, 24.8 ± 5.4; 27 males; 8 with diabetes) were included for a period of 6.5 ± 3.7 days (n = 20 in each center). The primary endpoint (time in target range 4.4 to 8.3 mmol/l) was reached in 88.3% ± 9.3 of the time and mean arterial blood glucose was 6.7 ± 0.4 mmol/l. The sampling interval was 2.2 ± 0.4 hours. The mean daily insulin dose was 87.2 ± 64.6 IU. The adherence to the given insulin dose advice was high (98.2%). While the percentage of time spent in a moderately hypoglycemic range (2.2 to 3.3 mmol/L) was low (0.07 ± 0.26% of the time), one severe hypoglycemic episode (<2.2 mmol/L) occurred (2.5% of patients or 0.03% of glucose readings). CONCLUSIONS SGC is a safe and efficient method to control blood glucose in critically ill patients as assessed in two European medical intensive care units.
Collapse
Affiliation(s)
- Karin Amrein
- Medical University of Graz, Austria, Department of Internal Medicine, Division of Endocrinology and Metabolism, Auenbruggerplatz 15, 8036 Graz, Austria
| | | | | | - Roman Hovorka
- Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Thomas R Pieber
- Medical University of Graz, Austria, Department of Internal Medicine, Division of Endocrinology and Metabolism, Auenbruggerplatz 15, 8036 Graz, Austria
- Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
| | - Johannes Plank
- Medical University of Graz, Austria, Department of Internal Medicine, Division of Endocrinology and Metabolism, Auenbruggerplatz 15, 8036 Graz, Austria
| | - Urs Wenger
- Medical University of Zurich, Department of Internal Medicine, Medical Intensive Care Unit, Zurich, Switzerland
| | - Barbara Lienhardt
- Medical University of Zurich, Department of Internal Medicine, Medical Intensive Care Unit, Zurich, Switzerland
| | - Marco Maggiorini
- Medical University of Zurich, Department of Internal Medicine, Medical Intensive Care Unit, Zurich, Switzerland
| |
Collapse
|
42
|
Abstract
Glycemic control targets in intensive care units (ICUs) have three distinct domains. Firstly, excessive hyperglycemia needs to be avoided. The upper limit of this varies depending on the patient population studied and diabetic status of the patients. Surgical patients particularly cardiac surgery patients tend to benefit from a lower upper limit of glycemic control, which is not evident in medically ill patient. Patient with premorbid diabetic status tends to tolerate higher blood sugar level better than normoglycemics. Secondly, hypoglycemia is clearly detrimental in all groups of critically ill patient and all measures to avoid this catastrophe need to be a part of any glycemic control protocol. Thirdly, glycemic variability has increasingly been shown to be detrimental in this patient population. Glycemic control protocols need to take this into consideration and target to reduce any of the available metrics of glycemic variability. Newer technologies including continuous glucose monitoring techniques will help in titrating all these three domains within a desirable range.
Collapse
Affiliation(s)
- Subhash Todi
- Director, Critical Care and Emergency Medicine, AMRI Hospitals, P4 & 5, CIT Scheme - LXXII, Block- A, Gariahat Road, Kolkatta, West Bengal, India
| |
Collapse
|
43
|
Abstract
This third and final installment of this series on innovative designs for the smart ICU addresses the steps involved in conceptualizing, actualizing, using, and maintaining the advanced ICU informatics infrastructure and systems. The smart ICU comprehensively and electronically integrates the patient in the ICU with all aspects of care, displays data in a variety of formats, converts data to actionable information, uses data proactively to enhance patient safety, and monitors the ICU environment to facilitate patient care and ICU management. The keys to success in this complex informatics design process include an understanding of advanced informatics concepts, sophisticated planning, installation of a robust infrastructure capable of both connectivity and interoperability, and implementation of middleware solutions that provide value. Although new technologies commonly appear compelling, they are also complicated and challenging to incorporate within existing or evolving hospital informatics systems. Therefore, careful analysis, deliberate testing, and a phased approach to the implementation of innovative technologies are necessary to achieve the multilevel solutions of the smart ICU.
Collapse
Affiliation(s)
- Neil A Halpern
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center; and Weill Cornell Medical College, New York, NY.
| |
Collapse
|
44
|
Braithwaite DT, Umpierrez GE, Braithwaite SS. A quadruply-asymmetric sigmoid to describe the insulin-glucose relationship during intravenous insulin infusion. JOURNAL OF HEALTHCARE ENGINEERING 2014; 5:23-53. [PMID: 24691385 DOI: 10.1260/2040-2295.5.1.23] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
Collapse
Affiliation(s)
- Daniel T Braithwaite
- Department of Mathematics, Statistics, and Computer Science, University of Illinois at Chicago, Chicago, IL, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Susan S Braithwaite
- Division of Endocrinology, Diabetes and Metabolism, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
45
|
Abstract
PURPOSE OF REVIEW Diabetes mellitus and its related comorbidities present a growing challenge in perioperative medicine. And also largely independent from a history of diabetes, dysregulations of glucose homeostasis occur as part of the body's stress response. Dysregulations of glucose homeostasis, acute or chronic, are closely correlated with impaired prognosis in perioperative medicine. Treatment strategies remain somewhat controversial, as both the affliction and its correction have a blind side. RECENT FINDINGS Anesthesia requires vigilant attention to diabetes-related comorbidities such as neuropathy, angiopathy, cardiopathy and immune dysfunction. Dysregulations of glycemia of any kind, in other words, hypoglycemia and hyperglycemia and fluctuations of blood glucose, should be avoided. Target glycemia remains a matter of discussion: moderate, achievable glycemic target below 180 or 150 mg/dl appears to be reasonable. Modern technical developments like continuous glucose measurement devices and computer-assisted control algorithms are under development, and will hopefully facilitate perioperative glycemic control in the future. SUMMARY Literature clearly shows that leaving glycemic control out of focus is dangerous for the patient; efforts to control glycemia to a moderate target improve the patient's outcome.
Collapse
|