Glucose Control in the Critically Ill Patient Utilizing Computerized Intravenous Insulin Dosing

Glucose Control in the Critically Ill Patient Utilizing Computerized Intravenous Insulin Dosing

Crockett Samuel E
US Endocrinology - Volume 5 Issue 1
Published: January 2010
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Abstract
Hyperglycemia and hypoglycemia in the critically ill patient are associated with increased morbidity and mortality. Numerous studies have investigated the benefits of glucose control in the critically ill patient receiving intravenous insulin. Tight glucose control (blood glucose 80–110mg/dl) in this patient population has been difficult to achieve. When accomplished, it has been accompanied by an increased risk of hypoglycemia and in some studies increased mortality. Computer-guided glucose management systems (CGGMS) offer an alternative to paper protocols for the attainment of improved glucose control in critically ill patients requiring intravenous insulin. CGGMS provide a way to achieve improved glucose control with reduced hypoglycemia while reducing insulin infusion calculation errors and standardizing insulin therapy, thus improving patient safety.

Keywords
Hyperglycemia, hypoglycemia, tight glucose control, computer-guided glucose management system, intravenous insulin

Disclosure: The author has no conflicts of interest to declare. As a consultant, he works with a healthcare system that uses a computerized glucose management system.
Received: September 17, 2009 Accepted: November 30, 2009
Correspondence: Samuel E Crockett, MD, PO Box 740060, Orange City, FL 32774. E: drummer63@cfl.rr.com

Inpatient hospital hyperglycemia is associated with increased morbidity and mortality.1,2 This is particularly true in the critically ill patient
admitted to the intensive care unit (ICU).3–9 Critically ill patients who require ICU care for more than five days have as high as a 20% risk of
death and significant morbidity.10 Hyperglycemia associated with insulin resistance is commonly encountered in the critically ill patient and is seen not only in those patients with pre-existing diabetes but also in those patients with undiagnosed diabetes and those with stress hyperglycemia.11 Retrospective and post hoc analysis of large randomized controlled studies of intensive insulin therapy in the ICU suggests that patients with newly discovered hyperglycemia are at a greater mortality risk than patients with euglycemia or those with a previous diagnosis of diabetes.1,12 Adverse outcomes have been reported in various critically ill populations.3–5,8,9 In several patient populations, improved morbidity and mortality has been reported at blood glucose ranges defined as ‘tight’ (glucose 80–110mg/dl) or those below 140mg/dl.3,4 Areas of controversy and discussion are ongoing related to the appropriate blood glucose goals in critically ill patients, as well as how and when to measure blood glucose and what the most appropriate glucose and study metrics should be.13–16 The one consistent finding with the highest statistical significance in all outcome studies is the increase in the incidence of hypoglycemia associated with glucose control.3–6,17 The contribution of ‘hypoglycemic events’ to outcomes associated with glycemic control protocols remains a topic of interest and major concern.16 Until studies are completed with the same, near-zero hypoglycemia incidence randomized to different target goals, the optimum target glucose range is likely to always be dependent on the method of control.

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Keywords:
Hyperglycemia, hypoglycemia, tight glucose control, computer-guided glucose management system, intravenous insulin, diagnosis hyperglycemia, hyperglycemia metabolism, causes hyperglycemia, effect of hyperglycemia, intensive insulin therapy, glycemic control,

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