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Glucose Control in the Critically Ill Patient Utilizing Computerized Intravenous Insulin Dosing
Computer-guided Glucose Management Systems hypoglycemia incidence has been suggested as offsetting benefit
The management of critically ill inpatients with hyperglycemia is derived from glucose control.
16
complex and necessitates an approach that facilitates safe practices
and reduces the risk of errors. Both the over-treatment and the under- Essential Success Factors for Computer-guided
treatment of hyperglycemia represent potential safety issues in Glucose Management Systems
hospitalized patients with and without diabetes.
1,2,4,22
Various treatment There are several CGGMS characteristics that are essential. CGGMS can
modalities are available to accomplish this goal. They encompass the help reduce the risk of insulin infusion calculation errors and
use of paper protocols and computer-guided glucose management standardize insulin therapy. The systems must facilitate the appropriate
systems (CGGMS).
31–34
use of scheduled insulin therapy administered by nursing staff that is
educated and knowledgeable in glycemic management. This is essential
Numerous paper protocols are currently in use to accomplish improved to attain safe and appropriate levels of glycemic control in the
metabolic control in the ICU.
31,32
These insulin infusion algorithms have hospitalized ICU patient and achieve maximal benefit of the CGGMS.
been reviewed in depth by Braithwaite and Clement.
33
The application of The CGGMS should be integrated into the workflow of the nursing staff
paper protocols is often complex, requiring strict adherence to timing with the clinical decision at the POC. Some systems use computerized
of blood glucose monitoring and the availability of specific patient data. ordering systems (computerized physician order entry [CPOE]) as the
One option in supporting nursing in the application of and adherence to starting point, with integration of a CGGMS into this system.
38
Others use
the paper protocol is the application of computer technology, or computers positioned close to the glucose analyzer as the location for
CGGMS.
34–36
CGGMS algorithms for infusing intravenous insulin include the nurse–system interaction.
39
mathematical equivalent of bedside paper protocols and newer, more
complicated mathematical protocols that would be difficult if not Common features among most CGGMS are that they are stand-alone
impossible to ask the bedside care-giver to perform on a frequent basis. systems not integrated into other clinical information systems. They are
Performing the mathematics in the computer and simply adding an alarm specific to a given patient and furnish management support if the
to remind the user of the time the next blood glucose is due would clinical care for the patient is not in accord with protocol. Reminders
certainly lead to improved protocol performance. In general, these regarding glucose measurement are received automatically without the
algorithms use a previous blood glucose, insulin infusion rate, current need to query and often include audible alarms. The majority of systems
blood glucose, and time interval between testing to assign the next blood receive reminders for insulin infusion rate that require clinicians to ask
glucose, test time, and insulin infusion rate in order to achieve glycemic for advice. In most of the reported studies, the blood glucose is manually
targets.
33
Shulman and colleagues found computerization of algorithms entered by the user into a separate CGGMS database. This is due to
still may not result in easy attainment of tight glycemic control (glucose unavailability of the data electronically or due to lack of connection
80–110mg/dl), especially during the early stages of infusion.
35
Other to the CGGMS. Since intravenous insulin has a short half-life and there is
investigators, including Kanji, the Specialized Relative Insulin and a pharmacodynamic delay in insulin action, any connection between the
Nutrition Tables (SPRINT) investigators, and investigators utilizing the POC device and the CGGMS will need to be immediate and fail-safe.
33
Glucose Regulation for Intensive Care Patients (GRIP) system,
demonstrated improved target glucose achievement.
25,37,38
In three of the studies reported by Eslami, the data were electronically
accessed.
34
Thirty percent of studies reviewed utilized ‘if–then’ on a
In a recent review of the literature by Eslami and colleagues, 17 peer- varying scale of intravenous insulin. This involves a list of simple rules,
reviewed studies on implementation and outcomes using CGGMS for with a condition (the ‘if’) and a conclusion part (the ‘then’), and is
TGC (glucose 80–110mg/dl) are reported. Of the 17 studies, two based on the current blood glucose measurement. The conclusion
were prospective RCTs studying fewer than 100 patients, seven were corresponds to the amount of insulin.
34
The majority of the reviewed
prospective observational or controlled studies, six were retrospective, studies utilize formula-based protocols relying on a familiar, simple
and two were observational without mention of the study design.
34
As equation (e.g. insulin dose/hour = [blood glucose – 60 x multiplier (insulin
with studies of IIT, studies of CGGMS report on at least one quality sensitivity)].
33,34,40
In a single study, individualized patient modeling was
indicator that is affected positively; however, the diversity of the studies accomplished by using multiple mathematical algorithms.
41
The software
in terms of case mix, insulin therapy, associated therapies, and up- and downregulates a quadratic insulin dosing relationship based on
indicators used severely hampers study comparisons and prevents valid the entered blood glucose readings from the POC device. Utilization of
meta-analysis; a common ‘vocabulary’ is lacking. This common engineering control mathematics allows consideration of the previous
vocabulary is essential and has been offered as a potential solution for four dose responses to regulate the dosing relationship. In this small,
evaluation and comparison of studies.
14,34
There are no randomized prospective, RCT in a cardiovascular ICU, improved glucose control with
studies with different target ranges utilizing CGGMS to control both arms a decreased mean time to capture range, and decreased ICU time, were
of the study. Basically, all of the randomized studies for target range accomplished. Patients spent 84% of their time in the desired range
effect on outcome have used paper protocols with the different target (90–150mg/dl) without an increase in hypoglycemia. Our experience with
ranges. The most consistent finding of these studies has been a highly this system in a larger cardiovascular surgery population has
significant increase in hypoglycemic incidences in the lower glucose demonstrated improved glycemic control with significant improvement
target population. The consequences of this increased incidence of in the incidence of hypoglycemia (unpublished data). Furthermore, the
hypoglycemia on outcomes has been associated with increased system provides recommended basal–bolus insulin doses when
mortality in some studies.
4,17
This consistent difference in the transition to subcutaneous insulin is appropriate.
US ENDOCRINOLOGY 47
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