Tight glycaemic control by an automated algorithm with time-variant sampling in medical ICU patients
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Tight glycaemic control (TGC) in critically ill patients improves clinical outcome, but is difficult to establish The primary objective of the present study was to compare glucose control in medical ICU patients applying a computer-based enhanced model predictive control algorithm (eMPC) extended to include time-variant sampling against an implemented glucose management protocol.
Open randomised controlled trial.
Nine-bed medical intensive care unit (ICU) in a tertiary teaching hospital.
Patients and participants
Fifty mechanically ventilated medical ICU patients.
Patients were included for a study period of up to 72 h. Patients were randomised to the control group (n = 25), treated by an implemented insulin algorithm, or to the eMPC group (n = 25), using the laptop-based algorithm. Target range for blood glucose (BG) was 4.4–6.1 mM. Efficacy was assessed by mean BG, hyperglycaemic index (HGI) and BG sampling interval. Safety was assessed by the number of hypoglycaemic-episodes < 2.2 mM. Each participating nurse filled-in a questionnaire regarding the usability of the algorithm.
Measurements and main results
BG and HGI were significantly lower in the eMPC group [BG 5.9 mM (5.5–6.3), median (IQR); HGI 0.4 mM (0.2–0.9)] than in control patients [BG 7.4 mM (6.9–8.6), p < 0.001; HGI 1.6 mM (1.1–2.4), p < 0.001]. One hypoglycaemic episode was detected in the eMPC group; no such episodes in the control group. Sampling interval was significantly shorter in the eMPC group [eMPC 117 min (± 34), mean (± SD), vs 174 min (± 27); p < 0.001]. Thirty-four nurses filled-in the questionnaire. Thirty answered the question of whether the algorithm could be applied in daily routine in the affirmative.
The eMPC algorithm was effective in maintaining tight glycaemic control in severely ill medical ICU patients.
- Capes SE, Hunt D, Malmberg K, Gerstein HC (2000) Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 355:773–778 CrossRef
- Yendamuri S, Fulda GJ, Tinkoff GH (2003) Admission hyperglycemia as a prognostic indicator in trauma. J Trauma 55:33–38 CrossRef
- McCowen KC, Malhotra A, Bistrian BR (2001) Stress-induced hyperglycemia. Crit Care Clin 17:107–124 CrossRef
- Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R (2001) Intensive insulin therapy in the critically ill patients. N Engl J Med 345:1359–1367 CrossRef
- Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R (2006) Intensive insulin therapy in the medical ICU. N Engl J Med 354:449–461 CrossRef
- McMullin J, Brozek J, Jaeschke R, Hamielec C, Dhingra V, Rocker G, Freitag A, Gibson J, Cook D (2004) Glycemic control in the ICU: a multicenter survey. Intensive Care Med 30:798–803 CrossRef
- Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32:858–873 CrossRef
- Meijering S, Corstjens AM, Tulleken JE, Meertens JH, Zijlstra JG, Ligtenberg JJ (2006) Towards a feasible algorithm for tight glycaemic control in critically ill patients: a systematic review of the literature. Crit Care 10:R19 CrossRef
- Wilson M, Weinreb J, Hoo GW (2007) Intensive insulin therapy in critical care: a review of 12 protocols. Diabetes Care 30:1005–1011 CrossRef
- Pittas AG, Siegel RD, Lau J (2004) Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials. Arch Intern Med 164:2005–2011 CrossRef
- Vriesendorp TM, van Santen S, DeVries JH, de Jonge E, Rosendaal FR, Schultz MJ, Hoekstra JB (2006) Predisposing factors for hypoglycemia in the intensive care unit. Crit Care Med 34:96–101 CrossRef
- Mitchell I, Finfer S, Bellomo R, Higlett T (2006) Management of blood glucose in the critically ill in Australia and New Zealand: a practice survey and inception cohort study. Intensive Care Med 32:867–874 CrossRef
- Weber-Carstens S, Deja M, Bercker S, Dimroth A, Ahlers O, Kaisers U, Keh D (2007) Impact of bolus application of low-dose hydrocortisone on glycemic control in septic shock patients. Intensive Care Med 33:730–733 CrossRef
- Plank J, Blaha J, Cordingley J, Wilinska ME, Chassin LJ, Morgan C, Squire S, Haluzik M, Kremen J, Svacina S, Toller W, Plasnik A, Ellmerer M, Hovorka R, Pieber TR (2006) Multicentric, randomized, controlled trial to evaluate blood glucose control by the model predictive control algorithm versus routine glucose management protocols in intensive care unit patients. Diabetes Care 29:271–276 CrossRef
- Pachler C, Plank J, Weinhandl H, Chassin L, Hovorka R, Smolle K, Pieber TR, Ellmerer M (2007) Efficacy and user acceptance of a computer algorithm to establish tight glycemic control (abstract). Intensive Care Med 33[Suppl 2]:54
- Kanji S, Buffie J, Hutton B, Bunting PS, Singh A, McDonald K, Fergusson D, McIntyre LA, Hebert PC (2005) Reliability of point-of-care testing for glucose measurement in critically ill adults. Crit Care Med 33:2778–2785 CrossRef
- Critchell CD, Savarese V, Callahan A, Aboud C, Jabbour S, Marik P (2007) Accuracy of bedside capillary blood glucose measurements in critically ill patients. Intensive Care Med 33:2079–2084 CrossRef
- Vogelzang M, Zijlstra F, Nijsten MW (2005) Design and implementation of GRIP: a computerized glucose control system at a surgical intensive care unit. BMC Med Inform Decis Mak 5:38 CrossRef
- Hovorka R, Canonico V, Chassin LJ, Haueter U, Massi-Benedetti M, Orsini Federici M, Pieber TR, Schaller HC, Schaupp L, Vering T, Wilinska ME (2004) Nonlinear model predictive control of glucose concentration in subjects with type 1 diabetes. Physiol Meas 25:905–920 CrossRef
- Hovorka R, Chassin LJ, Wilinska ME, Canonico V, Akwi JA, Federici MO, Massi-Benedetti M, Hutzli I, Zaugg C, Kaufmann H, Both M, Vering T, Schaller HC, Schaupp L, Bodenlenz M, Pieber TR (2004) Closing the loop: the adicol experience. Diabetes Technol Ther 6:307–318 CrossRef
- Kanji S, Singh A, Tierney M, Meggison H, McIntyre L, Hebert PC (2004) Standardization of intravenous insulin therapy improves the efficiency and safety of blood glucose control in critically ill adults. Intensive Care Med 30:804–810 CrossRef
- Vogelzang M, van der Horst IC, Nijsten MW (2004) Hyperglycaemic index as a tool to assess glucose control: a retrospective study. Crit Care 8:R122–127 CrossRef
- Vlasselaers D, Notele G, Van den Berghe G, Wouters P, Chassin L, Wilinska G, Hovorka R (2006) Tight glycaemic control in ICU with model predictive control and time-variant sampling (abstract). Intensive Care Med 32[Suppl 1]:272
- Mader J, Korsatko S, Ikeoka D, Plank J, Bodenlenz M, Suppan M, Sinner F, Smolle K, Pieber TR, Ellmerer M (2007) Subcutaneous glucose monitoring in patients with severe sepsis (abstract). Crit Care 11[Suppl 2]:58
- Diabetes Control and Complications Trial Research Group (1997) Hypoglycemia in the Diabetes Control and Complications Trial. The Diabetes Control and Complications Trial Research Group. Diabetes 46:271–286 CrossRef
- UK Prospective Diabetes Study (UKPDS) Group (1998) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 352:837–853 CrossRef
- Cryer PE (2006) Hypoglycaemia: the limiting factor in the glycaemic management of the critically ill? Diabetologia 49:1722–1725 CrossRef
- Furnary AP, Gao G, Grunkemeier GL, Wu Y, Zerr KJ, Bookin SO, Floten HS, Starr A (2003) Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 125:1007–1021 CrossRef
- Meynaar IA, Dawson L, Tangkau PL, Salm EF, Rijks L (2007) Introduction and evaluation of a computerised insulin protocol. Intensive Care Med 33:591–596 CrossRef
- Clayton SB, Mazur JE, Condren S, Hermayer KL, Strange C (2006) Evaluation of an intensive insulin protocol for septic patients in a medical intensive care unit. Crit Care Med 34:2974–2978
- Lacherade JC, Jabre P, Bastuji-Garin S, Grimaldi D, Fangio P, Theron V, Outin H, De Jonghe B (2007) Failure to achieve glycemic control despite intensive insulin therapy in a medical ICU: incidence and influence on ICU mortality. Intensive Care Med 33:814–821 CrossRef
- Tight glycaemic control by an automated algorithm with time-variant sampling in medical ICU patients
Intensive Care Medicine
Volume 34, Issue 7 , pp 1224-1230
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- Critically ill
- Insulin resistance
- Tight glycemic control
- Computer algorithm
- Industry Sectors
- Author Affiliations
- 1. Department of Internal Medicine, Medical University Graz, Stiftingtalstrasse 24, 8010, Graz, Austria
- 2. Department of Paediatrics, University of Cambridge, Cambridge, UK