Hypoglycemia Prevention by Algorithm Design During Intravenous Insulin Infusion
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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.
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.
KeywordsHypoglycemia Critical care Insulin protocol Insulin infusion Best practices Critical care protocols
Continuous glucose monitoring
Intensive care unit
Infusion rate of insulin
Maintenance rate of insulin infusion
Compliance with Ethical Standards
Conflict of Interest
Susan Shapiro Braithwaite has a patent for an insulin algorithm which has not yet been embodied as a device (U.S. Patent No. 8,721,584 issued). She is on the Editorial Board for Endocrine Practice, as an Associate Editor. She also receives honoraria form the American Diabetes Association for book reviews.
Lisa P. Clark, Thaer Idrees, Faisal Qureshi, and Oluwakemi T. Soetan declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
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