Research

Computerized intensive insulin dosing can mitigate hypoglycemia and achieve tight glycemic control when glucose measurement is performed frequently and on time

Rattan Juneja¹ , Corbin P Roudebush^{^ 2} , Stanley A Nasraway³ , Adam A Golas² , Judith Jacobi⁴ , Joni Carroll⁴ , Deborah Nelson⁵ , Victor J Abad⁶ and Samuel J Flanders⁷

¹Division of Endocrinology, Indiana University School of Medicine, 545 Barnhill Drive, EH 421, Indianapolis, IN 46202, USA

²Department of Medicine and Clarian Health, Indiana University School of Medicine, 545 Barnhill Drive, EH 421, Indianapolis, IN 46202, USA

³Department of Surgery, Tufts Medical Center, Tufts University School of Medicine, 750 Washington Street, NEMC Box 4630, Boston, MA 02111, USA

⁴Methodist Hospital/Clarian Health, 1701 N. Senate Blvd., Indianapolis, IN 46202, USA

⁵Medical Quality, Clarian Health, ERC 6102, 1701 N. Senate Blvd., Indianapolis, IN 46202, USA

⁶The Epsilon Group Virginia LLC, 615 Woodbrook Drive, Charlottesville, VA 22901, USA

⁷William Beaumont Hospital, 3601 W 13 Mile Road, Royal Oak, MI 48073-9952, USA

author email corresponding author email^Deceased

Critical Care 2009, 13:R163doi:10.1186/cc8129

Published:	12 October 2009

Abstract

Introduction

Control of blood glucose (BG) in critically ill patients is considered important, but is difficult to achieve, and often associated with increased risk of hypoglycemia. We examined the use of a computerized insulin dosing algorithm to manage hyperglycemia with particular attention to frequency and conditions surrounding hypoglycemic events.

Methods

This is a retrospective analysis of adult patients with hyperglycemia receiving intravenous (IV) insulin therapy from March 2006 to December 2007 in the intensive care units of 2 tertiary care teaching hospitals. Patients placed on a glycemic control protocol using the Clarian GlucoStabilizer™ IV insulin dosing calculator with a target range of 4.4-6.1 mmol/L were analyzed. Metrics included time to target, time in target, mean blood glucose ± standard deviation, % measures in hypoglycemic ranges <3.9 mmol/L, per-patient hypoglycemia, and BG testing interval.

Results

4,588 ICU patients were treated with the GlucoStabilizer to a BG target range of 4.4-6.1 mmol/L. We observed 254 severe hypoglycemia episodes (BG <2.2 mmol/L) in 195 patients, representing 0.1% of all measurements, and in 4.25% of patients or 0.6 episodes per 1000 hours on insulin infusion. The most common contributing cause for hypoglycemia was measurement delay (n = 170, 66.9%). The median (interquartile range) time to achieve the target range was 5.9 (3.8 - 8.9) hours. Nearly all (97.5%) of patients achieved target and remained in target 73.4% of the time. The mean BG (± SD) after achieving target was 5.4 (± 0.52) mmol/L. Targeted blood glucose levels were achieved at similar rates with low incidence of severe hypoglycemia in patients with and without diabetes, sepsis, renal, and cardiovascular disease.

Conclusions

Glycemic control to a lower glucose target range can be achieved using a computerized insulin dosing protocol. With particular attention to timely measurement and adjustment of insulin doses the risk of hypoglycemia experienced can be minimized.