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01-07-2008 | Original

Tight glycaemic control by an automated algorithm with time-variant sampling in medical ICU patients

Authors: Christoph Pachler, Johannes Plank, Heinz Weinhandl, Ludovic J. Chassin, Malgorzata E. Wilinska, Roman Kulnik, Peter Kaufmann, Karl-Heinz Smolle, Ernst Pilger, Thomas R. Pieber, Martin Ellmerer, Roman Hovorka

Published in: Intensive Care Medicine | Issue 7/2008

Abstract

Objective

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.

Design

Open randomised controlled trial.

Setting

Nine-bed medical intensive care unit (ICU) in a tertiary teaching hospital.

Patients and participants

Fifty mechanically ventilated medical ICU patients.

Interventions

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.

Conclusions

The eMPC algorithm was effective in maintaining tight glycaemic control in severely ill medical ICU patients.

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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 355:773–778PubMedCrossRef

Yendamuri S, Fulda GJ, Tinkoff GH (2003) Admission hyperglycemia as a prognostic indicator in trauma. J Trauma 55:33–38PubMedCrossRef

McCowen KC, Malhotra A, Bistrian BR (2001) Stress-induced hyperglycemia. Crit Care Clin 17:107–124PubMedCrossRef

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 345:1359–1367CrossRef

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 354:449–461CrossRef

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 30:798–803PubMedCrossRef

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 32:858–873PubMedCrossRef

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:R19PubMedCrossRef

Wilson M, Weinreb J, Hoo GW (2007) Intensive insulin therapy in critical care: a review of 12 protocols. Diabetes Care 30:1005–1011PubMedCrossRef

10.

Pittas AG, Siegel RD, Lau J (2004) Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials. Arch Intern Med 164:2005–2011PubMedCrossRef

11.

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 34:96–101PubMedCrossRef

12.

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 32:867–874PubMedCrossRef

13.

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 33:730–733PubMedCrossRef

14.

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 29:271–276PubMedCrossRef

15.

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

16.

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 33:2778–2785PubMedCrossRef

17.

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 33:2079–2084PubMedCrossRef

18.

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 5:38PubMedCrossRef

19.

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 25:905–920PubMedCrossRef

20.

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 6:307–318PubMedCrossRef

21.

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 30:804–810PubMedCrossRef

22.

Vogelzang M, van der Horst IC, Nijsten MW (2004) Hyperglycaemic index as a tool to assess glucose control: a retrospective study. Crit Care 8:R122–127PubMedCrossRef

23.

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

24.

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

25.

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 46:271–286CrossRef

26.

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 352:837–853CrossRef

27.

Cryer PE (2006) Hypoglycaemia: the limiting factor in the glycaemic management of the critically ill? Diabetologia 49:1722–1725PubMedCrossRef

28.

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 125:1007–1021PubMedCrossRef

29.

Meynaar IA, Dawson L, Tangkau PL, Salm EF, Rijks L (2007) Introduction and evaluation of a computerised insulin protocol. Intensive Care Med 33:591–596PubMedCrossRef

30.

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 34:2974–2978PubMed

31.

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 33:814–821PubMedCrossRef

Title: Tight glycaemic control by an automated algorithm with time-variant sampling in medical ICU patients
Authors: Christoph Pachler
Johannes Plank
Heinz Weinhandl
Ludovic J. Chassin
Malgorzata E. Wilinska
Roman Kulnik
Peter Kaufmann
Karl-Heinz Smolle
Ernst Pilger
Thomas R. Pieber
Martin Ellmerer
Roman Hovorka
Publication date: 01-07-2008
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 7/2008
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-008-1033-8

At a glance: The STEP trials

Springer Medicine

Tight glycaemic control by an automated algorithm with time-variant sampling in medical ICU patients

Abstract

Objective

Design

Setting

Patients and participants

Interventions

Measurements and main results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Objective

Design

Setting

Patients and participants

Interventions

Measurements and main results

Conclusions

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