Presentation
International Hospital Diabetes Meeting
American Diabetes Association Scientific Sessions
Date
May 2010
June 2010
Authors
Paul Davidson, R Dennis Steed, Bruce Bode, Harry Hebblewhite
Abstract
The optimal target BG range for critically ill patients is controversial. Normoglycemia has been publicized as ideal but many studies have failed to achieve this goal without severe hypoglycemia. NICE-SUGAR observed significantly higher mortality in the intensively managed group. Considering that the reason for this may be increased hypoglycemia, the guidelines of ADA/AACE have been revised. Multiple recent studies of intensive insulin management in ICUs have reported severe hypoglycemia ranging from 5.2% to 28.6%. In our combined non-CIIC data, the average rate of severe hypoglycemia is 10.6%. CIIC is a computerized system for advising on insulin dosing to control BG to any desired target with very limited hypoglycemia. When BG does drop insulin is phased out while enteral or parenteral nutrition continues. In a further move to prevent hypoglycemia the carbohydrate intake is augmented with a titrated D50 correcting glucose level to mid-target range. CIIC has been used in over 100 hospitals and is currently available to any investigators proposing a randomized control trial. The data available to the inventors of the device was {6693 runs in 18 hospitals, showing BGs <40 mg/dl in 1.1% of runs}. This compared favorably (p <0.0001), to both NICE-SUGAR, and to all the paper protocols. The data from the inventors’ current version, CIIC4, shows that severe hypoglycemia is virtually eliminated, i.e. 0.3% of 3095 runs without any BG <40 mg/dl. This is compared in the figure to other large studies.
Background
Glucommander
Glucommander is a computer-controlled algorithm for managing IV insulin, which is able to achieve any desired target range with very limited hypoglycemia. Its features are:
All-Glucommander Group, Versions and Sources of Data
Statistical comparison of All-Glucommander to Other Groups
(The combined All-Glucommander data: 5082 patients in 10 hospitals.)
Comparison to NICE-SUGAR:
Comparison to Tight-Control Paper Protocols:
Four tight-control paper protocols (*Di La Rosa used non-parametric methods) were combined and compared to All Glucommander:
Standard Deviation and Accuracy
Glucommander StDev = 25 mg/dl. The small Standard Deviation of Glucommander allows the Target Range to be placed with a fine degree of precision.
Conclusions of Comparison Study
It is possible with the Glucommander to implement tight glycemic control in all institutions and to achieve the ideal 110-140 range cited by ADA / AACE. We propose that more hospital settings should implement this effective, safe, and more normoglycemic algorithm, in an accurate, computer-controlled system.
Affiliations
Atlanta Diabetes Associates, Atlanta, Georgia.