title: Computerized intensive insulin dosing can mitigate hypoglycemia and achieve tight glycemic control when glucose measurement is performed frequently and on time.
abstract: BACKGROUND
  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.
authors.affiliation: Division of Endocrinology, Indiana University School of Medicine, 545 Barnhill Drive, EH 421, Indianapolis, IN 46202, USA. rajuneja@iupui.edu
authors.forename: Rattan
authors.initials: R
authors.lastname: Juneja
authors.forename: Corbin P
authors.initials: CP
authors.lastname: Roudebush
authors.forename: Stanley A
authors.initials: SA
authors.lastname: Nasraway
authors.forename: Adam A
authors.initials: AA
authors.lastname: Golas
authors.forename: Judith
authors.initials: J
authors.lastname: Jacobi
authors.forename: Joni
authors.initials: J
authors.lastname: Carroll
authors.forename: Deborah
authors.initials: D
authors.lastname: Nelson
authors.forename: Victor J
authors.initials: VJ
authors.lastname: Abad
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Flanders
mesh_terms: D000328:Adult; D000465:Algorithms; D001786:Blood Glucose / Q000032:analysis*; D004360:Drug Therapy, Computer-Assisted / Q000295:instrumentation / Q000592:standards*; D038321:Glycemic Index; D006801:Humans; D007003:Hypoglycemia / Q000517:prevention & control*; D007262:Infusions, Intravenous; D007328:Insulin / Q000008:administration & dosage* / Q000494:pharmacology; D007362:Intensive Care Units; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D001786:Blood Glucose; D007328:Insulin