title: The impact of measurement frequency on the domains of glycemic control in the critically ill--a Monte Carlo simulation.
abstract: The role of blood glucose (BG) measurement frequency on the domains of glycemic control is not well defined. This Monte Carlo mathematical simulation of glycemic control in a cohort of critically ill patients modeled sets of 100 patients with simulated BG-measuring devices having 5 levels of measurement imprecision, using 2 published insulin infusion protocols, for 200 hours, with 3 different BG-measurement intervals-15 minutes (Q15'), 1 hour (Q1h), and 2 hours (Q2h)-resulting in 1,100,000 BG measurements for 3000 simulated patients. The model varied insulin sensitivity, initial BG value and rate of gluconeogenesis. The primary outcomes included rates of hyperglycemia (BG > 180 mg/dL), hypoglycemia (BG < 70 and 40 mg/dL), proportion of patients with elevated glucose variability (within-patient coefficient of variation [CV] > 20%), and time in range (BG ranges 80-150 mg/dL and 80-180 mg/dL). Percentages of hyperglycemia, hypoglycemia at both thresholds, and patients with elevated glucose variability as well as time outside glycemic targets were substantially higher in simulations with measurement interval Q2h compared to those with measurement interval Q1h and moderately higher in simulations with Q1h than in those with Q15'. Higher measurement frequency mitigated the deleterious effect of high measurement imprecision, defined as CV ≥ 15%. This Monte Carlo simulation suggests that glycemic control in critically ill patients is more optimal with a BG measurement interval no longer than 1h, with further benefit obtained with use of measurement interval of 15'. These findings have important implications for the development of glycemic control standards.
authors.affiliation: Division of Critical Care, Stamford Hospital, Stamford, CT, USA Columbia University College of Physicians and Surgeons, New York, NY, USA jkrinsley@stamhealth.org.
authors.forename: James S
authors.initials: JS
authors.lastname: Krinsley
authors.affiliation: Department of Pathology, University of Virginia, Charlottesville VA, USA.
authors.forename: David E
authors.initials: DE
authors.lastname: Bruns
authors.affiliation: Department of Pathology, University of Virginia, Charlottesville VA, USA.
authors.forename: James C
authors.initials: JC
authors.lastname: Boyd
mesh_terms: D001786:Blood Glucose / Q000032:analysis*; D016638:Critical Illness; D003920:Diabetes Mellitus / Q000097:blood; D006801:Humans; D006943:Hyperglycemia / Q000097:blood; D007003:Hypoglycemia / Q000097:blood; D009010:Monte Carlo Method
chemical_list: D001786:Blood Glucose
keywords: Monte Carlo simulation; blood glucose; critically ill; glucose variability; hyperglycemia; hypoglycemia; monitoring frequency; time in range