OBJECTIVE
Intensive insulin therapy (IIT) in the critically ill reduces mortality but carries the risk of increased hypoglycemia. Point-of-care (POC) blood glucose analysis is standard; however anemia causes falsely high values and potentially masks hypoglycemia. Permissive anemia is routinely practiced in most intensive care units (ICUs). We hypothesized that POC glucometer error due to anemia is prevalent, can be mathematically corrected, and correction uncovers occult hypoglycemia during IIT.
DESIGN
The study has both retrospective and prospective phases. We reviewed data to verify the presence of systematic error, determine the source of error, and establish the prevalence of anemia. We confirmed our findings by reproducing the error in an in-vitro model. Prospective data was used to develop a correction formula validated by the Monte Carlo method. Correction was implemented in a burn ICU and results evaluated after nine months.
SETTING
Burn and trauma ICUs at a single research institution.
PATIENTS/SUBJECTS
Samples for in-vitro studies were taken from healthy volunteers. Samples for formula development were from critically ill patients on IIT.
INTERVENTIONS
Insulin doses were calculated based on predicted serum glucose values from corrected POC glucometer measurements.
MEASUREMENTS
Time-matched POC glucose, laboratory glucose, and hematocrit values.
MAIN RESULTS
We previously found that anemia (HCT<34%) produces systematic error in glucometer measurements. The error was correctible with a mathematical formula developed and validated using prospectively collected data. Error of uncorrected POC glucose ranged from 19% to 29% (p<0.001), improving to ≤5% after mathematical correction of prospective data. Comparison of data pairs before and after correction formula implementation demonstrated a 78% decrease in the incidence of hypoglycemia in critically ill and anemic patients treated with insulin and tight glucose control (p<0.001).
CONCLUSIONS
A mathematical formula that corrects erroneous POC glucose values due to anemia in ICU patients reduces the incidence of hypoglycemia during IIT.
Few training programs at Walter Reed have a dedicated leadership curriculum. The survey data provide important information for programs considering implementing a leadership development curriculum in terms of content and delivery.
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