Analytic Review: Glucose Controversies in the ICU

Honiden, Shyoko; Inzucchi, Silvio E.

doi:10.1177/0885066610387892

Cited by 16 publications

(12 citation statements)

References 151 publications

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“…The clinicians in charge of a specific eProtocol incorporate new data as they are published. For example, when new studies regarding glycemic control in the ICU were published, eProtocol-insulin was updated to reflect the new data [36,37,[39][40][41]. By the time these studies were published, our cumulative experience using eProtocol was ample and we had significant data showing excellent performance and safety of eProtocol-insulin.…”

Section: Eprotocol Maintenancementioning

confidence: 99%

The evolution of eProtocols that enable reproducible clinical research and care methods

Blagev

Sward

Thompson

et al. 2012

J Clin Monit Comput

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Unnecessary variation in clinical care and clinical research reduces our ability to determine what healthcare interventions are effective. Reducing this unnecessary variation could lead to further healthcare quality improvement and more effective clinical research. We have developed and used electronic decision support tools (eProtocols) to reduce unnecessary variation. Our eProtocols have progressed from a locally developed mainframe computer application in one clinical site (LDS Hospital) to web-based applications available in multiple languages and used internationally. We use eProtocol-insulin as an example to illustrate this evolution. We initially developed eProtocol-insulin as a local quality improvement effort to manage stress hyperglycemia in the adult intensive care unit (ICU). We extended eProtocol-insulin use to translate our quality improvement results into usual clinical care at Intermountain Healthcare ICUs. We exported eProtocol-insulin to support research in other US and international institutions, and extended our work to the pediatric ICU. We iteratively refined eProtocol-insulin throughout these transitions, and incorporated new knowledge about managing stress hyperglycemia in the ICU. Based on our experience in the development and clinical use of eProtocols, we outline remaining challenges to eProtocol development, widespread distribution and use, and suggest a process for eProtocol development. Technical and regulatory issues, as well as standardization of protocol development, validation and maintenance, need to be addressed. Resolution of these issues should facilitate general use of eProtocols to improve patient care.

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Section: Eprotocol Maintenancementioning

confidence: 99%

The evolution of eProtocols that enable reproducible clinical research and care methods

Blagev

Sward

Thompson

et al. 2012

J Clin Monit Comput

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“…Post hoc multivariate logistic regression analysis of the study by van den Berghe et al suggests that the lowered blood glucose level rather than the insulin dose is related to the reduction in mortality (Van den Berghe et al, 2003). Apart from glucose lowering, insulin has a number of nonglycemic metabolic effects that may be important in critical illness (reviewed in (Honiden & Inzucchi, 2010)). Insulin can modulate inflammation via the mannose binding lectin pathway, via NF-kB and via modulation of pro-and anti-inflammatory cytokines.…”

Section: Glucose Is Toxic To the Brainmentioning

confidence: 99%

Hypoglycemia in Critically Ill Patients

Hoedemaekers¹,

Hoeven²

2011

Diabetes - Damages and Treatments

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“…Intensive insulin therapy was subsequently widely adopted outside of the clinical trial setting, but questions arose as newer studies failed to reproduce the initially positive reports [33]. Two studies, VISEP [12], and GLUCONTROL [34], had to be discontinued due to excessive rates of hypoglycemia.…”

Section: Insulin Infusion Therapy Debate --A Role For Systems Engineementioning

confidence: 99%

“…For instance, Van den Berghe's studies were done at a single center, with a high ratio of nurses to patients, using an insulin infusion protocol that entailed considerable clinical judgment from providers [35], and with the majority of BG measurements made from arterial blood on a point-of-care (POC) blood gas/glucose analyzer [33]. The NICE-SUGAR trial was an international, multicenter effort, which used a detailed insulin infusion protocol posted on the internet, contained a wide variety of patients, and permitted each hospital to use whatever BG measurement method that was in its normal practice-point-of-care handheld glucose monitors, blood gas/glucose analyzers, or laboratory (Simon Finfer, personal communication, February 17, 2010).…”

Section: Insulin Infusion Therapy Debate --A Role For Systems Engineementioning

confidence: 99%

“…The use of less accurate techniques has so far been justified by their practicality and the thought that benefits (e.g. rapid turnaround, less blood loss, infection risk) outweighed risks of methods to obtain more accurate BG measurements [33]. Besides the source of blood (capillary, venous, or arterial), the state of the patient's circulatory perfusion (peripheral vasoconstriction, shock) and interfering substances (e.g.…”

Section: Insulin Infusion Therapy Debate --A Role For Systems Engineementioning

confidence: 99%

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Simulation of Glycemic Variability in Critically Ill Burn Patients

Ortiz

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AcknowledgementWithout the patient, thoughtful guidance of my advisor, Dr. Stephen Patek, I could not have come this far or look forward to so much more. Thank you, Steve.The faculty of the Center for Diabetes Technology, Drs. Boris Kovatchev, Marc Breton, Leon Farhi, and Stephen Patek, have created and nurtured a first-class learning environment, which I was extremely fortunate to have experienced. They employ and share their knowledge with a zest that I am sure comes from their love of the work they It has been a delight to be with all of you. AbstractTight glycemic control with insulin therapy protocols in the intensive care unit (ICU) can reduce mortality and morbidity from stress-induced hyperglycemia, but this control comes with the risk of hypoglycemia. Computer simulation can be an essential tool in evaluating protocols for insulin delivery in this setting, and to this end, it is necessary to have mathematical models that explain BG variability within this patient population.Current models of stress-induced hyperglycemia do not adequately incorporate the known physiology of stress hyperglycemia and are limited in their ability to account for the resistance to the actions of insulin found in these patients. In this thesis, we develop, validate, and illustrate applications for a new model of glucose variability. The new model is built from an existing model of glucose-insulin interactions for normal, pre-diabetic, and type II diabetic patients, with new features that account for the effects of trauma and physiological stress commonly experienced in the ICU. Hourly blood glucose, insulin, and feeding data from 154 burn-unit patients were input to our model. The in silico patient whose simulated BG most closely matched the BG of a burn-unit patient was determined with the method of least squares. For this in silico patient, a time-varying coefficient ("SA", stress action) was fitted to modify hepatic glucose production (HGP) and peripheral glucose uptake (PGU) to produce a simulated BG that matched a BG of a burn-unit patient. HGP was limited to a literature-derived maximum of 4.25 mg/kg/min. From the data of the 154 unique burn-unit patients, 212 SA vectors of at least 24 hours each and 86 unique in silico patients were identified. The simulator incorporating this model is validated by comparing cumulative distributions of simulated BGs with the cumulative distribution of real burn-unit BGs under the same intensive insulin therapy protocol used in the original data collection. This simulator, coded into a MATLAB Simulink simulation model, allows for testing insulin protocols in silico, before use in patients. As an illustrative application, the simulation model is used to optimize process control thresholds for an insulin protocol used in the burn unit.

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Analytic Review: Glucose Controversies in the ICU

Cited by 16 publications

References 151 publications

The evolution of eProtocols that enable reproducible clinical research and care methods

The evolution of eProtocols that enable reproducible clinical research and care methods

Hypoglycemia in Critically Ill Patients

Simulation of Glycemic Variability in Critically Ill Burn Patients

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