Glucommander

Abstract

OBJECTIVE -Intravenous insulin is now the recommended method of diabetes management in critically ill persons in the hospital. The published methods for administering the insulin are complex and are usually limited to intensive care units with a low patient-to-nurse ratio. RESEARCH DESIGN AND METHODS-A computer-directed algorithm for advice on the delivery of intravenous insulin that is flexible in blood glucose timing and advises insulin dosing in a graduated manner has been developed. This software program, known as the Glucommander, has been used extensively by our group. The data were analyzed for this study.RESULTS -The data from 5,080 intravenous insulin runs over 120,683 h show that blood glucose levels can be safely stabilized in a target range without significant hypoglycemia by nonspecialized nurses working on any unit of a general hospital. The mean glucose level reached Ͻ150 mg/dl in 3 h. Only 0.6% of all glucose values were Ͻ50 mg/dl. The prevalence of hypoglycemia Ͻ40 mg/dl was 2.6% of all runs. No hypoglycemia was severe.CONCLUSIONS -This computer-directed algorithm is a simple, safe, effective, and robust method for maintaining glycemic control. It has been extensively studied and is applicable in a wide variety of conditions. In contrast to other published intravenous insulin protocols, which have been limited to intensive care units, Glucommander can be used in all units of any hospital. Diabetes Care 28:2418 -2423, 2005A large, randomized, controlled trial of patients admitted to a surgical intensive care unit in Leuven, Belgium, and reported by Van den Berghe et al. (1) showed that regulation of blood glucose levels to Ͻ110 mg/dl using an intravenous insulin protocol improved clinical outcomes. In the Leuven study, intensive insulin therapy reduced intensive care unit (ICU) mortality by 34% and also reduced sepsis, the need for dialysis, prolonged ventilator support, and the duration of ICU stay.Strict glycemic control has been demonstrated to be beneficial in other settings as well, with intravenous insulin in preference to the subcutaneous route in many clinical situations, including diabetic ketoacidosis and the nonketotic hyperosmolar state (2), critical care illness (1), myocardial infarction or cardiogenic shock (3-5), and the postoperative period after cardiac surgical procedures (6). Other indications for intravenous insulin infusion therapy include use in patients with diabetes who are receiving nothing by mouth, general perioperative care, total parental nutrition, or high-dose corticosteroid therapy; in patients who have had a stroke; in women during labor and delivery; as a dose-finding strategy in anticipation of initiation of subcutaneous insulin; and in prevention or treatment of infection.Based on the emerging clinical evidence, there are widespread efforts to maintain very strict glycemic control in critically ill patients. However, achieving this goal requires extensive nursing efforts, including frequent bedside capillary glucose monitoring and the implementation of compl...

Blood glucose control using a computer-guided glucose management system in allogeneic hematopoietic cell transplant recipients

“…38 Our data, in a more difficult population, are comparable to other CGGM data, in which, among over 5000 insulin runs (over 120 000 h) 0.6% of values were found to be o 50 mg/dL. 28 Hypoglycemia will always remain a limiting factor of insulin therapy, but the frequency of hypoglycemia in our study is minimal as we documented no levels below 50 mg/dL and only 0.9% below 70 mg/dL.…”

“…28 Using a physician-selected glucose target range and a weightbased multiplier, the computer-based algorithm calculates and recommends an insulin infusion rate and interval to next BG measurement. To initiate the system a desired BG target, patient's weight and BG value are manually entered by a health-care provider, and the initial insulin infusion rate and the time for the next BG measurement are calculated by the software.…”

Tight glycemic control in critical care – The leading role of insulin sensitivity and patient variability: A review and model-based analysis

“…Other protocols, adjust based on a surrogate response to insulin decreases (e.g. resistance increases) [116,117], but do so in fixed multiples, rather than via an explicit or patient-specific algorithm.…”

Impact of improvement efforts on glycemic control and hypoglycemia at a University Medical Center

“…These characteristics included easy physician ordering (requiring only a signature), ability to quickly reach and maintain a BG target range, minimal risk for hypoglycemic events, adaptability for use anywhere in the hospital setting, and acceptance and implementation by nursing staff. 16 The IV protocol, a web-based calculator (Figure 1), was developed based on the concept of the multiplier by White et al 17 For this protocol, the IV infusion (IVI) rate is changed based on a formula that uses a ''multiplier'' (a surrogate for insulin sensitivity factor) and the difference between measured BG and target blood glucose (TBG). The calculator uses the following mathematical formula: rate of insulin infusion/hour ¼ (current BG À 60 mg/dL) Â 0.03.…”