The treatment of hyperglycaemia in critically ill patients: comparison of standard protocol and computer algorithm

Česká verzia

Authors: J. Křemen ¹; J. Bláha ²; P. Kopecký ²; L. Bošanská ¹; E. Kotrlíková ¹; T. Roubíček ¹; K. Anderlová ¹ ; Š. Svačina ¹; M. Matias ²; J. Rulíšek ²; R. Hovorka ³; M. Haluzík ¹
Authors place of work: III. interní klinika 1. lékařské fakulty UK a VFN Praha, přednosta prof. MUDr. Štěpán Svačina, DrSc., MBA ¹; Klinika anesteziologie, resuscitace a intenzivní medicíny 1. lékařské fakulty UK a VFN Praha, přednosta MUDr. Martin Stříteský, CSc. ²; Department of Paediatrics, School of Clinical Medicine, University of Cambridge, Velká Británie, přednosta prof. Ieuan Hughes, MD, Ph. D. ³
Published in the journal: Vnitř Lék 2007; 53(12): 1269-1273
Category: Original Contributions

Summary

Introduction:
Hyperglycemia is commonly observed in patients hospitalized on intensive care units. It is has been demonstrated that normalization of blood glucose level using intensive insulin therapy significantly improves prognosis of these patients. The aim of our study was comparison of standard protocol of intensive insulin therapy used on cardiac surgery ICU in General University Hospital in Prague and computer algorithm MPC (Model Predictive Control).

Patients and methods:
20 patients with glycaemia higher than 6.7 mmol/l at the time of admission to ICU were included into the study, 10 subjects were randomized for standard treatment, 10 for treatment with MPC algorithm. Glycaemia was measured hourly during 48 hours, insulin infusion was rate was adjusted hourly in MPC algorithm or in 1–2 hours in standard protocol group.

Results:
Blood glucose levels were in the target range significantly longer in MPC relative to standard protocol group (26.3 ± 2.1 hrs vs 20.3 ± 2.5 hrs). Mean blood glucose was also lower using MPC algorithm (6.47 ± 0.11 vs 6.72 ± 0.23 mmol/l). On the contrary the target range was established faster using standard protocol (8.9 ± 1.2 vs 10.3 ± 0.9 hrs), duration of hyperglycaemia was the same in both groups (7.3 ± 1.9 in standard protocol vs 7.3 ± 1.3 hrs in MPC algorithm). Average 48-hours insulin dose was higher in MPC than standard protocol group (230.2 ± 38.8 vs 199.1 ± 27.8 IU/48 hrs). 2 hypoglycaemic episodes occured in 2 patients in standard protocol group.

Conclusions:
Our results show that the use of MPC algorithm result in more effective blood glucose control in critically ill patients than standard protocol.

Keywords:
tight control of blood glucose – critically ill patients – computer algorithm

Zdroje

1. Aulak KS, Koeck T, Crabb JW et al. Dynamics of protein nitration in cells and mitochondria. Am J Physiol Heart Circ Physiol 2004; 286: H30-H38.

2. Basi S, Pupim LB, Simmons EM et al. Insulin resistance in critically ill patients with acute renal failure. Am J Physiol Renal Physiol 2005; 289: F259-F264.

3. Beckman JA, Goldfine AB, Gordon MB et al. Ascorbate restores endothelium-dependent vasodilation impaired by acute hyperglycemia in humans. Circulation 2001; 103: 1618-1623.

4. Butler SO, Btaiche IF, Alaniz C. Relationship between hyperglycemia and infection in critically ill patients. Pharmacotherapy 2005; 25: 963-976.

5. Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project. Endocr Pract 2004; 10(Suppl 2): 21-33.

6. Goldberg PA, Siegel MD, Sherwin RS et al. Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care 2004; 27: 461-467.

7. Grimble RF. Inflammatory status and insulin resistance. Curr Opin Clin Nutr Metab Care 2002; 5: 551-559.

8. Hovorka R, Canonico V, Chassin LJ et al. Nonlinear model predictive control of glucose concentration in subjects with type 1 diabetes. Physiol Meas 2004; 25: 905-920.

9. Hovorka R, Chassin LJ, Wilinska ME et al. Closing the loop: the adicol experience. Diabetes Technol Ther 2004; 6: 307-318.

10. Johan Groeneveld AB, Beishuizen A, Visser FC. Insulin: a wonder drug in the critically ill? Crit Care 2002; 6: 102-105.

11. Křemen J, Bláha J, Matias M et al. Monitorování glykemie u kriticky nemocných pacientů: srovnání arteriálních a intersticiálních hladin glukózy měřených pomocí mikrodialýzy tukové tkáně. Vnitř Lék 2006; 52: 777-781.

12. Levi M, ten Cate H. Disseminated intravascular coagulation. N Engl J Med 1999; 341: 586-592.

13. Marfella R, Nappo F, De Angelis L et al. Hemodynamic effects of acute hyperglycemia in type 2 diabetic patients. Diabetes Care 2000; 23: 658-663.

14. Marfella R, Nappo F, De Angelis L et al. The effect of acute hyperglycaemia on QTc duration in healthy man. Diabetologia 2000; 43: 571-575.

15. Marik PE, Raghavan M. Stress-hyperglycemia, insulin and immunomodulation in sepsis. Intensive Care Med 2004; 30: 748-756.

16. McCowen KC, Malhotra A, Bistrian BR. Stress-induced hyperglycemia. Crit Care Clin 2001; 17: 107-124.

17. Mechanick JI. Metabolic mechanisms of stress hyperglycemia. JPEN J Parenter Enteral Nutr 2006; 30: 157-163.

18. Mizock BA. Alterations in carbohydrate metabolism during stress: a review of the literature. Am J Med 1995; 98: 75-84.

19. Pittas AG, Siegel RD, Lau J. Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials. Arch Intern Med 2004; 164: 2005-2011.

20. Scott JF, Robinson GM, French JM et al. Glucose potassium insulin infusions in the treatment of acute stroke patients with mild to moderate hyperglycemia: the Glucose Insulin in Stroke Trial (GIST). Stroke 1999; 30: 793-799.

21. Title LM, Cummings PM, Giddens K et al. Oral glucose loading acutely attenuates endothelium-dependent vasodilation in healthy adults without diabetes: an effect prevented by vitamins C and E. J Am Coll Cardiol 2000; 36: 2185-2191.

22. Van den Berghe G. How does blood glucose control with insulin save lives in intensive care? J Clin Invest 2004; 114: 1187-1195.

23. Van den Berghe G. Neuroendocrine pathobiology of chronic critical illness. Crit Care Clin 2002; 18: 509-528.

24. Van den Berghe G, Wilmer A, Hermans G et al. Intensive insulin therapy in the medical ICU. N Engl J Med 2006; 354: 449-461.

25. Van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345: 1359-1367.

26. Williams SB, Goldfine AB, Timimi FK et al. Acute hyperglycemia attenuates endothelium-dependent vasodilation in humans in vivo. Circulation 1998; 97: 1695-1701.