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A comparison of two insulin infusion protocols in the medical intensive care unit by continuous glucose monitoring

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ABSTRACT

Background: Achieving good glycemic control in intensive care units (ICU) requires a safe and efficient insulin infusion protocol (IIP). We aimed to compare the clinical performance of two IIPs (Leuven versus modified Yale protocol) in patients admitted to medical ICU, by using continuous glucose monitoring (CGM). This is a pooled data analysis of two published prospective randomized controlled trials. CGM monitoring was performed in 57 MICU patients (age 64 ± 12 years, APACHE-II score 28 ± 7, non-diabetic/diabetic: 36/21). The main outcome measures were percentage of time in normoglycemia (80–110 mg/dl) and in hypoglycemia (<60 mg/dl), and glycemic variability (standard deviation, coefficient of variation, mean amplitude of glucose excursions, mean of daily differences).

Results: Twenty-two subjects were treated using the Leuven protocol and 35 by the Yale protocol; >63,000 CGM measurements were available. The percentage of time in normoglycemia (80–110 mg/dl) was higher (37 ± 15 vs. 26 ± 11%, p = 0.001) and percentage of time spent in hypoglycemia was lower (0[0–2] vs. 5[1–8]%, p = 0.001) in the Yale group. Median glycemia did not differ between groups (118[108–128] vs. 128[106–154] mg/dl). Glycemic variability was less pronounced in the Yale group (median SD 28[21–37] vs. 47[31–71] mg/dl, p = 0.001; CV 23[19–31] vs. 36[26–50]%, p = 0.001; MODD 35[26–41] vs. 60[33–94] mg/dl, p = 0.001). However, logistic regression could not identify type of IIP, diabetes status, age, BMI, or APACHE-II score as independent parameters for strict glucose control.

Conclusions: The Yale protocol provided better average glycemia, more time spent in normoglycemia, less time in hypoglycemia, and less glycemic variability than the Leuven protocol, but was not independently associated with strict glycemic control.

Electronic supplementary material: The online version of this article (doi:10.1186/s13613-016-0214-9) contains supplementary material, which is available to authorized users.

No MeSH data available.


Average percentage time in range and SD over the groups (Yale vs. Leuven) for the different glycemia target ranges. P < 0.0001 for all three ranges
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Fig1: Average percentage time in range and SD over the groups (Yale vs. Leuven) for the different glycemia target ranges. P < 0.0001 for all three ranges

Mentions: Patients in the Leuven group required much more IV insulin compared to those treated by the Yale protocol (Table 1). Despite a similar number of arterial blood glucose measurements, patients in the Yale protocol had better glucometrics with a higher percentage of time in target glycemia (80–110 mg/dl) (37 ± 15 vs. 26 ± 11%, p = 0.001) and a lower percentage of time spent in hypoglycemia (0[0–2] vs. 5[1–8]%, p = 0.001). Also percentage of time spent between 60 and 150 mg/dl (81 ± 7 vs. 66 ± 24%, p < 0.0001), 80–125 mg/dl (57 ± 18 vs. 36 ± 21%, p < 0.0001), between 80 and 145 mg/dl (74 ± 17 vs. 48 ± 23, p < 0.0001), and between 70 and 180 mg/dl (91 ± 10 vs. 69 ± 19%, p < 0.0001) was higher in the Yale group. Figure 1 shows the time-in-band for the different ranges of targets for both groups. Median glycemia, however, did not differ between groups (118[108–128] (log: 114[105–125]) vs. 128[106–154] (log: 122[99–136]) mg/dl) (Table 1). Glycemic variability was less pronounced with the use of the Yale protocol (median[IQR] SD 28[21–37] vs. 47[31–71] mg/dl, p = 0.001; median CV 23[19–31] vs. 36[26–50]%, p = 0.001; median MODD 35[26–41] vs. 60[33–94] mg/dl, p = 0.001). Significant better LBGI and HBGI were observed in the Yale group (Table 1). Eight insulin/glucose plots comparing non-diabetic and diabetic patients treated according to the Leuven protocol versus according to the modified Yale protocol are shown in Fig. 2, providing the reader with a good visual image.Fig. 1


A comparison of two insulin infusion protocols in the medical intensive care unit by continuous glucose monitoring
Average percentage time in range and SD over the groups (Yale vs. Leuven) for the different glycemia target ranges. P < 0.0001 for all three ranges
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5120161&req=5

Fig1: Average percentage time in range and SD over the groups (Yale vs. Leuven) for the different glycemia target ranges. P < 0.0001 for all three ranges
Mentions: Patients in the Leuven group required much more IV insulin compared to those treated by the Yale protocol (Table 1). Despite a similar number of arterial blood glucose measurements, patients in the Yale protocol had better glucometrics with a higher percentage of time in target glycemia (80–110 mg/dl) (37 ± 15 vs. 26 ± 11%, p = 0.001) and a lower percentage of time spent in hypoglycemia (0[0–2] vs. 5[1–8]%, p = 0.001). Also percentage of time spent between 60 and 150 mg/dl (81 ± 7 vs. 66 ± 24%, p < 0.0001), 80–125 mg/dl (57 ± 18 vs. 36 ± 21%, p < 0.0001), between 80 and 145 mg/dl (74 ± 17 vs. 48 ± 23, p < 0.0001), and between 70 and 180 mg/dl (91 ± 10 vs. 69 ± 19%, p < 0.0001) was higher in the Yale group. Figure 1 shows the time-in-band for the different ranges of targets for both groups. Median glycemia, however, did not differ between groups (118[108–128] (log: 114[105–125]) vs. 128[106–154] (log: 122[99–136]) mg/dl) (Table 1). Glycemic variability was less pronounced with the use of the Yale protocol (median[IQR] SD 28[21–37] vs. 47[31–71] mg/dl, p = 0.001; median CV 23[19–31] vs. 36[26–50]%, p = 0.001; median MODD 35[26–41] vs. 60[33–94] mg/dl, p = 0.001). Significant better LBGI and HBGI were observed in the Yale group (Table 1). Eight insulin/glucose plots comparing non-diabetic and diabetic patients treated according to the Leuven protocol versus according to the modified Yale protocol are shown in Fig. 2, providing the reader with a good visual image.Fig. 1

View Article: PubMed Central - PubMed

ABSTRACT

Background: Achieving good glycemic control in intensive care units (ICU) requires a safe and efficient insulin infusion protocol (IIP). We aimed to compare the clinical performance of two IIPs (Leuven versus modified Yale protocol) in patients admitted to medical ICU, by using continuous glucose monitoring (CGM). This is a pooled data analysis of two published prospective randomized controlled trials. CGM monitoring was performed in 57 MICU patients (age 64&nbsp;&plusmn;&nbsp;12&nbsp;years, APACHE-II score 28&nbsp;&plusmn;&nbsp;7, non-diabetic/diabetic: 36/21). The main outcome measures were percentage of time in normoglycemia (80&ndash;110&nbsp;mg/dl) and in hypoglycemia (&lt;60&nbsp;mg/dl), and glycemic variability (standard deviation, coefficient of variation, mean amplitude of glucose excursions, mean of daily differences).

Results: Twenty-two subjects were treated using the Leuven protocol and 35 by the Yale protocol; &gt;63,000 CGM measurements were available. The percentage of time in normoglycemia (80&ndash;110&nbsp;mg/dl) was higher (37&nbsp;&plusmn;&nbsp;15 vs. 26&nbsp;&plusmn;&nbsp;11%, p&nbsp;=&nbsp;0.001) and percentage of time spent in hypoglycemia was lower (0[0&ndash;2] vs. 5[1&ndash;8]%, p&nbsp;=&nbsp;0.001) in the Yale group. Median glycemia did not differ between groups (118[108&ndash;128] vs. 128[106&ndash;154]&nbsp;mg/dl). Glycemic variability was less pronounced in the Yale group (median SD 28[21&ndash;37] vs. 47[31&ndash;71] mg/dl, p&nbsp;=&nbsp;0.001; CV 23[19&ndash;31] vs. 36[26&ndash;50]%, p&nbsp;=&nbsp;0.001; MODD 35[26&ndash;41] vs. 60[33&ndash;94] mg/dl, p&nbsp;=&nbsp;0.001). However, logistic regression could not identify type of IIP, diabetes status, age, BMI, or APACHE-II score as independent parameters for strict glucose control.

Conclusions: The Yale protocol provided better average glycemia, more time spent in normoglycemia, less time in hypoglycemia, and less glycemic variability than the Leuven protocol, but was not independently associated with strict glycemic control.

Electronic supplementary material: The online version of this article (doi:10.1186/s13613-016-0214-9) contains supplementary material, which is available to authorized users.

No MeSH data available.