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Tight Glucose Control in Critically Ill Patients Using a Specialized Insulin-Nutrition Table

Tight Glucose Control in Critically Ill Patients Using a Specialized Insulin-Nutrition Table. Development Implementation of the SPRINT Protocol T. Lonergan , J.G. Chase, A. Le Compte, M. Willacy et al. Department of Mechanical Engineering Centre for Bio-Engineering University of Canterbury

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Tight Glucose Control in Critically Ill Patients Using a Specialized Insulin-Nutrition Table

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  1. Tight Glucose Control in Critically Ill Patients Using a Specialized Insulin-Nutrition Table Development Implementation of the SPRINT Protocol T. Lonergan, J.G. Chase, A. Le Compte, M. Willacy et al. Department of Mechanical Engineering Centre for Bio-Engineering University of Canterbury Christchurch, New Zealand

  2. Overview • Background • Stress-induced hyperglycaemia • Active Insulin Control (AIC) • SPRINT • Introduction • Development • Clinical Testing and Results

  3. Background • Stress-Induced hyperglycaemia prevalent in critical care • Impaired endogenous insulin production • Increased effective insulin resistance • Average blood glucose values > 10mmol/L not uncommon in some critical care units (over length of stay) • Tight control  better outcomes: • Reduced mortality 27-43% (4.0-7.75 mmol/L) [van den Berghe et al, 2001; Krinsley, 2004; …] • Reduced length of stay and length of mechanical ventilation Goal: Keep Blood Glucose ~Normal (4.0 – 6.0 mmol/L, 75 – 110 dg/mL)

  4. Active Insulin Control Evolution AIC 1 – 3 Development of Mathematical Model + 1st Trials  Insulin-only AIC 4 Computerised Control Protocol  Insulin + Nutrition • AIC 5 • Develop new protocol with same (or better) control • Easy to implement in clinical environment • Compare to international protocols

  5. SPRINT Step 1 = Feed Rate Table Requires current glucose measurement and last hour change in glucose

  6. SPRINT Step 2 = Insulin Table Requires current glucose measurement, last hour change and last hours insulin bolus If feed rate = 0 use only insulin wheel

  7. Clinical Testing • Virtual trials using fitted long term patient data to create virtual patient responses • Tests algorithms and methods safely • Provides insight into potential long term usage • 33+ Clinical trials in Christchurch ICU • Clinical proof of concept • Ethical consent granted by Canterbury Ethics Committee • Process Improvement Change

  8. Development & Protocol Comparison SPRINT Protocol AIC4 Protocol Mayo Clinic Protocol (Krinsley) Leuven Protocol (van den Berghe et al) Bath University Protocol Yale University Protocol CDHB Insulin Sliding Scale Protocol Aggressive Insulin Sliding Scale Protocol • Goal #1 = SPRINT ≥ Best Clinical Practice • Goal #2 = Effectiveness of AIC4 with ease of Leuven Protocol Insulin rate BG level Standard Aggressive < 4 mmol/L 0 U/hr 0 U/hr 0 U/hr 4 – 5.9 mmol/L 1 U/hr 1 U/hr 6 – 7.9 mmol/L 2 U/hr 2 U/hr 8 – 9.9 mmol/L 3 U/hr 4 U/hr 10 – 11.9 mmol/L 4 U/hr 6 U/hr 12 – 13.9 mmol/L 5 U/hr 6 U/hr >= 14 mmol/L 6 U/hr 6 U/hr • Use same virtual trial cohort as previously to test all protocols

  9. Protocol Comparison Results 45% 25% Bad! Also Bad! Very Bad! Not Trying?

  10. Clinical Results • 4688 total hours of control • 3578 measurements (47.4% two-hourly) • Overall Average BG = 5.9 +/- 0.9 mmol/L • Time in 4-6.1 mmol/L = 59.363% • Time in 4-7.0 mmol/L = 86% • Time in 4-7.75 mmol/L = 94% • Percentage of measurements < 4 mmol/L = 1.8% • Percentage of measurements < 3 mmol/L = 0.0% • Minimum 3.1 mmol/L Extremely tight control !

  11. Clinical Results • Average Insulin = 2.6 U/hr • Average Feed = 62% = 1150 kcal/day!!!! • versus prior hospital rate of 58%! • Age: Mean = 55, Range = 27-84 • APACHE II (Risk of Death) = 20 (36.7%) • APACHE III = 58 • SAPS II (Risk of Death) = 43 (33.3%) • Mortality (at ICU discharge) = 24.2%

  12. Conclusions • Implemented tight glycaemic control into the ICU • Developed a simple, easy-to-use system: SPRINT • High compliance by clinical staff due to ease of use • Performance amongst the best in the world • 33+ patients and growing • Clinical results match desired outcomes • Exceed published protocols by 3-5x on variation • Better average glucose for same or less insulin • Much more critically ill cohort

  13. Acknowledgements Jason Wong & AIC4 Assoc. Prof. Geoff Chase Jessica Lin & AIC3 Dunedin Maths and Stats Gurus Thomas Lotz The Danes Dr Kirsten McAuley Prof Jim Mann Prof Graeme Wake Dr Bob Broughton Mike Willacy Aaron Le Compte Dr Dom Lee Dr Chris Hann Prof Steen Andreassen AIC2 & Dr. G. Shaw

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