Abstract
Background: Despite guidelines that recommend strongly against Sliding Scale Insulin (SSI) it continues to be the most commonly insulin regimen used in hospitals to treat hyperglycemia. In addition to being reactionary to a glucose that has already increased, SSI offers practical challenges in the randomness of the doses of insulin prescribed and often a disconnect with glucose testing that should be occurring in congruence to the insulin dosing. While many clinical trials have shown improved glycemic control in critical care patients receiving intravenous insulin; few studies have demonstrated the efficacy of subcutaneous (SQ) insulin in this setting. In this study, we have evaluated the safety and efficacy of SQ insulin administration utilizing a computerized program, the Clarian GlucoStabilizer™ Subcutaneous Program (CGS-SQ) in the intensive care unit (ICU). This program is designed to overcome some of the most common barriers of SQ insulin delivery, those of dose calculation and timing. Methods: A computerized SQ insulin delivery program -The Clarian GlucoStabilizer™ Subcutaneous Program (CGS-SQ)- was made available to ICU practitioners, facilitating standardized calculation of insulin doses and incorporating reminder alarms for blood glucose (BG) testing. This program used three defaults Insulin Sensitivity Factors (ISF) and Insulin to Carbohydrate Ratios (CR) to calculate insulin doses. Additionally, there is an option for practitioner determined ISF and ICR. Patients, aged ≥ 18 years, initiated on the CGS-SQ and admitted to the (ICU) were eligible for inclusion in this retrospective evaluation. Patients were divided into four groups based on initial insulin sensitivity factor (ISF) and carbohydrate ratio (CR). Three of the groups used a default ISF and CR; ISF 60, CR 15; ISF 30, CR 10 and ISF 15, CR 8. These groups were compared with those where the practitioner specified an individualized ISF and CR, referred to as PDS (practitioner defined setting). Primary endpoints included: mean glucose, time to target glucose, hyperglycemic and hypoglycemic events. Results: In the 1,384 patients identified, patients initiated with a predefined setting had lower mean glucose compared to patients with PDS (ISF 60, CR 15: 135 mg/dL vs. ISF 30, CR 10: 140 mg/dL vs. ISF 15, CR 8: 134 mg/dL vs. PDS: 143 mg/dL; p < 0.0001). Patients in the default settings had shorter time to target glucose and decreased incidence of hyperglycemia and hypoglycemia. Conclusions: Using a system of computerized prompts with standardization of insulin dose calculation, SQ insulin can be effectively used in the treatment of ICU patients to target BG of 100-150 mg/dL with minimal risk of hypoglycemia.
Highlights
Hyperglycemia in the critical care setting has shown to contribute to increased morbidity and mortality and canlead to multiple complications such as increased risk of infection, increased mechanical ventilation time, changes in hemodynamics, and changes in renal function [1, 2]
Seven hundred seventy-one patients (56%) had initial blood glucose readings outside their target glucose range (100-150 mg/dl); in the remainder, the program was initiated by the practitioner presumably to keep BG in target of 100-150 mg/dl during the intensive care unit (ICU) stay
The Clarian GlucoStabilizer (CGS-SQ) is the first software program that has evaluated the effectiveness of SQ insulin in the treatment of the critically ill patient
Summary
Hyperglycemia in the critical care setting has shown to contribute to increased morbidity and mortality and canlead to multiple complications such as increased risk of infection, increased mechanical ventilation time, changes in hemodynamics, and changes in renal function [1, 2]. The results of our computerized Clarian GlucoStabilizerTM Intravenous Program (CGS-IV) demonstrating its effectiveness and safety in achieving and maintaining tight glucose targets in the ICU[10]. We have evaluated the safety and efficacy of SQ insulin administration utilizing a computerized program, the Clarian GlucoStabilizerTM Subcutaneous Program (CGS-SQ) in the intensive care unit (ICU). This program is designed to overcome some of the most common barriers of SQ insulin delivery, those of dose calculation and timing
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