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

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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
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Overview

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

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Background

• Stress-Induced hyperglycaemia prevalent in
  critical care
• Impaired endogenous insulin production
• Increased effective insulin resistance
• Average blood glucose values gt 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)
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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

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

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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 lt 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 gt 14 mmol/L 6 U/hr 6 U/hr

• Use same virtual trial cohort as previously to
  test all protocols

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Protocol Comparison Results
45
25
Bad!
Also Bad!
Very Bad!
Not Trying?
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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 lt 4 mmol/L 1.8
• Percentage of measurements lt 3 mmol/L 0.0
• Minimum 3.1 mmol/L

Extremely tight control !
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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

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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

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Acknowledgements
AIC2 Dr. G. Shaw