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Tight Glucose Control in Tight Glucose Control in Critically Ill Patients Using a Critically Ill Patients Using a Specialized Insulin-Nutrition Specialized Insulin-Nutrition
TableTable
Development Implementation of the SPRINT Protocol
T. Lonergan, J.G. Chase, A. Le Compte, M. Willacy et al.
Department of Mechanical EngineeringCentre for Bio-EngineeringUniversity of Canterbury
Christchurch, New Zealand
OverviewOverview
• Background– Stress-induced hyperglycaemia– Active Insulin Control (AIC)
• SPRINT– Introduction– Development
• Clinical Testing and Results
BackgroundBackground
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)
AIC 5
• Develop new protocol with same (or better) control
• Easy to implement in clinical environment
• Compare to international protocols
Active Insulin Control Active Insulin Control EvolutionEvolution
AIC 4 Computerised Control Protocol
Insulin + Nutrition
AIC 1 – 3 Development of Mathematical Model + 1st Trials
Insulin-only
SPRINT Step 1 = Feed Rate SPRINT Step 1 = Feed Rate Table Table
Requires current glucose measurement and last hour change in glucose
SPRINT Step 2 = Insulin TableSPRINT Step 2 = Insulin Table
If feed rate = 0 use only insulin wheel
Requires current glucose measurement, last hour change and last hours insulin bolus
Clinical TestingClinical 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
Development & Protocol Development & Protocol ComparisonComparison
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
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
• Goal #1 = SPRINT ≥ Best Clinical Practice
• Goal #2 = Effectiveness of AIC4 with ease of Leuven Protocol
• Use same virtual trial cohort as previously to test all protocols
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0 2 4 6 8 10 12 14 16 18 20
Blood glucose level [mmol/L]
Den
sity
of
mea
sure
men
ts
SPRINT
AIC4
Bath
Leuven
Mayo Clinic
Yale
Sliding Scale
Aggressive sliding scale
Protocol Comparison Protocol Comparison ResultsResults
45%
25%
Bad!
VeryBad!
Also Bad!
Not Trying?
Clinical ResultsClinical 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 !
Clinical ResultsClinical 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%
ConclusionsConclusions• 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
AcknowledgementsAcknowledgements
Maths and Stats Gurus
Dr Dom LeeDr Bob Broughton Dr Chris Hann
Prof Graeme Wake
Thomas LotzJessica Lin & AIC3
AIC2 & Dr. G. Shaw
Jason Wong & AIC4
The Danes
Prof Steen Andreassen
Dunedin
Dr Kirsten McAuley Prof Jim Mann
Assoc. Prof. Geoff Chase
Aaron Le Compte
Mike Willacy