A comparison study of continuous insulin infusion protocols in the medical intensive care unit: Computer‐guided vs. standard column‐based algorithms

Observational studies in hospitalized patients with and without diabetes indicate that hyperglycemia is a predictor of poor clinical outcome and mortality.1–4 Early randomized controlled trials of intensified insulin therapy in patients with surgical and medical acute critical illness reported a reduction on the risk of multiorgan failure and systemic infections,3–5 as well as short- and long-term mortality.1,4 Recent randomized controlled trials, however, have failed to confirm the previously suggested benefits of intensive glucose control,6 and the large multicenter normoglycaemia in intensive care evaluation and survival using glucose algorithm regulation (NICE-SUGAR) study reported an absolute increase in mortality rate with intensive glucose control.7 In addition, intensified insulin therapy in critically-ill patients has been shown to be associated with a higher rate of severe hypoglycemic events than less aggressive glycemic control protocols.7–10 These results have led to a heightened interest in improving the quality and safety of the management of diabetes and hyperglycemia in the hospital. The use of intravenous continuous insulin infusion (CII) is the preferred route of insulin administration for the management of hyperglycemia in the critical care setting.1,11 Numerous examples of successful CII algorithms in achieving glycemic control are reported in the literature.4,5,12 Traditionally, order forms to “titrate drip” to achieve a target blood glucose (BG) range using an established algorithm or by the application of mathematical rules have been used in clinical practice. Recently, computer-based algorithms aiming to direct the nursing staff adjusting insulin infusion rate have become commercially available.13,14 It is not known, however, if computer-based algorithms are superior to standard paper form-based protocols in achieving glucose control and in reducing hypoglycemic events in critically-ill patients. Accordingly, this multicenter randomized study aimed to determine differences in glycemic control and hypoglycemic events between treatment with a computer-guided CII device and a standard column-based paper algorithm in critically-ill patients in the medical intensive care unit (ICU).