Objective : Intravenous insulin therapy using paper protocols or electronic glucose management systems (eGMS) represent the standard of care for critically ill patients. Target blood glucose vary, and most paper protocols or eGMS require the users to set the upper goal (UG) and lower goal (LG), i.e. the goal range. Consequently, these dosing algorithms increase the insulin dosing when the blood glucose reading (BG) is above the UG and reduce the doses when the BG is below the LG. The methodology to raise or lower the model differentiate protocols. The UG is often set as the primary controller of the incidence of hypoglycemia, defined as a BG less than 70 mg/dl (HYPO). There is little research that reports the effect of goal range on HYPO outcomes for intravenous insulin dosing. This work was focused on the potential effect of the goal range on HYPO in a large database from hospitals using an eGMS for IV insulin dosing.
Methods : Analysis was applied to a database of more than 3.5 million BG readings of de-identified data without exclusions from 5 unaffiliated hospital systems using the eGMS. The data was collected from January 2015 to November 2017. The analysis was stratified for two goal ranges, 100 to 140 mg/dL (807,873 BGs) and 150 to 200 mg/dL (127,647 BGs). For this retrospective study, the observed incidence of HYPO was calculated based on the previous BG values, which were further allocated in sub-ranges of 10 mg/dL increments within each of the two goal ranges.
Results : For patients with an UG of 140, there was a 5-fold increase in HYPO incidence if the previous BG value was within the lowest sub-range compared to the upper sub-range. No insulin dosing model changes occurred for BGs in range. More than 66.7% of all HYPO readings occurred when the previous BG was less than the median of the goal range for the 140 UG. For patients with an UG of 200 mg/dl, there was little difference in the HYPO incidence in the sub-ranges. The overall incidence of HYPO for the stratified data from the UG 200 subset was less than that from the 140 UG subset, 0.22% vs. 0.34%, respectively.
Discussion : These observations suggest that as the UG is lowered towards 70 mg/dL, a tighter goal range would be appropriate as it would cause for the down regulation of the insulin dosing model in the sub-ranges that appear to be at higher risk for HYPO. A potential consequence of a reduced goal range may result in a higher mean BG after the patient’s BG first reach UG and may lead to a higher variance.
Conclusion : The observations from this work generate the hypothesis that with a lower UG, the incidence of HYPO is likely to be reduced significantly by reducing the goal range. Studies to test this hypothesis are needed.
Anderson Schrader– Undergraduate majoring in Bioengineering, Clemson University
W Patrick Burgess– Founder & Inventor, EndoTool, Monarch Medical Technologies, Charlotte, North Carolina
Laurel Fuqua– Executive VP and Chief Clinical Officer, Monarch Medical Technologies, Charlotte, North Carolina
Undergraduate majoring in Bioengineering
Anderson Schrader is a student at Clemson University majoring in Bioengineering with a concentration in Biomaterials. She is expected to graduate in May 2020. During the summer of 2018, Anderson served as an intern at Monarch Medical Technologies where she was responsible for performing retrospective analysis of glucose data trends.
Founder & Inventor, EndoTool
Monarch Medical Technologies
Charlotte, North Carolina
Dr. Patrick Burgess founded EndoTool in 2003 with the goal of improving glucose management for hospitalized patients. Today, he remains an active contributor to the development and advancement of the EndoTool suite of solutions as he pursues his goal of controlling elevated glucose levels in all settings and eliminating the threat of hypoglycemia.
Prior to founding EndoTool, Dr, Burgess spent more than 20 years practicing medicine in the Charlotte area. He served as a partner and president of Metrolina Nephrology Associates, P.A, and was affiliated with the Carolinas Medical Center, part of the Atrium Health System. At Carolinas Medical Center, Dr. Burgess served as the Chief of Internal Medicine and Chief of the Nephrology Division. He was involved in many physician leadership roles, including serving as the President of the Medical and Dental Staff. Dr. Burgess also served in teaching roles as a Clinical Associate Professor in the Department of Internal Medicine at Wake Forest University School of Medicine and for the Department of Medicine at the University of North Carolina.
Dr. Burgess received his bachelor’s in engineering from Ohio State University followed by a PhD in chemical engineering with a focus in digital control mathematics at Princeton University. He then later received his medical degree from the University of Miami and completed his residency and nephrology fellowship at the University of Alabama, Birmingham. Dr. Burgess is a frequent author and presenter, and continues to remain an active participant in industry societies. He is a member of the American Diabetes Association, American Medical Association, and American Society of Nephrology.