Category: Diabetes/Prediabetes/Hypoglycemia

Monitor: 16


Thursday, Apr 25
11:30 AM – 12:00 PM

Objective : Hyperglycaemia in critically ill patients increases the risk of morbidity and mortality. Conventional sliding scales for insulin infusion has been shown to be associated with delay in reaching target blood glucose (BG), increased risk of hypoglycaemia and glycaemic variability. In the year 2001, Dazzi et al applied fuzzy logic principles and neural network techniques to modify intravenous insulin administration to control BG. After a pilot study, we have modified the regime in accordance with current recommendations for BG levels in critically ill patients. The main aims of the study were to evaluate the effectiveness and risk of hypoglycaemia of the Neuro-Fuzzy Logic Algorithm (NFA) versus standard sliding scale insulin infusion for BG control in critically ill patients.

Methods : Sixty critically ill patients were randomly assigned to two insulin infusion regimes. In group A, insulin infusion rate (IIR) was adjusted every one to two hours (hrs) based on a neuro-fuzzy nomogram and in group B, IIR was adjusted according to conventional sliding scale.

Results : Baseline BG levels were similar in the two groups {A: 15.20(2.3) vs B: 15.52(2.9) mmol/l: p=0.90}. In Group A, target BG was reached significantly faster than in group B {A: 4(2) vs B: 8(4.5) hrs; p < 0.001}.  Mean BG was 9.04 ± 1.81 mmol/l in group A and 12.2 ± 3.3 mmol/l in group B, p < 0.05 at 4 hrs with a mean IIR that did not differ at 4 hrs {A: 3.29 ± 1.12 vs B: 3.49 ± 0.86 U/hr, p=0.21}. NFA arm had significantly longer duration of euglycemia {A:51.43 ± 19.47 vs B: 41.89 ± 13.21 hrs, p<0.05} with less glycaemic variability {A: 2.84 ± 1.44 vs B: 5.26 ± 2.29, p<0.05} measured by MAGE. Four patients experienced hypoglycaemia in group A vs ten patients in group B; p=0.07.

Discussion : Since the insulin infusion rates were similar, the faster attainment in target BG and the better BG profile with NFA are attributed to the fact that it considers the gradient (delta) change in BG levels in adjusting the insulin infusion instead of depending on a single BG reading at any single point in time. The fine-tuned insulin infusion adjustment to each BG value in NFA arm resulted in fewer episodes of hypoglycemia. Moreover, the 2-point BG levels needed to determine the subsequent insulin infusion rate in NFA helped to provide consistency in the rate of the insulin infusion and less fluctuations in BG, resulting in less variability in BG.

Conclusion : The NFA algorithm resulted in significantly rapid control of blood glucose levels albeit with less incidence of hypoglycaemia. The patients in NFA arm too had longer duration of euglycemia with less variability in blood glucose levels.


Nasheeda Saeed

Senior Registrar in Internal Medicine
National University Hospital Malaysia

Hailing from the tiny island nation of the Republic of Maldives, Dr Nasheeda Saeed has been attached to National University Hospital, Malaysia (UKM Hospital) doing her residency in Internal Medicine since 2013 and has now completed the programme and qualified as a specialist in Internal Medicine. During her tenure in Malaysia, she was posted as a registrar in Endocrinology during her final year. She has seen a vast majority of endocrinology cases at outpatient clinics and had been involved in the management of inpatients. She has been actively involved in the management of patients with diabetes in UKM hospital as well as at Indira Gandhi Memorial Hospital where she saw patients weekly in the diabetic clinic when she worked as a Medical Officer in the department of Internal Medicine at IGM hospital before pursuing her specialization. Her main interest is in Endocrinology with a keen interest in diabetes and aspires to complete her fellowship in Endocrinology.

Elliyyin Katiman

Consultant Endocrinologist
National University Hospital Malaysia

Dr. Elliyyin had completed her fellowship in Endocrinology and is currently working as a consultant Endocrinologist.

Norasyikin A.Wahab

Associate Professor in Endocrinology
National University Hospital Malaysia

Dr. Norasyikin is an Associate Professor in Endocrinology unit and a Lecturer in Medicine in Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia.

Norlela Sukor

Professor in Endocrinology
National University Hospital Malaysia

Dr. Norlela Sukor is a Professor in Endocrinology unit and a lecturer in medicine at the National University Hospital Malaysia.

Wan Rahiza Wan Mat

Consultant Anaesthesiologist and Critical Care Medicine
National University Hospital Malaysia

Dr. Wan Rahiza is a Consultant Anaesthesiologist and Critical Care Medicine in National University Hospital Malaysia.

Nor Azmi Kamaruddin

Professor in Endocrinology
National University Hospital Malaysia

Dr. Nor Azmi Kamaruddin is a Professor of Medicine at the Department of Medicine, National University of Malaysia (UKM) and Head of the Diabetes and Endocrine Unit, UKM Medical Centre, Kuala Lumpur. He is also a visiting endocrinologist for the National Heart Institute (IJN) Kuala Lumpur. He graduated from Monash University, Melbourne, Australia in 1986 and obtained his Master of Medicine (Internal Medicine) from UKM in 1994. He did his postgraduate endocrine training in Hospital Kuala Lumpur and the Northern General Hospital, Sheffield, UK. In 2009 he was made Fellow of the American College of Endocrinology.

He has contributed more than 100 international and national research papers including publications in New England Journal of Medicine, Clinical Endocrinology, Thyroid, Diabetes Care, JAMA, American Heart journal, International Journal of Clinical Nutrition and World Journal of Surgery. He was a reviewer for Clinical Endocrinology, Malaysian Medical Medical Journal and Malaysian Journal Medical Science (MJMS). He sits on the editorial boards of Journal of ASEAN Federation of Endocrine Societies (JAFES) and Journal of Endocrinology & Metabolism (JEM).

Dr. Nor Azmi has participated in several international collaborative researches among others with the National Institute of Health (NIH), USA in the field of genetics of Type 1 Diabetes and diabetic pharmacological surveillance with the University of Nottingham, UK. He was the principal investigator for more than 75 and co-investigator for 50 Clinical Drug Trials. His research interests include adrenal hypertension, pharmacological treatment of obesity and thyroid autoimmunity.

Dr. Nor Azmi is a member of various professional committees of the Ministry of Health Malaysia and Academy of Medicine Malaysia. He is also actively involved in the training of physicians and endocrinologists.