Computerized intensive insulin dosing can mitigate hypoglycemia and achieve tight glycemic control when glucose measurement is performed frequently and on time.

INTRODUCTION: Control of blood glucose (BG) in critically ill patients is considered important, but is difficult to achieve, and often associated with increased risk of hypoglycemia. We examined the use of a computerized insulin dosing algorithm to manage hyperglycemia with particular attention to frequency and conditions surrounding hypoglycemic events. METHODS: This is a retrospective analysis of adult patients with hyperglycemia receiving intravenous (IV) insulin therapy from March 2006 to December 2007 in the intensive care units of 2 tertiary care teaching hospitals. Patients placed on a glycemic control protocol using the Clarian GlucoStabilizer IV insulin dosing calculator with a target range of 4.4-6.1 mmol/L were analyzed. Metrics included time to target, time in target, mean blood glucose +/- standard deviation, % measures in hypoglycemic ranges <3.9 mmol/L, per-patient hypoglycemia, and BG testing interval. RESULTS: 4,588 ICU patients were treated with the GlucoStabilizer to a BG target range of 4.4-6.1 mmol/L. We observed 254 severe hypoglycemia episodes (BG <2.2 mmol/L) in 195 patients, representing 0.1% of all measurements, and in 4.25% of patients or 0.6 episodes per 1000 hours on insulin infusion. The most common contributing cause for hypoglycemia was measurement delay (n = 170, 66.9%). The median (interquartile range) time to achieve the target range was 5.9 (3.8 - 8.9) hours. Nearly all (97.5%) of patients achieved target and remained in target 73.4% of the time. The mean BG (+/- SD) after achieving target was 5.4 (+/- 0.52) mmol/L. Targeted blood glucose levels were achieved at similar rates with low incidence of severe hypoglycemia in patients with and without diabetes, sepsis, renal, and cardiovascular disease. CONCLUSIONS: Glycemic control to a lower glucose target range can be achieved using a computerized insulin dosing protocol. With particular attention to timely measurement and adjustment of insulin doses the risk of hypoglycemia experienced can be minimized.

Health-Related Quality of Life and Physiological Outcomes of Peroral Endoscopic Myotomy for Achalasia.

BACKGROUND: Peroral endoscopic myotomy (POEM) has gained acceptance as a treatment for achalasia. The aim of this study was to assess symptomatic, quality of life (QoL), and physiological outcomes of POEM using standardized methods. MATERIALS AND METHODS: Patients who were planned to undergo POEM were evaluated pre- and postoperatively with timed barium esophagogram (TBE), high-resolution manometry (HRM), the achalasia symptom questionnaire (ASQ) (best score 10, worst score 31), and the short form (SF)-36 (best score 100, worst score 0). Nine patients completed postoperative HRM, TBE, and 48 hours esophageal pH monitoring. A P-value of <.05 was considered statistically significant. RESULTS: A total of 34 of 37 patients completed the POEM procedure. There was improvement in the ASQ scores and in QoL. HRM integrated relaxation pressures (IRPs) improved from 31.4 ± 10.8 mmHg preoperatively to 12.3 ± 6.7 mmHg postoperatively, and lower esophageal sphincter pressure (LESP) improved from 49.1 ± 16.9 mmHg preoperatively to 23.1 ± 9.4 mmHg postoperatively. Of the 7 patients who were evaluated with 48-hour pH monitoring postoperatively, 5 patients (71%) demonstrated pathological reflux with an average Demeester score of 23.1 ± 19.1. There was a negative linear correlation between LESP change and Demeester scores (r = -0.7, P = .03). CONCLUSION: The POEM procedure significantly improves achalasia-related symptoms and improves social functioning. Physiologically, there is reduction in both IRP and LESP. Postoperative pathological reflux is correlated with LESP reduction.

Safety and effectiveness of a computerized subcutaneous insulin program to treat inpatient hyperglycemia.

BACKGROUND: This proof of concept study was designed to evaluate the safety and effectiveness of a computerized insulin program, the Clarian GlucoStabilizer Subcutaneous Insulin Program (CGS-SQ). This paper discusses the CGS-SQ's impact on the glycemic control of hospitalized patients with hyperglycemia. METHODS: Patients at Methodist and Indiana University Hospitals requiring subcutaneous insulin were treated using the CGS-SQ. This program calculates subcutaneous bolus insulin doses based on the current blood glucose (BG), using an insulin sensitivity factor, the number of grams of carbohydrates eaten, and an insulin-to-carbohydrate ratio, with a goal of maintaining the patient's BG in a prespecified target range. The target range, insulin sensitivity factor, and insulin-to-carbohydrate ratio are established by the physician. RESULTS: From April 2006 to September 2007, the CGS-SQ treated 1772 patients at Methodist and Indiana University Hospitals, with 46,575 BGs in its database. For these patients, the average BG was 158.3 mg/dl, 40.5% percent of BGs were in the default target range of 100-150 mg/dl, and 69.8% were in the wider range of 70-180 mg/dl. The hypoglycemia (BG <40 mg/dl) rate was 0.18%. CONCLUSIONS: The CGS-SQ provided a means to deliver insulin in a standardized manner, resulting in satisfactory BG control with a low hypoglycemia rate, thus serving as a tool for safe and effective insulin therapy for hospitalized patients.