Glucose regulation

Insulin Therapy in hyperglycemic patients with an Acute Coronary Syndrome

Hyperglycemia is a common finding in patients presenting with an Acute Coronary Syndrome (ACS) and is associated with adverse outcomes. Different studies were performed to investigate whether insulin therapy after admission is associated with improved survival in hyperglycemic patients with acute coronary syndrome. A systematic review of randomized controlled trials and cohort studies including patients with acute coronary syndrome and known diabetes or high blood glucose levels treated with insulin was done: Seven studies met the inclusion criteria. DIGAMI II, HI-5, ECLA-I, ECLA-II and Kosiborod et al. did not show a reduction in mortality between patients using insulin therapy and the control group. DIGAMI I showed that glucose normalization has a positive effect on long-term prognosis and MINAP showed that treatment with insulin is associated with a reduction in mortality. Thus insulin therapy per se is not associated with a reduction in mortality. However, normalization of blood glucose levels in patients presenting with acute coronary syndrome has a possible benefit regarding long term mortality and cardiovascular events. The optimal target range for glucose levels, and best means to achieve this range, is still unknown.

Automation of Glucose protocol

along with insulin infusion rates and patient data from the Patient Data Management System. For each new glucose value a pop-up is generated with the protocol advised action for insulin dosage and time for the next glucose measurement. Temporal trends in glucose and insulin values are displayed as an additional aid. An evaluation database is included in the design to provide feedback to the users on protocol compliance and glucose control. To do this web-based application was developed. The process is described in a paper for Computers in Cardiology 2008, and also available as a poster. The technical aspects of the implementation are presented in a paper and poster at 12th Conference on Artificial Intelligence in Medicine 2009.

Effect of a Clinical Decision Support for Glucose Regulation on the Intensive Cardiac Care Unit.

Glucose control in acute cardiac disease is difficult to achieve and may improve patient outcome. Because glucose levels were high at the Intensive Cardiac Care Unit, and adherence to a paper protocol was low, a web based clinical decision support system (CDSS) for glucose control was developed. The CDSS consists of an automated version of the existing paper protocol. A touch-screen monitor on the ICCU displays a board view of the currently admitted patients; new glucose values are retrieved along with insulin infusion rates and patient data from the Patient Data Management System. For each new glucose value a pop-up is generated with the protocol advised action for insulin dosage and time for the next glucose measurement. Temporal trends in glucose and insulin values are displayed as an additional aid. Over 11 months 667 patients were evaluated, 425 before and 242 after implementation of the CDSS. After implementation more patients had a mean glucose level within the target range of 4.5-7.0 mmol/l (31% vs. 43%; P=0.01); compliance with the advised measurement time increased from 39,5% to 51,8% (P<0.001) and compliance regarding insulin dosage increased from 48,9% to 60,6% (P<0.001). Monthly evaluation identified reasons for protocol non-compliance (eg. nutritional status and time of day) and will be used to improve the existing protocol. Implementation of a CDSS for glucose control increased glucose regulation and protocol compliance. Regular evaluation provided important information for further improvements to achieve optimal glycemic regulation.

The 'glucose screen', a touchscreen interface for an automated glucose protocol

A presentation was given on the implementation of the Glucose screen at the European Society of Cardiology meeting 2009.

Glycemic dysregulation and outcome on the intensive cardiac care unit: an observational study.

During a 18 month period almost 20.000 glucose measurements were analyzed. We investigated the relation between glycemic regulation and outcomes, and identified patient characteristics associated with hyperglycemia during admission. This information will be used to help improve the existing glucose protocol.

Repeated measurements analysis of glucose values

Predictive value of pre-existent diabetes for glucose disregulation in hyperglycemic patients admitted to the Intensive Cardiac Care Unit.

Continuous Glucose Measurement in the Intensive Cardiac Care Setting

Measurement of glucose using venous sampling is limited in it's accuracy, as many measurements are needed to capture high frequency fluctuations in glucose levels. Thus using conventional techniques, hypoglycemic episodes may not be noticed (for example at night, when a patient is asleep) and hyperglycemia occuring at a later stage during admission may go undetected as well. Devices that measure glucose continuously are available; typically using a sensor set on, in or just beneath the skin. These devices have proven to be usefull in maintaining glycemic targets in an outpatient setting, and general hospital wards. We strive to evaluate the accuracy and usefullness of a continuous glucose sensor for measuring and regulating glucose levels in the Cardiac Intensive Care. Our main concern is that the accuracy will be insufficient in patients with compromised (sub)cutaneous circulation. The study is in planning stages.