Saint Francis University

About: Saint Francis University is a education organization based out in Loretto, Pennsylvania, United States. It is known for research contribution in the topics: Population & Osteoblast. The organization has 1694 authors who have published 2038 publications receiving 87149 citations.

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Algorithm Maxima for Intravenous Insulin Infusion

Abstract: Dear Editor, In a case series of 378 patients, we attempt to identify a threshold rate of continuous intravenous insulin infusion associated with increased risk of hypoglycemia. Much of the relevant medical literature focuses upon glycemic targets, often discussed in relation to specific populations. We anticipate a future day when glycemic targets routinely may be personalized according to preadmission glycemia. At the time of the planning of our study, a consensus goal for blood glucose (BG) during intravenous insulin infusion was 100–150 mg/dL, a hypoglycemia alert value was defined as BG £70 mg/dL, and clinically significant hypoglycemia as BG <54 mg/dL. It was hypothesized that a threshold value of peak insulin infusion rate might be discerned, above which the occurrence of BG <54 mg/dL became excessive. In a retrospective observational study of eligible consecutive intravenous insulin infusion treatment courses, we aimed to determine odds ratio (OR) and relative risk (RR) for BG <54 or ‡54 mg/dL according to peak insulin infusion rate. The Saint Joseph Hospital Institutional Review Board reviewed and approved the study. Three institutional column-based tabular algorithms for intravenous insulin infusion were identified as the ‘‘study algorithms,’’ each having the same goal range 130–149 mg/dL and acceptable range 100–149 mg/dL for BG control, recommending titration every 1–2 h, similar in design and sharing some columns, but differing with respect to aggressiveness of initiation and titration rules. The maximum insulin infusion rate in the highest column under the ‘‘Conservative’’ and ‘‘Standard Default’’ algorithms is 14.6 units/h and under the ‘‘Aggressive’’ algorithm is 29.2 unit/h. The unit of observation was the earliest qualified treatment course of a unique patient using insulin infusion rate values represented under at least one of three ‘‘study algorithms.’’ Data were collected from the electronic medical record EPIC for consecutive treatment courses ordered within the timeframe between July 1, 2012 through August 31, 2016 at Saint Joseph Hospital in the Chicago Lakeview neighborhood, an urban academic hospital having a combined medical and surgical intensive care unit (ICU). Inclusion required orders for continuous intravenous regular insulin infusion under one of the three ‘‘study algorithms.’’ Exclusion criteria consisted of age under 18, pregnancy, hyperglycemic crisis, treatment for hypertriglyceridemia, and occurrence of hypoglycemia before peak insulin infusion rate without any hypoglycemia after peak insulin infusion rate during the data collection interval. After identification of 611 potential cases having orders for intravenous regular insulin infusion, 233 were disqualified having one or more of the following criteria: no record of insulin administration by intravenous infusion (40), treatment with intravenous insulin infusion conducted for <4 h (26), pregnancy (77), inability to identify a ‘‘study algorithm start time’’ (8), recurring use of insulin infusion rates not represented on at least 1 of the 3 ‘‘study algorithms’’ (3), ‘‘Hyperglycemic Crisis’’ algorithm ordered with use confirmed by review of insulin infusion rates (48), hyperglycemic crisis diagnosis confirmed by chart review of clinical data (75), treatment for hypertriglyceridemia (12), contradiction between nonzero insulin infusion rates under 2 otherwise qualified orders (6), qualified treatment course that was contradicted by the Full Administration Report of a disqualified earlier