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Time to band average of 6 hours and control maintained throughout patient stay. 0.35. Clinical ICU data - SPRINT. Simulation - van den Berghe. 0.3. Simulation - Krinsley. Simulation - Insulin sliding scale. Simulation - SPRINT. 0.25. Simulation predictions match clinical results. 0.2. - PowerPoint PPT Presentation
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INTRODUCTION• Stress-induced hyperglycaemia is common in critical care1
• Hyperglycaemia worsens patient outcomes, increasing risk of infection2, myocardial infarction1, polyneuropathy and multi-organ failure3
• Published protocols require significant added clinical effort4
• Very high effective insulin resistance challenges insulin-only protocols4,5
• Model-based protocols that modulate both insulin and nutrition have shown promising results, however computational resources are not typically available in critical care
• SPRINT is an easy-to-use alternative that provides control equivalent to model-based methods
• Developed from model-based methods using virtual cohorts6
• Nurse-driven protocol requires no external clinical intervention
• Hourly blood glucose measurements to gain control. Two-hourly measurements once stable to reduce clinical effort
• Insulin administered in bolus form for patient safety
• “Goal feed” computed based on age, size and gender, effectively customising the protocol for each patient5
• Nutrition optimised to improve critical care outcome7
• Easy-to-implement protocol gained high level of support from clinical and nursing staff and minimum non-compliance (<0.1%)
JG Chase, G. Shaw, A. Le Compte, D. Lee, T. Lonergan, M. Willacy, J. Wong, J. Lin, T. Lotz, C. Hann
Tight Glycaemic Control in Critical Care Using Insulin and Nutrition: The SPRINT
Protocol
METHOD: SPRINT(Specialised Relative Insulin-Nutrition Tables)
RESULTS & CONCLUSIONS
REFERENCES
[1] S. E. Capes, et al., "Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview," Lancet, vol. 355, pp. 773-778, 2000.
[2] B. R. Bistrian, "Hyperglycemia and Infection: Which is the Chicken and Which is the Egg?," JPEN J Parenter Enteral Nutr, vol. 25, pp. 180-181, 2001.
[3] G. Van den Berghe, et al., "Intensive insulin therapy in the critically ill patients," N Engl J Med, vol. 345, pp. 1359-1367, 2001.
[4] S. Meijering, et al., "Towards a feasible algorithm for tight glycaemic control in critically ill patients: a systematic review of the literature," Crit Care, vol. 10, pp. R19, 2006.
[5] G. M. Shaw, et al., "Rethinking glycaemic control in critical illness - from concept to clinical practice change," Crit Care Resusc, vol. 8, pp. 90-9, 2006.
[6] T. Lonergan, et al., "A Simple Insulin-Nutrition Protocol for Tight Glycemic Control in Critical Illness: Development and Protocol Comparison," Diabetes Technol Ther, vol. 8, pp. 191-206, 2006.
[7] J. A. Krishnan, et al., "Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes," Chest, vol. 124, pp. 297-305, 2003.
• Over 23,000 hours of control for 165 severely ill patients
• Tight control to the 4-6 mmol/L and 4-7.75 mmol/L bands
• No clinically significant hypoglycaemia
• Statistically significant reductions in mortality compared to similar hyperglycaemic retrospective cohort (APACHE II =21, Risk of Death = 33%)
Time (days)302520151050
100
90
80
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40
SPRINT - ICU MortalityRetrospective - ICU Mortality
Per
cen
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Time (days)
302520151050
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SPRINT - Hospital Mortality
Retrospective - Hospital Mortality
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• Improved ICU and hospital survival.
0 5 10 15 20 25 30 35 40 450
2
4
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14
Time since initiation of SPRINT [hours]
Ave
rage
BG
[mm
ol/L
]
Time to band average of 6 hours and control maintained throughout patient stay
0%
5%
10%
15%
20%
25%
30%
3 days 4 days 5 days
Length of ICU stay
Perc
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tag
e m
ort
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Retrospective
SPRINT
33% reduction in mortality (p=0.04)
41% reduction in mortality (p=0.03)
46% reduction in mortality (p=0.03)
Significance in mortality reductions improves with increasing stay
Overall data (n=15,874 measurements) Number of patients 165 Hours of control 23,324 hours APACHE II score 20 ± 7.8 APACHE II risk of death 36% ± 25% Total BG measurements 15,874 BG mean 5.9 [4.1 – 8.3]* mmol/L BG standard deviation 1.3 mmol/L Percentage between 4-6.1 mmol/L 61% Percentage between 4-7.0 mmol/L 82% Percentage between 4-7.75 mmol/L 89% Percentage < 4 mmol/L 3.3% Percentage < 2.5 mmol/L 0.1% Total < 2.2 mmol/L 6 Per-patient data (n=165 patients) Hours of control 95 [12 – 447]* hours Number of measurements 68 [10 – 271]* BG mean 5.9 [5.0 – 7.4]* mmol/L BG standard deviation 1.1 [0.7 – 2.3]* mmol/L Average hourly insulin 2.5 [1.3 – 4.1]* U Average nutrition rate (RESOURCE Diabetic) 37.5 [0 – 80.3]* ml/hr (caloric density 1.06 cal/mL) 954 [0 – 2043]* kCal/day
* 5th – 95th percentile range
5 10 15 20 25
0.05
0.1
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0.35
Blood glucose [mmol/L]D
ensi
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Clinical ICU data - SPRINTSimulation - van den BergheSimulation - KrinsleySimulation - Insulin sliding scaleSimulation - SPRINT
Simulation predictions match clinical results.
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Goal feed:90 m l/hr30%
26m l/hr
40%
36m l/hr
50%
45m l/hr
60%
53m l/hr
70%
62m l/hr
80%
72m l/hr
90%
81m l/hr
100%
90m l/hr