Risk and reward: Extending stochastic glycaemic control intervals to reduce workload

Type of content
Journal Article
Thesis discipline
Degree name
Publisher
Springer Science and Business Media LLC
Journal Title
Journal ISSN
Volume Title
Language
eng
Date
2020
Authors
Uyttendaele V
Shaw, Geoff
Desaive T
Knopp, Jennifer
Chase, Geoff
Abstract

Background: STAR is a model-based, personalised, risk-based dosing approach for glycaemic control (GC) in critically ill patients. STAR provides safe, effective control to nearly all patients, using 1-3 hourly measurement and intervention intervals. However, the average 11-12 measurements per day required can be a clinical burden in many intensive care units. This study aims to significantly reduce workload by extending STAR 1-3 hourly intervals to 1 to 4-, 5-, and 6-hourly intervals, and evaluate the impact of these longer intervals on GC safety and efficacy, using validated in silico virtual patients and trials methods. A Standard STAR approach was used which allowed more hyperglycaemia over extended intervals, and a STAR Upper Limit Controlled approach limited nutrition to mitigate hyperglycaemia over longer intervention intervals. Results: Extending STAR from 1-3 hourly to 1-6 hourly provided high safety and efficacy for nearly all patients in both approaches. For STAR Standard, virtual trial results showed lower % blood glucose (BG) in the safe 4.4-8.0 mmol/L target band (from 83 to 80%) as treatment intervals increased. Longer intervals resulted in increased risks of hyper- (15% to 18% BG > 8.0 mmol/L) and hypo- (2.1% to 2.8% of patients with min. BG < 2.2 mmol/L) glycaemia. These results were achieved with slightly reduced insulin (3.2 [2.0 5.0] to 2.5 [1.5 3.0] U/h) and nutrition (100 [85 100] to 90 [75 100] % goal feed) rates, but most importantly, with significantly reduced workload (12 to 8 measurements per day). The STAR Upper Limit Controlled approach mitigated hyperglycaemia and had lower insulin and significantly lower nutrition administration rates. Conclusions: The modest increased risk of hyper- and hypo-glycaemia, and the reduction in nutrition delivery associated with longer treatment intervals represent a significant risk and reward trade-off in GC. However, STAR still provided highly safe, effective control for nearly all patients regardless of treatment intervals and approach, showing this unique risk-based dosing approach, modulating both insulin and nutrition, to be robust in its design. Clinical pilot trials using STAR with different measurement timeframes should be undertaken to confirm these results clinically.

Description
Citation
Uyttendaele V, Knopp JL, Shaw GM, Desaive T, Chase JG (2020). Risk and reward: Extending stochastic glycaemic control intervals to reduce workload. BioMedical Engineering Online. 19(1). 26-.
Keywords
Humans, Models, Statistical, Risk Assessment, Stochastic Processes, Workload, Glycemic Control, hyperglycaemia, blood glucose, insulin therapy, insulin sensitivity, insulin resistance, trade-off
Ngā upoko tukutuku/Māori subject headings
ANZSRC fields of research
0903 Biomedical Engineering
Fields of Research::32 - Biomedical and clinical sciences::3202 - Clinical sciences::320212 - Intensive care
Fields of Research::32 - Biomedical and clinical sciences::3202 - Clinical sciences::320208 - Endocrinology
Fields of Research::40 - Engineering::4003 - Biomedical engineering::400306 - Computational physiology
Rights
All rights reserved unless otherwise stated