Nutrition rates and impact of clinical stoppages for two AGC protocols
Nutrition is an important factor in the treatment of patients in critical care. Potential hyper-rmetabolism means underfeeding may cause malnourishment, while overfeeding increases risk of hyperglycemia and the associated physiological impact. Hyperglycemia can be treated through accurate glycemic control (AGC), and this paper examines the link between nutrition and achievement of AGC. Clinically validated virtual trials were carried out on the 371 patients in the SPRINT cohort using STAR, an adaptive AGC protocol targeting 80-145mg/dL. Nutrition results were compared to the rates given clinically to investigate the effect modulating nutrition has on the final level of nutrition administered. The effect of clinical nutrition stoppages on this level of nutrition was also isolated. The link between nutrition and the ability to achieve AGC was investigated by targeting STAR to both 80-145mg/dL and 140-180mg/dL, allowing STAR to modulate nutrition as well as delivering constant rates of 60%, 80%, 100%, 120% and 140% ACCP goal. Performance was assessed as %BG within the target range, hyperglycemia as %BG above the range and clinical workload as the number of BG measurements. Relative tightness was estimated using BG IQR. As expected, modulating nutrition led to a range of total nutrition delivered to patients. Importantly, low nutrition administration corresponded to low insulin sensitivity, and clinical nutrition stoppages were shown to drop median nutrition rates by 10% over the first 4 days in ICU, suggesting a significant effect if a nutrition target is desired. Variable nutrition in STAR was shown to lead to reduced BG variability and clinical workload, and different nutrition rates showed significant differences in BG outcomes despite the adaptive STAR framework. Combined, these results show that AGC could be better achieved with less effort if variable nutrition was permitted. In part, this effect is due to constant nutrition restricting the ability of a protocol to respond to low insulin sensitivity. Constant nutrition will also have a strong effect on the ability to target a specific range.