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Cited by 85Hyperglycemia and glycemic control in critically ill and hospitalized patientsDiabetes Management and ResearchPatient Safety and Medication Errors

A comparison study of continuous insulin infusion protocols in the medical intensive care unit: Computer-guided vs. Standard column-based algorithms

Open access
Newton, Christopher A., Smiley, Dawn, Bode, Bruce W., Kitabchi, Abbas E., Davidson, Paul C., Jacobs, Sol, Steed, R. Dennis, Stentz, Frankie +5 more·2010·Journal of Hospital Medicine
DOI 10.1002/jhm.816PMC PMC3733454
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Abstract

PURPOSE: To compare the safety and efficacy of continuous insulin infusion (CII) via a computer‐guided and a standard paper form protocol in a medical intensive care unit (ICU). METHODS: Multicenter randomized trial of 153 ICU patients randomized to CII using the Glucommander (n = 77) or a standard paper protocol (n = 76). Both protocols used glulisine insulin and targeted blood glucose (BG) between 80 mg/dL and 120 mg/dL. RESULTS: The Glucommander resulted in a lower mean BG value (103 ± 8.8 mg/dL vs. 117 ± 16.5 mg/dL, P < 0.001) and in a shorter time to reach BG target (4.8 ± 2.8 vs.7.8 hours ± 9.1 hours, P < 0.01), and once at target resulted in a higher percentage of BG readings within target (71.0 ± 17.0% vs. 51.3 ± 19.7%, P < 0.001) than the standard protocol. Mean insulin infusion rate in the Glucommander was similar to the standard protocol (P = 0.12). The percentages of patients with ≥1 episode of BG <40 mg/dL and <60 mg/dL were 3.9% and 42.9% in the Glucommander and 5.6% and 31.9% in the standard, respectively [P = not significant (NS)]. Repeated measures analyses show that the probabilities of BG reading <40 mg/dL or <60 mg/dL were not significantly different between groups (P = 0.969, P = 0.084) after accounting for within‐patient correlations with or without adjusting for time effect. There were no differences between groups in the length of hospital stay (P = 0.704), ICU stay (P = 0.145), or inhospital mortality (P = 0.561). CONCLUSION: Both treatment algorithms resulted in significant improvement in glycemic control in critically ill patients in the medical ICU. The computer‐based algorithm resulted in tighter glycemic control without an increased risk of hypoglycemic events compared to the standard paper protocol. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.

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Crossref · 10.1002/jhm.816

Cites

25 of 25 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 34 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The frequency of blood glucose monitoring per hour of infusion was not different between groups (0.68 vs 0.62 tests/hour, P=NS).

    “Similarly, when normalized to the duration of insulin infusion, the frequency of BG monitoring was not different with the protocols (0.68 ± 0.18 and 0.62 ± 0.22 tests/hour respectively, P = NS).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Repeated measures analyses found no significant between-group difference in probabilities of blood glucose <40 or <60 mg/dL after accounting for within-patient correlation, with or without time adjustment.

    “Based on repeated measures analyses, the probabilities of BG reading <40 mg/dL or <60 mg/dL were not significantly different between groups (P = 0.969, P = 0.084) after accounting for within-patient correlations with or without adjusting for time effect.”
    Quote in the paperSubstantial claim
  • Findingown data

    Fewer Glucommander patients had at least one blood glucose >200 mg/dL (11.7% vs 25%; P=0.057 unadjusted, P=0.034 adjusted for site).

    “The number of patients with 1 or more episodes of BG >200 mg/dL (11.7% vs. 25%, P = 0.057 before adjusting for potential site difference and P = 0.034 after adjusting for site difference) were less in the Glucommander group than in the standard paper regimen.”
    Quote in the paperSubstantial claim
  • Findingown data

    During insulin infusion, the Glucommander group had a lower mean glucose than the standard group (115.5 vs 131.0 mg/dL, P<0.001).

    “The Glucommander group had a lower mean glucose value during insulin infusion (115.5 ± 20.7 vs. 131.0 ± 24.6 mg/dL, P < 0.001)”
    Quote in the paperSubstantial claim
  • Findingown data

    The Glucommander group reached the blood glucose target in less time than the standard group (4.8 vs 7.8 hours, P<0.001).

    “The mean time to reach the BG target was shorter in the Glucommander group (4.8 ± 2.8 vs. 7.8 ± 9.1 hours, P < 0.001).”
    Quote in the paperSubstantial claim
  • May combine two claims. 12
  • Classified as probably not a substantial claim. 11

  • May combine two claims.

    Findingown data

    The Glucommander was associated with tighter glycemic control and less glucose variability than the standard paper protocol.

    “The Glucommander algorithm was associated with tighter glycemic control and less glucose variability than the standard paper form protocol.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The mean inpatient blood glucose difference was 15.5 mg/dL, and daily differences were 17.4 to 24.4 mg/dL lower with Glucommander on days 2 to 6.

    “The mean inpatient BG difference between treatment groups was 15.5 mg/dL (P < 0.001), with a mean daily BG difference ranging from 17.4 mg/dL to 24.4 mg/dL less for the Glucommander group during days 2 to 6 of therapy (P < 0.01).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The proportion of patients with at least one blood glucose <60 mg/dL was 42.9% with Glucommander and 31.9% with standard, not significantly different.

    “The number of patients who experienced one or more BG <40 mg/dL and <60 mg/dL was 3.9% and 42.9% in the Glucommander and 5.6% and 31.9% in the standard regimen, respectively (both, P = not significant [NS]).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The proportion of patients with at least one blood glucose <40 mg/dL was 3.9% with Glucommander and 5.6% with standard, not significantly different.

    “The number of patients who experienced one or more BG <40 mg/dL and <60 mg/dL was 3.9% and 42.9% in the Glucommander and 5.6% and 31.9% in the standard regimen, respectively (both, P = not significant [NS]).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    None of the hypoglycemia episodes caused seizures or were judged to be associated with clinical deterioration.

    “None of these episodes resulted in seizures or were otherwise judged to be associated with deterioration of clinical status.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Early randomized trials of intensified insulin therapy in surgical and medical acute critical illness reported reduced risk of multiorgan failure, systemic infections, and short- and long-term mortality.

    “Early randomized controlled trials of intensified insulin therapy in patients with surgical and medical acute critical illness reported a reduction on the risk of multiorgan failure and systemic infections,3–5 as well as short- and long-term mortality.1,4”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [3] Van den Berghe G Wilmer A Hermans G Intensive insulin therapy in the medical ICU N Engl J Med 2006 354 449 461 16452557 source

      Not checked in the free run.

    • cites [4] Van den Berghe G Wouters P Weekers F Intensive insulin therapy in the critically ill patients N Engl J Med 2001 345 1359 1367 11794168 source

      Not checked in the free run.

    • cites [5] Furnary AP Gao G Grunkemeier GL Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting J Thorac Cardiovasc Surg 2003 125 1007 1021 12771873 source

      Not checked in the free run.

    • cites [1] Clement S Braithwaite SS Magee MF Management of diabetes and hyperglycemia in hospitals Diabetes Care 2004 27 553 597 14747243 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Seven randomized patients were excluded because of consent withdrawal, subcutaneous insulin during CII, or less than 4 hours of CII.

    “Of them, 7 patients were excluded due to withdrawal of consent, treatment with subcutaneous basal or supplemental short-acting insulin during CII, or receiving less than 4 hours of CII.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A meta-analysis of 26 studies with 13,567 patients found no benefit in the general ICU population but a favorable mortality effect of intensive glycemic control in surgical ICU patients (RR 0.63; CI 0.44-0.91).

    “Although a recent meta-analysis9 of 26 studies involving 13,567 patients reported no benefits in the general ICU population, it found a favorable effect of intensive glycemic control on mortality in surgical ICU patients (relative risk [RR], 0.63; confidence interval [CI], 0.44–0.91).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] De La Rosa Gdel C Donado JH Restrepo AH Strict glycaemic control in patients hospitalised in a mixed medical and surgical intensive care unit: a randomised clinical trial Crit Care 2008 12 R120 18799004 PMC2592751 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Blood glucose targets above 180 mg/dL or below 110 mg/dL are no longer recommended for ICU patients.

    “Glucose targets >180 mg/dL or <110 mg/dL are no longer recommended in ICU patients.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] Moghissi ES Korytkowski MT DiNardo M American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control Diabetes Care 2009 32 1119 1131 19429873 PMC2681039 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    The treatment groups did not differ in mean age, gender, race, diabetes history, or primary admitting diagnosis.

    “There were no differences in the mean age, gender, race, history of diabetes, or primary admitting diagnosis between treatment groups.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The study excluded patients with severe renal insufficiency and those with a history of hyperglycemic crises.

    “We also excluded patients with severe renal insufficiency and patients with a history of hyperglycemic crises.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    The study was conducted in the medical ICU and excluded postsurgical patients and those expected to have major surgery during hospitalization.

    “First, this study was conducted in the medical ICU and excluded postsurgical patients and subjects expected to undergo a major surgical procedure during the hospital stay.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    Raising blood glucose targets is likely to reduce or prevent mild and severe hypoglycemic events in the ICU.

    “Raising the BG targets is likely to reduce or prevent the rate of mild and severe hypoglycemic events in the ICU.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The trial was open-label.

    “In this multicenter, prospective, open-label randomized study, 160 adult patients admitted to a medical ICU with new hyperglycemia or with a known history of diabetes treated with diet, insulin therapy or with any combination of oral antidiabetic agents were enrolled after written informed consent had been obtained from the patient or closest family member (Figure 1).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Hypoglycemia can impair cerebral glucose metabolism and cause brain metabolic dysfunction.

    “and can impair cerebral glucose metabolism resulting in brain metabolic dysfunction, as suggested by recent clinical studies.22”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Oddo M Schmidt JM Carrera E Impact of tight glycemic control on cerebral glucose metabolism after severe brain injury: a microdialysis study Crit Care Med 2008 36 3233 3238 18936695 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The study planned 80 patients per group to have 80% power to detect a mean blood glucose difference of at least 30 mg/dL.

    “We expected differences in mean BG concentration ≥30 mg/dL between groups. Assuming 2-tailed alpha of 0.05, a standard deviation of approximately 40, and a one-to-one allocation and no subject attrition, 80 patients per treatment group were thought to be sufficient to achieve 80% power for group mean comparisons.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Hypoglycemia may increase the risk of ventricular arrhythmias partly through QT prolongation.

    “Hypoglycemia may increase the risk of ventricular arrhythmias, in part due to the prolongation QT interval21”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] Cryer PE Axelrod L Grossman AB Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline J Clin Endocrinol Metab 2009 94 709 728 19088155 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    The computer-guided algorithm achieved tighter glycemic control without increasing hypoglycemic events compared with the standard paper protocol.

    “The computer-based algorithm resulted in tighter glycemic control without an increased risk of hypoglycemic events compared to the standard paper protocol.”
    • Also stated in: § Discussion · plain
      “Both treatment algorithms resulted in significant improvement in glycemic control with the Glucommander achieving glycemic glucose target in a shorter time of treatment, a lower mean glucose concentration, and in greater percentage of glucose measurements maintained within target range, without an increased risk of severe hypoglycemia compared to the standard paper protocol.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Insulin-induced hypoglycemia is associated with increased proinflammatory cytokines and oxidative stress.

    “Moreover, insulin-induced hypoglycemia is also associated with increased proinflammatory cytokines (tumor necrosis factor [TNF]-alpha, interleukin [IL]-1beta, IL-6, and IL-8) and oxidative stress23”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] Razavi Nematollahi L Kitabchi AE Stentz FB Proinflammatory cytokines in response to insulin-induced hypoglycemic stress in healthy subjects Metabolism 2009 58 443 448 19303962 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Patients were randomized using a computer randomization table.

    “Patients were randomized using a computer randomization table to receive CII following a computer-guided algorithm (Glucommander) or CII following a standard paper form insulin infusion algorithm.”
    Quote in the paperSubstantial claim
20 of 20

  • The authors state this as an assumption.

    It is not known whether computer-based algorithms are superior to standard paper protocols for achieving glucose control and reducing hypoglycemic events in critically ill patients.

    “It is not known, however, if computer-based algorithms are superior to standard paper form-based protocols in achieving glucose control and in reducing hypoglycemic events in critically-ill patients.”

  • The authors state this as an assumption.

    This study is the first to compare the safety and efficacy of continuous insulin infusion via a computer-guided algorithm and a standard paper form protocol in nonsurgical ICU patients.

    “This study is the first to compare the safety and efficacy of a CII via a computer-guided algorithm and a standard paper form protocol in nonsurgical patients in the ICU.”
2 of 2

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Automated computerized IV insulin protocols, whether commercial or institutional, have improved glycemic control and are well accepted by nursing staff.

    “Automated, computerized, IV insulin protocols, including commercially available or institutional-based protocols, have improved glycemic control, with good acceptance by nursing personnel.1294–1307”

    From American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. (2022) · cites this paper as [1295]

    The Abstract Conclusion and Discussion report improved glycemic control with the computer-guided Glucommander protocol in medical ICU patients. The Methods say nurses used the protocol, but our copy does not report nursing acceptance or test an institutional computerized protocol; its comparator was paper-based. Page numbers are unavailable in our copy. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Target-range percentage differs between abstract and results

    Minor

    The abstract reports 71.0% of Glucommander readings within target after reaching the target, while the results report 71.1% for the same measure. Both values are printed to one decimal place.

1 of 1

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Authors
Newton, C. A., Smiley, D., Bode, B. W., Kitabchi, A. E., Davidson, P. C., Jacobs, S., Steed, R. D., Stentz, F., Peng, L., Mulligan, P., Freire, A. X., Temponi, A., & Umpierrez, G. E.
Affiliations
  • Emory University (US)
  • Piedmont Atlanta Hospital (US)
  • University of Tennessee Health Science Center (US)
Corresponding author
Umpierrez, Guillermo E.
ORCID
Venue
Journal of Hospital Medicine
Publisher
Wiley
Published
2010-10
Volume
5
Issue
8
Pages
432-437
ISSN
  • 1553-5592 (ISSN-L)
  • 1553-5606
DOI
10.1002/jhm.816
PMC
PMC3733454
OpenAlex
W2172222386
Semantic Scholar
570bb6544809c28d3060bf18cd4df50c8835ef38
Cited by
84
References
25
Citations by year
2026: 5 · 2025: 2 · 2024: 3 · 2023: 4 · 2022: 3 · 2021: 4 · 2020: 8 · 2019: 9 · 2018: 3 · 2017: 7 · 2016: 3 · 2015: 7 · 2014: 7 · 2013: 8 · 2012: 8
FWCI
4.60
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor, 11 d)
Locations
  • Journal of Hospital Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health (UL1TR000454)
  • National Institute of Diabetes and Digestive and Kidney Diseases (U01DK074556, K08DK083036)
  • National Center for Research Resources (M01-RR00039, UL1RR025008, M01RR000039)
  • National Center for Advancing Translational Sciences
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hyperglycemia and glycemic control in critically ill and hospitalized patients
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
Keywords
continuous insulin infusion, glycemic control, glycemic targets, hypoglycemia, medical intensive care unit, critically ill patients
MeSH terms
Aged, Algorithms, Blood Glucose, Drug Therapy, Computer-Assisted, Female, Humans, Hypoglycemic Agents, Insulin, Insulin Infusion Systems, Intensive Care Units, Male, Middle Aged, Prospective Studies

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