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

70

60

50

40

SPRINT - ICU MortalityRetrospective - ICU Mortality

Per

cen

t

Time (days)

302520151050

100

90

80

70

60

50

40

30

SPRINT - Hospital Mortality

Retrospective - Hospital Mortality

Perc

en

t

• Improved ICU and hospital survival.

0 5 10 15 20 25 30 35 40 450

2

4

6

8

10

12

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

en

tag

e m

ort

ali

ty

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

0.15

0.2

0.25

0.3

0.35

Blood glucose [mmol/L]D

ensi

ty

Clinical ICU data - SPRINTSimulation - van den BergheSimulation - KrinsleySimulation - Insulin sliding scaleSimulation - SPRINT

Simulation predictions match clinical results.

leehWnilusnI

thgirypoCTNIRPS hcraeseRCIA6002 6002/1/21

SEY nilusniynaevigtonoDruohsiht

.1 tsetalehtsI esoculgdoolbL/lomm7 rednuro dna tisahdeppord suoiverpehtmorf

tnemerusaem ?5.1nahteromyb

wolebspetsehtwolloF:ON

.2 tneitapotleehwetatoRlevelesoculgtnerruc nidekram

.yerg

.3 ehtrehtehwenimreteDlevelesoculg rodesaercnisahdnadesaerced ehttceles

leehwehtfoedistcerroc

.4 ehtgnisU foedisdetcelesleehweht 3morf ehthctam,

sulobnilusnisuoiverp ehtotsulobnilusniwen

.6 evahuoyfileehWdeeFesU.ydaerlaosenodton

.5 retsinimdA sulobnilusniwen.kcehcelbuodeugaellocevahdna

:TRATSleehWdeeF

%08

%09

%09

%001

%08

%09

%09

%001

%07

%08

%08

%09

%07%08

%08

%09

%06%07

%08%08

%06%07%08%08

%05

%06

%07%07

%05

%06

%07

%07

%04

%05

%06

%06

%04

%05

%06

%06

%03

%04

%05

%05

%03

%04

%05

%05

%03%03

%04

%04

%03 %03 %04 %04

%09

%001

%001

%001

%09

%001

%001

%001

%08

%09

%09

%001

%08

%09

%09

%001

%07

%08

%08

%09

%07%08

%08

%09

%06%07

%08%08

%06%07%08%08

%05

%06

%07%07

%05

%06

%07

%07

%04

%05

%06

%06

%04

%05

%06

%06

%03

%04

%05

%05

%03

%04

%05

%05

%03%03

%04

%04

%03 %03 %04 %04

%09

%001

%001

%001

%09

%001

%001

%001

deefhcattAnoisrevnocerehrekcits

deefhcattAnoisrevnocerehrekcits

thgirypoCTNIRPS hcraeseRCIA 6002/1/21

:TRATS

.2 tneitapotleehwetatoRdeefegatnecreptnerruc

level nidekram yerg

.4 ehtgnisU edisdetcelesleehwehtfo 3morf hctam,

eht levelesoculgtnerrucehtot leveldeefwen

.5 noisrevnocdeefehtesUetulosbaehtdnifotrekcits

.]rh/lm[nideef

.1 noisrevnocdeefehtesUtnerrucehtdnifotrekcits

.leveldeefegatnecrep

.3 tsetalehtsI doolbL/lomm7esoculg rednuro

dna tisah deppord ehtmorftnemerusaemsuoiverp yb

?5.1nahterom

:ON edisesU foleehw

.6 uoyfileehWnilusnIesU.ydaerlaosenodtonevah

:SEY edisesU foleehw

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