Availability of a highly accurate in-hospital automated blood glucose (BG) monitor could facilitate implementation of intensive insulin therapy protocols through effective titration of insulin therapy, improved BG control, and avoidance of hypoglycemia. We evaluated a functional prototype BG monitor designed to perform frequent automated blood sampling for glucose monitoring.
Methods:
Sixteen healthy adult volunteer subjects had intravenous catheter insertions in a forearm or hand vein and were studied for 8 hours. The prototype monitor consisted of an autosampling unit with a precise computer-controlled reversible syringe pump and a glucose analytical section. BG was referenced against a Yellow Springs Instrument (YSI) laboratory analyzer. Sampling errors for automated blood draws were assessed by calculating the percent of failed draws, and BG data were analyzed using the Bland and Altman technique.
Results:
Out of 498 total sample draws, unsuccessful draws were categorized as follow: 11 (2.2%) were due to autosampler technical problems, 21 (4.2%) were due to catheter-related failures, and 37 (7.4%) were BG meter errors confirmed by a glucometer-generated error code. Blood draw difficulties or failures related to the catheter site (e.g., catheter occlusion or vein collapse) occurred in 6/15 (40%) subjects. Mean BG bias versus YSI was 0.20 ± 12.6 mg/dl, and mean absolute relative difference was 10.4%.
Conclusions:
Automated phlebotomy can be performed in healthy subjects using this prototype BG monitor. The BG measurement technology had suboptimal accuracy based on a YSI reference. A more accurate BG point-of-care testing meter and strip technology have been incorporated into the future version of this monitor. Development of such a monitor could alleviate the burden of frequent BG testing and reduce the risk of hypoglycemia in patients on insulin therapy.
The Diabetes Control and Complications Trial (DCCT). Design and methodologic considerations for the feasibility phase. The DCCT Research Group. Diabetes.1986;35 (5): 530–45.
2.
MalmbergKRydenLEfendicSHerlitzJNicolPWaldenstromAWedelHWelinL. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am College Cardiol.1995;26 (1): 57–65.
3.
ZerrKJFurnaryAPGrunkemeierGLBookinSKanhereVStarrA. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg.1997;63 (2): 356–61.
4.
Van den BergheGWoutersPWeekersFVerwaestCBruyninckxFSchetzMVlasselaersDFerdinandePLauwersPBouillonR. Intensive insulin therapy in the critically ill patients. N Engl J Med.2001;345 (19): 1359–67.
5.
FinneySJZekveldCEliaAEvansTW. Glucose control and mortality in critically ill patients. JAMA.2003;290 (15): 2041–7.
6.
KrinsleyJS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc.2004;79 (8): 992–1000.
7.
LairdAMMillerPRKilgoPDMeredithJWChangMC. Relationship of early hyperglycemia to mortality in trauma patients. J Trauma.2004;56 (5): 1058–62.
8.
GreyNJ. Perdrizet GA. Reduction of nosocomial infections in the surgical intensive-care unit by strict glycemic control. Endocr Pract.2004;10Suppl 2: 46–52.
9.
BochicchioGVSungJJoshiMBochicchioKJohnsonSBMeyerWScaleaTM. Persistent hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma.2005;58 (5): 921–4.
10.
ReedCCStewartRMShermanMMyersJGCorneilleMGLarsonNGerhardtSBeadleRGamboaCDentDCohnSMPruittBAJr.Intensive insulin protocol improves glucose control and is associated with a reduction in intensive care unit mortality. J Am Coll Surg.2007;204 (5): 1048–54.
11.
Van den BergheGWilmerAHermansGMeerssemanWWoutersPJMilantsIVan WijngaerdenEBobbaersHBouillonR. Intensive insulin therapy in the medical ICU. N Engl J Med.2006;345 (5): 449–61.
12.
GandhiGYNuttallGAAbelMDMullanyCJSchaffHVO'BrienPCJohnsonMGWilliamsARCutshallSMMundyLMRizzaRAMcMahonMM. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Ann Intern Med.2007;146 (4): 233–43.
13.
LacheradeJCJabrePBastuji-GarinSGrimaldiDFangioPThéronVOutinHDe JongheB. Failure to achieve glycemic control despite intensive insulin therapy in a medical ICU: incidence and influence on ICU mortality. Intensive Care Med.2007;33 (5): 814–21.
14.
VanhorebeekILangoucheLVan den BergheG. Tight blood glucose control with insulin in the ICU: facts and controversies. Chest.2007;132 (1): 268–78.
15.
BrunkhorstFMEngelCBloosFMeier-HellmannARagallerMWeilerNMoererOGruendlingMOppertMGrondSOlthoffDJaschinskiUJohnSRossaintRWelteTSchaeferMKernPKuhntEKiehntopfMHartogCNatansonCLoefflerMReinhartK; German Competence Network Sepsis (SepNet). Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med.358 (2): 125–39.
16.
TreggiariMMKarirVYanezNDWeissNSDanielSDeemSA. Intensive insulin therapy and mortality in critically ill patients. Crit Care.2008;12 (1): R29.
17.
EgiMBellomoRStachowskiEFrenchCJHartGKHegartyCBaileyM. Blood glucose concentration and outcome of critical illness: the impact of diabetes. Crit Care Med.2008;36 (8): 2249–55.
18.
KaufmanS. Normalization of glucose in the intensive care unit: does one size really fit all?. Crit Care Med.2008;36 (8): 2448–9.
19.
ButterworthJWagenknechtLLegaultCZaccaroDKonNHammonJRogersATroostBStumpDFurbergCCokerL. Attempted control of hyperglycemia during cardiopulmonary bypass fails to improve neurologic or neurobehavioral outcomes in patients without diabetes mellitus undergoing coronary artery bypass surgery. J Thorac Cardiovasc Surg.2005;130 (5): 1319–25.
20.
NICE-SUGAR Study Investigators, FinferSChittockDRSuSYBlairDFosterDDhingraVBellomoRCookDDodekPHendersonWRHébertPCHeritierSHeylandDKMcArthurCMcDonaldEMitchellIMyburghJANortonRPotterJRobinsonBGRoncoJJ. Intensive versus conventional glucose control in critically ill patients. N Engl J Med.2009;360 (13): 1283–97.
21.
MalhotraA. Intensive insulin in intensive care. N Engl J Med.2006;354 (5): 516–8.
22.
MoghissiEKorytkowskiMDiNardoMEinhornDHellmanRHirschIBInzucchiSEIsmail-BeigiFKirkmanMSUmpierrezGE; American Association of Clinical Endocrinologists; American Diabetes Association. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Prac.15 (4): 353–69.
23.
DellingerRPLevyMMCarletJMBionJParkerMMJaeschkeRReinhartKAngusDCBrun-BuissonCBealeRCalandraTDhainautJFGerlachHHarveyMMariniJJMarshallJRanieriMRamsayGSevranskyJThompsonBTTownsendSVenderJSZimmermanJLVincentJL. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med.2008;34 (1): 17–60.
24.
ChaneyMNikolovMBlakemanPBakhosM. Attempting to maintain normoglcyemia during cardiopulmonary bypass with insulin may initiate postoperative hypoglycemia. Anesth Analg.1999;89 (5): 1091–5.
25.
MechanickJHandelsmanYBloomgardenZ. Hypoglycemia in the intensive care unit. Curr Opin Clin Nutr Metab Care.2007;10 (2): 193–6.
26.
KrinsleyJSGroverA. Severe hypoglycemia in critically ill patients: risk factors and outcomes. Crit Care Med.2007;35 (10): 2262–7.
27.
AragonD. Evaluation of nursing work effort and perceptions about blood glucose testing in tight glycemic control. Am J Crit Care.2006;15 (4): 370–7.
28.
SadhuARAngACIngram-DrakeLAMartinezDSHsuehWAEttnerSL. Economic benefits of intensive insulin therapy in critically Ill patients: the targeted insulin therapy to improve hospital outcomes (TRIUMPH) project. Diabetes Care.2008;31 (8): 1556–61.
29.
CorstjensAMLigtenbergJJvan der HorstICSpanjersbergRLindJSTullekenJEMeertensJHZijlstraJG. Accuracy and feasibility of point-of-care and continuous blood glucose analysis in critically ill ICU patients. Crit Care.2006;10 (5): R135.
30.
BrunkhorstFM. Wahl HG. Blood glucose measurements in the critically ill: more than just a blood draw. Crit Care.2006;10 (6): 178.
31.
TorjmanMCGoldbergMEHirshRALittmanJ. Thinking like a pancreas: a look ahead at diabetes technology in the perioperative setting. Anesth Analg.2007;105:(2): 545.
32.
TorjmanMCDalalNGoldbergME. Glucose monitoring in acute care: technologies on the horizon. J Diabetes Sci Technol.2008;2 (2): 178–81.
33.
GaneshAHipszerBLoombaNSimonBTorjmanMJosephJ. Evaluation of the VIA blood chemistry monitor for glucose in healthy and diabetic volunteers. J Diabetes Sci Technol.2008;2 (2): 182–93.
34.
YamashitaKOkabayashiTYokoyamaTYatabeTMaedaHManabeMHanazakiK. The accuracy of a continuous blood glucose monitor during surgery. Anesthesia Analgesia.2008;106 (1): 160–3.
35.
YamashitaKOkabayashiTYokoyamaTYatabeTMaedaHManabeMHanazakiK. Accuracy and reliability of continuous blood glucose monitor in post-surgical patients. Acta Anaesthesiol Scand.2009;53 (1): 66–71.
36.
HirschIBBrownleeM. Should minimal blood glucose variability become the gold standard of glycemic control?. J Diabetes Complications.2005;19 (3): 178–81.
37.
EgiMBellomoRStachowskiEFrenchCJHartG. Variability of blood glucose concentration and short-term mortality in critically ill patients. Anesthesiology.2006;105 (2): 244–52.
38.
OuattaraAGrimaldiARiouB. Blood glucose variability: a new paradigm in critical care?. Anesthesiology.2006;105 (2): 233–4.
39.
DossettLACaoHMoweryNTDortchMJMorrisJMJrMayAK. Blood glucose variability is associated with mortality in the surgical intensive care unit. Am Surg.2008;74 (8): 679–85.
40.
Van den BergheG. How to compare adequacy of algorithms to control blood glucose in the intensive care unit?. Crit Care.2004;8 (3): 151–2.
WilinskaMEChassinLJHovorkaR. Automated glucose control in the ICU: effect of nutritional protocol and measurement error. Conf Proc IEEE Eng Med Biol Soc.2006;1: 67–70.
