Name: improving iv insulin administration in a community hospital
Uploaded: 2012-06-11T12:00:00
Duration: 12 min 8 s
Description: Watch this Scientific Journal Video about Improving IV Insulin Administration in a Community Hospital at JoVE.com

笔者承认安妮·金特里与编制本手稿，兰迪Wesnitzer，初始纸静脉（IV）胰岛素协议和Devy A.李某，理学士（医药），CMPP的数据收集和分析的药学博士，药学博士，她协助她在编辑和手稿准备的援助。

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	<li>Umpierrez, G. E., Isaacs, S. D., Bazargan, N., You, X., Thaler, L. M., Ktabchi, A. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hyperglycemia:+an+independent+marker+of+in-hospital+mortality+in+patients+with+undiagnosed+diabetes.">Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes.</a> J. Clin. Endocrinol. Metab. 87, 978-982 (2002).</li><li>Bochicchio, G. V., Sung, J., Josh, M. I., Bochicchio, K., Johnson, S. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Persistent+hyperglycemia+is+predictive+of+outcome+in+critically+ill+trauma+patients.">Persistent hyperglycemia is predictive of outcome in critically ill trauma patients.</a> J. Trauma. 58, 921-924 (2005).</li><li>Finfer, S., Delaney, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tight+glycemic+control+in+critically+ill+adults.">Tight glycemic control in critically ill adults.</a> JAMA. 300, 963-965 (2008).</li><li>American Diabetes Association. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Standards+of+medical+care+in+diabetes-2008.">Standards of medical care in diabetes-2008.</a> Diabetes Care. 31, S12-S54 (2008).</li><li>Moghissi, E. S., Korytkowski, M. T., DiNardo, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+Association+of+Clinical+Endocrinologists+and+American+Diabetes+Association+Consensus+statement+on+inpatient+glycemic+control.">American Association of Clinical Endocrinologists and American Diabetes Association Consensus statement on inpatient glycemic control.</a> Endocr. Pract. 15, 1-17 (2009).</li><li>. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+NICE-SUGAR+Study+Investigators.+Intensive+versus+conventional+glucose+control+in+critically+ill+patients.">The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients.</a> N. Engl. J. Med. 360, 1283-1297 (2009).</li><li>Brunkhorst, F. M., Engel, C., Bloos, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intensive+insulin+therapy+and+pentastarch+resuscitation+in+severe+sepsis.">Intensive insulin therapy and pentastarch resuscitation in severe sepsis.</a> N. Engl. J. Med. 358, 125-139 (2008).</li><li>Griesdale, D. E., de Souza, R. J., van Dam, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intensive+insulin+therapy+and+mortality+among+critically+ill+patients:+a+meta-analysis+including+NICE-SUGAR+study+data.">Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data.</a> CMAJ. 180, 821-827 (2009).</li><li>Van den Berghe, G., Wilmer, A., Hermans, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intensive+insulin+therapy+in+the+medical+ICU.">Intensive insulin therapy in the medical ICU.</a> N. Engl. J. Med. 354, 449-461 (2006).</li><li>Trence, D. L., Kelly, J. L., Hirsch, I. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+rationale+and+management+of+hyperglycemia+for+in-patients+with+cardiovascular+disease:+time+for+change.">The rationale and management of hyperglycemia for in-patients with cardiovascular disease: time for change.</a> J. Clin. Endocrinol Metab. 88, 2430-2437 (2003).</li></ol>

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这EndoTool系统的选择，因为其复杂的算法和易用性。该计划是美国食品和药物管理局（FDA）批准，并协助该机构在健康保险可移植性和责任法案（HIPAA）符合。它可以装上了医院的服务器和内联网，而不需要额外的硬件。 该软件采用数学建模来计算病人特定的生理胰岛素剂量曲线的基础上，输入特定病人的血糖浓度。第四胰岛素剂量的基础是一个复杂的反馈机制，在控制的数学基础。该软件采用33算法分析和解释以前的病人的血糖读数，结合最近四个读数 - 在那个时间点来计算最合适的第四胰岛素剂量。随着每个后续的血糖读数的条目，曲线进行调整，以微量IZE极端的血糖浓度。初步匡算，因素影响血糖浓度，如糖尿病或糖皮质激素的使用存在/缺席，系统帐户。虽然协调小组提供准确和及时的在床边的剂量和速度信息，批判性思维仍然需要静脉胰岛素注射。制导计算机软件最终用户关于第四的胰岛素利率和碳水化合物的摄入量，新病人开始，在计算机中断（即服务器停机）做什么的信息提供指导。 的CGMS实施后，有一些医师的初步阻力，直到他们认为他们能够理解和信任的软件。然而，抵抗力减弱时，医务人员看到系统如何容易使用的，如何有效地控制血糖浓度，以及他们如何能够覆盖其建议，如果clinicallŸ必要的。总体而言，护理人员是渴望实现的CGMS由于他们的挫折与纸协议。然而，最初有一些护士在接受胰岛素输注率和丸剂量的CGMS建议犹豫。有时，系统会建议高得多的输液率和丸剂量保持在目标范围内的病人，比通常建议由纸协议。护士，早已成为舒适与协调小组的建议，并建议输注速率/丸剂量很少偏离。 住院患者良好的血糖控制的重要性已得到了很好的文献记载。这些研究表明当葡萄糖被有效地控制在住院期间的发病率和死亡率在下降。开关使用一个计算机化的葡萄糖在怀俄明州医学中心的管理体系文件的第四胰岛素协议。主要导致LLY改善目前的指导方针，按照高血糖患者的血糖控制，同时减少低血糖的风险。良好的血糖控制的好处，即使是医护专业人员之间，实施这样的策略了精心策划（ 见表2）。尽管纸协议的多个版本，在达到正常血糖水平，同时减少低血糖的结果是最理想的。总体而言，协调小组允许更迅速和更严格的血糖控制，实现了在所有读数大于75％的目标浓度。管理静脉注射胰岛素时，有一个天然的低血糖的恐惧。然而，使用CGMS低血糖的患病率为1％以下。

improving iv insulin administration in a community hospital

糖尿病是一个重要的独立危险因素，增加发病率和死亡率在住院和血糖浓度升高，即使在非糖尿病患者，预测不良后果。1-4美国临床内分泌学家协会（2008年共识声明AACE的）和美国糖尿病协会（ADA）指出，“在高血糖住院的病人，不论其原因，是明确不良后果。”重要的是要认识到，高血糖以及已知或确诊的糖尿病患者发生在那些以前糖耐量正常的急性疾病。 在重症监护评价生存的正常血糖葡萄糖算法规例（纳爱斯糖）超过600万成人重症监护病房（ICU）患者强化血糖控制或常规血糖，随机参与研究控制6令人惊讶的是，这项试验发现，强化血糖控制的死亡风险增加了14％（胜算比为1.14; P = 0.02）。此外，有严重的低血糖，在密集的对照组的患病率增加，比常规对照组（分别为6.8％和0.5％，P &lt;0.001）。从这一关键试验和另外两个人，7,8怀俄明州医学中心（WMC）实现了控制在住院的病人的高血糖，同时也避免了由此产生的低血糖的负面影响的重要性。 尽管静脉注射胰岛素纸协议，从纸协议在WMC的节目，在达到正常血糖水平，同时减少低血糖，结果不理想的使用数据分析的多个版本。因此，通过系统的实施计划，监测患者的血糖水平，使用纸张第四胰岛素协议切换到电脑葡萄糖managemenT系统。通过比较血糖水平的电脑系统使用纸协议，它被确定，总体来说，电脑的血糖管理系统，比传统的纸协议更迅速和更严格的血糖控制。具体来说，在大幅增加的时间花费在目标血糖浓度范围内，以及减少在严重的低血糖（血糖&lt;40毫克/升），临床低血糖（BG &lt;70毫克/升），高血糖的患病率（BG&gt; 180毫克/升），被目击在首五个月后葡萄糖计算机化管理系统的实施。电脑化系统，实现了在所有读数大于75％的目标浓度，同时减少低血糖的风险。低血糖的患病率（BG &lt;70毫克/升）与计算机的血糖管理系统的使用是在1％以下。

Watch this Scientific Journal Video about Improving IV Insulin Administration in a Community Hospital at JoVE.com

Improving IV Insulin Administration in a Community Hospital

相比上一纸协议，一个计算机化的血糖管理系统在目标范围内的大幅增加在血糖浓度测量结果的执行情况。使用一个计算机化的血糖管理系统，以监测血糖水平，减少严重低血糖（&lt;40毫克/升），临床低血糖（&lt;70毫克/升），也可以观察到的高血糖（&gt; 180毫克/升）。

提高在社区医院静脉注射胰岛素政府

Diabetes mellitus is a major independent risk factor for increased morbidity and mortality in the hospitalized patient, and elevated blood glucose ...

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