New Title GLUCOMMANDER: A COMPUTER-DIRECTED IV INSULIN SYSTEM SHOWN TO BE SAFE, SIMPLE, AND EFFECTIVE IN 120,618 HOURS

3. What is the Glucommander? Glucommander is a computer-based system for controlling blood glucose in hospital patients on IV or tube-feeding. Works by prompting the on-site measurement of glucose and advising an intravenous insulin infusion rate. Located in a computer at the patient’s bedside or nearby nursing station.

4. How is the Glucommander used? Physician orders Glucommander therapy, specifying initial parameters. Nurse enters these parameters and the current glucose. Glucommander recommends an insulin infusion rate and a time to check the next BG test. At the recommended time Glucommander prompts the nurse to measure BG and enter it. Glucommander recommends an insulin infusion rate and a time to check the next BG test. This process is repeated indefinitely.

5. How much insulin is infused with the Glucommander? Infusion follows the formula: Insulin / hr = multiplier x (BG – 60) “Multiplier” is a parameter which is automatically adjusted based on the glucose pattern and response to insulin.

6. How does it work? A multiplier is selected. Insulin infusion is proportional to BG reading. Multiplier is adjusted to achieve targeted BG.

7. How does the Glucommander adjust the multiplier? If the BG is above target and failing to decrease, the multiplier will increase. If the BG is below target and failing to increase, the multiplier will decrease.

9. How is the Glucommander ordered? To order, the physician must specify five parameters: The low end of the target range for BG. The high end of the target range for BG. The initial multiplier. This reflects the physician’s best estimate for the multiplier, although the Glucommander will adjust this based on the glucose response. The maximum time interval between BG measurements. The insulin concentration (used to translate the units per hour to milliliters per hour).

10. How should I set the target range? As low as 80 to 95 for healthy patients being stabilized overnight in preparation for testing. As high as 140 to 200 for patients undergoing surgery with an anesthesiologist who is uncomfortable with BG’s in the normal range.

11. How do I choose initial multiplier? Normal adult: A multiplier of 0.01 is a good initial choice. It is a bit low, but it will be automatically adjusted upwards as needed. It is possible to solve for the multiplier from experience? Multiplier = insulin rate / (BG – 60) For example, if you know that a patient on an insulin pump has previously required 0.5 units per hour to maintain a glucose of 100, a multiplier of 0.5 / (100 – 60) = 0.0125 could be used.

12. How should I set maximum time interval? Depends on perceived risk of sudden shift in the blood glucose. 120 minutes is reasonable for most patients. 60 minutes for patients in surgery or critically ill. BG can be entered more frequently than the Glucommander requests.

13. What is an appropriate insulin concentration? Dependent on infusion device. Select to allow adjustment of the infusion rate by increments of less than 0.1 units per hour. Currently using 0.5 units per cc solution in infusers that are adjustable to the nearest 0.1 ml per hour. Infusion can be adjusted by 0.05 unit per hour. Higher concentrations can be used in volume critical patients with insulin resistance.

14. What else must be ordered? An appropriate IV or tube feeding. To ensure a constant glucose flux, a controller should be used. The insulin drip is typically “piggy backed” into a maintenance IV at a side port close to the infusion catheter to eliminate lag in insulin delivery.

15. How often are blood sugars checked? From 20 minutes to Maximum Interval specified in the initial orders. Typically about an hour. Interval is programmed by Glucommander to increase when BG’s stabilize in the target range and decrease if BG’s are low or falling rapidly.

16. Can the patient eat or receive glucose in IV fluids? Constant rate of infusion of glucose-containing IV solutions. Constant enteral tube feeding. No discrete meals.

18. How has the Glucommander been used? Treatment of ketoacidosis Perioperative glucose management Hyperosmolar non-ketotic state Gastroparesis with intractable nausea and vomiting Labor and delivery “Learning” a patient’s insulin sensitivity Critically ill patients on ICU Myocardial infarction Hyperalimentation

19. Experience Glucommander is an evolution of protocols already in clinical use. Over 120,000 hours of experience in over 5000 runs. Safe and effective: Only one run out of 50 with transient, non-problematic hypoglycemia. Average of all runs to target in four hours. In all cases, the Glucommander’s recommendations have been appropriate. Appropriate recovery from all occurrences of the following deviations: Interruptions in IV fluids or tube feedings. Improper entry of initial parameters. Disconnected insulin infusion pumps. Patients receiving trays of food when they should not, etc. Eliminates ambiguity in the complex orders used to write insulin drips. Results in a much more accurate implementation of physicians’ intentions. Capable of stabilizing blood sugar even if the patient is fasting.