A stochastic model-based control methodology for glycemic management in the intensive care unit

Introduction: Intensive care unit (ICU) patients exhibit erratic blood glucose (BG) fluctuations, including hypoglycemic and hyperglycemic episodes, and require exogenous insulin delivery to keep their BG in healthy ranges. Glycemic control via glycemic management (GM) is associated with reduced mortality and morbidity in the ICU, but GM increases the cognitive load on clinicians. The availability of robust, accurate, and actionable clinical decision support (CDS) tools reduces this burden and assists in the decision-making process to improve health outcomes. Clinicians currently follow GM protocol flow charts for patient intravenous insulin delivery rate computations. Methods: We present a mechanistic model-based control algorithm that estimates the optimal intravenous insulin rate to keep BG within a target range; the goal is to develop this approach for eventual use within CDS systems. In this control framework, we employed a stochastic model representing BG dynamics in the ICU setting and used the linear quadratic Gaussian control methodology to develop a controller. Results: We designed two experiments, one using virtual (simulated) patients and one using a real-world retrospective dataset. Using these, we evaluated the safety and efficacy of this model-based glycemic control methodology. The presented controller avoids hypoglycemia and hyperglycemia in virtual patients, maintaining BG levels in the target range more consistently than two existing GM protocols. Moreover, this methodology could theoretically prevent a large proportion of hypoglycemic and hyperglycemic events recorded in a real-world retrospective dataset. Discussion: The current version of the methodology shows potential usefulness in GM of ICU patients. However, it is limited to a subgroup of the ICU patient population, who are fed through and enteral tube and delivered intravenous insulin. After extending to a broader ICU patient population who can consume oral nutrition and are delivered subcutaneous insulin for GM, the methodology could be tested with pilot studies and clinical trials for eventual use as a CDS tool.