U.S. patent application number 13/725115 was filed with the patent office on 2017-06-15 for systems and methods for determining insulin therapy for a patient.
This patent application is currently assigned to EndoTool, LLC. The applicant listed for this patent is ENDOTOOL, LLC. Invention is credited to William Patrick Burgess, John Dumas, III, Ronald Lisiecki, Carol Dian Martin, Timothy L. Ruchti, Laura Santana, John Harrison Thornley, Joanne Marie Watt.
Application Number | 20170165425 13/725115 |
Document ID | / |
Family ID | 48669535 |
Filed Date | 2017-06-15 |
United States Patent
Application |
20170165425 |
Kind Code |
A9 |
Ruchti; Timothy L. ; et
al. |
June 15, 2017 |
SYSTEMS AND METHODS FOR DETERMINING INSULIN THERAPY FOR A
PATIENT
Abstract
In example methods and systems described, insulin therapy for a
patient can be determined. At least one of a short-acting
subcutaneous insulin dosage recommendation, a correction
subcutaneous insulin dosage recommendation, an intravenous insulin
dosage recommendation, a recommended amount of carbohydrates to be
administered to the patient, or combinations thereof, can be
determined. In addition, information indicating a confirmation of a
nutrition intake for the patient, and a long-acting
insulin-on-board for the patient can be received, and based on this
information, a required long-acting subcutaneous or intravenous
insulin dosage for the patient can be determined. The short-acting
subcutaneous or intravenous insulin dosage recommendation can be
adjusted based, at least in part, on a difference between the
long-acting insulin-on-board and the required long-acting
subcutaneous or intravenous insulin dosage.
Inventors: |
Ruchti; Timothy L.; (Gurnee,
IL) ; Burgess; William Patrick; (Charlotte, NC)
; Dumas, III; John; (Libertyville, IL) ; Lisiecki;
Ronald; (Libertyville, IL) ; Martin; Carol Dian;
(Charlotte, NC) ; Santana; Laura; (Charlotte,
NC) ; Thornley; John Harrison; (Charlotte, NC)
; Watt; Joanne Marie; (Tower Lakes, IL) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
ENDOTOOL, LLC |
Charlotte |
NC |
US |
|
|
Assignee: |
EndoTool, LLC
Charlotte
NC
|
Prior
Publication: |
|
Document Identifier |
Publication Date |
|
US 20130165901 A1 |
June 27, 2013 |
|
|
Family ID: |
48669535 |
Appl. No.: |
13/725115 |
Filed: |
December 21, 2012 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
61578693 |
Dec 21, 2011 |
|
|
|
Current U.S.
Class: |
1/1 |
Current CPC
Class: |
G16H 50/20 20180101;
A61B 5/14532 20130101; A61M 5/1723 20130101; A61B 5/7275 20130101;
G16H 20/17 20180101; G06F 19/345 20130101; G06F 19/3456 20130101;
G06Q 50/22 20130101 |
International
Class: |
A61M 5/172 20060101
A61M005/172 |
Claims
1. A non-transitory computer readable medium having stored therein
instructions executable by a computing device to cause the
computing device to perform functions comprising: receiving
information associated with a glucose measurement value of a
patient; receiving information associated with anticipated
nutrition intake for the patient; receiving information indicating
a short-acting insulin-on-board for the patient, wherein
short-acting insulin-on-board is associated with an amount of
short-acting insulin that remains in the patient due to a prior
insulin administration; based, at least in part, on the information
associated with the glucose measurement value of the patient, the
anticipated nutrition intake for the patient and the short-acting
insulin-on-board, determining at least one of a short-acting
subcutaneous insulin dosage recommendation, a correction
subcutaneous insulin dosage recommendation, an intravenous insulin
dosage recommendation, a recommended amount of carbohydrates to be
administered to the patient, or combinations thereof; receiving
information indicating a confirmation of a nutrition intake for the
patient; receiving information indicating a long-acting
insulin-on-board for the patient, wherein long-acting
insulin-on-board is associated with an amount of long-acting
insulin that remains in the patient due to a prior insulin
administration; based, at least in part, on the information
associated with the long-acting insulin-on-board for the patient,
the glucose measurement value of the patient, and the confirmation
of the nutrition intake for the patient, determining a required
long-acting subcutaneous or intravenous insulin dosage for the
patient; adjusting the short-acting subcutaneous insulin dosage or
intravenous insulin dosage recommendation based on a difference
between the long-acting insulin-on-board and the required
long-acting subcutaneous or intravenous insulin dosage; and
outputting an indication of at least one of the required
long-acting subcutaneous insulin dosage, the adjusted short-acting
subcutaneous or intravenous insulin dosage recommendation, the
intravenous insulin dosage recommendation, the correction
subcutaneous insulin dosage recommendation, the recommended amount
of carbohydrates to be administered to the patient, or combinations
thereof.
2. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to perform the functions in the
order of: receiving information associated with a glucose
measurement value of the patient; receiving information associated
with anticipated nutrition intake for the patient; receiving
information indicating a short-acting insulin-on-board for the
patient, wherein short-acting insulin-on-board is associated with
an amount of short-acting insulin that remains in the patient due
to a prior insulin administration; receiving information indicating
a long-acting insulin-on-board for the patient, wherein long-acting
insulin-on-board is associated with an amount of long-acting
insulin that remains in the patient due to a prior insulin
administration; based, at least in part, on the information
associated with the glucose measurement value of the patient, the
anticipated nutrition intake for the patient and the short-acting
insulin-on-board, determining at least one of a short-acting
subcutaneous insulin dosage recommendation, a correction
subcutaneous insulin dosage recommendation, an intravenous insulin
dosage recommendation, a recommended amount of carbohydrates to be
administered to the patient, or combinations thereof; receiving
information indicating a confirmation of a nutrition intake for the
patient; based, at least in part, on the information associated
with the long-acting insulin-on-board for the patient, the glucose
measurement value of the patient, and the confirmation of the
nutrition intake for the patient, determining a required
long-acting subcutaneous or intravenous insulin dosage for the
patient; adjusting the short-acting subcutaneous insulin dosage or
intravenous insulin dosage recommendation based on a difference
between the long-acting insulin-on-board and the required
long-acting subcutaneous or intravenous insulin dosage; and
outputting an indication of at least one of the required
long-acting subcutaneous insulin dosage, the adjusted short-acting
subcutaneous or intravenous insulin dosage recommendation, the
correction subcutaneous insulin dosage recommendation, the
intravenous insulin dosage recommendation, the recommended amount
of carbohydrates to be administered to the patient, or combinations
thereof.
3. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to cause the computing device to
further perform functions comprising: receiving information
indicating a confirmation of a last insulin dose given
subcutaneously to the patient; and determining at least one of the
short-acting subcutaneous insulin dosage recommendation, the
intravenous insulin dosage recommendation, the correction
subcutaneous insulin dosage recommendation, the required
long-acting subcutaneous or intravenous insulin dosage for the
patient, or combinations thereof, based at least in part on the
confirmation of the last insulin dose given subcutaneously to the
patient.
4. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to cause the computing device to
further perform functions comprising: receiving information
indicating demographics of the patient; receiving information
indicating a serum creatinine level of the patient; determining a
glomerular filtration rate (GFR) of the patient based, at least in
part, on the demographics and the serum creatinine level of the
patient; and determining at least one of the short-acting
subcutaneous insulin dosage recommendation, the intravenous insulin
dosage recommendation, the correction subcutaneous insulin dosage
recommendation, the required long-acting subcutaneous or
intravenous insulin dosage, or combinations thereof, for the
patient based on the GFR of the patient.
5. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to cause the computing device to
further perform functions comprising: receiving information
indicating a total daily dosage amount for the patient of
short-acting insulin and long-acting insulin; and determining at
least one of the short-acting subcutaneous insulin dosage
recommendation, the intravenous insulin dosage recommendation, the
correction subcutaneous insulin dosage recommendation, the required
long-acting subcutaneous or intravenous insulin dosage, or
combinations thereof, for the patient based, at least in part, on
the total daily dosage amount for the patient of short-acting
insulin and long-acting insulin.
6. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to further cause the computing
device to perform functions comprising: receiving information
indicating drugs administered to the patient including one or
steroids and antibiotics; and determining at least one of the
short-acting subcutaneous insulin dosage recommendation, the
intravenous insulin dosage recommendation, the correction
subcutaneous insulin dosage recommendation, the required
long-acting or intravenous subcutaneous insulin dosage, or
combinations thereof, for the patient based, at least in part, on
the information indicating drugs administered to the patient.
7. The non-transitory computer readable medium of claim 1, wherein
the anticipated nutrition intake for the patient includes
information indicating a timing and rate of a feeding tube.
8. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to cause the computing device to
further perform functions comprising: receiving information
indicating whether a postprandial emesis has occurred; and
determining at least one of the short-acting subcutaneous insulin
dosage recommendation, the intravenous insulin dosage
recommendation, the correction subcutaneous insulin dosage
recommendation, the required long-acting subcutaneous or
intravenous insulin dosage, or combinations thereof, for the
patient based, at least in part, on the information indicating
whether a postprandial emesis has occurred.
9. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to further cause the computing
device to perform functions comprising: receiving information
indicating intravenous (IV) therapy provided to the patient; and
determining at least one of the short-acting subcutaneous insulin
dosage recommendation, the correction subcutaneous insulin dosage
recommendation, the required long-acting subcutaneous insulin
dosage, or combinations thereof, for the patient based, at least in
part, on the information indicating IV therapy provided to the
patient.
10. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to further cause the computing
device to perform functions comprising: receiving information
indicating total parenteral nutrition (TPN) provided to the
patient; and determining at least one of the short-acting
subcutaneous insulin dosage recommendation, the intravenous insulin
dosage recommendation, the correction subcutaneous insulin dosage
recommendation, the required long-acting subcutaneous or
intravenous insulin dosage, or combinations thereof, for the
patient based, at least in part, on the information indicating TPN
provided to the patient.
11. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to further cause the computing
device to perform functions comprising: receiving underlying
patient-specific control variables for the patient determined
based, at least in part, on (i) a therapy provided for the patient
and (ii) an observed patient-specific response to the therapy;
based, at least in part, on the underlying patient-specific control
variables for the patient, determining an amount of insulin used
per day by the patient and an insulin sensitivity factor; and
determining at least one of the short-acting subcutaneous insulin
dosage recommendation, the intravenous insulin dosage
recommendation, the correction subcutaneous insulin dosage
recommendation, the required long-acting subcutaneous or
intravenous insulin dosage for the patient, or combinations
thereof, based, at least in part, on the amount of insulin used per
day by the patient and the insulin sensitivity factor.
12. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to further cause the computing
device to perform functions comprising: determining the recommended
amount of carbohydrates to be administered to the patient when a
value of the short-acting insulin-on-board is negative.
13. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to cause the computing device to
further perform functions comprising: determining the short-acting
subcutaneous insulin dosage recommendation when the patient is
anticipated to consume a quantity of carbohydrates.
14. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to further cause the computing
device to perform functions comprising: determining the correction
subcutaneous insulin dosage recommendation when the glucose
measurement value of the patient is not within a target range.
15. The non-transitory computer readable medium of claim 1, wherein
the instructions are executable to further cause the computing
device to perform functions comprising: decreasing the short-acting
subcutaneous insulin dosage recommendation when the long-acting
insulin-on-board is more than the required long-acting subcutaneous
insulin dosage.
16. A method for determining a patient therapy, the method
comprising: receiving information associated with a glucose
measurement value of the patient; receiving information associated
with anticipated nutrition intake for the patient; receiving
information indicating a short-acting insulin-on-board for the
patient, wherein short-acting insulin-on-board is associated with
an amount of short-acting insulin that remains in the patient due
to a prior insulin administration; based, at least in part, on the
information associated with the glucose measurement value of the
patient, the anticipated nutrition intake for the patient and the
short-acting insulin-on-board, determining at least one of a
short-acting subcutaneous insulin dosage recommendation, a
correction subcutaneous insulin dosage recommendation, an
intravenous insulin dosage recommendation, a recommended amount of
carbohydrates to be administered to the patient, or combinations
thereof; receiving information indicating a confirmation of a
nutrition intake for the patient; receiving information indicating
a long-acting insulin-on-board for the patient, wherein long-acting
insulin-on-board is associated with an amount of long-acting
insulin that remains in the patient due to a prior insulin
administration; based, at least in part, on the information
associated with the long-acting insulin-on-board for the patient,
the glucose measurement value of the patient, and the confirmation
of the nutrition intake for the patient, determining a required
long-acting subcutaneous or intravenous insulin dosage for the
patient; adjusting the short-acting subcutaneous insulin dosage or
intravenous insulin dosage recommendation based, at least in part,
on a difference between the long-acting insulin-on-board and the
required long-acting subcutaneous or intravenous insulin dosage;
and outputting an indication of at least one of the required
long-acting subcutaneous insulin dosage, the adjusted short-acting
subcutaneous insulin dosage recommendation, the intravenous insulin
dosage recommendation, the correction subcutaneous insulin dosage
recommendation, the recommended amount of carbohydrates to be
administered to the patient, or combinations thereof.
17. The method of claim 16, further comprising: receiving
information indicating drugs administered to the patient including
one or steroids and antibiotics; and determining at least one of
the short-acting subcutaneous insulin dosage recommendation, the
correction subcutaneous insulin dosage recommendation, the
intravenous insulin dosage recommendation, the required long-acting
subcutaneous or intravenous insulin dosage for the patient, or
combinations thereof, based, at least in part, on the information
indicating drugs administered to the patient.
18. The method of claim 16, further comprising receiving
information indicating demographics of the patient; receiving
information indicating a serum creatinine level of the patient;
determining a glomerular filtration rate (GFR) of the patient
based, at least in part, on the demographics and the serum
creatinine level of the patient; and determining at least one of
the short-acting subcutaneous insulin dosage recommendation, the
correction subcutaneous insulin dosage recommendation, the
intravenous insulin dosage recommendation, the required long-acting
subcutaneous or intravenous insulin dosage for the patient, or
combinations thereof, based, at least in part, on the GFR of the
patient.
19. A system for determining a patient therapy, the system
comprising: at least one processing unit; memory storing
instructions executable by the at least one processing unit for
carrying out functions, the functions comprising: receiving
information associated with a glucose measurement value of the
patient; receiving information associated with anticipated
nutrition intake for the patient; receiving information indicating
a short-acting insulin-on-board for the patient, wherein
short-acting insulin-on-board is associated with an amount of
short-acting insulin that remains in the patient due to a prior
insulin administration; based, at least in part, on the information
associated with the glucose measurement value of the patient, the
anticipated nutrition intake for the patient and the short-acting
insulin-on-board, determining at least one of a short-acting
subcutaneous insulin dosage recommendation, a correction
subcutaneous insulin dosage recommendation, or an intravenous
insulin dosage recommendation to be administered to the patient;
receiving information indicating a confirmation of a nutrition
intake for the patient; receiving information indicating a
long-acting insulin-on-board for the patient, wherein long-acting
insulin-on-board is associated with an amount of long-acting
insulin that remains in the patient due to a prior insulin
administration; based, at least in part, on the information
associated with the long-acting insulin-on-board for the patient,
the glucose measurement value of the patient, and the confirmation
of the nutrition intake for the patient, determining a required
long-acting subcutaneous or intravenous insulin dosage for the
patient; adjusting the short-acting subcutaneous insulin dosage or
intravenous insulin dosage recommendation based, at least in part,
on a difference between the long-acting insulin-on-board and the
required long-acting subcutaneous or intravenous insulin dosage;
and outputting the required long-acting subcutaneous insulin
dosage, the adjusted short-acting subcutaneous or intravenous
insulin dosage recommendation, the intravenous insulin dosage
recommendation, the correction subcutaneous insulin dosage
recommendation, or combinations thereof to be administered to the
patient.
20. The system of claim 19, wherein the instructions are executable
to further perform functions of: receiving information indicating
drugs administered to the patient including one or steroids and
antibiotics; and determining at least one of the short-acting
subcutaneous insulin dosage recommendation, the correction
subcutaneous insulin dosage recommendation, the intravenous insulin
dosage recommendation, and the required long-acting subcutaneous or
intravenous insulin dosage for the patient based on the information
indicating drugs administered to the patient.
21. The system of claim 19, wherein the instructions are executable
to further cause the at least one processing unit to perform
functions comprising: receiving information indicating demographics
of the patient; receiving information indicating a serum creatinine
level of the patient; determining a glomerular filtration rate
(GFR) of the patient based, at least in part, on the demographics
and the serum creatinine level of the patient; and determining at
least one of the short-acting subcutaneous insulin dosage
recommendation, the correction subcutaneous insulin dosage
recommendation, the intravenous insulin dosage recommendation, the
required long-acting subcutaneous or intravenous insulin dosage for
the patient, or combinations thereof, based, at least in part, on
the GFR of the patient.
22. A non-transitory computer readable medium having stored therein
instructions executable by a computing device to cause the
computing device to perform functions comprising: providing a
graphical user interface (GUI) to display information divided based
on a category of input, the categories including information:
associated with a glucose measurement value of a patient;
associated with anticipated nutrition intake for the patient;
indicating a short-acting insulin-on-board for the patient, wherein
short-acting insulin-on-board is associated with an amount of
short-acting insulin that remains in the patient due to a prior
insulin administration; indicating a confirmation of a nutrition
intake for the patient; and indicating a long-acting
insulin-on-board for the patient, wherein long-acting
insulin-on-board is associated with an amount of long-acting
insulin that remains in the patient due to a prior insulin
administration; based, at least in part, on the information
associated with the glucose measurement value of the patient, the
anticipated nutrition intake for the patient and the short-acting
insulin-on-board, determining at least one of a short-acting
subcutaneous insulin dosage recommendation or a correction
subcutaneous insulin dosage recommendation to be administered to
the patient; based, at least in part, on the information associated
with the long-acting insulin-on-board for the patient, the glucose
measurement value of the patient, and the confirmation of the
nutrition intake for the patient, determining a required
long-acting subcutaneous insulin dosage for the patient; adjusting
the short-acting subcutaneous insulin dosage recommendation based,
at least in part, on a difference between the long-acting
insulin-on-board and the required long-acting subcutaneous insulin
dosage; and providing on the GUI a display of the required
long-acting subcutaneous insulin dosage, the adjusted short-acting
subcutaneous insulin dosage recommendation, and the correction
subcutaneous insulin dosage recommendation to be administered to
the patient.
23. A non-transitory computer readable medium of claim 22, wherein
the instructions are executable to further cause the computing
device to perform functions comprising: providing on the GUI a
startup screen including selectable protocols, wherein the
selectable protocols include a glucose measurement schedule, an
insulin therapy schedule, and a nutritional plan; and providing the
categories of input based, at least in part, on at least one
protocol selected.
Description
CROSS REFERENCE TO RELATED APPLICATION(S)
[0001] This application claims the benefit under 35 U.S.C.
.sctn.119(e) of the earlier filing date of U.S. Provisional
Application 61/578,693 entitled "SYSTEMS AND METHODS FOR
DETERMINING SUBCUTANEOUS INSULIN THERAPY FOR A PATIENT," filed Dec.
21, 2011, and which provisional application is hereby incorporated
by reference in its entirety for any purpose.
TECHNICAL FIELD
[0002] Examples described herein include therapeutic decision
support systems involving periodic delivery of medications to a
patient to achieve a particular physiological objective. For
example, examples described herein relate to systems and methods
for determining insulin therapy for a patient. The insulin therapy
may be subcutaneous, intravenous, or may be a combination of
subcutaneous and intravenous therapies.
BACKGROUND
[0003] Treatment of hospitalized patients frequently involves
control of one or more physiological parameters in concert with
administration of fluids, pharmaceuticals, and nutrition. For
patients diagnosed with diabetes, treatment generally includes
monitoring blood glucose levels, and administering insulin or
carbohydrates when the blood glucose levels are not within
acceptable ranges.
[0004] A patient may be diagnosed with specific types of diabetes
mellitus that differ in onset, therapy and underlying disease
state. In the case of "type 1" diabetes, the patient is dependent
upon administration of exogenous insulin on a daily basis either by
subcutaneous injections or by delivery from an externally worn
insulin pump. In a person with "type 2" diabetes, the patient may
or may not be dependent on the administration of exogenous insulin
subcutaneously. Type 2 patients may require oral medications to
either stimulate their pancreas to secrete insulin, or sensitize
their tissues to the insulin provided by their pancreas. At times,
type 2 patients may need additional insulin administered
subcutaneously for them to remain in glycemic control. In a third
type of diabetes, a "gestational" type, a female who exhibits
normal glycemic control during non-gravid periods loses this
control while pregnant (typically in the third trimester) and
behaves somewhat like a type 2 diabetic. Persons with these three
types of diabetes generally arrive at or are admitted into a
hospital with known diabetes. In contrast, in a fourth type,
"stress" diabetes, hyperglycemia occurs as a result of stress,
illness or steroid administration, often just prior to or during a
hospital stay and the patient requires therapeutic intervention
through oral medications or by insulin administration. Studies have
shown that proper glucose management during in-patient treatment
reduces morbidity and mortality.
[0005] A goal in the treatment of any of the types of diabetic
patients is to maintain blood glucose levels within an acceptable
range, typically 80-120 mg/dL, 100-140 mg/dL or 100-180 mg/dL,
using oral medications or through administration of insulin
(subcutaneously or via a pump intravenously) while at the same time
reducing the risk of hypoglycemia (glucose levels less than 70
mg/dL). Existing subcutaneous insulin dosing protocols may be
limited in their goal to maintain glycemic control while accounting
for patient-to-patient variability in insulin requirements as well
as changes through time. Limitations may be related to the
availability, management and utilization of information that would
aid in an improved calculation of an insulin dose. However, access
to useful information, entry of the useful information into some
form of a calculation sheet, and calculating the dose based on the
information would be a time consuming task for a nurse.
SUMMARY OF THE INVENTION
[0006] Within one aspect described herein, a method for determining
a patient therapy is provided. An example method may include
receiving information associated with a glucose measurement value
of the patient, receiving information associated with anticipated
nutrition intake for the patient, and receiving information
indicating a short-acting insulin-on-board for the patient. The
short-acting insulin-on-board may be associated with an amount of
short-acting insulin that remains in the patient due to a prior
insulin administration. The method may also include based, at least
in part, on the information associated with the glucose measurement
value of the patient, the anticipated nutrition intake for the
patient and the short-acting insulin-on-board, determining at least
one of a short-acting subcutaneous insulin dosage recommendation,
an intravenous insulin dosage recommendation, a correction
subcutaneous insulin dosage recommendation, a recommended amount of
carbohydrates to be administered to the patient, or combinations
thereof. The method may also include receiving information
indicating a confirmation of a nutrition intake for the patient,
and receiving information indicating a long-acting
insulin-on-board, for the patient. The long-acting insulin-on-board
may be associated with an amount of long-acting insulin that
remains in the patient due to a prior insulin administration. The
method may also include based, at least in part, on the information
associated with the long-acting insulin-on-board for the patient,
the glucose measurement value of the patient, and the confirmation
of the nutrition intake for the patient, determining a required
long-acting subcutaneous or IV insulin dosage for the patient. The
method may also include adjusting the short-acting subcutaneous
insulin dosage or IV insulin dosage recommendation based, at least
in part, on a difference between the long-acting insulin-on-board
and the required long-acting subcutaneous or IV insulin dosage, and
outputting an indication of at least one of the required
long-acting subcutaneous insulin dosage, the adjusted short-acting
subcutaneous or IV insulin dosage recommendation, the IV insulin
dosage recommendation, the correction subcutaneous insulin dosage
recommendation, the recommended amount of carbohydrates to be
administered to the patient, or combinations thereof.
[0007] Any of the methods described herein may be provided in a
form of instructions stored on a non-transitory, computer readable
medium, that when executed by a computing device (e.g. a computing
system), perform functions described. Embodiments may also include
articles of manufacture including a tangible computer-readable
media that have computer-readable instructions encoded thereon, and
the instructions may comprise instructions to perform functions
described herein.
[0008] In another aspect, a non-transitory computer readable medium
having stored therein instructions executable by a computing device
to cause the computing device to perform functions is provided. The
functions may comprise providing a graphical user interface (GUI)
to display information divided based on a category of input. The
categories may include information associated with a glucose
measurement value of a patient, associated with anticipated
nutrition intake for the patient, indicating a short-acting
insulin-on-board for the patient, indicating a confirmation of a
nutrition intake for the patient, and indicating a long-acting
insulin-on-board for the patient, for example. The functions may
also include based, at least in part, on the information associated
with the glucose measurement value of the patient, the anticipated
nutrition intake for the patient and the short-acting
insulin-on-board, determining at least one of a short-acting
subcutaneous insulin dosage recommendation or a correction
subcutaneous insulin dosage recommendation to be administered to
the patient. The functions may also include based, at least in
part, on the information associated with the long-acting
insulin-on-board for the patient, the glucose measurement value of
the patient, and the confirmation of the nutrition intake for the
patient, determining a required long-acting subcutaneous insulin
dosage for the patient, and adjusting the short-acting subcutaneous
insulin dosage recommendation based on a difference between the
long-acting insulin-on-board and the required long-acting
subcutaneous insulin dosage. The functions may also include
providing on the GUI a display of the required long-acting
subcutaneous insulin dosage, the adjusted short-acting subcutaneous
insulin dosage recommendation, and the correction subcutaneous
insulin dosage recommendation to be administered to the
patient.
[0009] The foregoing summary is illustrative only and is not
intended to be in any way limiting. In addition to the illustrative
aspects, embodiments, and features described above, further
aspects, embodiments, and features will become apparent by
reference to the figures and the following detailed
description.
BRIEF DESCRIPTION OF THE DRAWINGS
[0010] FIG. 1 illustrates an example system configuration for
managing and delivering patient therapy.
[0011] FIG. 2 is a block diagram of an example insulin dosing
methodology showing inputs and outputs.
[0012] FIG. 3 illustrates another example system configuration for
managing and delivering patient therapy.
[0013] FIG. 4 is a block diagram of an example method to determine
an adjustment to an insulin recommendation based on an amount of
insulin-on-board, in accordance with at least some embodiments
described herein.
[0014] FIG. 5 is a plot representing example calculated insulin
effect curves for six different types of insulin based upon example
known pharmacokinetics.
[0015] FIG. 6 is a block diagram of another example method to
determine insulin therapy for a patient, in accordance with at
least some embodiments described herein.
[0016] FIG. 7 is a block diagram illustrating an example flow of
information to estimate insulin-on-board determinations and
adjustments to insulin recommendations.
[0017] FIG. 8 is a functional block diagram illustrating an example
computing device used in a computing system that is arranged in
accordance with at least some embodiments described herein.
[0018] FIGS. 9A-9L illustrate example GUIs that may be implemented
on a computing device to receive and display information according
to embodiments disclosed herein.
DETAILED DESCRIPTION
[0019] In the following detailed description, reference is made to
the accompanying figures, which form a part hereof. In the figures,
similar symbols typically identify similar components, unless
context dictates otherwise. Illustrative embodiments described in
the detailed description, figures, and claims are not meant to be
limiting. Other embodiments may be utilized, and other changes may
be made, without departing from the scope of the subject matter
presented here. It will be readily understood that the aspects of
the present disclosure, as generally described herein, and
illustrated in the Figures, can be arranged, substituted, combined,
and designed in a wide variety of different configurations, all of
which are explicitly contemplated and made part of this
disclosure.
[0020] This disclosure may disclose, inter alia, systems and
methods for determining subcutaneous insulin therapy for a patient.
In one example, information associated with a glucose measurement
value of the patient, anticipated nutrition intake for the patient,
and a short-acting insulin-on-board for the patient can be
received. Based, at least in part, on this information at least one
of a short-acting subcutaneous insulin dosage recommendation, a
correction subcutaneous insulin dosage recommendation, an
intravenous insulin dosage recommendation, a recommended amount of
carbohydrates to be administered to the patient, or combinations
thereof can be determined. In addition, information indicating a
confirmation of a nutrition intake for the patient, and a
long-acting insulin-on-board for the patient can be received, and
based, at least in part, on this information, a required
long-acting subcutaneous or intravenous insulin dosage for the
patient can be determined. The short-acting subcutaneous insulin
dosage or intravenous insulin dosage recommendation can be adjusted
based on a difference between the long-acting insulin-on-board and
the required long-acting subcutaneous or intravenous insulin
dosage. Other embodiments and examples are described herein.
[0021] In some examples, intravenous (IV) insulin dosing may be
recommended and/or adjusted in a manner that accounts for
insulin-on-board due in part to prior or simultaneous long- and/or
short-acting subcutaneous insulin doses.
[0022] Referring now to the figures, FIG. 1 illustrates an example
configuration for managing and delivering patient therapy. A
hospital information system 102 may be provided to support, for
example, admission, discharge, and transfer of patient data
throughout a hospital or medical community. The hospital
information system 102 may be in the form of a server or other type
of computing system (e.g. workstation), and may be connected to a
computing system 104 via a network or other interface, such as for
example, an interface server 106. Additionally, the hospital
information system 102 and/or computing system 104 may include or
be in communication with any of the laboratory, medication
administration record, food services, vitals, pharmacy, and other
information systems that may have information relevant to a patient
and may broadcast information to other systems. The computing
system 104 may include an application server 108 coupled to a
database 110 that may include patient-specific information relating
to treatment for the patient. The computing system 104 may also
include a web server 112 enabling connections to the computing
system 104 by other components using Internet, http, and messaging
protocols over a local area network, wide-area network, or mobile
network, wired or wireless.
[0023] The interface server 106 may also transmit data or messages
through a common protocol, such as HL7, to the hospital information
system 102. For example, orders determined by the applications
described herein, glucose values and other patient specific
information, which may be entered by clinicians as described
herein, and confirmed meal and insulin dosing information, which
may be entered by clinicians as described herein, may be
transmitted to and from the hospital information system 102.
[0024] A workstation 114 may be connected to the system 104 for use
by a hospital administrator, physician or nurse to input patient
data, and to provide the ability to generate reports, receive
patient status information, generate and print subcutaneous insulin
dosing orders, and modify configuration parameters, for example.
The workstation 114 may connect to the system 104 through the web
server 112 or the interface server 106, or may connect directly to
the application server 108, for example. The hospital information
system 102, the system 104, and the workstation 114 may be located
in a hospital or off-site as well.
[0025] The configuration in FIG. 1 may include additional
components, such as other medical network servers connected to the
system 104 to access and receive patient-specific data, critical
care information, or other information useful for hospital
personnel. Still further one or more of the described components or
functions of the configuration in FIG. 1 may be divided up into
additional functional or physical components, or combined into
fewer functional or physical components. For example, the
workstation 114 may alternatively be configured for autonomous
operation without connection to a server or any of the hospital
information system 102 or the system 104, for example. In some
further examples, additional functional and/or physical components
may be added to the examples illustrated by FIG. 1.
[0026] It is to be understood that examples of computing systems
described herein may be quite flexible. In some examples, the
application server 108 that may provide therapy recommendations
based on received inputs as described herein, may be located at a
hospital site. In some examples, the application server 108 may be
integrated with the workstation 114 such that a same computing
system used to input patient information may also be used to
determine the therapy recommendation. In other examples, the
application server 108 that may provide therapy recommendations may
be located remotely, e.g. software described herein may be
implemented as a cloud-based solution, where a server (e.g. the
application server 108) may be programmed to provide therapy
recommendations in accordance with examples described herein and
communicate with local devices (e.g. workstation 114) over a
network, such as the Internet.
[0027] A user (e.g. a nurse or other medical personnel 116) may
input data to the workstation 114 to receive information regarding
therapy to deliver to a patient 118. In other examples, data may be
input to the workstation 114 and/or provided to the system 104 in
an automated manner, such as by transmission by a measuring unit
that obtains one or more measured values regarding a patient's
condition. A user (e.g. medical personnel 116) may input data to
the workstation 114 directly, or the medical personnel 116 may use
an input unit 120 that can communicate the data to the workstation
114 and/or to the system 104, such as to the application server
108, using a wireless or wired connection, for example. As one
example, the input unit 120 may be a hand-held device such as a
PDA, tablet, cellular phone, or mobile interface system.
[0028] A measuring unit 122 can be operatively connected to,
associated with or used on the patient 118 to sense, monitor or
measure a patient physiological characteristic or response to
therapy. Blood or another fluid can be withdrawn from the patient
and tested or analyzed by the measuring unit 122. For example, the
measuring unit 122 may include a blood pressure monitor,
temperature sensor, activity monitor, a blood-glucose monitor, or
other monitor/meter as needed to measure a desired characteristic
of the patient 118. For example, patients carrying the diagnoses of
diabetes or hyperglycemia may have their blood tested periodically
usually using a hand-held glucometer or in a continuous or
semi-continuous manner through a continuous glucose measurement
system (CGMS). The test can be performed by a nurse, nursing
assistant or by a diabetic team. In some examples, the test may be
performed in an automated (e.g. scheduled) manner. The test may be
a "Finger Blood Glucose" test (FBG), and values obtained from these
tests are in units of milligrams per deciliter (mg/dL) for United
States hospitals and can range from 20-600 mg/dL. Meters outside
the United States use units of millimoles per liter (mmol/L) and
can range from 1.12-33.6 mmol/L (conversion factor=0.056).
[0029] The glucometer readings can be entered into the workstation
114 by the medical personnel 116, or alternatively, the measuring
unit 122 may provide the readings to the workstation 114 via a
wireless or wired connection. Blood glucose tests may be performed
on patients, four times a day on any one patient in one example.
The tests can be performed before each meal and at bedtime, for
example. Additional tests can be performed if before a meal there
is an abnormally high glucose reading (>150-200 mg/dL) or an
abnormally low glucose reading (<60 mg/dL). These additional
tests can be performed in a time range of about 30-60 minutes after
the abnormal reading or after an intervention in response to the
original abnormal reading has been initiated (e.g., administration
of insulin, administration of intravenous or oral glucose).
[0030] Alternately, blood glucose may be measured automatically by
a device that is connected to the patient and analyzes a blood
sample either continuously or regularly. The device may, for
example, draw blood from a peripheral access point through an IV
set, perform a glucose analysis via an in-line glucose-oxidase
sensor and re-infuse the blood back into the patient automatically
and without clinician intervention. In another arrangement, blood
glucose may be measured by a continuous glucose monitor that is
connected to the patient and may be based upon a sensor measurement
in which the sensor is inserted into the patient's subcutaneous
tissue layer.
[0031] Glucose measurements may be electronically transferred from
the glucose measurement device to the application server or other
computing system or computing system component through a number of
arrangements. First, the clinician may manually enter the glucose
value into the workstation or handheld device, which enables
communication to the application and database systems. Second, the
glucose measurement may be communicated directly from the glucose
measurement device to the remote workstation or handheld device.
Third, the glucose measurement may be electronically transferred
from the glucose measurement device to the application through
either a wireless, local area network or messaging system. Fourth,
the glucose measurement may be collected and communicated either
electronically or manually to the hospital laboratory information
system. In this last arrangement, the glucose value associated with
a particular patient is provided to the glucose management system
through the Hospital Information System 102.
[0032] The medical personnel 116 may enter additional data into the
workstation 114 including data indicating an activity level of the
patient 118, an event or drug administration affecting blood
glucose such as emesis or a change in steroid therapy, and data
indicating an amount of carbohydrates consumed by the patient 118
or anticipated to be consumed by the patient 118. The workstation
114 may then provide a recommendation of therapy to the medical
personnel 116, such as by displaying a recommendation on a display
of the workstation 114 and/or input device or by printing a
recommendation or providing the recommendation for display on
another device associated with the care provider (e.g. a tablet,
PDA, or other mobile device). In addition, or alternatively, the
workstation 114 may provide the recommendation of therapy to the
input unit 120. The recommendation may indicate to administer to
the patient a short-acting insulin dosage recommendation(s), a
long-acting subcutaneous insulin dosage recommendation(s), a
correction subcutaneous insulin dosage recommendation, an
intravenous insulin dosage recommendation, or combinations thereof.
The intravenous insulin dosage recommendation may represent either
an overall intravenous insulin dosage recommendation, a correction
to an existing intravenous insulin dosage recommendation, or
combinations thereof. The recommendation may additionally or
alternatively recommend an amount of carbohydrate to be given to
the patient. The recommendation may in some examples recommend no
action to be taken at this time for the patient. In addition to
providing a recommended dosage for insulin, including for different
types of insulin in some examples, the workstation 114 may provide
a time for a next glucose measurement.
[0033] The medical personnel 116 may administer insulin to the
patient 118 subcutaneously using a syringe, or using an infusion
pump, for example. The insulin administration may be in accordance
with the therapy recommendation provided, for example, by the
application server 108 to the workstation 114 and/or input unit
120. In some examples, the insulin administration may be provided
automatically, e.g. by an infusion pump or other device receiving
the therapy recommendation provided by the application sever 108
and/or workstation 114. An example infusion pump may be programmed
with software, such as ENDOTOOL.TM., where the software may include
instructions for calculating appropriate insulin doses/rates and
glucose measurement intervals to provide intensive insulin therapy.
The software may provide clinicians with insulin dosage, D50W
dosage (Dextrose 50% in water) or other carbohydrate amount, and
testing frequency (time of next glucose test) recommendations
through a pump interface, for example. After the clinician has
confirmed or modified the recommended insulin infusion rate, the
pump infusion rate can be automatically changed.
[0034] When a patient is placed on a subcutaneous insulin regimen,
a calculation that may be performed, e.g. by the insulin pump or by
the application server 108, is that of determining a total daily
dose of insulin that the patient will receive. For type 1
diabetics, about 0.1-0.3 units/kg of insulin may be required. For
type 2 diabetics, about 0.4-1.0 units/kg of insulin may be
required. Half of these amounts may be given subcutaneously as a
long-acting insulin (e.g., detemir, glargine) before bedtime. The
other half of these amounts may be distributed equally among three
doses of fast-acting insulin (e.g., aspart, lispro) given
subcutaneously 15 minutes before each meal, for example. If the
patient is already taking insulin, the patient may be kept on the
same home routine, or placed on a four-dose a day regimen using the
total daily dose estimates. Glucometer readings guide any
additional insulin that is added to the preprandial (before meal)
doses of insulin. In the event of hypoglycemia, insulin doses may
be withheld and some type of glucose containing product may be
given to the patient either orally or intravenously until
subsequent glucometer readings are above a physician's ordered
level, for example. The above calculations and insulin
administration may be generalizations that work well for some
patients.
[0035] A patient in some examples may be placed on an intravenous
insulin regimen where the patient had received, either previously
or simultaneously, one or more subcutaneous insulin doses. In that
event, insulin-on-board calculations as described herein may be
used to provide an intravenous insulin dosage recommendation that
accounts for the insulin-on-board due to subcutaneous insulin
therapy. In the event a subcutaneous insulin dose is provided
during intravenous insulin therapy, insulin-on-board calculations
as described herein may be used to provide an intravenous insulin
dosage recommendation that accounts for the insulin-on-board due to
subcutaneous insulin therapy. The intravenous insulin dosage
recommendation may be provided in the form of an adjustment to an
existing intravenous insulin dosage recommendation.
[0036] The workstation 114 may be configured to provide a
recommendation for therapy per patient based on a number of
patient-specific inputs. The provided recommendation may utilize
information received, for example, by the application server 108.
Example inputs may include an amount of carbohydrates that the
patient is likely to consume before an insulin dose, a timing and
rate of any tube feedings, an amount of physical activity that the
patient is/has performed, an administration of any
dextrose-containing solutions, an administration of any steroid
medications, an administration of any antibiotics, a lab value or
biomarker related to renal and hepatic clearance, such as serum
creatinine and albumin, any post-prandial emesis that occurred,
subcutaneous insulin dose(s) received, and combinations thereof.
Provision of any of these items and/or combinations of these items
may influence a calculation of an insulin dose made by the
workstation 114, web server 112 and/or the application server
108.
[0037] As an example, the workstation 114, web server 112 and/or
the application server 108 may execute a software program
associated with the software program EndoTool.TM., to calculate
insulin dosing based on past glucose measurements. EndoTool may be
used in intensive care units, for example, to assist a nursing
staff in calculations of insulin dosing for patients that require
glycemic control. The workstation 114, web server 112 and/or the
application server 108 may execute an additional software program
as a step-down tool from EndoTool to allow the nursing staff to
calculate subcutaneous and/or intravenous insulin dosing based on
past glucose measurements, for example.
[0038] The workstation 114 may be a general computer or computing
device that executes the software program as an application program
on the workstation 114. Alternatively, the workstation 114 may
access the application program through the web server 112, and
thus, the application program may be a web-based program located on
a server (e.g. the application server or web server) and executed
through a client browser program on the workstation 114.
[0039] FIG. 2 is a block diagram showing inputs and outputs of an
example insulin dosing methodology. The insulin dosing methodology
may be implemented by the workstation 114 or the system 104 (or
components of the system 104, e.g. the application server or web
server) in FIG. 1, for example, to determine insulin dosage
recommendations for administration to the patient. Accordingly, the
workstation and/or the system 104 (e.g. the application server or
web server) may be programmed to implement examples of the insulin
dosing methodology described herein. For example, the workstation
and/or the application server of FIG. 1 may include or be in
communication with one or more computer readable mediums encoded
with instructions that, when executed, cause the application server
and/or the workstation to perform the actions for providing an
insulin dosage recommendation described herein. The method may
utilize three types of inputs, for example, that can be input per
patient by a nurse or other user to a workstation and/or input
device as described above. For example, static inputs, glucometer
inputs, and/or drug (per oral (PO)) inputs may be used. Static
inputs may include, but are not limited to, information indicating
a diabetes control method used by the patient, any institutional
parameters specific to the hospital, a diabetes type of the
patient, a renal status (creatinine levels) of the patient, a
hepatic status (albumin levels) of the patient, and any other
information associated with an insulin history of the patient.
Glucometer inputs may include, but are not limited to, blood
glucose values (point-of-care (POC) glucose readings) obtained from
glucometers used by the patients. Drug/PO inputs may include, but
are not limited to, any predicted or actual enteral or parenteral
carbohydrates taken in by the patient (e.g. including tube
feedings), information associated with any dextrose intravenous
(IV) drugs administered to the patient, information associated with
any steroids administered to the patient, information indicating
anticipated or actual activity levels of the patient, information
indicating any emesis by the patient, information regarding
previous or simultaneous subcutaneous insulin dose(s), and any
other subjective information regarding activity of the patient.
[0040] The insulin dosing methodology may output a subcutaneous or
intravenous insulin order to be administered to the patient. The
subcutaneous insulin order may be an order to administer a
short-acting insulin dosage, a long-acting insulin dosage, a
correction insulin dosage, or combinations thereof, for example.
The intravenous insulin order may specify a bolus and drip rate of
IV insulin. The insulin dosing methodology may also or instead
output a call for a POC glucose measurement to request an updated
glucose reading. The insulin dosing methodology may further output
an order to administer a carbohydrate containing solution to the
patient (e.g., orange juice), for example, if the patient becomes
hypoglycemic.
[0041] The insulin dosing methodology may calculate subcutaneous
and/or intravenous doses of insulin that are to be administered to
a patient to maintain a glycemic range of control, such as for
example, between 80-120 mg/dL of glucose in the bloodstream of the
patient. The glycemic, range of control may be adjusted, per
patient, as set by a physician or hospital administrator.
[0042] The insulin dosing methodology may provide other outputs
including but not limited to a graphical visualization of past
glucose values, medical record reports of the blood glucoses,
discharge summaries containing discharge instructions for the
patient and the primary care provider, and quality assurance
reports as required by an institution, for example.
[0043] The insulin dosing methodology may operate based on a
proactive system of glucose control to predict preprandial and
basal insulin doses based on glucometer readings preprandially, and
on the history of glucometer readings as well as previous insulin
doses and other status of the patient (e.g., steroid
administration, oral intake), rather than based on a reactive
system of glucose control where insulin doses may be only dependent
upon the glucometer reading prior to a preprandial insulin
dose.
[0044] The workstation 114, web server 112 and/or application
server or system 104 may execute the insulin dosing methodology to
provide a number of glucose control methods. Example glucose
control methods include, but are not limited to, intravenous
insulin, a single bedtime dose of long-acting insulin and three
preprandial doses of short-acting insulin, a single bedtime dose of
long-acting insulin and two preprandial doses of short-acting
insulin, a single bedtime dose of long-acting insulin and one
dinner dose of short-acting insulin, breakfast and dinner doses of
insulin mixtures (e.g., Neutral Protamine Hagedorn
(NPH)/Regular-70/30), and a single bedtime dose of long-acting
insulin.
[0045] FIG. 3 illustrates another example configuration for
managing and delivering patient therapy. The configuration may be
in the setting of a hospital, for example. Initially, orders to
initiate a drug therapy may originate from a physician (MD) 302
using, for example, an electronic order system 304 (or
alternatively, a paper-based order system). The order may include
all or selected combinations of the following component orders as
part of the order: 1) patient identification, 2) diabetic status of
patient: type 1, type 2, hyperglycemic, or gestational, 3) a method
of glycemic control to be used (e.g., use of a long-acting insulin
in the evening and short-acting insulin before each of the three
major meals, use of intravenous insulin, and/or glucometer readings
to be performed before each meal and at bedtime), 4) changes to the
diet, 5) a hypoglycemia protocol to use, and 6) required patient
health status information (e.g., including creatinine, mass and
other laboratory values).
[0046] The order system 304 may be configured to disseminate orders
to various locations in the hospital that act on these orders. One
of these locations may be a nurse 306 (or nurse station) assigned
to a target patient 308. Methods of disseminating nursing orders
include paper orders via patient charts and electronic orders via a
workstation 114 or hospital information system 102, for example.
Orders that define diet and food intake of the patient 308 may be
disseminated to a food services department 310 (e.g., via paper,
electronic transmission 106 or electronic orders to a workstation)
and may not be intervened or controlled by nursing staff. Food for
the patient 308 can be delivered to the patient 308 at specified
times during the day and records can be kept by food services or
the nursing staff as to what was actually delivered or
consumed.
[0047] A medication administration record (MAR) system 312 may be
coupled to the order system 304 to inform the order system 304 of
drugs administered to the patient 308. The MAR 312 my provide drug
administration orders that define a drug type, amount and timing of
a drug to administer to the patient 308. The MAR 312 may be
configured to generate drug orders from information received from
the order system 304.
[0048] The order system 304 may also couple to a drug storage
facility 314 to link drug orders to the order system 304 and to
cause nursing staff to interact with the drug storage facility 314
to obtain a drug (or other treatment) for administration to the
target patient 308. When items/drugs are removed from the drug
storage facility 314, the order, pharmacy or billing systems can be
notified of this removal. Alternatively, if a drug is not located
in the drug storage facility 314 (e.g., insulin for patients may be
part of a common drug storage facility located at a nursing station
or other storage area), the MAR 312 can be updated with a dosage of
any drug removed from the other areas and administered to the
patient 308.
[0049] A lab system 316 may also receive orders from the order
system 304 including instructions to perform blood draws and
process these draws in the hospital's clinical laboratory, for
example. Other orders to the lab system 316 may include orders
involving studies to be performed on the target patient 308 such as
radiologic, nuclear medicine or other procedure-like studies, for
example. The lab system 316 processes orders with posting of
laboratory results to the lab system 316 when available for future
review/interpretation by healthcare personnel. This data could be
available to the nursing staff at a workstation 318, and may
include data relating to creatinine levels and point of care (POC)
glucometer values, for example. Alternatively, the nurse 306 may
enter the POC glucometer values manually into the workstation
318.
[0050] The patient 308 may receive a drug administered as directed
by the order system 304. For example, the patient 308 may receive
intravenous insulin, and/or may receive subcutaneous insulin
administered by the nurse 306 once a day, four times a day, or
other amounts. Additional doses of short-acting insulin may be
given to the patient 308 dependent upon glucometer readings that
dictate a need for additional doses based on a "sliding-scale" of
insulin that the physician has ordered. In the event of
hypoglycemia (blood glucose <60 mg/dL), the patient 308 may
receive oral orange juice, oral glucose tablets or intravenous
dextrose.
[0051] The patient 308 may be tested for their glucose levels using
glucometers, and the nurse 306 can enter a glucometer reading into
the workstation 318. In addition, the nurse 306 may enter activity
levels and subjective information about the patient 308 into the
workstation 318 that can be used to modify insulin dosing. As an
example, the nurse 306 may measure activity levels of the patient
308 using a "pedometer-type" of device.
[0052] The workstation 318 may issue orders to administer insulin
to the patient 308 depending upon a type of glycemic control
methodology ordered by the physician 302 and allowed by the medical
administrator of the floor/unit. After administration of
subcutaneous insulin to the patient 308, the nurse 306 may enter a
record of administration both into the MAR 312 and into the
workstation 318.
[0053] The workstation 318 may receive glucose values/measurement
times periodically from glucometer readings from the patient as
well as quantity and times of predicted oral intake and/or actual
intake as entered by the nurse 306, for example. Any tube feedings,
emesis, quantity and type of activity performed by the patient, and
any other drugs administered to the patient including steroids or
dextrose containing solutions can also be entered into the
workstation 318. The workstation 318 may use any of this
information to determine future insulin doses and glucometer
testing times, e.g. by executing a program for determining insulin
doses in accordance with methodologies described herein.
[0054] The workstation 318 may interact with a database (e.g. a
structured query language (SQL) database located on a SQL server
database 320). The database may contain records of patients and
their history. In the event that the patient 308 might have
recently been cared for in the intensive care unit (ICU) using a
system (e.g. the ENDOTOOL system) 322 for intravenous glycemic
control, then underlying adaptive control parameters from this
system 322 can be provided to the workstation 318 and used as a
starting point for glycemic control. Such control parameters may
characterize the patient's quantity of insulin used per day and
insulin sensitivity. See co-pending US Ser. No. 12/970,777 filed
Dec. 16, 2010, which is incorporated by reference herein in its
entirety, for additional information regarding the EndoTool system
and transfer of control parameters for glucose control.
[0055] As an example, if the patient is "nothing by mouth" (NPO),
an insulin dosing calculation may take the form of:
I.sub.t=f(t,g.sub.t, .sub.t-1,.theta..sub.t,G) where t is the time,
I.sub.t is a calculated regular (short-acting) insulin dose at time
t, .sub.t-1 is a delivered insulin dose over the previous time
period, g.sub.t is a glucose measurement at time t, .theta..sub.t
is a vector of calculated underlying patient-specific control
parameters, G is a set of target glucose concentrations, and f is a
function that maps or translates the parameters into a recommended
insulin dose. The parameter vector .theta..sub.t may be referred to
as underlying patient-specific control variables or parameters. The
control parameters may enable determination of a patient specific
insulin dose because the control parameters are calculated on the
basis of an observed glucose response to insulin dosing. Additional
inputs may be used including, but not limited to, prior glucose
values, patient carbohydrate intake, changes in medications, such
as steroids, exercise and patient specific conditions or states, or
combinations thereof. Workstations or computing systems described
herein may be programmed (e.g. using computer readable media
encoded with executable instructions) to perform the insulin dosing
methodologies described herein.
[0056] In some examples, the function f above can be defined and
the calculation of I.sub.t can be performed on the basis of the
following nonlinear equation:
I.sub.t=M.sub.1(g.sub.t-G)+M.sub.2(g.sub.t-G).sup.2 where I.sub.t
is greater than zero, g.sub.t is a glucose measurement, and
M.sub.1,M.sub.2.epsilon..theta..sub.t, are multiplication constants
estimated over time on the basis of error between an observed and
desired glucose response to insulin dosing. The insulin dosing
calculation is nonlinear because, for example, it includes a square
term (g.sub.t-G).sup.2. Accordingly, the calculation of I.sub.t may
not linearly depend on the difference between the measured glucose
and target glucose levels. Rather, a more complex, nonlinear
relationship may be specified that may result in some examples in a
more accurate representation of the recommended insulin dose. The
method of calculating the underlying patient-specific control
variables can be performed using a recursive least squares
estimator, a Kalman filter, a Bayes estimator, or control rules
based upon a level and change of patient glucose concentration over
time, for example.
[0057] As an example, the method of calculating the underlying
patient-specific control variables can be performed using
established methods of parameter estimation, such as extended
Kalman filtering, recursive least squares estimation, Bayesian
estimation, or proportional control rules that are used to adjust
M.sub.1 and M.sub.2 on the basis of a calculated error, such as a
difference between observed and expected glucose concentrations.
For example, see Goodwin and Sin, Adaptive Filtering, Prediction
and Control, 1984, the entire contents of which are incorporated
herein by reference.
[0058] As a specific illustrative example, under the assumption
that the partial derivative of an observed glucose concentration
with respect to a calculated insulin rate is negative (e.g.,
glucose levels decreases with increased insulin), a pseudo gradient
descent methodology may be used to determine M.sub.1 and M.sub.2 on
the basis of a difference between observed and desired glucose
readings. For example, given the error: e.sub.t=g.sub.t-g.sub.t
where g.sub.t is a desired or target glucose concentration at time
t, the parameters M.sub.1 and M.sub.2 can be updated according to
the following:
M.sub.1=M.sub.1-.alpha.e.sub.t
M.sub.2=M.sub.2=.beta.e.sub.t
where .alpha. and .beta. are tunable positive constants. At each
measurement, estimated underlying control variables may be updated
according to non-linear equation
(I.sub.t=M.sub.1(g.sub.t-G)+M.sub.2(g.sub.t-G).sup.2) and, in time,
become personalized to the insulin-glucose response of the patient.
These underlying control variables can be provided to the
workstation 318 and used as a starting point for glycemic control,
for example, in instances in which a patient has been cared for
using such glucose dosing methodologies. Workstations and/or
computing systems described herein may be programmed (e.g. using
one or more computer readable media encoded with appropriate
executable instructions) to calculate, the underlying control
variables and insulin dosing.
[0059] In some examples, I.sub.t may be determined through a
feedback control methodology, such as proportional integral control
(PID) or model predictive control.
[0060] Referring again to FIG. 1, the workstation 114 may determine
and recommend a dose of each insulin administration after receiving
information regarding prior insulin delivery, glucose measurements
and/or expected carbohydrate consumption, for example. Any number
of calculations may be used to determine long and short-acting
subcutaneous insulin doses (injections) and/or intravenous insulin
doses.
[0061] General or personalized insulin dosing recommendations and
regimes may be used to treat a patient with diabetes.
[0062] As an example, if a patient is eating, an insulin and
carbohydrate dose administration may be calculated, e.g. by the
workstation 114 and/or by the system 104, such as by the
application server 108) based upon the patient's daily basal
insulin requirements, carbohydrate to insulin ratio (CIR in
servings per unit of insulin) and/or pre-prandial glucose
measurement. First, the computing system may recommend that the
patient receive a basal insulin dose either one or two times per
day of long or intermediate acting insulin (e.g., glargine, detemir
or NPH). The dose may be recommended to be divided and distributed
equally in the case of twice daily administration. Prior to each
meal, a pre-prandial meal-dose of short-acting insulin may be
determined, e.g. by the workstation 114 and/or by the system 104,
such as by the application server 108) by dividing the expected
carbohydrate intake by CIR and rounding down to the nearest unit.
Based upon the patient's glucose level, a correction dose of
short-acting insulin may also be recommended. The dose may be
determined according to a correction scale as 1-4 units of insulin
for every 50 mg/dL the patient's glucose level is above 150 mg/dL.
The correction dose may be combined with the meal dose. In some
examples, an intravenous insulin dosage recommendation may be
provided that may, for example, specify a bolus size and drip rate
for IV insulin therapy.
[0063] The basal rate, CIR and correction scale may be adjusted,
e.g. as recommended by the workstation 114 and/or by the system
104, such as by the application server 108, every other day or as
frequently as eight times per day based upon the patient's response
to prior insulin administration. Two times per day may be used in
one example. For example, if the patient's fasting glucose
measurements and pre-prandial glucose measurements are received by
the workstation 114 and/or the system 104, such as by the
application server 108, and are recognized as consistently
elevated, the recommended basal dose may be increased by a
percentage (e.g., 10%). Alternately, a persistently low glucose
value may lead to a decrease in the basal dose. In some examples,
the nurse may increase or decrease the dose absent a recommendation
from a computing system. The CIR may be increased or decreased,
e.g. in accordance with a recommendation by the workstation 114
and/or by the system 104, such as by the application server 108,
based upon an additional patient's post-prandial glucose response.
For example, if the patient's two hour post-meal glucose is over
200 mg/dL, as received by data communicated to the workstation 114
and/or the system 104, such as the application server 108, the CIR
may be increased by 10%. Similarly, the correction scale may be
increased or decreased by 1 unit on a daily basis if the patient's
glucose is consistently high or low respectively.
[0064] The basal rate and CIR may be known based upon the patient's
home insulin regimen. If the patient is newly diagnosed or
experiencing stress induced hyperglycemia, the basal dose may be to
0.2-0.3 units/kg of total body weight. The CIR may be initially
estimated as 15 grams of carbohydrate per unit of insulin and
increased or decreased by the physician depending upon the
patient's age, body size, activity level, steroid usage and insulin
resistance.
[0065] As a second example, the general dosing recommendations may
include a single injection of long-acting (e.g., basal) insulin in
either the evening or morning and an injection of short-acting
insulin prior to each meal. As an example, an order may be issued
for administration of a basal dose of insulin at approximately 9 PM
every evening for control methods that utilize this type of
insulin. The insulin that may be administered can include NPH
(e.g., Novolin N or Humulin N), Insulin detemir (e.g., Levemir),
and Insulin glargine (e.g., Lantus), for example. The dose can be
calculated, e.g. by the workstation 114 and/or system 104, such as
the application server 108 of FIG. 1) as follows:
Basal qPM Insulin Dose=0.5*TDD
where TDD is the total daily dose in units of any type of insulin
given to the patient in one day. The remaining portion of the total
daily dose of insulin may be equally distributed among three
short-acting insulin injections prior to each meal.
[0066] In another general example, a method for calculating a
subcutaneous dose of short-acting preprandial insulins is provided.
For example, an order may be issued for the administration of a
dose of insulin prior to each meal. The insulin that can be
administered may include insulin aspart (e.g., Novolog), insulin
glulisine (e.g., Apidra), insulin lispro (e.g., Humulog), regular
(e.g., Novolin R), and regular (e.g., Humulin R), for example. The
dose may be calculated (e.g. by the workstation 114 and/or the
system 104, such as the application server 108 of FIG. 1) as
follows:
[0067] Preprandial Insulin Dose=Expected Carbohydrate Intake (grams
or servings)/CIR and a correction dose as
Correction Dose=.beta.(f[BG.sub.i-target])
[0068] where f is related to the patient's insulin resistance
derived from the basal rate (Units/mg/dL), target is an upper
glucose limit, BGi is the measured glucose concentration, and
.beta. is a multiplier (e.g., 0.4) that may be varied depending
upon the patient's type of diabetes and kidney and hepatic
clearance rates, (Units/(mg/dL)2
[0069] In still another general example, a method for calculating a
subcutaneous dose of 70/30, 75/25 and 50/50 insulin mixtures is
provided (e.g. the workstation 114 and/or system 104 such as the
application server 108 of FIG. 1 may be programmed to calculate the
subcutaneous dose). For example, an order may be issued for
administration of bi-daily doses of insulin mixtures. The insulin
that can be administered may include insulin aspart protamine
suspension/aspart (e.g., Novolog Mix 70/30), insulin lispro
protamine suspension/insulin lispro (e.g., Humulog Mix 75/25),
insulin lispro protamine suspension/insulin lispro (e.g., Humulog
Mix 50/50), NPH/Regular (e.g., Humulin 70/30), NPH/Regular (e.g.,
Humulin 50/50), and NPH/Regular (e.g., Novolin 70/30).
[0070] In one embodiment, any of the general examples of insulin
dosing regimes provided above may be personalized per patient. A
set of methodologies may be provided (e.g. the workstation and/or
computing systems described herein may be programmed to implement
the described methodologies) to personalize recommendations to each
individual patient by adapting a set of internal control parameters
on the basis of patient variables (e.g., diabetes status, steroid
use, etc.), observed nutritional intake and observed blood glucose
response to insulin injections. Initialization of the control
parameters can be made patient specific by considering age, weight,
height, diabetes status, glomerular filtration rate (GFR) (via
serum creatinine level) and prior insulin(s), for example. Adaptive
control parameters may be used including a total daily dose of
insulin, a nonlinear physiological dosing coefficient, and the
ratio of long and short acting insulins. Updates to each parameter
can be made on the basis of the nurse-entered information.
[0071] Example methodologies may further utilize GFR corrected
insulin effect curves to account for insulin-on-board in order to
reduce "stacking" of frequent short-acting insulin administrations
that accumulate in the interstitium and to adjust for changes in
the estimated total daily dose. Insulin-on-board refers to insulin
that remains in the blood stream following prior insulin
administrations. A distribution of insulin-on-board depends on the
pharmacokinetics of the drug as well as the physiology of an
individual. The effect of the insulin on board related to patient
glucose management can be considered as part of an insulin dosing
regimen.
[0072] A volume of all insulin in a person that will be active over
a period of time (e.g., next five hours in one example) may be
referred to as insulin-on-board. Thus, insulin-on-board includes
previous insulin doses administered (over a previous T.sub.max
hours), and may additionally include recommended insulin doses that
may affect insulin activity during the period of time. In one
embodiment, an amount of insulin-on-board in a patient can be
determined, e.g. by the workstation 114 and/or system 104 of FIG.
1, such as by the application server 108 or web server, and may be
used to determine amounts of short-acting or long-acting insulin
requirements, or intravenous insulin, to be administered to a
patient. For example, insulin requirements may be calculated using
estimated internal control parameters including the patient's total
daily dose (TDD) or basal dose, and an adjustment to a current
insulin recommendation (associated with meals or correction scale)
may be made to compensate for insulin-on-board. The adjustment dose
can be negative or positive and may have one of many effects.
Adjustments can be made utilizing GFR adjusted insulin effect
curves to provide appropriate action when the patient suffers from
renal insufficiency, for example.
[0073] Adjustments to a calculated required amount of short-acting,
long-acting, or intravenous insulin dosages can be made to adjust
for changes associated with increased or decreased insulin
sensitivity following delivery of a long-acting dose of insulin,
changes associated with a change in diet following delivery of a
long-acting dose of insulin, changes associated with an insulin
therapy provided to the patient, changes due to non-uniformity in
the shape of the insulin effect curve associated with long-acting
insulin, changes due to residual insulin-on-board as a result of
renal or hepatic insufficiency, and changes due to the correction
scale portion of the short-acting insulin dose from frequent
glucose measurements or snacks that precede a meal, for example. In
addition, if a negative adjustment exceeds a recommended
short-acting dose then a quantity of carbohydrates can be
recommended for consumption/injection, for example.
[0074] Example adjustment scenarios are described below in Table 1.
The examples indicate how a computing system (e.g. workstation 114
of FIG. 1, system 104, and/or application server 108 or web server)
may alter a recommendation base don inputs received regarding
patient status.
TABLE-US-00001 TABLE 1 1. When the patient's estimated
insulin-requirements drop following a prior delivery of long-acting
insulin, a negative adjustment dose is used to reduce the
short-acting insulin dose to account for the previously
administered long-acting insulin that had been administered on the
higher TDD (or basal dose) schedule. 2. In the setting of an
increased TDD associated with long-acting insulin or basal dose, a
positive adjustment dose increases the short-acting insulin to
account for a previously administered long-acting dose that was
based on a smaller TDD. 3. In the setting of starting a patient
without any long-acting insulin previously administered, a positive
adjustment may be calculated increasing the short-acting insulin to
account for the basal requirements prior to the long-acting insulin
dose administration 4. In the setting of acute control situations
for high blood glucose levels that dictate more frequent blood
glucose checks, the adjustment dose may reduce the correction scale
insulin in the setting of adequate blood glucose changes and in the
setting of frequent short-acting insulin doses. This may have the
effect of un-stacking the frequently dosed insulin to avoid
hypoglycemia. 5. In the setting of an insulin regime change, an
adjustment can be made to correct the dosing from the effects of
previous regimes while transitioning to a new regime. 6. In the
setting of frequent short-acting insulin doses (e.g., a snack
followed by a meal), an adjustment can be made to account for the
insulin-on-board and adjust the correction dose. 7. In
consideration of the non-uniform action of long-acting insulin, an
adjustment dose may compensate for periods of low or high insulin
release.
[0075] FIG. 4 is a block diagram of an example method to determine
an adjustment to an insulin recommendation based on an amount of
insulin-on-board, in accordance with at least some embodiments
described herein. Method 400 shown in FIG. 4 presents an embodiment
of a method that, for example, could be used with the configuration
shown in FIG. 1, and may be performed by the system 104 (e.g. by
the application server 108 or web server), the workstation 114, or
a combination of the system 104 and the workstation 114. Method 400
may include one or more operations, functions, or actions as
illustrated by one or more of blocks 402-414. The method may be
implemented by programming one or more of the computing systems
(e.g. workstations and/or servers) of FIG. 1 to perform the
operations, functions, or actions illustrated. Although the blocks
are illustrated in a sequential order, these blocks may also be
performed in parallel, and/or in a different order than those
described herein. Also, the various blocks may be combined into
fewer blocks, divided into additional blocks, and/or removed based
upon the desired implementation.
[0076] In addition, for the method 400, and other processes and
methods disclosed herein, the flowchart shows functionality and
operation of one possible implementation of present embodiments. In
this regard, each block may represent a module, a segment, or a
portion of program code, which includes one or more instructions
executable by a processor for implementing specific logical
functions or steps in the process. The program code may be stored
on any type of computer readable medium, for example, such as a
storage device including a disk or hard drive. The computer
readable medium may include non-transitory computer readable
medium, for example, such as computer-readable media that stores
data for short periods of time like register memory, processor
cache and Random Access Memory (RAM). The computer readable medium
may also include non-transitory media, such as secondary or
persistent long term storage, like read only memory (ROM), optical
or magnetic disks, or compact-disc read only memory (CD-ROM), for
example. The computer readable media may also be any other volatile
or non-volatile storage systems. The computer readable medium may
be considered a computer readable storage medium, for example, a
tangible storage device, or other article of manufacture.
[0077] In addition, for the method 400, and other processes and
methods disclosed herein, each block in FIG. 4 may represent
circuitry that is wired to perform the specific logical functions
in the block.
[0078] Initially, at block 402, the method 400 includes receiving
information associated with a patient. For example, patient data
may be received including, but not limited to, levels of serum
creatinine, a diabetes type, an age, weight, and gender of the
patient for example. Any combination of patient data may generally
be received at block 402. The method 400 also includes, at block
404, receiving information associated with prior therapy
information. For example, a type of insulin previously administered
as well as amounts previously administered and times of previous
administrations can be identified. The method 400 also includes, at
block 406, determining a recommended short-acting insulin dosage or
an intravenous insulin dosage. For example, the short-acting
insulin dosage can be determined based upon the patient's current
condition (e.g., current blood glucose levels) and expected
carbohydrate intake using known insulin effect curves. The insulin
effect curves may be stored as data accessible to the computing
system implementing block 406. The data representing the insulin
effect curves may generally be stored in any suitable electronic
storage medium in communication with the relevant computing system,
which storage medium may be the same or a different storage medium
than the medium storing instructions to perform the sort-acting
insulin dosage calculation.
[0079] At block 408, the method 400 may optionally include
determining an estimate of the patient's GFR. Estimated GFR may
include a measure of kidney function in medicine. Kidney filtration
has an effect on insulin elimination from the body. A half-life of
insulin may be increased by roughly two fold with a loss of kidney
function (e.g., decreased GFR of .ltoreq.10 mL/min/1.73 m2). An
example equation to determine an estimated GFR is provided below
that provides a relationship between serum creatinine, gender, age,
and ethnicity.
GFR = 141 .times. min ( 1 , SCr .kappa. ) .alpha. .times. max ( 1 ,
SCr .kappa. ) - 1.209 .times. 0.993 age .times. F gender .times. F
ethnicity ##EQU00001## where ##EQU00001.2## .kappa. = { 0.9 gender
= male 0.7 gender = female , .alpha. = { - 0.411 gender = male -
0.329 gender = female , F gender = { 1 gender = male 1.018 gender =
female , F ethnicity = { 1.159 ethnicity = african american 1
otherwise , and SCr = { SCr default , child ( SCr = NULL ) ( age
< 21 ) SCr default , adult ( SCr = NULL ) SCr max SCr > SCr
max SCr min SCr < SCr min SCr otherwise . ##EQU00001.3##
[0080] GFR amounts may be estimated using other methods as well,
and in other examples different values of the constants described
above also be used.
[0081] At block 410, the method 400 includes determining insulin
effect curves for insulins administered over a prior period of
time. For example, insulin effect curves can be determined or
identified for insulin injected over the last 36 hours. Known
insulin effect curves can be used based on types and amounts of
insulins administered. At block 410, a computing system may select,
for example, among a variety of stored insulin effect curves base
don types and amounts of insulin administered. In other examples,
an insulin effect curve and/or data representing an insulin effect
curve may be calculated in block 410.
[0082] Insulin effect generally describes the action of insulin
through time and its availability to act on the patient's blood
glucose. Insulin effect curves may determine insulin effect for
each insulin type based upon the patient's kidney clearance as
represented in the calculated GFR. In addition, an area under an
insulin effect curve may determine a volume, and/or a 75% and 95%
utilization time (e.g., in hours) of the insulin. Initially,
pharmaco-kinetic/dynamic (PK/PD) curves for each insulin type may
be provided with a sampling constant interval through time equal to
T.sub.S which may be nominally set to 15 minutes, for example. In
the event that PK/PD curves are unknown, a short-acting insulin
response may be approximated to be uniform over a five hour period
and a long-acting insulin response may be approximated to be
uniform over a 24 hour period.
[0083] For each type of insulin, the insulin effect (R(type,
j).A-inverted.j=1, 2, . . . , N.sub.R) may be a normalized vector
that defines an expected serum insulin availability versus time
taking into account the patient's GFR. In one example, insulin
effect curves may be determined given the following:
TABLE-US-00002 TABLE 2 1. An estimate of the GFR 2 P recent insulin
administration times, ti.sub.k, where k: 1, 2, . . . , P, t.sub.i -
ti.sub.k < T.sub.max hours, and t.sub.i is a current time 3.
Indices to a global insulin list specifying a type of long-acting
and short-acting insulin administered at each administration event,
LAtype.sub.k and SAtype.sub.k, respectively, where k: 1, 2, . . . ,
P refers to the administration event 4. Times associated with
short-acting and long-acting insulin administration prior to
patient enrollment and during a last T.sub.max hours
(ti.sub.SA,init and ti.sub.LA,init, respectively) and types of
short- acting and long-acting insulin administered prior to patient
enrollment (SAtype.sub.init and LAtype.sub.init , respectively)
where t.sub.i - ti.sub.LA,init < T.sub.max and t.sub.i -
ti.sub.SA,init < T.sub.max 5. A matrix of insulin actions for
each insulin delivered, E(type, j), where (type) is an m-
dimensional index to the unique insulin types (specified in
LAtype.sub.k , SAtype.sub.k , SAtype.sub.init and LAtype.sub.init)
and j is the index of Ts-minute time intervals such that an example
insulin response time is determined according to t.sub.R = (j - 1)
.times. Ts minutes 6. A number (N.sub.R) of j elements in the
insulin response matrix E(type, j), such that N R = T max .times.
60 Ts ##EQU00002##
[0084] To determine the insulin effect curves, the estimate of the
GFR can be bounded such as:
GFR b = { GFR max GFR i > GFR max GFR min GFR i < GFR min GFR
i otherwise ##EQU00003##
[0085] Next, a unique subset of M indices, type(m) where m: 1, 2, .
. . , M, of insulin type index variables LAtype.sub.k,
SAtype.sub.k, SAtype.sub.init and LAtype.sub.init can be
established.
[0086] Coefficients of a second order digital filter defining
insulin effect from insulin PK curves can be specified. For
example, using definitions of total plasma clearance term n=0.16,
the portion or plasma clearance attributable to the kidney
r.sub.k=0.6, the sampling interval T.sub.S=15 minutes and the time
constant associated with the interstitial clearance T=36 minutes,
the coefficients can be specified according to:
B = [ 1 2 1 ] ##EQU00004## A = [ ( k 1 + 2 Ts ) ( k 2 + 2 Ts ) 2 k
1 k 2 - 2 ( 2 Ts ) 2 ( k 1 - 2 Ts ) ( k 2 - 2 Ts ) ] ##EQU00004.2##
where ##EQU00004.3## k 1 = - ln ( 0.5 ) T ##EQU00004.4## k 2 = n (
r k GFR 100 + ( 1 - r k ) ) , ##EQU00004.5##
and B and A correspond to coefficients of the numerator and
denominator of a transfer function of the filter, respectively.
Then, for each insulin type, (type(m)) where m: 1, 2, . . . , M,
the insulin effect can be calculated recursively according to a
following form of the transfer function:
R ( type , j ) = 1 A ( 1 ) ( S 2 ( j - 1 ) + B ( 1 ) E ( type , j )
) ##EQU00005## S 2 ( j ) = S 3 ( j - 1 ) + B ( 2 ) E ( type , j ) -
A ( 2 ) R ( type , j ) ##EQU00005.2## S 3 ( j ) = B ( 3 ) E ( type
, j ) - A ( 3 ) R ( type , j ) ##EQU00005.3##
where j=1, 2, . . . , NR, A(j) and B(j) correspond to the jth
element of the vectors A and B, the states S2(0) and S3(0) are zero
and (type) is used to denote (type(m)). After calculation, each
insulin effect curve can be normalized to an area of one:
R ( type , j ) = R ( type , j ) Y .A-inverted. j = 1 , 2 N R
##EQU00006## where ##EQU00006.2## Y = j = 1 N R R ( type , j ) .
##EQU00006.3##
Calculation of the 75% and 90% cut-off points for each insulin type
may occur by determining insulin.sub.75(type) and insulin
(type).sub.90 from the distribution curves of R(type,j). For
example,
insulin 75 ( type ) = j 75 60 / Ts ##EQU00007## such that
##EQU00007.2## j = 1 j 75 - 1 R ( type , j ) < 0.75 .ltoreq. j =
1 j 75 R ( type , j ) ##EQU00007.3##
[0087] Similarly,
insulin 90 ( type ) = j 90 60 / Ts ##EQU00008## such that
##EQU00008.2## j = 1 j 90 - 1 R ( type , j ) < 0.90 .ltoreq. j =
1 j 90 R ( type , j ) . ##EQU00008.3##
[0088] In some examples, insulin on board due to a previously or
simultaneously administered subcutaneous insulin dose may be
calculated utilizing the insulin on board calculation methodologies
described herein. The insulin volume (I.sub.effect) may be
determined by summing an area under the insulin curve, which may be
for example calculated as follows:
I effect = Idose .A-inverted. j R ( tc ' ( j ) ) ; ##EQU00009##
Idose corresponds to a dose of previously-administered subcutaneous
insulin, and tc represents a time since the administered does of
subcutaneous insulin. I.sub.effect accordingly may correspond with
an amount of insulin from a subcutaneous insulin dose that may be
effective over a next time period (e.g. t.sub.delta). In some
examples, however, if the subcutaneous insulin dose was a dose of
short-acting insulin, and the time since the administration of the
dose exceeds a threshold for activity of the short-acting insulin
(e.g. 300 minutes in one example), then I.sub.effect may be
represented as zero (e.g. there is no further insulin-on-board due
to the dose). Similarly, if the subcutaneous insulin dose was a
dose of long-acting insulin, and the time since the administration
of the dose exceeds a threshold for activity of the long-acting
insulin (e.g. 36 hours in one example), then I.sub.effect may be
represented as zero.
[0089] FIG. 5 is a plot representing example calculated insulin
effect curves for six different types of insulin based upon example
known pharmacokinetics and the method described above (TS=15
minutes and GFR=100). The insulin effect curves may be calculated
by programmed computing systems described herein in some examples,
and/or may be provided to the computing systems for use in insulin
dosing calculations described herein.
[0090] Referring back to FIG. 4, at block 412, the method 400
includes determining an amount of insulin-on board. For example,
based on an estimate (or known) time of a prior administration of
insulin, an amount of long-acting insulin-on-board can be estimated
using the insulin effect curves.
[0091] At block 414, the method 400 includes determining an
adjustment to the recommended insulin dosage. For example, an
adjustment can be determined to compensate for short-acting insulin
that is currently on board, changes in the patient's total daily
dose that effect the expected long acting insulin-on-board and/or
the non-uniform PK/PD curves associated with different types of
insulin. An adjustment can be negative or positive. Adjustments may
be made to recommended short-acting and long-acting insulin
dosages, including subcutaneous doses, intravenous doses, or
combinations thereof.
[0092] As an example, to determine an adjustment to the long-acting
insulin dosage recommendation, an estimated long-acting
insulin-on-board, LA.sub.5hour, may be calculated (e.g. by the
workstation 114 or system 104 of FIG. 1) according to:
LA 5 hour = [ k = 1 P j = rstart k rstop k LAused k R ( LAtype k ,
j ) ] + [ j = 1 5 ( 60 / Ts ) LAused current R ( LAtype current , j
) ] + I TPN .times. 5 where rstart k = round ( 60 Ts ( t i - ti k
hours ) ) + 1 rstop k = min ( N R , rstart k + 5 60 Ts ) ,
##EQU00010##
[0093] I.sub.TPN is the rate of insulin infusion via TPN,
LAused.sub.k and SAused.sub.k are associated confirmed (used) doses
of long and short-acting insulin, LAtype.sub.k and SAtype.sub.k are
associated indices specifying the type of long- and short-acting
insulin administered, and Latype.sub.current and LAused.sub.current
are recommended long-acting insulin type and dose associated with
the current event. During this same period an expected
insulin-on-board may be determined (e.g. by the workstation and/or
system 104 of FIG. 1) according to:
LA ideal = LSDist i TDD i 5 24 . ##EQU00011##
If the current TDD is not equal (or about equal) to the previous
TDD, then the adjustment dose is determined to be the difference
between the expected and estimated long-acting insulin on
board:
SA adj , LA = { LA ideal - LA 5 hour TDD i .noteq. TDD i - 1 0
otherwise . ##EQU00012##
[0094] As another example, to determine an adjustment for the
short-acting insulin dosage recommendation, an estimated
short-acting insulin-on-board, SA.sub.5hour, includes the insulin
following from prior doses:
SA 5 hour = [ k = 1 P j = rstart k rstop k SAused k R ( SAtype k ,
j ) ] ##EQU00013## where ##EQU00013.2## rstart k = round ( 60 Ts (
t i - ti k hours ) ) + 1 ##EQU00013.3## rstop k = min ( N R ,
rstart k + 5 60 Ts ) ##EQU00013.4##
[0095] Note that the recommended insulin associated with the
current event is not included in this calculation, and the expected
or ideal amount of short-acting insulin-on-board may be assumed to
be zero.
[0096] The total adjustment dose, SA.sub.adj, that will compensate
for both long and short-acting insulin on board, can be determined
according to the following:
SA.sub.adj=SA.sub.adj,LA-SA.sub.5hour.
[0097] In the equation above, SA.sub.adj,LA is the estimated volume
of long-acting insulin level that should be available over the next
five hours. Other time intervals may be used in other examples. As
noted previously, due to patient variability through time and/or
previous sub-optimal estimates of long-acting insulin injections,
the actual long-acting insulin on board may differ from the
expected or optimal estimate. Specifically, the following
situations may occur that impact SA.sub.adj,LA:
[0098] If the patient's insulin requirements are unchanged, then
SA.sub.adj,LA will be negative or positive depending on the PK/PD
effect curve and will only compensate for the lack of uniform
effectiveness through time. A non-zero value for SA.sub.adj,LA
compensates for the non-uniform shape of the insulin action through
time.
[0099] If the patient's insulin requirements have increased beyond
what was estimated prior to the delivery of the last long-acting
insulin volume, then SA.sub.adj,LA will be positive.
[0100] If the patients insulin requirements have decreased beyond
what was previously estimated, then SA.sub.adj,LA will be
negative.
[0101] In summary, SA.sub.adj,LA represents the difference between
the future actual and ideal long-acting insulin on board. Because
this volume is known, it can be used to adjust the short-acting
insulin that is to be delivered whether or not the short-acting
insulin dose is used for correction or meal coverage.
[0102] In another example, an intravenous (IV) dosing
recommendation or adjustment to an IV dosing recommendation may be
calculated in block 414 taking into account insulin-on-board,
including insulin-on-board from previous or simultaneous
subcutaneous insulin doses.
[0103] For example, an adjusted IV insulin bolus (e.g. short-acting
insulin) dose may be calculated by subtracting the volume of
short-acting subcutaneous insulin on board from a recommended or
existing IV bolus volume. The adjusted IV insulin bolus dose may
further in some examples be increased by an insulin volume
sufficient to compensate for any entered carbohydrates.
Accordingly, the adjusted IV insulin bolus dose
(I.sub.bolus.sub._.sub.adjust) may be expressed as:
I.sub.bolus.sub._.sub.adjust=I.sub.bolus+I.sub.CS-I.sub.effect,SA;
where I.sub.bolus refers to an IV insulin bolus recommendation or
dose, and I.sub.CS refers to an amount of IV or short-acting
insulin required to compensate for any entered carbohydrates.
[0104] An adjusted IV delivery drip rate (e.g. long-acting insulin)
may be calculated as a continuous infusion rate (e.g. units/hour)
after converting and subtracting a long-acting insulin-on-board
from an existing recommended or administered IV delivery rate. For
example, the long-acting insulin volume calculated as
insulin-on-board may be divided by a time between glucose
measurements and subtracted from an existing recommended or
administered IV drip rate. For example, the following equation may
be used in some examples to calculate an adjusted IV insulin
delivery rate (I.sub.drip.sub._.sub.adjust):
I drip _ adjust = I drip - I effect , LA ( t delta / 60 ) ;
##EQU00014##
where I.sub.drip refers to an existing recommended or administered
IV insulin delivery rate (units/hour), I.sub.effect,LA refers to a
volume of long-acting insulin on board, and t.sub.delta refers to a
time interval between glucose measurements. The factor of 60 is
provided to convert the t.sub.delta into units commensurate with
the delivery rates used, and is accordingly flexible based on the
units employed in a given example.
[0105] The adjusted IV insulin bolus and continuous delivery doses
may then be combined in accordance with the following examples:
[0106] If I.sub.bolus.sub._.sub.adjust<0 and
I.sub.drip.sub._.sub.adjust>0 OR if
I.sub.bolus.sub._.sub.adjust>0 and
I.sub.drip.sub._.sub.adjust<0, OR if both are positive then a
revised adjusted IV insulin recommendation may be generated for use
in an IV dosing recommendation as follows:
I drip _ adjust = I drip _ adjust + I bolus _ adjust ( t delta / 60
) ; ##EQU00015## and ##EQU00015.2## I bolus _ adjust = 0
##EQU00015.3##
[0107] Accordingly, examples of providing IV dosing recommendations
or adjusted IV dosing recommendations in view of insulin on board
(including insulin on board related to previous subcutaneous
insulin doses), if an adjustment is warranted due to either an
adjusted IV insulin bolus or continuous delivery rate
recommendation being positive, the overall adjustment may be
converted into an IV insulin continuous delivery rate for use in IV
dosing.
[0108] Where I.sub.drip.sub._.sub.adjust<0 and
I.sub.bolus.sub._.sub.adjust<0, then the IV insulin adjusted
delivery rate may be 0 and a carbohydrate bolus may be
recommended.
[0109] A user (e.g. nurse or IV dosing apparatus) may be provided
with a revised IV dose as follows:
I.sub.drip,new=I.sub.drip.sub._.sub.adjust and
I.sub.bolus,new=I.sub.bolus.sub._.sub.adjust. A recommended
carbohydrate bolus may also or instead be provided if appropriate
as described above. Accordingly, a drip rate and/or bolus volume
may be altered based on insulin-on-bard calculations, including
insulin-on-board due to previous or simultaneously administered
subcutaneous insulin doses.
[0110] FIG. 6 is an example block diagram of another method to
determine subcutaneous insulin therapy for a patient, in accordance
with at least some embodiments described herein. Method 600 shown
in FIG. 6 presents an embodiment of a method that, for example,
could be used with the configuration shown in FIG. 1, for example,
and may be performed by the system 104, the workstation 114, or a
combination of the system 104 and the workstation 114. Method 600
may include one or more operations, functions, or actions as
illustrated by one or more of blocks 602-618. Although the blocks
are illustrated in a sequential order, these blocks may also be
performed in parallel, and/or in a different order than those
described herein. Also, the various blocks may be combined into
fewer blocks, divided into additional blocks, and/or removed based
upon the desired implementation.
[0111] Initially, at block 602, the method 600 includes receiving
information associated with a glucose measurement value of a
patient. For example, a nurse may use a glucometer to determine a
glucose measurement value of the patient, and the nurse may enter
the glucose measurement value into a system. In other examples, the
glucose measurement may be received by automated equipment and
provided to a computing system implementing block 602 of the method
600.
[0112] The method 600 also includes receiving information
associated with anticipated nutrition intake for the patient, at
block 604. For example, a nurse may enter into a system the
anticipated nutrition intake for the patient including any
nutrition consumed orally, intravenously, or via feeding tubes. The
information associated with the anticipated nutrition intake for
the patient may include information indicating a timing and rate of
a feeding tube, for example.
[0113] The method 600 also includes receiving information
indicating a short-acting insulin-on-board for a patient, at block
606. Short-acting insulin-on-board may be associated with an amount
of short-acting insulin that remains in the patient due to a prior
insulin administration. A nurse may determine the short-acting
insulin-on-board for the patient using many different methods
(e.g., as described above in FIG. 4), and may enter the information
into a system.
[0114] The method 600 also includes, at block 608, based on the
information associated with the glucose measurement value of the
patient, the anticipated nutrition intake for the patient and/or
the short-acting insulin-on-board, determining at least one of a
short-acting subcutaneous insulin dosage recommendation, a
correction subcutaneous insulin dosage recommendation, an
intravenous insulin dosage recommendation, a recommended amount of
carbohydrates to be administered to the patient, or combinations
thereof. For example, if the short-acting insulin-on-board is
negative (e.g., too low), a recommended amount of carbohydrates can
be determined to be administered to the patient. If the patient is
about to consume a number of carbohydrates, a short-acting
subcutaneous or IV insulin dosage may be recommended. If the
glucose measurement value of the patient is not within a target
range, a correction subcutaneous or IV insulin dosage may be
recommended. In addition, based on the inputs received at blocks
602, 604, and 606, the recommendation may be to do nothing (e.g.,
if glucose values are within targets and no carbohydrates are
anticipated to be ingested in the near future).
[0115] The method 600 also includes, at block 610, receiving
information indicating a confirmation of a nutrition intake for the
patient. For example, the nurse may confirm that the patient
ingested the anticipated nutrition amounts, or may confirm the
amount of nutrition that was administered to the patient. The nurse
may input the confirmation information into a system and/or the
information regarding nutrition intake may be provided by a food
provider or other user of a system implementing the method 600.
[0116] The method 600 also includes, at block 612, receiving
information indicating a long-acting insulin-on-board for a
patient. Long-acting insulin-on-board may be associated with an
amount of long-acting insulin that remains in the patient due to a
prior insulin administration. In some examples, an amount of
long-acting insulin may remain in a patient due to a previous or
simultaneously administered subcutaneous insulin dose for a patient
on or transitioning to IV insulin therapy. A nurse may determine
the long-acting insulin-on-board for the patient using many
different methods (e.g., as described above in FIG. 4), and may
enter the information into a system. In other examples, the system
may calculate the long-acting insulin-on-board as described
above.
[0117] The method 600 also includes, at block 614, based on the
information associated with the long-acting insulin-on-board for
the patient, the glucose measurement value of the patient, and the
confirmation of the nutrition intake for the patient, determining a
long-acting subcutaneous or IV insulin dosage for the patient. For
example, the long-acting subcutaneous insulin dosage may be
determined based on anticipated needs of the patient.
[0118] The method 600 also includes, at block 616, adjusting the
short-acting subcutaneous or IV insulin dosage recommendation based
on a difference between the long-acting insulin-on-board and the
required long-acting subcutaneous or IV insulin dosage. For
example, if the difference between the long-acting insulin-on-board
and the required long-acting subcutaneous or IV insulin dosage is
large and the long-acting insulin-on-board is more than the
required long-acting insulin dosage, then there remains an excess
amount of long-acting insulin-on-board and the short-acting
subcutaneous insulin dosage recommendation may be lowered.
Alternatively, if the difference between the long-acting
insulin-on-board and the required long-acting subcutaneous or IV
insulin dosage is large and the long-acting insulin-on-board is
less than the required long-acting insulin dosage, then
short-acting subcutaneous or IV insulin dosage recommendation may
be increased (depending on the amount of long-acting insulin to be
administered).
[0119] Still further, if the difference between the long-acting
insulin-on-board and the required long-acting subcutaneous or IV
insulin dosage is small and the long-acting insulin-on-board is
more than the required long-acting insulin dosage, then there
remains an excess amount of long-acting insulin-on-board and the
short-acting subcutaneous or IV insulin dosage recommendation may
be lowered. Similarly, if the difference between the long-acting
insulin-on-board and the required long-acting subcutaneous or IV
insulin dosage is small and the long-acting insulin-on-board is
less than the required long-acting insulin dosage, then the
short-acting subcutaneous or IV insulin dosage recommendation may
also be lowered.
[0120] The method 600 also includes, at block 618, outputting an
indication of at least one of the required long-acting subcutaneous
insulin dosage, the adjusted short-acting subcutaneous or IV
insulin dosage recommendation, the IV dosage recommendation, the
correction subcutaneous insulin dosage recommendation, the
recommended amount of carbohydrates to be administered to the
patient, or combinations thereof. For example, any of this
information may be output onto a display, such as for example,
within a graphical user interface (GUI).
[0121] The method 600 may be performed in the order as shown in
blocks 602-616, or in other orders, such as by receiving
information and following performing determination steps.
[0122] In addition, the method 600 may include additional steps not
shown. For example, the method 600 may include receiving
information indicating a confirmation of a last insulin dose given
subcutaneously to the patient so as to determine when a last dosage
was given and an amount given. As another example, other
information such as demographics of a patient and a serum
creatinine level of the patient may be received, and a glomerular
filtration rate (GFR) of the patient can be determined based on the
demographics and the serum creatinine level of the patient. As
further examples, information indicating a total daily dosage
amount for the patient of short-acting insulin and long-acting
insulin can be received, as well as information indicating drugs
administered to the patient including one or steroids and
antibiotics. As still further examples, information indicating
whether a postprandial emesis has occurred, information indicating
intravenous (IV) therapy provided to the patient, and information
indicating total parenteral nutrition (TPN) provided to the patient
can be received. Insulin dosages can then be determined taking into
account any of this additional information.
[0123] FIG. 7 is a block diagram illustrating an example
architecture of processing modules and information flow of a
glucose management system that includes a safety component to
estimate insulin-on-board determinations and adjustments to insulin
recommendations. The information may include personalization
information 702, control information 704, and safety information
706. Personalization information 702 may include, but is not
limited to, information per patient such as insulin requirements,
internal adaptive control parameters describing an insulin therapy
according to an adaption algorithm, patient initialization
information (age, weight, SCR, diabetes type, gender, steroid
usage, etc.), and population specific parameters. Control
information 704 may include, but is not limited to, insulin dosing
methodologies, D50W dosing methodologies, glucose measurement
interval methodologies, glucose prediction methodologies, and
glucose target assessments. Safety information 706 may include, but
is not limited to, risk assessment modules, insulin-on-board
modules, hypoglycemia prediction modules, an advisory rule base,
and dosing limits.
[0124] Based on the personalization information 702, the control
information 704, and the safety information 706, therapy
recommendations, measurement intervals, advisories and alerts may
be determined, for example, according to the methods described
herein.
[0125] In one embodiment, a computerized system is provided for
adapting an existing insulin regimen according to diet changes or
other factors described herein. A user may enter a modified diet
and the system may provide a new insulin regimen. The system may
operate using a graphical user interface (GUI) to display events in
a chronological manner such that nurses or other users can easily
determine patient state. The GUI may be provided in as an
interrogative interface in which the GUI provides specific requests
for additional information when glucose values are
unexpected/unanticipated. The computerized system provides a
mechanism for transferring patient specific estimated control
variables to and from IV insulin dosing tools, and may be used
within a hospital setting or as an at-home use module to determine
treatment decisions and calculation of subcutaneous insulin
dosages.
[0126] FIG. 8 is a functional block diagram illustrating an example
computing device 800 used in a computing system that is arranged in
accordance with at least some embodiments described herein. The
computing device may be a personal computer or mobile device, and
may be implemented as one of the components FIGS. 1 and 3, for
example, such as the workstation 114, or all or a component of the
system 104, such as the application server 108. In one
configuration 802, computing device 800 may typically include one
or more processors 810 and system memory 820. A memory bus 830 may
be used for communicating between the processor 810 and the system
memory 820. Depending on the desired configuration, processor 810
can be of any type including but not limited to a microprocessor
(.mu.P), a microcontroller (.mu.C), a digital signal processor
(DSP), or any combination thereof. A memory controller 815 can also
be used with the processor 810, or in some implementations, the
memory controller 815 can be an internal part of the processor
810.
[0127] Depending on the desired configuration, the system memory
820 can be of any type including but not limited to volatile memory
(such as RAM), non-volatile memory (such as ROM, flash memory,
etc.) or any combination thereof. System memory 820 may include one
or more applications 822, and program data 824. Application 822 may
include instructions for insulin dosage recommendations 823 that
are arranged to implement insulin dosing methodologies described
herein, and may provide inputs to the electronic circuits, in
accordance with the present disclosure. Program Data 824 may
include content information 825 that could be directed to any
number of types of data as described in FIG. 7, for example. In
some example embodiments, application 822 can be arranged to
operate with program data 824 on an operating system.
[0128] Computing device 800 can have additional features or
functionality, and additional interfaces to facilitate
communications between the basic configuration 802 and any devices
and interfaces. For example, data storage devices 840 can be
provided including removable storage devices 842, non-removable
storage devices 844, or a combination thereof. Examples of
removable storage and non-removable storage devices include
magnetic disk devices such as flexible disk drives and hard-disk
drives (HDD), optical disk drives such as compact disk (CD) drives
or digital versatile disk (DVD) drives, solid state drives (SSD),
and tape drives to name a few. Computer storage media can include
volatile and nonvolatile, non-transitory, removable and
non-removable media implemented in any method or technology for
storage of information, such as computer readable instructions,
data structures, program modules, or other data.
[0129] System memory 820 and storage devices 840 are examples of
computer storage media. Computer storage media includes, but is not
limited to, RAM, ROM, EEPROM, flash memory or other memory
technology, CD-ROM, digital versatile disks (DVD) or other optical
storage, magnetic cassettes, magnetic tape, magnetic disk storage
or other magnetic storage devices, or any other medium which can be
used to store the desired information and which can be accessed by
computing device 800. Any such computer storage media can be part
of device 800.
[0130] Computing device 800 can also include output interfaces 850
that may include a graphics processing unit 852, which can be
configured to communicate to various external devices such as
display devices 860 or speakers via one or more A/V ports or a
communication interface 870. The communication interface 870 may
include a network controller 872, which can be arranged to
facilitate communications with one or more other computing devices
880 over a network communication via one or more communication
ports 874. The communication connection is one example of a
communication media. Communication media may be embodied by
computer readable instructions, data structures, program modules,
or other data in a modulated data signal, such as a carrier wave or
other transport mechanism, and includes any information delivery
media. A modulated data signal can be a signal that has one or more
of its characteristics set or changed in such a manner as to encode
information in the signal. By way of example, and not limitation,
communication media can include wired media such as a wired network
or direct-wired connection, and wireless media such as acoustic,
radio frequency (RF), infrared (IR), cellular, and other wireless
media.
[0131] Computing device 800 can be implemented as a portion of a
small-form factor portable (or mobile) electronic device such as a
cell phone, tablet, a personal data assistant (PDA), a personal
media player device, a wireless web-watch device, a personal
headset device, an application specific device, or a hybrid device
that include any of the above functions. Computing device 800 can
also be implemented as a personal computer including both laptop
computer and non-laptop computer configurations.
[0132] FIGS. 9A-9L illustrate example GUIs that may be implemented
on a computing device or computing system to receive and display
information according to embodiments disclosed herein. Initially, a
user may login to a server and be presented with an interface
similar to that shown in FIG. 9A. A user may select a hospital and
unit, as shown in FIG. 9B, and may be presented with GUIs
customized to the selected hospital and unit parameters, for
example. Additional information may be presented for selection at
the startup screen including a glucose measurement schedule, an
insulin therapy schedule, and a nutritional plan, and GUIs may be
presented that are customized according to the protocol
selected.
[0133] A user may then perform a search for information associated
with a patient, and may be presented with an interface as shown in
FIG. 9C. Any number or kind of information may be presented, such
as a medical record number, name, birth date, gender, hospital
room, etc.
[0134] Additional information associated with the patient may be
accessed through a tabbed GUI as shown in FIG. 9D. For example, the
interface in FIG. 9D illustrates six tabs labeled Patient
Demographics, Glucose and Nutrition, IV/TF/TPN, Confirmation,
Order, and Summary. More or fewer tabs may be presented. FIG. 9D
illustrates the Patient Demographics tab highlighted and selected,
in which general patient information is displayed. A nurse or other
user may retrieve such information by inputting the patient's
medical record number, or by direct input.
[0135] Within FIG. 9D, a nurse or other user may enter glucose
dosage information. Similarly, the nurse or other user may access a
GUI as shown in FIG. 9E to enter glucose dosage information of a
patient including prior glucose therapy administered, and last
dosage times and amounts for short-acting and long-acting insulin,
for example. The nurse or other user may access further information
regarding glucose and nutrition by selecting the glucose and
nutrition tab, as shown by the GUI in FIG. 9F. In FIG. 9F, the
nurse or other user may enter last glucose dosages, as well as
information regarding anticipated nutrition intake including times
and carbohydrate amounts. Values for carbohydrates can be
determined using a lookup function, as shown by the GUI in FIG. 9G,
for example.
[0136] FIG. 9H illustrates information provided by selecting the
Intravenous (IV)/Tube Feeding (TF)/Total Parenteral Nutrition (TPN)
tab. In this interface, a nurse or other user may enter or
determine information associated with any other IVs provided to the
patient, whether the patient is on antibiotics, whether the patient
is receiving any tube feeding, and information associated with TPN
in general.
[0137] FIG. 9I illustrates information provided by selecting the
Confirmation tab. In this GUI, a nurse or other user may confirm
information that has been entered including glucose dosages as well
as actual nutrition consumed (as compared to previously entered
anticipated nutritional intake).
[0138] FIGS. 9J and 9K are examples of information that may be
provided by selecting the Order tab. In FIG. 9J, and example
recommendation for glucose dosages are provided. An amount of
long-acting insulin, meal coverage insulin (e.g., short-acting
insulin), and correction insulin are recommended to be administered
to the patient. A glucose value is also provided, and due to the
glucose value being high, a recommendation is made to check the
glucose value of the patient again in two hours, for example. FIG.
9K illustrates another example of a received recommendation in
which a recommendation is made for an amount of carbohydrates to be
administered to the patient since the glucose value was low. Also,
since the glucose value was low, a recommendation is made to check
the glucose value again in 15 minutes.
[0139] FIG. 9L illustrates example information that is provided by
selecting the Summary tab. In this GUI, glucose measurements,
glucose orders, and carbohydrate intakes can be seen in a table
format to illustrate a medical history and status of the patient,
for example.
[0140] It should be understood that arrangements described herein
are for purposes of example only. As such, those skilled in the art
will appreciate that other arrangements and other elements (e.g.
machines, interfaces, functions, orders, and groupings of
functions, etc.) can be used instead, and some elements may be
omitted altogether according to the desired results. Further, many
of the elements that are described are functional entities that may
be implemented as discrete or distributed components or in
conjunction with other components, in any suitable combination and
location.
[0141] Additionally, although the specification refers primarily to
short and long-acting insulin types, the invention contemplates and
is applicable to more specific categories of insulin types
including rapid-acting, short acting, intermediate acting, long
acting, and insulin mixtures. Further, the invention anticipates
the use of specific insulins or insulin analogs beyond those listed
in the examples, including the modification of IV insulin, dosed
for remediation of hyperglycemia, on the basis of all types of
insulin on board.
[0142] While various aspects and embodiments have been disclosed
herein, other aspects and embodiments will be apparent to those
skilled in the art. The various aspects and embodiments disclosed
herein are for purposes of illustration and are not intended to be
limiting, with the true scope being indicated by the following
claims, along with the full scope of equivalents to which such
claims are entitled. It is also to be understood that the
terminology used herein is for the purpose of describing particular
embodiments only, and is not intended to be limiting.
* * * * *