Continuous Insulin Infusion Research Articles

Management of hospitalized patients with mild to moderate diabetic ketoacidosis using a continuous insulin infusion protocol on a medical surgical ward and observation level of care: A retrospective cohort study.

Although the practice of using rapid-acting subcutaneous insulin for the management of mild-to-moderate diabetic ketoacidosis is becoming increasingly popular, the continuous insulin infusion remains widely utilized, and its real-world applicability and safety on a medical surgical unit (Med Surg) and observation level of care are unclear. We assessed whether a continuous insulin infusion protocol for mild-to-moderate diabetic ketoacidosis on Med Surg/observation level of care over a 6.5-year period was associated with adverse outcomes.A retrospective cohort study of adults hospitalized with mild-to-moderate diabetic ketoacidosis was conducted at 2 community hospitals in Northern California, USA, from January 2014 to May 2020. Demographic and clinical variables were collected using an electronic health record. Admission to Med Surg/observation was compared to intensive care unit admission for the outcomes of 30-day readmission, presence of hypoglycemia, rate of hypoglycemic episodes, in-hospital and 30-day mortality, and length of stay using bivariate analysis.Among 227 hospital encounters (mean age 41 years, 52.9% women, 79.3% type 1 diabetes, 97.4% utilization of continuous insulin infusion), 19.4% were readmitted within 30 days, and 20.7% developed hypoglycemia. For Med Surg/observation encounters compared to the intensive care unit, there were no statistically significant differences in the risk of readmission (RR 1.48, 95% CI, 0.86–2.52), hypoglycemia (RR 1.17, 95% CI, 0.70–1.95), or increased length of stay (RR 0.71, 95% CI, 0.55–1.02); there was a lower risk of hypoglycemic events during hospitalization (RR 0.69, 95% CI, 0.54–0.96).Continuous insulin infusion utilization may be a safe option for treatment of mild-to-moderate diabetic ketoacidosis on Med Surg/observation level of care. Further investigation is needed.

Continuous Intravenous versus Subcutaneous Administration of Insulin for Glycemic Variability in Acute Ischemic Stroke.

BackgroundContinuous intravenous infusion (IV) or subcutaneous injection (SC) of insulin was widely applied to control hyperglycemia after ischemic stroke. However, the impact of different administration modes on glycemic variability was unknown.MethodsConsecutive stroke patients treated with intravenous thrombolysis were screened. Subjects who received insulin treatment were included and entered into the IV or SC group according to the respective administration mode. Blood glucose was closely monitored within the first 72 hours, and the target range of glucose was from 7.7 to 10.0 mmol/L for all patients. The variabilities of glucose, assessed using standard deviation of the mean, variable coefficient and range from the maximum to the minimum value, were compared between the two groups.ResultsA total of 130 patients were enrolled with 66 in the IV groups and 64 in the SC group. Compared with the SC group, the IV group had higher glycemic variability evaluated as either standard deviation (2.7 ± 0.7 mmol/L vs 2.2 ± 0.9 mmol/L, p = 0.002), variable coefficient (0.26 ± 0.06 vs 0.23 ± 0.08, p = 0.011) or range (10.0 ± 3.6 mmol/L vs 8.1 ± 3.1 mmol/L, p = 0.001). Multivariate logistic regression analyses found that continuous intravenous infusion was associated with higher level of the standard deviation (adjusted OR 3.01, 95% CI 1.29–7.28, p = 0.011), variable coefficient (adjusted OR 5.97, 95% CI 2.55–13.96, p < 0.001) and range (adjusted OR 6.08, 95% CI 2.63–14.05, p < 0.001).ConclusionContinuous intravenous infusion of insulin was associated with higher glycemic variability than subcutaneous injection in acute stroke patients receiving thrombolysis.

Effect of the Concomitant Use of Subcutaneous Basal Insulin and Intravenous Insulin Infusion in the Treatment of Severe Hyperglycemic Patients.

BackgroundNo consensus exists regarding the early use of subcutaneous (SC) basal insulin facilitating the transition from continuous intravenous insulin infusion (CIII) to multiple SC insulin injections in patients with severe hyperglycemia other than diabetic ketoacidosis. This study evaluated the effect of early co-administration of SC basal insulin with CIII on glucose control in patients with severe hyperglycemia.MethodsPatients who received CIII for the management of severe hyperglycemia were divided into two groups: the early basal insulin group (n=86) if they received the first SC basal insulin 0.25 U/kg body weight within 24 hours of CIII initiation and ≥4 hours before discontinuation, and the delayed basal insulin group (n=79) if they were not classified as the early basal insulin group. Rebound hyperglycemia was defined as blood glucose level of >250 mg/dL in 24 hours following CIII discontinuation. Propensity score matching (PSM) methods were additionally employed for adjusting the confounding factors (n=108).ResultsThe rebound hyperglycemia incidence was significantly lower in the early basal insulin group than in the delayed basal insulin group (54.7% vs. 86.1%), despite using PSM methods (51.9%, 85.2%). The length of hospital stay was shorter in the early basal insulin group than in the delayed basal insulin group (8.5 days vs. 9.6 days, P=0.027). The hypoglycemia incidence did not differ between the groups.ConclusionEarly co-administration of basal insulin with CIII prevents rebound hyperglycemia and shorten hospital stay without increasing the hypoglycemic events in patients with severe hyperglycemia.

768-P: Clinical Outcomes of Euglycemic DKA with a Computerized Insulin Algorithm: Descriptive Analysis of a Nationwide Cohort

Euglycemic DKA (euDKA) is an underdiagnosed endocrine emergency and may not be treated appropriately treated due to lower than expected glucose levels. EuDKA has been increasing in prevalence due to the use of SGLT2-inhibitors. Glycemic or insulin outcomes for hospitalized patients with euDKA have been limited to case reports and series and have not been reported in a large cohort. Individual-level data were extracted from the Glytec Inpatient Database from 154 hospitals across the United States from (2017-2021) . All patients were on Glucommander IV, a computerized continuous insulin infusion (CII) algorithm, for at least 1 hour, to examine glycemic outcomes and insulinometrics. EuDKA was defined as patients with age ≥18 years with a BG &amp;lt; 250 mg/dl and who met the following criteria on admission: bicarbonate &amp;lt;18 mmol/L, pH &amp;lt;7.3, with ketones present in serum or urine. All patients had an ICD of Eor Eor A1c &amp;gt;6.5%. We identified 533 patients with euDKA (Table) . Time to HCO3 &amp;gt; 18 mEq/L was 14.1 hours. The incidence of hypoglycemia was low. Analysis of a nationwide cohort shows that euDKA can be safely and effectively treated with a computerized algorithm in the hospital, as patients achieved rapid time to target, resolution of DKA, and low mortality. Disclosure J.Messler: Employee; Glytec, LLC. P.Vellanki: n/a. R.Booth: Employee; Glytec, LLC.

Acute Respiratory Distress Syndrome Associated with Multisystem Inflammatory Syndrome in a Child with Covid-19 and Diabetic Ketoacidosis: A Case Report.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or coronavirus disease 2019 (Covid-19), has uncontrollable effects on many organs. A great number of previously published scientific reports have revealed that patients with diabetes mellitus face a more severe form of Covid-19 with a higher death rate. Here we present the case of a 13-year-old unvaccinated boy who was admitted to an intensive care unit (ICU) with a history of fever, cough, dyspnea, throat pain, nausea, and confusion that progressed to lethargy after 24 h. On clinical examination, he was in a coma with Kussmaul’s breathing, and was anuric. His blood biochemical analysis demonstrated hyperglycemia, severe metabolic acidosis, kidney failure, electrolyte disturbances, and inflammation. Chest x-ray showed pneumonia and a pleural effusion. The results of the SARS-CoV-2 real-time polymerase chain reaction were positive. The patient was diagnosed with Covid-19-induced acute respiratory distress syndrome associated with multisystem inflammatory syndrome in children secondary to his acute respiratory failure, acute kidney injury, and new-onset type 1 diabetes mellitus with diabetic ketoacidosis. He was intubated for invasive mechanical ventilation and received a normal saline infusion and continuous insulin infusion (0.1 IU/kg/h) for the treatment of his diabetic ketoacidosis. He was also treated with methylprednisolone, aspirin, and heparin, and underwent continuous renal replacement therapy for acute renal failure for 9 days. The patient was discharged from ICU on day 16 and was followed up regularly as an outpatient with daily treatment, including subcutaneous insulin injection (30 IU/day) and a calcium channel blocker for hypertension (nifedipine 20 mg/day).

Bolus versus continuous insulin infusion in immediate postoperative blood glucose control in liver transplantation: pragmatic clinical trial.

ABSTRACTObjective:To analyze the effectiveness and safety of two insulin therapy techniques (continuous and intermittent infusion) in the blood glucose control of people who have undergone liver transplantation, in the immediate postoperative period.Methods:The study was a prospective, open, pragmatic clinical trial with 42 participants, divided into two groups of 21 patients each, in the immediate postoperative period following liver transplantation. Participants in the Experimental Group and Control Group received continuous infusion and bolus insulin, respectively, starting at capillary blood glucose ≥150mg/dL.Results:There were no statistically significant differences in the blood glucose reduction time to reach the target range between the Experimental Group and Control Group in the transplanted patients (p=0.919). No statistically significant differences regarding the presence of low blood glucose (p=0.500) and in the initial blood glucose value (p=0.345) were found. The study identified the final blood glucose value in postoperative intensive care unit lower and statistically significant in the continuous infusion pump group in relation to the Bolus Group (p<0.001). Additionally, the variation of blood glucose reduction was higher and statistically significant in the continuous method group (p<0.05).Conclusion:The continuous infusion method was more effective in the blood glucose control of patients in the postoperative period following liver transplantation.Brazilian Registry of Clinical Trials:RBR-9Y5tbp

Microvascular Blood Flow Response to Hyperinsulinemic‐Euglycemic Clamp in Zucker Diabetic Sprague Dawley Rat Model of Type 2 Diabetes

ObjectiveQuantify and characterize the skeletal muscle microvascular blood flow in Zucker Diabetic Sprague Dawley (ZDSD) rat model of T2D at rest and during a hyperinsulinemic‐euglycemic clamp.HypothesisChronic hyperglycemia in the ZDSD rat model of T2D causes blunted capillary hemodynamic response to hyperinsulinemic‐euglycemic clamp compared to the age and diet matched control Sprague Dawley (SD) rats.MethodsBiweekly blood glucose and conscious blood pressure measurements were collected from 7‐ to 25‐week‐old male SD (n=12) and ZDSD (n=18) rats. At 27 weeks of age, animals were fasted overnight prior to intravital video microscopy experiments. On the day of experiment animals were anaesthetized with an intraperitoneal injection of pentobarbital, tracheotomized, and carotid and external jugular cannulas were inserted to monitor physiological status and for administration of fluids. The extensor digitorum longus (EDL) muscle of the lower hind limb was isolated, blunt dissected and reflected over a glass coverslip on the stage of an inverted microscope. Recordings of the EDL were completed at baseline and during hyperinsulinemic‐euglycemic clamp. Hyperinsulinemic‐euglycemic clamp was achieved by continuous intravenous infusion of insulin (Humulin R 2U/hr/kg) and a 50% glucose mixture to titrate blood glucose to euglycemia (5‐7 mM). Mixed blood samples were collected from a tail clip to determine systemic blood glucose. Analysis of intravital videos were completed offline using custom MATLAB software. ZDSD rats that had fasting blood glucose of less than 20 mM at 19 weeks of age were excluded from the hyperglycemic group. Animals exhibiting aberrant microvascular blood flow at baseline or during euglycemic clamp were excluded from the data set. All animal protocols were approved by Memorial University of Newfoundland’s Animal Care and Use Committee.ResultsHyperglycemic ZDSD rats had a significantly higher blood glucose than SD controls from 17 to 25 weeks old and at the beginning of euglycemic clamp (26.13 ± 0.97 and 5.95 ± 0.37, p &lt; 0.0001, Fig 1A). SD rats had a significantly higher glucose infusion rate than ZDSD rats (22.58 ± 1.81 and 13.19 ± 2.76, p &lt; 0.0001, Fig 1B). SD rats had a significant increase in red blood cell (RBC) velocity (149.8 ± 56.71 and 210.0 ± 62.14 µm/s, p = 0.0051, Fig 2A), RBC supply rate (SR) (12.49 ± 8.23 and 19.91 ± 12.25 cells/s, p = 0.004, Fig 2B) and RBC oxygen saturation(sO2) (38.05 ± 11.65 and 45.70 ± 10.13, p = 0.014, Fig 2D) between baseline and euglycemia. However, ZDSD animals had no significant difference in RBC velocity (178.1 ± 63.91 and 194.7 ± 37.69 µm/s, p = 0.3683, Fig 2A), RBC supply rate (14.63 ± 7.55 and 20.03 ± 7.46 cells/s, p = 0.0704, Fig 2B), hematocrit (31.03 ± 3.23 and 33.02 ± 6.22 %, p = 0.4309, Fig 2C), and RBC sO2 (61.91 ± 11.40 and 64.00 ± 11.59, p = 0.5324 Fig 2D). The RBC sO2 was significantly higher in ZDSD than SD at baseline (61.91 ± 11.40 compared to 38.05 ± 11.65, p = 0.0166, Fig 2D).ConclusionSD rats had a robust increase in capillary hemodynamics during hyperinsulinemic‐euglycemic clamp. However, the skeletal muscle capillary hemodynamics of ZDSD rats did not significantly change between baseline and during euglycemia. These finding suggests a potential impairment in skeletal muscle microvascular blood flow response in this type 2 diabetic rodent mode. The elevated RBC sO2 in ZDSD rats may indicate a dysregulation of capillary blood flow in the ZDSD model.

A continuous intravenous insulin infusion protocol to manage high-dose methylprednisolone-induced hyperglycemia in patients with severe COVID-19

BackgroundMany patients with severe COVID-19 have impaired glucose tolerance, and steroid therapy is a standard treatment. Thus, good glycemic control is important and correlates with better patient outcomes. We began using a continuous intravenous insulin infusion protocol for glycemic control whose infusion rate changes based on the currently measured value and previous value. This study aimed to evaluate this protocol for COVID-19 patients requiring mechanical ventilation.MethodsThis single-center, retrospective, case control study was conducted on all adult patients who required mechanical ventilation for severe COVID-19 pneumonia admitted to our critical care center from April 1, 2020 through June 20, 2021. Blood glucose levels were measured in all patients every 4 h after admission. We started using the insulin infusion protocol from August 1, 2020. Patients before starting the protocol comprised the non-protocol group and those after starting the protocol comprised the protocol group. Blood glucose levels and hypo- or hyperglycemia events were compared between groups. We also surveyed ICU nurses about their experience using the protocol.ResultsDuring the study period, 173 patients with COVID-19 were admitted. After 15 patients were excluded for several reasons, the study included 158 patients: non-protocol group (n = 14) and protocol group (n = 144). In the initial phase (days 1–2), blood glucose levels of the protocol group were higher compared with the non-protocol group, and as the number of measurements increased, blood glucose levels were gradually brought under control within the target range in the protocol group. Almost no hypoglycemic events (blood glucose < 80 mg/dL) were detected in either group. The rate of hyperglycemia (blood glucose > 300 mg/dL) was about 5–10% in the initial phase in the protocol group and about 10–15% in the early phase (days 3–4) in the non-protocol group. The questionnaire survey revealed that 80% of ICU nurses responded favorably.ConclusionsThis insulin protocol gradually brought the blood glucose level within target levels in severe COVID-19 patients treated with high-dose steroid. Some hyperglycemia events were detected despite patients being under the protocol in the initial phase, and thus, minor modifications of the protocol might be required in the initial phase.

Clinical investigation of patients with jaw deformity with comorbidities

BackgroundWith improvements in the safety and stability of surgeries, the number of orthognathic surgeries is increasing. Most patients who undergo orthognathic surgeries are younger, and the number of orthognathic surgeries for patients with comorbidities is also increasing. We report a survey and clinical investigation of patients with comorbidities who underwent orthognathic surgeries at our department to improve the safety of orthognathic surgery.ResultsThe participants included 296 men and 712 women, with a mean age of 28 years (13–19 years, n=144; 20–29 years, n=483; 30–39 years, n=236; 40–49 years, n=102; 50–59 years, n=39; ≥60 years, n=4). In total, 347 patients underwent one-stage Le Fort type I osteotomy and sagittal split ramus osteotomy (SSRO), 243 underwent SSRO, 287 underwent plate removal, 126 underwent genioplasty and plate removal, and five underwent other surgeries. In total, 529 patients had comorbidities (52%), including allergic diseases (n=220, 33%), respiratory diseases (n=107, 16%), neurologic and psychiatric diseases (n=69, 10%), gynecologic diseases (n=28, 4%), hematologic diseases (n=27, 4%), cardiovascular diseases (n=24, 4%), digestive diseases (n=22, 3%), metabolic and endocrine diseases (n=18, 3%), spinal diseases (n=11, 2%), ophthalmologic diseases (n=11, 2%), renal and urological diseases (n=9, 1%), and other diseases (n=117, 18%). Among the patients with comorbidities, 11 with hemorrhagic diatheses (hemophilia and von Willebrand disease), arrhythmia (atrioventricular block), psychiatric disease (adjustment disorder), and metabolic disease (diabetes) required cautious perioperative management. The patient with hemophilia was managed with regular low-dose recombinant factor VIII replacement therapy, and the patient with type I diabetes mellitus was administered continuous insulin infusion and sliding-scale insulin therapy; both patients had an uneventful course.ConclusionsThe study findings suggest that with the increase in orthognathic surgeries, oral and maxillofacial surgeons should adequately manage cases requiring cautious perioperative control and highlight the importance of preoperative screening. Despite the well-established safety and postoperative stability of orthognathic surgeries, oral surgeons should adopt appropriate additional preventive measures for patients with comorbidities.

Management of Type 1 Diabetes in Children in the Outpatient Setting.

Management of Type 1 Diabetes in Children in the Outpatient Setting.

Effect of different perioperative glycemic protocols in nondiabetic patients undergoing open heart surgery: a comparative study

Introduction: Hyperglycemia during cardiac surgery is common due to stress response and cardiopulmonary bypass. Increased blood glucose is associated with poor outcomes, more complications and increased mortality in diabetic as well as nondiabetic patients due to negative effect on endothelial function, myocardium and inflammatory response. Perioperative blood glucose control and correct target value in cardiac surgery patients remain an ongoing controversy. This study was conducted to observe the effect of two different glycemic protocols in non-diabetic patients undergoing on pump cardiac surgery. Materials and methods: A total of 102 non diabetic patients were randomly distributed into two groups: Group A, Group B. After induction a continuous insulin infusion at the rate of 0.1 unit/kg/hr was started in both groups when blood glucose level (BGL) was &gt;140mg/dl in Group A and &gt;180mg/dl in Group B. The infusion rate was adjusted to maintain BGL at 120-140mg/dl in Group A and 160-180mg/dl in Group B. BGL was measured at different points of time. Perioperative effects, requirement of cardiac drugs, insulin used and infection related complications were assessed. Results: Finally data of 100 patients were analyzed. Rate of deep sternal wound infection [Group A:B= 3(6.12%):4(7.84%)] and other infection related complications were similar in both the groups (p&gt;0.05). Length of ICU stay was significantly longer in Group B than Group A (p=0.013). Conclusion: Perioperative infection rate in nondiabetic cardiac patients is not higher when Target blood glucose level is 160-180mg/dl as compared to120-140mg/dl. Though length of ICU stay is less in lower blood glucose group; perioperative morbidities and 30 day mortality is similar in both blood glucose range.

Serial album on Continuous Insulin Infusion System as an innovative educational technology in diabetes

RESUMO Objetivo: construir e validar conteúdo e aparência de álbum seriado sobre insulinoterapia por Sistema de Infusão Contínua. Método: estudo metodológico, realizado em três etapas em Fortaleza, Ceará, Brasil, nos meses de agosto a novembro de 2018. Realizou-se a construção do álbum seriado e a validação de conteúdo e aparência pelos especialistas, e avaliação do público-alvo. Calcularam-se Índice de Validade de Conteúdo e Índice de Concordância. Resultados: os juízes consideraram válidos o conteúdo e a aparência do álbum, o que representa que o material é adequado como tecnologia educativa. Os especialistas sugeriram ajustes, incorporados ao material para produção impressa da versão final. O público-alvo também avaliou de forma positiva o álbum seriado. Conclusão: percebemos que o álbum seriado foi considerado uma tecnologia educacional inovadora em diabetes, valiosa para a promoção do conhecimento sobre Sistema de Infusão Contínua de Insulina, com conteúdo rico, atualizado, aliado à clareza, formato adequado e ilustrações explicativas.

Serial album on Continuous Insulin Infusion System as an innovative educational technology in diabetes.

to build and validate a serial album content and appearance on insulin therapy using a Continuous Infusion System. a methodological study, carried out in three stages in Fortaleza, Ceará, Brazil, from August to November 2018. The serial album construction and content and appearance validity were carried out by experts, and assessment, by the target audience. Content Validity Index and Concordance Index were calculated. the judges considered the serial album content and appearance to be valid, which means that the material is suitable as an educational technology. Experts suggested adjustments, incorporated into the material for print production of the final version. The target audience also assessed the serial album positively. we realized that the serial album was considered an innovative educational technology in diabetes, valuable for promoting knowledge about Continuous Insulin Infusion System, with rich, updated content, combined with clarity, suitable format and explanatory illustrations.

Recent Advances in Insulin Delivery Devices and Modes of Insulin Therapy

The discovery of insulin was 100 years old till 2021. Insulin, the first diabetic medication, is now the safest and most effective glucose-lowering medication available. Despite its efficacy, the most significant challenge with insulin has been the prevalence of hypoglycemia, which has resulted in the majority of patients being prescribed optimum dosages. Insulin delivery devices include syringes, pens, and pumps. Soon, artificial pancreas (AP) by using a very closed-loop delivery method will be a big step towards the advancement of insulin delivery devices. This article looks at the invention of syringes, disposable, long-lasting pens, and smart connected pens, continuous intraperitoneal insulin infusion (CIPII) and patch insulin pumps, artificial pancreas and other medical devices. Hence, insulin administration that is both minimally invasive and non-invasive towards the advancement is required. We review the available information on the evolution of insulin delivery systems, focusing on the advantages and disadvantages of technology as well as anticipated advances. Due to the wide variety of technological solutions accessible via the international platform, only the most common methods essential to the patient’s care are detailed here in the article.

The effect of intraoperative glycemic control on surgical site infections among diabetic patients undergoing coronary artery bypass graft (CABG) surgery

ObjectivePerioperative poor glycemic control in diabetic patients undergoing Coronary Artery Bypass Graft (CABG) surgery has been associated with infectious complications, particularly surgical site infections that are linked with adverse health surgical outcomes. The purpose of this study was to investigate the effect of two different intraoperative glycemic control protocol, tight and conventional, on thirty-day postoperative surgical site infection (SSI) rates among diabetic patients undergoing CABG surgery. DesignA randomized controlled trial (RCT) design was employed in the study, with a convenience sample of 144 adult patients who were scheduled to undergo coronary artery bypass grafting surgery. SettingA main referral heart institute in Amman, Jordan. ParticipantsSubjects were randomly assigned to either the tight glycemic control group (n = 72), which maintained an intraoperative blood glucose level of 110–149 mg/dl via continuous intravenous insulin infusion, or the conventional glycemic control group (n = 72), which maintained an intraoperative blood glucose level of 150–180 mg/dl via continuous intravenous insulin infusion. The postoperative SSIs among both groups were evaluated and compared by independent blinded physicians. ResultsThe primary findings of this study indicated no statistically significant difference between the two treatment groups in terms of SSI rates and their potential adverse surgical outcomes (p = 0.512). ConclusionNurses should consider the glycemic stability and glycemic control approach to minimize adverse surgical outcomes post CABG surgery. Healthcare providers should also carefully consider diabetic patients who have undergone CABG surgery and are at risk of developing postoperative SSIs. Clinicaltrials.gov identifierNCT04451655 was retrospectively registered in 30/06/2020.

Tight glycaemic control and surgical site infections post cardiac surgery: a systematic review.

Surgical site infection (SSI) is one of the most serious potential complications post cardiac surgery among patients with diabetes and has a number of adverse health outcomes. The literature shows discrepancies regarding the effect of different glycaemic control protocols on reducing adverse health outcomes including SSIs. The aim of this study was to conduct a systematic review that investigated the effect of the optimal range of tight glycaemic control protocols using a continuous insulin infusion on reducing the incidence of SSIs in adult patients with diabetes undergoing cardiac surgery. A systematic review was conducted following the PRISMA statement and guidelines. Search terms were used to identify research studies published between 2000 and 2019 across five key databases, including CINAHL, Medline, PubMed, Cochrane Database and Google Scholar. A total of 12 studies met the review inclusion criteria. The reviewed literature tended to support the implementation of a tight glycaemic control protocol, particularly in the postoperative phase, that demonstrated fewer potential complications associated with cardiac surgery. On the other hand, the literature also supported the application of a moderate glycaemic control protocol in the intraoperative phase to obtain better glycaemic stability with fewer potential complications among those patients with diabetes undergoing cardiac surgery. This analysis concludes that tight glycaemic control is more effective than moderate glycaemic control intraoperatively in terms of glycaemic stability among patients with diabetes undergoing cardiac surgery. Results also emphasised the importance of time-based protocol implementation to ensure better health outcomes and better quality of care for patients.

Hypertriglyceridemia-associated acute pancreatitis: Response to continuous insulin infusion.

To assess the response of serum triglycerides (TG) to continuous insulin infusion (CII) in adults with hypertriglyceridemia-associated acute pancreatitis (HTGP). Retrospective analysis of TG response to standardized CII therapy in 77 adults admitted to intensive care with TG >1000 mg/dL and HTGP. Participants had initial TG 3869.0 [2713.5, 5443.5] mg/dL and were 39.3 ± 9.7 years old, 66.2% males, 58.4% Hispanic, BMI 30.2 [27.0, 34.8] kg/m2, 74.0% with diabetes mellitus (DM) and 50.6% with excess alcohol use. TG-goal, defined as ≤1,000 ± 100 mg/dL, was achieved in 95%. Among the 73 TG-goal achievers (responders), 53.4% reached TG-goal in <36 hours after CII initiation (rapid responders). When compared to slow responders taking≥36 hours, rapid responders had lower initial TG (2862.0 [1965.0, 4519.0] vs 4814.5 [3368.8, 6900.0] mg/dL), BMI (29.4 [25.9, 32.8] vs 31.9 [28.2, 38.3] kg/m2), DM prevalence (56.4 vs 94.1%), and reached TG-50% (half of respective initial TG) faster (12.0 [6.0, 17.0] vs 18.5 [13.0, 32.8] hours). Those with DM (n = 57) vs non-DM (n = 20) were obese (31.4 [28.0, 35.6] vs 27.8 [23.6, 30.3] kg/m2), took longer to reach TG-final (41.0 [25.0, 60.5] vs 14.5 [12.5, 25.5] hours) and used more daily insulin (1.7 [1.3, 2.1] vs 1.1 [0.5, 1.9] U/kg/day). Among those with DM, the rapid responders had higher daily use of insulin vs slow responders 1.9 [1.4, 2.3] vs 1.6 [1.1, 1.8] U/kg/day. All results significant. In multivariable analysis, predictors of faster TG response were absence of DM, lower BMI and initial TG. CII was effective in reaching TG-goal in 95% of patients with HTGP. Half achieved TG-goal within 36 hours. Presence of DM, higher BMI and initial TG slowed the time to reach TG-goal. These baseline parameters and rate of decline to TG-50% may be real-time indicators to initiate and adjust the CII for quicker response.

Strategies for extended lifetime of implantable intraperitoneal insulin catheters

Implantable insulin infusion systems using the intra-peritoneal route have dramatically changed the management of diabetes paving the way toward the realization of the potential “holy grail” of a fully implantable artificial pancreas. However, the wear duration of delivery catheters is compromised by the foreign body-mediated immune response. Both occlusion material present at the distal catheter tip end and fibrotic encapsulation surrounding the catheters influence the controlled and precise delivery of insulin, which eventually leads to the need for surgical intervention. The novel part of the current work is the investigation of the roles of implant physical properties (catheter size and tip configuration), as well as local inflammation control (through utilization of an anti-inflammatory agent) on the host fibrotic response using a previously developed animal model. The cellular and molecular response, the medication delivery efficacy as well as the ability to flush the catheters were examined and further compared among the different mitigation strategies. Reduction in catheter size as well as tuning the tip configuration from a cone shape to a round shape showed delayed host recognition and delayed propagation of the fibrotic response. However, the round shaped tips had an increased occurrence of lumen occlusion as a result of flow change. It became apparent that changing the physical properties of the catheters was not a long-term solution to catheter obstructions caused by the foreign body reaction. In comparison, control of the local inflammatory response through the use of an anti-inflammatory agent demonstrated a promising strategy for maintenance of catheter functionality without any type of obstructions. These finding will have a large impact toward the development of long-term use catheters for continuous intraperitoneal insulin infusion.

Non-balanced translocation between the short arms of chromosomes 8 and 6 associated with type 1 diabetes mellitus.

SummaryWe describe a rare case of a girl with an initial diagnostic hypothesis of chromosome 8 trisomy based on clinical findings and karyotyping, which identified a structural change in the short arm of chromosome 8 (46,XX,add(8)(p23)). At the age of 7, she developed type 1 diabetes mellitus and started insulin therapy with multiple daily doses, and then she started to use a continuous insulin infusion system (pump) at 10 years of age. At the age of 12, she underwent a molecular study that identified an unbalanced translocation between the short arms of chromosomes 6 and 8 – 46,XX,add(8)(p23).ish der(8)t(6;8)(GS-196I5+;RP-11338B22−).Learning pointsPatients with an unbalanced translocation between the short arms of chromosomes 6 and 8 – 46,XX,add(8)(p23).ish der(8)t(6;8)(GS-196I5+;RP-11338B22-) may present syndromic features suggestive of chromosome 8 trisomy.Main characteristics are a prominent forehead, ocular and breast hypertelorism, ocular, external ear and palate abnormalities, a short neck, heart defects, and developmental delay.Patients with 46,XX,add(8)(p23).ish der(8)t(6;8)(GS-196I5+;RP-11338B22-) may present autoimmune type 1 diabetes mellitus.Karyotyping is an essential tool for the diagnosis of chromosomal changes, but it has some limitations.Multiplex ligation-dependent probe amplification, array-single nucleotide polymorphism and fluorescence in situ hybridization can help diagnose genetic syndromes in patients with atypical evolution.

AN UNUSUAL CASE OF RECURRENT HYPERTRIGLYCERIDEMIC PANCREATITIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hypertriglyceridemia (HTG) induced recurrent acute pancreatitis (RAP) is a rare entity. Its occurrence with normal pancreatic enzyme levels has not been commonly reported. Herein, we report a case of RAP secondary to hypertriglyceridemia with normal blood lipase level. CASE PRESENTATION: A 48-year old male with a history of hypertriglyceridemia presented with a 72-hour history of right upper quadrant (RUQ) and epigastric abdominal pain. He had hypertriglyceridemic pancreatitis 5 years ago, however was not compliant with treatment. On presentation, he was febrile with RUQ and epigastric tenderness. His laboratory investigations revealed: white cell 10.59 x 10^9/L, sodium 133mmol/L, carbon dioxide 18mmol/L, creatinine 0.7 mg/dL, glucose 138 mg/dL calcium 8.8mg/dL; albumin 4.2g/dL, total bilirubin 1.9mg/dL, alanine transferase 37u/L, aspartate transferase 60u/L, alkaline phosphatase 138 u/L. Triglycerides were significantly elevated at >2,625mg/dL with serum lipase 113 u/L (normal 23-300). CT scan of the abdomen and pelvis revealed extensive inflammatory stranding centered at the head and uncinate process of the pancreas, consistent with acute pancreatitis. He received intravenous crystalloids, opioids and continuous insulin infusion which was discontinued on day 4 once triglyceride level was <500. He was started on gemfibrozil and discharged home. DISCUSSION: With an incidence of 13–45/100,000 acute pancreatitis is one of the most common diagnoses for contacting emergency services and for hospitalization in Europe and the USA. Acute pancreatitis (AP) is defined by two of three criteria: typical belt-like abdominal pain, elevated serum lipase level three times above the normal threshold, or radiological imaging signs of pancreatitis. RAP is defined as 2 or more attacks of AP without any evidence of chronic pancreatitis. HTG is the third-most common, possibly underestimated and missed, cause of AP and it accounts for 1%–7% of cases. Serum amylase can be normal hypertriglyceridemia-induced pancreatitis, but lipase is more sensitive and specific than amylase for diagnosis of AP. Normal lipase levels in HTG induced AP, as in this case, is rare. Several studies have reported a negative predictive value of serum lipase in diagnosing acute pancreatitis to be between 94 and 100 percent. CONCLUSIONS: Though uncommon, HTG induced Acute Pancreatitis can present with normal biomarkers, and if suspicion is high, imaging should be pursued to confirm or exclude the diagnosis. REFERENCE #1: Weiss, F. U., Laemmerhirt, F., & Lerch, M. M. (2019). Etiology and Risk Factors of Acute and Chronic Pancreatitis. Visceral medicine, 35(2), 73–81. https://doi.org/10.1159/000499138 REFERENCE #2: Kumar, P., Ghosh, A., Sinha, N., & Tonk, R. S. (2018). Secondary Hypertriglyceridemia Causing Recurrent Acute Pancreatitis with Normal Pancreatic Enzymes. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine, 22(5), 381–383. https://doi.org/10.4103/ijccm.IJCCM_353_17 REFERENCE #3: Shah, A. M., Eddi, R., Kothari, S. T., Maksoud, C., DiGiacomo, W. S., & Baddoura, W. (2010). Acute pancreatitis with normal serum lipase: a case series. JOP : Journal of the pancreas, 11(4), 369–372 DISCLOSURES: No relevant relationships by Janeen Grant-Sittol, source=Web Response No relevant relationships by Fausto Lisung, source=Web Response No relevant relationships by Anna-Belle Robertson, source=Web Response No relevant relationships by Rani Sittol, source=Web Response