Continuous Intravenous Insulin Infusion Research Articles

Feasibility and Performance of Continuous Glucose Monitoring to Guide Computerized Insulin Infusion Therapy in Cardiovascular Intensive Care Unit.

We evaluated the feasibility of real-time continuous glucose monitoring (CGM) for titrating continuous intravenous insulin infusion (CII) to manage hyperglycemia in postoperative individuals in the cardiovascular intensive care unit and assessed their accuracy, nursing acceptance, and postoperative individual satisfaction. Dexcom G6 CGM devices were applied to 59 postsurgical patients with hyperglycemia receiving CII. A hybrid approach combining CGM with periodic point-of-care blood glucose (POC-BG) tests with two phases (initial-ongoing) of validation was used to determine CGM accuracy. Mean and median absolute relative differences and Clarke Error Grid were plotted to evaluate the CGM accuracy. Surveys of nurses and patients on the use of CGMs experience were conducted and results were analyzed. In this cohort (mean age 64, 32% female, 32% with diabetes) with 864 paired POC-BG and CGM values analyzed, mean and median absolute relative difference between POC-BG and CGM values were 13.2% and 9.8%, respectively. 99.7% of paired CGM and POC-BG were in Zones A and B of the Clarke Error Grid. Responses from nurses reported CGMs being very or quite convenient (n = 28; 93%) and it was favored over POC-BG testing (n = 28; 93%). Majority of patients (n = 42; 93%) reported their care process using CGM as being good or very good. This pilot study demonstrates the feasibility, accuracy, and nursing convenience of adopting CGM via a hybrid approach for insulin titration in postoperative settings. These findings provide robust rationale for larger confirmatory studies to evaluate the benefit of CGM in postoperative care to improve workflow, enhance health outcomes, and cost-effectiveness.

Management of diabetic ketoacidosis in internal medicine: insulin protocols, electrolyte balance, and clinical outcomes

Diabetic ketoacidosis (DKA) is a critical complication of diabetes mellitus (DM), characterized by hyper-glycemia, acidosis, and ketosis. It poses a substantial risk of morbidity and mortality, especially in type 1 DM patients. DKA can be triggered by various factors, including insulin deficiency, infections, alcohol abuse, and other medical conditions. Hospital admissions for DKA are increasing, with mortality rates of up to 5-9%, often linked to severe underlying illnesses and complications such as myocardial infarction and stroke. Effective DKA management involves rehydration, correction of electrolyte imbalances, insulin administration, and addressing precipitating factors. Fluid resuscitation with isotonic saline is vital to restore hydration, and continuous intravenous insulin infusion is the preferred method to control blood glucose and suppress ketone production. Electrolyte imbalances, particularly potassium, sodium, phosphate, and magnesium, require careful monitoring and correction. Clinical outcomes in DKA management include resolving acidosis, normalizing blood glucose, and restoring electrolyte balance, all while achieving and maintaining clinical stability. Complications like cerebral edema and acute respiratory distress syndrome can significantly impact the prognosis. Long-term considerations encompass diabetes management, patient education, and follow-up care.

Efficacy and safety of different insulin infusion methods in the treatment of total parenteral nutrition-associated hyperglycemia: a systematic review and network meta-analysis.

To systematically evaluate the efficacy and safety of different insulin infusion methods in the treatment of total parenteral nutrition (TPN)-associated hyperglycemia based on published literature and the data of completed clinical trials using a network meta-analysis. A comprehensive search of PubMed, Elsevier, Web of Science, EMBASE, Medline, clinicaltrials.gov, Cochrane Library, and three Chinese databases (Wanfang Data, China National Knowledge Infrastructure, and SINOMED) up to December 15, 2022, was performed to collect information on different insulin infusion methods used for the treatment of TPN-associated hyperglycemia, and the Cochrane systematic review method was used to screen the literature, evaluate the quality of the included literature, and extract clinical characteristics for a network meta-analysis. Clinical outcomes included mean blood glucose (MBG), hypoglycemia, hospital length of stay, hyperglycemia, surgical site infection (SSI) and mean total daily insulin. A total of 21 articles, including 1,459 patients, were included to analyze 6 different routes of insulin infusion, including continuous intravenous insulin infusion (CVII), continuous subcutaneous insulin infusion (CSII), subcutaneous glargine insulin (s.c. GI), the addition of regular insulin to the PN mixture (RI-in-PN), multiple subcutaneous insulin injections (MSII) and 50% of insulin administered as RI-in-PN + 50% of insulin administered as s.c. GI (50% RI-in-PN + 50% s.c. GI). The results of the network meta-analysis showed that MSII was the least effective in terms of MBG, followed by CVII. The 6 interventions were basically equivalent in terms of the hypoglycemia incidence. In terms of the length of hospital stay, patients in the CVII group had the shortest hospital stay, while the MSII group had the longest. CVII was the best intervention in reducing the incidence of hyperglycemia. The incidence of SSI was the lowest in the CSII and CVII groups, and the mean daily insulin dosage was the lowest in the CVII group. Current literature shows that for the treatment of TPN-associated hyperglycemia, CVII is the most effective, reducing the incidence of hyperglycemia and shortening the length of hospital stay without increasing the incidence of hypoglycemia. MSII has the worst efficacy, leading to a higher MBG and longer hospital stay, and RI-in-PN, CSII, s.c. GI and 50% RI-in-PN + 50% s.c. GI are better in terms of efficacy and safety and can be substituted for each other. https://www.crd.york.ac.uk/prospero/, identifier CRD42023439290.

Intrapartum continuous subcutaneous insulin infusion vs intravenous insulin infusion among pregnant individuals with type 1 diabetes mellitus: a randomized controlled trial

Intrapartum glucose management is critical to reducing neonatal hypoglycemia shortly after birth. Although it is known that insulin is required for all pregnant individuals with type 1 diabetes mellitus, the optimal mode of intrapartum glycemic control is not known. This study aimed to compare the effect of intrapartum use of continuous subcutaneous insulin infusion with that of intravenous insulin infusion for glucose management among pregnant individuals with type 1 diabetes mellitus on neonatal blood glucose levels. This was a randomized controlled trial of pregnant participants with type 1 diabetes mellitus. After written informed consent, participants were randomly allocated to 1 of 2 intrapartum insulin administration strategies: continuation of their continuous subcutaneous insulin infusion or intravenous insulin infusion. The primary outcome was the first neonatal blood glucose level. Between March 2021 and April 2023, 76 participants were approached, and 70 participants were randomized (35 participants in the intravenous insulin infusion group and 35 participants in the continuous subcutaneous insulin infusion group). The groups were similar in terms of age, race/ethnicity, pregravid body mass index, nulliparity, and gestational age at delivery. There was no statistically significant difference in the first neonatal glucose measurement between the 2 groups (50.1±23.4 vs 49.2±22.6; P=.86). In addition, there were no statistically significant differences in any secondary neonatal outcomes. Approximately 57.1% of neonates in the continuous subcutaneous insulin infusion group required either oral, intravenous, or both treatments for hypoglycemia, whereas 51.4% of neonates in the intravenous infusion group required treatment. In both groups, 28.6% of neonates required intravenous treatment for hypoglycemia. Pregnant individuals with type 1 diabetes mellitus using either intravenous insulin infusion or continuation of their continuous subcutaneous insulin infusion for intrapartum insulin administration had no difference in the primary outcome of neonatal hypoglycemia. Patients should be given the option of both glycemic management strategies intrapartum.

1014-P: Evaluation of Diabetic Ketoacidosis Management with a Subcutaneous Insulin Lispro PowerPlan

Diabetic ketoacidosis (DKA) has traditionally been treated with a continuous intravenous insulin infusion, often requiring management in an intensive care unit (ICU) or step-down unit. There has been growing evidence supporting the use of subcutaneous rapid-acting insulin analogs to treat mild-to-moderate DKA (alert patient able to tolerate oral fluid intake, pH >7.0, bicarbonate ≥10), helping to decrease costs and ICU-bed utilization. We sought to establish the efficacy and safety of a subcutaneous insulin lispro protocol developed at UPMC for the treatment of mild-to-moderate DKA. A retrospective chart review was performed on patients across 15 institutions in the UPMC network from February-October 2022 who had the adult DKA PowerPlan subcutaneous insulin lispro subphase ordered. Of 111 cases analyzed, 47 cases were included that properly used the PowerPlan to treat mild-to-moderate DKA. DKA resolution using the PowerPlan was reached in 45/47 (95.7%) cases. The two unsuccessful cases involved delayed recognition of DKA in the emergency department and premature transition to a prandial insulin regimen before DKA resolution. Hypoglycemia (defined as glucose <70) occurred in 9/47 (19.1%) encounters. Only 1/47 (2.1%) encounters involved hypoglycemia directly attributable to the subcutaneous insulin lispro PowerPlan. The remaining cases of hypoglycemia were attributed to not reducing insulin doses when glucoses were <250, giving insulin doses sooner than 2 hours before the prior dose, not starting dextrose-containing fluids when glucoses were <250, and higher co-administered basal insulin doses (>0.3 units/kg). Overall, these results suggest that a subcutaneous insulin analog can be safely and effectively used to treat mild-to-moderate DKA in non-ICU settings. Disclosure J.Quaytman: None. E.Karslioglu-french: Research Support; Abbott. A.Donihi: None.

Acute Management of Hypertriglyceridemia With a Disease-Specific Intravenous Insulin Infusion Order Set.

Hypertriglyceridemia-associated acute pancreatitis is a disease lacking a standardized management approach. The main objective of this study was to evaluate the safety and efficacy of a continuous intravenous insulin infusion order set specifically designed for managing hypertriglyceridemia. This study compared the safety and efficacy of a standardized (postintervention) approach to managing hypertriglyceridemia to a nonstandardized (preintervention) approach. The primary efficacy outcome was the percentage of patients who achieved a triglyceride level less than 500 mg/dL. Additional outcomes included the time to achieving a triglyceride level less than 500 mg/dL and the percent reduction in triglyceride levels. The primary safety outcome was the number of patients who experienced hypoglycemia (glucose less than 70 mg/dL). Twenty patients were included in both the preintervention and postintervention groups. There was a significantly greater reduction in triglyceride levels observed in the postintervention group. The number of patients who achieved a triglyceride level less than 500 mg/dL in the preintervention and postintervention groups were 10 (50%) and 17 (85%), respectively, P = 0.018. Within the postintervention group, the time to achieving a triglyceride level less than 500 mg/dL in those with and without diabetes was 56.8 hours (38.2-64.0) versus 27.6 hours (19.7-45.0), respectively, P = 0.028. Our findings demonstrate that insulin infusions are safe and effective when therapy is standardized and accounts for nursing to patient ratios. Our results provide the medical community with a standardized approach to acutely managing hypertriglyceridemia.

Diabetes management in patients undergoing total pancreatectomy: A single center cohort study.

Total pancreatectomy (TP) has been increasingly performed in recent years. However, studies on diabetes management after TP during different postoperative periods are still limited. This study aimed to evaluate the glycemic control and insulin therapy of patients undergoing TP during the perioperative and long-term follow-up period. Ninety-three patients undergoing TP for diffuse pancreatic tumors from a single center in China were included. Based on preoperative glycemic status, patients were divided into three groups: nondiabetic group (NDG, n = 41), short-duration diabetic group (SDG, preoperative diabetes duration ≤12 months, n = 22), and long-duration diabetic group (LDG, preoperative diabetes duration >12 months, n = 30). Perioperative and long-term follow-up data, including the survival rate, glycemic control, and insulin regimens, were evaluated. Comparative analysis with complete insulin-deficient type 1 diabetes mellitus (T1DM) was conducted. During hospitalization after TP, glucose values within the target (4.4-10.0 mmol/L) accounted for 43.3% of the total data, and 45.2% of the patients experienced hypoglycemic events. Patients received continuous intravenous insulin infusion during parenteral nutrition at a daily insulin dose of 1.20 ± 0.47 units/kg/day. In the long-term follow-up period, glycosylated hemoglobin A1c levels of 7.43 ± 0.76% in patients following TP, as well as time in range and coefficient of variation assessed by continuous glucose monitoring, were similar to those in patients with T1DM. However, patients after TP had lower daily insulin dose (0.49 ± 0.19 vs 0.65 ± 0.19 units/kg/day, P < 0.001) and basal insulin percentage (39.4 ± 16.5 vs 43.9 ± 9.9%, P = 0.035) than patients with T1DM, so did those using insulin pump therapy. Whether in the perioperative or long-term follow-up period, daily insulin dose was significantly higher in LDG patients than in NDG and SDG patients. Insulin dose in patients undergoing TP varied according to different postoperative periods. During long-term follow-up, glycemic control and variability following TP were comparable to complete insulin-deficient T1DM but with fewer insulin needs. Preoperative glycemic status should be evaluated as it could guide insulin therapy after TP.

Transient loss of consciousness immediately after total pancreatectomy for pancreatic metastases from renal cell carcinoma: a case report

BackgroundTotal pancreatectomy (TP) is often selected for treatment of various pancreatic diseases. However, the resultant lack of autoregulation of glycometabolism necessitates careful postoperative management.Case presentationA 77-year-old man who had undergone right nephrectomy for renal cell carcinoma 11 years previously presented with multiple histologically diagnosed pancreatic metastases. The patient had no notable comorbidities, including diabetes. Because no extrapancreatic organ metastasis was identified, he underwent TP as a curative treatment. He awoke from anesthesia and was extubated without any problems in the operating room. However, 15 min after entering the intensive care unit, he suddenly lost consciousness and became apneic, resulting in reintubation. Blood gas analysis revealed an increased glucose concentration (302 mg/dL) and mixed acid–base disorder (pH of 7.21) due to insulin insufficiency and fentanyl administration. After induction of continuous intravenous insulin infusion and termination of fentanyl, the glucose concentration and pH gradually improved. He regained clear consciousness and spontaneous ventilation and was extubated the next day with no difficulties or complications.ConclusionThis case highlights the importance of active monitoring of the glycemic state and pH after TP because of the possibility of deterioration due to TP itself as well as the lingering effects of anesthesia.

321: OUTPATIENT DIABETES MANAGEMENT INFLUENCES GLYCEMIC CONTROL IN ICU PATIENTS DURING NUTRITION SUPPORT

Introduction: Appropriate glycemic control improves clinical outcomes during critical illness. We proposed that outpatient diabetes management would influence glycemic control in critically ill patients who require nutrition support (NS). Methods: Adult patients admitted to the trauma intensive care unit (ICU), who required NS, and exhibited hyperglycemia (blood glucose concentration (BG) > 150 mg/dL) or had diabetes mellitus (DM), were retrospectively evaluated. Outpatient DM pharmacotherapy was discontinued upon ICU admission. NS was initiated on day 3 + 3 following ICU admission. A serum hemoglobin (Hgb) A1c was obtained on day 3 + 3. The daily amount/mode of insulin therapy, carbohydrate intake, and point of care BGs for the first 7 days of NS were recorded. Patients were classified as controlled DM (Hgb A1c < 7%), uncontrolled DM (Hgb A1c >/= 7%), or as hyperglycemic patients without DM (Hgb A1c < 6.5%). Target BG was 70 to 150 mg/dL. Hypoglycemia was defined as a BG < 70 mg/dL. Regular human insulin sliding scale (SSI), subcutaneous NPH insulin with concurrent SSI, or continuous intravenous insulin infusion (CIVI) were used for glycemic control at the discretion of the NS service or primary service. Continuous data were given as mean + S.D. Chi-square analysis or ANOVA were used to compare groups. Results: Seventy-eight (14 controlled DM, 21 uncontrolled DM, and 43 non-DM) patients were studied. Maximum BG prior to initiation of NS was significantly different between groups (201 + 54 vs. 334 + 192 vs. 191 + 57 mg/dL, respectively, P < 0.001). The proportion of patients who required higher intensity insulin therapy (NPH + SSI or CIVI) was different among groups (50% vs. 86% vs. 15%, respectively, P < 0.001). The amount of insulin given per gram of carbohydrate intake was 0.45 + 0.50, 1.24 + 1.21, and 0.15 + 0.21 units/g, respectively, P < 0.001. Time within the target BG range was 11 + 6, 12 + 5, and 17 + 6 hrs/day, respectively, P < 0.001. Hypoglycemia occurred in 1 (7%), 5 (24%), and 3 (7%) patients, respectively (P = 0.120). Conclusions: Glycemic control during NS in the ICU is more challenging for those patients whose outpatient DM was uncontrolled compared to those with controlled DM and those with stress-induced hyperglycemia without DM.

ODP153 Recurrent hypertriglyceridemia-induced pancreatitis due to multifactorial chylomicronemia syndrome in a patient with ketosis-prone diabetes mellitus

Abstract Background Hypertriglyceridemia-induced pancreatitis is associated with significant morbidity and mortality. The triad of diabetic ketoacidosis (DKA), severe hypertriglyceridemia, and acute pancreatitis have been occasionally described in severely obese patients with type 2 diabetes mellitus (T2DM). However, the occurrence of this triad in newly diagnosed ketosis-prone diabetes mellitus (KPDM) is rarely reported. Herein, we report a long-term follow-up of a Thai man with KPDM complicated with recurrent pancreatitis due to multifactorial chylomicronemia syndrome. Case Description A 33-year-old Thai male patient with a history of insulin-independent diabetes mellitus, recurrent hypertriglyceridemic pancreatitis, and recurrent DKA (three times within the past 5 years) came to our hospital in 2020 for the management of plasma triglyceride levels. At the age of 29 years (BMI 31.2 kg/m2), he experienced the first hypertriglyceridemia-induced pancreatitis (plasma triglyceride 8,189 mg/dL) in association with DKA. After resolution of DKA, insulin therapy was successfully discontinued for 3 years. Then, recurrent hypertriglyceridemic pancreatitis in association with multiple organ failures was developed during travelling to India. After treatment with plasmapheresis and continuous intravenous insulin infusion, he was able to extubate but pulmonary embolism at right pulmonary artery was discovered. Subcutaneous low molecular weight heparin was given for 6 months and then discontinued. The last hypertriglyceridemia-induced pancreatitis attack in association with DKA was aggravated by a high fat buffet meal 1 month prior to our hospital visit. He denied any tobacco, alcohol, or substance use. The patient had no known family medical history of lipid disorders. Further investigations revealed preserved beta-cell function by mixed meal stimulation test and negative pancreatic autoantibodies. Genetic testing showed no mutation in lipoprotein lipase (LPL) and its co-factors. Therefore, multifactorial chylomicronemia syndrome with KPDM was diagnosed. The patient was referred to multidisciplinary team for lifelong weight loss, limiting intake of fat and simple carbohydrates, and adherence to lipid-lowering medications. Subsequent follow-up 2 years later showed no recurrent pancreatitis. Conclusion The triad of acute pancreatitis, severe hypertriglyceridemia and DKA constitutes a unique subgroup of patients which insulin deficiency state is the core defect in association with underlying genetic predisposition. Molecular diagnosis of underlying genetic defect should be pursued to exclude familial chylomicronemia syndrome. In patients with multifactorial chylomicronemia syndrome, long-term management with dietary modifications together with pharmacotherapy remains the cornerstone of successful treatment. Presentation: No date and time listed

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.

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.

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.

Saved by Insulin! Continuous Intravenous Insulin Infusion as an Adjunctive Treatment for Refractory Hyperkalaemia

Intravenous insulin infusion which is used in treatment of hyperglycaemic emergencies can cause hypokalemia. We report a case of how this disadvantage was utilised to save a patient with life threatening hyperkalaemia. A 46-year-old lady with diabetes mellitus and chronic kidney disease (CKD) presented with breathlessness for 3 days. She had been taking excessive durian for 5 days before admission. Her medications included atenolol. On examination, she was severely bradycardic with pulse rate of 35 beats per minute. She had clinical features of fluid overload. Her renal profile showed elevated urea (17.5 mmol/l) potassium (7.8 mmol/l) and creatinine (322 umol/l). Electrocardiograph (ECG) showed junctional bradycardia. Despite counselling, she declined renal replacement therapy. Various potassium lowering therapies were given including regular nebulised salbutamol, calcium polystyrene sulfonate, intravenous furosemide, and regular insulin chase. After 5 rounds of insulin chases, potassium level remained markedly elevated at 8.2 mmol/l. When she finally consented, haemodialysis was performed. 9 hours post haemodialysis, potassium level was 7.6 mmol/l. While waiting for a next session of haemodialysis, fixed rate intravenous insulin infusion (0.1 unit/kg/hour) was given with concurrent dextrose fluids. Blood glucose was monitored hourly. 15 hours later potassium dropped to 5 mmol/l. ECG changes resolved with resolution of hyperkalemia. She did not require further haemodialysis. Patients with CKD should be cautious with durian intake as it is rich in potassium and may lead to severe hyperkalemia. This case highlights a novel use of continuous fixed-rate insulin infusion for treatment of refractory hyperkalemia when all else fails.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S8

Dynamic changes in insulin requirements with post-operative time using bedside artificial pancreas to maintain normoglycemia without hypoglycemia after cardiac surgery.

It is difficult to manage postoperative blood glucose levels without hyperglycemia and hypoglycemia in cardiac surgery patients even if continuous intravenous insulin infusion is used. Therefore, the insulin requirements for maintaining normoglycemia may be difficult to evaluate and need to be elucidated. In this single-center retrospective study, 30 adult patients (age 71.5 ± 9.0years old, men 67%, BMI 22.0 ± 3.1kg/m2, diabetes 33%) who underwent cardiac surgery and used bedside artificial pancreas (STG-55) as a perioperative glycemic control were included. We investigated the insulin and glucose requirements to maintain normoglycemia until the day after surgery. The bedside artificial pancreas achieved intensive glycemic control without hypoglycemia under fasting conditions for 15h after surgery (mean blood glucose level was 103.3 ± 3.1mg/dL and percentage of time in range (70-140mg/dL) was 99.4 ± 2.0%). The total insulin requirement for maintaining normoglycemia differed among surgical procedures, including the use of cardiopulmonary bypass during surgery, while it was not affected by age, body mass index, or the capacity of insulin secretion. Moreover, the mean insulin requirement and the standard deviationof the insulin requirements were variable and high, especially during the first several hours after surgery. Treatment using the bedside artificial pancreas enabled intensive postoperative glycemic control without hypoglycemia. Furthermore, the insulin requirements for maintaining normoglycemia after cardiac surgery vary based on surgical strategies and change dynamically with postoperative time, even in the short term.

Acute Occlusion of the Lower Limb Artery Associated with Hyperosmolar Hyperglycemic Nonketotic Coma in a Patient with Amyotrophic Lateral Sclerosis: A Case Report

A 61-year-old man with amyotrophic lateral sclerosis (ALS) on tracheostomy positive pressure ventilation was brought to the emergency room due to decreased consciousness. He was diagnosed with hyperosmolar hyperglycemic nonketotic coma (HHNC) with severe systemic hypotension. He exhibited an adequate response to treatment of continuous intravenous insulin infusion and fluid replacement. On the third day, he developed acute limb ischemia due to extensive occlusion from the left common iliac artery to the femoral artery.

195-OR: A Comparison of Inpatient Glycemic Control Using Continuous Subcutaneous Insulin Infusion vs. Multiple Daily Injections in Persons with Type 1 Diabetes

Background: Continuous subcutaneous insulin infusion (CSII) therapy is increasingly being used in the outpatient setting, but there is little known information about its efficacy in the inpatient setting. This study compares inpatient glycemic control of persons with type 1 diabetes (T1D) using CSII, multiple daily injections (MDI), or both. Method: This retrospective chart review assessed the glycemic control of adult patients with T1D who used CSII, MDI or a combination of both during their hospitalization between January 1, 2017 and December 31, 2019. Those who were pregnant and/or treated with continuous intravenous insulin infusion were excluded. Variables were summarized descriptively using means and frequencies. Continuous variables were compared across groups using the ANOVA or Kruskal-Wallis test, and categorical variables were compared using the Fisher’s Exact test. Results: We analyzed records of 65 patients who were mostly male (53.8%) and white (72%) with a mean age of 51.7 ± 16.0 years. The mean hemoglobin A1c was 7.80 ± 1.08%. Though not statistically significant, both mean blood glucose and proportion of hyperglycemic events (proportion of blood glucose measures &amp;gt; 300 mg/dL) were lowest in the CSII group. Mean blood glucose for CSII, MDI, and both was 172.88 ± 40.14, 195.40 ± 43.90, and 199.50 ± 49.99 mg/dL, respectively (p=0.17). The proportion of hyperglycemic events for CSII, MDI, and both was found to be 0.11 ± 0.11, 0.26 ± 0.20, and 0.27 ± 0.27, respectively (overall p=0.0267, pairwise comparisons not significant). Conclusion: Glycemic control of patients with CSII is not significantly different than patients with MDI or a combination of both in persons with T1D, thus suggesting that patients can remain on CSII therapy while inpatient. Disclosure Y. Ye: None. S. Izard: None. A. Myers: None.

Glucose-6-phosphate Dehydrogenase Deficiency Induced Haemolysis in Male With Newly Diagnosed Diabetes During Diabetic Ketoacidosis Treatment: A Case Report

Background: Glucose-6-phosphate dehydrogenase (G6PD) deficiency could be a risk factor for diabetes, as suggested by various epidemiological data, but still a matter of debate. The occurrence of haemolysis during diabetes crises was reported in patients with G6PD deficiency, furthermore the fall in glucose level during the treatment of hyperglycemia is suggested as a possible cause for hemolysis in G6PD deficiency. We reviewed the mechanisms that may link the two diseases. Clinical Case: A 19-year-old male, with G6PD deficiency, presented to the emergency department in our institution with history of generalised weakness, epigastric pain, nausea, and vomiting. He gave history of polyuria, polydepsia and weight loss over a period of two weeks. Diagnosis of DM was confirmed by laboratory tests that showed a mild DKA: arterial pH 7.28, HCO3 18 mmol/l, plasma glucose 21 mmol/l, urinary ketones ++, and hemoglobin 16.1 g/dl (12.0–15.0 g/dl). DKA was treated according to DKA guidelines. Ketoacidosis remission was achieved two days after rehydration and treatment with continuous intravenous insulin infusion (0.05–0.1 IU/kg). The patient then started on subcutaneous intensive insulin injection therapy, three times daily before meals and once before bedtime. Fasting and post-prandial blood glucose levels decreased to 7-8mmol/L, and 10 –13 mmol/l respectively. On day 4, the patient developed dizziness while he was taking a bath, On examination he was pale and had icterus, however, the vital signs and systemic examination were normal, blood tests revealed a hemolytic anemia as follows: (normal values): Hemoglobin 9 g/dl (12.0–15.0 g/dl), reticulocytes 8.5% (0.5–1.5%), total bilirubin 82 umol/l (0–20 umol/l), unconjugated bilirubin 58 umol/l (3–15 umol/l), By the 7th day, hemoglobin levels had fallen to the lowest value of 8.3, then gradually raised to 10.2 g/dl, 2 weeks later, hemoglobin electrophoresis was normal, Coombs test was negative. G6PD activity was below 300 U/L (reduced activit<600) with two separate measurements. The patient had no bacterial infections and had not ingested haemolytic drugs. Hemolysis ceased spontaneously and hemoglobin increased gradually. Conclusion: G6PD deficiency and diabetes mellitus could aggravate each other, and In patients at risk of G6PD deficiency screening of the enzyme activity should be considered following diabetes decompensation, and in case of G6PD deficiency, it is advisable to correct plasma glucose level gradually to avoid the rapid drop in glucose availability, which may cause hemolysis in these patients.