Intravenous Insulin Infusion Therapy Research Articles

Control of blood glucose levels by an artificial pancreas in patients with severe coronavirus disease 2019 pneumonia.

Many patients with severe coronavirus disease 2019 (COVID-19) pneumonia experience hyperglycemia. It is often difficult to control blood glucose (BG) levels in such patients using standard intravenous insulin infusion therapy. Therefore, we used an artificial pancreas. This study aimed to compare the BG status of the artificial pancreas with that of standard therapy. Fifteen patients were included in the study. BG values and the infusion speed of insulin and glucose by the artificial pancreas were collected. Arterial BG and administration rates of insulin, parenteral sugar, and enteral sugar were recorded during the artificial pancreas and standard therapy. The target BG level was 200 mg/dl. Arterial BG was highly correlated with BG data from the artificial pancreas. A higher BG slightly increased the difference between the BG data from the artificial pancreas and arterial BS. No significant difference in arterial BG was observed between the artificial pancreas and standard therapy. However, the standard deviation with the artificial pancreas was smaller than that under standard therapy (p < 0.0001). More points within the target BG range were achieved with the artificial pancreas (180-220 mg/dl) than under standard therapy. The hyperglycemic index of the artificial pancreas (8.7 ± 15.6mg/dl) was lower than that of standard therapy (16.0 ± 21.5mg/dl) (p=0.0387). No incidence of hypoglycemia occurred under the artificial pancreas. The rate of achieving target BG was higher using artificial pancreas than with standard therapy. An artificial pancreas helps to control BG in critically ill patients.

Combination Use of U-500 Regular Insulin via Insulin Pump and Rapid-Acting U-100 Prandial Injections for Treatment of Pre-Existing Type 2 Diabetes in Pregnancy.

The high-dose large-volume insulin injections that may become necessary during pregnancy due to marked pregnancy-induced insulin resistance may result in suboptimal therapeutic effectiveness. Use of U-500 insulin, a concentrated insulin formulation, has been suggested during pregnancy. However, the pharmacokinetic properties of U-500 insulin monotherapy can impede achievement of strict pregnancy glycemic targets. We propose a novel regimen for treatment of severe pregnancy-induced insulin resistance that enables precise delivery of U-500 basal insulin therapy through continuous subcutaneous insulin infusion (CSII) while maintaining the desired kinetics of prandial rapid-acting U-100 insulin therapy. This combination approach, guided by continuous glucose monitoring data, enabled achievement of pregnancy glycemic targets while reducing basal insulin requirements by approximately one-third. We report our method for (1) conversion to U-500 insulin delivery through CSII during pregnancy and (2) conversion from U-500 basal insulin delivery through CSII to U-100 intravenous insulin infusion therapy at delivery, to offer clinicians who encounter similar challenging scenarios a novel approach to diabetes management during pregnancy in the setting of marked insulin resistance.

876-P: Accuracy of Continuous Glucose Monitoring Compared with Capillary Blood and Venous Plasma Glucose Measurements in Medical Intensive Care Unit Patients

Objective: To assess the accuracy of the subcutaneous continuous glucose monitoring (CGM) sensor by comparing to the capillary blood glucose (CBG) and venous plasma glucose (VPG) measurements in the medical intensive care unit (MICU) patients. Subjects and Methods: In a prospective study in patients in the MICUs, Medtronic Enlite sensor was inserted in the abdominal area. Paired sensor glucose readings with reference glucose values (CBG and VPG) were collected from MICU patients receiving intravenous insulin infusion therapy. The accuracy was assessed using the mean absolute relative difference (MARD), surveillance error grid (SEG) analysis and modified Bland-Altman plot. Results: Twelve patients completed the study (age 69.3 ± 11.6 years; BMI 21.6 ± 2.9 kg/m2; APACHE II score 21.8 ± 6.3 and duration of CGM use 108.7 ± 41.1 hours). A total of 353 paired CGM and CBG glucose readings and 125 paired CGM and VPG readings were included in the analysis. Using CBG as the reference, MARD was 7.2%. The modified Bland-Altman plot showed 95% of the limit of agreement (LoA) was -18.4% to 19.2%. The SEG analysis showed that 100% of paired glucose values were within zones A or B. No clinically significant difference in the accuracy was seen between subgroups of vasopressor use (MARD 6.1% in the vasopressor group vs. 6.8% in the non-vasopressor group, p = NS). Using VPG as the reference, the MARD was 8.8%. The modified Bland-Altman plot showed 95% LoA of - 22.6% to 28.2%. The SEG analysis showed 95.2% of glucose readings were within zones A or B. Conclusion: The accuracy of the subcutaneous CGM sensor in MICU patients was comparable to that observed in non-critical care settings, with no device-related adverse events. The sensor accuracy remained within the similar range when using VPG as the references compared to using CBG as the references. No differences in terms of accuracy between the vasopressor and non-vasopressor groups were found in this study. Disclosure N. Laichuthai: None. P. Buranasupkajorn: None. W. Khovidhunkit: Speaker’s Bureau; Self; Amgen, AstraZeneca. Funding Quality Improvement Fund; King Chulalongkorn Memorial Hospital; Thai Red Cross Society (1-62-30101-A-11)

The Management of Blood Glucose Should be Emphasized in the Treatment of COVID-19

Based on the higher mortality and the higher proportion of critically ill adults in coronavirus disease 2019 (COVID-19) patients with diabetes, good inpatient glycemic control is particularly important in the comprehensive treatment of COVID-19. Individualized blood glucose target goals and treatment strategies should be made according to specific circumstances of COVID-19 inpatients with diabetes. For mild patients, a strict glycemic control target (fasting plasma glucose (FPG) 4.4-6.1 mmol/L, 2-hour postprandial plasma glucose (2 h PG) 6.1-7.8 mmol/L) are recommended; a target for the glycemic control of common type patients (FPG 6.1-7.8 mmol/L, 2 h PG 7.8-10.0 mmol/L) and subcutaneous insulin deliver therapy are recommended; a target nonfasting blood glucose range of 10.0 mmol or less per liter for severe-type COVID-19 patients, a relatively Less stringent blood glucose control target (FPG 7.8-10.0 mmol/L, 2 h PG 7.8-13.9 mmol/L) for critically ill patients and intravenous insulin infusion therapy are recommended. Due to the rapid changes in the condition of some patients, the risk of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar status (HHS) maybe occur during the treatment. Blood glucose monitoring, dynamic evaluation and timely adjustment of strategies should be strengthened to ensure patient safety and promote early recovery of patients.

392-P: Impact of Late Glucose Checks on Hypoglycemia Incidence

Objective: Hypoglycemia (hypo) is frequently associated with blood glucose (BG) readings that are late. However, there are few reports describing the quantitative effect of untimely BG readings. This work focused on the quantitative evaluation of BG timing and hypo events related to insulin infusion therapy. Methods: This study is a retrospective, quantitative analysis of incidence of hypo, defined as &amp;lt; 70 mg/dL, relative to the lateness of the BG determination. The dataset includes 3.55 million de-identified BG readings and recorded times from 5 unaffiliated systems using the same eGMS for intravenous insulin infusion therapy between 2007-2017. The timing of all BGs scheduled for every 1 and 2 hour were calculated from the dataset without any restrictions or exclusions. Incidence of hypo events occurring from BG readings 5 minutes (min) late or less was used as a baseline to measure the relative risk of later, low BGs in 10 min increments. The relative risk of late BGs was further stratified by hospital, year, and goal range. Results: For all hospitals, goal ranges, and for each hospital database stratified by year, the relative risk of hypo appeared to have the same relationship as a function of minutes late. The results reveal that between 15-25 min late the risk of a hypo event was almost 2-fold and between 55-65 min late was 4-fold higher when compared to the baseline. Discussion: The timing of the next BG has a profound effect on the incidence of hypo. The relationship of increased risk of hypo with lateness of BG readings remains irrespective of the goal range, year, hospital, or overall incidence of hypo in that hospital. All data within this study is from an eGMS with accurate time data. Future research efforts can compare different insulin dosing applications for the purpose of analyzing late BG checks and hypo. Conclusion: Late BG readings contribute significantly to hypo. These observations should be an important mainstay of bedside care education. The findings also strongly endorse the use of alerts to maintain proper timing of BG readings Disclosure L.J. Dunlap: Employee; Self; Monarch Medical Technologies. A.D. Weber: Employee; Self; Monarch Medical Technologies. J. Scapinello: None. A. Schrader: Employee; Self; Monarch Medical Technologies. W.P. Burgess: Consultant; Self; Monarch Medical Technologies.

STUDY THE EFFICACY OF CHRONIC INTERMITTENT INTRAVENOUS INSULIN INFUSION THERAPY OVER AND ABOVE CONVENTIONAL TREATMENT IN PATIENTS OF DIABETIC AUTONOMIC NEUROPATHY

Objective: This study aims to emphasize the importance of chronic intermittent intravenous insulin infusion therapy (CIIIT) over and above conventional treatment in patients with diabetic autonomic neuropathy.Methods: In our study, we had 50 patients; most of the patients were in the age group of 30–50 years and sex ratio for male:female was 3:2. The patients were divided into two groups. One group which received monthly CIIIT for 8 h per month for 6 months (Group-1) whereas other group did not receive it (Group-2). However, both groups continued their old treatment (oral hypoglycemic or subcutaneous insulin).Results: On 12-month follow-up, in Group-1, palpitation improved in 16 of 17 (94.1%), giddiness improved in 12 of 20 (60.0%), constipation improved in 7 of 12 (58.3%), diarrhea improved in 7 of 8 (87.5%), erectile dysfunction improved in 3 of 5 (60.0%), abdominal fullness improved in 12 of 17 (70.5%), and abnormal sweating improved in 6 of 20 (30%). In comparison to this, in Group 2, palpitation improved in 6 of 19 (31.5%), giddiness improved in 2 of 15 (13.3%), constipation improved in 3 of 13 (23.0%), diarrhea improved in 3 of 7 (42.8%), erectile dysfunction improved in 3 of 5 (20.0%), abdominal fullness improved in 4 of 13 (13.7%), and abnormal sweating improved in 5 of 17 (29.4%).Conclusion: At the conclusion of our study, we found that patients, who were previously refractory to conventional pharmacotherapy, showed a considerable response to CIIIT with most patients giving a history of improvement in their symptoms after therapy and during follow-up. Therefore, it is recommended that patients presenting with complaints of diabetic autonomic neuropathy should be managed by CIIIT rather than the conventional pharmacological therapies.

Rhinocerebral mucormycosis: a rare infection.

Rhinocerebral mucormycosis, also known as zygomycosis, is an acute opportunistic fungal infection with high associated mortality rates. There are some predisposing factors for mucormycosis such as hematological malignancies, severe burns, neutropenia, diabetes mellitus, and the use of corticosteroids. Treatment of rhinocerebral mucormycosis consists of treating the predisposing disease, aggressive surgical debridement and systemic antifungal therapy. We present the case of a 55-year-old diabetic patient treated with insulin who was admitted to the emergency department for headache and left purulent rhinorrhea for 3 days. The patient was hospitalized for diabetic ketoacidosis, and intravenous insulin infusion therapy and intravenous antibiotherapy were administered. The day after hospitalization the patient developed a ptosis of the left eye associated with edema of the upper eyelid and the left cheek. The nasal endoscopy showed necrotic tissue in the left middle meatus and the middle turbinate associated withprofuse purulent discharge. The culture of the nasal swab identified a Rhizopusoryzae and the diagnosis of rhino-cerebral mucormycosis was retained.The patient was put on amphotericin B (1 mg/kg/daily) under medical care in hospital. The patient underwent a functional endoscopic sinus surgery with debridement of sinuses, ethmoidectomy and bilateral antrotomie. Histopathological findings from biopsy of the maxillary sinus presented aseptate hyphae in necrotic tissue. The outcome was fatal on the third day of hospitalization, despite appropriate reanimation measures.

Multiple daily injection of insulin regimen for a 10-month-old infant with type 1 diabetes mellitus and diabetic ketoacidosis.

The incidence of type 1 diabetes is increasing worldwide, and the greatest increase has been observed in very young children under 4 years of age. A case of infantile diabetic ketoacidosis in a 10-month-old male infant was encountered by these authors. The infant's fasting glucose level was 490 mg/dL, his PH was 7.13, his pCO2 was 15 mmHg, and his bicarbonate level was 5.0 mmol/L. The glycosylated hemoglobin level had increased to 9.4%. Ketonuria and glucosuria were detected in the urinalysis. The fasting C-peptide and insulin levels had decreased. The infant was positive for anti-insulin and antiglutamic acid decarboxylase antibodies. Immediately after the infant's admission, fluid therapy and intravenous insulin infusion therapy were started. On the second day of the infant's hospitalization and after fluid therapy, he recovered from his lethargic condition, and his general condition improved. Feeding was started on the third day, and he was fed a formula 5 to 7 times a day and ate rice, vegetables, and lean meat. Due to the frequent feeding, the frequency of rapid-acting insulin injection was increased from 3 times before feeding to 5 times, adjusted according to the feeding frequency. The total dose of insulin that was injected was 0.8–1.1 IU/kg/day, and the infant was discharged on the 12th day of his hospitalization. The case is presented herein with a brief review of the relevant literature.

Continuous Insulin infusion therapy for acute stress hyperglycaemia secondary to asthma exacerbation in a paediatric emergency setting

Introduction Hyperglycaemia is thought to be an adaptive response to stress and is recognized to be associated with an adverse outcome. Although mild stress hyperglycaemia in paediatric illness is common, severe hyperglycaemic responses (≥25 mmol/L) to stress are unusual in children. The role of intravenous insulin infusion therapy in the treatment

Fulminant Type 1 Diabetes Mellitus: A Study of Nine Cases

The study aims to explore the prevalence and clinical features of fulminant type 1 diabetes mellitus (F1DM). We analyzed 11,202 patients who were diagnosed having diabetes and admitted to the Department of Endocrinology, Nanjin First Hospital, Nanjin, China, from September 2005 to April 2011. Among 198 patients classified having type 1 diabetes mellitus (T1DM), nine patients were diagnosed having F1DM. Clinical features of F1DM were analyzed and compared with typical T1DM. The prevalence of F1DM was 4.5% (nine of 198 T1DM patients) in this study. F1DM patients had significantly high levels of random blood glucose (40±9 mmol/L). However, glycated hemoglobin (7.1±1.0%) and C-reactive peptide (0.21±0.15 μg/L) at 2 h postprandial were significantly lower in F1DM patients compared with typical T1DM patients. Six of them had flu-like symptoms. Five of them showed gastrointestinal symptoms. Three patients experienced disturbance of consciousness. However, none of these symptoms was found in patients with typical T1DM. A continuous intravenous insulin infusion therapy using a portable pump was given during the acute phase to control hyperglycemia and ketoacidosis. All F1DM patients survived after treatment. In this single hospital-based study, nine Chinese patients met the criteria for diagnosis of F1DM. Although F1DM may be fatal, prompt treatment is required and useful to rescue these patients.

Utilization of an abbreviated diabetes impact management scale to assess change in subjective disability during a trial of pulsatile insulin delivery demonstrates benefit

A prospective interventional study of pulsatile intravenous insulin infusion therapy has demonstrated reduction of left ventricular mass and blunting of progression of diabetic nephropathy. We anticipated that improvements in objective parameters would be associated with similar improvement measurable by the self-administered Diabetes Impact Management Scale (DIMS). The DIMS was administered at baseline and 12 months for 19 participants randomized to receive either standard insulin treatment of 3 to 4 injections of insulin daily or insulin treatment plus an additional day per week of 3 intravenous pulses over an 8-hour period. For standard vs pulsed intravenous insulin therapy, mean baseline scores were similar for the 12 total questions as well as the groups of 7 questions with emotional content and 5 with physical (neurologic) content. Mean study group scores at 1 year and changes over 1 year were not significantly different for the 7 questions with emotional content ( P = .3143, .7574). Score results for the 5 questions related to neurologic status at 1 year and changes over 1 year were significantly different between patients with standard and with pulsed insulin therapy ( P = .0144, 0.0004). Pulsatile intravenous insulin, when added to standard multiple-dose insulin therapy, was demonstrated to improve subjective perception of neurologic disability on repeated use of an abbreviated form of the DIMS.

A pilot study to assess utility of changes in elements of the Diabetes Impact Management Scale in evaluating diabetic patients for progressive nephropathy

A prospective study involving the use of the Diabetes Impact Management Scale (DIMS) in individuals with diabetic nephropathy as part of an interventional study of pulsatile intravenous insulin infusion therapy is used to define the utility of repeated subjective DIMS testing. We hypothesized that repeated use of such an evaluation would correlate well with other objective end points. The DIMS was administered at baseline and 12 months for 19 participants randomized to receive either standard insulin treatment of 3 to 4 injections of insulin daily or standard insulin treatment plus an additional day per week of 3 intravenous pulses over an 8-hour period. Measures of glycemic control, renal function, hemostatic factors, hemodynamics, left ventricular mass, and function were assessed at baseline and 12 months. Of 44 questions on impact of diabetes management, only 12 (5 reflecting physical and 7 reflecting emotional status) showed significant change from baseline to 1 year. Changes in the 5 physical questions related to neurologic status correlated with stable creatinine ( P = .0001), stable creatinine clearance ( P = .0001), and decrease in left ventricular hypertrophy ( P =.0117). Repeated use of an abbreviated, standardized subjective instrument uncovered changes in quality of life that correlated with differences in renal function and left ventricular mass over 12 months. Further use of such an instrument may help us focus treatment for maximum impact.

Practice Changes in Glycemic Management and Outcomes in Coronary Artery Bypass Surgery Patients

This study aims to evaluate whether a quality improvement initiative in hyperglycemia management could result in substantiated practice changes and improved outcomes for coronary artery bypass surgery patients. Retrospective chart review and analysis of 103 randomly selected patients hospitalized for coronary artery bypass surgery was used. After the glycemia awareness initiative, the perioperative use of intravenous insulin infusion therapy increased in the total population (P = .01) as well as in the diabetes population (P = .03). Frequency of blood glucose level tests ordered for nondiabetic patients increased from 2.8 per day to 4.3 per day (P = .38). Blood glucose values improved in the diabetic population (Ps = .02, .048). The average length of stay improved in all nondiabetic patients (10.7-8.1 days, P = .07) including those who had coronary artery bypass graft surgery with cardiac catheterization (7.8-6.2 days, P = .09) and coronary artery bypass graft surgery with catheterization with complications (15.0-9.0 days, P = .12). The glycemia awareness initiative resulted in a positive impact on practice patterns. Undiagnosed diabetes and impaired fasting glucose are important and unrecognized issues within this hospital population. It is recommended that healthcare practitioners assume that cardiac patients have an increased likelihood of impaired fasting glucose and hyperglycemia. Advanced practice nurses can improve patient outcomes by ordering glucose testing and glycemic management as a routine practice for all cardiac surgery patients, regardless of diabetes diagnosis. Cardiac staff nurses can recommend glucose testing and screening for prediabetes and diabetes as a routine part of all nursing assessment.

Intravenous Insulin Infusion Therapy: Indications, Methods, and Transition to Subcutaneous Insulin Therapy

To describe indications for intravenous (IV) insulin infusion therapy and glycemic thresholds, discuss methods and protocols, and promote use of and access to IV insulin infusion therapy for all appropriate patients in the hospital setting. Randomized, prospectively designed trials support the use of IV insulin infusion therapy for patients in the surgical intensive-care unit, including postoperative cardiac patients and patients having myocardial infarction. Among patients in the surgical intensive-care unit, reanalysis of the data suggested no threshold at which benefit occurred above the blood glucose level of 110 mg/dL. In another study, retrospective analysis of data among critically ill medical and surgical patients suggested a target blood glucose level of 145 mg/dL or less. In other populations, the threshold or ideal target blood glucose range has not been determined. Three protocols for IV insulin infusion are described that maintain blood glucose levels safely below the upper limit of their respective target ranges without substantial risk of hypoglycemia. The threshold for initiation of IV insulin infusion is 110 mg/dL for critically ill surgical patients, 140 mg/dL for other medical or surgical patients, 180 mg/dL for patients in whom subcutaneous insulin regimens fail, and 100 mg/dL for pregnant women. The blood glucose target range is 80 to 110 mg/dL for selected critically ill surgical patients, 70 to 100 mg/dL for pregnant women, and 90 to 140 mg/dL for all other patients. Hospitals should develop procedures to make IV insulin infusion therapy available to all appropriate patients.

Relative roles of insulin clearance and insulin sensitivity in the prebreakfast increase in insulin requirements in insulin-dependent diabetic patients.

During continuous subcutaneous or intravenous insulin infusion therapy, many patients with insulin-dependent diabetes (IDD) require more insulin in the prebreakfast period (0600-0800 h) than earlier in the morning (0100-0300 h). This study was designed to assess whether variations in insulin clearance or insulin sensitivity might contribute to overnight variations in insulin requirements. Euglycemic insulin clamp studies were performed in random sequence from 2400 to 0300 h and from 0500 to 0800 h on successive nights in 10 subjects with IDD. Insulin was infused at a rate of 40 mU/min/m2 and plasma glucose concentration was maintained at 100 mg/dl by a variable rate glucose infusion from a Biostator GCIIS (Miles Laboratories, Elkhart, Indiana). Insulin clearance was (mean +/- SEM) 277 +/- 41 ml/min/m2 between 0700 and 0800 h compared with 256 +/- 41 ml/min/m2 between 0200 and 0300 h (P less than 0.05), while glucose infusion rates were the same [3.86 +/- 0.52 mg/kg/min from 0730 to 0800 h versus 3.99 +/- 0.51 mg/kg/min from 0230 to 0300 h (P = NS)]. All eight patients with a previously documented prebreakfast increase in insulin requirements had higher insulin clearance at this time. These results indicate that differences in insulin clearance between the prebreakfast period and the early morning may account partially for the higher prebreakfast insulin requirements in some subjects with IDD, and the variations in insulin requirements during the night are not due to variations in insulin sensitivity.

Oxygen Transport System of Red Cells During Recovery from Diabetic Ketoacidosis with Continuous Intravenous Insulin Infusion Therapy

Oxygen Transport System of Red Cells During Recovery from Diabetic Ketoacidosis with Continuous Intravenous Insulin Infusion Therapy