Rate Intravenous Infusion Research Articles

Intravenous Insulin Infusion Rate and Its Impact on the Time to Resolution of Diabetic Ketoacidosis

Background: Diabetic ketoacidosis (DKA) is an acute and severe complication of type 1 diabetes that is highly prevalent in children and adolescents. Intravenous (IV) insulin infusion is the mainstay of DKA treatment in the intensive care unit; however, standard-dose (0.1 U/kg/h) insulin infusion increases the risk of cerebral edema.Objective: To compare the efficacy and safety of low-dose (0.05 U/kg/h) vs high-dose (0.1 U/kg/h) IV insulin infusion in children and adolescents treated for DKA. Materials and methods: Our randomized single-blind study included 86 patients aged 5 to 14 years urgently hospitalized with symptoms of DKA. Group 1 comprised 40 children who received IV insulin at the low rate (0.05 U/kg/h), whereas group 2 included 46 children who received IV insulin at the standard rate (0.1 U/kg/h). During the treatment we compared the time to DKA resolution and blood glucose level decrease to 15 mmol/L and recorded cases of hypoglycemia, hypokalemia, and papilledema. The MannWhitney test was used to determine whether differences were statistically significant.Results: There was no difference between groups 1 and 2 in DKA treatment duration. The blood glucose level was found to decline to 15 mmol/L more slowly in children who received IV insulin at 0.05 U/kg/h. Hypoglycemia, hypokalemia, and papilledema were more common in the standard-dose (0.1 U/kg/h) group.Conclusions: The low-dose IV insulin infusion (0.05 U/kg/h) is safer in terms of complications (cerebral edema) associated with pediatric DKA treatment in the intensive care unit and not inferior to the standard recommended dose (0.1 U/kg/h) in efficacy.

Evaluating the efficacy of different volume resuscitation strategies in acute pancreatitis patients: a systematic review and meta-analysis

IntroductionAcute pancreatitis poses a significant health risk due to the potential for pancreatic necrosis and multi-organ failure. Fluid resuscitation has demonstrated positive effects; however, consensus on the ideal intravenous fluid type and infusion rate for optimal patient outcomes remains elusive.MethodsA comprehensive literature search was conducted using PubMed, Embase, the Cochrane Library, Scopus, and Google Scholar for studies published between 2005 and January 2023. Reference lists of potential studies were manually searched to identify additional relevant articles. Randomized controlled trials and retrospective studies comparing high (≥ 20 ml/kg/h), moderate (≥ 10 to < 20 ml/kg/h), and low (5 to < 10 ml/kg/h) fluid therapy in acute pancreatitis were considered.ResultsTwelve studies met our inclusion criteria. Results indicated improved clinical outcomes with low versus moderate fluid therapy (OR = 0.73; 95% CI [0.13, 4.03]; p = 0.71) but higher mortality rates with low compared to moderate (OR = 0.80; 95% CI [0.37, 1.70]; p = 0.55), moderate compared to high (OR = 0.58; 95% CI [0.41, 0.81], p = 0.001), and low compared to high fluids (OR = 0.42; 95% CI [0.16, 1.10]; P = 0.08). Systematic complications improved with moderate versus low fluid therapy (OR = 1.22; 95% CI [0.84, 1.78]; p = 0.29), but no difference was found between moderate and high fluid therapy (OR = 0.59; 95% CI [0.41, 0.86]; p = 0.006).DiscussionThis meta-analysis revealed differences in the clinical outcomes of patients with AP receiving low, moderate, and high fluid resuscitation. Low fluid infusion demonstrated better clinical outcomes but higher mortality, systemic complications, and SIRS persistence than moderate or high fluid therapy. Early fluid administration yielded better results than rapid fluid resuscitation.

FRI642 The Effect Of Early Basal Insulin Administration On Diabetic Ketoacidosis (DKA) Management

Abstract Disclosure: H. Al-Marsumi: None. S.Z. Pollack: None. N. Simon: None. Background: DKA and HHS are considered serious acute complications of diabetes and constitute endocrine emergencies. Management of DKA and HHS consists of fluid, potassium replacement and weight-based adjusted rate intravenous insulin infusion, with close monitoring of capillary glucose, serum electrolytes, venous PH, and Beta-hydroxybutyrate. Current Standard DKA management protocols introduce and overlap subcutaneous insulin with intravenous insulin infusion after anion gap closure. In United states, few studies looked at different outcomes after early administration of basal insulin (i.e. before anion gap closure) during DKA management. Objective: The purpose of this research is to study the effect of early administration of basal long-acting insulin in addition to intravenous insulin on the time to anion gap closure, incidence of rebound hyperglycemia, hypoglycemia, transitional failure, length of ICU stays and length of Hospital stays, compared to intravenous insulin infusion only. Methods: This was a single-center, retrospective chart review study of adults 21 years or older admitted to the hospital with DKA diagnosis between September 2020 and May 2022. The patients were divided into two groups (Study group which includes those with early administration of basal long-acting insulin in addition to intravenous insulin infusion and Standard group which includes patients who received intravenous insulin infusion only). The primary outcome was the time to anion gap closure. The other outcomes included incidence of rebound hyperglycemia, hypoglycemia, transitional failure, length of ICU stay, as well as the length of hospital stay. Results: A total of 231 admissions were included for analysis; 29 patients were included in the (Study group) and 202 in the (Standard group). The mean time ± standard deviation for hours till anion gap closure in the study group and standard group were (21.3938 ± 25.2603 and 12.7679 ± 9.3512) respectively showing no statistical difference between the two groups with a P value of 0.0789. The incidence of hypoglycemia was 21% in the study group and 24% in the standard group with P value of 0.8173. There was no statistical difference in length of ICU stays, length of hospital stays, incidence of rebound hyperglycemia, transitional failure between the study and control groups with a p value of (0.3867, 0.7207, 0.7758 and 0.1387) respectively. Conclusion: There was no statistical difference in time to anion gap closure, length of ICU stays, length of hospital stays, incidence of rebound hyperglycemia, hypoglycemia, transitional failure between the study and Standard groups. Further Studies are needed to evaluate the effect of early basal insulin administration on DKA management. Presentation: Friday, June 16, 2023

167-OR: Significant Differences in DKA Outcomes across Hospitals Despite Same Guidelines Highlights the Need for Better Implementation Strategies—Results from DEKODE Initiative

Aim: To measure differences in DKA care and outcomes between hospitals having same guidelines. Method: The data was gathered as part of the DEKODE (Digital Evaluation of Ketosis and Other Diabetes-related Emergencies) initiative from October 2021 to September 2022 in six hospitals (anonymised as A to F) in the UK which has guidelines based on Joint British Diabetes Societies-Inpatient (JBDS-IP) recommendations. We collected data on adherence to Fixed Rate Intravenous Insulin Infusion (FRIII), fluids administration, glucose monitoring, and ketones monitoring. Pseudonymised data on dates and times of admission, discharge, DKA diagnosis and resolution was collected. Independent-Samples Kruskal-Wallis test was performed to assess differences in various parameters of DKA care and outcomes. Results: A total of 442 DKA episodes were analysed. There were differences between hospitals in fluids administration (median: A-92.1%, B-101.3%, C-89.7%, D-76.0%, E-98.3%, F-115.5%; p&amp;lt;0.001), glucose monitoring (median: A-103.1%, B-86.1%, C-88.9%, D-106.4%, E-99.2%, F-95.7%; p&amp;lt;0.001), and ketone monitoring (median: A-71.5%, B-85.1%, C-70.0%, D-59.3%, E-65.0%, F-85.7%; p&amp;lt;0.001). There was no significant difference in FRIII (median: A- 99.5%, B- 100.0%, C- 100.0%, D- 100.0%, E- 93.9%, F- 99.8%; p=0.064). We found inter-hospital differences in DKA duration (median in hours; A-13.3, B-13.4, C-18.5, D-15.1, E-17.1, F-16.3; p=0.002), and length of stay (median in days; A-2.1, B-2.5, C-3.5, D-3.6, E-2.5, F-3.0; p&amp;lt;0.001). Conclusion: Despite similar guidelines, significant variations in DKA outcomes exist between hospitals. Variations in various components of DKA highlight there may be differences in guidelines implementation. A centralised data collection system can identify and share best practices between centres, which may help minimise inter-hospital variations and facilitate uniform patient care. Disclosure P.Kempegowda: None. L.Rengarajan: None. P.Narendran: Advisory Panel; Omnipod, Speaker's Bureau; Abbott Diabetes, Lilly Diabetes. Dekode team: n/a.

A Retrospective Cohort Analysis of Two Computerized Insulin Infusion Protocols.

The primary objective of this analysis was to compare the safety and efficacy of a novel computerized insulin infusion protocol (CIIP), the Lalani Insulin Infusion Protocol (LIIP), with an established CIIP, Glucommander. We conducted a 10-month retrospective analysis of 778 patients in whom LIIP was used (August 18, 2020 to June 25, 2021) at six HonorHealth Hospitals in the Phoenix metropolitan area. These data were compared with Glucommander that was used at those same hospitals from January 1, 2018 to August 17, 2020, n = 4700. Primary end points of the project included average time to euglycemia and average time in hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL). Additional subgroup analysis was done to evaluate CIIP performance in patients in whom maintenance of euglycemia was more challenging. The LIIP had a faster time to euglycemia (191 vs 222 minutes, P < .001) and similar time in hypoglycemia (2.79 vs 2.76 minutes, P = .50) for all patients, when compared with Glucommander. Similar observations were made for the following subgroups: diabetic ketoacidosis/hyperosmolar hyperglycemic state (DKA/HHS) patients, COVID-19 patients, patients on steroids, patients with ≥60 glomerular filtration rate (GFR), patients with renal insufficiency, and patients with sepsis. The LIIP is a safe and effective CIIP in managing intravenous insulin infusion rates. Utilization of LIIP resulted in reduced time to euglycemia, P < .001, when compared with Glucommander and did not cause increased hypoglycemia during the project period. Contributing factors to the success of LIIP may include improved clinical workflow, learnability and ease of use, compatibility with the Epic electronic health record (EHR), and its unique, dynamic and adaptive algorithm.

Adjustment of Maternal Variable Rate Insulin Infusions Using Real-Time Continuous Glucose Monitoring in Pregnant Women with Type 1 Diabetes.

Real-time continuous glucose monitoring (CGM) in hospital holds promise; however, further evidence is required on its use to guide adjustment of variable rate intravenous insulin infusion (VRIII). We retrospectively analyzed data from 20 women with type 1 diabetes during the peripartum period who were commenced on VRIII. Data were analyzed for CGM accuracy (Dexcom G6) using point-of-care glucose-CGM matched pairs. The study was entirely observational, with no deviation from standard clinical care. Twenty women were included; median age 30 (26-35) years with first glycated hemoglobin in pregnancy of 57 (49-60) mmol/mol. Overall median absolute relative difference was 6.1 (1.6-17.3)%. The total simulated CGM-adjusted VRIII was 2.5 U per hour, compared with 2.4 U per hour with capillary blood glucose-adjusted VRIII. In this retrospective analysis of CGM adjustment of maternal VRIII, we demonstrate early feasibility and considerable accuracy. Further prospective studies are required to confirm the safety and potential efficacy of CGM-based insulin titration.

Perioperative variable rate intravenous insulin infusion: a quality improvement project on a vascular surgery ward

AimsVariable rate intravenous insulin infusion (VRIII) is used perioperatively to maintain normoglycaemia in patients with diabetes who are undergoing surgery. The aims of this project were as follows: (1) to...

Evaluation of a constant rate intravenous infusion of dexmedetomidine on the duration of a femoral and sciatic nerve block using lidocaine in dogs.

This study investigated the effects of 1 μg/kg/h intravenous constant rate infusion (CRI) of dexmedetomidine on the sensory and motor blockade for femoral and sciatic nerve blocks in dogs undergoing stifle surgery. Client-owned dogs referred for stifle surgery were enrolled in this prospective, randomized, blinded study. Dogs were pre-medicated with acepromazine (0.005-0.01 mg/kg intramuscularly, IM); anesthesia was induced with propofol intravenously and maintained with isoflurane in a mixture of air and oxygen. Electrolocation-guided sciatic and femoral nerve blocks with lidocaine 2% (0.15 mL/kg) were performed using the parasacral and lateral pre-iliac approaches, respectively. After performing local block, a systemic infusion of saline solution (group C) or dexmedetomidine (group D) was started at a CRI at 1 ml/kg/h and continued until the end of surgery. Dexmedetomidine was infused at a dose of 1 μg/kg/h. Respiratory and hemodynamic variables were recorded during surgery. Sensory and motor blockade was evaluated by response to pinching the skin innervated by the sciatic/femoral nerves, with forceps and by observing the dogs' ability to walk and testing proprioception at 30, 60, 120, 180, and 240 min after extubation. Analgesia was monitored with SF-GCPS. Methadone IM was administered as rescue analgesia. Intraoperative data were analyzed by analysis of variance, while postoperative data were analyzed by the independent two-tailed t-test and a Kaplan-Meier test (p < 0.05). Twenty dogs were included in this study (10/group). A significant difference in the recovery of sensory nerve function was observed between the groups. The mean durations of the sensory blockade for femoral and sciatic nerves, respectively, was longer (p < 0.001) for group D [168 (146-191, 95% CI), 161 (143-179, 95% CI) min] than in group C [120 (96.1-144, 95% CI), 116 (90.9-142, 95% CI]. No differences in the recovery of patellar and tibial reflexes, proprioceptive function, and ability to walk were found among groups. The overall postoperative rescue analgesia requirement was significantly different (p = 0.019) between groups, with an incidence of 5/10 (50%) dogs in group D and 10/10 (100%) dogs in group C. Dexmedetomidine administered as a CRI (1 μg/kg/h) combined with local lidocaine increases the duration of the sensory component of the sciatic and femoral nerve blocks and reduces the requirement for additional analgesia during the immediate postoperative hours.

A clinically utilized intravenous continuous rate infusion of diltiazem does not significantly decrease systolic function in healthy dogs.

To determine if left ventricular systolic function on echocardiography, systemic blood pressure, and electrocardiography change with a clinically accepted intravenous (IV) diltiazem constant rate infusion (CRI) compared to a control. 10 healthy client-owned adult dogs. Prospective, masked, crossover study from May 27, 2021, to August 22, 2021. Dogs were randomized to receive diltiazem (loading dose of 240 μg/kg, IV followed by a CRI of 6 μg/kg/min for 300 minutes) or the same volume of 5% dextrose in water (D5W) administered IV followed by the opposite intervention after a 7-day washout. Blood pressure was monitored during each CRI, and echocardiographic and electrocardiographic studies were performed immediately before the CRI and during the last hour of the CRI. Postdiltiazem systolic time interval (STI) (median, 0.30; range, 0.16 to 0.34) was significantly lower than post-D5W STI (median, 0.32; range, 0.22 to 0.40; P = .046). All other echocardiographic parameters did not differ significantly between each of the groups after receiving diltiazem or D5W. Systemic blood pressure did not change significantly with either diltiazem (P = .450) or D5W (P = .940), and none of the dogs became hypotensive at any point in the study. Expectedly, negative dromotropy was observed with diltiazem. A significant decrease in left ventricular systolic function was not appreciated in healthy dogs receiving diltiazem at a clinically accepted intravenous infusion rate at this dosing regimen. Further studies are needed in dogs with cardiac disease.

Comparison of DripAssist to Traditional Method for Achieving Rate Infusions by U.S. Army Medics.

Literature finds improper intravenous (IV) infusion rates as the most common cause of medication administration errors (MAE). Calculating drip rates and manipulating roller clamps while counting drops within the drip chamber to manage IV infusions - known as the traditional method (TM) - increases the likelihood of IV MAEs compared to electronic infusion pumps. The DripAssist, a novel in-line device, allows users to monitor and adjust infusion rates without calculating rates or counting drops. We conducted a prospective, randomized, crossover study with a convenience sample of U.S. Army medics initiating infusion rates using the DripAssist and the TM. Investigators randomized participants to start with the TM or DripAssist and achieve three specific infusions using an in vitro model. The primary outcome was the time to achieve the desired infusion rate measured in seconds. Secondary outcomes included drip rate accuracy and volume infused over one hour. End user feedback included method confidence on a 100-point Bandura scale and appraisal using a five-point Likert item. Twenty-two medics demonstrated faster time to achieve infusion rates with the DripAssist over TM (median 146.5 seconds vs. 207.5 seconds, p = .003). A sequence effect noted faster time to achieve desired infusion rates with the TM after completing infusions with DripAssist (p = .033). The DripAssist demonstrated significantly improved accuracy for drip rate and volume administered over one hour compared to TM (median rate error: 5% versus 46%, p <.001; median volume percentage error: 26.5% versus 65%, p <.001). The DripAssist had significantly higher user confidence (median 80 vs. 47.5, p <.001) and was perceived as easier to use (median 4 vs. 2, p = <.001) and more likely to be learned, remembered, and performed by a medic (median 5 vs. 3, p <.001). Most participants (90%) preferred the DripAssist for establishing a rate-specific infusion. The DripAssist demonstrated significantly faster time to achieve infusion rates, improved accuracy, and increased user confidence. Sequence effects may confound time data. We recommend further studies of the DripAssist by prehospital medical personnel in more austere environments.

Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group.

Hyperosmolar Hyperglycaemic State (HHS) is a medical emergency associated with high mortality. It occurs less frequently than diabetic ketoacidosis (DKA), affects those with pre-existing/new type 2 diabetes mellitus and increasingly affecting children/younger adults. Mixed DKA/HHS may occur. The JBDS HHS care pathway consists of 3 themes (clinical assessment and monitoring, interventions, assessments and prevention of harm) and 5 phases of therapy (0-60 min, 1-6, 6-12, 12-24 and 24-72 h). Clinical features of HHS include marked hypovolaemia, osmolality ≥320 mOsm/kg using [(2×Na+ ) + glucose+urea], marked hyperglycaemia ≥30 mmol/L, without significant ketonaemia (≤3.0 mmol/L), without significant acidosis (pH >7.3) and bicarbonate ≥15 mmol/L. Aims of the therapy are to improve clinical status/replace fluid losses by 24 h, gradual decline in osmolality (3.0-8.0mOsm/kg/h to minimise the risk of neurological complications), blood glucose 10-15 mmol/L in the first 24 h, prevent hypoglycaemia/hypokalaemia and prevent harm (VTE, osmotic demyelination, fluid overload, foot ulceration). Underlying precipitants must be identified and treated. Interventions include: (1) intravenous (IV) 0.9% sodium chloride to restore circulating volume (fluid losses 100-220 ml/kg, caution in elderly), (2) fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia (FRIII should be commenced at the same time as IV fluids). (3) glucose infusion (5% or 10%) should be started once glucose <14 mmol/L and (4) potassium replacement according to potassium levels. HHS resolution criteria are: osmolality <300 mOsm/kg, hypovolaemia corrected (urine output ≥0.5ml/kg/h), cognitive status returned to pre-morbid state and blood glucose <15 mmol/L.

Pharmacokinetics and Pharmacodynamics of Nipocalimab Administered at Different Rates of Intravenous Infusion in Healthy Participants: Results of a Phase 1 Placebo-Controlled Single-Dose Study

Background: Warm autoimmune hemolytic anemia (wAIHA) is a rare autoimmune condition driven by autoantibodies that can significantly impact a patient's quality of life. wAIHA is characterized by the premature destruction of red blood cells (RBCs) in the presence of autoantibodies which preferentially bind to RBCs at 37°C. There is currently no approved treatment for wAIHA. Patients with severely symptomatic anemia are typically managed with corticosteroids and rituximab, both of which are associated with potential relapse and adverse events. Nipocalimab, which is in clinical development for the treatment of wAIHA (NCT04119050), is a fully human, aglycosylated, effectorless IgG1 monoclonal antibody that targets the IgG binding site on the neonatal Fc receptor (FcRn) with high affinity to lower circulating IgG levels. This study assessed the pharmacokinetics (PK) and pharmacodynamics (PD) of single doses of nipocalimab administered at different IV infusion rates in healthy adults to support the potential use of shortened infusions in future studies. Nipocalimab was generally safe and well-tolerated at all doses and infusion rates; detailed safety results have been presented separately [Leu JH, et al. EHA 2022. Presentation P1534]. Methods: The trial was a single dose, sequential, randomized, double-blind, placebo-controlled, escalating dose and infusion rate study. Eligible participants were males or females aged 18-55 years with no clinically significant medical or physical conditions. Participants were randomized to 1 of 5 cohorts (n=8 per cohort [6 nipocalimab, 2 placebo]) to receive nipocalimab 30 mg/kg IV infused over 60, 30, 15 or 7.5 min (0.5, 1, 2, or 4 mg/kg/min), nipocalimab 60 mg/kg IV infused over 15 min (4 mg/kg/min) or matching placebo. Escalation to the next dose level was permitted following review by a safety monitoring committee. Pharmacokinetic sampling of nipocalimab was conducted predose, midpoint of infusion (MOI), end of infusion (EOI), EOI + 0.083h, EOI + 0.25h, EOI + 1h, start of infusion + 24h, Day 8, and Day 15 postdose; MOI and EOI varied for each dose. In terms of PD, total serum IgG was assessed. Results: A total of 40 participants (70% female, 93% white) received study drug, of which 30 were included in the PK analysis; 39 completed the study. Mean serum nipocalimab concentration-time profiles were similar following all 30 mg/kg doses regardless of infusion rate; mean serum concentrations were ~2 times higher following a 60 mg/kg infusion. Nipocalimab remained detectable up to ~169 hours postdose for 30 mg/kg groups and ~337 hours postdose for the 60 mg/kg group. Geometric mean peak (Cmax) and overall exposure (AUC) to nipocalimab were unaffected by infusion rate when administered at 30 mg/kg. Following a 60 mg/kg infusion, AUCs were 2.4-2.8 times higher and Cmax was 2.0-2.2 times higher than with 30 mg/kg infusions. Median Tmax was approximately at EOI following the 60 mg/kg infusion. Mean half-life (t½) values were similar in all treatment groups. In terms of total serum IgG, changes from baseline were decreased among all nipocalimab cohorts at all postdose time points. The maximum decrease in mean serum IgG levels was 79% at day 15 with nipocalimab 60 mg/kg. Conclusion: Nipocalimab Cmax and AUC were not affected by infusion rates when given at a dose of 30 mg/kg, but Tmax was delayed at the fastest infusion rates. Following the 60 mg/kg infusion, peak and overall nipocalimab exposures were 2-2.8 times higher than following 30 mg/kg infusions.

PSUN220 Audit on Variable Rate Intravenous Insulin Infusion (VRIII) in inpatients in Scarborough General Hospital

Abstract Introduction A Variable Rate Intravenous Insulin Infusion (VRIII) is an infusion of insulin at an interchangeable rate. It involves taking regular capillary blood glucose levels, aiming to control the serum glucose levels with in a specific range and an infusion of glucose containing fluid to prevent insulin induced hypoglycaemia (1). A VRIII is used in patients with known diabetes or with hospital related hyperglycaemia who are unable to take oral fluids/food and for whom adjustment of their own insulin regime is not possible (1). The advantage of a VRIII is the fact is that it involves target driven glucose control for specified indications and avoids metabolic decompensation. Aim To test the compliance of the ward medical staff with VRIII protocol against the local trust policy and the Joint British Diabetes Society guidelines (JBDS). Methodology A retrospective audit on sample of 15 patients at Scarborough General Hospital receiving VRIII on medical and surgical wards. Data was collected over a period of a month. Data collection and analysis performed utilising Microsoft Excel. Audits standards based on trust guidelines and JBDS guidelines. Results Most patients were above age of 60 years, female and type 2 diabetic. 100% of patients had daily electrolytes monitoring, 27% had hypoglycaemia, 13% did not have long-acting insulin started before stopping the VRIII. In 40% of patients, blood glucose levels were not maintained between 6-12 mmol/L. Furthermore, in 13% of patients, blood glucose was not monitored hourly. Conclusion This audit showed a good compliance with daily electrolytes measurement, early referral to diabetic team as well as starting the VRIII with dextrose. It is concerning however that integral measures such as ruling out DKA, not prescribing the correct fluid, not checking blood glucose levels and lowering the incidence of hypoglycaemia were not always present. Overall, this audit has identified areas required for improvement to optimise our compliance with VRIII protocol against local and national guidelines. We hope this can be improved via spreading greater awareness of the VRIII protocol, to promote early recognition of DKA and ensure safety checks occur when applying the VRIII protocol. References George, S., 2022. JBDS-IP The use of Variable Rate Intravenous Insulin Infusion (VRIII) in medical patients. Joint British Diabetes Society. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

ODP628 Quality Improvement Project (QIP) On Management Of Diabetic Ketoacidosis (DKA) In Adults In A District General Hospital.

Abstract Aim A Quality Improvement Project was conducted to assess if Bedford Hospital NHS Foundation Trust was meeting current Trust guidelines for the diagnosis and management of diabetic ketoacidosis (DKA) in adult patients. Method Retrospective data was collected from adult patients admitted with a diagnosis of DKA from January 2020 to December 2020. Data was collected for five key standards based on Trust guidelines: (1) Correct diagnosis of DKA, (2) Correct prescription of Intravenous (IV) fluids and potassium chloride (KCL) replacement, (3) Switching from Fixed Rate Intravenous Insulin Infusion (FRIII) to Variable Rate Intravenous Insulin Infusion (VRIII) following resolution of DKA, (4) The prescription of long-acting insulin during FRIII/VRIII and (5) Appropriate biochemical monitoring via regular venous blood gases (VBGs). Following data analysis, an intervention phase (with distribution of 'DKA diagnosis and management' posters, DKA teaching sessions and email updates on DKA management for medical doctors) was implemented. The cycle was repeated a further two times, with the most recent cycle based on patients admitted between August to November 2021. Results The first cycle consisted of 25 patients. Results showed a 72% adherence to Standard 1, a 64% adherence to Standard 3 and a 76% adherence to Standard 5. There was a notably low adherence to Trust guidelines for Standards 2 and 5, which were 32% and 12% respectively. After the intervention phases described earlier, results from the final cycle of 20 patients admitted between August to November 2021 showed significant improvement in standards 1,3 and 4 with 90%, 100% and 100% adherence to Trust guidelines respectively. Although there was a slight improvement in biochemical monitoring of patients with regular VBGs (20% adherence in the final cycle versus 12% in the first cycle), the correct prescription of IV fluids and KCL replacement remained low (17% adherence in the final cycle versus 32%). Conclusion Awareness and diagnosis of DKA remains high at Bedford Hospital, however there are issues regarding the ongoing management of DKA patients. In particular, the correct prescription of IV fluids with KCL replacement, and regular biochemical monitoring. There is still a lack of awareness as to the appropriate rate of IV fluid resuscitation, and the correct monitoring and replacement of potassium, as well as pH. Recommended changes to improve DKA management are to expand teaching sessions to include Emergency Department (ED) doctors, as well as ED and medical nursing staff, to improve awareness of the correct management and diagnosis of DKA. Further emphasis will be placed on keeping a paper copy of the Trust Adult DKA management protocol in the patients’ notes. Presentation: No date and time listed

A Neonatal Intravenous Monitor Prototype

An intravenous (IV) infusion monitoring system prototype H2neO has been developed for low drip rates (25–400 drops/hr) using a macrodrip infusion set (gtt/drop factor of 20 drops/ml), corresponding to low IV infusion rates (1–20 mL/hr). We demonstrate H2neO as an accurate, low-cost, gravity-based solution that can be used in low-resourced settings for neonates. H2neO uses an infrared emitter, detector, interface circuit, and signal processor implemented on an Arduino-based microcontroller to detect drops in a standard macrodrip infusion system. The infrared signal was preprocessed using a median filter to establish the baseline (no drop) condition and an 8.5% threshold to determine the initial presence of a drop in the IV drip chamber. Using signal preprocessing alone, the monitoring system underestimated the drip rate and flow rate by a maximum error of 1.33% and overestimated it with a maximum error of 0.91%. Using a <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">k</i> -means approach to classify drops into “normal” and “noisy” clusters and then considering drip rates estimated from only the “normal” cluster, underestimation errors improved at all infusion rates tested while overestimation errors improved at half of the infusion rates tested. The average detection error over 1–20 mL/h infusion rates was +/- 0.5% compared to +/- 1% for commercially available monitors and +1.8% for recent results reported in the literature. This approach, based on both signal preprocessing and analyzing the shape of each drop, is promising for implementation on a standalone, microcontroller-based drip-based IV infusion monitoring system for neonates and other populations, including adults.

Real-world evaluation of glucose-lowering therapies and the use of weight-adjusted variable rate intravenous insulin infusion in the management of hyperglycaemia in patients with acute coronary syndrome (REGULATE-ACS)

IntroductionAdmission hyperglycaemia in acute coronary syndromes (ACS) is a strong independent predictor of adverse clinical outcomes post-ACS. We examined the safety, efficacy, and feasibility of a modified, weight-adjusted variable rate intravenous insulin infusion (VRIII) and evaluated current practice of prescribing novel cardio-protective glucose-lowering therapies in patients presenting with acute hyperglycaemia across the ACS spectrum. MethodsREGULATE-ACS was an observational single-centre study of consecutive patients admitted with acute hyperglycaemia post-ACS between 2020 and 2021. Following updated local guidance on a modified VRIII, we evaluated its safety and efficacy in glycaemic control, cardio-metabolic complications including hypoglycaemia (blood glucose <3 mmol/L) and 30-day mortality. We also determined the prescription of glucose-lowering therapies pre-discharge. ResultsOut of 107 patients, mean age was 64.9 ± 12.2 years, 82% had known diabetes, and 15% newly diagnosed diabetes. 86.9% (n = 93) had an admission glucose ≥11 mmol/L. In patients treated with VRIII (n = 63/93, 67.7%), glucose improved from 17.5 to 9.0 mmol/L (IQR 7.1–12.1), which was 3 mmol/L lower (p = 0.03) than in patients not treated with VRIII (n = 30/93, 32.3%) where median glucose reduced from 12.6 to 12 mmol/L (IQR 8.6–13.9). No significant hypoglycaemia, arrhythmia or worsening pulmonary oedema associated with VRIII was found. Novel glucose-lowering therapies were initiated in 20/71 (28.2%) and 3/15 (20.0%) of patients with prior and newly diagnosed diabetes, respectively. ConclusionThis real-world analysis provides further support of efficacy, safety, and feasibility of a modified, weight-adjusted VRIII in managing acute hyperglycaemia in ACS. Despite established cardio-protective benefits of novel glucose-lowering therapies, <1/3 of eligible patients received such agents pre-discharge, demanding further research and awareness.

Gluclas: A software for computer-aided modulation of glucose infusion in glucose clamp experiments

Background and ObjectiveThe glucose clamp (GC) is an experimental technique for assessing several aspects of glucose metabolism. In these experiments, investigators face the non-trivial challenge of accurately adjusting the rate of intravenous glucose infusion to drive subjects’ blood glucose (BG) concentration towards a desired plateau level. In this work we present Gluclas, an open-source software to support researchers in the modulation of glucose infusion rate (GIR) during GC experiments. MethodsGluclas uses a proportional-integrative-derivative controller to provide GIR suggestions based on BG measurements. The controller embeds an anti-wind-up scheme to account for actuator physical limits and suitable corrections of control action to accommodate for possible sampling jitter due to manual measurement and actuation. The software also provides a graphic user interface to increase its usability. A preliminary validation of the controller is performed for different clamp scenarios (hyperglycemic, euglycemic, hypoglycemic) on a simulator of glucose metabolism in healthy subjects, which also includes models of measurement error and sampling delay for increased realism. In silico trials are performed on 50 virtual subjects. We also report the results of the first in-vivo application of the software in three subjects undergoing a hypoglycemic clamp. ResultsIn silico, during the plateau period, the coefficient of variation (CV) is in median below 5% for every protocol, with 5% being considered the threshold for sufficient quality. In terms of median [5th percentile, 95th percentile], average BG level during the plateau period is 12.18 [11.58 - 12.53] mmol/l in the hyperglycemic clamp (target: 12.4 mmol/), 4.92 [4.51 – 5.14] mmol/l in the euglycemic clamp (target: 5.5 mmol/) and 2.38 [2.33 – 2.64] in the hypoglycemic clamp (target: 2.5 mmol/). Results in vivo are consistent with those obtained in silico during the plateau period: average BG levels are between 2.56 and 2.68 mmol/l (target: 2.5 mmol/l); CV is below 5% for all three experiments. ConclusionsGluclas offered satisfactory control for tested GC protocols. Although its safety and efficacy need to be further validated in vivo, this preliminary validation suggest that Gluclas offers a reliable and non-expensive solution for reducing investigator bias and improving the quality of GC experiments.

Trends in rates of complications and adverse outcomes in diabetic ketoacidosis following changes to the Joint British Diabetes Societies' management guidelines

Serious complications of diabetes-related ketoacidosis (DKA) and its management with fixed rate intravenous insulin infusion (FRIII) include hypoglycaemia, hyperkalaemia and hypokalaemia. Revised Joint British Diabetes Societies for Inpatient Care (JBDS) guidelines in June 2021 recommend a reduced

Hypoglycaemia associated with variable rate intravenous insulin infusion and concurrent administration of balanced electrolyte solution: A single hospital experience

Hypoglycaemia associated with variable rate intravenous insulin infusion and concurrent administration of balanced electrolyte solution: A single hospital experience

Modelling the use of variable rate intravenous insulin infusions in hospitals by comparing Work as Done with Work as Imagined.

Variable rate intravenous insulin infusions (VRIIIs) are widely used to treat elevated blood glucose (BG) in adult inpatients who are severely ill and/or will miss more than one meal. VRIIIs can cause serious harm to the patient if used incorrectly. Recent safety initiatives have embraced the Resilient Health Care (RHC) approach to safety by understanding how VRIIIs are expected to be used (Work as Imagined, 'WAI') and how it is actually used in everyday clinical care (Work as Done, 'WAD'). To systematically compare WAI and WAD and analyse adaptations used in situ to develop a model explaining VRIII use. A qualitative observational study video-recording healthcare practitioners using VRIII. The video data were transcribed and inductively coded to develop a hierarchical task analysis (HTA) to represent WAD. This HTA was compared with a HTA previously developed to represent WAI. The comparison output was used to develop a model of VRIII use. While many of the tasks in the WAD HTA were aligned with the tasks presented in the WAI HTA, some important ones did not. When misalignment was observed, permanent adaptations (e.g. signing as a witness for a changed VRIII's rate without independently verifying whether the new rate was appropriate) and temporary workarounds (e.g. not administering intermediate-acting insulin analogues although the intermediate-acting insulin prescription was not suspended) were the most frequently observed adaptations. The comparison between WAI and WAD assisted in developing a model of VRIII use. The model shed light on strategies used to imagine everyday work (e.g. incident reports, VRIII guidelines), how everyday work was accomplished (e.g. context-dependent adaptations) and how these contributed to both successful and unsuccessful outcomes. This study provided in-depth understanding of the tasks required while using VRIIIs, and responses and adaptations needed to achieve safer care in a complex environment.