Use Of Intravenous Insulin Research Articles

7834 Case Series using intravenous insulin to treat Severe Hypertriglyceridemia

Abstract Disclosure: F. Khan: None. M. Eltayeb: None. J. Ryan: None. M. Murphy: None. Background: Very severe hypertriglyceridemia (>22.4 mmol/L) is associated with high risk of acute pancreatitis and atherosclerotic cardiac events. Conventional treatments tend not to yield immediate results. There is a lack of clinical guidelines for acute very severe HTG; and potential therapeutic options such as insulin, heparin, plasmapheresis, and octreotide have been tested and shown to be effective. We present a series of four cases where intravenous insulin was useful as an emergency treatment for severe HTG. Clinical Cases: Case 1: 48-year-old male was admitted with very severe hypertriglyceridemia with triglycerides levels of 45.3mmol/L (reference range: 0-1.7 mmol/L), new diagnosis Diabetes Mellitus with ketosis and was started on intravenous insulin. After three days of intravenous insulin, triglyceride levels reduced by 47.93%. Case 2: 28-year-old male, admitted with acute pancreatitis secondary to very severe hypertriglyceridemia (66.9mmol/L), a new diagnosis of Diabetes Mellitus with ketosis, was commenced on intravenous insulin. There was a reduction in triglycerides by 77.5% in 3 days and 96.6% in 9 days with intravenous insulin treatment. Case 3: 29-year-old female, admitted with new diagnosis Diabetes Mellitus with ketosis and very severe hypertriglyceridemia (50.67mmol/L) was treated with intravenous insulin. Total triglyceride reduction was 65.8% in 48 hours. Case 4: 27-year-old female, admitted Diabetic Ketoacidosis (DKA), new diagnosis Diabetes Mellitus, very severe hypertriglyceridemia (24.3mmol/L) was treated with intravenous insulin. 65.8% reduction in triglycerides was seen in after 72 hours. Conclusion: These cases show the efficacy of insulin infusion with encouraging results, especially when plasmapheresis is not readily available however larger studies including a randomized controlled trials is needed to confirm the efficacy and safety for the use of intravenous insulin to establish a universal and effective treatment for this severe life-threatening metabolic disorder. Reference: Simha V. Management of hypertriglyceridemia BMJ 2020; 371 :m3109 doi:10.1136/bmj.m3109 Presentation: 6/3/2024

Triglyceride Clearance in Hypertriglyceridemic Pancreatitis: Time Course and Its Implications for Management

ObjectiveTo characterize the time course of triglyceride (Tg) lowering in hypertriglyceridemic (HTg) pancreatitis according to the initial Tg values, causes, and interventions. MethodsPatients hospitalized from October 2013 through December of 2018 with a diagnosis of pancreatitis associated with HTg (Tg level, ≥500 mg/dL), in the absence of other causes, were identified by medical record review. Tg lowering was retrospectively assessed for differences in relation to the initial Tg values, use of intravenous insulin, ethanol-associated versus nonethanol-associated causes, and time to Tg values of <500 versus <1000 mg/dL. ResultsSixty-six cases were identified, and 45 had multiple measurements for time-course evaluation. Those with initial Tg values of <4000 mg/dL achieved Tg levels of <1000 mg/dL in <3 days, whereas 18.8% with higher values took 5–9 days. Insulin therapy was associated with a longer duration of HTg, whereas ethanol was associated with a shorter duration. Tg clearance in ethanol-associated HTg appeared independent of insulin treatment. Time to Tg levels of <500 mg/dL versus <1000 mg/dL was significantly longer when the initial Tg levels were >2000 mg/dL. ConclusionA threshold of 4000 mg/dL for the initial Tg levels in HTg pancreatitis appears to separate patients who are likely to achieve Tg levels of <1000 mg/dL in <3 versus >3 days, independent of cause or treatment. Insulin therapy is appropriate for patients with hyperglycemia but appears unnecessary for those with isolated ethanol-associated HTg. A threshold Tg level of <1000 mg/dL appears more practical than that of <500 mg/dL for resuming nutritional intake.

Clinical impact after implementing an insulin protocol involving a switch to insulin glargine 300 U/ml as basal insulin for inpatient glycaemic control: A retrospective single-centre study

AimsTo evaluate the benefit and safety of a switch in the basal insulin protocol to glargine 300 U/ml (Gla-300) on inpatients' overall dysglycemic events. Efficacy and safety data on insulin Gla-300 in the inpatient setting are limited. MethodsRetrospective observational study conducted on 7455 patients admitted to acute care (n = 5414) or geriatric and social healthcare (n = 2041) units of the Regional Hospital of Amposta (Spain) between January 2017 and December 2020 who received basal insulin during hospitalization. Hypo- and hyperglycaemic events were indirectly assessed through hospital pharmacy usage of intravenous glucose and vials of rapid-acting intravenous insulin for 27 months after the switch, and the impact on overall dysglycemic events was analysed. ResultsAfter protocol implementation, patients were mostly treated with Gla-300 (83.06 % in acute care; and 83.44 % in geriatric and social healthcare), and presented a significant decrease in the use of intravenous insulin (−60.80 %, P = 0.005) and glucose (−62.13 %, P < 0.001), which translated into a significantly reduced overall dysglycemic events (−62.25 %, P < 0.001), with a good safety and tolerability profile. ConclusionsOverall inpatient dysglycemic events were improved upon the introduction of the new insulin protocol, which calls for the use of Gla-300 as one of the choices of basal insulin for inpatient care.

A Comparison of Variable Versus Fixed Insulin Infusion Rate on Resolution of Diabetic Ketoacidosis.

Diabetic ketoacidosis (DKA) is a well-known, potentially fatal complication of diabetes. The American Diabetes Association hyperglycemic crises guidelines suggest the use of intravenous insulin in patients presenting with DKA, along with a recommended rate of glucose reduction of 50-75 mg/dL/h. However, no specific guidance is provided regarding how to best achieve this rate of glucose decline. Is there a difference in time to DKA resolution between a variable intravenous insulin infusion strategy and a fixed infusion strategy in the absence of an institutional protocol? Single-center, retrospective cohort study of DKA patient encounters in 2018. Insulin infusion strategy was considered to be variable if the infusion rate changed within the first 8 hours of therapy or was considered fixed if the rate remained unchanged for the same period. The primary outcome was time to resolution of DKA. Secondary outcomes were hospital length of stay, intensive care unit length of stay, hypoglycemia, mortality, and DKA recurrence. The median time to resolution of DKA was 9.3 hours in the variable infusion group compared with 7.8 hours in the fixed infusion group (HR, 0.82; 95% CI, 0.43-1.5, P = 0.5360). Severe hypoglycemia was observed in 13% of patients in the variable infusion group and in 50% of patients in the fixed infusion group ( P = 0.006). In this analysis, insulin infusion strategy (variable vs. fixed) was not associated with a significant difference in the time to resolution of DKA in the absence of an institutional protocol. The fixed infusion strategy was associated with a higher incidence of severe hypoglycemia.

Treatment of Hypertriglyceridemia with Aggressive Continuous Intravenous Insulin.

Severe hypertriglyceridemia requiring hospitalization for intravenous insulin to lower triglycerides and prevent complications of pancreatitis is becoming an increasing problem with little consensus treatment evidence. This is the largest case series to date to evaluate this under-studied area of literature. The objective of this study was to determine the average time to triglyceride lowering less than 500 mg/dL. This was a retrospective case series from March 2018 to March 2020 at a single rural academic medical center. 23 patients were included who received weight-based intravenous insulin at 0.1 units/kg/hour through a hypertriglyceridemia management order-set over a two-year period. The median triglyceride level at initiation of the insulin infusion was 3759 mg/dL with an interquartile range of 5555. The median time to a triglyceride level less than 1000 mg/dL and 500 mg/dL was 45 hours (1.8 days) and 75 hours (3.1 days) respectively. Patients remained on intravenous insulin for a median of 60 hours (2.5 days). In this largest case series to date evaluating the use of intravenous insulin for the treatment of hypertriglyceridemia, a weight-based insulin infusion demonstrated reduction of triglyceride levels to less than 1000 mg/dL in approximately 2 days and less than 500 mg/dL in approximately 3 days.

Impact of short term oral steroid use for intravenous contrast media hypersensitivity prophylaxis in diabetic patients undergoing nonemergent coronary angiography or interventions.

Oral steroids are routinely administered in the United States for prophylaxis of iodinated contrast media hypersensitivity (ICMH). We studied the impact of short-term steroid use in diabetic patients with ICMH undergoing nonemergent coronary angiography. We retrospectively analyzed records of diabetic patients with and without ICMH who underwent nonemergent coronary angiography at our center. Primary study endpoint was 30-day major adverse cardiac events (MACE) and secondary endpoints were pre- and postprocedure fasting blood glucose (FBG), highest in hospital blood glucose, pre- and postprocedure systolic blood pressure (SBP), and use of intravenous insulin and antihypertensive medications. A total of 88 diabetics with ICMH (study group) and 76 diabetics without ICMH (control group) undergoing angiography were enrolled. Demographics and hemoglobin A1c values were similar in both groups. Preprocedural FBG was significantly higher in the study group. The study group had significantly higher post angiography FBG (239.93 + 96.88 mg/dl vs. 156.6 + 59.88 mg/dl) and greater use of intravenous (IV) insulin (67.27% vs. 32.43%). Further, those who received steroids had significantly higher systolic SBP postprocedure (146.16 + 25.35 mmHg vs. 130.8 + 21.59 mmHg), a higher incidence of severe hypertension and use of IV antihypertensive medications (80.95% vs. 19.05%) periprocedurally. There were no differences in 30-day MACE between groups. Short-term steroid use for ICMH results in a significant increase in surrogate markers for adverse clinical events after coronary procedures. Study findings highlight the need for better periprocedural management of these patients and to limit steroid prophylaxis to those with only true ICMH.

European Stroke Organisation (ESO) guidelines on glycaemia management in acute stroke.

Hyperglycaemia is a frequent complication in acute stroke that has been shown to be independently associated with larger infarct size, haematoma growth, poor clinical outcome and mortality. This Guideline Document presents the European Stroke Organisation (ESO) Guidelines for the management of blood glucose levels in patients with acute ischemic or haemorrhagic stroke. The working group identified related questions and developed its recommendations based on evidence from randomised controlled trials following the standard operating procedure of the ESO. This Guideline Document was reviewed and approved by the European Stroke Organisation Guidelines Committee and the European Stroke Organisation Executive Committee. We found low-quality evidence from clinical trials in ischemic or haemorrhagic stroke exploring the use of intravenous insulin aimed to achieve a tight glycaemic control with different glucose level targets and several other sources of heterogeneity. None of these trials neither the meta-analysis of them have demonstrated any significant benefit of tight glycaemic control with intravenous insulin in acute ischemic or haemorrhagic stroke patients on functional outcome or in survival and they have shown an increased risk for hypoglycaemia. We suggest against the routine use of tight glycaemic control with intravenous insulin as a means to improve outcomes. The currently available data about the management of glycaemia in patients with acute stroke are limited and the strengths of the recommendations are therefore weak. Nevertheless, this does not prevent that hyperglycaemia in acute stroke patients could be treated as any other hospitalised patient.

Del Nido cardioplegia in the setting of minimally invasive aortic valve surgery.

The purpose of this study is to report our experience with del Nido cardioplegia (DNC) in the setting of minimally invasive aortic valve surgery. Forty-six consecutive patients underwent minimally invasive aortic valve replacement (AVR) through a "J" ministernotomy: twenty-five patients received the DNC (Group 1) and 21 patients received standard blood cardioplegia (SBC) (Group 2). The rate of ventricular fibrillation at unclamping was significantly lower in the DNC group (12% vs 52%, p=0.004), as well as postoperative creatinine kinase-MB (CK-MB) values (11.4±5.2 vs 17.7±6.9 µg/L, p=0.004). There were no deaths, myocardial infarctions or major complications in either group. Less postoperative use of intravenous insulin (28% vs 81%, p<0.001) was registered in the DNC group. In conclusion, the DNC is easy to use and safe during minimally invasive AVR, providing a myocardial protection at least equivalent to our SBC, improved surgical efficiency, minimal cost and less blood glucose perturbations.

Intravenous Insulin Treatment in Acute Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Poststroke hyperglycemia has been associated with unfavorable outcome. Several trials investigated the use of intravenous insulin to control hyperglycemia in acute stroke. This meta-analysis summarizes all available evidence from randomized controlled trials in order to assess its efficacy and safety. We searched PubMed until 15/02/2013 for randomized clinical trials using the following search items: 'intravenous insulin' or 'hyperglycemia', and 'stroke'. Eligible studies had to be randomized controlled trials of intravenous insulin in hyperglycemic patients with acute stroke. Analysis was performed on intention-to-treat basis using the Peto fixed-effects method. The efficacy outcomes were mortality and favorable functional outcome. The safety outcomes were mortality, any hypoglycemia (symptomatic or asymptomatic), and symptomatic hypoglycemia. Among 462 potentially eligible articles, nine studies with 1491 patients were included in the meta-analysis. There was no statistically significant difference in mortality between patients who were treated with intravenous insulin and controls (odds ratio: 1.16, 95% confidence interval: 0.89-1.49). Similarly, the rate of favorable functional outcome was not statistically different (odds ratio: 1.01, 95% confidence interval: 0.81-1.26). The rates of any hypoglycemia (odds ratio: 8.19, 95% confidence interval: 5.60-11.98) and of symptomatic hypoglycemia (odds ratio: 6.15, 95% confidence interval: 1.88-20.15) were higher in patients treated with intravenous insulin. There was no heterogeneity across the included trials in any of the outcomes studied. This meta-analysis of randomized controlled trials does not support the use of intravenous insulin in hyperglycemic stroke patients to improve mortality or functional outcome. The risk of hypoglycemia is increased, however.

Glycemic control and diabetes management in hospitalized patients in Brazil

BackgroundThe importance of tight blood glucose control among outpatients with diabetes mellitus is well established, however, the management of diabetes in the hospital setting is generally considered secondary in importance. This study sought to assess glycemic control and diabetes management in adult patients admitted to hospitals in Brazil.MethodsA cross-sectional and nationwide survey was conducted from July 2010 to January 2012. Eligible cases were 18 years of age or older, had a diagnosis of diabetes and a hospitalization length of stay ≥72 hours. Socio-demographic information, hospitalization details, and data on diabetes diagnosis, management and treatment were collected for all patients by chart review. Information on all blood glucose (BG) readings for a maximum of 20 consecutive days of hospitalization was recorded for each patient.ResultsOverall, 2,399 patients were surveyed in 24 hospitals located in 13 cities from all five Brazilian regions. The prevalence of patients presenting hyperglycemic (BG >180 mg/dL) or hypoglycemic (BG <70 mg/dL) events was 89.4% and 30.9% in patients in general wards, and 88.2% and 27.7% in those in Intensive Care Units (ICUs), respectively. In addition, a BG measure >180 mg/dL was recorded in two-thirds of the patient-days. A high proportion of patients were treated with sliding-scale insulin regimen alone in the general wards (52.0%) and in the ICUs (69.2%), and only 35.7% and 3.9% received appropriate insulin therapy in general wards (basal + bolus insulin) and in ICUs (continuous IV insulin), respectively.ConclusionsInpatient glycemic control and diabetes management needs improvement. Opportunities to improve care in Brazilian hospitals include expanded use of intravenous insulin and subcutaneous basal-bolus insulin protocols, avoiding use of sliding-scale insulin alone, increased frequency of blood glucose monitoring, and institution wide quality improvement efforts targeting both physician and nursing behavior.

Obstacles to Optimal Management of Inpatient Hyperglycemia in Noncritically Ill Patients

Compelling evidence continues to evolve linking hyperglycemia in hospitalized patients with adverse clinical outcomes. In 2012, The Endocrine Society's clinical practice guidelines for management of hyperglycemia in non-critical care settings were published, and explicit blood glucose targets for noncritically ill patients were recommended. These matched those set by the American Diabetes Association (ADA) in the Standards of Medical Care in Diabetes–2012. Although there are more specific targets for achieving optimal glycemic control in critically ill and noncritically ill inpatients, implementing standardized processes to achieve these goals continues to remain a challenge. This article summarizes these obstacles and emphasizes the quality of care and safety issues (eg, hypoglycemia and insulin errors) that are associated with the management of hyperglycemia in hospitalized patients. The use of intravenous insulin via computerized or manual standardized protocols in critically ill patients has been shown to be effective in achieving glucose control; we focus on the barriers to the appropriate use of subcutaneous insulin in hospitalized patients with noncritical illness. We also elaborate on how to overcome most of these obstacles and the clinical inertia to treat hyperglycemia through focused education and surveillance, and then “re-education,” using a multidisciplinary, collaborative approach. Transition from intravenous insulin to subcutaneous insulin, and transition from an inpatient to an outpatient glycemic regimen at the time of discharge, are identified as aspects of management that require extra attention. We also emphasize the need for a multidisciplinary task force responsible for monitoring and enhancing glycemic control practices in the hospital on an ongoing basis.

The Effects of Intravenous Insulin in Sakel'S Hypoglycaemic Treatment

The use of intravenous insulin in Sakel's shock treatment as an alternative to intramuscular insulin was first reported by Ventriglia (1939), whose findings may be summarized as follows:(1) Hypoglycaemic symptoms appear more quickly than with intramuscular insulin, so that the pre-shock period is shortened.(2) The coma dose of insulin is reduced by 50 per cent. on an average, but may be reduced by considerably more.(3) In some cases the hypoglycaemic symptoms are more abrupt and violent.(4) There is a greater tendency to tonic-clonic spasms and convulsions generally.

A Year's Experience of Intravenous Insulin in the Hypoglycaemic Shock Treatment of Schizophrenia

In a preliminary report (Brit. Med. Journ.,2, 310, 1940), two modifications were introduced in Sakel's technique for the insulin treatment of schizophrenia, with the primary object of continuing the treatment under wartime conditions. The first and most important of these was concerned with the saving of sugar. This simple method, by which glucose is given intravenously and is followed by a drink of potato soup as soon as the patient is awake, has already been fully described by us. We discovered incidentally that this method effected a saving of insulin amounting to 46.6 per cent. in seven patients. Various critics have asked why other workers have not effected a saving by using intravenous insulin. Further, we have been asked what advantages are to be gained by giving insulin intravenously apart from this saving of the drug; whether intravenous insulin adds any dangers to the treatment, and whether it brings about a remission in schizophrenia comparable with intramuscular insulin. We have had more than a year's experience with the use of intravenous insulin, and this paper aims at describing our first year of this experience and answering the questions set out above. We may mention that in 24 additional patients treated, an average saving of 28.3 per cent. of insulin has been effected.