Variable Rate Intravenous Insulin Infusion Research Articles

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...

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

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.

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

Management of Glucocorticoid-Induced Hyperglycemia.

Glucocorticoids are potent immunosuppressive and anti-inflammatory drugs used for various systemic and localized conditions. The use of glucocorticoids needs to be weighed against their adverse effect of aggravating hyperglycemia in persons with diabetes mellitus, unmask undiagnosed diabetes mellitus, or precipitate glucocorticoid-induced diabetes mellitus appearance. Hyperglycemia is associated with poor clinical outcomes, including infection, disability after hospital discharge, prolonged hospital stay, and death. Furthermore, clear guidelines for managing glucocorticoid-induced hyperglycemia are lacking. Therefore, this consensus document aims to develop guidance on the management of glucocorticoid-induced hyperglycemia. Twenty expert endocrinologists, in a virtual meeting, discussed the evidence and practical experience of real-life management of glucocorticoid-induced hyperglycemia. The expert group concluded that we should be proactive in terms of diagnosis, management, and post-steroid care. Since every patient has different severity of underlying disease, clinical stratification would help understand patient profiles and determine the treatment course. Patients at home with pre-existing diabetes who are already on oral or injectable therapy can continue the same as long as they are clinically stable and eating adequately. However, depending on the degree of hyperglycemia, modification of doses may be required. Initiating basal bolus with correction regimen is recommended for patients in non-intensive care unit settings. For patients in intensive care unit, variable rate intravenous insulin infusion could be temporarily used, but under supervision of diabetes inpatient team, and patients can be transitioned to subcutaneous insulin once stable baseline assessment and continual evaluation are crucial for day-to-day decisions concerning insulin doses. Glycemic variability should be carefully monitored, and interventions to treat patients should also aim at achieving and maintaining euglycemia. Rational use of glucose-lowering drugs is recommended and treatment regimen should ensure maximum safety for both patient and provider. Glucovigilance is required as the steroids taper during transition, and insulin dosage should be reduced subsequently. Increased clinical and economic burden resulting from corticosteroid-related adverse events highlights the need for effective management. Therefore, these recommendations would help successfully manage GC-induced hyperglycemia and judiciously allocate resources.

Using video reflexive ethnography to explore the use of variable rate intravenous insulin infusions

BackgroundThe use of variable rate intravenous insulin infusion (VRIII) is a complex process that has consistently been implicated in reports of error and consequent harm. Investment in patient safety has focused mainly on learning from errors, though this has yet to be proved to reduce error rates. The Resilient Health Care approach advocates learning from everyday practices. Video reflexive ethnography (VRE) is an innovative methodology used to capture everyday practices, reflect on and thereby improve these. This study set out to explore the use of VRIIIs by utilising the VRE methodology.MethodsThis study was conducted in a Vascular Surgery Unit. VRE methodology was used to collect qualitative data that involved videoing healthcare practitioners caring for patients treated with VRIII and discussing the resulting clips with participants in reflexive meetings. Transcripts of these were subjected to thematic analysis. Quantitative data (e.g. blood glucose measurements) were collected from electronic patient records in order to contextualise the outcomes of the video-observed tasks.ResultsThe use of VRE in conjunction with quantitative data revealed that context-dependent adaptations (seeking verbal orders to treat hypoglycaemia) and standardised practices (using VRIII guidelines) were strategies used in everyday work. Reflexive meetings highlighted the challenges faced while using VRIII, which were mainly related to lack of clinical knowledge, e.g. prescribing/continuing long-acting insulin analogues alongside the VRIII, and problems with organisational infrastructure, i.e. the wireless blood glucose meter results sometimes not updating on the electronic system. Reflexive meetings also enabled participants to share the meanings of the reality surrounding them and encouraged them to suggest solutions tailored to their work, for example face-to-face, VRIII-focused training.ConclusionsVRE deepened understanding of VRIII by shedding light on its essential tasks and the challenges and adaptations entailed by its use. Future research might focus on collecting data across various units and hospitals to develop a full picture of the use of VRIIIs.

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)

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)

A service evaluation of the impact of adoption of JBDS guidelines for the management of glucose during labour and birth in women with diabetes

Aims: The aim of this retrospective observational study was to report on the impact of adopting the Joint British Diabetes Society for Inpatients (JBDS-IP) guidelines on the achievement of targets recommended by the National Institute for Health and Care Excellence (NICE) and the maternal and neonatal outcomes.Methods: We analysed case records of pregnant women with diabetes who delivered in the period between November 2017 and October 2018 from our data base ‘Euroking’ (Wellbeing Software Ltd, Mansfield). Data were collected in relation to the availability of a dedicated prescription chart in the notes, capillary blood glucose (CBG) monitoring, use of variable rate intravenous insulin infusion (VRIII), maintenance of CBG targets within 4.0–7.0 mmol/L, maternal hypoglycaemia during labour when on VRIII and neonatal hypoglycaemia.Results: Sixty women with diabetes in our database delivered during this period. Thirty-six (60%) were monitored with hourly CBG monitoring and 30 (50%) achieved CBG levels within the NICE recommended target range. Only five women (8.3%) were started on VRIII. There was no maternal hypoglycaemia in the VRIII group. One baby (1.7%) developed mild neonatal hypoglycaemia.Conclusion: Adoption of JBDS guidelines contributed to 60% of women with diabetes receiving complete CBG monitoring, of whom 70% achieved the NICE recommended target of 4.0–7.0 mmol/L during labour and birth. Repeat CBG measurements before starting VRIII, strict adherence to clear JBDS guidelines and protocols, daily review by the diabetes team during the working week and appropriate use of VRIII was associated with good maternal and neonatal outcomes.

Safe use of variable rate intravenous insulin infusion: a trust wide audit

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Low rates of hyponatraemia in patients with diabetes treated with variable rate intravenous insulin infusion (VRIII)

Aims: To investigate the risk of developing hyponatraemia or hypoglycaemia in individuals requiring variable rate intravenous insulin infusion (VRIII) using a protocol of variable rate insulin infused with 10% dextrose and 20 mmol/L potassium chloride.Methods: A prospective study was performed of 50 consecutive medical and surgical patients requiring VRIII. Sodium, potassium and glucose were measured before, during and after VRIII use.Results: Medical patients had significantly higher glucose values prior to VRIII. Glucose fell significantly in this group. Sodium concentrations were marginally low prior to commencing VRIII in seven medical and six surgical patients. One patient had significant hyponatraemia prior to VRIII (114 mmol/L) and this improved to 118 mmol/L during the VRIII. Overall there were no significant changes in sodium or potassium during VRIII. There were no significant differences in sodium or potassium between the two groups at any point.Conclusion: There was a low incidence of clinically significant hyponatraemia and hypokalaemia associated with a commonly used intravenous insulin regimen that combines insulin with 10% dextrose.

Managing hyperglycaemia during antenatal steroid administration, labour and birth in pregnant women with diabetes.

Optimal glycaemic control before and during pregnancy improves both maternal and fetal outcomes. This article summarizes the recently published guidelines on the management of glycaemic control in pregnant women with diabetes on obstetric wards and delivery units produced by the Joint British Diabetes Societies for Inpatient Care and available in full at www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. Hyperglycaemia following steroid administration can be managed by variable rate intravenous insulin infusion (VRIII) or continuous subcutaneous insulin infusion (CSII) in women who are willing and able to safely self-manage insulin dose adjustment. All women with diabetes should have capillary blood glucose (CBG) measured hourly once they are in established labour. Those who are found to be higher than 7mmol/l on two consecutive occasions should be started on VRIII. If general anaesthesia is used, CBG should be monitored every 30min in the theatre. Both the VRIII and CSII rate should be reduced by at least 50% once the placenta is delivered. The insulin dose needed after delivery in insulin-treated Type 2 and Type 1 diabetes is usually 25% less than the doses needed at the end of first trimester. Additional snacks may be needed after delivery especially if breastfeeding. Stop all anti-diabetes medications after delivery in gestational diabetes. Continue to monitor CBG before and 1h after meals for up to 24h after delivery to pick up any pre-existing diabetes or new-onset diabetes in pregnancy. Women with Type 2 diabetes on oral treatment can continue to take metformin after birth.

Improving outcomes for pregnant women with diabetes

Improving outcomes for pregnant women with diabetes

The feasibility and impact of implementing NICE guidance on diabetes control during delivery

Aims: The aim of this study was to report on the practicality, feasibility and impact of implementing the National Institute for Health and Care Excellence (NICE) guidelines for the control of diabetes in women during labour and birth. Methods: We analysed case records of pregnant women with diabetes who delivered in the period between July 2014 and June 2015. The data were collected in relation to the availability of a plan in the notes, capillary blood glucose (CBG) monitoring, use of variable rate intravenous insulin infusion (VRIII), maintenance of CBG targets within 4–7 mmol/L, maternal hypoglycaemia during labour and neonatal hypoglycaemia. Results: Fifty-one women with diabetes delivered during this period. Only 45% of women were monitored by complete hourly CBGs until delivery. 27.4% of women had CBG ≥7 mmol/L but only 17.6% were started on VRIII. The VRIII group had a 22.2% incidence of minor maternal hypoglycaemia. Neonatal hypoglycaemia occurred in 47% of the babies. Conclusion: A CBG target of 4–7 mmol/L during labour and initiation of VRIII when levels are above this target in pregnant women with diabetes is difficult to achieve and is associated with some maternal hypoglycaemia. Repeat CBG measurements within half an hour and strict adherence to clear guidelines and protocols supported by more education and adequate staffing may improve results.

The Variable Rate Intravenous Insulin Infusion in Clinical Practice 2015: an audit against the new JBDS guidance

Background: Variable rate intravenous insulin infusion (VRIII) is an established method to achieve normoglycaemia in unwell or fasting patients. The Joint British Diabetes Societies (JBDS) released new guidance for the use of VRIII in medical inpatients in October 2014. This specifies the appropriate clinical circumstances in which a VRIII should be used and how it should be initiated, managed and discontinued safely. Methods: We developed an audit tool based on the guidelines and audited the current practice at the Royal Sussex County Hospital, Brighton, prior to the roll out of the new standards. We have audited 50 patients on VRIII under non-specialist medical and surgical care. Results: Several parameters were checked. VRIII prescription was signed appropriately as per the guidance in 98% of patients. Oral hypoglycaemic medications were omitted in 83%. Short-acting and mix insulins were omitted only in 88%. Long-acting insulin was administered only in 77% of the patients. Blood glucose was tested 1–2 hourly in 90% of patients. All patients with hypoglycaemic episodes were treated as per protocol. On the occasions where VRIII was discontinued, it was reinitiated within 20 min as per the guidelines only in 36% of cases. In patients with persistent hyperglycaemia, the rate was increased in 80% of cases. Discussion: Clinical practice surrounding the use, appropriate management and monitoring parameters appeared to fall short of the standards suggested by the latest JBDS guidance. Our audit outcome was to prepare a protocol for the trust summarising the indications for VRIII, target capillary blood glucose, how and when to stop VRIII for patients with diabetes and also a prompt to prescribe basal insulin for patients with diabetes and when a referral should be made to the diabetes inpatient team. Introducing teaching sessions to all the professionals and raising the awareness through a hospital communication programme on the wards would also help to theoretically improve the results. Conclusions: The majority of patients on VRIII are managed by non-diabetic teams and practice may vary from set guidance due to unfamiliarity and lack of diabetes specific knowledge. The appropriate use of VRIII needs to be tackled through remedial education, introduction of the new JBDS guidance and allied to improvements in systems and processes.

Peri-Operative Management of the Surgical Patient With Diabetes: A Guideline Summary

Background: Diabetes significantly increases the risk of morbidity and mortality associated with surgery. These guidelines target anesthetists, providing guidelines for management of the diabetic patients in the pre-operative, peri-operative and post-operative periods. Methods: The following paper summarizes the Association of Anaesthetists of Great Britain and Ireland clinical guidelines on peri-operative management of the surgical patients with diabetes 2015. Results: It is recommended that where possible all diabetic patients achieve an HbA1c less than 69 mmol/mol (8.5%) prior to surgery. On the day of surgery, fasting periods should be limited to one meal and if this is not possible, a variable-rate intravenous insulin infusion should be started. Intra-operatively blood glucose should remain between 6 and 10 mmol/L. Post-operatively, the key to resuming normal diabetic management is through returning to an normal diet as soon as possible. Conclusions: The aim of management of a diabetic patient during the operative period is to maintain normal blood glucose levels (6 - 10 mmol/L). This is achieved through careful pre-operative planning, appropriate management of blood glucose levels and fluid balance intra-operatively and a smooth transition to resume the patients normal diabetic management. J Endocrinol Metab. 2016;6(3):97-99 doi: http://dx.doi.org/10.14740/jem350w

An evaluation of the safety and efficacy of a variable rate intravenous insulin infusion in the management of hyperglycaemia in acute coronary syndrome: experience of the TITAN-ACS

Aim: To assess the safety and efficacy of a variable rate intravenous insulin infusion to lower blood glucose (BG) in patients presenting with acute coronary syndrome and hyperglycaemia. Methods: We evaluated the response over 24 hours of a variable rate insulin infusion with 5% dextrose and potassium chloride (40 mEq/L), to control hyperglycaemia in 776 patients with an admission BG ≥10 mmol/L in 36 UK hospitals. Patients had either ST segment elevation or non-ST segment elevation myocardial infarction and the study included both patients with or without a diagnosis of diabetes. We measured blood glucose, initially hourly, and serum potassium at admission, at 24 hours and at the time of major arrhythmias. We measured survival to 30 days. Results: Median admission BG was 14.3 mmol/L (interquartile range 11.7, 18.1). At 6 hours BG was 8.0 mmol/L (6.2, 10.8), and at 20-24 hours it was 8.3 mmol/L (6.5, 11.0). Hypokalaemia due to the infusion was not observed. Hypoglycaemia (BG 10.8 mmol/L at 6 hours; adjusted odds ratio 1.82, p=0.011. Conclusions: This insulin regimen was safe and effective with low rates of hypoglycaemia and no excess mortality in the hypoglycaemic subgroup. Further adjustments are required for those in the lowest and highest quartiles of weight.

A guideline for the use of variable rate intravenous insulin infusion (VRIII) in medical inpatients

A variable rate intravenous insulin infusion (VRIII) is used commonly to achieve normoglycaemia in hospital inpatients. Most acute trusts in the UK have VRIII guidelines, but there is wide variation in the indications for its use, in rates of infusion, and in duration of use. This heterogeneity increases the risk of errors which can potentially lead to significant morbidity and mortality and also hinders study of the efficacy, optimisation and safety of VRIII. Thus, VRIII is often used when not indicated, for too long, and with inappropriate transfer to other glucose lowering medication. This article summarises the key recommendations in a recent guideline produced by the Joint British Diabetes Societies for Inpatient Care on the use of VRIII in ‘medical’ inpatients. The guideline is designed to be a practical guide to support the safe and effective use of VRIII by any healthcare professional who manages ‘medical’ inpatients with hyperglycaemia. Use of the guideline will help to harmonise the use of VRIII, with added benefits of facilitating collection of outcomes data from at multiple sites and allowing continual refinement in the therapeutic use of VRIII.

A guideline for the use of variable rate intravenous insulin infusion in medical inpatients.

The present paper summarizes the key recommendations in a recent publication produced by the Joint British Diabetes Societies for Inpatient Care on the use of variable rate i.v. insulin infusion in 'medical' inpatients. The full guideline is available at http://www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_VRIII.pdf and is designed to be a practical guide that can used by any healthcare professional who manages medical inpatients with hyperglycaemia. Its main aim is to allow variable rate i.v. insulin infusion to be used safely, effectively and efficiently for this specific group of inpatients.