The rationale and management of hyperglycemia for in-patients with cardiovascular disease: time for change

Electronic Glycemic Management System Improved Glycemic Control and Reduced Complications in Patients With Diabetes Undergoing Coronary Artery Bypass Surgery: A Randomized Controlled Trial

BACKGROUND

In-hospital hyperglycemia poses significant risks for patients with diabetes mellitus undergoing coronary artery bypass graft (CABG) surgery. Electronic glycemic management systems (eGMSs) like InsulinAPP offer promise in standardizing and improving glycemic control (GC) in these settings. This study evaluated the efficacy of the InsulinAPP protocol in optimizing GC and reducing adverse outcomes post-CABG.

METHODS

This prospective, randomized, open-label study was conducted with 100 adult type 2 diabetes mellitus (T2DM) patients post-CABG surgery, who were randomized into two groups: conventional care (gCONV) and eGMS protocol (gAPP). The gAPP used InsulinAPP for insulin therapy management, whereas the gCONV received standard clinical care. The primary outcome was a composite of hospital-acquired infections, renal function deterioration, and symptomatic atrial arrhythmia. Secondary outcomes included GC, hypoglycemia incidence, hospital stay length, and costs.

RESULTS

The gAPP achieved lower mean glucose levels (167.2 ± 42.5 mg/dL vs 188.7 ± 54.4 mg/dL; P = .040) and fewer patients-day with BG above 180 mg/dL (51.3% vs 74.8%, P = .011). The gAPP received an insulin regimen that included more prandial bolus and correction insulin (either bolus-correction or basal-bolus regimens) than the gCONV (90.3% vs 16.7%). The primary composite outcome occurred in 16% of gAPP patients compared with 58% in gCONV (P < .010). Hypoglycemia incidence was lower in the gAPP (4% vs 16%, P = .046). The gAPP protocol also resulted in shorter hospital stays and reduced costs.

CONCLUSIONS

The InsulinAPP protocol effectively optimizes GC and reduces adverse outcomes in T2DM patients' post-CABG surgery, offering a cost-effective solution for inpatient diabetes management.

Cardiovascular disease and risk factors in adults with diabetes mellitus in Hungary: a population-based study

Introduction

Diabetes mellitus (DM) and cardiovascular disease (CVD) such as acute myocardial infarction, stroke, and coronary artery disease are highly prevalent conditions that are responsible for significant morbidity and mortality, particularly in Hungary. The conditions are attributed to identical risk factors, and individuals with DM are primarily susceptible to cardiovascular complications, which are the leading causes of death and disability in patients with DM. The objective of this study was to estimate the prevalence of CVD in individuals with DM and to investigate the association between potential risk factors and the presence of CVD among individuals with DM in a population-based sample.

Methods

The study was based on data from three waves of the European Health Interview Surveys (EHIS) conducted in Hungary in 2009, 2014, and 2019.

Results

The prevalence of CVD among patients with DM decreased during the study period and that socioeconomic factors, cardiometabolic risk factors including high blood pressure and high cholesterol, and depression are major contributors to CVD burden in patients with DM in Hungary.

Discussion

Our findings suggest the importance of regular check-up for hypertension and hypercholesterolemia, better focus on socioeconomic status, as well as ongoing monitoring of mental health among patients with diabetes. Further research is needed to understand the potential causes behind the observed decrease in CVD prevalence.

[Hospital diabetes management (Update 2023)]

This position statement presents the recommendations of the Austrian Diabetes Association for diabetes management of adult patients during inpatient stay. It is based on the current evidence with respect to blood glucose targets, insulin therapy and treatment with oral/injectable antidiabetic drugs during inpatient hospitalization. Additionally, special circumstances such as intravenous insulin therapy, concomitant therapy with glucocorticoids and use of diabetes technology during hospitalization are discussed.

Comparison of weight-based insulin titration (WIT) and glucose-based insulin titration using basal-bolus algorithm in hospitalized patients with type 2 diabetes: a multicenter, randomized, clinical study

INTRODUCTION

Subcutaneous administration of insulin is the preferred method for achieving glucose control in non-critically ill patients with diabetes. Glucose-based titration protocols were widely applied in clinical practice. However, most of these algorithms are experience-based and there is considerable variability and complexity. This study aimed to compare the effectiveness and safety of a weight-based insulin titration algorithm versus glucose-based algorithm in hospitalized patients with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

This randomized clinical trial was carried out at four centers in the South, Central and North China. Inpatients with T2DM were randomly assigned (1:1) to receive weight-based and glucose-based insulin titration algorithms. The primary outcome was the length of time for reaching blood glucose (BG) targets (fasting BG (FBG) and 2-hour postprandial BG (2hBG) after three meals). The secondary outcome included insulin dose for achieving glycemic control and the incidence of hypoglycemia during hospitalization.

RESULTS

Between January 2016 and June 2019, 780 patients were screened, and 575 completed the trial (283 in the weight-based group and 292 in the glucose-based group). The lengths of time for reaching BG targets at four time points were comparable between two groups. FBG reached targets within 3 days and 2hBG after three meals within 4 days. There is no significant difference in insulin doses between two groups at the end of the study. The total daily dosage was about 1 unit/kg/day, and the ratio of basal-to-bolus was about 2:3 in both groups. The incidence of hypoglycemia was similar in both groups, and severe hypoglycemia was not detected in either of the groups.

CONCLUSIONS

Weight-based insulin titration algorithm is equally effective and safe in hospitalized patients with T2DM compared with glucose-based algorithm.

TRIAL REGISTRATION NUMBER

NCT03220919.

Impacto do controle glicêmico intensivo na lesão renal aguda: ensaio clínico randomizado

Resumo Objetivo Avaliar o impacto do controle glicêmico intensivo na redução da incidência de lesão renal aguda em pacientes adultos submetidos à cirurgia cardíaca. Métodos Ensaio clínico randomizado que avaliou 95 pacientes submetidos a duas estratégias de controle glicêmico. Os pacientes foram randomizados para o grupo intervenção (GI), com a meta de manutenção da glicemia pós-operatória entre 90 e 110 mg/dl. Nos pacientes alocados no grupo convencional (GC) o objetivo era a manutenção da glicemia entre 140 e 180 mg/dl. O ajuste da dose de insulina foi baseado em medições de glicose no sangue arterial não diluído, em intervalos de uma hora por meio de um sistema de monitoramento de glicose e beta-cetona no sangue. Resultados A incidência de LRA foi de 53,7% (KDIGO estágios 1, 2 ou 3). Não houve diferença significante entre os grupos quanto ao desfecho primário (p=0,294). Entretanto, observou-se maior frequência de recuperação da função renal (p=0,010), na alta da UTI (p=0,028) e alta hospitalar (p=0,048) entre os pacientes submetidos ao controle glicêmico convencional. A utilização do controle glicêmico intensivo esteve associada com maior tempo de permanência na UTI (p=0,031). O número de episódios de hipoglicemia foi semelhante nos dois grupos (1,6 ± 0,9 vs. 1,3 ± 0,6, p=0,731), demonstrando a segurança das estratégias utilizadas. Conclusão Não se observou o impacto do controle glicêmico intensivo na redução da incidência de lesão renal aguda. Em contrapartida, os pacientes tratados no GC apresentaram maior frequência de recuperação da função renal.

Insulin-Based Infusion System: Preliminary Study

BACKGROUND

Optimal glucose control has been shown to be useful in critical care as well as in other settings. Glucose concentrations in patients admitted to critical care are characterized by marked variability and hypoglycemia due to inadequate sensing and treatment technologies.

METHODS

The insulin balanced infusion system (IBIS) is a closed-loop system that uses a system controller, two syringe pumps, and capillary glucose sensor intravenously infusing regular insulin and/or dextrose. The IBIS performance was evaluated in terms of glucose stability in response to various conditions in subjects with type 1 and insulin requiring type 2 diabetes mellitus (n = 15) with frequent intermittent capillary measurements, entered into the system and an adaptive algorithm adjusting the treatment modalities without other nursing intervention.

RESULTS

Target glucose concentrations (80-125 mg/dl) were achieved from hyperglycemic levels in 2.49 hours in the first study with mean and standard deviation of 105.2 mg/dl and 11.5 mg/dl, respectively.

CONCLUSION

Preliminary studies using a prototype closed-loop glucose control system for critical care produced noticeable results. Improvements were initiated within the system and further studies performed.

Evaluation of Counseling Practices and Patient's Satisfaction Offered by Pharmacists for Diabetics Attending Outpatient Pharmacies in Al Ahsa

Introduction

Patient counseling can be helpful in improving the outcome of disease management, particularly chronic diseases such as diabetes mellitus, which is common in Saudi Arabia. The present study looks to investigate the levels of counseling and satisfaction among patients attending diabetic clinics in outpatient hospital pharmacy in Al Ahsa, Saudi Arabia.

Method

This is a cross-sectional investigation, carried out by using interview-structured questionnaire, targeting diabetes mellitus patients with or without comorbid states. The questionnaire was divided into 3 parts comprising of demographics, counseling types given while collecting prescription, and satisfaction rating of services provided.

Result

More males than females participated; most of whom were college graduates older than 51 years. Sixty-three percent of the entire participants are type 1 diabetic patients, while 37% are type 2 diabetes mellitus patients. Coexistence of hypercholesterolemia was higher among type 1 diabetes patients with 51.9%, while hypertension was more common among type 2 diabetic patients representing 68.2%. Findings also showed that counseling was provided for medication use among type 1 diabetic patients but was deficient in the case of type 2 diabetic patients. Patients received low level of counseling on side effects and healthy lifestyle living. Satisfaction level was only 11.1%, indicating that counseling services might be deficient.

Conclusion

This study has revealed poor counseling practices and low satisfaction levels in services provided by outpatient hospital pharmacies to diabetic patients. In the face of increasing prevalence of diabetes and comorbidity, counseling of diabetic patients is critical.

[Hospital diabetes management (Update 2019)]

This position statement presents the recommendations of the Austrian Diabetes Association for diabetes management of adult patients during inpatient stay. It is based on the current evidence with respect to blood glucose targets, insulin therapy and treatment with oral antidiabetic drugs during inpatient hospitalization. Additionally, special circumstances such as intravenous insulin therapy, concomitant therapy with glucocorticoids and use of diabetes technology during hospitalization are discussed.

Hypoglycemia Prevention by Algorithm Design During Intravenous Insulin Infusion

PURPOSE OF REVIEW

This review examines algorithm design features that may reduce risk for hypoglycemia while preserving glycemic control during intravenous insulin infusion. We focus principally upon algorithms in which the assignment of the insulin infusion rate (IR) depends upon maintenance rate of insulin infusion (MR) or a multiplier.

RECENT FINDINGS

Design features that may mitigate risk for hypoglycemia include use of a mid-protocol bolus feature and establishment of a low BG threshold for temporary interruption of infusion. Computer-guided dosing may improve target attainment without exacerbating risk for hypoglycemia. Column assignment (MR) within a tabular user-interpreted algorithm or multiplier may be specified initially according to patient characteristics and medical condition with revision during treatment based on patient response. We hypothesize that a strictly increasing sigmoidal relationship between MR-dependent IR and BG may reduce risk for hypoglycemia, in comparison to a linear relationship between multiplier-dependent IR and BG. Guidelines are needed that curb excessive up-titration of MR and recommend periodic pre-emptive trials of MR reduction. Future research should foster development of recommendations for "protocol maxima" of IR appropriate to patient condition.

Hyperglycemia is associated with cardiac complications in elderly nondiabetic patients receiving total parenteral nutrition

Adverse outcomes have been associated with hyperglycemia in patients receiving total parenteral nutrition (TPN). The relationship may be characteristic in elderly patients. However, limited data are available about the relationship between TPN-related hyperglycemia and cardiac adverse outcome in elderly patients without previously known diabetes. This study aims to identify whether there is an association between hyperglycemia and 45-day cardiac adverse outcomes in critically and noncritically ill elderly nondiabetic patients receiving TPN.Outcome measures of 45-day cardiac complications after receiving TPN were recorded from a retrospective review of 1517 medical and surgical elderly patients. The mean glucose levels were significantly higher in patients with cardiac complications than in patients without cardiac complications (P < .001). In multivariate logistic regression analysis adjusting for age, gender, comorbidities, and medications, higher mean blood glucose levels were independently associated with increased 45-day cardiac complications (odds ratio, 1.62; 95% confidence interval, 1.453-1.816; P < .001). Furthermore, Kaplan-Meier event-free survival curves demonstrated that patients with mean blood glucose level ≥11.1 mmol/L had worse cardiac complications event-free survival compared with those mean blood glucose level <11.1 mmol/L during 45 days after receiving TPN.This study showed that TPN-induced hyperglycemia was associated with increased risk of cardiac complications in both critically and noncritically ill elderly patients without a history of diabetes.

The GesTIO protocol experience: safety of a standardized order set for subcutaneous insulin regimen in elderly hospitalized patients

BACKGROUNDS

In non-critical hospitalized patients with diabetes mellitus, guidelines suggest subcutaneous insulin therapy with basal-bolus regimen, even in old and vulnerable inpatients.

AIM

To evaluate safety, efficacy, and benefit on clinical management of the GesTIO protocol, a set of subcutaneous insulin administration rules, in old and vulnerable non-ICU inpatients.

METHODS

Retrospective, observational study. Patients admitted to Geriatric Clinic of Padua were studied. 88 patients matched the inclusion criteria: type 2 diabetes or hospital-related hyperglycemia, ≥65 years, regular measurements of capillary glycemia, and basal-bolus subcutaneous insulin regimen managed by "GesTIO protocol" for five consecutive days.

MAIN OUTCOME MEASURES

ratio of patients with blood glucose (BG) <3.9 mmol/l; number of BG per patient in target range (5-11.1 mmol/l); daily mean BG; and calls to physicians for adjusting insulin therapy.

RESULTS

Mean age was 82 ± 7 years. 9.1% patients experienced mild hypoglycaemia, and no severe hypoglycaemia was reported. The median number of BG per patients in target range increased from 2.0 ± 2 to 3.0 ± 2 (p < 0.001). The daily mean BG decreased from 11.06 ± 3.03 to 9.64 ± 2.58 mmol/l (-12.8%, p < 0.005). The mean number of calls to physicians per patient decreased from 0.83 to 0.45 (p < 0.05).

CONCLUSIONS

Treatment with GesTIO protocol allows a safe and effective treatment even in very old and vulnerable inpatients with a faster management insulin therapy.

A unified Hyperglycemia and Diabetic ketoacidosis (DKA) insulin infusion protocol based on an Excel algorithm and implemented via Electronic Medical Record (EMR) in Intensive Care Units

BACKGROUND

To assess the efficacy of a unified hyperglycemia and diabetic ketoacidosis (DKA) insulin infusion protocol (IIP), based on an Excel algorithm and implemented as an electronic order set, in achieving glycemic targets and minimizing hypoglycemia.

METHODS

An IIP was instituted in medical and surgical intensive care units for post-cardiac surgery (PCS) and other stress hyperglycemia (SH), diabetes hyperglycemia (DH), and DKA. The IIP initiated therapeutic insulin rates at elevated blood glucose (BG), and decreased insulin when target range was achieved. A convenience sample (n=62) was studied; 20 PCS, 15 with DH, 9 with SH, 8 with diabetes on vasopressors, 7 with diabetes on glucocorticoids and 3 with DKA were assessed.

RESULTS

The protocol maintained BG at 144±24.7mg/dL for PCS and 167±36mg/dL for patients with diabetes mellitus. It maintained acceptable target range (ATR) (100mg/dL-180mg/dL) 89% of the time for PCS and 67% of the time for patients with diabetes mellitus. There were no measurements of BG<70mg/dL. The protocol lowered the BG at a similar rate and time period in those with diabetes, DKA and those with or without vasopressors or glucocorticoids. To determine long-term efficacy, a retrospective review of Point of Care (POC) RALS (Remote Automated Data System) BG data 2 years post implementation demonstrated fewer episodes of hypoglycemia<70mg/dL and hyperglycemia>240mg/dL and more BG values within ATR.

CONCLUSIONS

This IIP maintained ATR without hypoglycemia for patients in the ICU setting without requiring complex nursing calculations.

Efficacy and Safety of Insulin Degludec for Hyperglycemia Management in Noncritical Hospitalized Patients with Diabetes: An Observational Study

INTRODUCTION

To assess the efficacy and safety of insulin degludec administered in a basal-bolus regimen according to the GesTIO protocol in noncritical hospitalized patients with T1DM and T2DM.

METHODS

Mean blood glucose levels (BG) and their standard deviations (SD) at admission vs. discharge were compared in 52 subjects (48.1% ≥75 years) managed through a basal-bolus scheme including degludec. The percentages of patients with BG at target (140-180 mg/dl) or below at discharge and the incidence rate (and the 95% confidence interval for it) of hypoglycemia were assessed.

RESULTS

From admission to discharge, fasting BG decreased from 237 to 153 mg/dl (p < 0.0001) and SD dropped from 125 to 38 mg/dl (p < 0.0001); average BG decreased from 189 to 145 mg/dl (SD dropped from 57 to 32 mg/dl). At discharge, 28.9% had BG at target, while 50.0% had lower levels (average 119.0 ± 14.4 mg/dl). The incidence rate of hypoglycemia was 0.07 (0.05; 0.11) episodes per person-day; 1 out of 27 episodes occurred during the night.

CONCLUSIONS

Degludec in hospitalized, mainly elderly patients is effective and minimizes glucose variability and nocturnal hypoglycemia.

Associations between home insulin dose adjustments and glycemic outcomes at hospital admission

AIMS

To describe patterns of home insulin dose adjustments for non-surgical, non-critically ill patients at admission and to describe associations between these adjustments and inpatient glycemic control.

METHODS

Hospital records of non-critically ill patients treated with basal insulin prior to admission were identified. After exclusion of records in which a confounding factor influencing insulin dosing was present, 258 patient-admissions over a 3-year time period were included. Multivariate logistic regression was used to analyze the association between adjustments to home insulin total daily dose (TDD) and inpatient glycemic control within the first 48h, adjusting for relevant confounders.

RESULTS

On hospital days 1 (HD1) and 2 (HD2), the home insulin TDD was reduced by 43.5% and 23.9%, respectively. Reductions in the home TDD ranging from 10% to 50% were not associated with normoglycemia or hyperglycemia, whereas increases ranging from 10% to 50% were associated with 2-5-fold increased odds of hyperglycemia. For patients with home insulin TDD ≥0.4units/kg/day, a weight-based dose of 0.4-0.6units/kg/day was associated with significantly higher odds of normoglycemia on HD2 (OR 3.99; 95% CI 1.42-11.21) compared to lower doses.

CONCLUSIONS

Compared to less aggressive increases, home insulin dose increases ranging from 10% to 50% were associated with greater odds of hyperglycemia without increased odds of hypoglycemia during early hospitalization. Weight-based insulin dosing may be a preferred strategy for glycemic control among patients whose home TDD is ≥0.4units/kg/day.

Early Hyperglycemia after Initiation of Glucocorticoid Therapy Predicts Adverse Outcome in Patients with Acute Graft-versus-Host Disease

Because of first-line treatment with high-dose glucocorticoids (GC), steroid-induced hyperglycemia develops frequently in patients with acute graft-versus-host disease (aGVHD), potentially affecting their outcome. We performed a retrospective analysis on 104 patients who received systemic GC for aGVHD and investigated the consequences of aberrant glucose metabolism. In particular, we focused on glucose parameters early after initiation of GC. With a median of 50 (range, 4 to 513) blood glucose measurements during GC treatment, increasing mean, median, and maximum glucose levels and the need for insulin treatment were associated with decreased overall survival (OS) in simple and multiple survival analysis. Early hyperglycemia, as defined by mean blood glucose levels >125 mg/dL during the first 3 days of GC therapy, was also found to be highly associated with adverse outcome (hazard ratio [HR], 2.5 for death; 95% confidence interval [CI], 1.3 to 4.8, and HR of 3.5 for death due to nonrelapse mortality, 95% CI, 1.7 to 7.5, in a competing risk analysis). A score based on early hyperglycemia and nonresponse to GC within 7 days allowed the identification of 3 risk groups: patients with both risk factors had an inferior OS at 5 years of 4.1% compared with 75.4% in patients with none. Patients with 1 risk factor had a 5-year OS rate of 32.0% (P = .0002 for trend). Early hyperglycemia after GC initiation is a prominent risk factor for adverse outcome in patients with aGVHD. A score based solely on early hyperglycemia and lack of response to GC can predict survival in these patients.

Population-Specific Models of Glycemic Control in Intensive Care: Towards a Simulation-Based Methodology for Protocol Optimization

Stress-induced hyperglycemia is common in critically ill patients, where elevated blood glucose and glycemic variability have been found to contribute to infection, slow wound healing, and short-term mortality. Early clinical studies demonstrated improvement in mortality and morbidity resulting from intensive insulin therapy targeting euglycemia. Follow-up clinical studies have shown mixed results suggesting that the risk of hypoglycemia may outweigh the benefits of aggressive glycemic control. None of the prior studies clarify whether euglycemic targets are in themselves harmful, or if the danger lies in the inadequacy of the available methods for achieving desired glycemic outcomes. In this paper, we use a recently developed simulation model of stress hyperglycemia to demonstrate that given an insulin protocol glycemic outcomes are specific to the patient population under consideration, and that there is a need to optimize insulin therapy at the population level. Next, we use the simulator to demonstrate that the performance of Adaptive Proportional Feedback (APF), a popular format for computerized insulin therapy, is sensitive to its parameters, especially to the parameters that govern the aggressiveness of adaptation. Finally, we propose a framework for simulation-based protocol optimization using an objective function that penalizes below-range deviations more heavily than comparable deviations above.

The impact of measurement frequency on the domains of glycemic control in the critically ill--a Monte Carlo simulation

The role of blood glucose (BG) measurement frequency on the domains of glycemic control is not well defined. This Monte Carlo mathematical simulation of glycemic control in a cohort of critically ill patients modeled sets of 100 patients with simulated BG-measuring devices having 5 levels of measurement imprecision, using 2 published insulin infusion protocols, for 200 hours, with 3 different BG-measurement intervals-15 minutes (Q15'), 1 hour (Q1h), and 2 hours (Q2h)-resulting in 1,100,000 BG measurements for 3000 simulated patients. The model varied insulin sensitivity, initial BG value and rate of gluconeogenesis. The primary outcomes included rates of hyperglycemia (BG > 180 mg/dL), hypoglycemia (BG < 70 and 40 mg/dL), proportion of patients with elevated glucose variability (within-patient coefficient of variation [CV] > 20%), and time in range (BG ranges 80-150 mg/dL and 80-180 mg/dL). Percentages of hyperglycemia, hypoglycemia at both thresholds, and patients with elevated glucose variability as well as time outside glycemic targets were substantially higher in simulations with measurement interval Q2h compared to those with measurement interval Q1h and moderately higher in simulations with Q1h than in those with Q15'. Higher measurement frequency mitigated the deleterious effect of high measurement imprecision, defined as CV ≥ 15%. This Monte Carlo simulation suggests that glycemic control in critically ill patients is more optimal with a BG measurement interval no longer than 1h, with further benefit obtained with use of measurement interval of 15'. These findings have important implications for the development of glycemic control standards.

Effects of measurement frequency on analytical quality required for glucose measurements in intensive care units: assessments by simulation models

BACKGROUND

Total error allowances have been proposed for glucose meters used in tight-glucose-control (TGC) protocols. It is unclear whether these proposed quality specifications are appropriate for continuous glucose monitoring (CGM).

METHODS

We performed Monte Carlo simulations of patients on TGC protocols. To simulate use of glucose meters, measurements were made hourly. To simulate CGM, glucose measurements were made every 5 min. Glucose was measured with defined bias (varied from -20% to 20%) and imprecision (0% to 20% CV). The measured glucose concentrations were used to alter insulin infusion rates according to established treatment protocols. Changes in true glucose were calculated hourly on the basis of the insulin infusion rate, the modeled patient's insulin sensitivity, and a model of glucose homeostasis. We modeled 18 000 patients, equally divided between the hourly and every-5-min measurement schemas and distributed among 45 combinations of bias and imprecision and 2 treatment protocols.

RESULTS

With both treatment protocols and both measurement frequencies, higher measurement imprecision increased the rates of hypoglycemia and hyperglycemia and increased glycemic variability (SD). These adverse effects of measurement imprecision were lower at the higher measurement frequency. The rate of hypoglycemia at an imprecision (CV) of 5% with hourly measurements was similar to the rate of hypoglycemia at 10% CV when measurements were made every 5 min. With measurements every 5 min, imprecision up to 10% had minimal effects on hyperglycemia or glycemic variability. Effects of simulated analytical bias on glycemia were unaffected by measurement frequency.

CONCLUSIONS

Quality specifications for imprecision of glucose meters are not transferable to CGM.

A novel glucose-insulin infusion maintains perioperative glycaemic control through multiple transitions of care

To measure the efficacy of the Glucose-Insulin Infusion--Parkland Protocol (GIPPr) compared to subcutaneous (SC) insulin, blood glucose readings were reviewed in diabetic adults admitted for surgical intervention of a soft tissue or bone infection in Dallas, Texas. Hypoglycaemia occurred in 0.69% of readings in GIPPr-treated patients compared to 4.52% in SC-treated patients. The GIPPr maintained a higher proportion of blood glucose readings between 3.89-10 mmol/L compared to SC insulin (85.40% versus 50.68%).

Acute in vivo performance evaluation of the fluorescence affinity sensor in the intravascular and interstitial space in Swine

OBJECTIVE

We assessed and compared the performance levels of a fiber-coupled fluorescence affinity sensor (FAS) for glucose detection in the intradermal tissue and intravascular bed during glucose clamping and insulin administration in a large animal model.

RESEARCH DESIGN AND METHODS

The FAS (BioTex Inc., Houston, TX) was implanted in interstitial tissue and in the intravenous space in nondiabetic, anesthetized pigs over 6-7 h. For intradermal assessment, a needle-type FAS was implanted in the upper back using a hypodermic needle. For intravenous assessment, the FAS was inserted through a catheter into the femoral artery and vein. Blood glucose changes were induced by infusion of dextrose and insulin through a catheterized ear or jugular vein.

RESULTS

Based on retrospective analysis, the mean absolute relative error (MARE) of the sensor in blood and interstitial tissue was 11.9% [standard deviation (SD) = ± 9.6%] and 23.8% (SD = ± 19.4%), respectively. When excluding data sets from sensors that were affected by exogenous insulin, the MARE for those sensors tested in interstitial tissue was reduced to 16.3% (SD = ± 12.5%).

CONCLUSIONS

The study demonstrated that the performance level of the FAS device implanted in interstitial tissue and blood can be very high. However, under certain circumstances, exogenous insulin caused the glucose concentration in interstitial tissue to be lower than in blood, which resulted in an overall lower level of accuracy of the FAS device. How significant this physiological effect is in insulin-treated persons with diabetes remains to be seen. In contrast, the level of accuracy of the FAS device in blood was very high because of high mass transfer conditions in blood. While the use of the FAS in both body sites will need further validation, its application in critically ill patients looks particularly promising.

Intravenous insulin infusions: what nurses need to know

Glucose control in the acute setting has long been a debate among leaders in the fields of diabetes and acute care. Providers struggle to maintain euglycemia in critically ill patients and simultaneously prevent hypoglycemia. Intravenous insulin infusions are frequently preferred in the critical care setting to control glucose, because they can be titrated for changing insulin requirements and can be cleared from the system rapidly. This article discusses the basics of the insulin drip, common insulin drips, and the role of the nurse in managing an insulin drip.

Inpatient treatment of type 2 diabetes

BACKGROUND

Type 2 diabetes is common in hospitalized patients and is often accompanied by comorbidities; it is thus reasonable to ask whether the current standard treatments for type 2 diabetes are suitable for in-hospital use. We discuss the current glucose-lowering strategies and glycemic targets and derive practical recommendations for their application in hospitalized patients.

METHODS

The pertinent literature, including clinical trials, review articles, guidelines, and manufacturers' information is selectively reviewed.

RESULTS

In critically ill patients with diabetes, the glucose concentration target value should be 140 to 180 mg/dL. In stable patients, the target should be less than 140 mg/dL in the fasting state and less than 180 mg/dL after meals. Hypoglycemic episodes should be strictly avoided. Temporary treatment with insulin is indicated for most hospitalized patients with diabetes, although oral antidiabetic agents may be continued if the hospitalization is expected to be brief. Intravenous insulin is advisable in certain situations, e.g., long operations or metabolic decompensation. Glucose-lowering strategies must be chosen individually for each patient, with consideration of the relevant comorbidities (e.g. coronary heart disease, congestive heart failure, cirrhosis, renal failure) and special conditions (e.g. prolonged fasting, administration of contrast agents, high-dose glucocorticoid treatment).

CONCLUSION

The treatment of patients with type 2 diabetes in the hospital is very different from their treatment at home. The particular conditions and comorbidities that can arise in the hospital necessitate flexible, individualized strategies for lowering blood glucose concentration.

Improving IV insulin administration in a community hospital

Diabetes mellitus is a major independent risk factor for increased morbidity and mortality in the hospitalized patient, and elevated blood glucose concentrations, even in non-diabetic patients, predicts poor outcomes. The 2008 consensus statement by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) states that "hyperglycemia in hospitalized patients, irrespective of its cause, is unequivocally associated with adverse outcomes." It is important to recognize that hyperglycemia occurs in patients with known or undiagnosed diabetes as well as during acute illness in those with previously normal glucose tolerance. The Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study involved over six thousand adult intensive care unit (ICU) patients who were randomized to intensive glucose control or conventional glucose control. Surprisingly, this trial found that intensive glucose control increased the risk of mortality by 14% (odds ratio, 1.14; p = 0.02). In addition, there was an increased prevalence of severe hypoglycemia in the intensive control group compared with the conventional control group (6.8% vs. 0.5%, respectively; p < 0.001). From this pivotal trial and two others, Wyoming Medical Center (WMC) realized the importance of controlling hyperglycemia in the hospitalized patient while avoiding the negative impact of resultant hypoglycemia. Despite multiple revisions of an IV insulin paper protocol, analysis of data from usage of the paper protocol at WMC shows that in terms of achieving normoglycemia while minimizing hypoglycemia, results were suboptimal. Therefore, through a systematical implementation plan, monitoring of patient blood glucose levels was switched from using a paper IV insulin protocol to a computerized glucose management system. By comparing blood glucose levels using the paper protocol to that of the computerized system, it was determined, that overall, the computerized glucose management system resulted in more rapid and tighter glucose control than the traditional paper protocol. Specifically, a substantial increase in the time spent within the target blood glucose concentration range, as well as a decrease in the prevalence of severe hypoglycemia (BG < 40 mg/dL), clinical hypoglycemia (BG < 70 mg/dL), and hyperglycemia (BG > 180 mg/dL), was witnessed in the first five months after implementation of the computerized glucose management system. The computerized system achieved target concentrations in greater than 75% of all readings while minimizing the risk of hypoglycemia. The prevalence of hypoglycemia (BG < 70 mg/dL) with the use of the computer glucose management system was well under 1%.

Nurse-led implementation of a safe and effective intravenous insulin protocol in a medical intensive care unit

BACKGROUND

Recent evidence has linked tight glucose control to worsened clinical outcomes among adults in intensive care units.

OBJECTIVE

To evaluate the effectiveness and safety of a nurse-led intravenous insulin protocol designed to achieve conservative blood glucose control in patients in a medical intensive care unit.

METHODS

A nurse-led intravenous insulin protocol was developed, targeting blood glucose levels at 110 to 149 mg/dL. Hypoglycemia was defined as a blood glucose level less than 70 mg/dL. Patients admitted to the medical intensive care unit who required an insulin infusion were enrolled in the study. Blood glucose levels in those patients were compared with levels in 153 historical control patients admitted to the unit in the 12 months before the protocol was implemented who required an insulin infusion.

RESULTS

Ninety-six patients were enrolled and treated with the protocol. The protocol and control groups had similar characteristics at baseline. More measurements in the protocol group than in the control group (46.3% vs 36.1%, P<.001) were within the target glucose range (110-149 mg/dL). Hyperglycemia (blood glucose ≥200 mg/dL) occurred less often in the protocol group than in the control group (14.8% vs 20.1%, P=.003). Hypoglycemic events (blood glucose <70 mg/dL) also occurred less often in the protocol group (0.07% vs 0.83%, P<.001).

CONCLUSIONS

Implementation of a nurse-led, conservative intravenous insulin protocol in the medical intensive care unit is effective and safe and markedly reduces the rate of hypoglycemia.

Insulin therapy for the management of hyperglycemia in hospitalized patients

It has long been established that hyperglycemia with or without a prior diagnosis of diabetes increases both mortality and disease-specific morbidity in hospitalized patients and that goal-directed insulin therapy can improve outcomes. This article reviews the pathophysiology of hyperglycemia during illness, the mechanisms for increased complications and mortality due to hyperglycemia and hypoglycemia, and beneficial mechanistic effects of insulin therapy and provides updated recommendations for the inpatient management of diabetes in the critical care setting and in the general medicine and surgical settings.

Management of inpatient hyperglycemia: assessing knowledge and barriers to better care among residents

To identify areas that should be targeted for improvement, we surveyed residents for their knowledge and barriers regarding management of inpatient hyperglycemia. One hundred thirty-five residents from 4 teaching hospitals completed a questionnaire to assess their knowledge about the different types of insulin, the perceived barriers toward managing inpatient hyperglycemia, and the problems they face when dealing with this commonly encountered problem. The majority of participants thought that managing inpatient hyperglycemia was very important in the critically ill and perioperative patients, whereas only 65% thought that it was very important for noncritically ill patients. Most residents reported that they will target blood glucose levels that are inconsistent with the current recommendations. Half of them reported that they were very comfortable with managing inpatient hyperglycemia and hypoglycemia. Of the participants, 46% said they will use a stand-alone insulin sliding scale for patients with difficult to control blood glucose and 43% thought that physicians still use it because of their unfamiliarity with ordering prandial and basal insulin. Unpredictable changes in patient diet and mealtimes, along with the risk of causing patient hypoglycemia, were the most frequently chosen as barriers to better management of inpatient hyperglycemia. Most participants lack important inpatient hyperglycemia knowledge, specifically about insulin types and pharmacokinetics. This study demonstrated the gap in knowledge about management of inpatient hyperglycemia among residents and illustrated the need to develop certain policies and to implement educational programs directed toward residents that reflect the current guidelines.

Glycemic control in non-diabetic critically ill patients

Hyperglycemia is a common and costly health care problem in hospitalized patients. In hospital hyperglycemia is defined as any glucose value >7.8 mmol/l (140 mg/dl). Hyperglycemia is present in 40% of critically ill patients and in up to 80% of patients after cardiac surgery, with ∼ 80% of ICU patients with hyperglycemia having no history of diabetes prior to admission. The risk of hospital complications relates to the severity of hyperglycemia, with a higher risk observed in patients without a history of diabetes compared to those with known diabetes. Improvement in glycemic control reduces hospital complications and mortality; however, the ideal glycemic target has not been determined. A target glucose level between 7.8 and 10.0 mmol/l (140 and 180 mg/dl) is recommended for the majority of ICU patients. This review aims to present updated recommendations for the inpatient management of hyperglycemia in critically ill patients with and without a history of diabetes.

Insulin therapy during hospitalization

Hyperglycemia occurring during hospitalization is a common phenomenon among patients with or without a known history of diabetes mellitus. For several years, hyperglycemia in hospitalized patients had been considered as an accompanying characteristic of the acute disease that resulted in admission. That point of view changed over time mainly because of emerging indications from clinical studies showing that hyperglycemia during hospitalization could aggravate prognosis and increase mortality. Further studies engaged on how hyperglycemia should be treated, yielded results that highlighted the increasing risk of mortality due to hypoglycemia in such efforts and also questioned the initial relation between hyperglycemia during hospitalization and a poor prognosis. Based on the fact that there is still no common ground on what is the best approach on hyperglycemia of hospitalized patients, the best practice remains to follow a different regime with different glycemic goals for different patient groups. In this review, hospitalized patients are divided into three groups; intensive care unit patients (general and cardiac), non-intensive care unit patients (general and cardiac) and peri-operative patients.

Implementation of a dedicated hospital subcutaneous insulin prescription chart: effect on glycaemic control

A dedicated subcutaneous insulin prescription chart incorporating glucose monitoring results, forced functions, and management guidelines was introduced to facilitate better hospital diabetes control. Point of care capillary blood glucose monitoring charts for 99 people with diabetes from the period before the introduction of the new chart, and 106 after its introduction were reviewed. A total of 12,649 blood glucose levels (BGLs) were collected for glucometric analysis. Following the introduction of the chart, there was an increase in the number of BGLs performed daily from 4.5 ± 1.2 to 4.9 ± 1.3 (p = 0.05). There was an increase in the proportion of BGLs within the ideal range of 4-9.9 mmol/L (51.8% vs. 54.1%, p = 0.01). There was a reduction in hypoglycaemic events (proportion of BGLs <4 mmol/L in the whole population decreased from 5.2% to 3.4% (p < 0.001), proportion of BGLs <4 mmol/L for each patient decreased from 5.6 ± 9.2% to 2.9 ± 5.4% (p = 0.01), proportion of days where patient had a BGL <4 mmol/L decreased from 17.6 ± 22.6% to 11.4 ± 18.8% (p = 0.03)), despite an increase in the use of supplemental insulin (14.2 ± 35.7 vs. 29.4 ± 51.4 u nits/patient, p = 0.02). We conclude that the use of a dedicated hospital subcutaneous insulin prescription chart can reduce hypoglycaemia and improve some measures of glycaemic control.

Hyperglycemia in hospitalized patients receiving corticosteroid premedication before the administration of radiologic contrast medium

RATIONALE AND OBJECTIVES

To assess the effect of short-term corticosteroid premedication on serum glucose in hospitalized patients.

MATERIALS AND METHODS

Serum glucose in adult inpatients receiving corticosteroid premedication before a radiology study was compared to serum glucose in nonpremedicated controls between May 1, 2008, and September 12, 2009. Patients were categorized by type of nonionic contrast medium (intravenous [IV] or none) and route of corticosteroid premedication (oral, IV, none). Diabetes mellitus (types I and II) was evaluated as an independent risk factor. Patients without glucose estimations before and after premedication were excluded. Results were analyzed with analysis of variance and a stepwise linear regression analysis.

RESULTS

There were 390 corticosteroid premedication episodes in 390 patients; 873 examinations in 844 patients served as controls. Cohorts receiving corticosteroid premedication experienced a brief (24-48 hour) increase in mean maximum postbaseline serum glucose (IV, +81 mg/dL; oral, +70 mg/dL) that was greater than the increase in nonpremedicated controls (+46 mg/dL). Type I (+144 mg/dL) and type II (+108 mg/dL) diabetics had a greater elevation than nondiabetics (+34 mg/dL). Both corticosteroid premedication (IV, P = .02; oral, P = .01) and diabetes mellitus (type I, P = .0002; type II, P < .0001) were significant independent risk factors of hyperglycemia. The use of nonionic intravascular contrast medium was not (P = .7). There was no significant difference between IV and oral premedication (P = .6), or type I and type II diabetes mellitus (P = .8).

CONCLUSIONS

Diabetes mellitus (type I and type II) and corticosteroid premedication (oral and IV) are significant independent risk factors for the development of brief hyperglycemia near the time of inpatient radiology studies.

Ensuring optimal insulin utilization in the hospital setting: role of the pharmacist

PURPOSE

To summarize essential information for the hospital pharmacist to support the safe and effective use of insulin for the treatment of inpatient hyperglycemia.

SUMMARY

Ensuring optimal insulin utilization in the hospital setting requires collaboration of a multidisciplinary team, including physicians (and endocrinologists specifically), nurses, pharmacists, dieticians, diabetes educators, laboratory staff, quality management staff, and others. The role of pharmacists in this multidisciplinary team is to assist in the standardization of insulin therapy via selection of appropriate insulin treatment protocols, participate in formulary management of insulin products, and contribute to the development of order sets and policies and procedures to minimize the risk of medication errors and misadventures. In addition, pharmacists can provide guidelines or treatment recommendations in special situations, such as those involving patients receiving enteral or parenteral nutrition or high-dose corticosteroids and the transition from i.v. to subcutaneous insulin therapy. Education of patients and providers is another key role for pharmacists. Nurses are important allies in the effort to ensure safe insulin use, as they are at the bedside of patients administering and adjusting insulin therapy. Recommendations are provided for the safe and effective use of insulin for the treatment of inpatient hyperglycemia.

CONCLUSION

Pharmacists are an integral part of the multidisciplinary team ensuring the safe and effective implementation of inpatient hyperglycemic control and insulin usage.

Dysglycemia following glucocorticoid therapy for acute graft-versus-host disease adversely affects transplantation outcomes

Disordered glucose metabolism is a common complication of glucocorticoid therapy for acute graft-versus-host disease (aGVHD) after allogeneic hematopoietic cell transplantation (HCT). We aimed to examine the impact of dysglycemia on outcomes in 173 recipients of HCT treated with glucocorticoids for aGVHD. A total of 147 of these patients contributed data to a landmark analysis performed at 12 weeks post-HCT. Median aGVHD onset was 21 days (range: 5-79) after transplant. Median duration of glucocorticoid therapy was 381 days (range: 15-1632). Glucose values were obtained from glucocorticoid initiation date to death or last follow-up, resulting in 11,588 total values. The median (range) for each parameter were: maximum 292 mg/dL (128-694), minimum 75 mg/dL (34-142), average 142 mg/dL (86-327), and standard deviation 46 mg/dL (12-108). Baseline diabetes mellitus predicted significantly greater maximum, mean, and standard deviation. With median follow-up of 20 months (range: 3-55), median overall survival (OS) was 33.7 months (95% confidence interval [CI] 16.4-not reached). On multivariable analysis, maximum, average, or standard deviation of glucose values predicted OS and maximum or average glucose values predicted nonrelapse mortality (NRM). Minimum glucose values of (0-60 mg/dL) were associated with worsened OS and increased NRM. Those patients treated with insulin or oral agents suffered significantly worse OS and increased NRM compared to patients who did not need therapy. Finally, those with sustained maximum values >200 mg/dL despite treatment suffered worse OS and increased NRM. These data suggest an independent adverse effect of dysglycemia in patients treated with glucocorticoids for aGVHD, and argue for stringent glycemic control in this setting.

Our experience of controlling diabetes in the peri-operative period of patients who underwent cardiac surgery

AIMS

We have different protocols applied in our cardiac center for control of blood glucose (BG), we like to see which protocol can achieve our goal.

METHODS

From a prospective study of 120 diabetic patients randomly assigned to either simple sliding scale or Braithwaite protocol who underwent open heart surgical procedures between 2005 and 2008. The study group included 80 patients treated with Braithwaite protocol; the control group included 40 patients treated with simple sliding scale in an attempt to maintain BG level less than 200 mg/dl.

RESULTS

In the study group all the patients were under 200 mg/dl at the end of 48 h postoperatively, which was not achieved in the control group (P<0.01). There was a significant reduction in hospital stay in the study group compared to the control group (mean in days 9.1+/-2.3/12.3+/-7.6) (P<0.001) and also there was no wound infection compared to the control group (0/5 cases).

CONCLUSION

The study showed that control of DM in peri-operative period using Braithwaite regimen was of great benefit and safety.

The use of insulin pumps in youth with type 1 diabetes

The use of insulin pump therapy (continuous subcutaneous insulin infusion) has increased dramatically in youth with type 1 diabetes (T1D) in the past decade. In this review we provide background and practical clinical advice on insulin basal rates and bolus doses and on the advantages of pump therapy with exercise. Acute complications of T1D (hypoglycemia and diabetic ketoacidosis) in the context of pump therapy are reviewed. The advantages of pump therapy in the school setting and in hospitalized patients are discussed. Finally, diabetes management in the 21st century, in which pump therapy is combined with continuous glucose monitoring, and its potential for a closed-loop pancreas are presented.

Addressing hyperglycemia from hospital admission to discharge

BACKGROUND

This review examines glycemia management practices in hospitalized patients. Optimal glycemic control remains a challenge among hospitalized patients. Recent studies have questioned the benefit of tight glycemic control and have raised concerns regarding the safety of this approach. As a result, medical societies have updated glycemic targets and have published new consensus guidelines for management of glycemia in hospitalized patients. This review highlights recent inpatient glycemic trials, the new glycemic targets and recommended strategies for management of glycemia in hospitalized patients.

METHODS

Medline and PubMed searches (diabetes, hyperglycemia, hypoglycemia, intensive therapy insulin, tight glycemic control, and hospital patients) were performed for English-language articles on treatment of diabetes, insulin therapy, hyperglycemia or hypoglycemia in hospitalized patients published from 2004 to present. Earlier works cited in these papers were surveyed. Clinical studies, reviews, consensus/guidelines statements, and meta-analyses relevant to the identification and management of diabetes and hyperglycemia in hospitalized patients were included and selected. This is not an exhaustive review of the published literature.

RESULTS

Insulin remains the most appropriate agent for a majority of hospitalized patients. In critically ill patients insulin is given as a continuous intravenous (IV) infusion and in non-critically ill inpatients hyperglycemia is best managed using scheduled subcutaneous (SC) basal-bolus insulin regimens supplemented with correction doses as needed and adjusted daily with the guidance of frequent blood glucose monitoring. Prevention of hypoglycemia is equally as important to patient outcomes and is an equally necessary part of any effective glucose control program. Modern insulin analogs offer advantages over the older human insulins (e.g., regular and neutral protamine Hagedorn [NPH] insulin) because their time-action profiles more closely correspond to physiological basal and prandial insulin requirements, and have a lower propensity for inducing hypoglycemia than human insulin formulations. Long-acting basal insulin analogs (glargine, detemir) are suitable and preferred for the basal component of therapy; rapid-acting insulin analogs (aspart, lispro, glulisine) are recommended for bolus and correction doses. Sliding-scale insulin (SSI) regimens are not effective and should not be used, especially as this excludes a basal insulin component from the therapy.

CONCLUSIONS

Optimal glycemic management in the hospital setting requires judicious treatment of hyperglycemia while avoiding hypoglycemia. Insulin is the most appropriate agent for management of hyperglycemia for the majority of hospitalized patients. Intravenous insulin infusion is still preferred during and immediately after surgery, but s.c. basal insulin analogs with prandial or correction doses should be used after the immediate post-operative period, and also should be used in non-critically ill patients. Frequent and effective glucose monitoring is critical for avoiding wide deviations from acceptable glucose levels, which under a recently promulgated consensus guideline currently range between 140 mg/dL and 180 mg/dL. Glucose targets near 140 mg/dL are recommended as being the most appropriate for all hospitalized patients.

Tight glycaemic control: clinical implementation of protocols

Implementation of tight glycaemic control in hospitalised patients presents a huge challenge. It concerns many patients, there are many interfering factors and many health-care professionals are involved. The current literature provides little practical guidance. This article offers the clinical anesthesiologist direction for the organisation of inpatient blood glucose control in acute situations, in the perioperative setting and in the intensive care unit. An effective, safe and user-friendly algorithm for intravenous insulin administration is presented that can be executed by regular nurses and used in many situations. Practical advice is offered for the use of subcutaneous basal-bolus insulin, for fasting orders and for transition to discharge care. The main safety considerations are discussed.

Insulin strategies for managing inpatient and outpatient hyperglycemia and diabetes

Optimal fasting and postprandial glycemic control are essential to limiting microvascular and macrovascular complications associated with diabetes. Recently, stringent control of hyperglycemia in critically ill hospitalized patients with diabetes or acute hyperglycemia has been shown to reduce the risk of morbidity and mortality. This article reviews effective strategies for insulin initiation, titration, and intensification in inpatient and outpatient settings and discusses current treatment strategies when patients are being transitioned from the intensive care unit to general wards and discharged. The development of insulin analogs and premixed insulin analogs has created new options for treating inpatients and outpatients. The more physiologic time-action profiles, improved insulin delivery systems, and standardized protocols for subcutaneous insulin administration and intravenous insulin infusion have improved the safety and convenience of insulin therapy.