scholarly journals Effect of Bolus Insulin Administration Followed by a Continuous Insulin Infusion on Diabetic Ketoacidosis Management

Pharmacy ◽  
2018 ◽  
Vol 6 (4) ◽  
pp. 129
Author(s):  
Hannah Brown ◽  
Richard Tran ◽  
John Patka
Keyword(s):  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Length Of Hospital Stay ◽  
Retrospective Chart Review ◽  
Regular Insulin ◽  
Bolus Administration ◽  
Emergency Department Admission ◽  
High Incidence ◽  
Bolus Insulin ◽  
Continuous Insulin Infusion

Despite the high incidence of diabetic ketoacidosis (DKA) there is no consensus on the most appropriate way to manage insulin therapy. This study was conducted to evaluate the effect of an insulin bolus on the resolution of DKA. A retrospective chart review of patients admitted between 1 September 2014 and 30 June 2016 with a diagnosis of DKA was conducted. Patients were assigned to the bolus or no bolus group based on provider preference. All patients were initiated on a 0.1 unit/kilogram (kg)/hour (h) intravenous (IV) regular insulin infusion, and patients in the bolus group were treated with a 0.1 unit/kg IV regular insulin bolus. Of the 145 admissions evaluated, 58 received a bolus and 87 did not. There was no difference in baseline demographics, except baseline blood glucose was higher in the bolus group (653 vs. 591 milligrams (mg)/deciliter (dL), p = 0.04). The time to resolution of DKA from emergency department admission did not differ between the bolus and no bolus group (15 vs. 15.9 h; p = 0.24). There was no difference in total insulin received (1.3 vs. 1.1 units/kg, p = 0.18), incidence of hypoglycemia (2 vs. 7%, p = 0.64), hypokalemia (16 vs. 29%, p = 0.65), or length of hospital stay (3.2 vs. 2.7 days, p = 0.27). The insulin bolus administration was not associated with reduced time to resolution of DKA.

scholarly journals Role of Insulin Glargine in Early Phase of Treatment of Diabetic Ketoacidosis

QJM ◽  
2020 ◽  
Vol 113 (Supplement_1) ◽  
Author(s):  
S S Wahba ◽  
M Elsersi ◽  
A M Alansary ◽  
M H Elzahaby
Keyword(s):  
Insulin Glargine ◽  
Hospital Stay ◽  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Length Of Hospital Stay ◽  
Regular Insulin ◽  
Controlled Study ◽  
High Morbidity ◽  
University Hospitals ◽  
Standard Regimen

Abstract Background Diabetic ketoacidosis (DKA) is a common cause of intensive care unit (ICU) admission, with high morbidity and mortality rates. A growing body of evidence has suggested that adding insulin Glargine to the standard regimen may facilitate the transition from an intravenous infusion of insulin to subcutaneous injection in the recovery of patients with DKA. Aim of the Work to investigate the effect of adding Insulin Glargine to the standard regimen of treatment of DKA on the recovery process of patients regarding the amount of intravenous insulin infusion and the duration of the patients’ stay in the ICU. Patient and Methods This randomized controlled study was conducted on 50 Egyptian individuals, in National Institute of Diabetes and Endocrinology & Ain Shams University Hospitals. 50 Patients with Diabetic Ketoacidosis diagnosed according to The American Diabetes Association criteria. All patients were divided into 2 groups according the protocol used for treatment: The first group including 25 patients treated only with the standard regimen of intravenous regular insulin infusion (0.1 unit/kg/hour). The second group including 25 patients treated with intravenous regular insulin (0.1 unit/kg/hour) + Iv infusion of normal saline. Results Added insulin Glargine resulted in a significantly shorter length of hospital stay, compared to SOC alone. The present study showed that insulin Glargine led to statistically significant less amount of insulin infused until resolution of DKA than the SOC alone. Conclusion subcutaneous insulin Glargine coadministration with regular insulin results in a shorter length of hospital stay and less amount of infused insulin in DKA patients admitted to ICU. Larger multi-centric trials are still needed to confirm our findings.

Insulin Therapy for Diabetic Ketoacidosis: Bolus insulin injection versus continuous insulin infusion

Diabetes Care ◽  
1995 ◽  
Vol 18 (8) ◽  
pp. 1187-1190 ◽  
Author(s):  
E. K. Butkiewicz ◽  
C. L. Leibson ◽  
P. C. O'Brien ◽  
P. J. Palumbo ◽  
R. A. Rizza
Keyword(s):  
Insulin Therapy ◽  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Insulin Injection ◽  
Bolus Insulin ◽  
Continuous Insulin Infusion

Utilizing serum bicarbonate instead of venous pH to transition from intravenous to subcutaneous insulin shortens the duration of insulin infusion in pediatric diabetic ketoacidosis

2019 ◽  
Vol 32 (1) ◽  
pp. 11-17
Author(s):  
Jennifer Gauntt ◽  
Priya Vaidyanathan ◽  
Sonali Basu
Keyword(s):  
Adverse Events ◽  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Tertiary Care ◽  
Pediatric Intensive Care ◽  
Regular Insulin ◽  
Serum Bicarbonate ◽  
Transition Group ◽  
Serum Bicarbonate Level ◽  
Transition Criteria

Abstract Background Standard therapy of diabetic ketoacidosis (DKA) in pediatrics involves intravenous (IV) infusion of regular insulin until correction of acidosis, followed by transition to subcutaneous (SC) insulin. It is unclear what laboratory marker best indicates correction of acidosis. We hypothesized that an institutional protocol change to determine correction of acidosis based on serum bicarbonate level instead of venous pH would shorten the duration of insulin infusion and decrease the number of pediatric intensive care unit (PICU) therapies without an increase in adverse events. Methods We conducted a retrospective (pre/post) analysis of records for patients admitted with DKA to the PICU of a large tertiary care children’s hospital before and after a transition-criteria protocol change. Outcomes were compared between patients in the pH transition group (transition when venous pH≥7.3) and the bicarbonate transition group (transition when serum bicarbonate ≥15 mmol/L). Results We evaluated 274 patient records (n=142 pH transition group, n=132 bicarbonate transition group). Duration of insulin infusion was shorter in the bicarbonate transition group (18.5 vs. 15.4 h, p=0.008). PICU length of stay was 3.2 h shorter in the bicarbonate transition group (26.0 vs. 22.8 h, p=0.04). There was no difference in the number of adverse events between the groups. Conclusions Transitioning patients from IV to SC insulin based on serum bicarbonate instead of venous pH led to a shorter duration of insulin infusion with a reduction in the number of PICU therapies without an increase in the number of adverse events.

Cerebral Edema and Ophthalmoplegia Reversed by Mannitol in a New Case of Insulin-Dependent Diabetes Mellitus

PEDIATRICS ◽  
1982 ◽  
Vol 69 (1) ◽  
pp. 87-90
Author(s):  
Bonita Franklin ◽  
John Liu ◽  
Fredda Ginsberg-Fellner
Keyword(s):  
Diabetic Ketoacidosis ◽  
Cerebral Edema ◽  
Insulin Infusion ◽  
Low Dose ◽  
Insulin Dependent Diabetes Mellitus ◽  
Dependent Diabetes Mellitus ◽  
Fluid Restriction ◽  
Insulin Dependent ◽  
Insulin Dependent Diabetic ◽  
Continuous Insulin Infusion

Cerebral edema is a sometimes fatal complication of diabetic ketoacidosis which occurs unpredictably and when biochemical parameters show improvement. A case of a young, newly diagnosed insulin-dependent diabetic boy who developed this complication while receiving a low-dose continuous insulin infusion is reported. Two hours after treatment signs of headache, ophthalmoplegia, and blurred disc margins suggested early cerebral edema. Despite fluid restriction, avoidance of alkali, and phosphate supplementation, cerebral edema ensued three hours later. This complication was then reversed by administration of mannitol. Our patient's ophthalmoplegia, unlike typical diabetic ophthalmoplegia, improved immediately and completely resolved within two weeks after this episode. It is concluded that the use of mannitol in the cerebral edema of diabetic ketoacidosis is beneficial if it is instituted promptly.

Treatment of Diabetic Ketoacidosis With Intravenous U-500 Insulin in a Patient With Rabson-Mendenhall Syndrome: A Case Report

2016 ◽  
Vol 30 (4) ◽  
pp. 468-475 ◽  
Author(s):  
Megan M. Moore ◽  
Abby M. Bailey ◽  
Alexander H. Flannery ◽  
Regan A. Baum
Keyword(s):  
Insulin Resistance ◽  
Case Report ◽  
Blood Glucose ◽  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Genetic Disorder ◽  
Regular Insulin ◽  
Control Blood Glucose ◽  
Intravenous Insulin ◽  
High Doses

Rabson-Mendenhall syndrome is a rare genetic disorder resulting from mutations in the insulin receptor and is associated with high degrees of insulin resistance. These patients are prone to complications secondary to their hyperglycemia including diabetic ketoacidosis (DKA). We report the case of a 19-year-old male with Rabson-Mendenhall syndrome presenting with DKA who required doses of up to 500 U/h (10.6 U/kg/h) of insulin. The patient’s insulin infusion was originally compounded with U-100 regular insulin, although to minimize volume, the product was compounded with U-500 insulin. The DKA eventually resolved requiring infusion rates ranging from 400 to 500 U/h. Although numerous opportunities for medication errors exist with the use of U-500 insulin, this case outlines the safe use of concentrated intravenous insulin when clinically indicated for patients requiring extremely high doses of insulin to control blood glucose.

scholarly journals VARIABILITY IN EMERGENT MANAGEMENT OF DIABETIC KETOACIDOSIS IN PEDIATRICS: A RETROSPECTIVE CHART REVIEW

2018 ◽  
Vol 23 (suppl_1) ◽  
pp. e11-e12
Author(s):  
Zoyah Thawer ◽  
David Saleh ◽  
Keith Gregoire
Keyword(s):  
Diabetic Ketoacidosis ◽  
Cerebral Edema ◽  
Insulin Infusion ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Evidence Based ◽  
Community Hospitals ◽  
Tertiary Centre ◽  
Paediatric Patients ◽  
Significant Difference

Abstract BACKGROUND Variability in the management of paediatric diabetic ketoacidosis (DKA) has been well described in the literature. Although there are many paediatric DKA management guidelines available at tertiary care centres, there seems to be a lack of familiarity with these in some community hospitals, leading to management inconsistent with evidence-based clinical practice. OBJECTIVES Our objectives were to review the management of paediatric patients who present in DKA, identify those that received initial emergent treatment not consistent with current guidelines, and track associated complications. DESIGN/METHODS Forty-seven charts of paediatric patients admitted to our institution (including patients transferred from peripheral hospitals) from January, 2012 to July, 2017 were identified by ICD-10 codes containing “ketoacidosis”. Primary outcome measures for inadequate management included major risk factors for cerebral edema - IV insulin boluses, IV bicarbonate boluses, hypo-osmolar IV fluid administration and non-NPO status - as well as inappropriate IV fluid boluses>10mL/kg, insulin infusion initiated within the first hour after IV fluids were initiated, and inadequate potassium replacement. RESULTS At least one area of inadequate management occurred at a rate of 74.5% with no significant difference between community hospitals and our tertiary centre. The most common parameter was inadequate replacement of potassium (44.7%), followed by receiving an IV fluid bolus>10mL/kg (40.4%). Twenty-three percent of patients received inadequate management that included a treatment-related major risk factor for cerebral edema. The most common complication was hypoglycemia (BG<4.0mM; 14.9%) and there were no cases of cerebral edema or patients that received a CT head. Though the mean time to insulin infusion initiation was 4.0 hours at outside centres and 2.8 hours at our tertiary centre, the difference was not statistically significant (p=0.26). However, there was a statistically significant difference in time to correction of acidosis, with correction of DKA happening more quickly at our tertiary centre (9.5h compared to 12.7h at outside centres; p=0.03). CONCLUSION Optimal paediatric DKA management continues to be a challenge despite the presence of multiple, evidence-based guidelines. Gradual resuscitation with appropriate fluids appears to be the most common area in which variability exists in community and tertiary care centres.

Pattern of insulin delivery affects hepatic insulin sensitizing substance (HISS) action and insulin resistance

2004 ◽  
Vol 82 (12) ◽  
pp. 1068-1074 ◽  
Author(s):  
Maria A. G Reid ◽  
W Wayne Lautt
Keyword(s):  
Insulin Sensitivity ◽  
Insulin Action ◽  
Insulin Infusion ◽  
Insulin Delivery ◽  
Glucose Disposal ◽  
Sprague Dawley ◽  
Fed State ◽  
Significant Difference ◽  
Bolus Insulin ◽  
Continuous Insulin Infusion

Hepatic insulin sensitizing substance (HISS) action accounts for 55% of the glucose disposal effect of a bolus of insulin in the fed state. To determine the effect of continuous versus pulsatile insulin delivery on HISS action in male Sprague–Dawley rats, insulin sensitivity was assessed using the rapid insulin sensitivity test (RIST) before and after a continuous, pulsatile, or bolus insulin (60 mU/kg i.v.) delivery. There was a significant difference in the RIST index after a continuous insulin infusion (247.9 mg/kg before, 73.2 mg/kg after) but not after 3 pulses where insulin action returned to baseline between pulses (211.6 mg/kg before, 191.0 mg/kg after) or single bolus (205.8 mg/kg before, 189.9 mg/kg after) insulin infusion. If a 3-pulse infusion was timed so that insulin action did not return to baseline between pulses, HISS action was suppressed. Continuous insulin infusion (10–30 min) showed progressive postinfusion blockade of HISS action. To maintain HISS-dependent insulin action, continuous insulin infusions should be avoided.Key words: pulsatile, glucose uptake, RIST, euglycemic clamp, insulin sensitivity.

Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Manish Bastakoti ◽  
Mohamad Muhailan ◽  
Ahmad Nassar ◽  
Tariq Sallam ◽  
Sameer Desale ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Emergency Department ◽  
Intensive Care ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Hospital Discharge ◽  
Length Of Hospital Stay ◽  
Retrospective Chart Review ◽  
Admission Diagnosis ◽  
Emergency Department Admission

Abstract Objectives Published discrepancy rates between emergency department (ED) and hospital discharge (HD) diagnoses vary widely (from 6.5 to 75.6%). The goal of this study was to determine the extent of diagnostic discrepancy and its impact on length of hospital stay (LOS), up-triage to the intensive care unit (ICU) and in-hospital mortality. Methods A retrospective chart review of adult patients admitted from the ED to a hospitalist service at a tertiary hospital was performed. The ED and HD diagnoses were compared and classified as concordant, discordant, or symptom diagnoses according to predefined criteria. Logistic regression analysis was conducted to examine the associations of diagnostic discordance with in-hospital mortality and up-triage to the ICU. A linear regression model was used for the length of stay. Results Of the 636 patients whose records were reviewed, 418 (217 [51.9%] women, with a mean age of 64.1 years) were included. Overall, 318 patients (76%) had concordant diagnoses, while 91 (21.77%) had discordant diagnoses. Only 9 patients (2.15%) had symptom diagnoses. A discordant diagnosis was associated with increased mortality (OR: 3.64; 95% CI: 1.026–12.91; p=0.045) and up-triage to the ICU (OR: 5.51; 95% CI: 2.43–12.5; p<0.001). The median LOS was significantly greater for patients with discordant diagnoses (7 days) than for those with concordant diagnoses (4.7 days) (p=0.004). Symptom diagnosis did not affect the mortality or ICU up-triage. Conclusions One in five hospitalized patients had discordant HD and admission diagnoses. This diagnostic discrepancy was associated with significant impacts on patient morbidity and mortality.

scholarly journals Treatment of Severe Hypertriglyceridemia With Insulin Infusions in Severe COVID-19: A Case Series

2021 ◽  
pp. 089719002110104
Author(s):  
Caitlin M. Thomas ◽  
Martie Vicent ◽  
Shawn Moore ◽  
Fahd Ali ◽  
Leslie Wooten ◽  
...  
Keyword(s):  
Insulin Infusion ◽  
Case Series ◽  
Retrospective Chart Review ◽  
Lipid Lowering ◽  
Optimum Dose ◽  
Infusion Therapy ◽  
Lipid Lowering Therapy ◽  
Omega 3 ◽  
Severe Hypertriglyceridemia ◽  
Continuous Insulin Infusion

Purpose: Rapid onset of severe hypertriglyceridemia was quickly recognized in critical COVID-19 patients. Associated causes have been due to secondary hemophagocytic lymphohystiocytosis (HLH) syndrome, medication-induced, or acute liver failure. Statins, omega-3 polyunsaturated acids, niacin, and fibrates are common oral lipid lowering therapy options in patients at risk for hypertriglyceridemia. The severity of hypertriglyceridemia in COVID-19 patients with triglyceride values reaching greater than 1,000 mg/dL put them at a heightened risk of pancreatitis and therefore an essential need to acutely lower their levels. We present a case series of 5 patients who achieved rapid triglyceride lowering through continuous insulin infusion therapy. Methods: A retrospective chart review of 48 critical COVID-19 patients who were admitted from March 22 to April 15, 2020 was conducted. Inclusion criteria consisted of mechanical ventilation and continuous insulin infusion to treat severe hypertriglyceridemia resulting with 5 eligible patients in this case report. Results and Conclusion: In addition to standard oral lipid lowering therapies, continuous insulin infusion successfully treated severe hypertriglyceridemia in critically ill COVID-19 patients. None of the patients experienced pancreatitis or hypoglycemia necessitating cessation of insulin. Further studies are needed to show the optimum dose and duration of insulin infusion as monotherapy and in combination with oral therapies.

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