Hypertriglyceridemia-associated acute pancreatitis: Response to continuous insulin infusion

Objective To assess the response of serum triglycerides (TG) to continuous insulin infusion (CII) in adults with hypertriglyceridemia-associated acute pancreatitis (HTGP). Methods Retrospective analysis of TG response to standardized CII therapy in 77 adults admitted to intensive care with TG >1000 mg/dL and HTGP. Results Participants had initial TG 3869.0 [2713.5, 5443.5] mg/dL and were 39.3 ± 9.7 years old, 66.2% males, 58.4% Hispanic, BMI 30.2 [27.0, 34.8] kg/m2, 74.0% with diabetes mellitus (DM) and 50.6% with excess alcohol use. TG-goal, defined as ≤1,000 ± 100 mg/dL, was achieved in 95%. Among the 73 TG-goal achievers (responders), 53.4% reached TG-goal in <36 hours after CII initiation (rapid responders). When compared to slow responders taking≥36 hours, rapid responders had lower initial TG (2862.0 [1965.0, 4519.0] vs 4814.5 [3368.8, 6900.0] mg/dL), BMI (29.4 [25.9, 32.8] vs 31.9 [28.2, 38.3] kg/m2), DM prevalence (56.4 vs 94.1%), and reached TG-50% (half of respective initial TG) faster (12.0 [6.0, 17.0] vs 18.5 [13.0, 32.8] hours). Those with DM (n = 57) vs non-DM (n = 20) were obese (31.4 [28.0, 35.6] vs 27.8 [23.6, 30.3] kg/m2), took longer to reach TG-final (41.0 [25.0, 60.5] vs 14.5 [12.5, 25.5] hours) and used more daily insulin (1.7 [1.3, 2.1] vs 1.1 [0.5, 1.9] U/kg/day). Among those with DM, the rapid responders had higher daily use of insulin vs slow responders 1.9 [1.4, 2.3] vs 1.6 [1.1, 1.8] U/kg/day. All results significant. In multivariable analysis, predictors of faster TG response were absence of DM, lower BMI and initial TG. Conclusion CII was effective in reaching TG-goal in 95% of patients with HTGP. Half achieved TG-goal within 36 hours. Presence of DM, higher BMI and initial TG slowed the time to reach TG-goal. These baseline parameters and rate of decline to TG-50% may be real-time indicators to initiate and adjust the CII for quicker response.

The Peruvian Experience: New-Onset Diabetes Presenting With Diabetic Ketoacidosis in Patients With COVID19 Infections

Introduction: Data has emerged about patients with T2DM may experience DKA and HHS if infected with SARS-CoV-2. There is limited data about new-onset diabetes in patients with COVID-19. We describe a case series of three Peruvian patients with new onset diabetes presenting with DKA who remained insulin dependent several months after infection resolution. Case 1: A 59-year-old man with no significant past medical history and normal glucose presented with fever and dyspnea for five days. He was hospitalized with hypoxemic respiratory failure and tested positive forCOVID19. Hypoxemia improved with supportive care, but on day three, he became lethargic, tachycardic, and tachypneic with 95% oxygen saturation on room air. Biochemistry revealed an anion gap metabolic acidosis with pH 7.3, bicarbonate 10 mmol/L (22–28), β-hydroxybutyrate 5.4 mmol/L (&lt;0.5), and glucose 679 mg/dL. He was treated with continuous insulin infusion. After DKA resolved, he was transitioned to basal-bolus insulin and remained insulin-dependent during outpatient follow-up. Case 2: A 49-year-old man in good health prior to admission, was transferred to our hospital for acute respiratory failure and positive testing for SARS-CoV-2. Two days later he became confused, tachycardic, and tachypneic with 90% oxygen saturation. DKA was diagnosed based on a pH 7.1, bicarbonate 8 mmol/L, β-hydroxybutyrate 5 mmol/L and glucose 625 mg/dL. He was transferred to the ICU for continuous insulin infusion. After resolution of his DKA, subcutaneous insulin was started. Preadmission hemoglobin A1c was 4.5%. He remained on insulin post hospital discharge. Case 3: A 33-year-old man with normal glucose prior to admission was transferred to our hospital from an outpatient office with a two-day history of dyspnea and altered sensorium. He was tachycardic and tachypneic with 96% oxygen saturation on 3L nasal cannula. He tested positive for SARS-CoV-2. DKA was diagnosed with glucose 690 mg/dL, bicarbonate 4 mmol/L, serum β-hydroxybutyrate 5.8 mmol/L and pH 6.6. He was resuscitated with intravenous fluids and an insulin infusion was started. DKA resolved after 5 days and he was discharged home on subcutaneous insulin. He remained insulin-dependent on follow-up. Conclusion: New-onset diabetes with DKA due to SARS-CoV-2 is increasingly recognized, and beta-cell dysfunction can be permanent, resulting in insulin-dependent diabetes. Accordingly, our patients remained insulin-dependent several months post discharge.

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

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.

The need for updating nurses’ knowledge and skills in the field of recommendations for diabetes care

Aim. The aim of this study was to assess the need for updating nurses’ knowledge and skills in the field of diabetes care recommendations.Material and methods. The study included 580 nurses who were master’s degree students. A knowledge test including 20 questions on 10 procedures mentioned in the recommendations was used to collect research data. A total of 93.3% of students in the study group were professionally active.Results. A total of 11.9% of respondents had access to diabetes care recommendations. The largest knowledge deficits were found for: leaving an ‘old’ cannula for continuous insulin infusion using an insulin pump for 2-3 hours in place to allow for absorption of the accumulated insulin after inserting a new one; the time it takes to calibrate a continuous glucose monitoring (CGM) system by measuring capillary blood glucose after insertion of a CGM electrode; and indications for alternate site testing. Poor, fair, and good level of knowledge on recommendations was found in 12.8%, 84.3%, and 2.9% of respondents, respectively.Conclusions. 1) The level of knowledge of studying nurses on diabetic care recommendations is unsatisfactory. 2) Specialised nurses, as well as those participating in in-house training courses on diabetes and those declaring the accessibility of recommendations at workplace show a higher level of knowledge. 3) In the light of the development of new medical technologies, periodic workshops focusing on practical skills should be organised for nurses in their workplace, enabling the use of equipment for insulin administration and glucose monitoring.

Simplified Approach to Incorporating Glycemic Response Within a Continuous Insulin Infusion Algorithm to Improve the Incidence of Hypoglycemia in a Single Burn Center

Attaining adequate glycemic control in burn patients has been shown to reduce infection-related mortality. Previous internal evaluation of continuous insulin infusion (CII) use revealed a hypoglycemia rate of 0.6% and an average time within goal glycemic range (70–149 mg/dl) of 13.8 h/day. A new algorithm, designed to adjust dosage based on glycemic response, underwent six iterations over 2 years before the final version was implemented. The purpose of this retrospective study was to assess the post-implementation performance of the newly developed CII algorithm. The current study was powered to detect a 50% reduction in hypoglycemic events, as compared to a pre-implementation historical control. The cohort was 62% male with a mean age of 54.5 ± 17.4. Sixty-five percent had thermal injuries with a median 23.5 (11–45) %TBSA. There were no differences in demographics between groups. Among the 20 records reviewed, 5239 point-of-care glucose values were assessed. Post-implementation, hypoglycemia rates were significantly lower (0.6% vs 0.2%; P &lt; .001). There was no difference in median blood glucose between groups (149.9 vs 146.5 mg/dl; P = .56). Time spent within goal glycemic range was not significantly different (13.8 vs 14.7 h/day; P = 0.23). There were no differences in infection, length of stay, or survival. The consolidation, education, and implementation of a single, dynamic CII algorithm reduced the incidence of hypoglycemia. The authors expect that education and diligence with follow-up glucose monitoring will further improve time within goal glycemic range by preventing rebound hyperglycemia.

513 Simplified Approach to Incorporating Glycemic Response Within a Continuous Insulin Infusion Algorithm to Improve Incidence of Hypoglycemia in a Single Burn Center

Introduction Attaining adequate glycemic control in burn patients can reduce infection-related mortality. Previous internal evaluation of four insulin infusion protocols showed a hypoglycemia (&lt; 60 mg/dL) rate of 0.6% and an average time within goal glycemic range (70-149 mg/dL) of 13.8 hours per day. A new algorithm underwent six iterations over two years before the final version was implemented. The purpose of our study was to assess the post-implementation performance of the newly-developed continuous insulin infusion (CII) protocol designed to adjust dosage based on glycemic fluctuation. Methods This study was a two year retrospective, IRB approved, review of adult patients admitted to a single burn center, who received a CII. The pre-implementation study served as a historical control comparator. The current study was powered to detect a 50% reduction in hypoglycemic events, requiring 4,245 point-of-care samples. Based on average usage, at least 20 patients were required for adequate power of 80 % and alpha of 0.05. Demographics, insulin infusion data, infection, and mortality outcomes were collected. Nominal data were analyzed by Fisher’s exact test. Continuous variables were compared using either Mann-Whitney U test or student’s t-test, depending on normality. Results Of the 27 records screened for inclusion, seven were excluded. The average patient was a 59-year-old Caucasian male with diabetes and a total body surface area burn of 17%. There were no differences in demographics between groups. Among the 20 records reviewed, 5,239 point-of-care glucoses were assessed. Post implementation, hypoglycemia rates were significantly lower (0.6% vs 0.2%; p &lt; 0.001). There was no difference in median blood glucose between groups (149.9 mg / dL vs. 146.5 mg / dL; p = 0.56) or time to achieve the goal glycemic range (6 vs 6.5 hours; p = 0.28). Time spent within goal glycemic range was not significantly different (13.8 vs. 14.7 hours / day; p = 0.23). The overall median time until glucoses were monitored after holding CII for down trending glucoses was 65.7 (53.5–111.3) minutes. Of the times CII were held, 53 of the follow up glucoses (25%) surpassed 200 mg / dL before subsequently settling. There was no differences in infection, length of stay, or survival. Conclusions The consolidation, education, and implementation of a single, dynamic CII algorithm reduced the incidence of hypoglycemia. The authors expect, education and diligence with follow up glucose monitoring will further improve time within goal glycemic range by preventing rebound hyperglycemia. Applicability of Research to Practice Improving glycemic control can be obtained by simple means. Implementing a two step algorithm that incorporates glycemic response and goal with vigorous education will reduce hypoglycemia and improve glycemic control.