Clinical Recommendations for Managing the Impact of Insulin Adsorptive Loss in Hospital and Diabetes Care

Abstract

Background: Adsorption of insulin to infusion sets impacts patient therapeutic outcomes and, unaccounted for, may exacerbate persistent hyperglycemia or result in therapy-induced hypoglycemia. This article aims to provide recommendations for clinicians involved in intensive care and/or outpatient pump therapy contexts. Methods: A dynamic adsorption model is used to evaluate time-varying insulin concentration in the infusion set outflow. Hourly and daily percentage insulin loss to adsorption is examined for neonatal, pediatric, and adult intensive care patients, as well as outpatient children and adults weighing 30, 50, and 80 kg. A short review of preconditioning methods is included. Results: Insulin adsorption in outpatient pump therapy is most pronounced in the first hour, where as much as 80% of the intended insulin dose may be lost to adsorption. Subsequently, insulin adsorptive loss is typically negligible. Overall, extra care should be taken in the first 1-6 h of a new infusion set, particularly in children or teenagers. Typically, insulin adsorption in the adult intensive care unit is negligible unless infused at low flow rates (<2 mL/h). Insulin adsorption is significant in pediatric and neonatal intensive care, resulting in delivery concentrations as low as 5%-50% of that intended. Thus, it is recommended that preconditioning of insulin delivery lines be carried out prior to infusion initiation in this context. However, no preconditioning method completely removes adsorption, and care should still be taken in the first 1-6 h of insulin dosing. Conclusions: Recommendations made in this article are dependent on the insulin concentration and flow rate used in each clinical context.

Glycemic Excursion and Insulin Action Revealed in a Rare Case of Type 1 Diabetes Complicated with Short Bowel Syndrome

“…In our case, the serum insulin levels increased after a delay during the initial phase but persisted after infusion. The delay was attributed to insulin adsorption into the infusion bag and infusion sets (9)(10)(11). Administration of rapid-acting insulin before parenteral nutrition successfully ameliorated initial hyperglycemia.…”

Increased insulin resistance in intensive care: longitudinal retrospective analysis of glycaemic control patients in a New Zealand ICU

“…There is the possibility of insulin adsorption affecting apparent insulin sensitivity by requiring greater insulin doses. 71 Trends in consumables have tended towards a better understanding of adsorption as an issue, so it seems unlikely that apparent insulin sensitivity would drop due to adsorptive effects. Equally, adsorption is only an issue in the adult ICU at the flow rates and concentrations over the first 1–3 h, 71 where insulin concentrations may get as low as 80% of intended, and thus adsorption is not going to have a significant effect on 72-h SI.…”

“… 71 Trends in consumables have tended towards a better understanding of adsorption as an issue, so it seems unlikely that apparent insulin sensitivity would drop due to adsorptive effects. Equally, adsorption is only an issue in the adult ICU at the flow rates and concentrations over the first 1–3 h, 71 where insulin concentrations may get as low as 80% of intended, and thus adsorption is not going to have a significant effect on 72-h SI. The authors also know of no other changes in insulin type, storage, preparation, or delivery over this period, mitigating the potential bias from these effects.…”

“…Cohort age was lowest in 2014 [62 (51-70) years] and highest in 2016 [67 (59)(60)(61)(62)(63)(64)(65)(66)(67)(68)(69)(70)(71)(72)(73) years], with a general overall trend to increasing median age by…”

Issues for the management of people with diabetes and COVID-19 in ICU

“…It seems, unfortunately, the case, according to reports on how glycemia was managed in several situations during this pandemic [24,25]. When facing high glucose levels due to severe infection per se, it is often required that patients are switched to insulin, with some concerns that insulin treatment might not always be safely managed in such situations, unless insulin is administered intravenously via an exactly dosing perfusion device to avoid subcutaneous absorption irregularities in critically ill patients [26,27]. Hyperglycemia is common in the Intensive Care Unit (ICU) both in patients with and without a previous diagnosis of diabetes [28].…”