Comparison of Insulin Infusion Protocols Targeting 110–140 mg/dL in Patients After Cardiac Surgery

Magaji, Vasudev; Nayak, Shriddha; Donihi, Amy C.; Willard, Lauren A.; Jampana, Srinivasa; Nivedita, Parachur; Eder, Raymond; Johnston, Jann M.; Korytkowski, Mary T.

doi:10.1089/dia.2012.0114

Cited by 16 publications

(17 citation statements)

References 16 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Patients who meet metabolic criteria for resolution of the diabetic crisis (table 3), but who remain critically ill and unable to tolerate oral intake, will need ongoing management with intravenous fluids and insulin, the latter titrated using an insulin infusion protocol with pre-specified glycemic targets for critical illness 8384…”

Section: Transition From Acute Managementmentioning

confidence: 99%

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

French

Donihi

Korytkowski

2019

BMJ

125

View full text Add to dashboard Cite

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.

show abstract

Section: Transition From Acute Managementmentioning

confidence: 99%

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

French

Donihi

Korytkowski

2019

BMJ

125

View full text Add to dashboard Cite

show abstract

“…Current hospital standard IIPs are adapted from the medical literature focused on primarily adult ICU and cardiac ICU populations, where the impact of hyperglycemia on surgical recovery, wound healing, and infection must be balanced with the mortality risks that are incumbent in this population and increased by occurrence of severe hypoglycemia. [18][19][20][22][23][24][25][26][27][28]30 In contrast, in the pediatric TPIAT population, mortality is rare, and maintenance of euglycemia is essential to reduce glycemic stress on the transplanted pancreatic islets and thereby improve engraftment and long-term diabetes outcomes. 9,[11][12][13] For this population, at our institution, we have adopted a modified IIP to target a lower and narrower target BG range, designed to minimize both significant hypoglycemic and hyperglycemic events.…”

Section: Discussionmentioning

confidence: 99%

“…18 Although early clinical trials favored strict BG targets (80-110 mg/dL) in postsurgical intensive care unit (ICU) patients, [23][24][25][26] more recent trials have favored moderate glycemic goals (conventionally approximately 140 mg/dL) to reduce hypoglycemia-associated mortality. [27][28][29] These findings have led to subsequent efforts to develop hospital-wide insulin infusion protocols that tolerate moderate hyperglycemia as a trade-off for reduced ICU mortality. [18][19][20]22,30 However, these general ICU protocols do not take into consideration the specific needs of the islet autotransplant population.…”

mentioning

confidence: 99%

Near-Euglycemia Can Be Achieved Safely in Pediatric Total Pancreatectomy Islet Autotransplant Recipients Using an Adapted Intravenous Insulin Infusion Protocol

Forlenza

Chinnakotla

Schwarzenberg

et al. 2014

Diabetes Technology & Therapeutics

View full text Add to dashboard Cite

Background: Children with severe chronic pancreatitis may undergo total pancreatectomy with islet autotransplantation (TPIAT) to relieve pain while minimizing the risk of postsurgical diabetes. Because overstimulation of transplanted islets by hyperglycemia can result in b-cell loss, we developed a specialized intravenous insulin infusion protocol (IIP) for pediatric TPIAT recipients to maintain euglycemia or near-euglycemia posttransplant. Subjects and Methods: Our objective was to review glucose control using an IIP specific for TPIAT recipients at a single institution. We reviewed postoperative blood glucose (BG) levels for 32 children 4-18 years old with chronic pancreatitis who underwent TPIAT between July 2011 and June 2013. We analyzed the proportion of BG values in the range of 70-140 mg/dL, mean glucose, glucose variability, and occurrence of hypoglycemia during the IIP; we also evaluated the transition to subcutaneous therapy (first 72 h with multiple daily injections [MDI]). Results: During IIP, the mean patient BG level was 116 -27 mg/dL, with 83.1% of all values in the range of 70-140 mg/dL. Hypoglycemia was rare, with only 2.5% of values <70 mg/dL. The more recent era (n = 16) had a lower mean BG and less variability than the early era (first 16 patients) (P £ 0.004). Mean glucose level (116 vs. 128 mg/dL) and glucose variability were significantly lower during the IIP compared with MDI therapy (P < 0.0001). Conclusions: Tight glycemic control without excessive severe hypoglycemia was achieved in children undergoing TPIAT using an IIP specifically designed for this population; the ability to maintain BG in target range improved with experience with the protocol.

show abstract

“…Une récente étude [13] a montré le bénéfice clair de maintenir une glycémie entre 110 et 140mg/dl en postopératoire immédiat d'une chirurgie cardiaque en adoptant un protocole d'infusion continue d'IO qui a été prouvé meilleur que le protocole d'ajustement par injection de bolus d'IO répété en fonction de la GC que ça soit pour le contrôle des chiffres glycémique que pour la prévention d'hypoglycémie qui était moins fréquente avec l'infusion continue d'IO. Dans notre série, nous avons mis comme GC cible entre 120 et 150mg/dl, 24,3% des patients avaient une GC moyenne dans la zone thérapeutique, alors que 48,5% des patients avaient une GC moyenne entre 150 et 200mg/dl alors que 27,9% des patients dépassaient 200mg/dl.…”

Section: Discussionunclassified

La chirurgie coronaire sous circulation extra-corporelle chez le patient diabétique

Moutakiallah¹,

Benzaghmout²,

Aithoussa³

et al. 2014

Pan Afr Med J

View full text Add to dashboard Cite

Nous rapportons les résultats de la chirurgie coronaire chez une population de coronariens diabétiques opérés sous circulation extra-corporelle dans le service de chirurgie cardiaque de l'hôpital militaire d'instruction Mohammed V de Rabat. C'est une étude rétrospective menée entre Janvier 2008 et Février 2012 (4 ans), portant sur 103 patients diabétiques consécutifs opérés pour pontage coronaire. L’âge moyen des patients était de 61±8,7ans (37-82ans) avec un sexe ratio (H/F) de 3,9. Tous les patients diabétiques de type 2 et sous traitement anti-diabétique ont été inclus dans cette étude. La sténose du tronc commun gauche était présente chez 26,2% des patients et 53,4% étaient tritronculaires. Quatre-vingt patients (78,6%) étaient insulino-nécessitant, l'Euro-score moyen était de 1,63±1% et le nombre moyen de pontage de 2,3±0,7. Les durées moyennes de la circulation extra-corporelle et du clampage aortique étaient respectivement de 134,4 ± 42 min et 76 ± 28 min. La mortalité hospitalière était de 2 décès (1,9%), les durées moyennes de ventilation artificielle, du séjour en réanimation et du séjour postopératoire étaient respectivement de 7h (5-16h), 48h (42-52h) et 15,6 ± 8,6 jours. Les complications postopératoires étaient l'infarctus du myocarde, l'infection de paroi, la médiastinite et le bas débit cardiaque chez respectivement 1,9%, 10,7%, 3,9% et 1,9% des patients. Il ressort de notre étude, que les facteurs prédictifs d'infection post opératoire étaient la durée de ventilation artificielle (p = 0,002), la durée de la circulation extra-corporelle (p < 0,001) en plus du tabac (p = 0,004) et de l'obésité (p = 0,005). Les patients ont été contactés par téléphone ou lors de la consultation régulière de contrôle. Le taux de suivi a atteint 92,1% et la survie à 2 ans était de 98,9% des patients contrôlés avec une mortalité tardive de 1% avec un décès suite à un accident vasculaire cérébral étendu. Le contrôle a montré un cas de ré-hospitalisation pour poussée d'insuffisance cardiaque mais aucun cas de récidive angineuse, d'infarctus du myocarde ou de besoin de revascularisation. La chirurgie coronaire chez le diabétique offre d'excellents résultats à court et à moyen terme au détriment d'une faible morbi-mortalité ce qui en fait le traitement de choix.

show abstract

Comparison of Insulin Infusion Protocols Targeting 110–140 mg/dL in Patients After Cardiac Surgery

Abstract: CII protocols targeting 110-140 mg/dL were effective in achieving revised targets with low hypoglycemia. Despite differences in mean BG level and time to target, each hospital continued using its existing protocols and identified areas for improvement.

Cited by 16 publications

References 16 publications

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

Near-Euglycemia Can Be Achieved Safely in Pediatric Total Pancreatectomy Islet Autotransplant Recipients Using an Adapted Intravenous Insulin Infusion Protocol

La chirurgie coronaire sous circulation extra-corporelle chez le patient diabétique

Contact Info

Product

Resources

About