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• Perioperative hyperglycemia is a proven risk factor for postoperative infectious complications in neurosurgery. • Scheduled BGC monitoring and the use of low-dose insulin infusion protocol can decrease the postoperative infection rate in patients undergoing elective craniotomy. • Implementation of the perioperative BGC monitoring and the correction protocol prevented both severe hyperglycemia (≥180 mg/dl) and hypoglycemia (<70 mg/dl). Severe perioperative hyperglycemia (SH) is a proven risk factor for postoperative complications after craniotomy. To reduce this risk, it has been proposed to implement the standardized clinical protocol for scheduled perioperative blood glucose concentration (BGC) monitoring. This would be followed by intravenous (IV) insulin infusion to keep BGC below 180 mg/dl in the perioperative period. The aim of this prospective observational study was to assess the impact of this type of protocol on the postoperative infection rate in patients undergoing elective craniotomy. A total of 42 patients were prospectively enrolled in the study. Protocol included scheduled BGC monitoring in the perioperative period and rapid-acting insulin IV infusion when intraoperative SH was detected. The diagnosis of infection (wound, pulmonary, blood stream, urinary tract infection or central nervous system infection) was established according to CDC criteria within the first postoperative week. A previously enrolled group of patients with sporadic BGC monitoring and subcutaneous insulin injections for SH management was used as a control group. An infectious complication (i.e., pneumonia) was diagnosed only in one patient (2 %) in the prospective group. In comparison with the control group, a decrease in the risk of postoperative infection was statistically significant with OR = 0.08 [0.009 – 0.72] (p = 0.02). Implementation of the perioperative BGC monitoring and the correction protocol prevented both severe hyperglycemia and hypoglycemia with BGC < 70 mg/dl. Scheduled BGC monitoring and the use of low-dose insulin infusion protocol can decrease the postoperative infection rate in patients undergoing elective craniotomy. Future studies are needed to prove the causality of the implementation of such a protocol with an improved outcome. [ABSTRACT FROM AUTHOR]

A 28-year-old single female diagnosed with transverse sinus thrombosis; she was also discovered to be diabetic with severe hyperlipidemia. She presented by recurrent episodes of diffuse dull aching abdominal pain referred to the back; she was diagnosed with acute pancreatitis with markedly elevated triglyceride (TG) levels. She started medical treatment for hypertriglyceridemia with no improvement. She started four sessions of plasma exchanges with marked improvement of the general condition, abdominal pain and appetite, and TGs declined.While the patient was on plasma exchange she developed catheter related infection so it is stopped and soon triglycerides raised again with recurrence of the abdominal pain and we started insulin infusion with improvement of her condition

Prevalence of type 2 diabetes increased from 2.5% of the US population in 1990 to 10.5% in 2018. This creates a major public health problem, due to increases in long-term complications of diabetes, including neuropathy, retinopathy, nephropathy, skin ulcers, amputations, and atherosclerotic cardiovascular disease. In this review, we evaluated the scientific basis that supports the use of physiologic insulin resensitization. Insulin resistance is the primary cause of type 2 diabetes. Insulin resistance leads to increasing insulin secretion, leading to beta-cell exhaustion or burnout. This triggers a cascade leading to islet cell destruction and the long-term complications of type 2 diabetes. Concurrent with insulin resistance, the regular bursts of insulin from the pancreas become irregular. This has been treated by the precise administration of insulin more physiologically. There is consistent evidence that this treatment modality can reverse the diabetes-associated complications of neuropathy, diabetic ulcers, nephropathy, and retinopathy, and that it lowers HbA1c. In conclusion, physiologic insulin resensitization has a persuasive scientific basis, significant treatment potential, and likely cost benefits.

Background and Aim: The stress induced by surgery disrupts the delicate balance between hepatic glucose production and glucose utilization in the body. Despite the significance of intraoperative glycaemic control for diabetic patients, limited attention has been given to this aspect. Two methods for administering insulin to manage glucose levels during surgery exist. This study aimed to compare intraoperative glucose levels in diabetic patients undergoing Coronary Artery Bypass Graft (CABG) surgery using either insulin infusion or the bolus method. Method: This was a Randomized Clinical Trial (RCT). Seventy diabetic patients aged 40 or older scheduled for CABG surgery were enrolled in the trial. They were randomly assigned, using block randomization, to receive intraoperative insulin via either infusion or the bolus method. The primary outcome measure was intraoperative glucose levels. Subsequent insulin unit requirements and intraoperative potassium levels were secondary outcomes. Data was monitored throughout the CABG procedure and recorded at six different checkpoints. Results: Male patients constituted the majority in both groups, with no significant differences in the preoperative characteristics of patients, including HbA1c levels and comorbidities. The infusion regimen demonstrated a statistically significant reduction in glucose levels (-19.12 mg/dL, 95% CI: -27.68 to -10.55, P<0.001, Cohen's d=1.06) compared to the bolus regimen. The total insulin units administered in the infusion group were 480 units, as opposed to 600 units in the bolus group (P=0.001, Cohen's d=0.85). Importantly, no cases of hypoglycemia or hyperkalemia were reported among the patients. Conclusion: Intraoperative glucose control using insulin was effective for CABG patients with diabetes. However, the infusion regimen exhibited statistically superior results compared to the bolus regimen. [ABSTRACT FROM AUTHOR]

One major obstacle that limits the lifespan of insulin infusion pumps is surmounting the tissue site reaction at the device implantation site. All commercial insulin formulations contain insulin phenolic preservatives (IPPs) designed to ensure insulin protein stability and prolong shelf-life. However, our laboratory demonstrated that these preservatives are cytotoxic and induce inflammation. Mature mast cells (MCs) reside in cutaneous tissue and are one of the first responders to an epidermal breach. Upon activation, MCs release proinflammatory and immunomodulatory prepacked mediators that exacerbate these inflammatory reactions. Thus, we hypothesized that once the epidermis is breached, cutaneous MCs are triggered inciting the inflammatory response to IPP-induced inflammation. This hypothesis was pursued utilizing our modified in vivo mouse air pouch model, including a c-kit dependent (C57BL/6J-kitW-sh/W-sh) and a c-kit independent (Cpa3-Cre; Mcl-1fl/fl) MC-deficient mouse model. Leukocytes were quantified in the mouse air pouch lavage fluid following flow cytometry analysis for IPP infusion under three different states, insulin-containing phenolic preservatives (Humalog®), insulin preservatives alone, and normal saline as a control. The air pouch wall was assessed using histopathological evaluations. Flow cytometry analysis demonstrated a statistically significant difference in inflammatory cell recruitment for both MC-deficient mouse models when compared to the control strain including infused control saline. Significantly less inflammation was observed at the site of infusion for the MC-deficient strains compared to the control strain. Overall, concordant results were obtained in both mouse types, C57Bl6-kitW-sh/W-sh and Cpa3-Cre; Mcl-1fl/fl. These findings in multiple model systems support the conclusion that MCs have important or possible unique roles in IPP-induced inflammation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Computerized insulin infusion protocols have demonstrated higher staff satisfaction, better compliance with protocols, and increased time with glucose in range compared to paper protocols. At University of California San Diego Health (UCSDH), we implemented an insulin infusion computer calculator (IICC) and transitioned it from a web-based platform directly into the electronic medication administration record (eMAR) of our primary electronic health record (EHR). METHODS: This is a retrospective analysis of 6306 adult patients at UCSDH receiving intravenous (IV) insulin infusion from March 7, 2013 to May 30, 2019. We created three periods of the study-(1) the pre-eMAR integration period; (2) the eMAR integration period; and (3) the post-eMAR integration period-and looked at the percentage of readings within goal range (90-150 mg/dL for intensive care unit [ICU], 90-180 mg/dL for non-ICU) in patients with and without hyperglycemic emergencies. As our safety endpoints, we elected to look at incidence of blood glucose (BG) readings

Objective: To compare the rate of neonatal hypoglycemia among newborns delivered by individuals with Type 2 diabetes mellitus (T2DM) in two clinical scenarios: who attempted vaginal delivery vs. had a planned cesarean delivery (CD); who had intrapartum insulin infusion vs. who did not. Methods: This was a retrospective cohort study of individuals with insulin-treated T2DM who had non-anomalous singleton pregnancy and delivered at a single tertiary center (March 2012 and May 2018). Individuals with chronic renal failure, proliferative retinopathy, or major congenital anomalies were excluded. The primary outcome was neonatal hypoglycemia (blood glucose < 40 mg/dl <24 h of age or < 50 mg/dl >24 h of age). Secondary outcomes included neonatal outcomes. Multivariable Poisson regression models with robust error variance were used to examine the association between groups and the primary outcome. Adjusted relative risk (aRR) and 95% confidence intervals (CI) were calculated. Results: Of 233 individuals with T2DM, 215 (92.2%) met the inclusion criteria, of whom 95 (44%) attempted vaginal delivery and 120 (56%) had a planned CD. Individuals who labored had a higher gestational age at delivery (36.6 vs. 35.8 weeks, p = .005), and higher blood glucose levels upon admission (125 vs 103, p < .001) compared to those with a planned CD. After adjustment for potential confounders, there was no difference in risk of neonatal hypoglycemia between the groups (41.2 vs 44.1%, aRR 1.05, 95% CI = 0.75-1.45). Among those who attempted vaginal delivery, 34 (35.8%) required insulin infusion. There was no difference in the risk of neonatal hypoglycemia (aRR = 0.79, 95% CI = 0.45-1.37) between newborns delivered by individuals who required insulin infusion and those who did not. Conclusion: Over 40% of newborns delivered by individuals with insulin-dependent T2DM had hypoglycemia; however, there was no significant difference in the risk of hypoglycemia, irrespective of the route of delivery and the use of insulin infusion. [ABSTRACT FROM AUTHOR]

One major obstacle that limits the lifespan of insulin infusion pumps is surmounting the tissue site reaction at the device implantation site. All commercial insulin formulations contain insulin phenolic preservatives (IPPs) designed to ensure insulin protein stability and prolong shelf-life. However, our laboratory demonstrated that these preservatives are cytotoxic and induce inflammation. Mature mast cells (MCs) reside in cutaneous tissue and are one of the first responders to an epidermal breach. Upon activation, MCs release proinflammatory and immunomodulatory prepacked mediators that exacerbate these inflammatory reactions. Thus, we hypothesized that once the epidermis is breached, cutaneous MCs are triggered inciting the inflammatory response to IPP-induced inflammation. This hypothesis was pursued utilizing our modified in vivo mouse air pouch model, including a c-kit dependent (C57BL/6J-kitW-sh/W-sh) and a c-kit independent (Cpa3-Cre; Mcl-1fl/fl) MC-deficient mouse model. Leukocytes were quantified in the mouse air pouch lavage fluid following flow cytometry analysis for IPP infusion under three different states, insulin-containing phenolic preservatives (Humalog®), insulin preservatives alone, and normal saline as a control. The air pouch wall was assessed using histopathological evaluations. Flow cytometry analysis demonstrated a statistically significant difference in inflammatory cell recruitment for both MC-deficient mouse models when compared to the control strain including infused control saline. Significantly less inflammation was observed at the site of infusion for the MC-deficient strains compared to the control strain. Overall, concordant results were obtained in both mouse types, C57Bl6-kitW-sh/W-sh and Cpa3-Cre; Mcl-1fl/fl. These findings in multiple model systems support the conclusion that MCs have important or possible unique roles in IPP-induced inflammation.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors have demonstrated efficacy in slowing the progression of chronic kidney disease (CKD), managing conditions such as congestive heart failure (CHF), and reducing cardiovascular and overall mortality in patients with type 2 diabetes mellitus (T2DM). However, their use is associated with complications, including euglycemic diabetic ketoacidosis (euDKA), genital fungal infections, and urinary tract infections (UTIs). Although rare, complications like euDKA can lead to serious consequences if not promptly addressed, as illustrated by this case report of a 90-year-old man with ischemic cardiomyopathy and type 2 diabetes who developed both euDKA and a UTI while on SGLT2 inhibitor therapy. Early identification of euDKA from SGLT2 inhibitor usage prompted cessation of the SGLT2 inhibitor and administration of insulin infusion, ultimately resolving the life-threatening condition., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Chauhan et al.)

Hyperglycaemia is recognized as a marker of adverse clinical outcomes for hospitalized patients with and without diabetes, including mortality, morbidity, increased length of stay, infections and overall complications. In some cases, intravenous (IV) insulin infusions are the optimal intervention and, to date, these have been compounded in hospital pharmacy departments or, alternatively, at the point of care, when timeliness is a concern or the pharmacy is closed. However, in-house compounding of high-risk medications such as IV insulin poses risks both for patients and institutions. The critical nature of certain high-risk therapies has led to the development of ready-to-administer products to improve the safety, timeliness, efficacy and efficiency of critical infusions. Recently, IV insulin, a high-alert therapy, has been added to the ready-to-use armamentarium. This narrative review explores the expanding indications, risks and opportunities associated with insulin infusions and potential options for improved safety.

Objective: Surgical site infection (SSI) is one of the most serious potential complications post cardiac surgery among patients with diabetes and has a number of adverse health outcomes. The literature shows discrepancies regarding the effect of different glycaemic control protocols on reducing adverse health outcomes including SSIs. The aim of this study was to conduct a systematic review that investigated the effect of the optimal range of tight glycaemic control protocols using a continuous insulin infusion on reducing the incidence of SSIs in adult patients with diabetes undergoing cardiac surgery. Method: A systematic review was conducted following the PRISMA statement and guidelines. Search terms were used to identify research studies published between 2000 and 2019 across five key databases, including CINAHL, Medline, PubMed, Cochrane Database and Google Scholar. Results: A total of 12 studies met the review inclusion criteria. The reviewed literature tended to support the implementation of a tight glycaemic control protocol, particularly in the postoperative phase, that demonstrated fewer potential complications associated with cardiac surgery. On the other hand, the literature also supported the application of a moderate glycaemic control protocol in the intraoperative phase to obtain better glycaemic stability with fewer potential complications among those patients with diabetes undergoing cardiac surgery. Conclusion: This analysis concludes that tight glycaemic control is more effective than moderate glycaemic control intraoperatively in terms of glycaemic stability among patients with diabetes undergoing cardiac surgery. Results also emphasised the importance of time-based protocol implementation to ensure better health outcomes and better quality of care for patients. [ABSTRACT FROM AUTHOR]

Background: We evaluated the feasibility of real-time continuous glucose monitoring (CGM) for titrating continuous intravenous insulin infusion (CII) to manage hyperglycemia in postoperative individuals in the cardiovascular intensive care unit and assessed their accuracy, nursing acceptance, and postoperative individual satisfaction., Methods: Dexcom G6 CGM devices were applied to 59 postsurgical patients with hyperglycemia receiving CII. A hybrid approach combining CGM with periodic point-of-care blood glucose (POC-BG) tests with two phases (initial-ongoing) of validation was used to determine CGM accuracy. Mean and median absolute relative differences and Clarke Error Grid were plotted to evaluate the CGM accuracy. Surveys of nurses and patients on the use of CGMs experience were conducted and results were analyzed., Results: In this cohort (mean age 64, 32% female, 32% with diabetes) with 864 paired POC-BG and CGM values analyzed, mean and median absolute relative difference between POC-BG and CGM values were 13.2% and 9.8%, respectively. 99.7% of paired CGM and POC-BG were in Zones A and B of the Clarke Error Grid. Responses from nurses reported CGMs being very or quite convenient (n = 28; 93%) and it was favored over POC-BG testing (n = 28; 93%). Majority of patients (n = 42; 93%) reported their care process using CGM as being good or very good., Conclusion: This pilot study demonstrates the feasibility, accuracy, and nursing convenience of adopting CGM via a hybrid approach for insulin titration in postoperative settings. These findings provide robust rationale for larger confirmatory studies to evaluate the benefit of CGM in postoperative care to improve workflow, enhance health outcomes, and cost-effectiveness., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: LA, YKL, LFS, YH, CAD, PA, FA, SK, ED, ND, YQ, RF, NHE, and RG have no conflicting interest to disclose. RPB received grant support to University of Michigan from Dexcom.

Objectives: This study aims to evaluate the impact of Microburst Insulin Infusion (MII) treatment on Type 1 and 2 diabetic patients' HbA1c, lipids, peripheral neuropathy, and patient-reported health status.Methods: We reviewed clinical charts, including lab results, for more than 80 diabetic and pre-diabetic patients treated at one U.S. outpatient clinic in St. Louis, Missouri between February 2017 and December 2019. Data included patient demographics, treatment data, lab and neuropathy tests, and self-reported patient health status questions.The explanatory variable was number of months of MII treatment. Treatments are 3–4 h in length, with two intensive infusions the first week and one treatment each week thereafter, usually for 12 weeks total. Lab tests were at 12-week intervals.Generalized linear modeling and t-tests assessed the significance of differences between patients' baseline lab values, neuropathy measures, and health status before treatment vs. after final treatment.Results: Number of MII treatments per patient ranged from 1 to 262, over 1–24 months. Time in MII treatment was significantly associated with reductions in HbA1c by nearly 0.04 points per month, and triglycerides declined 3 points per month. Neuropathy measures of large toe vibratory sensation (clanging tuning fork) improved significantly, as did patient-reported health and feelings of improvement since beginning treatment.Discussion: The MII therapy appears to be efficacious in treating diabetic patients, particularly those with complications like neuropathy. Our findings affirmed several other studies. We uniquely incorporated patient health questionnaires, and empirically studied MII treatment efficacy for diabetes in a population large enough to permit statistically valid inferences. With multiple waves of data for over 80 patients, this is one of the most extensive quantitative studies of microburst insulin infusion therapy conducted to date, with protocols more uniformly implemented and survey instruments more consistently administered by the same clinical team. Given the advances in insulin infusion therapy brought by MII, and early indications of its efficacy, the time is right for more in-depth studies of the outcomes patients can achieve, the physiological mechanisms by which they occur, MII's comparative effectiveness vis-à-vis traditional treatments, and cost-effectiveness.

Introduction: In critical care setting, insulin infusion rather than subcutaneous insulin is recommended to maintain the blood glucose (BG) level in the target range. We have devised an insulin infusion protocol which requires monitoring of blood glucose and insulin dose adjustment one hourly. In this study, we have studied the efficacy of our insulin infusion protocol (IIP) in terms of bringing and maintaining blood glucose to target range, and its safety in terms of preventing hypoglycemia. Research design and methods: It is a retrospective review of all patients who received insulin infusion from the 1st of July 2017 to the 30th of June 2018. A total of 231 were included and data pertaining to demographic details and related to insulin infusion was documented in a predefined questionnaire. Results: Insulin infusion was continued for a mean duration of 26.3 ± 13.7 h taking 5.7 ± 3.1 h to reach the target BG level < 180 mg/dl. Once the BG was in the target range, 44.3% of blood glucose readings were between 140 and 180 mg/dl, 62.52% of readings were within the safe range, i.e. 110–180 mg/dl while hypoglycemia (< 70 mg/dl) was observed in only 0.44% times with only one episode of severe hypoglycemia (< 40 mg/dl). The 31.65% of BG readings were found to be above the target BG level (> 180 mg/dl) but the mean BG remains 168.95 ± 45.52 within the desired target range. Conclusion: Our insulin infusion protocol not only achieved and maintained the blood glucose in the target range, it is safe with a very low risk of hypoglycemia. [ABSTRACT FROM AUTHOR]

Hyperglycemia in acute coronary syndrome (ACS) is linked to raised morbidity and mortality. Insulin administration using insulin infusion protocols (IIP) is the preferred strategy to control hyperglycemia in critically ill patients. To date, no specific IIP has been identified as the most efficient for achieving glycemic control. to compare glycemic achievements (safety) (primary objective), and coronary and other clinical outcomes (efficacy) (secondary objective) by hyperglycemia management in Cardiac Care Unit (CCU) using computerized Atlanta Protocol (Group (I)) versus paper-based Joint British Diabetes Societies (JBDS) For Inpatient Care Protocol (Group (II)). The study was done on 100 ACS patients admitted to Alexandria Main University hospital CCU with RBG >180 mg/dL. They were randomized into the 2 groups in a 1:1 ratio. CBG was measured hourly for 72 hours and was managed by IV insulin infusion. Group (I) showed statistically significant less mean time for target BG achievement (3.52 ± 1.53hours), lower incidence of Level 1 hypoglycemia (2%) than Group (II) (4.76 ± 2.33 hours, 22%, p = 0.013, 0.002 respectively) and statistically significant less mean number of episodes above the glycemic target after its achievement than Group (II) (p < 0.001). Regarding Level 2 hypoglycemia the difference was not significant statistically. Both protocols successfully maintained target BG level with low incidence of clinically significant hypoglycemia, however, the computerized Atlanta protocol achieved better glycemic outcomes. We recommend the use of the computerized Atlanta protocol in CCU rather than JBDS for Inpatient Care Protocol whenever this is feasible. • Hyperglycemia management in patients admitted to cardiac care units with acute coronary syndrome is essential. • No significant difference in coronary outcome was found between using Atlanta or JBDS For Inpatient Care Protocol. • Computerized Atlanta protocol achieved better glycemic control than JBDS For Inpatient Care Protocol. • There was a low incidence of clinically significant hypoglycemia in both studied intravenous insulin infusion protocols. [ABSTRACT FROM AUTHOR]

Background: Hyperglycemia complicates the course of illness of many critically ill patients and contributes to the increased morbidity and mortality in adult intensive care units (ICUs). Objective: The objective of this study is to compare the effectiveness of a modified nurse-implemented insulin infusion protocol (NIIP) against the original protocol used in the adult ICUs, in terms of controlling hyperglycemia while averting significant hypoglycemia. Methodology: Blood glucose (BG) readings that were collected over 3 months in medical and surgical ICUs (SICUs) while on the original insulin infusion protocol were retrospectively reviewed. A modified insulin infusion protocol was prepared by a dedicated adult ICU quality focus group composed of physicians, nurses, clinical pharmacists, and quality representative. The rate of insulin infusion was increased by 10%–20% for the BG ranges above 13.1 mmol/L, allowing early transition from a mild-to-moderate scale. The new protocol was implemented for 2 months, and BG readings were compared to the results of the original insulin infusion protocol. Results: A total of 3490 BG readings in the medical ICU and 3006 in SICU were analyzed. Hyperglycemia was found in 1743 readings (26.83%) while on the original insulin protocol. When the modified insulin infusion protocol was applied, hyperglycemia was significantly less (19.83%, P < 0.0001) and significantly more readings were in the range of 7.8–10 mmol/L (52.57% vs. 46.54%, P= 0.0001). The reduction in hyperglycemia was more significant in SICU patients (19.20% vs. 31.27%, P < 0.0001). Meanwhile, severe hypoglycemia remained within the benchmark. Conclusions: The modified NIIP achieved fewer episodes of hyperglycemia in critically ill patients while avoiding the deleterious effects of hypoglycemia. This affirms the value of periodic monitoring and adjustment of ongoing protocols in ICUs.

Prevalence of type 2 diabetes increased from 2.5% of the US population in 1990 to 10.5% in 2018. This creates a major public health problem, due to increases in long-term complications of diabetes, including neuropathy, retinopathy, nephropathy, skin ulcers, amputations, and atherosclerotic cardiovascular disease. In this review, we evaluated the scientific basis that supports the use of physiologic insulin resensitization. Insulin resistance is the primary cause of type 2 diabetes. Insulin resistance leads to increasing insulin secretion, leading to beta-cell exhaustion or burnout. This triggers a cascade leading to islet cell destruction and the long-term complications of type 2 diabetes. Concurrent with insulin resistance, the regular bursts of insulin from the pancreas become irregular. This has been treated by the precise administration of insulin more physiologically. There is consistent evidence that this treatment modality can reverse the diabetes-associated complications of neuropathy, diabetic ulcers, nephropathy, and retinopathy, and that it lowers HbA1c. In conclusion, physiologic insulin resensitization has a persuasive scientific basis, significant treatment potential, and likely cost benefits.

Hypertriglyceridemia-induced acute pancreatitis causes significant morbidity and mortality. It is important to promptly identify the underlying etiology and deliver the appropriate care to affected patients. Management includes supportive care and attempts to lower the serum triglyceride level. A case report of a patient treated successfully with an insulin infusion is presented. [ABSTRACT FROM AUTHOR]

Context: Stress hyperglycemia in critically ill patients has been a matter of debate for years without any conclusive answer till date regarding glucose management and treatment thresholds. Aims: We planned a study with an aim to compare the efficacy of intensive versus conventional insulin therapy in reducing the mortality and morbidity in critically ill patients. The primary objective was to compare mortality between the two groups. The secondary objective was to find out if intensive insulin therapy is better than conventional insulin therapy in terms of various outcomes such as infections and need for inotropes and transfusion requirements. Settings and Design: It was a prospective randomized controlled study. The study population included 100 patients who received mechanical ventilation and admitted to the intensive care department of a tertiary care institute. Subjects and Methods: Patients were randomly assigned to two groups: intensive insulin therapy (IIT) and conventional insulin therapy (CIT) to receive either intensive or conventional insulin therapy. Insulin infusion was started only when blood glucose levels exceeded 200 mg%. Blood glucose levels were maintained between 80 and 110 mg% in the IIG and between 180 and 200 mg% in the CIG. Statistical Analysis Used: The data collected were analyzed separately for both the groups using Student's t-test and Chi-square test. Results: The two groups were comparable in terms of baseline demographic data including age, sex, preadmission diabetic status, and HbA1c at the time of admission. The two groups were not comparable in terms of Acute Physiology and Chronic Health Evaluation-II scores, and the difference between them was statistically significant with higher scores in the conventional group. The primary outcome, that is, mortality, was higher in the CIG with 29 patients (58%) versus 3 (6%) in the IIG (P = 0.02). The secondary outcomes were the measures of morbidity including infections, need for inotropic support, and need for blood transfusions, and these were significantly higher in the conventional group (P < 0.05). Conclusions: We conclude that tight glycemic control significantly lowers mortality and morbidity in critically ill patients, both surgical and medical. These benefits appear with the maintenance of tight blood glucose control of 80–110 mg.dL− 1 and not due to administration of insulin. [ABSTRACT FROM AUTHOR]

Chest pain is a common and high-risk chief complaint in the emergency department. There is an array of cardiac and non--cardiac-related conditions that could lead to this symptom. It is important for the clinician to have a broad perspective when treating patients complaining of chest pain so that dangerous and potentially life-threatening conditions are not overlooked. Here, we present one such cause of chest pain that can be detrimental if the clinician fails to correctly identify the underlying condition. A brief review of hypertriglyceridemia-induced acute pancreatitis is provided, and challenges faced by the treatment team are discussed. [ABSTRACT FROM AUTHOR]

Background: The use of an intravenous insulin infusion protocol (IIP) is recommended for management of hyperglycemia in the intensive care unit (ICU); however, limited evidence of comparison has been made with subcutaneous (SC) insulin regimens. Objective: This study aims to evaluate the safety and effectiveness of an IIP compared with SC insulin regimens in an ICU patient sample since the implementation of an IIP using a computerized clinical-decision support tool. Methods: This investigation was a retrospective cohort study of patients who were treated for hyperglycemia while admitted to any of the ICUs at a Veterans Affairs Medical Center. Patients who were treated with either an IIP or a scheduled SC insulin regimen between May 1, 2015, and May 25, 2016, were included for evaluation. Results: Blood glucose (BG) was within the normoglycemia range (70-180 mg/dL) for 63.0% of the measurements in patients treated with an IIP (n = 171) compared with 45.7% in those treated with SC insulin regimens (n = 121; P < 0.01). Overall, patients managed with an IIP had a lower proportion of hypoglycemic BG measurements (1.2% vs 2.1%, P < 0.01), a lower proportion of hyperglycemic BG measurements (35.8% vs 52.2%, P < 0.01), and a lower mean BG (172.4 vs 194.3 mg/dL, P < 0.01). Conclusion and Relevance: The results of this study suggest that an IIP in a sample of adult ICU patients was associated with better BG control and lower occurrence of hypoglycemia compared with SC insulin regimens. [ABSTRACT FROM AUTHOR]

Abstract Aims Although diabetic ketoacidosis (DKA) commonly presents as a pure diabetic ketoacidosis (PDKA), up to 30% of cases may be associated with a mixed hypochloremic metabolic alkalosis (HMA). It is unknown whether there is a difference in treatment outcomes between these two entities. We evaluated an insulin infusion protocol (IIP), previously validated for hyperglycemia management in ICU's, for the management of PDKA and HMA. Materials and methods A retrospective case series/cohort study of 41 DKA admissions was further characterized as having PDKA or HMA. HMA was defined in those having an elevated delta-delta gradient (ΔAG-ΔHCO3) ≥ 5 mmol/L and base excess chloride (BE Cl) > 2.7 mmol/L. The main outcome measures were times to recovery of glucose levels to ≤250 mg/dL and of anion gap to ≤12 mmol/L. Results The initial serum glucose was 553 ± 265 mg/dL, serum bicarbonate of 8.8 ± 5.1 mmol/L, and venous pH 7.13 ± 0.2). Recovery of glucose occurred in 5 h: 25 min (±3 h:39min), and for anion gap in 11 h:25 min (±6 h:56min). HMA compared with PDKA had a delayed recovery of serum glucose (7 h: 23min ± 3 h: 35min vs. 4 h: 31min ± 3:h:21min, p = 0.017), which was due to the higher initial level of glucose (p = 0.02) rather than level of BE Cl (p = 0.17). There was no difference in time to anion gap closure between the PDKA and HMA. Conclusions Correction of hyperglycemia and acidosis in PDKA as well as in HMA was managed through the IIP. The simultaneous fluid and electrolyte management corrected the hypochloremic alkalosis. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 13-month-old boy who was referred to our hospital because of tachypnea after a 3-day episode of fever, vomiting, and diarrhea, and he had been diagnosed with T2d by urinary organic acid analysis. The article aggressive glucose with insulin infusion can be effective for ketoacidosis crisis in patients with beta-thiolase deficiency and frequent measuring of blood glucose is warranted.

Purpose Of Review: We reviewed the strategies associated with hypoglycemia risk reduction among critically ill non-pregnant adult patients.Recent Findings: Hypoglycemia in the ICU has been associated with increased mortality in a number of studies. Insulin dosing and glucose monitoring rules, response to impending hypoglycemia, use of computerization, and attention to modifiable factors extrinsic to insulin algorithms may affect the risk for hypoglycemia. Recurring use of intravenous (IV) bolus doses of insulin in insulin-resistant cases may reduce reliance upon higher IV infusion rates. In order to reduce the risk for hypoglycemia in the ICU, caregivers should define responses to interruption of continuous carbohydrate exposure, incorporate transitioning strategies upon initiation and interruption of IV insulin, define modifications of antihyperglycemic therapy in the presence of worsening renal function or chronic kidney disease, and anticipate the effects traceable to other medications and substances. Institutional and system-wide quality improvement efforts should assign priority to hypoglycemia prevention. [ABSTRACT FROM AUTHOR]