No abstract

Objectives: Insulin infusion therapy is commonly used in the hospital setting to manage diabetic ketoacidosis and hyperosmolar hyperglycemic state. Clinical evidence suggests both hypoglycemia and glycemic variability negatively impact patient outcomes. The hypothesis of this study was that moderate-intensity insulin therapy decreases hospital length of stay and prevalence of hypoglycemia in patients with diabetic ketoacidosis and hyperosmolar hyperglycemic state. Design: Pre-post study. Setting: Large academic medical center in the United States. Patients: Two-hundred one consecutive, nonpregnant, adult patients admitted for diabetic ketoacidosis and hyperosmolar hyperglycemic state between October 2010 and December 2014. Interventions: High-intensity insulin therapy versus moderate-intensity insulin therapy. High-intensity insulin therapy was designed to rapidly normalize blood glucose levels with bolus doses of insulin and rapid insulin titration. Moderate-intensity insulin therapy was designed to mitigate glycemic variability and hypoglycemia through avoidance of bolus dosing, a liberalized blood glucose target, and gradual insulin titration. Measurements and Main Results: Hospital and ICU length of stay were reduced by 23.6% and 38%, respectively. The relative risk of remaining in the hospital at day 7 (0.51; p = 0.022) and day 14 (0.28; p = 0.044) were significantly reduced by the moderate-intensity insulin therapy strategy. The relative risk of remaining in the ICU at 48 hours was significantly lower in the moderate-intensity insulin therapy cohort (0.34; p = 0.0048). The prevalence (35% vs 1%; p = 0.0003) and relative risk (0.028; p = 0.0004) of hypoglycemia were significantly lower in the moderate-intensity insulin therapy cohort. Glycemic variability decreased by 28.6% (p < 0.0001). There was no difference in the time to anion gap closure (p = 0.123). Conclusions: Moderate-intensity insulin therapy for diabetic ketoacidosis and hyperosmolar hyperglycemic state resulted in improvements in hospital and ICU length of stay, which appeared to be associated with decreased glycemic variability.

The preferred regimen was not prescribed for the majority of patients admitted with a history of type 2 diabetes, despite computerized decision support. Nutritional insulin was the most common missing component in the nonpreferred regimens. Baseline clinical factors, educational modalities, and guideline content may have influenced prescribing patterns.

The observed median effect of D50W on BG was approximately 4 mg/dL per gram of D50W administered. Application of these data may aid in rescue protocol development that may reduce glucose variability associated with hypoglycemic episodes and the correction.

Introduction Intensive care unit (ICU) readmission is associated with increased mortality, hospital and ICU length of stay (LOS), and healthcare cost. Scoring systems that use physiologic markers to predict readmission have been used with varying degrees of success and literature is lacking on which medication classes might contribute to ICU readmission. Objectives The primary objective of this study was to identify medication classes associated with preventable ICU readmissions. Methods This was a retrospective, single‐center, observational, and cross‐sectional study of adult patients readmitted to the ICU within 72 h of ICU discharge between June 2015 and December 2016. Patients were excluded if they had multiple ICU readmissions. Readmissions were classified as non‐medication related (NMIR), non‐preventable medication related (NPMIR), or potentially preventable medication related (PPMIR) relative to ICU readmission diagnosis. Clinical outcomes including hospital LOS, ICU LOS, ICU LOS for readmission period, overall mortality, or presence of a rounding ward clinical pharmacist were evaluated, as was the estimated cost of readmissions. Results A total of 173 patients were included. Seventy‐six readmissions were determined to be medication‐related (44%) with 43 (57%) of those deemed preventable. The medication classes identified in PPMIRs were diuretics (32.5%), anti‐infectives (14%), opioids (11.6%), benzodiazepines (11.6%), electrolytes (7%), and antiarrhythmics (7%). No difference was observed for median hospital LOS, ICU LOS, ICU LOS for readmission period or overall mortality between those patients with a NMIR, NPMIR and those with a PPMIR. Total avoidable ICU LOS was 240.8 days based on median LOS. Conclusions Diuretics, benzodiazepines, opioids, antiarrhythmics, and anti‐infectives were the most frequently identified medication classes associated with PPMIRs. Further study is needed to identify the impact of screening for high‐risk medication classes identified in this investigation and greater pharmacist involvement post ICU discharge in reducing ICU readmissions.