Comparison of 3 Algorithms for Basal Insulin in Transitioning from Intravenous to Subcutaneous Insulin in Stable Patients after Cardiothoracic Surgery

Abstract

Objective The objective was to determine the efficacy of an algorithim containing aspart dosed according to carbohydrate intake and one of 3 initial doses of detemir in stable cardiac surgery patients requiring intravenous (IV) insulin. Methods Patients were extubated, off pressors and otherwise stable, requiring at least 1 unit/hr of IV insulin at least 48 hours following surgery. Subjects were randomized to once daily detemir at 50, 65, or 80% of IV basal insulin requirements and received aspart according to carbohydrate intake. The dose of detemir was adjusted daily over 72 hours. Results The number of patients with an initial morning glucose 80–130 mg/dl was 36, 63, and 56% of patients at the 50, 65, and 80% doses (p=0.12) (n=82). However, the mean overall glucose at 24 and 72 hours was similar between groups, and 86, 93, and 92% achieved a mean glucose 80–180 mg/dl at 72 hours (p=0.60). Hypoglycemia (<65 mg/dl) only occurred in the 65% (21%) and 80% (12%) groups over the first 72 hours (p=0.02 in the 50% compared to the 65 and 80% groups combined) with one event <40 mg/dl in the 80% group. There was no loss of glycemic control by the end of the once daily dosing interval. Conclusions Glycemic targets can be achieved without hypoglycemia by 72 hours in most cardiac surgery patients requiring IV insulin with a regimen containing an initial detemir dose of 50% of basal IV insulin requirements and prandial and supplemental insulin.

Transition From Intravenous to Subcutaneous Insulin in Critically Ill Adults

“…[14][15][16][17] However, the most appropriate metric to describe glucose variability has not yet been defined. [10][11][12][13][14]16 In the present study, there was no difference detected between the groups in terms of glucose variability (P = .895).…”

“…These results are consistent with the findings of Dungan and colleagues. 13 Despite the high rate of goal achievement in the 50-59% group, only 9 of the 100 (9%) patients were transitioned via this strategy. The majority of the patients were transitioned to 0-49%, resulting in the lowest rate of target goal achievement.…”

“…10 However, due to the conflicting results in the literature, there is currently no consensus to facilitate the conversion from IV to subcutaneous insulin. [11][12][13] A validated protocol for this transition is imperative as the complications of an inaccurate subcutaneous insulin dose may impact glycemic control and thus morbidity and mortality. Also, overcorrection may result in hypoglycemia, which can have significant negative sequelae of its own.…”

Effect of the approach to insulin therapy on glycaemic fluctuations and autonomic tone in hospitalized patients with diabetes

“…However, rebound hyperglycaemia was minimized by the overlap of 4 h between the infusion and the SQ basal insulin in this study. A higher conversion factor for dose calculation could have been considered, but the trade‐off is an increase in the risk of hypoglycaemia . Careful consideration for smooth transitions in therapy in general, such as at the time of admission and at discharge, would be of interest for further study.…”

Glycemic Variability and Glycemic Control in the Acutely Ill Cardiac Patient

“…In such patients, subcutaneous rapid-acting insulin may be provided to cover meals. 117 An alternative is to use an infusion algorithm that provides a programmable temporary step-up in infusion rate after a meal. 111,118 …”