Transition From Intravenous to Subcutaneous Insulin

Abstract

OBJECTIVEThe study objectives were 1) to assess the effectiveness and safety of a standardized protocol for the transition to subcutaneous insulin and oral feeding in diabetic or hyperglycemic patients with acute coronary syndrome (ACS) who were receiving intravenous insulin and glucose at the time of the transfer from the intensive cardiac care unit to a general ward and 2) to identify predictors of transition outcome.RESEARCH DESIGN AND METHODSThis was a prospective observational study. The protocol specifies that patients receive a 100% of their daily subcutaneous insulin requirement from the first day of oral feeding, calculated from the intravenous insulin rate during the final 12 h divided into two: 50% basal and 50% prandial.RESULTSIn 142 patients (93 male, 49 female, age range 47–88 years, 135 with known diabetes) the first day after transition, 44.8% of blood glucose (BG) measurements were within the strict range of 100–140 mg/dL before meals and 100–180 mg/dL after meals, and 70.8% were within the broader ranges of 80–160 mg/dL and 80–200 mg/dL, respectively. Pre- or postprandial hypoglycemia (BG <70 mg/dL) occurred in 11 patients (7.7%) on the first day and in 38 patients (26.8%) on the first 3 days after transition. Old age, high doses of intravenous insulin, and wide BG variations in the 24 h before insulin infusion was stopped were predictive of poor BG control after transition.CONCLUSIONSThis study shows the effectiveness and safety of a standardized protocol for the transition from intravenous to subcutaneous insulin in patients with ACS when regular oral feeding was resumed.

Conventional insulinvsinsulin infusion therapy in acute coronary syndrome diabetic patients

“…a prediabetic state is frequently observed during acute cardiac events [2,5,8,11,22,24,25] . Furthermore, diabetic patients show an increased mortality and morbidity after both AMI and ACS in general when compared with nondiabetic patients [8] .…”

“…Also, a major risk of intensive insulin treatment is the greater appearance of hypoglycaemic episodes which are mainly related to diabetes life span, frequency of previous hypoglycaemic attacks and pre-existing coronary artery disease [29,30] with worsening of prognosis and prolongation of in-hospital stay. Several insulin-infused operational protocols to be adopted in ICUs have been proposed so far [15][16][17][18][19][20][21][22] but no specific guidelines with validate protocols in day-to-day clinical practice and definite glycaemic target values have been provided. Furthermore, an additional concern is represented by a recurrence of hyperglycaemic states during the transition from intravenous to subcutaneous treatment regimen.…”

“…We adopted the nurse-implemented continuous intravenous insulin infusion protocol as proposed by Avanzini et al [21] developed also to drive the optimal transition to subsequent subcutaneous insulin therapy [22] , with little modifications. In particular targeting glycemic values were 120-180 mg/dL (i.e., 6.6-10 mmol/L) instead of 100-139 mg/dL (i.e., 5.5-7.7 mmol/L), and infusion treatment was stopped in presence of glycemic values below 120 mg/dL (i.e., 6.7 mmol/L) instead of 100 mg/dL (i.e., 5.5 mmol/L) To facilitate acceptance, during year 2012 all nurses involved in the study were previously trained by a weeklong series of 1-h in-service training sessions and all experienced very good compliance with the infusion protocol at the time of the study.…”

“…For the above reasons, the European Society of Cardiology/European Association for the Study of Diabetes recommends blood glucose control by intensive insulin treatment (Class Ⅰ recommendation) in patients with AMI (Class Ⅱ, level of evidence B) [14] . Some schemes of insulin infusion therapy have been proposed for critically ill patients [15][16][17][18][19][20][21][22] ; however, among the nurseimplemented insulin infusion protocols available none was specifically tested in patients with ACS during the day-today clinical activity of a coronary care unit [21] .…”

Insulin Use in Hospitalized Patients With Diabetes: Navigate With Care

“…[10][11][12][13][14] Most patients on an insulin infusion are not eating because of the severity of their critical illness or other factors. In patients who are on a continuous insulin infusion for DKA, assuming that they have not yet started eating while on the insulin infusion, the total daily basal insulin requirement may be estimated by extrapolating from infused insulin received at a stable rate for at least 6-8 hours.…”