Transitioning from intravenous to subcutaneous insulin in the medical intensive care unit

Keren Zhou; Mia F Williams; Mary Angelynne Esquivel; Anne Song; Farah Rahman; James Bena; Simon W Lam; Deborah A Rathz; M Cecilia Lansang

doi:10.1016/j.diabres.2017.05.016

Transitioning from intravenous to subcutaneous insulin in the medical intensive care unit

Diabetes Res Clin Pract. 2017 Dec:134:199-205. doi: 10.1016/j.diabres.2017.05.016. Epub 2017 Aug 12.

Authors

Keren Zhou¹, Mia F Williams², Mary Angelynne Esquivel³, Anne Song⁴, Farah Rahman⁵, James Bena⁶, Simon W Lam⁷, Deborah A Rathz⁸, M Cecilia Lansang⁹

Affiliations

¹ Cleveland Clinic Foundation, Department of Endocrinology, Diabetes and Metabolism, 9500 Euclid Avenue, Mail Code: F-20, Cleveland, OH 44195, USA. Electronic address: zhouk2@ccf.org.
² Cleveland Clinic Foundation, Department of Endocrinology, Diabetes and Metabolism, 9500 Euclid Avenue, Mail Code: F-20, Cleveland, OH 44195, USA. Electronic address: mia.williams@ucsf.edu.
³ Cleveland Clinic Foundation, Department of Endocrinology, Diabetes and Metabolism, 9500 Euclid Avenue, Mail Code: F-20, Cleveland, OH 44195, USA. Electronic address: mary_esquivel@brown.edu.
⁴ Cleveland Clinic Foundation, Department of Endocrinology, Diabetes and Metabolism, 9500 Euclid Avenue, Mail Code: F-20, Cleveland, OH 44195, USA. Electronic address: songa@ccf.org.
⁵ Cleveland Clinic Foundation, Department of Endocrinology, Diabetes and Metabolism, 9500 Euclid Avenue, Mail Code: F-20, Cleveland, OH 44195, USA. Electronic address: fxr51@case.edu.
⁶ Cleveland Clinic Foundation, Department of Quantitative Health Science, 9500 Euclid Avenue, Mail Code: JJN3, Cleveland, OH 44195, USA. Electronic address: benaj@ccf.org.
⁷ Cleveland Clinic Foundation, Department of Pharmacy, 9500 Euclid Avenue, Mail Code: JJN1, Cleveland, OH 44195, USA. Electronic address: lams@ccf.org.
⁸ Cleveland Clinic Foundation, Department of Critical Care Medicine, Mail Code: L22, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Electronic address: rathzd@ccf.org.
⁹ Cleveland Clinic Foundation, Department of Endocrinology, Diabetes and Metabolism, 9500 Euclid Avenue, Mail Code: F-20, Cleveland, OH 44195, USA. Electronic address: lansanm@ccf.org.

PMID: 29154154
DOI: 10.1016/j.diabres.2017.05.016

Abstract

Background: There is a paucity of studies on transitions from IV insulin infusion (IVII) to subcutaneous (SC) insulin in the medical ICU (MICU).

Methods: We conducted a retrospective study of patients admitted to the Cleveland Clinic MICU from June 2013 to January 2014 who received IVII. We compared blood glucose (BG) control between 3 cohorts based on timing of basal insulin dose: (1) NB (no basal), (2) IB (incorrect basal), (3) CB (correct basal) at 5 time points post-IVII discontinuation (1, 4, 8, 12, and 24h). Insulin doses used for transitioning were compared with 80% of estimated 24h IVII total. Analysis was done using chi-square, ANOVA and t-tests.

Results: There were 269 patients (NB 166, IB 45, CB 58), 55% male with a mean age 58±16years. 103 patients (38%) had a transition attempted (IB 21%, CB 17%). The NB cohort had better BG than the IB cohort at all time points (p<0.001) but also lower HbA1c, prior DM diagnosis and home insulin use (p<0.001). IB and CB did not have significantly different BG with mean BG>180mg/dL at 4/5 time intervals. However, the dose of basal insulin used was less than 80% of estimated 24h IVII total (IB 21.4 vs 49.6U, CB 25vs 57.1U). Despite this, 15% of patients in the IB cohort and 24% of patients in the CB had hypoglycemic events.

Conclusion: The low rates of IV to SC insulin transitions raises the question of challenges to transitions.

MeSH terms

Blood Glucose / analysis
Blood Glucose / metabolism*
Female
Humans
Hypoglycemic Agents / therapeutic use*
Infusions, Intravenous / methods*
Injections, Subcutaneous / methods*
Insulin / therapeutic use*
Insulin Infusion Systems / statistics & numerical data*
Intensive Care Units
Male
Middle Aged
Retrospective Studies

Substances

Blood Glucose
Hypoglycemic Agents
Insulin