Doing Insulin Like A Pharmacist

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Lauren Igneri
Critical care pharmacist and proud Rutgers University graduate. Enjoys rock climbing, cycling, travel, and lively discussions on the finer points of pharmacokinetics and critical care over a beer with friends.

The Pre-brief:

Dysregulation of glucose control is observed frequently in critically ill patients due to numerous reasons including sepsis, stress response, and use of corticosteroids. The 3 domains of critical illness dysglycemia include hyperglycemia, hypoglycemia, and glycemic variability, and all are associated with increased morbidity and mortality.1 Unfortunately, there are not standard definitions for glycemic variability or the thresholds associated with poor outcomes.However, evidence suggests fluctuations in blood glucose are associated with increased mortality in septic patients, independent of hypoglycemia and/or mean blood glucose.

Most guidelines recommend initiation of insulin therapy in critically-ill patients when blood glucose levels are 150-180 mg/dL or greater to maintain a goal of <180 mg/dL.4 While IV insulin infusion therapy is standard of care, many patients can achieve appropriate glycemic control with subcutaneous insulin regimens – here’s how!

The Debrief

  • Initiate insulin therapy when BG >150 mg/dL, with the goal of maintaining a blood glucose less than 180 mg/dL. Evaluate patients’ glycemic control and insulin requirements daily.
  • IV insulin infusion dosing protocols should be initiated in patients with marked hyperglycemia.
    • Once at goal, convert 50-70% of the 24-hour requirements into basal insulin such as NPH (intermediate-acting) given q12 hours or glargine (long-acting) given once daily plus correctional coverage.5
    • Beware of converting to subcutaneous regimens if there is acute kidney injury and/or escalating or high-dose vasopressor requirements since insulin is renally eliminated and subcutaneous absorption may be impaired in shock.
  • For patients maintained on subcutaneous regimens that are still above goal, add 50% of 24-hour correctional insulin requirements to the basal regimen and reassess.
  • Depending on the baseline diabetic status, most patients with diabetes will require basal insulin administration even if they’re NPO.
    • May initiate a 50% reduced basal regimen if there is significant risk for hypoglycemia.

References

  1. Plummer MP, Deane AM. Dysglycemia and Glucose Control During Sepsis. Clin Chest Med. 2016; 37(2):309-19.
  2. Honiden S, Inzucchi SE. Metabolic Management during Critical Illness: Glycemic Control in the ICU. Semin Respir Crit Care Med. 2015; 36(6):859-69.
  3. Plummer MP, Bellomo R, Cousins CE, et al. Dysglycaemia in the critically ill and the interaction of chronic and acute glycaemia with mortality. Intensive Care Med. 2014; 40(7):973-80. 
  4. Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med. 2012; 40(12):3251-76.
  5. Doolin MK, Walroth TA, Harris SA, Whitten JA, Fritschle-Hilliard AC. Transition From Intravenous to Subcutaneous Insulin in Critically Ill Adults. J Diabetes Sci Technol.

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