Increased hypoglycemia associated with renal failure during continuous intravenous insulin infusion and specialized nutritional support

Objective: To evaluate glycemic control for critically ill, hyperglycemic trauma patients with renal failure who received concurrent intensive insulin therapy and continuous enteral (EN) or parenteral nutrition (PN). Methods: Adult trauma patients with renal failure, who were given EN or PN concurrently with continuous graduated intravenous regular human insulin (RHI) infusion for at least 3 days were evaluated. Our conventional RHI algorithm was modified for those with renal failure by allowing greater changes in blood glucose concentrations (BG) before the infusion rate was escalated. BG was determined every 1-2 hours while receiving the insulin infusion. BG control was evaluated on the day prior to RHI infusion and for a maximum of 7 days while receiving RHI. Target BG during the RHI infusion was 70 to 149 mg/dL (3.9 to 8.3 mmol/L). Glycemic control and incidence of hypoglycemia for those with renal failure were compared to a historical cohort of critically ill, hyperglycemic trauma patients without renal failure given our conventional RHI algorithm. Results: Twenty-one patients with renal failure who received the modified RHI algorithm were evaluated and compared to forty patients without renal failure given our conventional RHI algorithm. Average BG was significantly greater for those with renal failure (133 + 14 mg/dL or 7.3 + 0.7 mmol/L) compared to those without renal failure (122 + 15 mg/dL or 6.8 + 0.8 mmol/L), respectively (p \u3c 0.01). Patients with renal failure experienced worsened glycemic variability with 16.1 + 3.3 hours/day within the target BG range, 6.9 + 3.2 hours/day above the target BG range, and 1.4 + 1.1 hours below the target BG range compared to 19.6 + 4.7 hours/day (p \u3c 0.001), 3.4 + 3.0 hours/day (p \u3c 0.001), and 0.7 + 0.8 hours/day (p \u3c 0.01) for those without renal failure, respectively. Moderate hypoglycemia (\u3c 60 mg/dL or \u3c 3.3 mmol/L) occurred in 76% of patients with renal failure compared to 35% without renal failure (p \u3c 0.005). Severe hypoglycemia (BG \u3c 40 mg/dL or \u3c 2.2 mmol/L) occurred in 29% of patients with renal failure compared to none of those without renal failure (p \u3c 0.001). Conclusion: Despite receiving a modified RHI infusion, critically ill trauma patients with renal failure are at higher risk for developing hypoglycemia and experience more glycemic variability than patients without renal failure

Increased hypoglycemia associated with renal failure during continuous intravenous insulin infusion and specialized nutritional support

Objective: To evaluate glycemic control for critically ill, hyperglycemic trauma patients with renal failure who received concurrent intensive insulin therapy and continuous enteral (EN) or parenteral nutrition (PN). Methods: Adult trauma patients with renal failure, who were given EN or PN concurrently with continuous graduated intravenous regular human insulin (RHI) infusion for at least 3 days were evaluated. Our conventional RHI algorithm was modified for those with renal failure by allowing greater changes in blood glucose concentrations (BG) before the infusion rate was escalated. BG was determined every 1-2 hours while receiving the insulin infusion. BG control was evaluated on the day prior to RHI infusion and for a maximum of 7 days while receiving RHI. Target BG during the RHI infusion was 70 to 149 mg/dL (3.9 to 8.3 mmol/L). Glycemic control and incidence of hypoglycemia for those with renal failure were compared to a historical cohort of critically ill, hyperglycemic trauma patients without renal failure given our conventional RHI algorithm. Results: Twenty-one patients with renal failure who received the modified RHI algorithm were evaluated and compared to forty patients without renal failure given our conventional RHI algorithm. Average BG was significantly greater for those with renal failure (133 + 14 mg/dL or 7.3 + 0.7 mmol/L) compared to those without renal failure (122 + 15 mg/dL or 6.8 + 0.8 mmol/L), respectively (p \u3c 0.01). Patients with renal failure experienced worsened glycemic variability with 16.1 + 3.3 hours/day within the target BG range, 6.9 + 3.2 hours/day above the target BG range, and 1.4 + 1.1 hours below the target BG range compared to 19.6 + 4.7 hours/day (p \u3c 0.001), 3.4 + 3.0 hours/day (p \u3c 0.001), and 0.7 + 0.8 hours/day (p \u3c 0.01) for those without renal failure, respectively. Moderate hypoglycemia (\u3c 60 mg/dL or \u3c 3.3 mmol/L) occurred in 76% of patients with renal failure compared to 35% without renal failure (p \u3c 0.005). Severe hypoglycemia (BG \u3c 40 mg/dL or \u3c 2.2 mmol/L) occurred in 29% of patients with renal failure compared to none of those without renal failure (p \u3c 0.001). Conclusion: Despite receiving a modified RHI infusion, critically ill trauma patients with renal failure are at higher risk for developing hypoglycemia and experience more glycemic variability than patients without renal failure

Sliding Scale Regular Human Insulin for Identifying Critically Ill Patients Who Require Intensive Insulin Therapy and for Glycemic Control in those with Mild to Moderate Hyperglycemia

Two sliding scale regular human insulin (RHI) algorithms (SSI) were retrospectively evaluated to identify those who develop severe hyperglycemia (blood glucose (BG) > 180 mg/dL) and for glycemic management of continuously-fed, critically ill trauma patients with mild to moderate hyperglycemia (BG 126 to 179 mg/dL). Assignment of low or high SSI was based upon anticipated severity of difficulty in glycemic control. BG was obtained every 3 to 6 hours. Target BG range was 70 to 149 mg/dL. Patients who were unable to achieve a BG < 150 mg/dL with SSI and who required a continuous intravenous RHI infusion were identified. Twenty-five of 121 patients (21%) failed SSI necessitating more intensive insulin therapy. The low and high intensity SSI groups exhibited a baseline BG of 123 + 33 mg/dL and 164 + 20 mg/dL (P = 0.001). Average BG for each group was 129 ± 14 mg/dL and 145 ± 21 mg/dL (P = 0.001). Each group spent 20 ± 4 and 16 ± 5 hours/day within the target BG range (P = 0.001), respectively. Mild hypoglycemia (BG 40 - 60 mg/dL) occurred in 11% and 7% of patients from each group (P = N.S.). Severe hypoglycemia (BG < 40 mg/dL) occurred in zero and two (5%) patients, respectively (P = N.S). SSI served as a useful technique to identify those requiring more intensive insulin therapy and was safe and efficacious for continuously-fed, critically ill trauma patients with mild to moderate hyperglycemia

Sliding Scale Regular Human Insulin for Identifying Critically Ill Patients Who Require Intensive Insulin Therapy and for Glycemic Control in those with Mild to Moderate Hyperglycemia

Two sliding scale regular human insulin (RHI) algorithms (SSI) were retrospectively evaluated to identify those who develop severe hyperglycemia (blood glucose (BG) > 180 mg/dL) and for glycemic management of continuously-fed, critically ill trauma patients with mild to moderate hyperglycemia (BG 126 to 179 mg/dL). Assignment of low or high SSI was based upon anticipated severity of difficulty in glycemic control. BG was obtained every 3 to 6 hours. Target BG range was 70 to 149 mg/dL. Patients who were unable to achieve a BG < 150 mg/dL with SSI and who required a continuous intravenous RHI infusion were identified. Twenty-five of 121 patients (21%) failed SSI necessitating more intensive insulin therapy. The low and high intensity SSI groups exhibited a baseline BG of 123 + 33 mg/dL and 164 + 20 mg/dL (P = 0.001). Average BG for each group was 129 ± 14 mg/dL and 145 ± 21 mg/dL (P = 0.001). Each group spent 20 ± 4 and 16 ± 5 hours/day within the target BG range (P = 0.001), respectively. Mild hypoglycemia (BG 40 - 60 mg/dL) occurred in 11% and 7% of patients from each group (P = N.S.). Severe hypoglycemia (BG < 40 mg/dL) occurred in zero and two (5%) patients, respectively (P = N.S). SSI served as a useful technique to identify those requiring more intensive insulin therapy and was safe and efficacious for continuously-fed, critically ill trauma patients with mild to moderate hyperglycemia