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. 2018 Jun 15;10(1):12-23.
doi: 10.1007/s13340-018-0358-y. eCollection 2019 Jan.

Performance of a 2-step insulin infusion protocol with adjustment of insulin doses for Asians in the medical intensive care unit following cardiothoracic surgery

Kazuma Ogiso  1   2 , Nobuyuki Koriyama  1 , Takahiko Obo  1   2 , Akinori Tokito  1 , Takayuki Ueno  3 , Yoshihiko Nishio  2
Affiliations

Performance of a 2-step insulin infusion protocol with adjustment of insulin doses for Asians in the medical intensive care unit following cardiothoracic surgery

Kazuma Ogiso et al. Diabetol Int. .

Abstract

Background: Most previous insulin infusion protocols are titrated for Westerners and are not simple to follow. In this study, we tested the efficacy and safety of our simple insulin infusion protocol utilizing lower insulin doses for Asians.

Methods: A total of 152 patients with type 2 diabetes undergoing cardiothoracic surgery were included. After surgery, blood glucose (BG) was initially managed according to our algorithm protocol, and subsequently by the post-algorithm protocol. Insulin infusion rates in the algorithm protocol were titrated in two steps according to (1) current BG levels and (2) the difference between current and previous BG levels. In the post-algorithm protocol, insulin lispro was injected subcutaneously in addition to intravenous insulin infusion according to BG levels. The efficacy was assessed as achievement rates of two target BG ranges (140-199 and 80-199 mg/dL), and safety was assessed as hypoglycemia (< 70 mg/dL) and protocol error rates.

Results: With the use of the algorithm protocol, 58.7% of 1749 BG measurements achieved a range of 140-199 mg/dL, and 95.9% achieved levels within the 80-199 mg/dL range. Hypoglycemia and protocol error rates were 0.47 and 0.51%, respectively. With the post-algorithm protocol, 48.7 and 98.3% of 898 BG measurements achieved each target range. Hypoglycemia and protocol error rates were 0.78 and 0.22%, respectively. Severe hypoglycemia (< 40 mg/dL) was not observed.

Conclusions: Our insulin infusion protocol seems to be efficacious, safe, and widely feasible for Asian patients because of its simplicity and lower insulin dose.

Keywords: Cardiac surgery; Hypoglycemia; Insulin; Insulin infusion protocol; Intensive care unit; Surgical diabetes.

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Conflict of interest statement

All the authors declare that they have no conflict of interest.Yoshihiko Nishio has received honoraria for scientific lectures from Eli Lilly. Kazuma Ogiso, Nobuyuki Koriyama, Takahiko Obo, Akinori Tokito, and Takayuki Ueno have nothing to disclose.All the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (National Hospital Organization Kagoshima Medical Center, Ethics Committee, date of approval: 6 February 2017, approval no. 28-71) and with the Helsinki Declaration of 1964 and later versions.

Figures

Fig. 1
Fig. 1
Schema of our insulin infusion protocol flow. After patients were transferred to the ICU, the algorithm protocol was applied and maintained until they fulfilled the three criteria shown in the figure. Once the criteria were fulfilled, the post-algorithm protocol was applied instead of the algorithm protocol and was maintained until initiation of oral intake. In the algorithm protocol, insulin administration consisted only of an intravenous infusion of regular insulin, while under the post-algorithm protocol, subcutaneous injection of a rapid-acting insulin analog was given as required, in addition to the intravenous insulin infusion. The graph shows an example course of insulin doses. When we switched to the post-algorithm protocol from the algorithm protocol, the insulin infusion rate was reduced by 20% and a rapid-acting insulin analog was subcutaneously given along with the intravenous insulin infusion as “corrective insulin”. CVII continuous intravenous insulin infusion, s.c. subcutaneous injection, ICU intensive care unit
Fig. 2
Fig. 2
Insulin infusion protocol
Fig. 2
Fig. 2
Insulin infusion protocol
Fig. 3
Fig. 3
Performance of the algorithm protocol. The upper graph represents BG levels and the lower graph insulin infusion rates for the first 18 h. Data are shown as mean ± SD. The numbers below the graph represent the number of patients applying the algorithm protocol at each time point. Time zero represents the start of applying algorithm protocol. The algorithm protocol was continued until switching to the post-algorithm protocol on condition of fulfilling the protocol switching criteria
Fig. 4
Fig. 4
Performance of the post-algorithm protocol. BG was measured and insulin infusion rates were titrated every 4 h. The upper graph represents BG levels and the lower graph represents total insulin infusion rates after switching from the algorithm to the post-algorithm protocol. In the lower graph, the black column represents intravenous insulin infusion rates and the oblique line column represents subcutaneous insulin infusion rates, which were calculated by dividing the number of units of the rapid-acting insulin analog lispro injected by 4. Data are shown as mean ± SD. The numbers below the graph represent the number of patients applying the post-algorithm protocol at each time point. Time zero represents the start of applying post-algorithm protocol. The post-algorithm protocol was continued until initiation of oral feeding in accordance with the cardiovascular surgeon’s decision
Fig. 5
Fig. 5
Performance of the insulin infusion protocol in each patient. The upper graph represents hourly BG levels and the lower graph hourly insulin infusion rates over the algorithm and post-algorithm protocol period in each patient. Missing BG values and insulin infusion rates were calculated from the hours before and after the missing BG values and insulin infusion rates. During the post-algorithm protocol, the calculated doses of subcutaneous insulin lispro were added to the intravenous insulin infusion rates. Data are shown as mean ± SD. The numbers below the graph represent the number of patients applying total insulin infusion protocol including both of the algorithm and post-algorithm protocol continuously. Time zero represents the start of applying algorithm protocol and insulin infusion protocol was continued until initiation of oral feeding
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