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Peak insulin requirements, protocol deviations linked to inpatient hypoglycemia
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Hypoglycemia in hospitalized patients is associated with high insulin infusion rates and doses, and protocol deviations, according to study findings published in Endocrine Practice.
Amisha Wallia, MD, MS, assistant professor in the division of endocrinology, metabolism and molecular medicine at Northwestern University Feinberg School of Medicine, and colleagues evaluated 164 patients randomly assigned intensive insulin therapy (n = 82; target glucose, 140 mg/dL) or moderate insulin therapy (n = 82; target glucose 180 mg/dL) while hospitalized after liver transplantation to determine causes of inpatient hypoglycemia. Nine participants were excluded for non-insulin-related hypoglycemia. All participants had postoperative glucose level of at least 180 mg/dL and required an insulin drip. Patients were followed for 30 days or until discharge.
Overall, there were 88 occurrences of hypoglycemia with blood glucose levels of 70 mg/dL or less. The intensive insulin therapy group had more hypoglycemia events (24 participants) compared with the moderate insulin therapy group (four participants; P < .05). Two participants experienced a severe insulin-related hypoglycemic episode; both were in the intensive insulin therapy group.
Two-thirds of hypoglycemic events occurred at night. Participants with hypoglycemia had longer hospital stays (P = .002), higher peak insulin drip rates, higher peak insulin glargine doses and higher model for end-stage liver disease scores (P = .021) compared with participants without hypoglycemia. Of participants who experienced hypoglycemia (n = 28), 10.7% died within 1 year compared with 5.5% who did not experience hypoglycemia (n = 127; P = .39).
In a case-matched analysis, protocol deviation (P = .004), provider insulin titration deviation (P = .02) and the need for high insulin doses on the day of the hypoglycemic episode (P = .025) were more common in participants who experienced hypoglycemia.
“Our findings suggest that identification and subsequent intensification of monitoring of patients with significantly high insulin requirements could be employed to reduce the risk of hypoglycemia,” the researchers wrote. “Addressing staff issues during evenings/nights and weekends may also be a subsequent means to decrease hypoglycemia rates further, especially outside the ICU.” – by Amber Cox
Disclosure: Wallia reports financial ties with Johnson & Johnson and Merck. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Kenneth Cusi, MD, FACP, FACE
Patient safety is increasingly complex, so understanding the preventable factors leading to inpatient hypoglycemia is of paramount importance. Welsh and colleagues studied causes of hypoglycemia in 164 post-liver transplant patients (about two-thirds without diabetes before surgery) who had been prospectively randomized to intensive or moderate glucose control (target 140 vs. 180 mg/dL, respectively). Eighteen percent of patients developed hypoglycemia. As expected, more hypoglycemia (≤ 70 mg/dL) occurred with intensive glucose control (about two-thirds occurred at night and with subcutaneous insulin). This was associated with almost a doubling of the length of stay, but likely other unidentified factors played a role.
Although this is a relative small study and the impact of intensive glucose control was not reported (eg, transplant outcomes, other complications), its strengths are its prospective nature, use of a well-defined treatment population and a multidisciplinary team adjudicating each hypoglycemic episode. Major take-home messages are that clinicians should try to avoid high-dose intravenous insulin, as it usually does more harm than good, and seek other causes of treatment failure; optimizing subcutaneous insulin therapy does not only call for careful timing/dosing of insulin to avoid nocturnal hypoglycemia, but requires close coordination with the primary team and other services involved (nursing, nutrition services, etc.); protocol deviations happened in nine out of ten hypoglycemic episodes, indicating the need for constant training of doctor and nursing staff, who usually undergo high turnover and in many cases only partially understand the principles of managing hyperglycemia in this setting.
This study is a significant contribution, highlighting where diabetes care teams must focus future attention. Endocrinologists must lead the way to overcome the shortcomings outlined in this study and work to develop stronger evidence (especially in non-ICU settings) on the most effective/safe approaches to inpatient hyperglycemia.
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