Intravenous (IV) insulin is recommended to treat stress hyperglycemia (SH) in nondiabetic (non-DM) patients after cardiac surgery. Many patients with SH require transition to subcutaneous (SQ) insulin after stopping IV drip in the ICU. We report a simplified protocol for the transition from IV to SQ insulin in cardiac surgery patients with SH. Patients requiring IV insulin >2 U/hour were transitioned to SQ basal bolus regimen at 70% of calculated daily insulin requirement. Patients requiring ≤ 2 U/hour were treated with sliding scale insulin (SSI), if >2 episodes of BG > 140 mg/dl patients were started on rescue therapy with basal insulin.

Among 150 non-DM patients with SH in the ICU, 30 patients (20%) required >2 U/hour and were transitioned to SQ basal/bolus at a mean SQ dose of 0.34 U/kg/day for a duration of treatment of 5.5±3.6 days. A total of 120 (80%) patients required ≤ 2 U/hour and were transitioned to SSI. Of them, the mean blood glucose (BG) was 129.8±16 mg/dl and only 3 (2.5%) patients required a single dose of basal insulin during the hospital stay. There were no differences in LOS or in a composite of complications between groups.

Our results indicate that cardiac surgery patients with SH requiring continuous IV insulin ≤ 2 U/hour in the ICU can be safely transitioned to SSI; however, patients requiring > 2 U/hour should be transitioned to basal insulin to maintain glycemic targets.

  Transition to SSI Transition to Basal p-value 
Patients, n (%) 120 (80) 30 (20)  
BMI, Kg/m2 28.8 ± 6.5 30.3 ± 5.4 0.15 
HbA1c, % 5.6 ± 0.4 5.8 ± 0.7 0.047 
ICU 
Daily BG during IV insulin drip, mg/dl 133.9 ± 17 142.9 ± 15 0.004 
Total insulin in the ICU, U/day 57.4 ± 89 73.8 ± 64 0.005 
TRANSITION 
Average BG after transition, mg/dl 123.4 ± 12 129.8 ± 16 0.022 
Patients who required SQ SSI 99 (83) 30 (100) <0.001 
Patients with BG < 70 mg/dl, n (%) 13 (10.8) 2 (6.7) 0.74 
Composite of complications 53 (44) 14 (47) 0.81 
Data are n (%) or mean ± SD. Composite complications: major CV events, infections, respiratory failure and acute kidney injury. 
  Transition to SSI Transition to Basal p-value 
Patients, n (%) 120 (80) 30 (20)  
BMI, Kg/m2 28.8 ± 6.5 30.3 ± 5.4 0.15 
HbA1c, % 5.6 ± 0.4 5.8 ± 0.7 0.047 
ICU 
Daily BG during IV insulin drip, mg/dl 133.9 ± 17 142.9 ± 15 0.004 
Total insulin in the ICU, U/day 57.4 ± 89 73.8 ± 64 0.005 
TRANSITION 
Average BG after transition, mg/dl 123.4 ± 12 129.8 ± 16 0.022 
Patients who required SQ SSI 99 (83) 30 (100) <0.001 
Patients with BG < 70 mg/dl, n (%) 13 (10.8) 2 (6.7) 0.74 
Composite of complications 53 (44) 14 (47) 0.81 
Data are n (%) or mean ± SD. Composite complications: major CV events, infections, respiratory failure and acute kidney injury. 
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Disclosure

S. Cardona: None. R.J. Galindo: None. K.G. Tsegka: None. M.A. Urrutia: None. P. Vellanki: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., AstraZeneca. M. Fayfman: None. J. Haw: None. F.J. Pasquel: Consultant; Self; Merck Sharp & Dohme Corp., Sanofi, Boehringer Ingelheim Pharmaceuticals, Inc.. L. Peng: None. G.E. Umpierrez: Research Support; Self; Sanofi US, Merck & Co., Inc., Novo Nordisk Inc., AstraZeneca. Advisory Panel; Self; Sanofi, Intarcia Therapeutics, Inc..

© 2018 by the American Diabetes Association.
2018
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