Safety and Efficacy of Various Intravenous Insulin Infusion Rates in Patients With and Without Diabetes Presenting With Hypertriglyceridemia

Background The use of IV insulin infusions in the acute management of hypertriglyceridemia has only been evaluated in small observational studies and case reports. Objective To evaluate the safety and efficacy of IV insulin infusions in the acute management of hypertriglyceridemia. Methods This was a retrospective chart review of adult patients who received an IV insulin infusion for the acute management of hypertriglyceridemia. The primary efficacy and safety outcomes were the number of patients who achieved a triglyceride level <500 mg/dL and experienced hypoglycemia (<70 mg/dL), respectively. A subgroup analysis was performed to compare outcomes between patients with and without diabetes, in addition to the IV insulin infusion rate received. Results In the total population (n = 51), there were no statistically significant differences between the insulin intensity groups in the number of patients who achieved TG levels <500 mg/dL. Compared to patients with a past medical history of diabetes, more patients without a past medical history of diabetes achieved triglyceride levels <500 mg/dL (14% vs 53%, respectively, P < 0.001). The number of hypoglycemic events observed in patients with and without a past medical history of diabetes were 5 (14%) and 4 (27%), respectively ( P = 0.023). Conclusion and Relevance Our findings suggest that patients who present with lower initial TG levels are more likely to achieve TG levels <500 mg/dL. To minimize the risk of hypoglycemia providers should consider prescribing a concomitant dextrose infusion and limiting IV insulin infusion rates ≤ 0.075 units/kg/h.

Sodium–glucose cotransporter 2 inhibitor-induced euglycemic diabetic ketoacidosis in a patient with coronavirus disease 2019: a case report

Background Sodium–glucose cotransporter 2 inhibitors are among the new-generation oral antihyperglycemic agents that have been used in the treatment of type 2 diabetes mellitus. With the recent coronavirus disease 2019 pandemic and rise of cases in the third wave, diagnosis of life-threatening euglycemic diabetic ketoacidosis may easily be overlooked or missed. Case presentation We present the case of a 37-year-old Malay gentleman with underlying type 2 diabetes mellitus on empagliflozin, who presented to our hospital with symptomatic coronavirus disease 2019 infection and diabetic ketoacidosis. He developed severe rebound euglycemic diabetic ketoacidosis due to the continuous usage of empagliflozin for glycemic control alongside intravenous insulin. Conclusions Physicians should have a high index of suspicion in diagnosing and managing euglycemic diabetic ketoacidosis, including withholding treatment of sodium–glucose cotransporter 2 inhibitors during the acute management of diabetic ketoacidosis.

Newly diagnosed type 1 diabetes in a 93 year old

Type 1 diabetes is typically a disease of young but can present at any age. We present a case of a 93-year-old woman who presented with 10 days history of feeling lethargic, polydipsia and decreased appetite. Her capillary blood glucose was raised at 25 mmol/L with significant ketonaemia and venous blood gas showing metabolic acidosis. She had a background of primary hypothyroidism and vitamin B12 deficiency with weakly positive parietal cell antibodies. Laboratory investigations confirmed diabetes with HbA1c of 117 mmol/mol (12.9%). In view of high clinical suspicion of type 1 diabetes, her diabetes autoantibodies were checked which showed strongly positive anti-GAD antibody with titre of >2000 IU/mL (range<10) confirming our diagnosis. She was treated with diabetic ketoacidosis protocol with intravenous fluids and intravenous insulin. On recovery, she was discharged home on once daily insulin with aim to self-manage diabetes with support from district nurses and to avoid hypoglycaemia.

Glycaemic control in critical care: Can flash glucose monitoring help?

Good glycaemic control confers an outcome benefit in both diabetic and non-diabetic critically unwell patients. Critically unwell patients receiving intravenous insulin in the intensive care unit (ICU) require hourly glucose monitoring. This brief communication highlights the impact of the introduction of the FreeStyle Libre glucose monitor, a form of continuous glucose monitoring, on the frequency of glucose recordings in patients receiving intravenous insulin in the ICU at York Teaching Hospital NHS Foundation Trust.

Intravenous insulin administration preparation for myocardial 18F-fluorodeoxyglucose viability imaging has the potential to reduce radiation exposure dose

Purpose This study aimed to identify and validate the optimal 18F-FDG activity and acquisition time for cardiac viability imaging with intravenous insulin administration based on a fixed 18F-FDG activity. Methods Cardiac positron emission tomography (PET) images from 30 patients with coronary artery disease (CAD) were retrospectively reconstructed into 900, 360, 180, 90, and 45 s durations. An optimal product of the maximum standardized uptake value (SUV) of the myocardium and segmental uptake (SU) and acquisition time (MSAT) was determined through a receiver operating characteristic curve. The optimal acquisition time (OAT) was equal to MSAT divided by mean SUV of the myocardium (MyoSUV) and validated in another 26 patients with CAD. Results The MyoSUV, mean SUV of the blood, SU, and their biases on reconstructed image durations of 90, 180, and 360 s were equivalent to those on an image duration of 900 s. The optimal MSAT was 848.2. In the validation group, the OAT was 129 ± 76 s (95% confidence interval, 99–160), approximately one-third of the usual acquisition time. The MyoSUV and SU were equivalent for the difference (0.15 ± 0.21, P < 0.001; −0.01 ± 0.03, P < 0.001) between PET image duration of OAT and 600 s (7.71 ± 3.01 vs. 7.56 ± 2.94, 67.1 ± 15.4% vs. 67.7 ± 15.6%). Conclusion Intravenous insulin administration preparation has the potential to reduce radiation exposure and acquisition time of cardiac 18F-FDG viability imaging without losing the accurate measurement of MyoSUV and SU when reaching an OAT.

Intravenous insulin administration preparation for myocardial 18F-fluorodeoxyglucose viability imaging has the potential to reduce radiation exposure dose

Purpose This study aimed to identify and validate the optimal 18F-FDG activity and acquisition time for cardiac viability imaging with intravenous insulin administration based on a fixed 18F-FDG activity. Methods Cardiac positron emission tomography (PET) images from 30 patients with coronary artery disease (CAD) were retrospectively reconstructed into 900, 360, 180, 90, and 45 s durations. An optimal product of the maximum standardized uptake value (SUV) of the myocardium and segmental uptake (SU) and acquisition time (MSAT) was determined through a receiver operating characteristic curve. The optimal acquisition time (OAT) was equal to MSAT divided by mean SUV of the myocardium (MyoSUV) and validated in another 26 patients with CAD. Results The MyoSUV, mean SUV of the blood, SU, and their biases on reconstructed image durations of 90, 180, and 360 s were equivalent to those on an image duration of 900 s. The optimal MSAT was 848.2. In the validation group, the OAT was 129 ± 76 s (95% confidence interval, 99–160), approximately one-third of the usual acquisition time. The MyoSUV and SU were equivalent for the difference (0.15 ± 0.21, P < 0.001; −0.01 ± 0.03, P < 0.001) between PET image duration of OAT and 600 s (7.71 ± 3.01 vs. 7.56 ± 2.94, 67.1 ± 15.4% vs. 67.7 ± 15.6%). Conclusion Intravenous insulin administration preparation has the potential to reduce radiation exposure and acquisition time of cardiac 18F-FDG viability imaging without losing the accurate measurement of MyoSUV and SU when reaching an OAT.

Hyperglycaemic crisis secondary to emphysematous pyelonephritis

A 49-year-old woman presented to the emergency department acutely unwell. Initial investigations revealed hyperglycaemia, ketosis and an acute kidney injury precipitated by urosepsis. She was found to have a new diagnosis of diabetes mellitus (type 2) with a glycated haemoglobin (HbA1c) of 156 mmol/mol. CT imaging of the abdomen and pelvis revealed unilateral emphysematous pyelonephritis (EPN), radiologically classified as stage 3 severity with gas extending beyond the renal collecting system. Escherichia coli was grown on blood and urine cultures. This was sensitive to second-generation cephalosporin cefuroxime. The patient was managed with fluid resuscitation, intravenous antibiotics and renal system decompression with urinary catheter insertion. She was commenced on an intravenous insulin infusion for hyperglycaemic crisis. This case illustrates a rare presentation of hyperglycaemic crisis precipitated by EPN in a patient without a previously known diagnosis of diabetes, successfully treated with medical management alone. Close clinical and radiological follow-up was arranged to monitor the need for future nephrectomy.

Strawberry pink blood: hypertriglyceridaemia and diabetic ketoacidosis secondary to poorly controlled type 2 diabetes mellitus

A 54-year-old woman with insulin-requiring type 2 diabetes mellitus presented with acute shortness of breath and drowsiness on a background of polydipsia, weakness and significant weight loss. One year ago, she had decided to stop her insulin and other medications and adopt lifestyle modifications instead. Initial emergency department (ED) blood samples were highly lipaemic and appeared strawberry pink. She was eventually diagnosed with diabetic ketoacidosis (DKA) with severe hypertriglyceridaemia, intubated for airway protection, and managed with fluid resuscitation and intravenous insulin to good effect. We share an uncommon DKA presentation at the ED. History was limited as the patient was drowsy and minimally communicative. Physical examination was unremarkable. Blood investigations were also delayed in view of the need for additional centrifugation. These contributed to a paucity of information in the acute setting and resulted in a diagnostic challenge.

Case of sodium–glucose cotransporter-2 inhibitor-associated euglycaemic diabetic ketoacidosis

Following non-elective orthopaedic surgery, a 61-year-old man with poorly controlled type 2 diabetes mellitus on empagliflozin developed high anion gap metabolic acidosis in the high-dependency unit. Metabolic acidosis persisted despite intravenous sodium bicarbonate, contributing to tachycardia and a run of non-sustained ventricular tachycardia. He was euglycaemic throughout hospital admission. Investigations revealed elevated urine and capillary ketones, and a diagnosis of sodium–glucose cotransporter-2 inhibitor-associated euglycaemic diabetic ketoacidosis was made. He was treated with an intravenous sliding scale insulin infusion and concurrent dextrose 5% with potassium chloride. Within 24 hours of treatment, his arterial pH, anion gap and serum bicarbonate levels normalised. After a further 12 hours, the intravenous insulin infusion was converted to a basal/bolus regimen of subcutaneous insulin, and he was transferred to the general ward. He was discharged well on subcutaneous insulin 6 days postoperatively.