Insulin infusion

Garg R, Chaudhuri A, Munschauer F, Dandona P. H3fperglycemia, insulin, and acute ischemic stroke a mechanistic justification for a trial of insulin infusion therapy. Stroke 2006 37 267-273. 

Scott JF, Robinson GM, French JM, O Connell JE, Alberti KG, Gray CS. Glucose potassium insulin infusions in the treatment of acute stroke patients with mild to moderate hyperglycemia the glucose insulin in stroke trial (GIST). Stroke 1999 30 793-799. 

When plasma glucose drops to 250 mg/dL, decrease insulin infusion rate and continue until acidosis is corrected (i.e., anion gap closes)... 

If hypoglycemia develops in the setting of continued ketoacidosis, lower the insulin infusion and administer glucose infusions to maintain euglycemia. Do not stop the insulin infusion... 

Currently, the most advanced form of insulin therapy is the insulin pump, also referred to as continuous subcutaneous insulin infusion (CSII). Using the short- or rapid-acting insulins only, these pumps are programmed to provide a slow release of small amounts of insulin as the basal portion of therapy, and then larger bolus doses are injected by the patient to account for the consumption of food. 

Continue above until patient is stable, glucose goal is 150-250 mg/dL, and acidosis is resolved. Insulin infusion may be decreased to 0.05-0.1 units/kg per hour. 

Administer intermediate or long-acting insulin as soon as patient is eating. Allow for overlap in insulin infusion and subcutaneous insulin injection. 

When preparing an insulin infusion for a patient, several factors must be considered. Insulin will absorb to glass and plastic, reducing the amount of insulin actually delivered by 20% to 30%. Priming the tubing will decrease variability of insulin infused. Therefore, when patients can be converted safely from infusion to needle and syringe therapy, the total daily dose should be reduced by 20% to 50% of the daily infusion amount. 

The patient was admitted to the hospital with a presumptive diagnosis of health care-associated pneumonia (based on the recent hospitalization). He received intravenous hydration with normal saline, 5 L oxygen via face mask, an insulin infusion to control his glucose, and empirical antimicrobial therapy with piperacillin-tazobactam 2.25 g intravenously every 6 hours and vancomycin 1 g intravenously every 24 hours. All other medications are continued with the exception of the diabetes medications. 

Insulin aggregation and precipitation was an impediment to the development of implantable devices for insulin delivery as noted by several investigators working with conventional insulin infusion devices [51-54]. The potential causes of the observed aggregation and precipitation are thermal effects, mechanical stress, the nature of the materials in contact with the insulin solution, formulation factors, and the purity of the insulin preparation. 

Aim of this study was to find out whether an increase of circulating FFA and prolonged experimental hyperinsulinemia might lead to an elevation of IMCL. The experimental protocol (which is given in more detail in Refs. 87 and 88) comprised three different study groups [1] combination of lipid infusion and hyperinsulinemia (L+HI, 12 male volunteers), [2] hyperinsulinemia alone (HI, 6 male volunteers), and [3] lipid infusion without concomitant insulin infusion (L, 3 male volunteers). 

II.f.1.3. Insulin delivery. Traditionally insulin was given intramuscularly and later subcutaneously. New technology has provided devices for insulin administrations including pen-devices, air powered injectors, external insulin infusion pumps (or continuous subcutaneous insulin infusion, CSII), and implantable insulin infusion pumps. Some novel forms of insulin delivery have been introduced, for example intranasal insulin gives peak insulin concentrations at 10-20 minutes after administration, but most insulin is still administered subcutaneously. 

E. L. Lim, K. G. Hollingsworth, P. E. Thelwall and R. Taylor, Measuring the acute effect of insulin infusion on ATP turnover rate in human skeletal muscle using phosphorus-31 magnetic resonance saturation transfer spectroscopy. NMR Biomed., 2010, 23,952-957. 

The standard mode of insulin therapy has traditionally been by subcutaneous injection using disposable needles/syringes. However, other routes of administration, including continuous subcutaneous insulin infusion pumps and inhalation of finely powdered aerosolized insulin, are currently being explored. 

CONTINUOUS SUBCUTANEOUS INSULIN INFUSION DEVICES (CSII, INSULIN PUMPS)... 

In a crossover study, 20 patients with type 2 diabetes were treated for 6 weeks with glucagon-like peptide-1 or saline added to continuous subcutaneous insulin infusion glucagon-like peptide-1 reduced appetite and caused nausea and reduced well-being (3). 

Continuous subcutaneous insulin infusion with fast-acting insulin has been used in two cases. 

A 43-year-old man with type 1 diabetes developed local pruritus, redness, and swelling 4—5 times a week, 15-20 minutes after an injection, subsiding within 1-2 hours (163). Later he had a generalized urticarial reaction 5 minutes after an injection. Insulin lispro did not help. When checked for allergens, he was positive for all types of insulin and negative for additives. With oral mizolastine the local reactions abated for a week, but then reappeared with every injection. Generalized urticaria recurred later. With continuous subcutaneous insulin infusion... 

Repeated episodes of catheter obstruction by fibrin clots or omental encapsulation can be a problem during continuous peritoneal insulin infusion from implanted pumps (SEDA 20, 397). In the encapsulated tissue, collagen fibrosis, inflammatory reactions with lymphocytes, and amyloid-like deposits reacting to anti-insulin antibodies can occur higher macrophage chemotaxis may also promote these processes. 

Diabetes mellitus in a 36-year-old man with acute pancreatitis could not be controlled with continuous subcutaneous insulin infusion, even with doses up to 1800 U/ day, because of insulin resistance (168). Intravenous insulin by pump had to be stopped because of a catheter infection. The continuous subcutaneous infusion of freeze-dried insulin and the addition of aprotinin, a protease inhibitor, soluble dexamethasone or prednisolone, and intravenous immunoglobulin was ineffective. An implantable pump for intraperitoneal delivery established good regulation at a dosage of 30 U/day. 

A 23-year-old diabetic woman had severe subcutaneous insulin resistance for 11 years (169). Continuous subcutaneous insulin infusion with regular or insulin lispro did not prevent periods of fluctuating responses to insulin. The addition of heparin to insulin lispro in the pump improved serum insulin concentrations and metabolic control. The addition of heparin to regular insulin gave no improvement. 

Continuous subcutaneous insulin infusion (CSII) often gives a better quality of life (189). 

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