Simplified Transition Algorithm from Intravenous to Subcutaneous Insulin in Nondiabetic Cardiac Surgery Patients with Stress Hyperglycemia

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 SSITransition to Basalp-valuePatients, n (%)120 (80)30 (20)BMI, Kg/m228.8 ± 6.530.3 ± 5.40.15HbA1c, %5.6 ± 0.45.8 ± 0.70.047ICUDaily BG during IV insulin drip, mg/dl133.9 ± 17142.9 ± 150.004Total insulin in the ICU, U/day57.4 ± 8973.8 ± 640.005TRANSITIONAverage BG after transition, mg/dl123.4 ± 12129.8 ± 160.022Patients who required SQ SSI99 (83)30 (100)<0.001Patients with BG < 70 mg/dl, n (%)13 (10.8)2 (6.7)0.74Composite of complications53 (44)14 (47)0.81Data are n (%) or mean ± SD. Composite complications: major CV events, infections, respiratory failure and acute kidney injury. 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..