Risk Factors for Hypoglycemia During Treatment of Hyperglycemic Crises.

Objective: Diabetic ketoacidosis and hyperosmolar hyperglycemic state are life-threatening hyperglycemic crises often requiring intensive care unit (ICU) management. Treatment includes intravenous (IV) insulin with a transition to subcutaneous (SC) insulin upon resolution. Hypoglycemia is a common complication associated with treatment of hyperglycemic crises, but risk factors have not been well established. This study aimed to assess risk factors associated with hypoglycemia during treatment for hyperglycemic crises. Methods: This case-control study included ICU patients admitted with hyperglycemic crises at a single Veterans Affairs health system from 1 January 2013 to 31 March 2020. Patients who developed hypoglycemia during insulin treatment were compared with a control group. Odds of hypoglycemia were assessed based on risk factors, including BMI, comorbidities, and type of SC insulin used. Results: Of the 216 cases of hyperglycemic crises included, hypoglycemia occurred in 61 cases (44 on SC insulin, 11 on IV insulin, and 6 on both). Odds for hypoglycemia were significantly higher for underweight patients (odds ratio 4.52 [95% CI 1.05-19.55]), type 1 diabetes (4.02 [2.09-7.73]), chronic kidney disease (1.94 [1.05-3.57]), those resumed on the exact chronic SC insulin regimen following resolution (2.91 [1.06-7.95]), and patients who received NPH versus glargine insulin (5.13 [1.54-17.06]). No significant differences were seen in the other evaluated variables. Conclusion: This study found several factors associated with hypoglycemia during hyperglycemic crises treatment, many of which are not addressed in consensus statement recommendations. These findings may help ICU clinicians prevent complications related to hyperglycemic crisis management and generate hypotheses for future studies.

Coronavirus Disease 2019-Related Extensive Thrombosis in a Patient Receiving Therapeutic Anticoagulation With Dabigatran.

Introduction and Objective: Coronavirus disease 2019 (COVID-19) is associated with respiratory failure and a hypercoagulable state. Studies have shown the use of oral anticoagulants, specifically dabigatran, can significantly decrease mortality from COVID-19. Dabigatran is an oral direct thrombin inhibitor commonly used for nonvalvular atrial fibrillation and for the treatment or prevention of venous thromboembolism. The association of COVID-19-related extensive thrombosis while receiving full therapeutic anticoagulation with dabigatran has not been well-established in current literature. Case Report: We present a 73-year-old male patient with a history of persistent atrial fibrillation anticoagulated with dabigatran presenting with an active COVID-19 infection admitted to the intensive care unit. On hospital day 7, he developed extensive arterial and venous thromboembolisms. To our knowledge, this is the first published case of COVID-19-related extensive thrombosis while receiving full therapeutic anticoagulation with dabigatran. Discussion: Guidelines recommend prophylactic or therapeutic-dose anticoagulation with unfractionated heparin or low-molecular weight heparin for all patients if no contraindications exist; however, recommendations for the use of therapeutic oral anticoagulants have not been well established. Further studies are warranted to establish appropriate use of oral anticoagulants in the setting of COVID-19. Conclusion: Evidence from this report suggests clinicians should closely monitor patients at risk for hypercoagulability regardless of the anticoagulation therapy the patient may be receiving. Additionally, evidence from this case suggests a possible inferiority in the anticoagulation ability of dabigatran in patients with active COVID-19.

Integration of Around-the-Clock Clinical Pharmacy Specialists Into the Critical Care Team Can Increase Safety of Hyperglycemic Crisis Management.

IN BRIEF "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an effort to improve the safety of hyperglycemic crisis management at a Veterans Affairs Medical Center by making clinical pharmacy specialists available to the critical care team 24 hours/day.

A Bedside Computerized Decision-Support Tool for Intravenous Insulin Infusion Management in Critically Ill Patients.

Intravenous (IV) insulin infusions using a validated protocol are the recommended method for blood glucose control in critically ill patients. Computerized decision-support tools improve quality over manual paper-based protocols. However, nonproprietary computerized tools targeting the recommended blood glucose range of 140-180 mg/dL are not readily available. A bedside computerized decision-support tool was developed at a US Department of Veterans Affairs health system to assist the nursing staff with the management of patients requiring IV insulin infusion. Initial evaluation showed that the tool was useful in the safe and effective management of an IV insulin infusion protocol for blood glucose control targeting the updated blood glucose range.