When is IV insulin therapy indicated?

Updated: Nov 06, 2018
  • Author: Guy W Soo Hoo, MD, MPH; Chief Editor: George T Griffing, MD  more...
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Answer

Answer

As noted above, patients with hyperglycemia are at risk for adverse outcomes and infections are a common clinical indicator of the risk associated with hyperglycemia. Patients undergoing cardiac surgery seem to be especially susceptible to deep wound infections, specifically sternal wound infections. This is probably the one group of patients who may still benefit from the routine use of intravenous insulin for glucose control. Experience from several institutions and data that incorporate both observational and randomized investigations indicate improvement in mortality and rate of sternal wound infections with the use of intravenous insulin. [2, 5]

The evidence to support the use of intravenous insulin in this patient subgroup has been designated as a class I recommendation by the Society of Thoracic Surgeons. [6] Routine use of continuous insulin protocols is not endorsed for any other subgroup, but general experience does support its use in those diabetic patients in whom control of hyperglycemia has been demonstrated to be difficult with conventional subcutaneous treatment. In some circumstances, diabetic patients who require therapy that interfere with optimal glucose control such as corticosteroid therapy may also be candidates for intravenous insulin therapy.

This is markedly different from previous practice and is a reflection of the results of the multicenter NICE-SUGAR trial. Intravenous insulin therapy can no longer be recommended as routine treatment in the ICU but should be reserved for patients who undergo open cardiac surgery and diabetic patients with suboptimal glucose control as a result of their underlying diabetes, infection or treatment that fails to be controlled with conventional subcutaneous insulin regimens.


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