New diabetes mitigation plan in the intensive care unit (ICU) during the COVID-19 pandemic.
The Coronavirus Disease of 2019 (COVID-19) was first announced to the world in late December. The new infectious respiratory disease is considered as the most crucial global health calamity since the Second World War. Many severe symptomatic patients require limited hospital resources that only an intensive care unit (ICU) can provide. The Mayo Clinic staff reports many of those with severe symptoms have underlying health conditions, such as diabetes. Unfortunately, patients with diabetes are twice as likely to require ICU and are at a much higher risk of developing complications or mortality related to COVID-19 infection.
“Given rising numbers of cases of patients with COVID-19 and diabetes, understanding their interaction on insulin requirement and glycemic control is prudent,” notes Dr. Osama Hamdy, a medical director of the inpatient diabetes program and a faculty member at Harvard Medical School in Boston. Dr. Hamdy reports an increase in blood glucose is one of many early COVID-19 symptoms. He suggests implementing new mitigating plans while diabetes management problems continue to rise in the ICU currently.
Insulin-dosing with patients on artificial ventilation while they are on continuous tube feeding is a challenge. Hypoglycemia is experienced with interruptions. Hospitals may implement different insulin dosing approaches tailored to meet a specific goal. For example, Neutral Protamine Hagedorn (NPH)-Regular insulin combination is preferred if the specific goal is to reduce the number of contacts. Intravenous insulin infusion is best when minimizing glycemic variability is a priority. Furthermore, if a long-acting insulin regimen is preferred, a portion of the insulin coverage may be given as fixed doses of regular insulin every six hours. Dr. Hamdy believes that the mitigations will increase safety and effectively reduce mortality while optimizing glucose management and cost.
Intravenous corticosteroids are commonly used in the ICU. Corticosteroid resolves many indications such as septic shock, acute respiratory distress syndrome, severe chronic obstructive pulmonary disease, and many others. For mild symptomatic cases, Dr. Hamdy reports injecting hydrocortisone 400 mg, twice a day, for the first day; then followed by a dose reduction of 200 mg, twice a day, for four days to suppress any possible inflammation effectively. Furthermore, he reports that the cytokine storm is commonly observed with prolonged steroid use. Glucose levels shooting up to 400-500 mg/dL were recorded with high doses of steroid injections. Dr. Hamdy suggests, “adding NPH insulin in a dose of 20–30 units in the morning in addition to the current insulin regimen.”
Injection of high doses of intravenous vitamin C is a common practice in the ICU. Studies report many beneficial effects of high dose vitamin C injections, but factitious high glucose readings make it difficult to dose. Typically, three grams of vitamin C are intravenously injected every six hours for seven days. To avoid error and possible hypoglycemia, testing plasma glucose with the finger-stick method twice a day for accuracy is essential.
Dr. Hamdy reveals that the CGM system may respond dangerously to inaccurate glucose values. Hypoxemia and reduction in peripheral perfusion, seen in many patients with COVID-19, may distort glucose measurement in the interstitial fluid, where the feedback sensor is located in the CGM. He also cautions interpreting the glucose value from CGM with paracetamol or albuterol administration.
Any present study on COVID-19 must be reviewed, like any new research, with scrutinizing eyes. While it is crucial to learn more about COVID-19 every day, it is as essential to keep everyone safe by reducing contact and being updated with new mitigation plans for patients with diabetes in the ICU during the COVID-19 pandemic.
- Patients with diabetes are alarmingly susceptible to COVID-19, requiring more attention than individuals without diabetes.
- It’s important to minimize the risk of severe hypoglycemia and improve glycemic control.
- Strive to reduce glucose variability and contact frequency.
Chakraborty, Indranil, and Prasenjit Maity. “COVID-19 outbreak: Migration, effects on society, global environment, and prevention.” The Science of the total environment vol. 728, (2020): 138882. doi:10.1016/j.scitotenv.2020.138882
Osama Hamdy, Robert A. Gabbay, “Early Observation and Mitigation of Challenges in Diabetes Management of COVID-19 Patients in Critical Care Units.” Diabetes Care 2020 May; dc200944.https://doi.org/10.2337/dc20-0944
Li Y, Han X, Alwalid O, et al. “Baseline characteristics and risk factors for short-term outcomes in 132 COVID-19 patients with diabetes in Wuhan China: A retrospective study [published online ahead of print, 2020 July 3].“ Diabetes Res Clin Pract. 2020;166:108299. doi:10.1016/j.diabres.2020.108299
Staff, Mayo Clinic. “COVID-19: Who’s at Higher Risk of Serious Symptoms?” Mayo Clinic, Mayo Foundation for Medical Education and Research, July 28, 2020, www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-who-is-at-risk/art-20483301.
Peter Jay Won, Pharm.D. Candidate, University of South Florida, Taneja College of Pharmacy