What insulin regimen adjustments are recommended for a type 1 diabetes patient with sepsis and elevated blood glucose levels on Lantus (insulin glargine) 14 units?

Insulin Management for Type 1 Diabetic Patient with Sepsis

For a type 1 diabetic patient with sepsis and persistently elevated blood glucose levels (279 and 272 mg/dL overnight), immediate insulin regimen adjustment is required using a protocolized approach targeting blood glucose levels ≤180 mg/dL.

Initial Assessment and Approach

• The patient's current regimen (Lantus 14 units daily with 1:10 carbohydrate ratio and medium correction scale) is insufficient to control blood glucose during sepsis 1
• Sepsis causes insulin resistance and hyperglycemia, which can worsen outcomes if not properly managed 2, 3
• The patient's weight (77 kg) and normal renal function (Cr 0.9) allow for aggressive insulin adjustment 1

Recommended Insulin Adjustments

Basal Insulin (Lantus)

• Increase Lantus (insulin glargine) from 14 units to 20-22 units (approximately 0.25-0.28 units/kg) 1, 4
• Lantus provides a peakless profile with duration of action up to 24 hours, making it suitable for once-daily dosing in sepsis 4

Bolus Insulin

• Strengthen carbohydrate ratio from 1:10 to 1:8 to address increased insulin resistance 1
• Increase correction scale from medium to high correction factor 1
• Consider temporary fixed supplemental insulin doses before meals and at bedtime regardless of carbohydrate intake during acute sepsis 1, 2

Monitoring Protocol

• Monitor blood glucose every 1-2 hours until glucose values and insulin rates stabilize, then every 4 hours 1
• If arterial access is available, use arterial blood rather than capillary blood for glucose measurements 1
• Target blood glucose ≤180 mg/dL rather than more aggressive targets to avoid hypoglycemia 1

Implementation Considerations

• Maintain insulin therapy even during periods of decreased oral intake 1, 2
• Adjust insulin doses daily based on glucose trends until sepsis resolves 1
• Consider IV insulin infusion if blood glucose remains >180 mg/dL despite subcutaneous insulin adjustments 1

Potential Pitfalls and Caveats

• Hypoglycemia risk increases during insulin intensification in sepsis; ensure frequent monitoring 1, 3
• Insulin requirements may change rapidly as sepsis resolves; be prepared to decrease insulin doses to prevent hypoglycemia 2, 3
• Point-of-care glucose testing may be less accurate during sepsis and hypoperfusion states; interpret with caution 1
• Avoid wide swings in glucose levels which can worsen outcomes 1

Additional Considerations

• Ensure adequate hydration and electrolyte management alongside glucose control 1
• Return to pre-sepsis insulin regimen once infection resolves and glucose levels stabilize 1, 5
• Document all insulin adjustments and glucose responses to guide future management 1, 5