{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T22:12:22Z","timestamp":1778019142791,"version":"3.51.4"},"reference-count":28,"publisher":"Oxford University Press (OUP)","issue":"5-6","funder":[{"name":"Defense Health Agency RESTORAL"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,5,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>The aeromedical evacuation environment introduces unique logistical and physiological stressors for both patients and medical staff. Treating critically ill patients in confined spaces, under low-light conditions, amid aircraft noise, and with limited resources increases the risk of adverse drug events (ADEs). However, the true frequency and impact of medication errors in the en route care (ERC) setting remain poorly documented in both civilian and military sectors. In-flight, Critical Care Air Transport (CCAT) teams administer multiple high-risk medications, including paralytics, analgesics, cardiac drugs, anticoagulants, and insulin. The current CCAT model for medication safety relies largely on healthcare personnel performing high-risk procedures without error. Yet, significant gaps remain in understanding the frequency, nature, and consequences of medication errors in the en route critical care (ERCC) military environment. The purpose of this study was to describe CCAT in-flight insulin administration, glucose monitoring, and related interventions. The findings will inform CCAT pre-deployment readiness training and guide future CCAT clinical care practice guidelines.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Materials and Methods<\/jats:title>\n                    <jats:p>We conducted a retrospective review of CCAT mission records for patients who received insulin during transport by USAF CCAT between 2012 and 2022. Research nurses trained at the En Route Care Research Center (ECRC) in San Antonio reviewed and abstracted data from Form 3899L into an Excel database. Descriptive statistics and univariate analyses were conducted for patient demographics and key measurements using SAS (version 9.4, SAS Institute, Inc., Cary, NC). Subgroup analyses stratified by insulin administration route were performed. Differences in hypoglycemia rates between administration routes were compared using the Fisher exact test.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The records of 3,320 patients evacuated by CCAT between 2012 and 2022 were screened. After exclusion criteria were applied, 2,998 records were screened for insulin administration, among which 2% (59\/2,998) documented at least one instance of insulin administration. Routes of insulin administration included 51 subcutaneous (SQ) injections, 15 intravenous pushes (IVPs), 13 continuous insulin infusions, and 3 unspecified. Four patients (6.8%) experienced at least one hypoglycemic event (blood glucose concentration [BG] &amp;lt;70 mg\/dL). Of these, three patients (75%) were receiving insulin infusions for hyperglycemia. For the 13 patients on insulin infusions, the median infusion rate was 4.0 U\/hour (IQR [2.75-8.25]), and six patients (46%) had at least one 2-hour interval without a documented BG check. Most (60%) episodes of IVP insulin administration lacked a glucose check within 1 hour.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Insulin infusions managed by CCAT teams were rarely administered but were associated with a relatively high hypoglycemia rate of 23%. Documented BG measures during intravenous insulin administration were inadequate. Unless a CCAT team can ensure reliable and undistracted glucose monitoring, SQ insulin should be considered the first-line treatment for hyperglycemia in the ERCC setting.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/milmed\/usaf476","type":"journal-article","created":{"date-parts":[[2025,9,11]],"date-time":"2025-09-11T12:03:51Z","timestamp":1757592231000},"page":"e924-e930","source":"Crossref","is-referenced-by-count":0,"title":["Insulin Administration Safety Profile During Military En Route Critical Care Transports"],"prefix":"10.1093","volume":"191","author":[{"given":"Richard","family":"Strilka","sequence":"first","affiliation":[{"name":"Center for Sustainment of Trauma and Readiness Skills, University of Cincinnati , Cincinnati, OH 45219,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8684-2764","authenticated-orcid":false,"given":"Shelia C","family":"Savell","sequence":"additional","affiliation":[{"name":"En route Care Research Center, 59MDW, Science & Technology, Defense Health Agency, Joint Base San Antonio , Ft Sam Houston, TX 78234,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Krystal K","family":"Valdez-Delgado","sequence":"additional","affiliation":[{"name":"En route Care Research Center, 59MDW, Science & Technology, Defense Health Agency, Joint Base San Antonio , Ft Sam Houston, TX 78234,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lane L","family":"Frasier","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, OH 45219,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jill","family":"Lear","sequence":"additional","affiliation":[{"name":"En route Care Research Center, 59MDW, Science & Technology, Defense Health Agency, Joint Base San Antonio , Ft Sam Houston, TX 78234,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4141-0738","authenticated-orcid":false,"given":"William T","family":"Davis","sequence":"additional","affiliation":[{"name":"En route Care Research Center, 59MDW, Science & Technology, Defense Health Agency, Joint Base San Antonio , Ft Sam Houston, TX 78234,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2025,10,4]]},"reference":[{"key":"2026050517463905100_usaf476-B1","author":"Grimm","year":"2024"},{"key":"2026050517463905100_usaf476-B2","author":"Crowe","year":"2024"},{"key":"2026050517463905100_usaf476-B3","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1093\/intqhc\/mzab138","article-title":"How safe is prehospital care? A systematic review","volume":"33","author":"O\u2019connor","year":"2021","journal-title":"Int J Qual Health Care"},{"key":"2026050517463905100_usaf476-B4","doi-asserted-by":"publisher","first-page":"e1874","DOI":"10.7205\/MILMED-D-17-0009","article-title":"Critical care air transport team evacuation of medical patients without traumatic injury","volume":"182","author":"Maddry","year":"2017","journal-title":"Mil Med"},{"key":"2026050517463905100_usaf476-B5","doi-asserted-by":"publisher","first-page":"3086","DOI":"10.1093\/milmed\/usac097","article-title":"Descriptive analysis of intratheater critical care air transport team patient movements during troop drawdown: Afghanistan (2017\u20132019)","volume":"188","author":"Zingg","year":"2023","journal-title":"Mil Med"},{"key":"2026050517463905100_usaf476-B6","doi-asserted-by":"publisher","first-page":"431","DOI":"10.1017\/S1049023X1500494X","article-title":"Medication administration in critical care transport of adult patients with hypoxemic respiratory failure","volume":"30","author":"Wilcox","year":"2015","journal-title":"Prehosp Disaster Med"},{"key":"2026050517463905100_usaf476-B7","doi-asserted-by":"publisher","first-page":"180","DOI":"10.1093\/milmed\/usae113","article-title":"Impact of rank, provider specialty, and unit sustainment training frequency on military critical care air transport team readiness","volume":"190","author":"Leib","year":"2025","journal-title":"Mil Med"},{"key":"2026050517463905100_usaf476-B8","doi-asserted-by":"publisher","first-page":"1376","DOI":"10.1093\/milmed\/usac142","article-title":"Relevance of deployment experience and clinical practice characteristics on military critical care air transport team readiness: a study of simulation construct validity","volume":"188","author":"Brown","year":"2023","journal-title":"Mil Med"},{"key":"2026050517463905100_usaf476-B9","doi-asserted-by":"publisher","first-page":"342","DOI":"10.1093\/milmed\/usae286","article-title":"Identifying and reducing insulin errors in the simulated military critical care air transport environment: a human factors approach","volume":"190","author":"Frasier","year":"2025","journal-title":"Mil Med"},{"key":"2026050517463905100_usaf476-B10","doi-asserted-by":"publisher","first-page":"S321","DOI":"10.2337\/dc25-S016","article-title":"Diabetes care in the hospital: standards of care in diabetes\u20142025","volume":"48","author":"American Diabetes Association","year":"2025","journal-title":"Diabetes Care"},{"key":"2026050517463905100_usaf476-B11","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1186\/s12976-016-0029-2","article-title":"Simulation and qualitative analysis of glucose variability, mean glucose, and hypoglycemia after subcutaneous insulin therapy for stress hyperglycemia","volume":"13","author":"Strilka","year":"2016","journal-title":"Theor Biol Med Model"},{"key":"2026050517463905100_usaf476-B12","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1186\/s41038-017-0073-0","article-title":"The influence of metabolic imbalances and oxidative stress on the outcome of critically ill polytrauma patients: a review","volume":"5","author":"Rogobete","year":"2017","journal-title":"Burns Trauma"},{"key":"2026050517463905100_usaf476-B13","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1186\/s13054-017-1883-y","article-title":"Glycaemic control targets after traumatic brain injury: a systematic review and meta-analysis","volume":"22","author":"Hermanides","year":"2018","journal-title":"Crit Care"},{"key":"2026050517463905100_usaf476-B14","doi-asserted-by":"publisher","first-page":"S41","DOI":"10.1097\/TA.0000000000003654","article-title":"Hemodynamic events during en route critical care for patients with traumatic brain injury","volume":"93","author":"Davis","year":"2022","journal-title":"Journal of Trauma and Acute Care Surgery"},{"key":"2026050517463905100_usaf476-B15","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1016\/j.oto.2024.101132","article-title":"Hyperglycemia in orthopaedic trauma patients: implications, management, and future directions","volume":"34","author":"Belmonte","year":"2024","journal-title":"Oper Tech Orthop"},{"key":"2026050517463905100_usaf476-B16","doi-asserted-by":"publisher","first-page":"e568","DOI":"10.1016\/j.amjmed.2020.03.012","article-title":"Hyperglycemia in medically critically ill patients: risk factors and clinical outcomes","volume":"133","author":"Becker","year":"2020","journal-title":"Am J Med"},{"key":"2026050517463905100_usaf476-B17","doi-asserted-by":"publisher","first-page":"157","DOI":"10.5455\/medarh.2015.69.157-160","article-title":"Hyperglycemia in critically ill patients: management and prognosis","volume":"69","author":"Godinjak","year":"2015","journal-title":"Med Arch"},{"key":"2026050517463905100_usaf476-B18","doi-asserted-by":"publisher","first-page":"1894","DOI":"10.2337\/diacare.24.11.1894","article-title":"Weighing in on type 2 diabetes in the military: characteristics of US military personnel at entry who develop type 2 diabetes","volume":"24","author":"Paris","year":"2001","journal-title":"Diabetes Care"},{"key":"2026050517463905100_usaf476-B19","doi-asserted-by":"publisher","first-page":"305","DOI":"10.1186\/cc12514","article-title":"Stress hyperglycemia: an essential survival response!","volume":"17","author":"Marik","year":"2013","journal-title":"Crit Care"},{"key":"2026050517463905100_usaf476-B20","doi-asserted-by":"publisher","first-page":"921","DOI":"10.1097\/01.ta.0000162141.26392.07","article-title":"Persistent hyperglycemia is predictive of outcome in critically ill trauma patients","volume":"58","author":"Bochicchio","year":"2005","journal-title":"J Trauma"},{"key":"2026050517463905100_usaf476-B21","doi-asserted-by":"publisher","first-page":"1058","DOI":"10.1097\/01.ta.0000123267.39011.9f","article-title":"Relationship of early hyperglycemia to mortality in trauma patients","volume":"56","author":"Laird","year":"2004","journal-title":"J Trauma"},{"key":"2026050517463905100_usaf476-B22","doi-asserted-by":"publisher","first-page":"80","DOI":"10.1097\/01.ta.0000171452.96585.84","article-title":"Admission hyperglycemia is predictive of outcome in critically ill trauma patients","volume":"59","author":"Sung","year":"2005","journal-title":"J Trauma"},{"key":"2026050517463905100_usaf476-B23","doi-asserted-by":"publisher","first-page":"107","DOI":"10.1016\/s0749-0704(05)70154-8","article-title":"Stress-induced hyperglycemia","volume":"17","author":"McCowen","year":"2001","journal-title":"Crit Care Clin"},{"key":"2026050517463905100_usaf476-B24","doi-asserted-by":"publisher","first-page":"e161","DOI":"10.1097\/CCM.0000000000006174","article-title":"Society of critical care medicine guidelines on glycemic control for critically ill children and adults 2024","volume":"52","author":"Honarmand","year":"2024","journal-title":"Crit Care Med"},{"key":"2026050517463905100_usaf476-B25","doi-asserted-by":"publisher","first-page":"10718","DOI":"10.1038\/s41598-020-67864-z","article-title":"Real-world characterization of blood glucose control and insulin use in the intensive care unit","volume":"10","author":"Baker","year":"2020","journal-title":"Sci Rep"},{"key":"2026050517463905100_usaf476-B26","doi-asserted-by":"publisher","first-page":"106","DOI":"10.6000\/1927-5951.2017.07.03.6","article-title":"Sliding scale regular human insulin for identifying critically ill patients who require intensive insulin therapy and for glycemic control in those with mild to moderate hyperglycemia","volume":"7","author":"Cogle","year":"2017","journal-title":"J Pharm Nutr Sci"},{"key":"2026050517463905100_usaf476-B27","doi-asserted-by":"publisher","first-page":"192","DOI":"10.1016\/j.jtbi.2014.04.023","article-title":"Qualitative analysis of subcutaneous lispro and regular insulin injections for stress hyperglycemia: a pilot numerical study","volume":"356","author":"Strilka","year":"2014","journal-title":"J Theor Biol"},{"key":"2026050517463905100_usaf476-B28","doi-asserted-by":"publisher","first-page":"1430","DOI":"10.1097\/CCM.0b013e3181de562c","article-title":"Hypoglycemia is associated with intensive care unit mortality","volume":"38","author":"Hermanides","year":"2010","journal-title":"Crit Care Med"}],"container-title":["Military Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/milmed\/article-pdf\/191\/5-6\/e924\/64549358\/usaf476.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/milmed\/article-pdf\/191\/5-6\/e924\/64549358\/usaf476.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T21:48:08Z","timestamp":1778017688000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/milmed\/article\/191\/5-6\/e924\/8277614"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,4]]},"references-count":28,"journal-issue":{"issue":"5-6","published-online":{"date-parts":[[2025,10,4]]},"published-print":{"date-parts":[[2026,5,1]]}},"URL":"https:\/\/doi.org\/10.1093\/milmed\/usaf476","relation":{},"ISSN":["0026-4075","1930-613X"],"issn-type":[{"value":"0026-4075","type":"print"},{"value":"1930-613X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,5]]},"published":{"date-parts":[[2025,10,4]]}}}