Polyvinyl chloride-related insulin adsorption in critical care: a narrative review with implications for patient safety and green hospital reform

Abstract

Introduction: Insulin infusion therapy is critical for glycemic management in intensive care units (ICUs), yet its effectiveness is compromised by adsorption to infusion materials, particularly polyvinyl chloride (PVC) tubing and bags plasticized with di(2-ethylhexyl) phthalate (DEHP). This phenomenon results in underdosing, unstable glucose control, and increased risk of hypo- and hyperglycemia. At the same time, PVC and DEHP raise environmental and toxicological concerns, driving global efforts toward green hospital reforms. Aim: This narrative review synthesizes current evidence on insulin adsorption across PVC and DEHP-free infusion systems, evaluating implications for clinical safety, glycemic control, and sustainable healthcare practices. Methods: A Structured Narrative Analysis Review (SNAR) was conducted, with systematic searches in eight databases guided by PICO and SPIDER frameworks. Thirty-eight studies met the inclusion criteria. Data were thematically analyzed using Braun and Clarke's six-phase method. Results: Insulin adsorption varied by material, with PVC demonstrating the highest losses (up to 70%), particularly at low flow rates and during the early infusion period. Alternatives such as polyethylene (PE), polypropylene (PP), and fluorinated ethylene propylene (FEP) showed significantly lower adsorption, while SEBS and TPO offered partial improvements but did not eliminate losses. Priming or preconditioning infusion sets with 20 mL of insulin solution consistently minimized early adsorption. Thematic analysis revealed four main domains: (1) insulin adsorption as a clinical safety risk, (2) material-dependent variability, (3) mitigation strategies, and (4) sustainability implications. Conclusion: Insulin adsorption on PVC infusion systems is a clinically significant barrier to precise glycemic control in critical care. Evidence supports the use of priming techniques and alternative materials (PE, PP, FEP) to reduce losses. Transitioning toward DEHP-free and non-PVC devices aligns with green hospital reforms, offering dual benefits for patient safety and environmental sustainability.