Diabetes Management in the Hospital: Case Studies Bruce W. Bode, MD, FACE Atlanta Diabetes...
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Transcript of Diabetes Management in the Hospital: Case Studies Bruce W. Bode, MD, FACE Atlanta Diabetes...
Diabetes Management in the Hospital:
Case Studies
Bruce W. Bode, MD, FACE
Atlanta Diabetes Associates
Atlanta, Georgia
Case 1: Patient with an Acute MI
53 yo male with DM 2 on SU, Metformin and Glitazone presents with an acute MI
BG random is 220 mg/dl
What do you recommend for glucose control?
1. Sliding scale rapid analog?
2. Basal Bolus insulin therapy?
3. IV insulin drip?
Case 1: Patient with an Acute MI
What is your glycemic goal?
1) 80 to 110 mg/dl
2) 80 to 140 mg/dl
3) 80 to 180 mg/dl
Do you give glucose and potassium with IV insulin? How much?
Glycemic Threshold in Acute MI and Intervention (PTCA)
DIGAMI supports BG < 180 mg/dl
Minimal other data:
- PTCA reflow better with BG 159 than 209 mg/dl
Iwakura K: JACC 2003; 41:1-7
Malmberg BMJ 1997;314:1512Malmberg BMJ 1997;314:1512
DIGAMI StudyDiabetes, Insulin Glucose Infusion in Acute Myocardial Infarction(1997)
Acute MI With BG > 200 mg/dl Intensive Insulin Treatment IV Insulin For > 24 Hours Four Insulin Injections/Day For > 3 Months Reduced Risk of Mortality By:
28% Over 3.4 Years
51% in Those Not Previous Diagnosed
Malmberg BMJ 1997;314:1512Malmberg BMJ 1997;314:1512
Cardiovascular RiskMortality After MI Reduced by Insulin Therapy in the DIGAMI Study
Malmberg, et al. BMJ. 1997;314:1512-1515.
All Subjects
(N = 620)Risk reduction (28%)
P = .011
Standard treatment
0
.3
.2
.4
.7
.1
.5
.6
0 1Years of Follow-up
2 3 4 5
Low-risk and Not Previously on Insulin
(N = 272)Risk reduction (51%)
P = .0004
IV Insulin 48 hours, then 4 injections daily
0
.3
.2
.4
.7
.1
.5
.6
0 1Years of Follow-up
2 3 4 5
6-11
Case 1: Patient with an Acute MI
For acute MI with elevated glucose, you can either give GIK in type 2’s who are easily controlled or IV variable rate insulin infusion in all persons with elevated glucose
If you order an IV insulin drip,
What dilution of IV insulin? 1U to 1cc or 0.5U to 1cc of drip mixture
How often do you check the glucose?
Continuous Variable Rate IV Insulin Drip
Mix Drip with 125 units Regular Insulin into
250 cc NS Starting Rate Units / hour = (BG – 60) x 0.02
where BG is current Blood Glucose
and 0.02 is the multiplier Check glucose every hour and adjust drip Adjust Multiplier to keep in desired glucose
target range (100 to 140 mg/dl)
Continuous Variable Rate IV Insulin Drip
Adjust Multiplier (initially 0.02) to obtain glucose in target range 100 to 140 mg/dL
If BG > 140 mg/dL, increase by 0.01
If BG < 100 mg/dL, decrease by 0.01
If BG 100 to 140 mg/dL, no change in Multiplier
If BG is < 80 mg/dL, Give D50 cc = (100 – BG) x 0.4
Give continuous rate of Glucose in IVF’s
Once eating, continue drip till 2 hours post SQ insulin
A System for the Maintenance of Overnight Euglycemia and the Calculation of Basal Insulin Requirements in Insulin-Dependent Diabetics
Practical Closed Loop Insulin Delivery
1/slope = Multiplier = 0.02
0
1
2
3
4
5
6
0 100 200 300 400
Glucose (mg/dl)
Insulin Rate (U/hr)
NEIL H. WHITE, M.D., DONALD SKOR, M.D., JULIO V. SANTIAGO, M.D.; Saint Louis, Missouri
Ann Int Med 1982 ;97:210-214
The Ideal IV Insulin Protocol
Easily ordered (signature only)
Effective (Gets to goal quickly)
Safe (Minimal risk of hypoglycemia)
Easily implemented
Able to be used hospital wide
Essentials of a good IV Insulin Algorithm
Easily implemented by nursing staff
Able to seek BG range via:
- Hourly BG monitoring
- Adjusts to the insulin sensitivity of the patient
Methods For Managing Hospitalized Persons with Diabetes
Continuous Variable Rate IV Insulin Drip
Major Surgery, NPO, Unstable, MI, DKA, Hyperglycemia, Steroids, Gastroparesis, Delivery, etc
Basal / Bolus Therapy (MDI) when eating
Case 1: Patient with an Acute MI now plans to go for CABG
What is your glycemic goal?
1) 80 to 110 mg/dl
2) 80 to 140 mg/dl
3) 80 to 180 mg/dl
Do you give glucose and potassium with IV insulin? How much?
0
2
4
6
8
10
12
14
16
<150 150-175 175-200 200-225 225-50 >250
Average Post-operative glucose (mg/dl)
Mo
rtali
ty
Cardiac-related mortalityNoncardiac-related mortality
Mortality of DM Patients Undergoing CABG
Furnary et al J Thorac Cardiovasc Surg 2003;123:1007-21
Glycemic Threshold in CABG
Portland data suggest BG:
< 150 mg/dl for mortality
< 175 mg/dl for infection
< 125 mg/dl for atrial fibrillation
Furnary et al J Thorac Cardiovasc Surg 2003;123:1007-21
0
5
10
15
20
25
30
35
40
45
0 50 100 150 200 250
Days after inclusion
Cum
ulat
ive
% M
orta
lity
(in h
ospi
tal d
eath
)
P=0.0009
P=0.026
BG<110
110<BG<150
BG>150
Surgical ICU MortalityEffect of Average BG
Van den Berghe et al (Crit Care Med 2003; 31:359-366)
Intensive Insulin Therapy in Critically Ill Patients—Morbidity and Mortality Benefits
Intensive therapy to achieve blood glucose 80 to 110 mg/dL reduced mortality (by 34%), sepsis (by 46%), dialysis (by 41%), blood transfusion (by 50%), and polyneuropathy (by 44%)
van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
-60
-50
-40
-30
-20
-10
0
Percent Reduction
Mortality Sepsis Dialysis PolyneuropathyBlood
Transfusion
34%
46%41%
44%
50%
Glycemic threshold in Surgical ICU
BG < 110 mg/dl
Van den Berghe et al Crit Care Med 2003; 31(2):359-66
Finney SJ et al JAMA 2003;290(15):2041-47
Other Medical Conditions
Infection data supports BG < 130 mg/dl
Hartford ICU study 125 mg/dl vs 179 mg/dl 10X decrease in infections
Stroke data supports BG < 140 mg/dl
Pregnancy data supports BG < 100 mg/dl
Stamford CT ICU Study (Retrospective): Description of Patient Subgroups (N = 1826)
Cardiac (medical): 28.6% (540)
Pulmonary: 15.8% (289)
Septic Shock: 5.0% (92)
Other Medical: 14.9% (272)
Neurological: 13.2% (241)
Surgical: 7.1% (313)
Trauma: 4.3% (79)
Krinsley JS: Mayo Clin Proc 2003; 78: 1471-1478
05
1015202530354045
80-99 100-119
120-139
140-159
160-179
180-199
200-249
250-299
>300
Average ICU glucose (mg/dl)
Mo
rtal
ity
%
Hyperglycemia and Hospital Mortality1826 consecutive ICU patients 10/99 thru 4/02, Stamford CT
Krinsley JS: Mayo Clin Proc 78: 1471-1478, 2003
Target blood glucose in mg/dL
80 – 110 in Surgical ICU patients
90 – 140 in other Surgical and Medical Patients
70 – 100 in Pregnancy
Threshold blood glucose in mg/dL for starting IV insulin infusion
Peri-operative care: > 140
Surgical ICU care: > 110 - 140 *
Non-surgical illness: > 140 - 180 * *
Pregnancy > 100
* Van den Berghe’s study supports 110; Finney’s study supports 145
* * If drip indication is failure of SQ therapy, use 180 ;
if indication is specific condition ( DM 1/ NPO, MI, etc ), use 140
Hospital Targets for GlucoseAACE and ADA Guidelines: Dec 2003
80–110 mg/dL ICU
110–180 mg/dL other units
Modify if:
cardiac disease (unstable)
hypoglycemic unawareness
recurrent hypoglycemia
New
Case 1: Patient with an Acute MI now post CABG and ready to eat
Currently on IV insulin at ~2 units IV per hour
What do you now do?
1. Sliding scale rapid acting insulin only?
2. Basal Bolus insulin therapy?
3. Premixed insulin therapy?
4:004:00
2525
5050
7575
8:008:00 12:0012:00 16:0016:00 20:00 20:00 24:0024:00 4:004:00
BreakfastBreakfast LunchLunch DinnerDinner
Pla
sma
insu
lin
(P
lasm
a in
suli
n (µ U
/ml)
U
/ml)
TimeTime
8:008:00
Physiological Serum Insulin Secretion Profile
4:00 16:00 20:00 24:00 4:00
Breakfast Lunch Dinner
8:0012:008:00
Time
Glargineor
Detemir
Lispro Lispro Lispro
Aspart Aspart Aspartor oror
Pla
sma
insu
lin
Basal/Bolus Treatment Program withRapid-acting and Long-acting Analogs
Converting to SC insulin
If More than 0.5 u/hr IV insulin required with If More than 0.5 u/hr IV insulin required with normal BG, start long-acting insulin (glargine)normal BG, start long-acting insulin (glargine)
Must start SC insulin at least 2 hours before Must start SC insulin at least 2 hours before stopping IV insulinstopping IV insulin
Some centers start long-acting insulin on initiation Some centers start long-acting insulin on initiation of IV insulin or the night before stopping the drip of IV insulin or the night before stopping the drip
Intravenous insulin infusion under basal conditions correlates well with subsequent subcutaneous insulin requirement.
Units SQ
Units IV
Overwrite
Hawkins et al Endocrine Practice: 1995; 1(6) 385-389
Converting to SC insulin
Establish 24 hr Insulin Requirement
– Extrapolate from average over last 6-8 hours if stable
Give One-Half Amount As Basal
Give p.c. Boluses Based on CHO Intake
– Start at CHO/Ins 1 CHO = 1.5 units Rapid-acting
Monitor a.c. tid, hs, and 3 am
Correction Blolus for All BG >140 mg/dl
– (BG-100)/(1700/Daily Insulin Requirement)
Insulin Requirements in Health and Illness
0
20
40
60
80
100
120
140
Correction
Nutritional
Prandial
Basal
Relative Proportion of
Insulin Requirement
(%)*
*Estimations for illustrative purposes: requirements may vary widely.
Clement S, et al. Diabetes Care. 2004;27:553–591.
Illness-Related
Healthy Sick/Eating
Sick/NPO
How to Initiate MDI Starting dose = 0.4 to 0.5 x weight in kilograms
Bolus dose (aspart/lispro) = 20% of starting dose at each meal
Basal dose (glargine) = 40% of starting dose given at bedtime or anytime
Correction bolus = (BG - 100)/ Correction Factor, where CF = 1700/total daily dose
How to Initiate MDI
Starting dose = 0.45 x wgt. in kg
Wt. is 100 kg; 0.45 x 100 = 45 units
Bolus dose (aspart / lispro) = 20% of starting dose at each meal; 0.2 x 45 = 9 units ac (tid)
Basal dose (glargine) = 40% of starting dose at HS; 0.4 x 45 = 18 units at HS
Correction bolus = (BG - 100)/ CF, where CF = 1700/total daily dose; CF = 40
Correction Bolus Formula
Example:
–Current BG: 250 mg/dl
– Ideal BG: 100 mg/dl
–Glucose Correction Factor: 40 mg/dl
Current BG - Ideal BGGlucose Correction factor
250 - 100 40
= ~4.0u
Case 2: A person with diabetes on tube feedings
What is the best insulin treatment for a DM patient on tube feedings? (BG 150 to 300 mg/dl)
1) sliding scale only with rapid acting insulin?
2) IV insulin variable rate infusion?
3) NPH or70/30 every 8 hours?
4) glargine every 12 hours?
5) regular every 6 hours?
Case 2: A person with diabetes on tube feedings
What is the best insulin treatment for a DM patient on tube feedings? (BG 150 to 300 mg/dl)
If unstable, first give IV insulin and determine the requirement over 24 hours and then change to SC basal (glargine Q 12 hours) with supplemental rapid acting every 4 to 6 hours.
Can also use NPH Q 8 hours or regular Q 6 hours as the basal
Case 3: A person with diabetes on TPN
What is the best insulin treatment for a DM patient on TPN? (BG 150 to 300 mg/dl)
If unstable, first give IV insulin variable drip and determine the requirement over 24 hours and then add all the insulin to the TPN bag.
Continue to supplement every 4 to 6 hours with SC rapid acting insulin using BG – 100 / CF where CF is equal to 3000 divided by weight in kg. On average, CF = ~ 30 to 40
Case 4: DM 1 patient going for outpatient surgery
What do you tell the patient to do?
1) Hold insulin
2) Take half their dose
3) Take their basal only with supplement if needed (>180 mg/dl)
4) Hold insulin and will start IV insulin
Case 4: DM 1 patient in DKA (ph 7.0; BG 400 mg/dl: weight 80 kg)
How much fluids do you give immediately?
1) 1 liter saline
2) 2 liters saline
3) 1 liter 0.45% saline
4) 2 liters 0.45% saline
Case 4: DM 1 patient in DKA (ph 7.0; BG 400 mg/dl: weight 80 kg)
Do you give NaCO3?
When do you start potassium and how much?
When do you start dextrose and how much?
My preference is 2 liters saline followed by D50.45 saline with 40 meq KCL/liter at 250 ml/hour. Monitor electrolytes Q 4 to 8 hours.
Case 5: Hypoglycemia
What is the preferred in hospital treatment of hypoglycemia?
1) Juice with sugar added
2) 50% IV dextrose (1 amp or 50cc)
3) 50% IV dextrose (1/2 amp or 25cc)
4) 50% IV dextrose (based on glucose level)
Protocol for Insulin in Hospitalized PatientProtocol for Insulin in Hospitalized Patient
Treatment of HypoglycemiaTreatment of Hypoglycemia
Any BG <80 mg/dl: D50 = (100-BG) x 0.4 ml IVAny BG <80 mg/dl: D50 = (100-BG) x 0.4 ml IV
If eating, may use 15 gm of rapid CHO If eating, may use 15 gm of rapid CHO
(prefer glucose tablets)(prefer glucose tablets)
Do Not Hold Insulin When BG Normal Do Not Hold Insulin When BG Normal
Piedmont Diabetes PlanPiedmont Diabetes PlanWhat Can We Do For Patients Admitted To Hospital?What Can We Do For Patients Admitted To Hospital?
NPO Pathway For All Diabetes PatientsNPO Pathway For All Diabetes Patients
Finger Stick BG ac qid on ALL AdmissionsFinger Stick BG ac qid on ALL Admissions
Check All Steroid Treated PatientsCheck All Steroid Treated Patients
Diagnose DiabetesDiagnose Diabetes
FBG >126 mg/dlFBG >126 mg/dl
Any BG >200 mg/dlAny BG >200 mg/dl
Piedmont Diabetes PlanPiedmont Diabetes PlanWhat Can We Do For Patients Admitted To Hospital?What Can We Do For Patients Admitted To Hospital?
Document Diagnosis in ChartDocument Diagnosis in Chart
Hyperglycemia Is Diabetes Until Proven Hyperglycemia Is Diabetes Until Proven
Bring to All Physician’s AttentionBring to All Physician’s Attention
Note on Problem List and Face SheetNote on Problem List and Face Sheet
Check Hemoglobin A1CCheck Hemoglobin A1C
Hold Metformin; Hold TZD with CHF, Liver DysfunctionHold Metformin; Hold TZD with CHF, Liver Dysfunction
Start Insulin in All Hospitalized Patients with BG >140 mg/dlStart Insulin in All Hospitalized Patients with BG >140 mg/dl
Piedmont Diabetes PlanPiedmont Diabetes PlanWhat Can We Do For Patients Admitted To Hospital?What Can We Do For Patients Admitted To Hospital?
Get Diabetes Education ConsultGet Diabetes Education Consult
Instruct Patient in Monitoring and RecordingInstruct Patient in Monitoring and Recording
See That Patient Has Meter on DischargeSee That Patient Has Meter on Discharge
Decide on Case Specific Program for DischargeDecide on Case Specific Program for Discharge
Arrange Early F/U with PCPArrange Early F/U with PCP
Treat Any Patient With BG >140 mg/dl With InsulinTreat Any Patient With BG >140 mg/dl With Insulin
– Treat Any BG >140 mg/dl with Rapid-acting Insulin Treat Any BG >140 mg/dl with Rapid-acting Insulin (BG-100) / (3000 / wt kg) or 1700 / total daily insulin(BG-100) / (3000 / wt kg) or 1700 / total daily insulin
– Treat Any Recurrent BG >180 mg/dl with IV Insulin if failing SC Treat Any Recurrent BG >180 mg/dl with IV Insulin if failing SC therapy or >140 mg/dl if NPO, acute MI, perioperative, ICU, or therapy or >140 mg/dl if NPO, acute MI, perioperative, ICU, or >100 mg/dl if pregnant>100 mg/dl if pregnant
If More than 0.5 u/hr IV Insulin Required with Normal BG Start Long If More than 0.5 u/hr IV Insulin Required with Normal BG Start Long Acting InsulinActing Insulin
Protocol for Insulin in Hospitalized PatientProtocol for Insulin in Hospitalized Patient
Protocol for Insulin in Hospitalized PatientProtocol for Insulin in Hospitalized Patient
Daily Total: Pre-Admission or Weight (#) x 0.2 uDaily Total: Pre-Admission or Weight (#) x 0.2 u
– 40 % as Glargine (Basal)40 % as Glargine (Basal)
– 60% as Rapid-acting insulin (Bolus)60% as Rapid-acting insulin (Bolus)
• Give in Proportion to Meal’s CHO EatenGive in Proportion to Meal’s CHO Eaten
BG >140 mg/dl: (BG-100) / CFBG >140 mg/dl: (BG-100) / CF
CF = 1700 / Total Daily Insulin or 3000 / wgt kgCF = 1700 / Total Daily Insulin or 3000 / wgt kg
Do Not Use Sliding Scale As Only Diabetes Do Not Use Sliding Scale As Only Diabetes ManagementManagement
Diabetes at Piedmont HospitalDiabetes at Piedmont HospitalConclusions 3Conclusions 3
Discharge Plan For BG ControlDischarge Plan For BG Control
You Are the Link Between the Best You Are the Link Between the Best Diabetes Care and the PatientDiabetes Care and the Patient
Use Your Diabetes ResourcesUse Your Diabetes Resources
Diabetes Education Center Diabetes Education Center EndocrinologistsEndocrinologists
Conclusion
All hospital patients should have normal glucose
Insulin
The agent we have
to control glucose
only
most powerfulpowerful
QUESTIONS
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