1. Sara Meltzer, MD, FRCPC, FACP 2010
In-Hospital Management
of Patients
with Diabetes
Sara Meltzer, MD, FRCPC, FACP
2010

2. In-Patient Diabetes Management Objectives:
Importance of Diabetes
as a risk factor
in hospital outcomes
Review physiology of stress and insulin needs
Aspects of glucose control in hospital
Diet and Testing,
Oral agents
Insulin use
Peri-operative care
Emergency Room management
Pump therapy – basics in case admitted

3. Objectives of presentation
Review physiology of stress and insulin needs
Pre-op considerations
Protocol concepts for IV insulin infusions for the OR
Post-op on IV’s initially, then eating
Emergency room concerns
Pump therapy and what to do if someone on pump is admitted…
May, 2008

4. Scope of the problem… Common and Increasing Costly:
Overall: > 8% Individuals 65+: > 15%
1 in 3 individuals born in 2000 will develop diabetes in their lifetime
25% of DM1 & 30% of DM2 admitted each year
49%  of DM in discharge diagnoses from 1980 to
Costly:
Medical expenditures/patient 2.4x > non-diabetics
4.6 million DM-associated admissions costs in 2001;
17 million hospital days at > $ 40 billion (US)
May, 2008

5. Vascular Disease Outcomes in Patients with or without DM: OASIS Registry
8,013 patients with unstable angina or non-Q wave MI
95 hospitals in 6 countries (incl. Canada)
Overall mortality
 57% in presence of DM
May, 2008
Malmberg, Circulation,2000

6. Vascular Disease Outcomes in Patients with or without DM: OACIS Registry
Figure 1. Long-term clinical outcomes among
Non-diabetic and diabetic patients in the OACIS registry
8,013 patients with unstable angina or non-Q wave MI
95 hospitals in 6 countries (incl. Canada)
Overall mortality increased 57% in presence of DM
% of patients
May, 2008
Malmberg, Circulation,2000

7. Canadian Acute Coronary Syndrome Registry
4,578 patients with acute coronary syndromes
9 Canadian provinces
Yan, JACC, 2004
May, 2008

8. Digami Trial - Sweden 620 patients with DM & MI; mean follow-up 3.4 y.
306 intensive insulin; 314 controls
One life saved for every 9 treated patients
Death Rate:
138 (44%) in controls;
102 (33%) in the int. tx group
(RR 0.72, P=0.011)
Malmberg, BMJ, 1997
May, 2008

9. Stoke patients… 2 - 4 x risk of CVA compared to non-diabetics
(Framingham Study, Paris Prospective Study, Whitehall
Study, MRFIT, Rancho Bernardo Study)
Hyperglycemia present in 40% of CVA admissions
Both ischemic and hemorrhagic CVA have 3X 30-day mortality risk when admission glucose>6-8 mM
(Capes, Stroke, 2001, 32-Study Meta-Analysis)
Return to work post-CVA 76% if normal admission glucose, vs. 43% if glucose > 6.7 mM
(Pulsinelli, Am J Med, 1983)
Persistent in-hospital glucose > 7   infarct expansion and  functional recovery
May, 2008

10. In-Patient Diabetes Management : Objectives
Importance of Diabetes
as a risk factor
in hospital outcomes
Review physiology of stress and insulin needs
Aspects of glucose control in hospital
Diet and Testing,
Oral agents
Insulin use
Peri-operative care
Emergency Room management
Pump therapy – basic concepts in case admitted

11. Hyperglycaemia in the Hospital Setting
Pathophysiology
Growth hormone
Cortisol
Catecholamines
Glucagon
Insulin
Glucose
May, 2008

12. Considerations in Assessment of Peri-operative Stress
Metabolic stress response
Stress hormones & peptides
 Glucose
 Insulin
Immune dysfunction
FFA
Ketones
Lactate
Reactive O2 species
Infection dissemination
Transcription factors
Cellular injury/apoptosis
Inflammation / Tissue damage
Altered tissue/wound repair
Acidosis / Infarction/ischemia
Secondary mediators
Prolonged hospital stay
Disability
Death
Clement, NEJM 2004
May, 2008

13. Optimal Insulin replacement – Why bother?
Surgical or illness related stress causes insulin needs to increase
Insulin is the BEST ANABOLIC HORMONE we have and if the amount available is inadequate for metabolic needs…
CATABOLISM occurs.
Hyperglycemia increases chances of infections
In patients severely ill in ICU, even glucose values > 6mmol/L can be associated with poorer outcomes.
May, 2008

14. Insulin secretion Proinsulin Insulin released in equimolar
amounts with C - peptide (90-97%)
Pro-insulin & conversion products (3 -10 %)
Released into
portal circulation
Basal secretion is approximately 1 unit / hour
In response to food, increases fold
Average insulin release about 40 units/day
May, 2008

15. Insulin Needs in Hospital
May, 2008

16. Surgical Site Infections Correlation with peri-operative glucose
Surgical Site Infection without DM – 5.3%
Surgical Site Infection with DM – 11.2% Adjusted OR 1.80
Adj OR 12.1
May, 2008
Ata et al Arch Surg Sept p858

17. In-Patient Diabetes Management: Objectives
Importance of Diabetes
as a risk factor
in hospital outcomes
Review physiology of stress and insulin needs
Aspects of glucose control in hospital
Diet and Testing,
Oral agents
Insulin use
Peri-operative care
Emergency Room management
Pump therapy – basic concepts in case admitted

18. Before the OR
Evaluate for concurrent illness and risks related to them e.g.
Silent cardiovascular disease (women and men)
Autonomic and/or peripheral neuropathy
Hypertension/ renal disease
Co-existent other autoimmune disease in type 1’s (hypothyroid, Addisons?)
Adjust diet to provide optimal nutrition
May, 2008

19. Concept of Diet for Diabetes
Not equal to
“ Don’t eat sugar”!
Adequate for caloric and nutritional needs
Spread carbohydrate (CHO) intake from food throughout day
Balance sources from fruits/vegetables and starches with needed protein & fat
Insulin must match carbohydrate intake
May, 2008

20. Diet orders… Clarity is very important!
Order ‘diabetic diet’ once eating
Clear fluids will often put sugars up as well… try to have it given in 30g servings at meal & snack times…
eg. 6 oz apple juice or ginger ale (15g) + 1 jello (15g)
Full fluids also better served Q3H and as 30g feeds, if possible...
e.g. 1c cream soup (15g) + 1c eggnog (15g)
May, 2008

21. Carbohydrate Intake Peri-operatively
If eating, must consider timing of insulin with meals, size and frequency
If on tube feeds – continuous or interrupted? – must plan insulin appropriately
If on IV fluids, must provide adequate calories to avoid catabolism and ketone formation, roughly 5g per hour
i.e. D5W or D5NS or ½ (~ 2 oz of orange juice only!)
If on Total Parental Nutrition – requirements for insulin increase as calories are continuous and similar to when eating
May, 2008

22. Capillary Blood Glucose Testing
Clinical Status of Patients
Options for CBGM
Patients actively treated, often with changes in dietary or CHO intake
Q1-4h for patients on IV insulin
Q 2-6h for patients on continuous feeds
AC meals and HS for patients eating
AC and PC meals, HS and 03h for patients requiring excellent control e.g. pregnancy
Patients with stable diabetes on insulin or oral agents eating consistent meals with minimal changes in diet plan
Routinely AC breakfast and AC supper
Once or twice weekly, AC meals and HS
Long-term care patients with diabetes which is unstable or DM1
AC meals and HS in order to adjust insulin dose
Long-term care patients on insulin or oral agents who are stable
AC bkft daily; PC breakfast, lunch, supper in rotation if on oral agents
AC meals and HS in rotation: once weekly
AC (ante-cebum ) = before meal and PC (post-cebum ) = after meal in Latin
May, 2008

23. Humulin R Humulin N Humulin R Humulin N Nov. 15 8u 6-2 4u 10u 7.2 5.4
9.3
10.5
16h 2.7
OJ given
2.7
Humulin N
16u
Nov. 16
Humulin R
8+2
10u
11.4
Humulin N

24. Oral Agents: Effects and Mechanisms of Action
Diet & Sulfonylureas Metformin a-Glucosidase TZD Insulin Exercise and Glitinides Inhibitors
1° mech ↓ insulin resist ↑ insulin secretion ↓ hepatic output ↓ CH2O absorpt ↑ insulin sens ↑[insulin]
HgbA1c↓
Agents Avoiding McD Glyburide Metformin Acarbose Rosiglitazone Gliclazide Miglitol Pioglitzone Glimepiride Repaglinide Nateglinide
Adverse Injury Hypoglycemia GI upset GI upset Edema ↓ glucose Effects Wt gain Lactic acidosis Wt gain

25. The Stable Hospitalized Diabetic Patient
Can sometimes continue home regimen, including oral agents, as long as:
1. Stable or improving medical status
2. Predictable nutritional intake
3. Frequent CBG monitoring
4. Sufficient glycemic control
May, 2008

26. Insulin Routes of Administration
Subcutaneous
variable absorption
variable duration of action
all formulations may be given this route
Intramuscular
all can be given, hurts more, faster action
Intravenous
faster action (T 1/2 = < 5 min.)
very consistent action
high levels of circulating insulin can be established
Intra-peritoneal
used in peritoneal dialysis
portal levels >> systemic - more physiologic
used in implanted pumps… trouble with omental blocking
May, 2008

27. Regular insulin - half life
If given IV…. T ½ = min.
If given IM… T ½ = hours
If given IP… T ½ = hours
If given SC … T ½ = 6 hours
May, 2008

28. Insulin Types & Action Profiles: Short-acting
May, 2008

29. Insulin Types & Action Profiles: Intermediate and Long-acting
Name
Onset
(h)
Peak action (h)
Duration of action (h)
NPH
Human
Novolin NPH
Humulin NPH 
1 – 3
5 – 10
16 – 18
Glargine
Lantus 
4 – 6
8 – 16
20 – 36
Detemir
Levemir 
2 – 4
6 – 12
May, 2008

30. Factors influencing insulin action
Blood Flow
Site
abd>>arm>>leg
lipodystrophy
Depth
Exercise
Ambient temperature
Smoking
Dissociation Rate
Species
human>pork
Type
zinc “heavy” >> crystals formed>>albumin bound>> protamine >> crytalline >> monomeric
Concentration
Volume
Jet injection
May, 2008

31. Insulin orders... Clarity counts!
For patient on IV’s
Best option = iv insulin with adjustment
2nd best option is Q6H regular SC or R ac meals and NPH at HS
For patients who are eating but unstable:
HS and Regular pre-meal … both with adjustment scale
For patients who are eating but unstable amounts:
HS and Regular pre-meal if needed
+ Rapid acting post-meal … only adjust pre-meal regular with sliding scale
For patients who are eating and stable:
Regular AC meals and NPH at HS, adjusted with sliding scale… may be able to reduce testing frequency but should still cover all parts of the day
May, 2008

32. Insulin Therapy: Temporary use...
Pregnancy… can’t use pills!
Surgery … increased need.
Medication such as steroids which dramatically increase insulin needs.
Concurrent illness … eg. MI or CVA… better peri-event sugar control improves morbidity and mortality.
Good sugar control helps patients recover and leave hospital faster!
May, 2008

33. Other Indications for Insulin Therapy in Type 2
Development of severe hyperglycemia with ketones
Uncontrolled weight loss.
Renal or hepatic disease with contraindications to use of oral agents
Allergy or hypersensitivity to oral agents
Latent autoimmune disease in adults - type 1 1/2 (?)
May, 2008

34. Concept of BASAL insulin needs
Any person, eating or not requires insulin to live… 24 hours a day!
Basal needs (no food):
often lower levels between 12 am and 4 am, an increase prior to awaking until about 8 am, then often about u/hr.
In response to food,
proportion of insulin release closely relates to CHO content of the meal +/- presence of protein & fat in it.
May, 2008

35. Insulin replacement for Type 1
In type 1… no insulin of their own without injections… never leave them without insulin coverage!
May, 2008

36. Insulin replacement for Type 2
Type 2 on diet: if not eating, can often keep fasting glucose normal… may not need basal
Type 2 on oral agents: if not eating… usually needs additional amounts of insulin to keep normal sugars, even without eating.
Type 2 on insulin: often some remaining basal insulin but needs coverage even if not eating to have good glucose entry into cells.
May, 2008

37. Establishing “basal” needs – i. e
Establishing “basal” needs – i.e. amount needed if no significant carbohydrate intake
Establish known total daily dose (TDD)
i.e. sum of all insulin taken in a normal day
Determine what ½ of that amount is… approximate amount of insulin needed if no CHO intake
Determine the necessary hourly rate of this “base need”
[i.e. [(TDD/2)]  24 = X u/h
Set up an IV insulin infusion with this hourly rate as a starting point and allow adjustment up or down until target range is reached
May, 2008

38. May, 2008

39. Patients taking insulin who are NPO or Pre-op:
Items of the order sheet are based on the following premises…
Patients should receive glucose IV at ~ 5g/h in order to provide essential minimum calories to avoid ketosis of fasting. Can be done using D10W at 50cc/h if fluid status is a problem, or D5W or for most patients.
Capillary blood glucose should be measured frequently initially Q1H and subsequently decreasing frequency depending on stability of blood sugar, with a minimum frequency of Q4H.
Intravenous insulin should always be REGULAR insulin (either Humulin R or Novolin Toronto – be precise to avoid confusion).
May, 2008

40. Patients taking insulin who are NPO or Pre-op:
Premise which permits determination of the
initial insulin infusion rate:
This is usually based on a simple calculation of the basal insulin requirements. Approximately half of the insulin given every day covers the meals – the other half covers the basal needs. Therefore, calculate ½ of the total daily dose (TDD) of insulin to allow coverage of basal needs, converted to units/hour.
i.e. ½ TDD ÷ 24 = starting insulin infusion rate.
If the infusion rate is < 1.0units/h – use 10units/250ml NS (1unit = 25ml.)
If the infusion rate is ≥ 1.0 units/h – use 25units/250ml NS (1unit / 10ml)
May, 2008

41. Establishment of basal infusion rate:
May, 2008

42. Adjustments to Insulin Infusion Rate:
If CBG (mmol/L) is:
≤ Stop insulin infusion temporarily; continue glucose
infusion at previous rate and give 20ml of D50W IV push
over 2-3 minutes. Inform MD. Recheck CBG in10 min. &
repeat D50W until CBG ≥6mmol/L, then resume the
insulin infusion at ½ previous rate.
4.1 – Decrease insulin infusion rate by (indicate with checkmark)
□ half of current rate (for fractions of a ml.,
decrease to nearest whole number)
□ ______ units/hr. (i.e. _______ ml/hr).
7.1 – Continue the current insulin infusion rate.
10.1 – Increase current infusion rate by ____units/hr (i.e. ___ml/hr).
14.1 – Increase current infusion rate by ____units/hr. (i.e. ___ml/hr).
> Increase current infusion rate by ____units/hr. (i.e. ___ml/hr).
and inform MD.
May, 2008

43. Post-operative orders once ready to resume full fluids
Re-order “diabetic diet …X….Kcal/day”
In patients normally on oral agents, re-order once patient is eating
may need lower doses as intake may be poor
may need “insulin adjustment scale” or “sliding scale” for values above 8 or 10 mmol/L
In patients normally on insulin, restart subcutaneous insulin dose at least minutes prior to the discontinuation of the IV, even if at a lower dose than prior to admission…
May, 2008

44. Returning to eating
Once patient ready to return to meals, likely not eating well, so work in reverse…
i.e. Hourly dose given X 24 = approximate present “basal needs” which can be distributed to be given prior to meals and HS in the proportion of:
Use insulin adjustment scale to correct for food and relative proportion errors
Adjust base dose daily based on previous day’s needs until control achieved and on normal diet
Time Breakfast Lunch Supper HS
NPH or basal %
Regular/rapid % % %
May, 2008

45. Insulin orders – patient eating
Ordered baseline dose
(Indicate clearly type and brand of insulin)
Breakfast or 0600h
Lunch or 12h
Supper or 18h
HS or 22h
NPH/glargine/detemir 0%
40%
Regular/lispro/aspart/glusine
25%
15%
20%
Example of insulin adjustment scale for pre-meal or HS insulin adjustment
If capillary blood glucose is:
≤ 4 mmol/L
Treat for low blood sugar; decrease ordered dose by 4units
4.1 – 6.0 mmol/L
Decrease ordered dose by 2 units
6.1 – 10.0 mmol/L
Give ordered baseline dose
10.1 – 12.0 mmol/L
Increase ordered dose by 2 units
12.1 – 14.0 mmol/L
Increase ordered dose by 4 units
14.1 – 16.0 mmol/L
Increase ordered dose by 6 units
16.1 – 18.0 mmol/L
Increase ordered dose by 8 units
> 18.0 mmol/L
Increase ordered dose by 10 units; inform MD
November, 2010

47. Additional considerations once eating:
IV insulin – Regular is preferred, as analogues have no advantage if not SC and are more expensive. Once eating, if previously on analog insulins, can re-start.
Monitor glucose at least every h; ideally, pre-meals.
In situation where changes of need may occur rapidly, use of aspart (Novorapid®) or lispro (Humalog®) SC may be easier, since it can be given with the meal. Rapid acting analogs, however, only lasts 4-6h, not 6-8h as “regular” does.
Initially CBG testing would be ordered as 0600, 1200, and 2400 but, if switched to eating, adjust timing to meal delivery & 2200 hr.
May, 2008

48. Patients going for tests
Adjust timing of tests to facilitate insulin and diet needs whenever possible.
If patient likely to be gone at a snack time or may have lunch delays by waiting times in X-ray, etc… send juice and a snack with them.
Reassess patient on return from test with capillary blood glucose & adjust therapy as needed.
May, 2008

49. “Sliding Scales” – why such a bad reputation?
Inappropriately, they are used alone….as the only insulin ordered…
To work, the sliding scale should only help fix the “ordered dose”
The information from the adjustments used in the sliding scale should be used to help correct the “base dose” the next day.
May, 2008

50. Sliding scale in hospital
May, 2008

51. Insulin adjustment scale for patients at home or for insulin sensitive type 1
May, 2008

52. In-Patient Diabetes Management:Objectives
Importance of Diabetes
as a risk factor
in hospital outcomes
Review physiology of stress and insulin needs
Aspects of glucose control in hospital
Diet and Testing,
Oral agents
Insulin use
Peri-operative care
Emergency Room management
Pump therapy – basic in case admitted

53. ER or Hospital Management - Challenges to Care:
Meals are :
irregular, or missed completely
rarely the same as normal diet or on time
Capillary Blood Glucose Monitoring is:
Done irregularly, not always in relation to meals
Difficult to arrange hourly for IV infusions due to nursing staff limitations on occasion.
Staff changes are frequent, thus less continuity of care.
Patient’s participation in self care may be severely limited.
Patient, by definition, will be ill and inter-current illness often substantially changes insulin requirements… often increasing them due to the psychological and physiological stresses.
May, 2008

54. Evaluation in the Emergency Room….
Usual treatment often gives valuable insight
into how patient’s care should be done
Is patient able to eat normally?
Is patient NPO or on IV infusion?
Does patient normally take insulin?
- If so, need to know:
what kinds of insulin, type and exact name
how much, and
at what times?
DETAILED EXACT INFO needed!!!
May, 2008

55. ER IV insulin infusions – pros and cons
In some ER situations, due to staffing issues, hourly CPG to adjust an IV protocol initially may not be possible.
Use an insulin adjustment scale as one would use normally pre-meal using ¼ of total daily dose [TDD] as top limit of sliding scale for highest glucose values.
To calculate dosage to use for basal needs if not eating…
Calculate Total Daily Dose (TDD) divide by 2
(since ½ insulin for food)
Divide this amount over the day % overnight and the rest split in 3 with a bit more at breakfast than lunch as regular or analogue pre-meal or 0600, 1200, 1800 hours and NPH at HS.
e.g % - 15% - 20% can be given pre-meal regular or RA
% as longer acting evening insulinspre
May, 2008

56. Continue usual diet and pills Is glucose stable and well controlled?
Patient with DM in ER
Normally on diet ± oral agents
Able to eat
Not able to eat
Give consistent glucose load by IV (~ 5 g/h) to avoid ketosis
Eg. IV D5 W or 100cc/h or
D10 50 cc/h if fluid an issue.
Continue usual diet and pills
Is glucose stable and well controlled?
YES NO
Initiate an IV insulin infusion with concept of giving 10 – 12 u/24 h. (or presumption of potential total insulin dose as 20 u/day)
Ie. IV insulin to 0.4 u/h or
Base dose ac meals & HS of : N
R/RA
with insulin adjustment scale.
Monitor glucose as needed.
Monitor glucose q 4-6 h as needed, no other therapy for DM likely needed.
May, 2008

57. Patient with DM in ER Normally on insulin Able to eat Not able to eat
Give consistent glucose load by IV (~ 5 g/h) to avoid ketosis
Eg. IV D5 W or 100cc/h or D10 50 cc/h if fluid volume is an issue.
Continue usual diet and insulin if possible
Is glucose stable and well controlled (ie < 10mmol/L)?
If type 1, initiate IV or Q4-6 SC insulin regimen once glucose above 6 mmol/L and check for ketones.
Monitor glucose q 4-6 h as needed, continuing therapy as planned.
YES NO
Ordered dose:
Breakfast
or 0600
Lunch
or 1200
Supper or 1800 HS
or 2400
NPH/lente/ultralente
(source, brand) X
Regular / Rapid acting
EG. Insulin adjustment scale for rapid acting insulin before each meal:
If capillary blood glucose is:
≤4.0 mmol/L
Treat for low blood sugar;
decrease ordered dose by 4 units
4.1–6.0 mmol/L
Decrease ordered dose by 2 units
6.1–10.0 mmol/L
Give ordered dose
10.1–12.0 mmol/L
Increase ordered dose by 2 units
12.1–14.0 mmol/L
Increase ordered dose by 4 units
14.1–18.0 mmol/L
Increase ordered dose by 6 units
>18.0 mmol/L
Increase ordered dose by 8 units
and inform physician
Initiate insulin …either as
an IV insulin infusion of base dose [total daily dose / 2] distributed over 24 hour as starting insulin dose for infusion… ie. IV insulin to start …
@ (TDD/2)  = X u/h (initial rate) & adjust or
Base dose ac meals & HS of :
N %
R/RA 25% - 15% - 20% - 0
with insulin adjustment scale.
Monitor glucose as needed.
May, 2008

58. In-Patient Diabetes Management Objectives:
Importance of Diabetes
as a risk factor
in hospital outcomes
Review physiology of stress and insulin needs
Aspects of glucose control in hospital
Diet and Testing,
Oral agents
Insulin use
Peri-operative care
Emergency Room management
Pump therapy – basic concepts in case admitted

59. The dilemma of pump patients…
That patient in Bed 3 is on an insulin pump – you take her!
No, I can’t… I don’t know anything about pump therapy…
Well neither does the doctor who’s on tonight – so what do we tell the patient?
May, 2008

60. Core Concepts of Insulin Pump Prescriptions (~25% of type 1’s now on pumps!)
“Basal” = Basal dose – units per hour
24 – 04h …0.6u
04–07h …1.0u
07–12h …0.8u
12–18 …0.6u
18–24h …0.7u
Bolus doses: Ratio of grams CHO covered by 1 unit of insulin
24–07h 1u/20g
07–11h 1u/8g
11–15h 1u/12g
15–20h 1u/10g
20-24h 1/15g
Correction factor – the amount of glucose lowered by 1 u (in mmols)
24–07h 1u/3
07–11h 1u/1.5
11–15h 1u/2
15–20h 1u/2
20-24h 1/3
Basal = baseline dose = insulin amount given over 24 hours without food
Bolus = dose given to cover food intake
Total daily dose = insulin amount used as basal + bolus given for meals
Insulin Sensitivity Factor (ISF) or Correction factor indicates
mmol increments for sliding scale (often must be doubled
if ill or stressed e.g. hospital i.e. mmol denominator must be decreased)
May, 2008

61. The Type 1 on pump or who “carb counts”…
In order to order IV or alternative subcutaneous insulin doses … need to know the total daily dose (TDD) – pumps have that info in their minicomputers… ask the patient!
For Patients who don’t know/can’t tell you their Total Daily Dose
To determine basal total: Ask them (or review basal on the pump) to find basal rates by hour… calculate: [basal rates X numbers of hours at each] = total basal rate
To determine meal amounts if carbohydrate counting:
Ask them what their “normal” meal carbohydrate intake is, then ask them what they usually take to cover that… will often get relative doses for breakfast, lunch and dinner that way.
If they are not able to tell you their usual meal CHO intake, assume 40g at breakfast and 50g for lunch and supper – multiply by ratio found under bolus wizard or EZ carbs eg 1u/8g at bkft = 5units
Total Daily Dose = sum of basal rates
+ usual amount for each meal…
May, 2008

62. Search for “micro” complications!
Nephropathy:
Check albumin/creatinine ratio
(> 2.0 men or 2.8 women = trouble)
creatinine clearance by Cockcroft-Gault equation
Urinalysis – for cells, protein, or signs of infection
Retinopathy
Be sure patient has been seen by competent ophthalmologist and eyes assessed within last year
Neuropathy
Test ankle jerks + 10g monofilament on toes
Ask about erectile dysfunction, bowel problems, excess sense of fullness post-meal, postural hypotensive symptoms
May, 2008

63. Search for “macro” risk factors or complications
Lipid profile at least yearly
evaluation of LDL and HDL cholesterols, Triglycerides, apo-B.
Cardiac assessment
ECG + / - stress test
Hypertension – assess and control to < 130/85
Peripheral Vascular Disease…
Vascular flow assessments with doppler PRN
Assess for bruits or intimal media thickening
Foot care…
Look at the foot – reflexes, monofilament, ulcers, redness, callouses and general state of care
May, 2008

64. Make sure outpatient follow-up well established
Remember to use entire team… nursing, dietitian, family MD, social worker and community services, if needed.
Plan appropriate steps long before day of discharge.
Survival booklets available in English & French – order via Endocrinology office…
May, 2008

65. Thank you for your attention… Questions ???65