Presentation is loading. Please wait.

Presentation is loading. Please wait.

Management of Hyperglycemia and Diabetes in the Hospital: Case Studies Bruce W. Bode, MD, FACE Atlanta Diabetes Associates Atlanta, Georgia.

Similar presentations


Presentation on theme: "Management of Hyperglycemia and Diabetes in the Hospital: Case Studies Bruce W. Bode, MD, FACE Atlanta Diabetes Associates Atlanta, Georgia."— Presentation transcript:

1

2 Management of Hyperglycemia and Diabetes in the Hospital: Case Studies Bruce W. Bode, MD, FACE Atlanta Diabetes Associates Atlanta, Georgia

3 Hyperglycemia in Hospitalized Patients Hyperglycemia occurred in 38% of hospitalized patients —26% had known history of diabetes —12% had no history of diabetes Newly discovered hyperglycemia was associated with: —Longer hospital stays —Higher admission rates to intensive care units —Less chance to be discharged to home (required more transitional or nursing home care) Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–982.

4 Hyperglycemia Is an Independent Marker of Inpatient Mortality in Patients With Undiagnosed Diabetes Adapted from Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–982. In-hospital Mortality Rate (%) Newly Discovered Hyperglycemia Patients With History of Diabetes Patients With Normoglycemia P < 0.01

5 Prevalence of Hyperglycemia in 181 Cardiac Patients Without Known Diabetes Norhammar A. Lancet. 2002;359: Percentage of Population (n = 1181) 66% of AMI patients have IGT or previously undiagnosed T2DM on 75 g OGTT (35% IGT; 31% DM) 66% of AMI patients have IGT or previously undiagnosed T2DM on 75 g OGTT (35% IGT; 31% DM)

6 Hospital Costs Account for Majority of Total Costs of Diabetes Hogan P, et al. Diabetes Care. 2003;26:917 – 932. Per Capita Healthcare Expenditures (2002) DiabetesWithout diabetes

7 Case 1: Patient With an Acute MI 53-year-old man 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?

8 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

9 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 Malmberg K. BMJ. 1997;314: Iwakura K, et al. J Am Coll Cardiol. 2003;41:1-7.

10 DIGAMI Study: Diabetes, Insulin Glucose Infusion in Acute Myocardial Infarction (1997) Acute MI with BG >200 mg/dL Control vs Intensive Insulin Treatment Intensive Insulin Treatment IV insulin for >24 hours followed by 4 insulin injections/day for >3 months Malmberg K, et al. BMJ. 1997;314:

11 Cardiovascular Risk: Mortality After MI Reduced by Insulin Therapy in the DIGAMI Study All Subjects (N=620) Risk reduction (28%) P=0.011 Standard treatment Years of Follow-up 2345 Low-risk and Not Previously on Insulin (N=272) Risk reduction (51%) P= IV insulin 48 hours, then 4 injections daily Years of Follow-up 2345 Malmberg K, et al. BMJ. 1997;314:

12 DIGAMI 2 Study l 48 hospitals in 6 countries l 3 groups: –Group 1: GIK for 24 hours followed by home insulin Rx (N = 474) –Group 2: GIK infusion followed by standard glucose control (N = 473) –Group 3: Routine metabolic management based on local practice (N = 306) Malmberg K et al DIGAMI 2. European Heart J 2005; 26 (650-61)

13 Conclusion l Overall mortality was lower than expected l Overall mortality similar to nondiabetic population l The 3 glucose management strategies did not result in differences of metabolic control l Target glucose levels not achieved in the intensively insulin treatment group

14 MRC Pentecost Hjermann P = Rogers Heng Satler Overview of GIK Therapy for Acute MI: A 30­year Perspective GIKControlO-EVariance Mortality Rate (%) Study GIK Better Placebo Better Odds Ratio and Cls All Patients P = GIK = glucose–insulin–potassium; MI = myocardial infarction; CI = confidence interval. Fath-Ordoubadi F, Beatt KJ. Circulation. 1997;96:1152–1156. Reprinted with permission (http://lww.com) 1 YearStanley Mittra P = Pilcher

15 CREATE-ECLA l Worldwide study with over 20,000 subjects with ST-elevation MI (STEMI) l GIK infusion vs Control l Outcome: 30 day CV events Mehta, S et al: JAMA 293: , 2005

16 Baseline Glucose Associated with Mortality JAMA 293:437, 2005 Lowest Middle Highest Glucose Tertile % mortality

17 Case 1: Patient With an Acute MI For acute MI with elevated glucose, you can either give: 1. IV insulin variable drip or 2. GIK in type 2’s who are easily controlled or 3. ? Intensive SC delivery

18 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

19 Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;123: Mortality of DM Patients Undergoing CABG

20 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 AP, et al. J Thorac Cardiovasc Surg. 2003;123:

21 Costs of Hyperglycemia in the Hospital For each 50 mg/dL rise in glucose: Length of Stay increases by 0.76 days Hospital Charges increase by $2824 Hospital Costs increase by $1769 Furnary et al Am Thorac Surg 2003;75:1392-9

22 Surgical ICU Mortality Effect of Average BG Van den Berghe G, et al. Crit Care Med. 2003;31: P= P=0.026 BG< 150

23 Intensive Insulin Therapy in Critically Ill Patients—Morbidity and Mortality Benefits van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367. Percent Reduction MortalitySepsisDialysisPolyneuropathy Blood Transfusion 34% 46% 41% 44% 50%

24 Target Blood Glucose 80–110 mg/dL ICU patients 80–140 mg/dL in other surgical and medical patients 70–100 mg/dL in pregnancy

25 Threshold Blood Glucose for Starting IV Insulin Infusion Perioperative care> 140 mg/dL Surgical ICU care> mg/dL* Nonsurgical illness> mg/dL † Pregnancy> 100 mg/dL *Van den Berghe’s study supports 110 mg/dL; Finney’s study supports 145 mg/dL. † If drip indication is failure of SQ therapy, use 180 mg/dL; if indication is specific condition (DM 1/ NPO, MI, etc ), use 140 mg/dL.

26 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

27 Essentials of a Good IV Insulin Algorithm Easily implemented by nursing staff Dilution of insulin per hospital policy (0.5 or 1U/cc) Able to seek BG range via: —Hourly BG monitoring —Adjusts to the insulin sensitivity of the patient Contains transition orders to SC insulin when stable

28 A System for the Maintenance of Overnight Euglycemia and the Calculation of Basal Insulin Requirements in Insulin-Dependent Diabetics 1/slope = Multiplier = Glucose (mg/dL) Insulin Rate (U/hr) White NH, et al. Ann Intern Med. 1982;97: Practical Closed Loop Insulin Delivery

29 Continuous Variable Rate IV Insulin Drip 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 (80 to 110 mg/dL or 100 to 140 mg/dL)

30 Continuous Variable Rate IV Insulin Drip Adjust multiplier (initially 0.02) to obtain glucose in target range 80 to 110 mg/dL —If BG >110 mg/dL and not decreased by 15%, increase by 0.01 —If BG <80 mg/dL, decrease by 0.01 —If BG 80 to 110 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 IVFs (do not feed meals on drip without bolus SC) Once eating, continue drip till 2 hours post SQ insulin

31 Glucommander Average and Standard Deviation of of All Runs 1985 to 1998; 5808 runs, 120,618 BG’s Davidson et al, Diabetes Care 28(10): , 2005

32 Hours Glucose Multiplier Insulin Glucose Typical Glucommander Run Hi Low Davidson et al, Diabetes Care 28(10): , 2005

33 Case 1: Patient With an Acute MI Now Post-CABG and Ready to Eat Currently on IV insulin at ~2 units IV/hr What do you now do? 1.Sliding scale rapid acting insulin only? 2.Basal/bolus insulin therapy? 3.Premixed insulin therapy? 4.Basal insulin?

34 4: :0012:0016:0020:0024:004:00 BreakfastLunchDinner Plasma insulin (μU/mL) 8:00 Physiologic Serum Insulin Secretion Profile Time

35 4: :0012:0016:0020:0024:004:00 BreakfastLunchDinner 8:00 Glargine or Detemir Time Aspart, Lispro or Glulisine Aspart, Lispro, or Glulisine Aspart, Lispro, Or Glulisine Basal/Bolus Treatment Program With Rapid-acting and Long-acting Analogs Plasma insulin (μU/mL)

36 Converting to SC Insulin If >0.5 U/hr IV insulin required with normal BG, start long-acting insulin (glargine) Must start SC insulin at least 2 hours before stopping IV insulin Some centers start long-acting insulin on initiation of IV insulin or the night before stopping the drip

37 IV Insulin Infusion Under Basal Conditions Correlates Well With Subsequent SC Insulin Requirement Units IV Hawkins JB Jr, et al. Endocr Pract. 1995;1: Total Intravenous vs Subcutaneous 24-Hour Insulin Requirements (units) Subcutaneous (units) Intravenous

38

39 Converting to SC Insulin Establish 24-hour insulin requirement —Extrapolate from average over last 4-8 hours, if stable Give half the amount as basal Give PC boluses based on CHO intake —Start at CHO/ins 1 CHO = 1.5 units rapid-acting insulin Monitor AC TID, HS, and 3 AM Correction bolus for all BG >140 mg/dL —(Bg-100)/(1700/daily insulin requirement)

40 Case 2: A Person on steroids with new hyperglycemia (BG ~225 mg/dl) What is the best insulin treatment for this patient on steroids? (BG 150 to 300 mg/dL) 1.Sliding scale only with rapid-acting insulin? 2.IV insulin variable rate infusion? 3.NPH or 70/30 twice a day? 4.Basal Insulin once a day? 5.Bolus insulin premeal? 6.Basal Bolus insulin therapy?

41 4: :0012:0016:0020:0024:004:00 BreakfastLunchDinner 8:00 Glargine or Detemir Time Aspart, Lispro or Glulisine Aspart, Lispro, or Glulisine Aspart, Lispro, Or Glulisine Basal/Bolus Treatment Program With Rapid-acting and Long-acting Analogs Plasma insulin (μU/mL)

42 How to Initiate MDI Starting dose = 0.5 x wt in kg Basal dose (glargine) = 40% to 50% of starting dose given at bedtime or anytime Bolus dose (aspart/lispro) = 15% to 20% of starting dose at each meal Correction bolus = (BG - 100)/correction factor, where CF=1700/total daily dose

43 How to Initiate MDI Starting dose = 0.5 x wt in kg Weight is 100 kg; 0.5 x 100 = 50 units Basal dose (glargine) = 50% of starting dose at HS; 0.5 x 50 = 25 units at HS Total bolus dose (aspart / lispro) = 50% of starting dose ÷ 3; 0.5 x 50 = 25 ÷ 3 = 8 units AC (TID) Correction bolus = (BG - 100)/ CF, where CF=1700/total daily dose; CF=  30

44 Correction Bolus Formula Example: —Current BG:250 mg/dL —Ideal BG: 100 mg/dL —Glucose correction factor: 30 mg/dL Current BG - Ideal BG Glucose correction factor 250 – = 5.0 units

45

46 Case 3: 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 or 70/30 every 8 hours? 4.Glargine every 12 hours? 5.Regular insulin every 6 hours?

47 Case 3: A Person With Diabetes on Tube Feedings (cont’d) 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 q12h) with supplemental rapid- acting every 4 to 6 hours Can also use NPH q8h or regular q6h as the basal dose

48 Case 4: 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

49 Case 5: 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 (>140 mg/dL) 4.Hold insulin and will start IV insulin

50 Case 6: DM 1 Patient in DKA (ph 7.0; BG 400 mg/dL: weight 80 kg) What amount of 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

51 Case 6: DM 1 Patient in DKA (ph 7.0; BG 400 mg/dL: weight 80 kg) Do you give NaCO 3 ? When do you start potassium and how much? When do you start dextrose and how much? My preference is 2 liters saline followed by D saline with 40 meq KCL/liter at 250 mL/hr. Monitor electrolytes q4-8h

52

53 Case 7: 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)

54 Protocol for Insulin in Hospitalized Patient Treatment of hypoglycemia Any BG <80 mg/dL: D50 IV = (100 - BG) x 0.4 If eating, may use 15 gm of rapid CHO (prefer glucose tablets) Do not hold insulin when BG normal

55 Hospital Diabetes Plan Protocols for all diabetes/hyperglycemic patients Finger stick BG AC QID on all admissions Check all steroid-treated patients Diagnose diabetes —FBG >126 mg/dL —Any BG >200 mg/dL What can we do for patients admitted to the hospital?

56 Hospital Diabetes Plan (cont’d) Document diagnosis in chart —Hyperglycemia is diabetes until proven —Bring to all physicians’ attention —Note on problem list and face sheet Check hemoglobin A1C Hold metformin; Hold TZD with CHF, liver dysfunction Start insulin in all hospitalized patients with BG >140 mg/dL What can we do for patients admitted to the hospital?

57

58 Hospital Diabetes Plan (cont’d) Treat any patient with BG >140 mg/dL with insulin —Treat any BG >140 mg/dL with rapid-acting insulin (BG-100) / (3000 / wt [kg]) or 1700 / total daily insulin —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 >100 mg/dL if pregnant If >0.5 U/h IV insulin required, start long-acting insulin Protocol for insulin in hospitalized patient

59 Hospital Diabetes Plan (cont’d) Daily total: Pre-admission or weight (kg) x 0.5 U —50% as glargine (basal) —50% as total rapid-acting insulin (bolus) Give in proportion to meal’s CHO eaten BG >140 mg/dL: (BG-100) / CF —CF = 1700 / total daily insulin or 3000 / wt (kg) Do not use sliding scale as only diabetes management Protocol for insulin in hospitalized patient

60 Hospital Diabetes Plan (cont’d) Get diabetes education consult Instruct patient in monitoring and recording —See that patient has meter on discharge Decide on case-specific program for discharge Arrange early follow-up with PCP What can we do for patients admitted to the hospital?

61 Questions For a copy or viewing of these slides, contact or hospital protocols, go to:


Download ppt "Management of Hyperglycemia and Diabetes in the Hospital: Case Studies Bruce W. Bode, MD, FACE Atlanta Diabetes Associates Atlanta, Georgia."

Similar presentations


Ads by Google