3 Inpatient Hyperglycemia and Poor Outcomes in Numerous Settings StudyPatient PopulationSignificant Hyperglycemia-Related OutcomesPasquel et al, 2010Total parenteral nutrition Mortality risk, pneumonia risk, ARFFrisch et al, 2009Noncardiac surgery Mortality risk, surgery-specific riskSchlenk et al, 2009Aneurysmal SAH Mortality risk; impaired prognosisPalacio et al, 2008All admitted patients, children’s hospital ICU length of stay (LOS), ICU admissionsBochicchio et al, 2007Critically injured/trauma LOS, mortality risk, ventilator time, infectionBaker et al, 2006Chronic obstructive pulmonary disease LOS, mortality risk, adverse outcomesMcAlister et al, 2005Community-acquired pneumonia LOS, mortality risk, complicationsUmpierrez et al, 2002All admitted patients(87% non-ICU) LOS, mortality risk, ICU admissions Home dischargesPasquel FJ, et al. Diabetes Care. 2010;33: ; Frisch A, et al. Diabetes. 2009;58(suppl 1):101-OR; Schlenk F, et al. Neurocrit Care. 2009;11:56-63; Palacio A, et al. J Hosp Med. 2008;3: ; Bochicchio GV, et al. J Trauma. 2007;63: ; Baker EH, et al. Thorax. 2006;61: ; McAlister FA, et al. Diabetes Care. 2005;28: ; Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:
4 Current Recommendations for Hospitalized Patients All critically ill patients in intensive care unit settingsTarget BG: mg/dLIntravenous insulin preferredNoncritically ill patientsPremeal BG: <140 mg/dLRandom BG: <180 mg/dLScheduled subcutaneous insulin preferredSliding-scale insulin discouragedHypoglycemiaReassess the regimen if blood glucose level is <100 mg/dLModify the regimen if blood glucose level is <70 mg/dLBG, blood glucose.Moghissi ES, et al. Endocrine Pract. 2009;15:Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.
6 Enteral and Parenteral Nutrition Provided to any patient who is malnourished or at risk for general malnutrition (ie, compromised nutrition intake in the context of duration/severity of disease)EnteralFor patients with intact gastrointestinal (GI) absorptionShort termNasogastric (NG)NasoduodenalNasojejunalLong term: (PEG)GastrostomyJejunostomyParenteralFor patients with or at risk for deranged GI absorption (intestinal obstruction, ileus, peritonitis, bowel ischemia, intractable vomiting, diarrhea)Short term: peripheral access (PPN)Long term: central access (TPN)Ukleja A, et al. Nutr Clin Pract. 2010;25:
7 Nutrition Support + Metabolic Control = Metabolic Support Synchronization of Nutrition Support and Metabolic Control Is ImportantNutrition support: to achieve a calorie targetOral (standard and preferred)Enteral (gastrostomy, postpyloric, jejunostomy tubes)Parenteral (IV: peripheral, central)Metabolic control: to achieve a glycemic targetInsulinNutrition Support + Metabolic Control = Metabolic Support
8 Enteral Nutrition and Hyperglycemia Continuous or intermittent delivery of calorie-dense nutrientsWide variety of schedules and formulasAltered incretin physiology (?)Increased risk of hyperglycemiaBasal insulin should be ideal treatment strategy, but…Concerns about potential hypoglycemia after abrupt discontinuation (eg, gastric residuals, tube pulled, etc)Combined basal-regular strategies may be optimal
9 Enteral Nutrition: Is It Diabetogenic? Hyperglycemia StatusPatients in an acute care hospital on enteral feeding: mean age 76 years; 54.7% female; mean days EN 15 days.*Blood glucose >200 mg/dL.Pancorbo-Hidalgo PL, et al. J Clin Nurs. 2001;10:
11 Variable Insulin Regimens Based on Different Types of Enteral Feeding Schedules Continuous ENBasal: 40%-50% of TDD as long- or intermediate-acting insulin given once or twice a dayShort acting 50%-60% of TDD given every 6 hCycled ENIntermediate-acting insulin given together with a rapid- or short-acting insulin with start of tube feedRapid- or short-acting insulin administered every 4-6 hours for duration of EN administrationCorrection insulin given for BG above goal rangeBolus enteral nutritionRapid-acting analog or short-acting insulin given prior to each bolusBG, blood glucose; EN, enteral; TDD, total daily dose of insulin.11
12 Insulin and Enteral Therapy: Coverage Protocol if Tube Feeds Abruptly Stopped Calculate total carbohydrate calories being given as tube feedsAssess BG every 1 hIf BG <100 mg/dL, give dextrose as D5W or D10W IVContinue dextrose for duration of action of administered insulinExamplePatient receiving 80 mL/h of Jevity™ enterallyJevity = 240 mL/8 oz can, containing 36.5 g carb1 mL Jevity ≈0.15 g (150 mg) carbohydrate@ 80 mL/h ≈12 gGive 120 mL/h D10W or 240 mL/h D5W100 mL=5 g100 mL=10 g
14 Glycemia in Patients Receiving TPN Mean BG and mortality rate in hospitalized patients on TPNPre-TPN24 h TPNTPN days 2-101050403020276 patients receiving TPNMean BGPre TPN: 123 ± 33 mg/dL24 h TPN: 146 ± 44 mg/dLTPN days 2-10: 147 ± 40 mg/dLMortality (%)< >180Mean Blood Glucose (mg/dL)Pasquel FJ, et al. Diabetes Care. 2010; 33:
15 TPN, Glucose, and Patient Outcomes StudyCheung (2005)Lin (2007)Sarkisian (2009)Pasquel (2010)Hyperglycemia Definition (mg/dL)>164*>180**≥180***>180****MortalityOR(95%CI)10.90( )^5.0( )^7.22( )^2.80( )^Any Infection3.9( )^3.1( )^0.9( )NACardiac6.2( )1.6( )1.3( )Acute Renal Failure10.9( )^3.0( )^1.9( )2.2( )Septicemia2.5( )Any Complication4.3( )^5.5( )^^ Significant at P<0.05.* ORs are expressed using blood glucose <124 mg/dL as a reference category.** ORs are expressed using blood glucose <110 mg/dL as a reference category.*** ORs are expressed using blood glucose <180 mg/dL as a reference category.**** ORs are expressed using blood glucose <120 mg/dL as a reference category as measured within 24 h of PN initiation.Kumar PR, et al. Gastroenterol Res Pract. 2011;2011. doi:pii:
16 Parenteral NutritionContinuous IV delivery of high concentrations of dextrose (20-25 gm/100 mL)No incretin stimulation of insulin secretionHyperglycemia extremely commonBasal insulin should be ideal treatment strategy, but...Concerns about potential hypoglycemia after abrupt discontinuation (eg, technical issues with line)
18 Should You Stop Insulin Infusion and Put Insulin in the TPN? ProsConsSimplifies number of infusions/linesEasier if patient will be discharged on TPNHard to predict insulin requirementOnce it is in the bag, you cannot take it out
20 Frequency of Hyperglycemia in Patients Receiving High-Dose Steroids ≥1 BG >200 mg/dL≥2 BG >200 mg/dL645681524175306090AllNo Hx DMHx DMPatients (%)Donihi A, et al. Endocr Pract. 2006;12:
21 Steroid Therapy and Inpatient Glycemic Control Steroids are counterregulatory hormonesImpair insulin action (induce insulin resistance)Appear to diminish insulin secretionMajority of patients receiving >2 days of glucocorticoid therapy at a dose equivalent to ≥40 mg/day of prednisone developed hyperglycemiaNo glucose monitoring was performed in 24% of patients receiving high-dose glucocorticoid therapyDonihi A, et al. Endocr Pract. 2006;12:21
22 TES Guidelines for Glucose Control and Glucocorticoid Therapy The majority of patients (but not all) receiving high-dose glucocorticoid therapy will experience elevations in blood glucose, which are often markedRecommended approachBlood glucose monitoring for patients with or without diabetes receiving glucocorticoid therapyPatients without diabetes: may discontinue BG monitoring if BG remains <140 mg/dL without insulin therapy for hUse continuous insulin infusion for patients with severe and persistent BG elevations despite use of scheduled basal-bolus SC insulinBG, blood glucose.Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.
23 Steroid Therapy and Glycemic Control Patients With and Without Diabetes Patients without prior diabetes or hyperglycemia or those with diabetes controlled with oral agentsBegin BG monitoring with low-dose correction insulin scale administered prior to mealsPatients previously treated with insulinIncrease total daily dose by 20% to 40% with start of high-dose steroid therapyIncrease correction insulin by 1 step (low to moderate dose)Adjust insulin as needed to maintain glycemic control (with caution during steroid tapers)
25 Insulin Pump TherapyElectronic devices that deliver insulin through a SC catheterBasal rate (variable) + bolus delivery for mealsUsed predominately in type 1 diabetes“Pumpers” tend to be fastidious about their glycemic controlOften reluctant to yield control of their diabetes to the inpatient medical teamHospital personnel typically unfamiliar with insulin pumpsHospitals do not stock infusion sets, batteries, etc, for insulin pumps (multiple models available from different manufacturers
26 The Challenge of Insulin Pump Use in the Hospital If patient is clinically stable, awake, alert, and able to independently manage his/her pump, continuation of pump therapy should be consideredBut…many medical-legal issues!And…many obstacles to safe pump therapy in the hospital (trained personnel, equipment, alarms, documentation, etc)Therefore, all hospitals should have a policy for the safe use of insulin pumps at their facilities
27 Insulin Pump Policy: Main Elements Patient qualifications for self-management (normal mental status, able to control device, etc)Pump in proper functioning order and supplies stocked by patient/familySigned patient contract/agreementOrder set entryDocumentation of doses delivered (pump flow sheet)Ongoing communication between patient and RNPolicies regarding procedures, surgeries, CTs, MRIs, etc
28 Inpatient Insulin Pump Therapy: A Single Hospital Experience N=65 patients (125 hospitalizations)Mean age: 57 ± 17 yDiabetes duration: 27 ± 14 yPump use: 6 ± 5 yA1C: 7.3% ± 1.3%Length of stay: 4.7 ± 6.3 daysPump therapy continued 66%Endocrine consults in 89%Consent agreements in 83%Pump order sets completed in 89%RN assessment of infusion site in 89%Bedside insulin pump flow sheets in only 55%Mean BG 175 mg/dL (same as off pump)No AEs (1 catheter kinking)Nassar AA, et al. J Diabetes Sci Technol. 2010;4:
29 A Validated Inpatient Insulin Pump Protocol Physician order setConsult diabetes service/endocrinologistDiscontinue all previous insulin ordersCheck capillary blood glucose frequencyPatient to self-administer insulin via pumpPatient to document all BG and basal/bolus ratesInsulin type order for pump: rapid-acting analog (lispro, aspart, glulisine)Set target BG rangeImplement hypoglycemia treatment protocolNoschese ML, et al. Endocr Pract. 2009;15:
31 A Validated Inpatient Insulin Pump Protocol Meal boluses based on:Carbohydrate countBreakfast ___ u/per _____gramLunch ___ u/per _____gramSupper ___ u/per _____gramSnacks ___ u/per _____gramFixed doses___ u at Breakfast___ u at Lunch___ u at Supper___ u with SnacksorCorrection boluses: _____ unit(s) for every ____mg/dL over ____ mg/dL (target glucose)Noschese ML, et al. Endocr Pract. 2009;15:
32 A Validated Inpatient Insulin Pump Protocol Hospitalizations After Implementation of an Inpatient Insulin Pump Protocol (IIPP)Mean BG (mg/dL)P valueGroup 1 - IIPP+DM consult (n=34)173 ±43NSGroup 2 - IIPP alone (n=12)187 ±62Group 3 - Usual care (n=4)218 ±46More inpatient days with BG >300 mg/dL in Group 3 (P<0.02.)No differences in inpatient days with BG <70 mg/dL1 pump malfunction; 1 infusion site problem; no SAEs86% of pumpers expressed satisfaction with ability to manage DM in the hospitalNoschese ML, et al. Endocr Pract. 2009;15:
34 Withhold noninsulin agents the morning of surgery Pre-Op Recommendations for Patients Admitted Day of Surgery: Patients on Noninsulin AgentsWithhold noninsulin agents the morning of surgeryInsulin is necessary to control glucose in patients with BG >180 mg/dL during surgeryNoninsulin agents can be resumed postoperatively when:Patient is reliably taking PORisk of liver, kidney, and heart failure are lower
35 Pre-op Recommendations for Insulin Treated Patients Morning of surgeryGive 50-75% of home basal insulin dose (NPH/glargine/detemir)Do NOT give prandial insulinGive correction for hyperglycemiaFor prolonged procedures initiate insulin infusion
36 Pre-op Recommendations: Patients Using Insulin Pump Discontinue insulin pump and change to IV insulin according to patient’s current basal rateIf basal rate <1 unit/h, start IV insulin at 0.5 units/hIf basal rate 1-2 units/h, start IV insulin at 1 units/hMonitor BG hourly, with titration per insulin infusion protocolFor brief surgical procedures in which the pump insertion site is not in surgical field, may consider continuing pump therapyReduce basal rate by 20% (eg, 1 u/h changes to 0.8 u/h)Remove pump and initiate insulin infusion if patient becomes hemodynamically unstableHypoglycemia and hyperglycemia treated in manner similar to that of patients receiving SC insulin pre-op
38 Surgical Care Improvement Project (SCIP) SCIP measures are a subset of the National Quality Hospital MeasuresCreated by the Centers for Medicare and Medicaid Services (CMS) and the Joint CommissionUsed to evaluate eligibility for Hospital Value-Based Purchasing (VBP) programA Medicare quality incentive program that rewards better, value, patient care, and innovation, rather than greater volume of servicesCMS. Fiscal Year 2014 Overview for Beneficiaries, Providers, and Stakeholders. Teleconference presentation; July 11, Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/NPCSlides pdf.
39 SCIP-Inf-4: Cardiac Surgery Patients With Controlled Postoperative Blood Glucose Cardiac surgery patients with controlled postoperative BG (≤180 mg/dL) hours after anesthesia end timeOne of 13 measures in Clinical Process of Care Domain included in Fiscal Year 2014 ProgramBG, blood glucose.CMS. Fiscal Year 2014 Overview for Beneficiaries, Providers, and Stakeholders. Teleconference presentation; July 11, Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value- based-purchasing/Downloads/NPCSlides pdf.National Quality Forum. Quality Positioning System (QPS) Measure Description Display information. Available at:
40 SCIP-Inf-4 Cardiac Surgery with Controlled Post-Op Glucose: Evaluations All blood sugars during the 6-hour time period from h post-op evaluatedLVAD patients included in this measurePass measureAll BG <180 mg/dLOne BG >180 mg/dL but all subsequent BG values <180 mg/dL prior to end pointFail measure≥2 BG values >180 mg/dLNo BG collectedBG, blood glucose; LVAD, left vetricular assist device; SCIP, Surgical Care Improvement Project.
41 SCIP-Inf-4 Cardiac Surgery with Controlled Post-Op Glucose: Assessment Apply SCIP Inf-4 criteria to current post-op cardiovascular surgery patientsAssess potential defects and causeMost patients are eating hours post surgery; was additional meal coverage given to cover caloric intake?Was the insulin infusion discontinued prior to 24 h with appropriate transition to subcutaneous insulin?Is there a dextrose IV infusion?Is the patient receiving timely blood glucose checks?Diabetic patients are at higher risk than nondiabetic patients for suboptimal blood glucose management
42 SCIP-Inf-4 Cardiac Surgery with Controlled Post-Op Glucose: Recommendations Optimize insulin ordersAll CVS patients should be on a continuous insulin infusion for 24 hRemove dextrose from IV fluids including IVPB where possibleMake sure noncaloric fluids offered during first 24 hCrystal light punch or lemonade, water, broth, diet lemon/lime, Coke zero, etcGive adequate subcutaneous insulin meal coverage if patient begins eating on insulin infusionTimely blood glucose monitoring, at least every 2 hShare information with cardiac surgeons, diabetes specialists, pharmacy, nursing-
43 SummaryHyperglycemia is associated with adverse clinical outcomes in the hospital setting, both in critically ill and noncritically ill patientsNational organizations have promoted safe and achievable glucose targets for inpatientsSpecial considerations are necessary for patientsOn enteral or parenteral nutritionReceiving steroidsUsing insulin pumpsEstablished pre-op procedures are also important to optimize glucose control during surgery