Download Diabetes Management in the Hospital: Case Studies

Management
of Hyperglycemia and
Diabetes in the Hospital:
Case Studies
Bruce W. Bode, MD, FACE
Atlanta Diabetes Associates
Atlanta, Georgia
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.
Hyperglycemia Is an Independent Marker of
Inpatient Mortality in Patients With Undiagnosed
Diabetes
P < 0.01
P < 0.01
18
16
16
14
12
In-hospital
Mortality
Rate (%)
10
8
6
4
2
3
1.7
0
Patients
With
Normoglycemia
Patients
With History
of Diabetes
Newly
Discovered
Hyperglycemia
Adapted from Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–982.
Percentage of Population (n = 1181)
Prevalence of Hyperglycemia in 181
Cardiac Patients Without Known Diabetes
100%
66% of AMI patients
have IGT or previously
undiagnosed T2DM on
75 g OGTT
(35% IGT; 31% DM)
75%
50%
25%
0%
At Discharge
Norhammar A. Lancet. 2002;359:2140-2144.
Hospital Costs Account for Majority
of Total Costs of Diabetes
Per Capita Healthcare Expenditures (2002)
7,000
6,000
5,000
Dollars
4,000
3,000
2,000
1,000
0
Inpatient
Nursing Home
Diabetes
Physician's
Office
Without diabetes
Hogan P, et al. Diabetes Care. 2003;26:917–932.
Outpatient
Prescription
Insulin and
Supplies
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?
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
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;314:1512-1515.
Iwakura K, et al. J Am Coll Cardiol. 2003;41:1-7.
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;314:1512-1515.
Cardiovascular Risk:
Mortality After MI Reduced by Insulin Therapy in the DIGAMI
Study
Standard treatment
IV insulin 48 hours, then 4 injections daily
All Subjects
Low-risk and Not Previously on Insulin
.7
.7
(N=620)
Risk reduction (28%)
P=0.011
.6
.5
.5
.4
.4
.3
.3
.2
.2
.1
.1
0
0
0
1
2
3
(N=272)
Risk reduction (51%)
P=0.0004
.6
4
5
Years of Follow-up
Malmberg K, et al. BMJ. 1997;314:1512-1515.
0
1
2
3
Years of Follow-up
4
5
DIGAMI 2 Study
 48 hospitals in 6 countries
 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)
Conclusion
 Overall mortality was lower than
expected
 Overall mortality similar to nondiabetic
population
 The 3 glucose management strategies
did not result in differences of metabolic
control
 Target glucose levels not achieved in the
intensively insulin treatment group
Overview of GIK Therapy for Acute MI:
A 30year Perspective
Year
Study
Mortality Rate (%)
GIK Control O-E
Variance
Odds Ratio and Cls
GIK Better
Placebo Better
1987
Satler
0.0
0.0
0.0
0.0
1983
Rogers
6.5
12.3
-1.9
2.4
1978
Stanley
7.3
16.4
-2.5
2.8
1977
Heng
8.3
0.0
0.6
0.2
1971
Hjermann
10.6
20.0
-4.8
6.8
1968
Pentecost
15.0
16.0
-0.5
6.5
1968
MRC
21.4
23.6
-5.1
41.5
1967
Pilcher
13.9
29.3
-2.6
3.4
1965
Mittra
11.8
28.3
-7.0
6.8
P = 0.007
All Patients 16.1
21.0
-24.0
70.4
P = 0.004
GIK = glucose–insulin–potassium; MI = myocardial infarction; CI = confidence interval.
P = 0.07
1
Fath-Ordoubadi F, Beatt KJ. Circulation. 1997;96:1152–1156. Reprinted with permission
(http://lww.com)
CREATE-ECLA
 Worldwide study with over 20,000
subjects with ST-elevation MI (STEMI)
 GIK infusion vs Control
 Outcome: 30 day CV events
Mehta, S et al: JAMA 293: 437- 446, 2005
Baseline Glucose Associated with
Mortality
16
14
JAMA 293:437, 2005
12
10
%
mortality
8
6
4
2
0
Lowest
Middle
Glucose Tertile
Highest
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
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
Mortality of DM Patients
Undergoing CABG
16
14
Cardiac-related mortality
Mortality
12
Noncardiac-related mortality
10
8
6
4
2
0
<150
150-175
175-200
200-225
225-50
Average postoperative glucose (mg/dL)
Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;123:1007-1021.
>250
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;123:1007-1021.
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
Surgical ICU Mortality
Effect of Average BG
P=0.000
9
Cumulative % mortality
(in hospital death)
45
BG>150
40
35
30
110<BG<150
25
P=0.026
20
BG<110
15
10
5
0
0
50
100
150
Days after inclusion
Van den Berghe G, et al. Crit Care Med. 2003;31:359-366.
200
250
Intensive Insulin Therapy in Critically
Ill Patients—Morbidity and Mortality
Benefits
Mortality
Sepsis
Dialysis
Blood
Transfusion Polyneuropathy
0
-10
-20
Percent
Reduction -30
-40
-50
34%
41%
44%
46%
50%
-60
van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
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
Threshold Blood Glucose for
Starting IV Insulin Infusion
• Perioperative care
> 140 mg/dL
• Surgical ICU care
> 110-140 mg/dL*
• Nonsurgical illness
> 140-180 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.
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
• 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
Practical Closed Loop Insulin
Delivery
A System for the Maintenance of Overnight Euglycemia
and the Calculation of Basal Insulin Requirements in
Insulin-Dependent Diabetics
1/slope = Multiplier = 0.02
Insulin Rate (U/hr)
6
5
4
3
2
1
0
0
100
200
Glucose (mg/dL)
White NH, et al. Ann Intern Med. 1982;97:210-214.
300
400
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)
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
Glucommander
Average and Standard Deviation of of All Runs
1985 to 1998; 5808 runs, 120,618 BG’s
400
350
Glucose mg/dl
mean-sd
300
250
200
150
100
50
Hours
Davidson et al, Diabetes Care 28(10): 2418-2423, 2005
24
22
20
18
16
14
12
10
8
6
4
2
0
0
Typical Glucommander Run
400
350
300
Glucose 250
Glucose
200
150
Hi
Low
100
50
7
0.06
6
0.05
Multiplier
5
0.04
Multiplier
4
Insulin
0.03
3
0.02
2
0.01
Insulin
1
0
0
0
10
20
30
40
Hours
Davidson et al, Diabetes Care 28(10): 2418-2423, 2005
50
60
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?
Physiologic Serum Insulin
Secretion Profile
75
Plasma insulin (μU/mL)
Breakfast
Lunch
Dinner
50
25
4:00
8:00
12:00
16:00
Time
20:00
24:00
4:00
8:00
Basal/Bolus Treatment Program With
Rapid-acting and Long-acting Analogs
75
Plasma insulin (μU/mL)
Breakfast
Lunch
Dinner
Aspart, Aspart,
Lispro Lispro,
or
or
Glulisine Glulisine
50
Aspart,
Lispro,
Or
Glulisine
Glargine
25
or
Detemir
4:00
8:00
12:00
16:00
Time
20:00
24:00
4:00
8:00
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
IV Insulin Infusion Under Basal Conditions
Correlates Well With Subsequent SC Insulin
Requirement
Subcutaneous (units)
Total Intravenous vs Subcutaneous 24-Hour
Insulin Requirements (units)
Intravenous
Units IV
Hawkins JB Jr, et al. Endocr Pract. 1995;1:385-389.
d) Have laboratory verify “stat” all BGs less than 40 or greater than 500
5) Determination of IV insulin infusion rate (units of insulin/hour) = (BG-60) x (Multiplier)
a) Initiate infusion using the drip rate (ml/hr) shown in column 2 for the current BG Tier (see Figure 1)
b) To determine the new drip rate for each hourly BG measurement, compare the current BG Tier with
the previous BG Tier.
1. If the current BG Tier has dropped, stay in the same column to determine the new drip rate (ml/hr).
2. If the current BG Tier has not changed or is higher, move 1 column to the right to determine the new drip
rate (ml/hr).
c) When hourly BG is 80-110, remain in the current column and adjust the rate according.
d) When hourly BG is less than 80, move 1 column to the left to calculate new drip rate and refer to Figure 2.
6) Treatment for hypoglycemia (BG less than 80)
a) Move 1 column to the left and give D50 by IV push using dosing chart provided (see Figure No. 2)
b) Recheck BG in 15 minutes (repeat 6a above if BG is still less than 80)
c) Resume hourly BG monitoring and insulin drip adjustments
7) Notify physician If:
a) BG is less than 60 for 2 consecutive BG measurements.
b) BG reverts back to levels greater than 200 for 2 consecutive BG measurements.
c) Insulin requirement exceeding 24 units per hour does not result in a lower BG level.
d) Patient’s K+ level drops to less than 4.
e) Continuous enteral feedings, TPN, or IV insulin infusion is stopped or interrupted.
8) Transition to subcutaneous insulin
a) BGs should be within target range for at least 4 hours before IV insulin is discontinued
b) Calculate total daily insulin (TDI) = (units of insulin for the last 4 hours of IV drip) x (6) for patients on D5W
c) Begin glargine = 50% TDI (for pregnant patients use NPH twice daily)
d) Begin fast acting analog = 50% TDI divided by 3 (give 3 times a day immediately before meals).
e) Continue IV insulin infusion for 2 hours after initiation of subcutaneous therapy.
f) Refer to Subcutaneous Insulin Standing Orders for administration times and dosage adjustments.
g) Refer patient for diabetes education, nutritional services, and discharge planning (to ensure the patient
can afford medications/supplies and has follow-up disease state management after discharge).
The Column Chart & Sample Clinical Guidelines are the property of the Georgia
Hospital Association’s Diabetes SIG: All Rights Reserved; Copyright Pending.
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)
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?
Basal/Bolus Treatment Program With
Rapid-acting and Long-acting Analogs
75
Plasma insulin (μU/mL)
Breakfast
Lunch
Dinner
Aspart, Aspart,
Lispro Lispro,
or
or
Glulisine Glulisine
50
Aspart,
Lispro,
Or
Glulisine
Glargine
25
or
Detemir
4:00
8:00
12:00
16:00
Time
20:00
24:00
4:00
8:00
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
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
Correction Bolus Formula
Current BG - Ideal BG
Glucose correction factor
• Example:
— Current BG:
250 mg/dL
— Ideal BG:
100 mg/dL
— Glucose correction factor: 30 mg/dL
250 – 100
= 5.0 units
30
4. CORRECTION DOSE INSULIN TYPE:
 Rapid Acting Analog
 Regular Insulin
[ ] Low Dose Algorithm (for thin, elderly, or renal patients) [Blood Glucose (BG) – 100 / 50]
BG ac, hs, 0300h
141-175
176-225
226-275
276-325
326-375
If greater than 375
Additional Insulin
1 unit
2 units
3 units
4 units
5 units
Contact M.D.
[ ] Moderate Dose Algorithm (for average size adult) [BG – 100/ 40]
BG ac, hs, 0300h
141-160
161-200
201-240
241-280
281-320
If great than 320
Additional Insulin
1 unit
2 units
3 units
4 units
5 units
Contact M.D.
[ ] Moderate High Dose Algorithm (for obese or infected patients or those on steroids) [BG-100/30]
BG ac, hs, 0300h
141-145
146-175
176-205
206-235
236-265
296-325
If greater than 326
Additional Insulin
1 unit
2 units
3 units
4 units
5 units
7 units
Contact M.D.
[ ] High Dose Algorithm (for very insulin resistant patients or septic patients) [BG-100/20]
BG ac, hs, 0300h
141- 150
151-170
171-190
191-210
211-230
231-250
251-270
271-290
If greater than 291
Additional Insulin
2 units
3 units
4 units
5 units
6 units
7 units
8 units
9 units
Contact M.D.
*If above correction is not working and BG is persistently >140 mg/dl, consider using an individualized
correction dose algorithm with calculations.
[ ] Calculate the Individualized Correction Dose for BG > 140 mg/dl, using the formula:
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?
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 rapidacting every 4 to 6 hours
Can also use NPH q8h or regular q6h as the basal
dose
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
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
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
Case 6: 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/hr. Monitor electrolytes q4-8h
intended to be a standard of practice. The legal standard of care applicable to each hospital and patient will vary depending on the circumstances. It is important to note
that Federal requirements prohibit the use of standing orders except where specifically allowed and that individual plans of care must be used for each patient.
Diabetic Ketoacidosis Adult Guidelines
1.
2.
3.
4.
5.
6.
7.
8.
9.
Place patient on DKA Pathway until DKA resolved (CO2 >18 or Venous pH >7.3 or Anion Gap <14)
Diet: NPO
Consult Nutritional Services for diet, so when DKA resolves patient specific subcutaneous insulin can begin
Strict I &O
Vital signs every 2 hr x 4 or until DKA resolved then every 4 hr
Continuous cardiac monitoring
Initial Labs/Diagnostics
_______ EKG if over age 40 or as indicated by: (co-morbid disease state, and/or labs and diagnostics)
_______ Complete Metabolic Profile, CBC with differential, lipid profile, venous pH, Hemoglobin A1C, & urinalysis
_______ If temp is greater than 101°F or greater than 20% Bands present in CBC, obtain blood cultures x 2, urine C&S, and Chest
X-ray
_______ Other Labs/Diagnostics: _________________________________________________________
Follow up Lab/Diagnostics until DKA resolved:
_______ Basic Metabolic Profile every ___ hour
_______ Phosphorus
_______ Venous pH every ___ hour
_______ Anion gap every ___ hour
IV Fluids: Administer NS 1 to 2 liters for first 4 hours (may need to adjust type & rate of fluid administration in the elderly and in
patients with CHF or renal failure). Normal Na+ levels are 135-145 meq/L. For subsequent fluid infusion, please refer to the chart
below.
Serum Sodium (Na+) level
Low Serum Na+
Normal Serum Na+
High Serum Na+
IV Fluid
0.9% NaCl
0.45% NaCl
0.45% NaCl
mEq K+ to add
See Chart Below
See Chart Below
See Chart Below
Rate of Infusion
7-14 ml/kg/hr based on hydration status
7-14 ml/kg/hr based on hydration status
7-14 ml/kg/hr based on hydration status
When plasma BG reaches a level of 250mg/dl or less, begin D5/ ½ NS at 100-200ml/hr (as stated in the IV infusion standing order set)
Initial IV Fluid__________________________ with ______________mEq K+ at _____________ ml/hr
(see No. 9 above)
(see No. 10 below)
(see No. 9 above)
10. Serum Potassium (K+) (If there is persistent acidosis due to hyperchloremia, consider using Potassium Phosphate instead of
Potassium Chloride)
Serum K+
mEq K+ To Administer
Greater than 5.4 mEq/L
DO NOT GIVE K+ but check level every 2 hours
Between 4.3 and 5.4 mEq/L
30 mEq K+ in each liter of IV fluid to keep level 4.0-5.0 mEq/L
Between 3.3 and 4.2 mEq/L
Less than 3.2 mEq/L
40 mEq K+ in each liter of IV fluid to keep level 4.0-5.0 mEq/L
HOLD INSULIN and give 40 mEq of K+ in 1 liter of fluid over 1 hour (smaller
volume can be used only if fluid compromised).. Retest and repeat until K+ > 3.2
Notify physician if corrective measures still result in serum K+ greater than 5.4 or less than 3.2
11. Insulin Insulin: Follow IV Insulin Protocol
12. BICARBONATE (for adult use only)
* If arterial pH is less than 7, may consider administration of 100ml NaHCO3
* Check acid-base 30 minutes later & may repeat if pH is still less than 7
* Bicarbonate should not be administered if K+ is less than 3.6
13. Continue with Insulin IV infusion standing orders inclusive of the subcutaneous insulin transition process.
14. Notify diabetes educator of admission.
Time:____________ Date:__________
MD Signature___________________________________________
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)
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
Hospital Diabetes Plan
What can we do for patients admitted to the hospital?
• 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
Hospital Diabetes Plan (cont’d)
What can we do for patients admitted to the hospital?
• 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
Defining and Identifying Hyperglycemic Patients
Goal: Studies have proven that the outcomes of hospitalized patients are greatly enhanced when
steps are taken to improve the patient’s glycemic state. Therefore, all patients presenting with
hyperglycemia will be identified using the patient’s initial “basic metabolic profile.”
Patient Presents with Hyperglycemia
Previously diagnosed DM
Diabetic Ketoacidosis
Hyperglycemic Crisis
Follow DKA Protocol
No Previous Diagnosis DM
And BG > 140
Begin BG testing
Modification of therapy
And referral for dietary
And educational consult
BG is >140 for a critically
ill patient, notify
physician for consideration
to initiate therapy
BG is > 180 for a non- ,
critically ill patient, notify
physician for initiation of
Subcutaneous therapy
When adult blood glucose levels > 140 still occur after initiation/modification of therapy,
consideration should be given to begin IV insulin infusion (see patient and departmental
special consideration listed below).
Insulin Pump
Pregnancy
Peri-Operative
ICU
Pediatrics
DKA
Abrupt or unplanned alteration of pump regimen can result in
rapid deterioration of metabolic control resulting in acute
complications, (DKA, hypoglycemia) and adverse outcome.
Accordingly, any change in regimen should only be ordered
by or in consultation with the primary diabetes physician.
Lack of optimal glycemic control in pregnancy has been
shown to cause significant and life-threatening complications
for both mother and child. Consultation should be obtained
with any admissions of pregnant patient with diabetes.* Preprandial BG goal of 60-90 and post-prandial BG goal of
<120 has been shown to enhance outcomes of this populace.
Optimal glycemic control will reduce post-operative
complications and therefore patients with hyperglycemia may
benefit from consultation and the use of IV insulin infusion.
Maintaining BG levels of 80-140 has been shown to be
effective in this setting.
Optimal glycemic control reduces both morbidity and
mortality rates in the ICU setting. Maintaining BG levels of
80-110 have been shown to benefit patients in the ICU area
of care.
The tendency toward labile blood sugars and special
considerations related to managing diabetes in pediatric
patients may result in compromised outcomes and therefore
may well benefit from consultation.
Since DKA is a serious condition which requires intensive
management, consultation with the patient’s primary diabetes
physician should be considered.*
Hospital Diabetes Plan (cont’d)
Protocol for insulin in hospitalized patient
• 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
Hospital Diabetes Plan (cont’d)
Protocol for insulin in hospitalized patient
• 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
Hospital Diabetes Plan (cont’d)
What can we do for patients admitted to the hospital?
• 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
Questions
• For a copy or viewing of these slides,
contact or hospital protocols, go to:
www.adaendo.com
www.gha.org