None 1 4/30/15 Past Lectures n Background Data on Goals n Nuts - - PDF document
4/30/15 Inpatient Hyperglycemia Rational Approach at a Time of Uncertainty How to Make Change Happen Robert J. Rushakoff, MD Professor of Medicine University of California, San Francisco robert.rushakoff@ucsf.edu Disclosures None 1
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Robert J. Rushakoff, MD Professor of Medicine University of California, San Francisco robert.rushakoff@ucsf.edu
Rational Approach at a Time
How to Make Change Happen
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n Background Data on Goals n Nuts and Bolts on How to do day to day
management
n Some other interesting stuff
n Background Data on Goals
n What’s old is old; What’s new is old n Same slides – different message
n Nuts and Bolts on How to do day to day
management
n There are better ways to teach this
n Some other interesting stuff
n For sure
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Inpatient Diabetes Goals
Who Cares Just get patient home Sliding Scales are fine Avoid that scary hypoglycemia
Inpatient Diabetes Goals
Normal glucoses for everyone A high glucose means failure Sliding Scales are banned Some hypoglycemia is acceptable
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Inpatient Diabetes Goals
Who Cares Just get patient home Sliding Scales are fine Avoid that scary hypoglycemia
Inpatient Diabetes Goals
Normal glucoses for everyone A high glucose means failure Sliding Scales are banned Some hypoglycemia is acceptable
Inpatient Diabetes Goals
Who Cares Just get patient home Sliding Scales are fine Avoid that scary hypoglycemia
Inpatient Diabetes Goals
Normal glucoses for everyone A high glucose means failure Sliding Scales are banned Some hypoglycemia is acceptable
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Inpatient Diabetes Goals
Who Cares Just get patient home Sliding Scales are fine Avoid that scary hypoglycemia
Inpatient Diabetes Goals
Normal glucoses for everyone A high glucose means failure Sliding Scales are banned Some hypoglycemia is acceptable
Inpatient Diabetes Goals
Appropriate Glucose Control Based on physiology and outcome studies
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abnormalities secondary to
morbidity and mortality
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Proinflammatory cytokines in response to DKA
n In DKA– increased 2-3 fold:
n counterregulatory hormones n proinflammatory cytokines
n (tumor necrosis factor [TNF]–α, n interleukin [IL]-6, IL-8, and IL-1β),
n markers of reactive oxygen species n markers of lipid peroxidation n C-reactive protein, and free fatty acids
Metabolism 2009, 58: 443-448
Glucose and Post-CABG Morbidity and Mortality
Diabetes and Coronary Artery Bypass Surgery
An examination of perioperative glycemic control and outcomes
Inpatient complications: For each 1 mmol/l (18 mg/dL) increase in post-op day 1 over 6.1 mmol/l (110 mg/dL), a 17% increased risk of complications
McAlister FA et al. Diabetes Care. 2003; 26:1518-1524.
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Other Associations
High Blood Glucose Levels Associated With Increased Mortality in ICU
patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati
mortality starting at 111 mg/dL
infarction, unstable angina, and stroke
– Raised MI risk from 1.7 to 6 times – Raised stroke risk from 1.8 to 29 times – Raised unstable angina from 1.4 to 3 times
Falciglia M et al. Crit Care Med. 2009; 37:3001-3009.
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with sepsis, pneumonia, and pulmonary embolism
mortality in diseases such as COPD and hepatic failure, hip fractures
not seen until mean glucose was >146 mg/dL
patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati
High Blood Glucose Levels Associated With Increased Mortality in ICU
Falciglia M et al. Crit Care Med. 2009; 37:3001-3009.
Hyperglycemia– related mortality in critically ill patients varies with admission diagnosis
Falciglia M et al. Crit Care Med. 2009; 37:3001-3009.
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Hyperglycemia Is Associated With Adverse Outcomes in Patients Receiving Total Parenteral Nutrition
Cheung et al: Diabetes Care, 28:2367-2371, 2005
Risk of complications in relation to mean daily blood glucose level OR (95% CI) P Any infection 1.40 (1.08–1.82) 0.01 Septicemia 1.36 (1.00–1.86) 0.05 Acute renal failure 1.47 (1.00–2.17) 0.05 Cardiac complications 1.61 (1.09–2.37) 0.02 Death 1.77 (1.23–2.52) <0.01 Any complication 1.58 (1.20–2.07) <0.01
Glycemic Control and Outcomes of Hospitalization in Noncritically Ill Patients with Type 2 diabetes admitted with cardiac Problems or Infections
n Retrospective – 378 patients
n primary composite out-come included death during
hospitalization, ICU transfer, initiation of enteral or parenteral nutrition, line infection, deep vein thrombosis, pulmonary embolism, rise in plasma creatinine by 1 or >2 mg/dL, new infection, an infection lasting for more than 20 days, and readmission within 30 days and between 1 and 10 months after discharge.
(Endocr Pract. 2014; 20:1303-1308)
4/30/15 ¡ 11 ¡ Glycemic Control and Outcomes of Hospitalization in Noncritically Ill Patients with Type 2 diabetes admitted with cardiac Problems or Infections
n mean blood glucose (BG) level:
n group 1 had mean BG of <180 mg/dL (n = 286; mean BG, 142 ±
23 mg/dL)
n group 2 had mean BG levels >181 mg/dL (n = 92; mean BG, 218 ±
34 mg/dL; P<.0001).
n Group 2 had a 46% higher occurrence of the primary outcome (P<.
0004). The rate of unfavorable events was greater in cardiac and ID patients with worse glycemic control (group 2).
n Our data strongly support a positive influence of
better glycemic control (average glycemia <180 mg/ dL or 10 mmol/L) on outcomes of hospitalization in patients with type 2 diabetes.
(Endocr Pract. 2014; 20:1303-1308)
0 ¡ 1 ¡ 2 ¡ 3 ¡ 4 ¡ 5 ¡ 6 ¡ 7 ¡ 8 ¡ 9 ¡ 10 ¡ 0 ¡ 2 ¡ 4 ¡ 6 ¡ 8 ¡ 10 ¡ 12 ¡ 14 ¡ 16 ¡
4/30/15 ¡ 12 ¡ The association of mean glucose level and glucose variability with intensive care unit mortality in patients with severe acute pancreatitis
J Crit Care. 2012 Apr;27(2):146-52.
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Insulin infusion improves neutrophil function in diabetic cardiac surgery patients Perioperative IV insulin infusion
Neutrophil phagocytic activity % baseline Control 47 Insulin 75
Rassias AJ et al. Anesth Analg. 1999; 88:1011-1016.
Glucose control lowers the risk of wound infection in diabetics after open-heart operations Perioperative IV insulin infusion Protocol to maintain glucoses <200 mg/dL
Incidence of Deep Wound Infections (%) 1997 1999 Routine Control 2.4 2.0 “Tight” Control 1.5 0.8
Zerr KJ et al. Ann Thorac Surg. 1997;63:356-361. Furnary AP et al. Ann Thorac Surg. 1999;67:352-360. Furnary AP et al. J Thorac Cardiovasc Surg. 2003;125:1007-1021.
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Glucose control decreases mortality in diabetics after open heart
Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021
2 4 6 8 10 12 14 16
<150 150-175 175-200 200-225 225-250 >250
Mortality (%)
Cardiac-related mortality Noncardiac- related Mortality
0.9% 1.3% 2.3% 4.1% 6.0% 14.5%
Declining In-Hospital Mortality in Patients Undergoing Coronary Bypass Surgery in the United States Irrespective of Presence of Type 2 Diabetes or Congestive Heart Failure
Clin Cardiol. 2012 Feb 23. (ahead online)
Steady decline in the age-adjusted coronary artery bypass grafting (CABG)-related in-hospital mortality in recent years. (X/100,000)
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Intensive Insulin Therapy in Critically Ill Patients
Decreased Morbidity and Mortality
glucoses between 80-110 mg/dL or conventional treatment (IV insulin if glucose >215 mg/dL then maintain glucose between 180-200)
Van den Berghe G et al. N Engl J Med. 2001;345:1359-1367.
% given insulin 24-hour dose
AM glucose Intensive 99 71 units 103 Conventional 39 33 units 153
12 month mortality Intensive 4.6% Conventional 8.6% Main effect on patients in ICU >5 days
NICE-SUGAR
treatment in the ICU on 3 or more consecutive days randomized to intensive blood glucose control (target range, 81 to 108 mg/dL) or conventional blood glucose control (<180 mg/dL)
within 90 days after randomization
The NICE-SUGAR Study Investigators. N Engl J Med. 2009;360:1283-1297.
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NICE- SUGAR: Data on Blood Glucose Level, According to Treatment Group
The NICE-SUGAR Study Investigators. N Engl J Med 2009;360:1283-1297
NICE-SUGAR: Probability of Survival and Odds Ratios for Death, According to Treatment Group
The NICE-SUGAR Study Investigators. N Engl J Med 2009;360:1283-1297
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Proinflammatory cytokines in response to insulin-induced hypoglycemic stress in healthy subjects
n In hypoglycemia– increased 2-3 fold:
n counterregulatory hormones n WBC n proinflammatory cytokines
n (tumor necrosis factor [TNF]–α, n interleukin [IL]-6, IL-8, and IL-1β),
n markers of reactive oxygen species n markers of lipid peroxidation n free fatty acids
Metabolism 2009, 58: 443-448
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Hypoglycemia and Mortality in Insulin-treated vs Non–Insulin-treated AMI Patients
Kosiborod M, et al. JAMA. 2009;301(15):1556-1564.
Hypoglycemia No hypoglycemia
P=.92 P<.001
Mortality, %
10.4 18.4 9.2 10.2 10 20 No Insulin Treatment Insulin Treatment
Hypoglycemia was a predictor of higher mortality in patients not treated with insulin, but not in patients treated with insulin Hazard Ratio for Death According to the Occurrence of Hypoglycemia on 1 Day or More Than 1 Day and Receipt or Nonreceipt of Insulin Therapy at the Time of the First Hypoglycemic Episode.
The NICE-SUGAR Study Investigators. N Engl J Med 2012;367:1108-1118
4/30/15 ¡ 21 ¡ Severe Hypoglycemia (glucose<40 mg/dl) 4 month audit
Unit Total Glucose Checks # Low from report (% low) False lows # of Actual Low (% low)
ICU (IV) 3378 3 (0.09%) 2/3 1 (0.03%) ICU (SQ) 5241 9 (0.17%) 8/9 1 (0.02%) Med/Surg 15661 18 (0.11%) 17/18 1 (<0.01%)
Unit Total False lows Immediate repeat not low (and no rx given) No low glucose found (and no rx noted)
ICU (IV) 2 2 ICU (SQ) 8 8 Med/Surg 17 12 5 False Low explanation In ICU, both patients with lows did die within 24 hours, but on review, these patients were both end stage and plans were already being discussed for withdrawal of life support prior to the low glucose.
Proportion of capillary blood glucose measurements <4mmol/l (72mg/dl) (left panel) and <2.5 mmol/l (45mg/dl)(right panel) by hour of day.
Trends in recorded capillary blood glucose and hypoglycemia in hospitalized patients with diabetes
Diabetes Research and Clinical Practice, Volume 104, Issue 1, 2014, 79 - 83
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2015 Inpatient Glucose Goals
Organization ICU Non-ICU Prepandial Non-ICU Maximum AACE/ACE 140-180 mg/dl <140 mg/dl 180 mg/dl ADA 140-180 mg/dl <140 mg/dl 180 mg/dl ACP 140-200 mg/dl Avoid <140 mg/dl Endocrine Society <140 mg/dl 180 mg/dl Society of Critical Care Medicine 100-150 mg/dl UCSF 100-160 mg/dl 100-180 mg/dl
Blood Glucose Levels During Isulin Treatment
Days of Therapy Blood glucose (mg/dL)
100 120 140 160 180 200 220 240 Admit 1 2 3 4 5 6 7 8 9 10
SSRI Lantus + glulisine
Mean Blood Glucose Levels During Insulin Therapy
* p<0.01 ¶ p<0.05
¶ * * * ¶ ¶ ¶
Day 3: P=0.06 Umpierrez GE Et al. Diabetes Care. 2007;30:2181–2186.
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How to Obtain “Tight” Control
Ø Bedside glucose monitoring Ø IV insulin drips Ø Diabetic Flow sheets Ø Discourage the use of traditional Sliding Scale
insulin
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Roller Coaster Effect of Insulin Sliding Scale
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admitted for “Giants” fever.
diabetes and takes a total of 75 Units insulin per day (2 shots). Glucoses at home are “poorly controlled.”
diabetes but she has good control taking about 25 units
Units glargine at night.
Fingerstick qid with regular insulin SQ coverage: FSBG Action < 50 1 amp D50 iv and call HO 51-80 give juice and repeat in 0.5-1 hr 81-150 no coverage 151-200 2U regular insulin SQ 201-250 4U regular insulin SQ 251-300 6U regular insulin SQ 301-350 8U regular insulin SQ 351-400 10U regular insulin SQ >400 12U regular insulin SQ, call HO
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Physiologic Insulin Secretion: Basal/Bolus Concept
Breakfast Lunch Supper Insulin (µUnits/mL) Glucose (mg/dL)
Basal Glucose
150 100 50
7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 A.M. P.M.
Time of Day
Basal Insulin
50 25
Nutritional Glucose Nutritional (Prandial) Insulin Suppresses glucose production between meals & overnight
The 50/50 Rule
The Components of a Physiologic Insulin Regimen
4/30/15 ¡ 28 ¡ Relative Insulin Level PM glargine
glargine
Time
Breakfast 12pm Lunch Dinner
Relative Insulin Level Time
Breakfast
TID lispro/aspart/glulisine and hs glargine
Lunch Dinner 12pm glargine
Lispro/aspart/ glulisine
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Insulin Order Forms
– DKA – Adult SQ Insulin – Patient eating – Adult SQ Insulin – NPO, TPN, Tube Feeding – IV insulin – ICU protocol – IV insulin – Med-Surgical Unit protocol – Adult Insulin pump
– Adult SQ insulin algorithm for NPO patients** – CV Surgery Specific orders – PREO-OP Pathway**
– SQ Insulin – Patient eating – IV Insulin form - delivery – Pump Form
– SQ Insulin – Patient eating – Pump Form
– DKA – IV insulin
** under development
Order set Adult SQ Insulin – Patient eating: set premeal dose Premeal Dosing Postmeal Dosing (based on amount consumed) Adult SQ Insulin – Patient eating: CHO Counting Premeal Dosing CHO dependent Postmeal Dosing (based on CHO consumed) Adult SQ Insulin – NPO, TPN Q4h nutrition and correction Nutrition dose timed to cycle TPN, correction q4h Adult SQ Insulin –Tube Feeding Q4h nutrition and correction Nutrition dose timed to cycle feedings, correction q4h Adult Insulin Pump IV Insulin protocol: ICU Specific initial rate for CVS/DKA/other IV insulin protocol: Medical/surgical units Specific initial rate for CVS/DKA/other DKA
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Subcutaneous Insulin Order Sheet
Introduction
Check blood glucose and give insulin before meals, bedtime, and 2 A.M.
BASAL AND NUTRITIONAL INSULIN DOSE (IN UNITS)
Patient Eating TIME Breakfast Lunch Dinner Bedtime Aspart (Novolog) Nutritional Dose NPH Glargine (Lantus) Novolog Mix 70/30
4/30/15 ¡ 31 ¡ Subcutaneous Insulin Order Sheet : Meal time insulin adjustments
nutritional dose of aspart Blood Glucose Range
¨ ¨ Sensitive
BMI less than 25 and/or <50 units per day
¨ ¨ Average
BMI 25-30 and/or 50-90 units per day
¨ ¨ Resistant
BMI >30 and/or >90 units per day
♦ Custom <70 mg/dl
Once BG≥100mg/dl give Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats.
2 units less 3 units less 4 units less _____units less 70-100 mg/dl 2 units less 2 units less 3 units less _____units less 101-130 mg/dl Give nutritional dose of Aspart as in # 1A above 131-150 mg/dl +0 unit +1 units +2 units +_______units 151-200 mg/dl +1 units +2 units +3 units +_______units 201-250 mg/dl +2 units +4 units +6 units +_______units 251-300 mg/dl +3 units +6 units +9 units +_______units 301-350 mg/dl +4 units +8 units +12 units +_______units 351-400 mg/dl +5 units +10 units +15 units +_______units Over 400 mg/dl +6 units +12 units +18 units +_______units
Bedtime and 2am insulin adjustments
Shown below is the section C the page for “patients eating”. The area indicates the orders for supplemental insulin that should be given at bedtime and/or 2am. Aspart insulin is to be used at these times. These testing times are important not just for checking for high glucoses but also to monitor and treat low glucoses. These checks are also important in helping to adjust the overall insulin doses.
BG Range: Default Value Or Custom 200-250 mg/dL 1 unit 251-300 mg/dL 2 units >300 mg/dL 3 units
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TPN continuous cycle _______________ TUBE FEED continuous cycle ______________
6:00 10:00 14:00 18:00 22:00 02:00 Aspart (Novolog) Nutritional Dose
5 5 5 5 5 5
Glargine (Lantus)
24 The final section of the both forms of the order sheets describes the treatment for hypoglycemia. The key item is that when a person can eat, the hypoglycemia is treated by oral glucose.
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Take 80% of last 24 h insulin infusion Basal: ½ of the value premeal: ½ of the value divided for the meals Example: 1.5 units per hour = 36U 36 x .8= 29 Basal: 30x.5=15 premeal: 30x.5=15 5 per meal
What to do if unclear how much the patient will eat? What if transition to clear liquids?
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Cases: IVE
Patient IVE is a 83 year old male. s/p cardiac surgery. Has been on IV insulin, with well controlled glucoses. Patient remains in critical condition, IV insulin is to be continued and patient is also starting to eat.
TIME 600 700 800 900 1000 1100 1200 Glucose 125 132 240 260 220 130 50 Insulin (units/h) 1 1 2.2 3.4 4.4 3.9 Breakfast
§ In general - continue patient's normal
§ Consider decrease to 70% to decrease risk of
hypoglycemia
§ Do not stop the outpatient insulin and use a
sliding scale
§ If outpatient glucoses have been poorly
controlled on current insulin regimen, consider starting more appropriate insulin regimen
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Patient on 40Uam, 30Upm of 70/30 Poorly controlled, 80kg 30 U glargine 10U aspart/humalog premeal
Easy method: Choose the U/kg (.3 to .5 U/kg) Basal: ½ of the value premeal: ½ of the value divided for the meals If on premixed insulin changing to MDI: Basal: ½ of the total dose premeal: ½ of the total dose divided for the meals
Pharmacologic Classes of Agents to Control Hyperglycemia in Type 2 Diabetes
Thiazolidinediones—e.g., rosiglitazone, pioglitazone
Class
Biguanides—e.g., metformin Alpha-glucosidase inhibitors—e.g., acarbose & miglitol
Insulin secretagogues—e.g., sulfonylureas (glyburide, glipizide); repaglinide
Takes 2-3 weeks to see initial effect. Effects continue for weeks or months after discontinuation of medication Keep in mind the metabolic t1/2 of each
Withhold in conditions predisposing to renal insufficiency and/or hypoxia CV collapse Acute MI or acute CHF Severe infection Use of iodinated contrast material Major surgical procedures In case of hypoglycemia (due to sulfonylurea or insulin treatment) Glucose (dextrose) must be administered Sucrose and complex carbohydrates should not be administered
Special Considerations
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Pharmacologic Classes of Agents to Control Hyperglycemia in Type 2 Diabetes
DDP 4 Inhibitor
Class
SGLT-2 inhibitor Other: Colesevelam Dopamine Agonist
GLP-1 Agonist
Minimal Data. Low risk of hypoglycemia Minimal Data. GI side effects, delayed gastric emptying. Low risk of hypoglycemia No Data. Risk of dehydration, urinary and yeast infections No Data. GI side effects Colesvelam: binds medications
Special Considerations
Safety and Efficacy of Sitagliptin Therapy for the Inpatient Management of General Medicine and Surgery Patients With Type 2 Diabetes: A pilot, randomized, controlled study. Diabetes Care. 2013 Jul 22. [Epub ahead
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Patient on Diet alone or Oral Agents who is Eating
Blood Glucose Range ¨ ¨ Sensitive
BMI less than 25 and/or <50 units per day
þ þ Average
BMI 25-30 and/or 50-90 units per day ¨ ¨ Resistant BMI >30 and/or >90 units per day
♦ Custom <70 mg/dl Once BG≥100mg/dl give Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats. 2 units less 3 units less 4 units less _____units less 70-100 mg/dl 2 units less 2 units less 3 units less _____units less 101-130 mg/dl Give nutritional dose of Aspart as in # 1A above 131-150 mg/dl +0 unit +1 units +2 units +_______units 151-200 mg/dl +1 units +2 units +3 units +_______units 201-250 mg/dl +2 units +4 units +6 units +_______units 251-300 mg/dl +3 units +6 units +9 units +_______units 301-350 mg/dl +4 units +8 units +12 units +_______units 351-400 mg/dl +5 units +10 units +15 units +_______units Over 400 mg/dl +6 units +12 units +18 units +_______units A. BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am.
Patient Eating TIME Breakfast Lunch Dinner Bedtime Aspart (Novolog) Nutritional Dose Glargine (Lantus)
Glucose 140 255 180 190 Insulin 1 A(0+1) 6 A(0+6) 2 A(+2) 0 glargine Change for next day:
kg
Patient is scheduled for a CT scan and is NPO tomorrow morning. Glucoses at what would be breakfast time is 240. Orders are as follows. What should be done with the insulin?
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Patient on Insulin who is Eating
Blood Glucose Range ¨ ¨ Sensitive
BMI less than 25 and/or <50 units per day ¨ ¨ Average BMI 25-30 and/or 50-90 units per day
þ þ Resistant
BMI >30 and/or >90 units per day
♦ Custom <70 mg/dl Once BG≥100mg/dl give Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats. 2 units less 3 units less 4 units less _____units less 70-100 mg/dl 2 units less 2 units less 3 units less _____units less 101-130 mg/dl Give nutritional dose of Aspart as in # 1A above 131-150 mg/dl +0 unit +1 units +2 units +_______units 151-200 mg/dl +1 units +2 units +3 units +_______units 201-250 mg/dl +2 units +4 units +6 units +_______units 251-300 mg/dl +3 units +6 units +9 units +_______units 301-350 mg/dl +4 units +8 units +12 units +_______units 351-400 mg/dl +5 units +10 units +15 units +_______units Over 400 mg/dl +6 units +12 units +18 units +_______units A. BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am.
Patient Eating TIME Breakfast Lunch Dinner Bedtime Aspart (Novolog) Nutritional Dose
21 14 19
Glargine (Lantus)
65 Glucose 240 Insulin 6 A(0+6) 65 glargine
Cases: FLAC
Patient FLAC is a 42 year old male who has a history of liver transplant. He is admitted with for knee surgery. Medications are Prednisone, 5 mg/day, stable immunosuppressive regimen, amlodipine, dapsone. Glucoses were high post transplant 2 years ago. HbA1c since then averages 4.9 (last check 2 weeks ago) No home monitoring. You are called in as a “medical consultant” and happen to see the glucose preop was 254 (also 2 weeks ago) . Should you be concerned and what should you do?
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Cases: FLAC
HbA1c: formed by non-enzymatic condensation of glucose with the N- terminal valine residue of the β chains of hemoglobin., HbA1c reflects the glucose level an erythrocyte has been exposed to during its lifespan and is a measure of glycemic control over the last 3 months with the immediately preceding 30 days contributing 50% to the HbA1c Dapsone: Three mechanism for false HbA1c: 1. Can induce hemolysis 2. Interference with assay 3. Hemolytic independent reduction in erythrocyte survival
Shah A, Fox RK, Rushakoff RJ. Falsely decreased HbA1c in a type 2 diabetic patient treated with dapsone. Endocr Pract. 2014 Nov;20(11):e229-32
Glucocorticoids and Diabetes
Peripheral Tissues (Muscle) Glucose Liver
Impaired insulin secretion Increased glucose production
postreceptor defect
Insulin resistance
Pancreas
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Breakfast Dinner Lunch Breakfast
Glucose
Bedtime
Breakfast Dinner Lunch Breakfast
Glucose
Bedtime
Typical sliding scale insulin
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Breakfast Dinner Lunch Breakfast
Glucose
Bedtime
Typical sliding scale insulin
Breakfast Dinner Lunch Breakfast
Glucose
Bedtime
Revved Up sliding scale insulin
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Breakfast Dinner Lunch Breakfast
Glucose
Bedtime
Revved Up sliding scale insulin
Breakfast Dinner Lunch Breakfast
Glucose
Bedtime
NPH and Regular
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Breakfast Dinner Lunch Breakfast
Glucose
Bedtime
NPH and Regular
Breakfast Dinner Lunch Breakfast
Glucose
Bedtime
Increase NPH and Regular
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Breakfast
Glucose
Insulin Requirements:
Need Daily Adjustments Adjustments on decrease:
glucocorticoids.
With “pulses” ---- remember past pulses!!
Blood Glucose Range ¨ ¨ Sensitive
BMI less than 25 and/or <50 units per day
þ þ Average
BMI 25-30 and/or 50-90 units per day ¨ ¨ Resistant BMI >30 and/or >90 units per day
♦ Custom <70 mg/dl Once BG≥100mg/dl give Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats. 2 units less 3 units less 4 units less _____units less 70-100 mg/dl 2 units less 2 units less 3 units less _____units less 101-130 mg/dl Give nutritional dose of Aspart as in # 1A above 131-150 mg/dl +0 unit +1 units +2 units +_______units 151-200 mg/dl +1 units +2 units +3 units +_______units 201-250 mg/dl +2 units +4 units +6 units +_______units 251-300 mg/dl +3 units +6 units +9 units +_______units 301-350 mg/dl +4 units +8 units +12 units +_______units 351-400 mg/dl +5 units +10 units +15 units +_______units Over 400 mg/dl +6 units +12 units +18 units +_______units A. BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am.
Patient Eating TIME Breakfast Lunch Dinner Bedtime Aspart (Novolog) Nutritional Dose
10 10 10
Glargine (Lantus)
30
Glucose 151 220 340 350 Insulin 12 A(10+2) 14 A(10+4) 18 A(10+8) 3A(+3) 15 glargine Change for next day would be increase Aspart Breakfast: 16units; Lunch 18 units; Dinner 18 units
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Case: MOD
Patient MOD is a 50 year old female admitted for
pioglitazone and sitagliptin at home for her type 2 diabetes (which has been described as in good control). You have just returned from this course. The oral medications are stopped and basal/bolus insulin is started. You round the next day and find out glucoses are totally crazy, from 128 in the morning, to 294 before lunch and then 36 mid afternoon.
Case: MOD
You investigate and find: At 7am: Glucose 128. patient did not eat and no insulin given. At 10am: Breakfast brought. Glucose 179. Nutrition dose plus correction given. At 11:30: Lunch Brought. Glucose 294. Nutrition dose plus correction dose given. At 2:30 you are called as the glucose is 38 mg/dl.
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Case: MOD
You notice a poster on the wall of the nursing station all about the new “meals on demand.” What should you do?
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11 ¡Long ¡started ¡the ¡on-‑demand ¡meal ¡system ¡~ ¡2 ¡yrs ¡ago ¡ Caloric ¡intake ¡has ¡improved ¡by ¡20%! ¡ Non-‑standardized ¡times ¡problematic ¡for ¡RNs ¡
Timing ¡of ¡insulin ¡ Timing ¡of ¡Blood ¡Glucose ¡Point ¡of ¡Care ¡Test ¡ ¡ Documentation ¡
Patient ¡Trigger ¡
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11 ¡Long ¡RNs ¡ ¡ Melissa ¡Lee, ¡MS, ¡RN, ¡CNS-‑BC ¡ ¡ Amy ¡Nichols, ¡RN ¡EdD ¡ ¡ Heidemarie ¡Windham, ¡PharmD, ¡CDE ¡ ¡ Flo ¡Agudelo, ¡BSN, ¡RN ¡ ¡Cami ¡Lenett, ¡RN ¡, ¡MS, ¡OCN ¡ Gabrielle ¡Perez, ¡RN ¡ ¡
n Physician Education n Daily High Glucose Report
n Nurse to check in on patients with very high glucoses
n Diabetes team for patients with high glucoses
n Physician n Nurse n Pharmacist
n Diabetes Team for All Patients
n Physician n Nurse n Pharmacist
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UCSF Intervention limitations
– Still not all residents get training – Residents not taking care of patients – Hospitalists (turnover)
– NPs managing patients
Big Brother
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How to communicate with teams
taking care of patient
which pager)
read other notes)
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Typical ICU patient
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s/p liver transplant
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1P203597 Rushakoff VirtualDm Rundate = 22APR15
L:\203597 Rushakoff VirtualDm\SASjobs\plot_20150422.sas Number of patients with 2 or more glucose readings gt 220 by date
30 Num_patients_gt220 10 20 recorded_date L:\203597 Rushakoff VirtualDm\SASjobs\plot_20150422.sas Please acknowledge CTSI grant #UL1 TR000004;see http://accelerate.ucsf.edu/cite. 01MAY2012 01SEP2012 01JAN2013 01MAY2013 01SEP2013 01JAN2014 01MAY2014 01SEP2014 01JAN2015 01MAY2015Before ¡vGMS ¡ A7er ¡vGMS ¡
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Make believe you are a hospital administrator Make believe you are in charge of risk management Make believe you are a medical center attorney
n
A piece of equipment (with several variations) that is used to manage a medication that is at the top of the list for inpatient danger – equipment that hospital engineers, nurses, physicians and pharmacists may not have any idea how to use.
LIKELY WILL
4/30/15 ¡ 58 ¡ Insulin Pump Settings
Basal ¡Rate: ¡
¡Con-nuous ¡subcutaneous ¡infusion ¡of ¡ insulin ¡(rapid ¡ac-ng) ¡ ¡Timing ¡starts ¡at ¡Midnight ¡ ¡Mul-ple ¡rates ¡ ¡Temporary ¡Rates ¡ ¡Suspend ¡ ¡ ¡0000-‑0600 ¡ ¡ ¡0.85 ¡U/h ¡ ¡0600-‑1200 ¡ ¡ ¡0.5 ¡U/h ¡ ¡1200-‑2400 ¡ ¡ ¡ ¡0.7 ¡U/h ¡ ¡ ¡ ¡ ¡
Bolus ¡SeKng: ¡
¡Insulin:Carbohydrate ¡Ra-o ¡ ¡Set ¡by ¡-me ¡of ¡day ¡ ¡ ¡1:10 ¡ ¡ ¡ ¡ ¡(1 ¡unit ¡for ¡10 ¡g ¡CHO) ¡ ¡ Sensi-vity ¡SeKng: ¡ ¡For ¡high ¡glucose ¡correc-on ¡ ¡Set ¡by ¡-me ¡of ¡day ¡ ¡ ¡1:60 ¡ ¡ ¡( ¡unit ¡for ¡every ¡60 ¡mg/dl ¡over ¡target) ¡ ¡ ¡ ¡ ¡
Insulin ¡on ¡Board: ¡
¡Sets ¡decay ¡curve ¡for ¡insulin ¡ ¡generally ¡set ¡at ¡4 ¡hours ¡ ¡ ¡ ¡ ¡ ¡
Target: ¡
¡Used ¡for ¡correc-on ¡dosing ¡ ¡generally ¡80-‑120 ¡ ¡ ¡ Type ¡of ¡Boluses: ¡ ¡simple ¡bolus ¡ ¡square ¡wave ¡ ¡double ¡bolus ¡ ¡ ¡ ¡ ¡
n
A piece of equipment (with several variations) that is used to manage a medication that is at the top of the list for inpatient danger – equipment that hospital engineers, nurses, physicians and pharmacists may not have any idea how to use.
n
An unknown liquid being infused into the patient
n
No one may know if patient is capable at baseline to manage any of above
n
Patient may temporarily be incompetent to use pump
n
Patient can give the medication at any time, not having any idea about other medications (glucocorticoids), tests, and medical staff may not know what the patient has done.
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n Most often Type 1 n Independent n Tied to their pump n May know more about their
management than anyone in hospital
n In ER n Preop n Postop n Any time
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Diabetes Care 31:238–239, 2008
Quantifying the Impact of a Short-Interval Interruption of Insulin-Pump Infusion Sets
n Tech guy: type 1, in ICU for week
long lidocaine infusion
n After 4 days, MS changes
n Spinal Surgery: Not able to move
to manage pump
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n Hypoglycemia: Glucoses in 150
range and all good. Then repeated lows.
n CV surgery: Unknown to everyone,
patient on pump and on IV insulin
n Every pump patient seen prehospital in DM
pump clinic
n Hire full time “ diabetes pump tech” who
would be available 24/7
n An order: let patient manage pump n Move patient to SQ insulin n No pumps in hospital
n ? Short NPO outpatient procedures
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n Policies and Procedures n Waivers n Order sets n Nursing Education n Physician Education n All specific for Adults/OB/Pediatrics
Cases: DCP and DCNP
Patient DCP is a 57 year old female. s/p total
Glucose control great at time of DC to home. Few days after DC to home, you get a call, patient in ER with mild DKA. They gave fluid and insulin and sent patient home. Next day, patient again in ER with same finding.
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Cases: DCP and DCNP
Patient DCNP is a 64 year old female. s/p start of insulin at recent hospital stay. On glargine/aspart (basal/ bolus) in hospital. Well trained by expert nurse
Few days after DC to home, you get a call. You are told patient has consistently had glucoses in the 2-300 mg/dl range.
Cases: DCP and DCNP
What do you do?.
1.
Increase the glargine and/or aspart
2.
Review the patient’s diet
3.
Ask “are there any problems giving the insulin?”
4.
Nothing, it is the problem for the outpatient providers to figure out.
5.
None of the above
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Rushakoff RJ, Sullivan MM, Shah A, Macmaster HW. What you “see” may not be what you get. Chapter in ADA Difficult cases. In press June 2015
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n Physicians
nRobert Rushakoff
nUmesh Masharani
nMelissa Weinberg
nSarah Kim
nAaron Neinstein
nBonnie Kimmel
nSaleh Adi
nStephen Gitelman
nJan Hirsch
nKathryn Rouine-Rapp
nDavid Robinowitz
nMichael Hwa
nHeather Nye
nSteve Pantilat n Pharmacists
nHeidemarie Windham
nLisa Kroon
nKethen So
nThomas Bookwalter
nAnna Seto
nYali Brennan n Administration
nRosanne Rappazini
nJennifer Pacholuk
nJoy Pao
nJanice Hull n Nurses
nMary Sullivan
nPauline Chin
nMarlene Bedrich
nCraig Johnson
nMolly Killion
nJeanne Buchanan
nNoraliza Salazar
nLynn Dow
nByanqa Robinson n Dietary
nMarian Devereaux
nAmi Bhow
PEOPLE CHANGING INPATIENT DM MANAGEMENT AT UCSF