Building and Implementing Effective Subcutaneous Insulin Orders and Protocols - PowerPoint PPT Presentation

Loading...

PPT – Building and Implementing Effective Subcutaneous Insulin Orders and Protocols PowerPoint presentation | free to download - id: 3d411f-NzA1N



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Building and Implementing Effective Subcutaneous Insulin Orders and Protocols

Description:

Building and Implementing Effective Subcutaneous Insulin Orders and Protocols Greg Maynard MD, MS Professor of Clinical Medicine and Chief, Division of Hospital Medicine – PowerPoint PPT presentation

Number of Views:38
Avg rating:3.0/5.0
Slides: 30
Provided by: swmedical
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Building and Implementing Effective Subcutaneous Insulin Orders and Protocols


1
Building and Implementing Effective Subcutaneous
Insulin Orders and Protocols
  • Greg Maynard MD, MS
  • Professor of Clinical Medicine and Chief,
    Division of Hospital Medicine
  • University of California, San Diego

2
Insulin Terminology
  • Basal insulin
  • Long-acting, all Type 1 and most Type 2 DM
    patients should have basal insulin whether they
    are eating or not (insulin glargine, insulin
    detemir, or NPH)
  • Nutritional or pre-meal / prandial insulin
  • Short-acting insulin given with meals in
    anticipation of carbohydrate load glycemic spike
    (scheduled insulin aspart, insulin lispro,
    insulin glulisine, regular insulin)
  • Correction or supplemental insulin
  • Short-acting insulin given to cover high glucose
    if substantial use, it should drive adjustment of
    basal and nutritional insulins

3
Insulin Terminology
  • Sliding scale insulin
  • This is a dirty word we dont use dirty words at
    UCSD
  • Mindless medicine, paralysis of thought,
    action without benefit, insulin insanity
  • Evidence does not support this technique without
    basal insulin unacceptably high rates of
  • Hyperglycemia
  • Hypoglycemia and insulin stacking
  • Iatrogenic DKA in patients with type 1 DM

Umpierrez G et al. J Hosp Med. 2006 1141-4.
4
Steps for Successful Implementation
  • Identify best practices and preferred regimens
  • Integrate into a protocol, summarize in one page.
  • Place protocol guidance into flow of work
  • Structured order sets, documentation tools,
    prompts
  • Use high reliability design, layer on other
    improvement methods (including special teams)
  • Proactively identify and mitigate outliers.
    Refine and redesign your educational efforts,
    order set design, and implementation strategies
    accordingly.

5
Integrate Best Practice into protocols, order
sets, documentation
  • Actionable glycemic target
  • Constant carbohydrate / dietary / consult
  • A1c
  • Specify hyperglycemic diagnosis
  • Education plan
  • Hypoglycemia protocol
  • Guidance for transitions (linked protocols)

6
Integrate Best Practice into protocols, order
sets, documentation
  • Coordinated insulin / nutrition / monitoring.
  • Insulin preferred - DC oral agents
  • Basal / Nutrition / Correction terminology
  • Dosing adjustment guidance
  • Specific regimens for different situations
  • NPO
  • Eating
  • Tube feeds
  • Steroids, etc

7
Problems with Oral Agents in the Hospital
  • Sulfonylureas (e.g., glyburide, glipizide, etc.)
  • Hypoglycemia (long acting)
  • ? CAD
  • Metformin
  • Lactic acidosis risk
  • Renal insufficiency, hypotension, heart failure)
  • Gastrointestinal
  • Nausea, abdominal pain, diarrhea
  • Thiazolidinediones (TZDs or glitazones) (e.g.,
    rosiglitazone)
  • Possible liver toxicity
  • Fluid overload, heart failure
  • Inability to titrate (very slow onset of action)

8
Physiologic Insulin SecretionBasal-Bolus
Concept
Nutritional (prandial) insulin
50
Insulin (µU/mL)
Suppresses glucose production
between meals and overnight
25
0
Basal insulin
Breakfast Lunch Supper
150
Nutritional glucose
The 50/50 rule (or maybe 40/60)
100
Glucose (mg/dL)
50
Basal glucose
0
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
A.M.
P.M.
Time of Day
9
Which Patients Need Basal Insulin in the Hospital?
  • Insulin-deficient patients should always have
    basal insulin (even NPO)
  • Type 1 DM or DKA, pancreatic insufficiency
  • A history of type 2 DM for 10 years or more
  • On any insulin for 5 years or more
  • Wide fluctuations of glucose values
  • Preprandial glucose gt ?130, 150 mg/dL
  • Any glucose gt 180 mg/dL

10
Constructing a Profile for Scheduled Subcutaneous
Insulin .
Glulisine Lispro Aspart
Regular
NPH
Glargine Detemir
6 am 12 pm 6 pm 12 am
11
SHM Glycemic Control Task ForcePreferred Insulin
Regimens
  • See handout
  • In interest of standardization, narrow down
    choices.
  • Eliminating other acceptable choices, but also
    many unacceptable ones!
  • Allow variation, while encouraging standardization

12
Common Features Increasing Risk of Hypoglycemia
in an Inpatient Setting
  • Malnutrition and low body weight
  • Chronic renal failure
  • Decreased oral intake, failure to provide
    nutrition or dextrose infusion
  • Advanced age
  • Liver disease
  • Beta-blockers
  • Iatrogenic Risk Factors SSI, distractions, poor
    regimens disconnect between testing,
    administration of insulin, and nutrition

13
(No Transcript)
14
(No Transcript)
15
Calculating Insulin Dosage (Total Daily Dose)
  • Calculate from insulin infusion amount
  • Recent steady state hourly rate x 20, for example
  • Add up insulins taken at home, adjust for
    glycemic control and other factors
  • Calculate from weight, body habitus, other factors

16
Starting Basal-Bolus from Scratch
  • Calculate starting total daily dose (TDD)
  • 0.3 units/kg/day (hypoglycemia risk factors,
    naïve patient)
  • 0.4 units/kg/day (conservative for most
    patients)
  • 0.5 0.6 units/kg/day (overweight to obese)
  • Adjust TDD up or down based on
  • Past response to insulin
  • Presence of hyperglycemia inducing agents, stress
  • This Is very conservative and safe (adjust up as
    needed)
  • Basal insulin 40-50 of TDD
  • Glargine q HS or q AM, detemir in 1 or 2 doses
  • Goal FBS and pre-meal glucose 80-110 mg/dL

17
Case 1 Initiating Subcutaneous Insulin in an
obese patient eating regular meals
  • 56 year old man admitted with diabetic foot
    infection, eating regular meals.
  • Obese, weighs 100 kg
  • Home regimen
  • 2 OHGs and 20 units of NPH q HS
  • Baseline Control
  • HbA1c of 10, POC glucose in ED 240 mg/dL
  • What are your initial orders for insulin?
  • What change would you make if he had to go to the
    OR the next morning?

18
Eating Patient (or Bolus TF)
19
Case 1 Solutions for Obese, eating patient
  • Accuchecks AC and HS
  • TDD 100 kg x 0.6 units/kg/day 60 units
  • Glargine (Lantus) Alternative
  • Basal Glargine 30 units q HS
  • Nutritional Lispro 10 units q ac
  • Correction Lispro per scale q ac and HS
  • For NPO p MN and OR the next AM
  • Hold nutritional dose, continue adjustment dose
  • Give the full dose of Glargine q HS No change.

20
Adjust, Adjust, Adjust
  • If glucoses going lt 70 mg / dL, use 80 of TDD as
    next days TDD
  • If glucose readings gt 150 and no hypoglycemic
    values, use 120 of yesterdays total as new TDD
    (or 130, depending on the uniformity and degree
    of poor control)

21
Case 2 Patient in IMU on Continuous TF
  • 65 year old you are seeing for the first time in
    the IMU, no outpatient history available except
    on insulin. Glucose gt 200 in ED, HbA1C pending.
  • 80 kg overweight woman started on continuous TF
    yesterday (HD3), with serum glucose in 200-250
    mg/dL range
  • What would you order?

22
TPN or Continuous Tube Feedings
23
Continuous Tube Feeding Insulin Regimen
24
Case 2 Solutions in a patient on continuous TF
or TPN
  • Accuchecks q 6 hours
  • TDD is 0.5 units/kg/day x 80 kg 40 units
  • Basal Glargine 16 units q hs (or q am)
  • Nutritional 6 units regular insulin q 6 h
  • Correction regular insulin q 6 h per scale
  • Patients being started on TPN do better with
    separate insulin infusions initially (with y
    connector) to find dose.
  • Conversion then can be made to insulin in TPN
    (80 of TDD), or subcutaneous regimen.

25
Case 3 Transition from IV to subcutaneous
insulin
  • 60 yo man with DM 2, well controlled in ICU on
    insulin infusion and continuous TF at 40 ml/hour.
  • Insulin Infusion rate 80 units in the last 24
    hours, 3 units / hour over last 6 hours.
  • Prior to hospitalization, baseline HbA1c was 8.7
    on 40 units of 70/30 insulin per day and OHGs.
  • Plan Transfer to ward, continue enteral
    nutrition
  • How do you transition this patient to a
    subcutaneous insulin regimen?

26
Stepwise approach to moving from IV to SC insulin
  • Calculate how much IV insulin the patient has
    been requiring. Modify down for safety cushion.
  • Was this insulin supplying Basal requirements, or
    Basal and Nutritional requirements? Translate
    into the subcutaneous regimen.
  • Consider any nutritional changes that may be
    implemented at the time of the transition off of
    the drip
  • Make sure SC insulin is given before
    discontinuation of the IV insulin

27
Case Transition to subcutaneous insulin(enteral
nutrition to continue)
  • Safe Estimate of 24 hour requirement
  • 3 units / hour x 20 60 units
  • 60 units represents the TDD Basal and
    nutritional insulin
  • 5050 Rule Example
  • Glargine 30 units Basal
  • Regular 7 units q 6 h Nutritional
  • Correction dose of regular insulin also given
    along with nutritional dose as needed.
  • Glargine / Nutritional should be given BEFORE IV
    insulin stopped

28
What if??? Enteral to PO
  • Instead of continuing enteral nutrition on the
    floor, you opt to stop enteral nutrition and
    start patient on a mechanical soft diet?
  • Glargine 30 units Basal
  • RAA 10 units q AC Nutritional / Prandial
  • (IF you expect them to eat a full meal! )
  • If po intake suspect at first, use CHO counting,
    or empirically reduce nutritional RAA dose and
    give the dose just AFTER the meal instead of just
    BEFORE the meal.
  • CORRECTION dose RAA insulin also needed.

29
Have a Discharge PlanTailored to Patient!
  • Diabetes and insulin education, survival skills
    START EARLY and repeat
  • Follow up and community resources
  • Covered by insurance
  • Patient and family can understand
  • Reconcile medications
  • Language, health literacy, and cultural barriers
  • Use HbA1c
  • Insulin requirement may decrease post discharge
About PowerShow.com