Management of Diabetes and Hyperglycemia in the Hospital

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Management of Diabetes and Hyperglycemia in the
Hospital

• Stephen Clement M.D.
• Associate Professor
• Georgetown University Hospital

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Insulin Rx is important

• Hyperglycemia in hospital is common
• Majority treated with insulin
• Insulin is one of five high alert meds with
  greatest risk for causing medication error
  injuries.
• Current Rx practices varied commonly do not
  enable targeted glucose control

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Scope of Problem at GU Hospital

• Multiple cases of errors in insulin
  orders/administration causing
• DKA (lack of basal insulin)
• Severe hypoglycemia (insulin stacking, wrong
  dose)
• Emergence of glucose control as a target to
  improve hospital outcomes (reduced mortality and
  reduced length of stay)
• New AACE/ADA targets

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Post-op Order
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Hyperglycemia A Common Comorbidity in
Medical-Surgical Patients in a Community Hospital
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26
64
Normoglycemia
n 2,020 Hyperglycemia Fasting BG ? 126
mg/dl or Random BG ? 200 mg/dl X 2
Known Diabetes
New Hyperglycemia
Umpierrez G et al, J Clin Endocrinol Metabol
87978, 2002
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Obstacles to In-Hospital Glucose Control

• Infection
• Severe Stress Illness
• Procedures
• NPO Status
• Fear of Hypoglycemia
• Lack of Activity
• Meals

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Hyperglycemia in the Hospital

• Nuisance
• or Opportunity?

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Hyperglycemia An Independent Marker of
In-Hospital Mortality in Patients with
Undiagnosed Diabetes
16
Mortality ()
1.7
3
Normoglycemia Known New
Diabetes Hyperglycemia
P lt 0.01
Umpierrez G et al, J Clin Endocrinol Metabol
87978, 2002
9
Hyperglycemia An Independent Marker of
In-Hospital Mortality in Patients with
Undiagnosed Diabetes
Non ICU Mortality
Mortality ()
10.0
1.7
0.8
Normoglycemia Known New
Diabetes Hyperglycemia
P lt 0.01
Umpierrez G et al, J Clin Endocrinol Metabol
87978, 2002
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Hyperglycemia Effect on Length of Stay and
Disposition at Discharge
New Known Normoglycemia
Hyperglycemia Diabetes
Length of stay (d) 9 0.7a, b 5.5 0.2
4.5 0.1 ICU admission () 29a, b
14a 9 Disposition at discharge Home
() 56a, b 74a 84 TCU ()
20a 15a 10 Nursing home () 8c
9a 4
Results are SEM. TCU, Transitional Care
Unit a P lt 0.01 vs. normoglycemia b P lt 0.01
vs. Known diabetes c P lt 0.02 vs. normoglycemia
Umpierrez GE et al, J Clin Endocrinol Metabol
87978, 2002
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In-Hospital Glucose and Acute Renal Graft
Rejection

• Glycemic control was assessed
  during the first 100 postoperative
  hours
• Only 3 of 27 patients (11)
  with mean BG lt 200 mg/dL
  had rejection episodes
• 58 with mean BG gt 200 mg/dl had rejection
  episodes

Thomas. Early peri-operative glycaemic control
and allograft rejection in patients with diabetes
mellitus a pilot study. Transplantation
2001721321.
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Mean perioperative glucose patients with diabetes
undergoing their first cadaveric renal
transplantation
300 mg/dl
200 mg/dl
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Post-operative Infection and Blood glucose
Pomposelli. Early postoperative glucose control
predicts nosocomial infection rate in diabetic
patients. J Parenteral and Enteral Nutrition
1998 22 77.
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Portland Diabetic Project Insulin Infusion
Reduces DSWI
CII
SCI
4.0
Patients with diabetes
3.0
Patients without
DSWI()
diabetes
2.0
1.0
0.0
92
97
87
88
89
90
91
93
94
95
96
(N 3,554)
Year
DSWI deep sternal wound infection CII
continuous insulin infusion.
Furnary AP, et al. Ann Thorac Surg.
199967352362
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Mortality Post-CABG Patients
14.5
Mortality
Cardiac-related mortality
Noncardiac-related mortality
6.0
4.1
2.3
1.3
0.9
lt150
150175
175200
200225
225250
gt250
Average postoperative glucose (mg/dL)
Furnary AP, et al. J Thoracic Cardiovasc Surg.
20031251007-1021
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Risk Reduction by Meticulous Blood Glucose
Control in an ICU

103 Vs 153 mg
Van Den Berghe NEJM 345 1359, 2001
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Metabolic stress response
? Stress hormones and peptides
? Glucose ? Insulin
? Reactive O2 species
? FFA ? Ketones ? Lactate
Immune dysfunction
? Transcription factors
Infection dissemination
Secondary mediators (i.e., nFkB)
Cellular injury/apoptosis Inflammation Tissue
damage Altered tissue/wound repair Acidosis Thromb
osis Infarction/ischemia
Prolonged hospital stay Disability Death
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79 mg/dl
110 mg/dl
Shechter et al, 1999
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Platelet-Derived Thrombosis
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Diabetes Care 27553-90, 2004 http//care.diabetesj
ournals.org
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Society of Hospital Medicine
AADE
Endocrine Practice 2004
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Glycemic Targetsfor Hospitalized Patients

• Non-ICU
• Fasting BG lt 110 mg/dl
• Peak BG lt 180 mg/dl
• ICU
• lt 110 mg/dl

Endocrine Practice 2004
Diabetes Care 27553-91, 2004
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Basal Insulin Requirement

• Amount of exogenous insulin per unit time
  necessary to maintain blood sugars in between
  meals and when not eating.
• In absence of basal insulin, BGs increase 45
  (mgdL-1hr-1) after insulin withdrawal in
  insulin-deficient patients.

Clement et al. Diab Tech Therapeutics 4459-466,
2002
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Example of Poor Outcome from Lack of Basal
Insulin

• BG at midnight 248 mg/dl,
• HC03 27, AG 10
• BG at 8 AM 616 mg/dl
• HCO3 11, AG 24

46 mgdL-1hr-1
Patient Arrested and Died
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Glucose and Ketone Rise After Insulin Withdrawal
2
1
0
Husband et al. Diab Res 3193-98, 1986
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Characteristics ofInsulin Deficient Patient

• Known type 1 DM
• H/O pancreatectomy or pancreatic dysfunction
• H/O wide BG fluctuations
• H/O Ketoacidosis
• H/O insulin use gt 5 years

If Yes, then Always provide basal insulin
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Nutritional insulin requirement

• Amount of insulin necessary to cover intravenous
  dextrose, TPN, enteral tube feedings, nutritional
  supplements /or discrete meals

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Illness or Stress-Related Insulin

• The increase in daily insulin requirement
  attributed to illness, stress, or treatment
• Wide individual variation
• Apportioned between basal, nutritional
  correction doses
• Need decreases as clinical condition improves

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Insulin Requirements in Health Illness
Illness-Related
Relative proportion of insulin requirement ()
Estimations for illustrative purposes
requirements may vary widely.
Adapted from ADA Technical Review Management of
Diabetes Hyperglycemia in Hospitals. Diabetes
Care 2004. In press.
Healthy
Sick/Eating
Sick/ NPO
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Correction/supplemental Insulin

• Amount of insulin give for unexpected
  hyperglycemia
• a.k.a. sliding scale

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Sliding Scale InsulinConcerns

• Use as only insulin replacement in
  insulin-deficient patient
• Better terminology, i.e., corrective or
  supplemental insulin
• Lack of standardization

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SLIDING SCALE INSULIN

• 171 patients, secondary dx DM, medicine SSI
  without programmed insulin
• 22.8 hypoglycemia (lt60 mg/dl)
• 40.4 hyperglycemia (gt300 mg/dl)
• SSI alone with 3x risk hyperglycemia

Insulin
? BG
(Normal)
? BG
Dextrose
Queale Brancati. 1997. Arch. Int. Med. 157
545-552
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TerminologyPhysiologic Insulin needs
ILLNESS-RELATED
SUPPLEMENTAL
NUTRITIONAL
BASAL
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Case 1

• 22 y/o Female with Acute Leukemia admitted for
  neutropenic fever
• No prior h/o diabetes, but during prior chemo
  tx regimens, insulin was required.
• Diet medium consistent carb (75g/meal)
• New Chemo Rx includes Predisone, 200 mg q A.M.

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Example 22 y/o with Acute Lymphoblastic Leukemia
with Neutropenic Fever
Illness/Stress-Related Insulin
Prednisone
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Insulin Drip Rate
Prednisone Dose
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Special Circumstances

• Perioperative Management
• Enteral Nutrition
• Parenteral Nutrition
• Glucocorticoid Use

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Practical GuidelinesEating

• Programmed
  Supplemental
• basal nutritional
• int bid or hs rapid ac
  rapid ac
• or BD
  or B,L,D
• LA hs or am
• insulin drip
• Comments
• Give rapid insulin 0-15 min ac
• Glargine usually given as once daily dose at hs
• Avoid reg rapid at hs to minimize nocturnal
  hypoglycemia risk

Rx
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Practical GuidelinesPerioperative or
peri-procedural

• NPO e.g major surgery
• Programmed
  Supplemental/
• Basal Nutritional
  Correction
• insulin drip n/a or per TPN
  until resumes po
• reg q 4-6 hours enteral guidelines
  reg q 4-6 hours
• rap q 4 hours
  rap q 4 hours
• int, give 1/2 usual
• am dose
• LA usual daily dose
• Comments
• If prolonged post-op NPO, insulin drip Rx
  recommended
• Periop insulin drip starting dose is 0.2
  units/kg/hour

Rx
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Enteral Nutrition

• Short acting insulin until tolerating well
• Continuous enteral regimen
• Regular insulin q 4-6 hrs during feeding period
• /- Basal insulin
• Bolus enteral regimen
• Regular insulin SQ prior to each bolus
• /- Basal insulin

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Practical Guidelines Total Parenteral Nutrition

• Programmed
  Supplemental/
• basal nutritional
  correction
• reg or rap added
  reg or rap q 4-6 hours
• to TPN bag
• Comments
• Basal nutritional needs met with reg or rap
  insulin added to TPN bag
• Consider use of separate iv insulin infusion for
  24 hours to determine daily insulin requirement,
  than add this amount to subsequent bags daily
• Use subcutaneous insulin with caution, as may
  lead to erratic BG control

Rx
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Initiating Insulin tx Hospitalized Patient

• Basal insulin 0.4 units/kg/day
  (i.e., Glargine)
• Prandial /or nutritional 0.1 unit/kg/meal
  (i.e., Novolog or Humalog)
• Patients with insulin deficiency always require
  basal insulin to prevent ketosis

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Transition of IV to Subcutaneous InsulinSome Dos
Donts

• Do overlap SC and IV insulin to minimize
  hyperglycemia escape.
• Dont switch to oral agents alone from IV
  insulin.
• Arrange for follow up of patients placed on
  temporary insulin.
• Ensure adequate food intake when switching
  patients with to SC insulin.

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Bedside Glucose Monitoring

• Strong quality control program essential
• Some systems can give falsely elevated readings
• Specific situations render capillary tests
  inaccurate
• Shock, hypoxia, dehydration
• Extremes in hematocrit
• Elevated bilirubin, TGs
• Drugs

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Prevention/Tx of Hypoglycemia

• Proactive Approach
• Missed meal, tube feeding D/Cd
• Schedule procedures in the AM
• Establish a nurse-driven protocol for starting
  dextrose and test hourly glucose testing if
  hypoglycemia anticipated.

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EducationCore knowledge for physicians

• Impact of BG on hospital outcomes
• Hospital targets for BG
• Terminology basal/nutritional/correction
• Insulins
• Hypoglycemia prevention treatment
• Avoid SSI
• Special circumstances

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Education Core competency for Nurses

• Bedside glucose monitoring technique
• Critical and target BG values
• Insulin administration technique
• Optimum timing of SQ insulin shots
• Hypoglycemia prevention treatment
• BG insulin dose documentation
• When to call the MD

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Patient EducationContent areas

• What is diabetes?
• Symptoms signs of high and low BG
• Hypoglycemia Rx
• Medications (specifics of discharge regimen)
• Self-glucose monitoring (keep a log)
• When to call the doctor
• Education resources
• Adapted from American Association of Diabetes
  Educators
• Survival Skills Education Guidelines.

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GU Hospital Initiatives2004 - 2006

• In-service all M.D.s and nursing units on proper
  basal/bolus insulin therapy
• Laminated cards
• I.V. Drip changes and any SC insulin injection
  requires second nurse check dose and sign
• Implement IV insulin protocol outside of ICU

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GU Hospital Initiatives(cont) 2004 - 2006

• Piloted standard order form and MAR for s.q.
  insulin administration
• Eliminated Regular insulin except for enteral
  feeding and insulin drips
• Roll out of revised order form for entire
  hospital (July 05.)

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Components of the standardized subcutaneous
insulin protocol

• BG monitoring frequency
• Target BG range
• Programmed insulin orders
• Suggested lag times for prandial insulin
• Correction dose algorithm
• Call parameters for high low BG
• Hypoglycemia Rx guidelines or reference to hypo
  protocol

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Insulin-Glucose Flow Sheet
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GU Hospital ResultsInsulin Error Rate
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Future GU Hospital Initiatives

• Within 8 hours of admission DM patients will have
  lab glucose and Bedside BGs started
• Any patient with a lab value gt 200 mg/dl will be
  checked to see if bedside BG orders are written
  and A1C ordered

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Future Initiatives (cont.)

• Patients with two or more bedside or lab BG
  values gt 300 or lt 60 receives automatic consult
  by diabetes NP
• Outcomes
• Mean BG and range of BG levels for all patients
• Mortality, LOS

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TEAM APPROACH TO THE TREATMENT OF THE
HOSPITALIZED DIABETIC PATIENT
Physician
Nurse Educator
Dietitian
Endocrinologist
Pharmacist
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Glucose Control Matters

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Collaborators

• Penny Smith, CNP
• Susan Braithwaite, M.D.
• Michelle Magee, M.D.
• Andrew Ahmann, M.D.
• Rebecca Schaffer, R.D.
• Irl Hirsch, M.D.
• American Diabetes Assoc.
• AACE