dm inpatient management surgery 1 - denver, colorado · d ea th s rok 4% 1% ... 291 diabetic...
Post on 21-Apr-2018
215 Views
Preview:
TRANSCRIPT
Diabetes MellitusInpatient Management
Surgical Patients2008
Michael T McDermott MDDirector, Endocrinology Practice and Diabetes Program
University of Colorado Hospital
UCH Diabetes Program
Carolee Whitehill RNCarolee Whitehill RNProgram AdministratorProgram Administrator
Bridget Everhart RNPBridget Everhart RNPProgram Nurse ManagerProgram Nurse Manager
Maureen Zaccardi RNMaureen Zaccardi RNDirector of Ambulatory ServicesDirector of Ambulatory Services
Michael McDermott MDMichael McDermott MDProgram DirectorProgram Director
Topics for Discussion Association of Diabetes Mellitus or
Hyperglycemia with Surgical Outcomes
Evidence that Control of Hyperglycemia
Improves Surgical Outcomes
Implementation of Inpatient Glucose Control
at University of Colorado Hospital
Definitions
Diabetes MellitusDiabetes Mellitus
Fasting BG > 125 mg/dlFasting BG > 125 mg/dl
2 hour PPBG > 200 mg/dl2 hour PPBG > 200 mg/dl
Stress HyperglycemiaStress Hyperglycemia
No prior dx of diabetesNo prior dx of diabetes
Hyperglycemia during stressHyperglycemia during stress
GlucoseUtilization
Stress HyperglycemiaPathophysiology
GlucoseProduction
GlucoseUtilization
Insulin
Hyperglycemia
Cortisol Catecholamines Glucagon
Growth Hormone
Association ofDiabetes Mellitus or Hyperglycemia
With Surgical Outcomes
0
5
10
15
20
25
A1C < 7% A1C > 7%
Pre-operative Glucose ControlPost-operative Infection Rate
Dronge AS, Arch Surg 2006; 141:375
RR = 2.13, p < .007
67%
490 patients with DM undergoing major non-cardiac surgery:
Infe
ctio
n R
ate
Ammori J, J Surg Res 2007; 140:227
Retrospective Review: 184 patients undergoing liver transplantationGood intra-operative BG control: mean BG < 150 mg/dl (N=60)Poor intra-operative BG control: mean BG > 150 mg/dl (N=124)
P = .02
605040302010
0
30 Day Infection Rate
Intra-Operative Glucose Control
30%
48%
P = .05
3025201510
50
1 Year Morality Rate
8.8%
21.9%
Intra-operative BG < 150Intra-operative BG > 150
Gandhi G, Ann Intern Med 2007; 146:233
RCT: 400 patients undergoing elective cardiac surgeryConventional (n=201): IV insulin if BG > 200; BG goal < 150 (mean 148)Intensive (n=199): IV insulin infusion to maintain BG of 80-100 (mean 120)Composite Endpoint: death, sternal infection, dysrhythmia, stroke,
prolonged ventilation, acute renal failure
P = NS
Conventional RxIntensive Insulin Rx
605040302010
0
Composite Endpoint
Intra-Operative Glucose Control
46% 44%
P = .06
6
4
2
0
2%
0%
Specific Endpoints
Death Stroke4%
1%
P = .02
0
10
20
30
40
50
60
70
BG < 200 BG > 200
Thomas MC, Transplantation 2001; 72:1321
Acu
te R
ejec
tion
Rat
e %
Post-Operative Glucose ControlAcute Rejection of Renal Transplant
50 patients with DM undergoing renal transplant: Prospective
11%
58%
Mean Blood Glucose in 1st 100 Hours Post-Transplant
5 Fold Increased
Risk
0
0.5
1
1.5
2
2.5
3
Lowest BG Quartile Highest BG Quartile
Post-Operative Glucose ControlCABG Complications StudyC
ompl
icat
ions
Adj
uste
d O
dds R
atio
McAlister FA, Diabetes Care 2003; 26:1518-24
291 Diabetic Patients with CAD undergoing CABGComplications measured: MI, Stroke, Sepsis, Death
2.5
2.5 Fold Increased
Risk
00.20.40.60.8
11.21.41.61.8
Non Diabetic Diabetic
Post-Operative Glucose ControlDeep Sternal Wound Infections
DSW
I Rat
e %
Zerr KJ, Ann Thorac Surg 1997; 63:356-61
0.4%
1.7%
4 Fold Increased
Risk
8,910 Patients having CABG surgery 1987-19931,585 (18%) had Diabetes Mellitus
0
5
10
15
20
25
30
Length of Stay (Days)0
10
20
30
40
50
60
Charges ($1000s)
DSWINo DSWI
Furnary AP, Circulation 1999; 100:11
Post-Operative Glucose ControlDeep Sternal Wound Study
24.8
8.8
54.60
28.20
0123456789
10
< 150 150-175 175-200 200-225 225-250 > 250
Post-Operative Glucose ControlCABG Survival Study
Furnary AP, J Thorac Cardiovasc Surg 2003; 125:1007
Mor
talit
y R
ate
%
Mean Blood Glucose Level
1.4% 1.7% 2.1%
3.8%
5.8%
8.6%
3554 patients undergoing CABG Surgery with elevated BG2612 treated with insulin infusion942 treated with SQ insulin
Gale S, Am Surg 2007; 73:454
Retrospective Review: 103 trauma patients admitted to SICU for > 48 hoursNon-DM: 87%; DM 13%Defined: Controlled BG < 140 mg/dl; Non-Controlled BG > 140 mg/dl
P = .05
Mortality - All
Post-Trauma Glucose Control
9%
22%
P = .05
3025201510
50
Mortality – Non DM
10%
32%
Controlled BG (< 140)Non-Controlled BG (> 140)
3025201510
50
HyperglycemiaRisk Factor for Complications/Mortality
UCH Study (Glasheen, 2006) – Poor BG Control in Elective Knee ReplacementSignificant: Joint Infections and Length of Stay
Renal transplant Cardiovascular surgery Orthopedic surgery Trauma Myocardial infarction Stroke Community acquired pneumonia Mortality in inpatients
Conclusions from these Studies
Hyperglycemia causes poor outcomes
Serious illnesses cause hyperglycemia
Hyperglycemia Causes Poor OutcomesPotential Mechanisms
Increased Infection Risk
Impaired Myocardial Metabolism
Generalized Inflammatory State
One BG > 220 mg/dl risk of nosocomial infection 5.8 fold
Two hours of hyperglycemia WBC function for 2 weeks
Hill, J Parenteral and Enteral Nutr 1998; 22:77-81
Hyperglycemia: Poor OutcomesInfection Risk
Glucose Utilization
ROS MVO2 Cytokines FFA
DysrythmiasNegative Inotropism
Myocardial DysfunctionEndothelial Dysfunction
Hyperglycemia: Poor OutcomesImpaired Myocardial Metabolism
HyperglycemiaGeneralized Inflammatory State
NF-
Glucose Insulin
iNOS
NO
ICAM-1VCAM-1E-selectin
EndothelialCell
AdhesionMolecules Inflammatory
Cytokines
TNF-IL-6 IL-8
MCP-1MMPs
Monocyte/Macrophage
CRP
LiverCell
Acute PhaseProteins
SAA
++
+ -
++
Evidence thatControl of Hyperglycemia
ImprovesSurgical Outcomes
Post-Operative Glucose ControlCABG Survival Study
Furnary AP, J Thorac Cardiovasc Surg 2003; 125:1007
3554 patients undergoing CABG Surgery with elevated BG2612 treated with IV insulin infusion942 treated with SQ insulin prior to IV protocol
MortalityRate%
InsulinInfusionN=2612
2.5%
6543210
SQ InsulinN=942
5.3% 50% Risk Reductionp < .0001
Schmetlz L, Diabetes Care 2007; 30:828
Retrospective Study: 614 consecutive patients undergoing CT surgeryIV Insulin started in ICU when BG > 108 mg/dlSQ Insulin started on wards when BG > 108 mg/dl
ICU admission BG > 198ICU admission BG < 198
P = .02
30
20
10
0
11%
21.4% 21.8%
32.1%
P = .02P = .04
2.3%
6.1%
Death RenalComplication
3.9%
10.7%
P = .02
PulmonaryComplication
CardiacComplication
Post-Operative Glucose Control
Van den Berghe G, NEJM 2001; 345:1359
RCT: 1548 Surgical ICU patients on mechanical ventilationConventional Group: IV insulin if BG > 215; mean BG 153 mg/dlIntensive Group: IV insulin if BG > 115; mean BG 103 mg/dl
In HospitalRisk
ReductionIntensive c/wConventional
0102030405060
Sepsis
46% 50%
DialysisBlood
TransfusionPoly-
neuropathy Mortality
41% 44%34%
Glucose Control Improves SICU OutcomesSICU Study
Brunkhorst F, N Engl J Med 2008; 358:125-39
RCT: 537 patients with severe sepsisIntensive Rx (N=247), mean BG 112; Conventional Rx (n=290), mean BG 151
Intensive Rx, mean BG 112Conventional Rx, mean BG 151
P < .001
40%
30%
20%
10%
04%
17%
5.2%10.9%
P = .01
P = .7426%24.7%
35.4%39.7%
P = .31
Severe Sepsis
Mortality28 Days
Mortality90 Days
Severe BG< 40 mg/dl
SAEs
AACE Position StatementRecommended Inpatient Glucose Targets
ICU: < 110 mg/dl
Non-ICU
Preprandial: < 110 mg/dl
Maximum: < 180 mg/dl
Labor and Delivery: < 100 mg/dlPosition Statement, Endocr Pract 2004; 10:77-82
Sliding ScaleRegularInsulin
Regular Insulin Sliding ScaleDelayed Onset
8 hr
InsulinInjection
4 hr 12 hr 16 hr
2-4 hrBG does not significantly
decrease for 2-4 hours
Regular Insulin Sliding ScaleDelayed Response and Stacking
8 hr
InsulinInjection
4 hr 12 hr 16 hr
InsulinInjection
InsulinInjection
Hypoglycemia
Queale W, Arch Intern Med 1997; 157:545-52Baldwin D, Diabetes Care 2005; 28:1008-11Golightly L, Pharmacotherapy 2006; 26:1421-32Umpierrez G, Diabetes Care 2007; 30:2181-6Datta S, Endocr Pract 2007; 13:225-31
Regular Insulin Sliding ScaleDelayed Response and Stacking
Inability to adequately control hyperglycemia
More frequent hypoglycemia
InsulinInjection
6 hr 12 hr 18 hr
InsulinInjection
InsulinInjection
InsulinInjection
0 hr
Rapid-Acting Correction Insulin for Inpatient HyperglycemiaFaster Acting – better control of hyperglycemiaNo Stacking – less hypoglycemia
InsulinInjection
6 hr 12 hr 18 hr
InsulinInjection
InsulinInjection
InsulinInjection
0 hr
Basal Insulin with Rapid-Acting Correction Insulin for Inpatient
HyperglycemiaSignificantly: Less Hyperglycemia
Less Hypoglycemia
Umpierrez G, Diabetes Care 30:2181-2186, 2007
BBI
SSI
Basal Bolus compared to Sliding Scale InsulinRCT: 130 Insulin naïve Type 2 DM patients, in hospital65 Basal Bolus Insulin (BBI) with Glargine and Glulisine65 Sliding Scale Insulin (SSI) QID
14% of patients, BG > 240 mg/dL
SSI
BBI
SSI
Umpierrez G, Diabetes Care 30:2181-2186, 2007
Basal Bolus compared to Sliding Scale InsulinRCT: 130 Insulin naïve Type 2 DM patients, in hospital65 Basal Bolus Insulin (BBI) with Glargine and Glulisine65 Sliding Scale Insulin (SSI) QID
SSI14% of patients, BG > 240 mg/dL
Implementation of Inpatient
Glucose Control
Inpatient Insulin TherapyPreprinted Order Sets - UCH
Available NowIntravenous Insulin Infusion
SQ Glargine and LisproSQ NPH and Lispro
SQ 70/30 Insulin for Tube FeedsDKA/HHS Treatment
Colorado Insulin Infusion Protocol
Initiation simple
Adjustments based on
Current BG level
Current Insulin infusion rate
Rate of BG change in past hour
Efficacy
Safety
UCH – 65 ICU Patients on IV Insulin Infusion
Subcutaneous Insulin Glargine & Lispro Order Set
Subcutaneous Insulin: Glargine & Lispro
66%
89% 82% 84% 86% 88%
0%20%40%60%80%
100%
Day 1Initial
Insulin
Day 1Prior
Insulin
Day 2 Day 3 Day 4 Day 5
Patient N = 28 on Day 1(total) N = 25 on Day 5
BG 71-179 mg/dL
Subcutaneous Insulin Glargine & Lispro Order Set
Rate of Hypoglycemia (591 BG Values)Rate of Hypoglycemia (591 BG Values)
≤ 70 mg/dL = 1.02%≤ 50 mg/dL = 0%
General Surgery
Blood Glucose Values - General Surgery (GSRG) July - Sept 2007
75% 90%
23% 9%
0%
20%
40%
60%
80%
100%
POC Only Lab
Mean BG 154 Mean BG 131
Total Hypoglycemia Rate = 1.1%
≥ 180 mg/dL
71-179 mg/dL
≤ 70 mg/dl
Surgical ICU
Blood Glucose Values - Surgical ICU (SIA & SIB) July - Sept 2007
85%
13%
0%
20%
40%
60%
80%
100%
Lab & Partial POC
Mean BG = 136
Hypoglycemia Rate = 1.5%
≥ 180 mg/dL
71-179 mg/dL
≤ 70 mg/dl
TransplantBlood Glucose Values - Transplant/Med (TXMS)
July-Sept 2007
70%84%
28% 14%
0%
20%
40%
60%
80%
100%
POC (Partial) LabMean BG 160 Mean BG 134
Total Hypoglycemia Rate = 1.9%
≥ 180 mg/dL71-179 mg/dL≤ 70 mg/dl
Orthopedics
Blood Glucose Values - Orthopedics (BONE) July - Sept 2007
66%86%
31%12%
0%
20%
40%
60%
80%
100%
POC Only Lab
Mean BG 164 Mean BG 137
Total Hypoglycemia Rate = 1.9%
≥ 180 mg/dL
71-179 mg/dL
≤ 70 mg/dl
Conclusions Hyperglycemia causes poor surgical outcomesHyperglycemia causes poor surgical outcomes
PrePre--Operative BG control improves outcomesOperative BG control improves outcomes
IntraIntra--Operative BG control not clearly beneficialOperative BG control not clearly beneficial
PostPost--Operative BG control improves outcomesOperative BG control improves outcomes
SS regular insulin does not control BG SS regular insulin does not control BG
Intravenous insulin orders available ICUsIntravenous insulin orders available ICUs
Subcutaneous insulin orders available on wardsSubcutaneous insulin orders available on wards
UCH insulin orders are safe and effective; UCH insulin orders are safe and effective; continuously monitored and upgradedcontinuously monitored and upgraded
Thank You
top related