management of hyperglycemia and diabetes in the hospital: case studies bruce w. bode, md, face...
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Managementof Hyperglycemia and
Diabetes in the Hospital: Case Studies
Bruce W. Bode, MD, FACEAtlanta 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
Adapted from Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–982.
1.73
16
0
2
4
6
8
10
12
14
16
18
In-hospital Mortality Rate (%)
Newly Discovered
Hyperglycemia
Patients With History of Diabetes
Patients With
Normoglycemia
P < 0.01
P < 0.01
Prevalence of Hyperglycemia in 181 Cardiac Patients Without Known Diabetes
Norhammar A. Lancet. 2002;359:2140-2144.
0%
25%
50%
75%
100%
At Discharge
0%
25%
50%
75%
100%
At Discharge
Per
cent
age
of P
opul
atio
n (n
= 1
181)
Per
cent
age
of P
opul
atio
n (n
= 1
181)
66% of AMI patients have IGT or previously undiagnosed T2DM on 75 g OGTT(35% IGT; 31% DM)
66% of AMI patients have IGT or previously undiagnosed T2DM on 75 g OGTT(35% IGT; 31% DM)
Hospital Costs Account for Majority of Total Costs of Diabetes
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
Inpatient Nursing Home Physician'sOffice
OutpatientPrescription
Insulin andSupplies
Dollars
Hogan P, et al. Diabetes Care. 2003;26:917–932.
Per Capita Healthcare Expenditures (2002)
Diabetes Without diabetes
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
All Subjects
(N=620)Risk reduction (28%) P=0.011
Standard treatment
0
.3
.2
.4
.7
.1
.5
.6
0 1
Years of Follow-up
2 3 4 5
Low-risk and Not Previously on Insulin
(N=272)Risk reduction (51%) P=0.0004
IV insulin 48 hours, then 4 injections daily
0
.3
.2
.4
.7
.1
.5
.6
0 1
Years of Follow-up
2 3 4 5
Malmberg K, et al. BMJ. 1997;314:1512-1515.
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
MRCMRC 21.4 23.6 -5.1 41.519681968
PentecostPentecost 15.0 16.0 -0.5 6.519681968
HjermannHjermann 10.6 20.0 -4.8 6.8 P = 0.0719711971
RogersRogers 6.5 12.3 -1.9 2.419831983
HengHeng 8.3 0.0 0.6 0.219771977
SatlerSatler 0.0 0.0 0.0 0.019871987
Overview of GIK Therapy for Acute MI:
A 30 year Perspective
GIKGIK ControlControl O-EO-E VarianceVarianceMortality Rate (%)Mortality Rate (%)StudyStudy
GIK BetterGIK Better Placebo BetterPlacebo BetterOdds Ratio and ClsOdds Ratio and Cls
All Patients 16.1 21.0 -24.0 70.4 P = 0.004
GIK = glucose–insulin–potassium; MI = myocardial infarction; CI = confidence interval.
Fath-Ordoubadi F, Beatt KJ. Circulation. 1997;96:1152–1156. Reprinted with permission (http://lww.com)
1
YearYear
StanleyStanley 7.3 16.4 -2.5 2.819781978
MittraMittra 11.8 28.3 -7.0 6.8 P = 0.00719651965
PilcherPilcher 13.9 29.3 -2.6 3.419671967
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
JAMA 293:437, 2005
0
2
4
6
8
10
12
14
16
Lowest Middle Highest
Glucose Tertile
% mortality
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
0
2
4
6
8
10
12
14
16
<150 150-175 175-200 200-225 225-50 >250
Average postoperative glucose (mg/dL)
Mo
rtal
ity
Cardiac-related mortality
Noncardiac-related mortality
Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;123:1007-1021.
Mortality of DM Patients Undergoing CABG
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
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0 50 100 150 200 250
Days after inclusion
Cu
mu
lati
ve %
mo
rtal
ity
(in
ho
spit
al d
eath
)
Surgical ICU MortalityEffect of Average BG
Van den Berghe G, et al. Crit Care Med. 2003;31:359-366.
P=0.0009
P=0.026
BG<110
110<BG<150
BG>150
Intensive Insulin Therapy in Critically Ill Patients—Morbidity and Mortality Benefits
van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
-60
-50
-40
-30
-20
-10
0
Percent Reduction
Mortality Sepsis Dialysis PolyneuropathyBlood
Transfusion
34%
46%41%
44%
50%
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
A System for the Maintenance of Overnight Euglycemia and the Calculation of Basal Insulin Requirements in Insulin-Dependent Diabetics
1/slope = Multiplier = 0.02
0
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0 100 200 300 400
Glucose (mg/dL)
Ins
uli
n R
ate
(U
/hr)
White NH, et al. Ann Intern Med. 1982;97:210-214.
Practical Closed Loop Insulin Delivery
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
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Hours
Glu
cose
m
g/dl
mea
n-sd
Glucommander
Average and Standard Deviation of of All Runs1985 to 1998; 5808 runs, 120,618 BG’s
Davidson et al, Diabetes Care 28(10): 2418-2423, 2005
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Glucose
Multiplier
MultiplierInsulin
Insulin
Glucose
Typical Glucommander Run
Hi
Low
Davidson et al, Diabetes Care 28(10): 2418-2423, 2005
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?
4:00
25
50
75
8:00 12:00 16:00 20:00 24:00 4:00
Breakfast Lunch Dinner
Pla
sma
insu
lin
(μ
U/m
L)
8:00
Physiologic Serum Insulin Secretion Profile
Time
4:00
25
50
75
8:00 12:00 16:00 20:00 24:00 4:00
Breakfast Lunch Dinner
8:00
Glargineor
Detemir
Time
Aspart,Lispro
orGlulisine
Aspart,Lispro,
orGlulisine
Aspart,Lispro,
OrGlulisine
Basal/Bolus Treatment Program With Rapid-acting and Long-acting Analogs
Pla
sma
insu
lin
(μ
U/m
L)
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
Units IV
Hawkins JB Jr, et al. Endocr Pract. 1995;1:385-389.
Total Intravenous vs Subcutaneous 24-HourInsulin Requirements (units)
Su
bc
uta
ne
ou
s (
un
its
)
Intravenous
(Column Calculated) INSULIN IV INFUSION STANDING ORDERS FOR TARGET BG 80-110mg/dl
1) Starting Orders a) Discontinue all previous diabetes medication orders.
b) Obtain Basic Metabolic profile now, in 6 hours, then daily. c) IV fluid: ( )Normal Saline ( )D5/½ Normal Saline ( )D5/½ Normal Saline/20meq K+ ( )Other______________________________________________________________ If patient is “NPO” and not receiving TPN or continuous enteral feedings and BG is less than 250, then the IV fluid selected and the rate of infusion should reflect a glucose source of not less than 5gm per hour. d) Rate of fluid infusion __________ml/hr (KVO rate at a minimum) e) ________meq KCl (If K+ level is less than 4, order the above listed IV fluid with 20meq K+) f) Diet: ( )NPO ( )Continuous enteral feeding ( )TPN mixed without insulin ( )Other__________________________________________________________________ (Do not feed calorie-containing foods unless additional mealtime insulin is ordered). 2) IV Insulin Administration a) Mix 250 units of Human R insulin in 250ml Normal Saline (1 unit/ml) b) Flush approximately 30ml through line prior to administration c) Do not use filter or filtered set with insulin d) Piggyback insulin drip into IV fluid using an IV infusion pump with capability of 0.1ml/hr 3) Initiate IV insulin flow sheet
4) Blood glucose testing a) Check BG now and every hour by finger stick using hospital certified BG meter b) Do not alternate sites without physician approval
c) After hourly BGs remain in the desired range for 4 consecutive hours, may begin BG testing every 2 hours. 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?
4:00
25
50
75
8:00 12:00 16:00 20:00 24:00 4:00
Breakfast Lunch Dinner
8:00
Glargineor
Detemir
Time
Aspart,Lispro
orGlulisine
Aspart,Lispro,
orGlulisine
Aspart,Lispro,
OrGlulisine
Basal/Bolus Treatment Program With Rapid-acting and Long-acting Analogs
Pla
sma
insu
lin
(μ
U/m
L)
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
• Example:— Current BG: 250 mg/dL
— Ideal BG: 100 mg/dL
— Glucose correction factor: 30 mg/dL
Current BG - Ideal BGGlucose correction factor
250 – 10030 = 5.0 units
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 Additional Insulin 141-175 1 unit 176-225 2 units 226-275 3 units 276-325 4 units 326-375 5 units If greater than 375 Contact M.D. [ ] Moderate Dose Algorithm (for average size adult) [BG – 100/ 40] BG ac, hs, 0300h Additional Insulin 141-160 1 unit 161-200 2 units 201-240 3 units 241-280 4 units 281-320 5 units If great than 320 Contact M.D. [ ] Moderate High Dose Algorithm (for obese or infected patients or those on steroids) [BG-100/30] BG ac, hs, 0300h Additional Insulin 141-145 1 unit 146-175 2 units 176-205 3 units 206-235 4 units 236-265 5 units 296-325 7 units If greater than 326 Contact M.D. [ ] High Dose Algorithm (for very insulin resistant patients or septic patients) [BG-100/20] BG ac, hs, 0300h Additional Insulin 141- 150 2 units 151-170 3 units 171-190 4 units 191-210 5 units 211-230 6 units 231-250 7 units 251-270 8 units 271-290 9 units If greater than 291 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 rapid-
acting 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
This Sample Clinical Guideline is a compilation of recommended best practices created by a multidisciplinary medical team whose goal is to improve the care of individuals with diabetes. This Guideline is designed to assist hospitals and providers in educating themselves and their patients on medical care to individuals with diabetes and is not 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. Place patient on DKA Pathway until DKA resolved (CO2 >18 or Venous pH >7.3 or Anion Gap <14) 2. Diet: NPO 3. Consult Nutritional Services for diet, so when DKA resolves patient specific subcutaneous insulin can begin 4. Strict I &O 5. Vital signs every 2 hr x 4 or until DKA resolved then every 4 hr 6. Continuous cardiac monitoring 7. 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: _________________________________________________________
8. Follow up Lab/Diagnostics until DKA resolved: _______ Basic Metabolic Profile every ___ hour _______ Phosphorus _______ Venous pH every ___ hour _______ Anion gap every ___ hour
9. 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.
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)
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___________________________________________
Serum Sodium (Na+) level IV Fluid mEq K+ to add Rate of Infusion Low Serum Na+ 0.9% NaCl See Chart Below 7-14 ml/kg/hr based on hydration status Normal Serum Na+ 0.45% NaCl See Chart Below 7-14 ml/kg/hr based on hydration status High Serum Na+ 0.45% NaCl See Chart Below 7-14 ml/kg/hr based on hydration status
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 40 mEq K+ in each liter of IV fluid to keep level 4.0-5.0 mEq/L
Less than 3.2 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
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
• 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
What can we do for patients admitted to the hospital?
Hospital Diabetes Plan (cont’d)
• 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
What can we do for patients admitted to the hospital?
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
Diabetic Ketoacidosis Hyperglycemic Crisis Follow DKA Protocol
No Previous Diagnosis DM And BG > 140
Previously diagnosed DM
Modification of therapy And referral for dietary And educational consult
Begin BG testing
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
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.
Pregnancy
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.* Pre-prandial BG goal of 60-90 and post-prandial BG goal of <120 has been shown to enhance outcomes of this populace.
Peri-Operative
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.
ICU
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.
Pediatrics
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.
DKA Since DKA is a serious condition which requires intensive management, consultation with the patient’s primary diabetes physician should be considered.*
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
Hospital Diabetes Plan (cont’d)
• 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
Protocol for insulin in hospitalized patient
Hospital Diabetes Plan (cont’d)
• 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
Protocol for insulin in hospitalized patient
Hospital Diabetes Plan (cont’d)
• 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
What can we do for patients admitted to the hospital?
Questions
• For a copy or viewing of these slides, contact or hospital protocols, go to:
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