diabetes management in the hospital: case studies bruce w. bode, md, face atlanta diabetes...

Diabetes Management in the Hospital:

Case Studies

Bruce W. Bode, MD, FACE

Atlanta Diabetes Associates

Atlanta, Georgia

Case 1: Patient with an Acute MI

53 yo male 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?


What is your glycemic goal?

1) 80 to 110 mg/dl

2) 80 to 140 mg/dl

3) 80 to 180 mg/dl

Do you give glucose and potassium with IV insulin? How much?

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

Iwakura K: JACC 2003; 41:1-7

Malmberg BMJ 1997;314:1512Malmberg BMJ 1997;314:1512

DIGAMI StudyDiabetes, Insulin Glucose Infusion in Acute Myocardial Infarction(1997)

Acute MI With BG > 200 mg/dl Intensive Insulin Treatment IV Insulin For > 24 Hours Four Insulin Injections/Day For > 3 Months Reduced Risk of Mortality By:

28% Over 3.4 Years

51% in Those Not Previous Diagnosed

Malmberg BMJ 1997;314:1512Malmberg BMJ 1997;314:1512

Cardiovascular RiskMortality After MI Reduced by Insulin Therapy in the DIGAMI Study

Malmberg, et al. BMJ. 1997;314:1512-1515.

All Subjects

(N = 620)Risk reduction (28%)

P = .011

Standard treatment

0

.3

.2

.4

.7

.1

.5

.6

0 1Years of Follow-up

2 3 4 5

Low-risk and Not Previously on Insulin

(N = 272)Risk reduction (51%)

P = .0004

IV Insulin 48 hours, then 4 injections daily

0

.3

.2

.4

.7

.1

.5

.6

0 1Years of Follow-up

2 3 4 5

6-11


For acute MI with elevated glucose, you can either give GIK in type 2’s who are easily controlled or IV variable rate insulin infusion in all persons with elevated glucose

If you order an IV insulin drip,

What dilution of IV insulin? 1U to 1cc or 0.5U to 1cc of drip mixture

How often do you check the glucose?

Continuous Variable Rate IV Insulin Drip

Mix Drip with 125 units Regular Insulin into

250 cc NS 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 (100 to 140 mg/dl)


Adjust Multiplier (initially 0.02) to obtain glucose in target range 100 to 140 mg/dL

If BG > 140 mg/dL, increase by 0.01

If BG < 100 mg/dL, decrease by 0.01

If BG 100 to 140 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 IVF’s

Once eating, continue drip till 2 hours post SQ insulin

A System for the Maintenance of Overnight Euglycemia and the Calculation of Basal Insulin Requirements in Insulin-Dependent Diabetics

Practical Closed Loop Insulin Delivery

1/slope = Multiplier = 0.02

0

1

2

3

4

5

6

0 100 200 300 400

Glucose (mg/dl)

Insulin Rate (U/hr)

NEIL H. WHITE, M.D., DONALD SKOR, M.D., JULIO V. SANTIAGO, M.D.; Saint Louis, Missouri

Ann Int Med 1982 ;97:210-214

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

Able to seek BG range via:

- Hourly BG monitoring

- Adjusts to the insulin sensitivity of the patient

Methods For Managing Hospitalized Persons with Diabetes


Major Surgery, NPO, Unstable, MI, DKA, Hyperglycemia, Steroids, Gastroparesis, Delivery, etc

Basal / Bolus Therapy (MDI) when eating

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

Do you give glucose and potassium with IV insulin? How much?

0

2

4

6

8

10

12

14

16

<150 150-175 175-200 200-225 225-50 >250

Average Post-operative glucose (mg/dl)

Mo

rtali

ty

Cardiac-related mortalityNoncardiac-related mortality

Mortality of DM Patients Undergoing CABG

Furnary et al J Thorac Cardiovasc Surg 2003;123:1007-21

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 et al J Thorac Cardiovasc Surg 2003;123:1007-21

0

5

10

15

20

25

30

35

40

45

0 50 100 150 200 250

Days after inclusion

Cum

ulat

ive

% M

orta

lity

(in h

ospi

tal d

eath

)

P=0.0009

P=0.026

BG<110

110<BG<150

BG>150

Surgical ICU MortalityEffect of Average BG

Van den Berghe et al (Crit Care Med 2003; 31:359-366)

Intensive Insulin Therapy in Critically Ill Patients—Morbidity and Mortality Benefits

Intensive therapy to achieve blood glucose 80 to 110 mg/dL reduced mortality (by 34%), sepsis (by 46%), dialysis (by 41%), blood transfusion (by 50%), and polyneuropathy (by 44%)

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%

Glycemic threshold in Surgical ICU

BG < 110 mg/dl

Van den Berghe et al Crit Care Med 2003; 31(2):359-66

Finney SJ et al JAMA 2003;290(15):2041-47

Other Medical Conditions

Infection data supports BG < 130 mg/dl

Hartford ICU study 125 mg/dl vs 179 mg/dl 10X decrease in infections

Stroke data supports BG < 140 mg/dl

Pregnancy data supports BG < 100 mg/dl

Stamford CT ICU Study (Retrospective): Description of Patient Subgroups (N = 1826)

Cardiac (medical): 28.6% (540)

Pulmonary: 15.8% (289)

Septic Shock: 5.0% (92)

Other Medical: 14.9% (272)

Neurological: 13.2% (241)

Surgical: 7.1% (313)

Trauma: 4.3% (79)

Krinsley JS: Mayo Clin Proc 2003; 78: 1471-1478

05

1015202530354045

80-99 100-119

120-139

140-159

160-179

180-199

200-249

250-299

>300

Average ICU glucose (mg/dl)

Mo

rtal

ity

%

Hyperglycemia and Hospital Mortality1826 consecutive ICU patients 10/99 thru 4/02, Stamford CT

Krinsley JS: Mayo Clin Proc 78: 1471-1478, 2003

Target blood glucose in mg/dL

80 – 110 in Surgical ICU patients

90 – 140 in other Surgical and Medical Patients

70 – 100 in Pregnancy

Threshold blood glucose in mg/dL for starting IV insulin infusion

Peri-operative care: > 140

Surgical ICU care: > 110 - 140 *

Non-surgical illness: > 140 - 180 * *

Pregnancy > 100

* Van den Berghe’s study supports 110; Finney’s study supports 145

* * If drip indication is failure of SQ therapy, use 180 ;

if indication is specific condition ( DM 1/ NPO, MI, etc ), use 140

Hospital Targets for GlucoseAACE and ADA Guidelines: Dec 2003

80–110 mg/dL ICU

110–180 mg/dL other units

Modify if:

cardiac disease (unstable)

hypoglycemic unawareness

recurrent hypoglycemia

New

Case 1: Patient with an Acute MI now post CABG and ready to eat

Currently on IV insulin at ~2 units IV per hour

What do you now do?

1. Sliding scale rapid acting insulin only?

2. Basal Bolus insulin therapy?

3. Premixed insulin therapy?

4:004:00

2525

5050

7575

8:008:00 12:0012:00 16:0016:00 20:00 20:00 24:0024:00 4:004:00

BreakfastBreakfast LunchLunch DinnerDinner

Pla

sma

insu

lin

(P

lasm

a in

suli

n (µ U

/ml)

U

/ml)

TimeTime

8:008:00

Physiological Serum Insulin Secretion Profile

4:00 16:00 20:00 24:00 4:00

Breakfast Lunch Dinner

8:0012:008:00

Time

Glargineor

Detemir

Lispro Lispro Lispro

Aspart Aspart Aspartor oror

Pla

sma

insu

lin

Basal/Bolus Treatment Program withRapid-acting and Long-acting Analogs

Converting to SC insulin

If More than 0.5 u/hr IV insulin required with If More than 0.5 u/hr IV insulin required with normal BG, start long-acting insulin (glargine)normal BG, start long-acting insulin (glargine)

Must start SC insulin at least 2 hours before Must start SC insulin at least 2 hours before stopping IV insulinstopping IV insulin

Some centers start long-acting insulin on initiation Some centers start long-acting insulin on initiation of IV insulin or the night before stopping the drip of IV insulin or the night before stopping the drip

Intravenous insulin infusion under basal conditions correlates well with subsequent subcutaneous insulin requirement.

Units SQ

Units IV

Overwrite

Hawkins et al Endocrine Practice: 1995; 1(6) 385-389

Converting to SC insulin

Establish 24 hr Insulin Requirement

– Extrapolate from average over last 6-8 hours if stable

Give One-Half Amount As Basal

Give p.c. Boluses Based on CHO Intake

– Start at CHO/Ins 1 CHO = 1.5 units Rapid-acting

Monitor a.c. tid, hs, and 3 am

Correction Blolus for All BG >140 mg/dl

– (BG-100)/(1700/Daily Insulin Requirement)

Insulin Requirements in Health and Illness

0

20

40

60

80

100

120

140

Correction

Nutritional

Prandial

Basal

Relative Proportion of

Insulin Requirement

(%)*

*Estimations for illustrative purposes: requirements may vary widely.

Clement S, et al. Diabetes Care. 2004;27:553–591.

Illness-Related

Healthy Sick/Eating

Sick/NPO

How to Initiate MDI Starting dose = 0.4 to 0.5 x weight in kilograms

Bolus dose (aspart/lispro) = 20% of starting dose at each meal

Basal dose (glargine) = 40% of starting dose given at bedtime or anytime

Correction bolus = (BG - 100)/ Correction Factor, where CF = 1700/total daily dose

How to Initiate MDI

Starting dose = 0.45 x wgt. in kg

Wt. is 100 kg; 0.45 x 100 = 45 units

Bolus dose (aspart / lispro) = 20% of starting dose at each meal; 0.2 x 45 = 9 units ac (tid)

Basal dose (glargine) = 40% of starting dose at HS; 0.4 x 45 = 18 units at HS

Correction bolus = (BG - 100)/ CF, where CF = 1700/total daily dose; CF = 40

Correction Bolus Formula

Example:

–Current BG: 250 mg/dl

– Ideal BG: 100 mg/dl

–Glucose Correction Factor: 40 mg/dl

Current BG - Ideal BGGlucose Correction factor

250 - 100 40

= ~4.0u

Case 2: 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 or70/30 every 8 hours?

4) glargine every 12 hours?

5) regular every 6 hours?

Case 2: 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)

If unstable, first give IV insulin and determine the requirement over 24 hours and then change to SC basal (glargine Q 12 hours) with supplemental rapid acting every 4 to 6 hours.

Can also use NPH Q 8 hours or regular Q 6 hours as the basal

Case 3: 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 4: 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 (>180 mg/dl)

4) Hold insulin and will start IV insulin

Case 4: DM 1 patient in DKA (ph 7.0; BG 400 mg/dl: weight 80 kg)

How much 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 4: 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/hour. Monitor electrolytes Q 4 to 8 hours.

Case 5: 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 PatientProtocol for Insulin in Hospitalized Patient

Treatment of HypoglycemiaTreatment of Hypoglycemia

Any BG <80 mg/dl: D50 = (100-BG) x 0.4 ml IVAny BG <80 mg/dl: D50 = (100-BG) x 0.4 ml IV

If eating, may use 15 gm of rapid CHO If eating, may use 15 gm of rapid CHO

(prefer glucose tablets)(prefer glucose tablets)

Do Not Hold Insulin When BG Normal Do Not Hold Insulin When BG Normal

Piedmont Diabetes PlanPiedmont Diabetes PlanWhat Can We Do For Patients Admitted To Hospital?What Can We Do For Patients Admitted To Hospital?

NPO Pathway For All Diabetes PatientsNPO Pathway For All Diabetes Patients

Finger Stick BG ac qid on ALL AdmissionsFinger Stick BG ac qid on ALL Admissions

Check All Steroid Treated PatientsCheck All Steroid Treated Patients

Diagnose DiabetesDiagnose Diabetes

FBG >126 mg/dlFBG >126 mg/dl

Any BG >200 mg/dlAny BG >200 mg/dl


Document Diagnosis in ChartDocument Diagnosis in Chart

Hyperglycemia Is Diabetes Until Proven Hyperglycemia Is Diabetes Until Proven

Bring to All Physician’s AttentionBring to All Physician’s Attention

Note on Problem List and Face SheetNote on Problem List and Face Sheet

Check Hemoglobin A1CCheck Hemoglobin A1C

Hold Metformin; Hold TZD with CHF, Liver DysfunctionHold Metformin; Hold TZD with CHF, Liver Dysfunction

Start Insulin in All Hospitalized Patients with BG >140 mg/dlStart Insulin in All Hospitalized Patients with BG >140 mg/dl


Get Diabetes Education ConsultGet Diabetes Education Consult

Instruct Patient in Monitoring and RecordingInstruct Patient in Monitoring and Recording

See That Patient Has Meter on DischargeSee That Patient Has Meter on Discharge

Decide on Case Specific Program for DischargeDecide on Case Specific Program for Discharge

Arrange Early F/U with PCPArrange Early F/U with PCP

Treat Any Patient With BG >140 mg/dl With InsulinTreat Any Patient With BG >140 mg/dl With Insulin

– Treat Any BG >140 mg/dl with Rapid-acting Insulin Treat Any BG >140 mg/dl with Rapid-acting Insulin (BG-100) / (3000 / wt kg) or 1700 / total daily insulin(BG-100) / (3000 / wt kg) or 1700 / total daily insulin

– Treat Any Recurrent BG >180 mg/dl with IV Insulin if failing SC 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 therapy or >140 mg/dl if NPO, acute MI, perioperative, ICU, or >100 mg/dl if pregnant>100 mg/dl if pregnant

If More than 0.5 u/hr IV Insulin Required with Normal BG Start Long If More than 0.5 u/hr IV Insulin Required with Normal BG Start Long Acting InsulinActing Insulin



Daily Total: Pre-Admission or Weight (#) x 0.2 uDaily Total: Pre-Admission or Weight (#) x 0.2 u

– 40 % as Glargine (Basal)40 % as Glargine (Basal)

– 60% as Rapid-acting insulin (Bolus)60% as Rapid-acting insulin (Bolus)

• Give in Proportion to Meal’s CHO EatenGive in Proportion to Meal’s CHO Eaten

BG >140 mg/dl: (BG-100) / CFBG >140 mg/dl: (BG-100) / CF

CF = 1700 / Total Daily Insulin or 3000 / wgt kgCF = 1700 / Total Daily Insulin or 3000 / wgt kg

Do Not Use Sliding Scale As Only Diabetes Do Not Use Sliding Scale As Only Diabetes ManagementManagement

Diabetes at Piedmont HospitalDiabetes at Piedmont HospitalConclusions 3Conclusions 3

Discharge Plan For BG ControlDischarge Plan For BG Control

You Are the Link Between the Best You Are the Link Between the Best Diabetes Care and the PatientDiabetes Care and the Patient

Use Your Diabetes ResourcesUse Your Diabetes Resources

Diabetes Education Center Diabetes Education Center EndocrinologistsEndocrinologists

Conclusion

All hospital patients should have normal glucose

Insulin

The agent we have

to control glucose

only

most powerfulpowerful

QUESTIONS

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diabetes management in the hospital: case studies bruce w. bode, md, face atlanta diabetes...

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