A Children s Bedtime Story
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- Carmel Dorsey
- 5 years ago
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1 A Children s Bedtime Story Setting: University Medical Center, Big Town, USA Scenario: 0500, last admission of the night, 10 previous admissions, all tucked in for the night Patient: 75 year old male with past medical history of diabetes mellitus on 70/30 insulin 15 units BID, chronic kidney disease (CKD), who presents with altered mental status and acute kidney injury on CKD. You admit the patient, putting orders in for his home insulin dose (15 units BID 70/30 ) with a now dose.
2 0700: Day Turned team arrives. Horror Story 0700: RN call to Night PA C, interrupting sign out: I gave the patient his 15 units upon arrival to the floor at His AM dose is due at Do you want me to give it? His blood sugar is currently 179. Also, he will get SSI correction too per protocol. Night PA C: Yes, give it. RN: Errr, are you sure? That is 2 doses of insulin in a short time period. Night PA C: Yes, I m sure, give the insulin.
3 From Goldilocks to American Horror Story 0830: Day PA C hears rapid response called overhead Arrives to find her new patient unresponsive Blood sugar on arrival is 35. This story is real. It happened 3 months ago on my service. WHY?
4 Diabetes Mellitus, Hyperglycemia & Hypoglycemia for Hospitalized Patients in th Annual Acute Care of the Complex Hospitalized Patient for NPs & PAs Krystal M Renszel, DO, MS Hospital Internal Medicine Mayo Clinic Arizona
5 Objectives Review current literature regarding glycemic targets & insulin dosing with focus on non ICU hospitalized patients Manage special populations (corticosteroids, ESRD/CKD, ICU) Discuss hypoglycemia and impact on mortality Choose dosing regimens based on patient population & nutritional status
6
7 Diabetes is an Ambulatory Care Problem, not mine million people in the US have DM or 8.3% 7 th leading cause of death and 4 th leading comorbid condition among hospital discharges 30% of patients with DM require 2 or more hospitalizations in any given year Observational studies have shown hyperglycemia is a/w prolonged hospital stay, increased infection incidence, more disability after d/c and death
8 Admission: Where do I start? All patients: blood glucose (BG) test upon admission & A1C* *If hyperglycemic and not checked in the last 2 3 months Discontinue oral agents and initiate insulin if DM2 Use a standardized subcutaneous insulin order set Scheduled basal & nutritional insulin therapy Nurse initiated hypoglycemia treatment protocol (BG < 70) Monitor patients w/ history of DM & BG > 140 mg/dl using bedside POC testing for at least h If BG > 140, continue POC testing Avoid solely sliding scale insulin (SSI) therapy POC schedules: Before meals and bedtime in patients who are eating q4 6h in patients who are NPO or getting continuous enteral feeding
9 For Non ICU Hospitalized Patients: Is there a goal? In hospital hyperglycemia is defined any BG > 140 mg/dl Non ICU maximum: BS = 180 Glycemic targets should be modified according to clinical status: For patients w/ terminal illness, or limited life expectancy, or at high risk for hypoglycemia, a higher target range < 200 mg/dl is reasonable; for patients who are able to achieve and maintain glycemic control w/o hypoglycemia, a lower target range may be reasonable.
10 For Non ICU hospitalized patients: How should I dose insulin? All DM1 & most DM2 = scheduled basal insulin Estimate total daily dose (TDD) insulin*: Malnourished, elderly, CKD, ESRD, ESLD units/kg Normal weight patients, incl. Type I DM 0.4 units/kg Overweight 0.5 units/kg Obese, high dose steroids, insulin resistance 0.6 units/kg *If patient on insulin at home, can use as starting point *
11 For Non ICU hospitalized patients: How should I dose insulin? NPO or clear liquids Basal: 50% TDD, nutritional: none Eating meals Basal: 50%, nutritional: 50% Continuous TFs Basal: 40%, nutritional: 60% Parenteral nutrition Regular insulin given parenterally, cont SSI *Adjust q1 2 days based on glucose trends; decrease by 20% if hypoglycemia*
12 How do I transition from Continuous Insulin Infusion to SC Insulin? Calculate average hourly rate once drip delivery rate has stabilized Multiply by 20 to get conservative TDD estimate Is patient NPO or eating? i.e., does my TDD estimate represent solely basal or basalbolus? Continue insulin infusion: For at least 1 hour after SC rapid acting or regular insulin For at least 2 3 hours after SC intermediate acting or longacting insulin.
13 For Non ICU hospitalized patients: What should I keep in mind?
14 Special Populations Steroid induced hyperglycemia Monitor with bedside POC testing for at least h after initiation of steroids; if BG > 140 mg/dl, continue POC testing Initiate insulin if persistent hyperglycemia (BG > 140) CKD Perioperative Intensive Care
15 Special Populations Steroid induced hyperglycemia CKD High risk for hypoglycemia A1C values are often unreliable Many patients stop needing insulin as CKD progresses Dose insulin at units/kg Perioperative Intensive Care
16 Special Populations Steroid induced hyperglycemia CKD Perioperative All patients w/ DM1 undergoing major or minor surgery receive either IV continuous insulin infusion or sc basal/bolus insulin D/c oral and non insulin injectables before surgery Basal for NPO patients and basal/bolus for patients who are eating Intensive Care
17 Special Populations Steroid induced hyperglycemia CKD Perioperative Intensive Care Intensive insulin therapy (BG at or below 110 mg/dl) reduces morbidity and mortality among critically ill patients in the surgical intensive care unit (2001) NICESUGAR: intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg/dl or less resulted in lower mortality than did a target of mg/dl (2009)
18 For Better or Worse: Hyper vs Hypo Glycemia In a retrospective study from 2009, hypoglycemia was seen in 7.7% of hospitalized patients Episodes of severe hypoglycemia constitute an independent cardiovascular risk factor, increased LOS, & higher mortality both during and after admission
19 Small Group Cases (10 min) In groups of 3 4 people, work through the cases at your tables Pick a table spokesperson We will discuss answers as a large group
20 References 1. Guillermo, E., et al. Management of Hyperglycemia in Hospitalized Patients in non critical care setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, January 2012, 97(1): Iyer, S. H. and Tanenberg, R. J. Managing diabetes in hospitalized patients with chronic kidney disease. Cleveland Clinic Journal of Medicine. April 2016, 83(4): The NICESUGAR Study Investigators. Intensive vs Conventional Glucose Control in Critically Ill Patients N Engl J Med 2009; 360: van den Berghe et al Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345: Society of Hospital Medicine, Stepwise Approach to Managing Inpatient Hyperglycemia Schnipper, JL, et al. Society of Hospital Medicine Glycemic Control Task Force Summary: Practical Recommendations for Assessing the Impact of Glycemic Control Efforts. Journal of Hospital Medicine Sept/Oct. Vol 3(5) Supplement 5: S Wesorick, D. et al. Management of Diabetes and Hyperglycemia in the Hospital: A Practical Guide to Subcutaneous Insulin Use in the Non Critically Ill, Adult Patient. Journal of Hospital Medicine Sept/Oct. Vol 3 (5): Supplement 5: S Turchin, A., et al. Hypoglycemia and Clinical Outcomes in Patients With Diabetes Hospitalized in the General Ward. Diabetes Care 2009 Jul; 32(7): Christensen, MB, et al. Efficacy of basal bolus insulin regimens in the inpatient management of non critically ill patients with type 2 diabetes: a systematic review and meta analysis. Diabetes/Metabolism Research and Review. Accepted manuscript online: 9 January 2017.
21 THANK YOU! Questions?
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