Management of Inpatient Blood Glucose at Temple Housestaff

Management of Inpatient Blood Glucose at Temple Housestaff Orientation 2014

Hyperglycemia is Associated with Morbidity and Mortality in Inpatients n n ICU Ward Surgical Medical n n n n Endocarditis Pneumonia Renal transplantation COPD exacerbation Post-MI Stroke Infection Wound healing 2

Glycemic Control Targets in Non–ICU Patients n Premeal BG <140 mg/d. L n Random BG <180 mg/d. L n To avoid hypoglycemia (BG <70 mg/dl), reassess insulin if BG levels fall below 100 mg/d. L 3

Estimating Insulin Requirement n Home insulin regimen n Weight-based dose n Recent insulin given (as inpatient) n Clinical status (hypoglycemia and insulin resistance factors) 4

Hypoglycemia and insulin resistance factors Hypoglycemia risk factors n Type 1 diabetes n Renal dysfunction n Severe cardiac dysfunction n Severe hepatic dysfunction n Advanced age Insulin resistance factors n Obesity n Infection n Open wounds n Steroids n Glucotoxicity n BG > ~300 mg/dl n A 1 c > ~10% 5

Continuing home insulin program in hospital n Must fully assess n Glucose control at home n Hypoglycemia, hyperglycemia, A 1 c Compliance (confirm meds/doses) n Does the regimen make sense? n n Consider along with weight-based estimate to calculate dose: use clinical judgment 6

Weight-based SC insulin dosing 1. Estimate Total Daily Dose (TDD, U/kg) n 0. 3 U/kg if high risk of hypoglycemia n 0. 4 – 0. 5 U/kg average type 2 diabetes n 0. 6 U/kg if insulin resistant 7

How to dose SC insulin 2. TDD = 50% basal insulin + 50% bolus insulin 3. Basal insulin = Lantus (glargine) q. HS or NPH q 12 h Ø 4. Do not hold for NPO (give 50 -80%) Bolus (nutritional, prandial) insulin = Humalog (lispro) q. AC Ø Ø Given with meal (or tube feeds) Given as long as premeal BG >70 mg/dl 8

Case: 78 yo woman, type 2 DM on metformin 1000 mg BID + glargine 20 units q. HS admitted for COPD, BG is 320 mg/dl, A 1 c is 9% n n n n Hypoglycemia risk factors: age, Cr 1. 6 Insulin resistance factors: steroids, hyperglycemia Estimated TDD = 0. 5 units/kg/day TDD = 66 kg x 0. 5 U/kg = 33 units 50% basal = 33/2 = 16 units glargine q. HS 50% bolus = 16/3 meals = 5 units lispro q. AC STOP all oral diabetes meds Assess glucose and titrate daily 9

What about correction insulin? 150 -200 2 U 201 -250 4 U 251 -300 6 U… 10

Sensitivity Factor The expected drop in glucose after administering 1 unit of insulin n HIS SF= 10 HER SF = 50 n AVERAGE SF= 30 n This scale assumes SF=25 n n 2 units for 50 mg/dl intervals 150 -200 2 U 201 -250 4 U 251 -300 6 U… 11

Correction Scales at TUH Insulin Correction Scale BG mg/dl #1 #2 #3 #4 151 -200 1 2 3 4 201 -250 2 4 6 8 251 -300 3 6 9 12 301 -350 4 8 12 16 351 -400 5 10 15 20 50 25 17 12. 5 SF 12

Rule of 1500 SF = 1500/TDD n From prior ex. , TDD = 33 n SF = 1500/33 = 45 n Use correction scale #1 n Better to use lower-dose scale if SF is between scales n Rubin DJ, Golden SH. Hypoglycemia in non-critically ill, hospitalized patients with diabetes: evaluation, prevention, and management. Hosp Pract (1995). 2013 13

A complete insulin program n Basal + Bolus + Correction n n Correction is given regardless of nutrition status (NPO) Should be ordered for: All type 1 diabetes n Most type 2 diabetes n n Except diet-controlled and BGs <140 mg/d. L 14

Key Points Inpatient blood glucose is important n Non-ICU BG targets: <140 premeal, <180 random n Do not use sliding scale alone n Stop oral diabetes meds n Order a complete SC insulin program n Check A 1 c on every diabetic or BG >140 n 15

TUH DIABETES PROTOCOLS

TUH Diabetes Protocols � Located in Share. Point � Hypoglycemia protocol � MIS Diabetes orderset instructions � Prandial insulin hold Guideline � DKA/HHS Guideline � Critical Care IV Insulin Guideline � Transitioning IV to SC insulin � Insulin instructions for discharge

How to access Share. Point � From any TUH computer, type “diabetes” in web browser

How to access Share. Point � From any TUHS network computer or via Citrix, use Share. Point directory

Select “Share. Point site directory”

Select “TUH Glycemic Control”

Hypoglycemia algorithm

Diabetes Orderset

Prandial Insulin Hold Guideline “Hold” parameters for Prandial/nutritional/bolus insulin, i. e. , Humalog (lispro) or Regular insulin �� Do not give dose if blood glucose <70 mg/d. L �� Give ½ the ordered dose if blood glucose is 70 -99 mg/d. L �� Give all of the ordered dose if blood glucose is ≥ 100 mg/dl

DKA/HHS Guideline

Critical Care Insulin Infusion � Applies to all patients in all ICUs except �DKA or HHS or expected transfer out of unit within 24 hrs � Start when 2 BG >160 mg/dl within 24 -48 hr � Target 120 -160 mg/dl � Nurses titrate � Give SC insulin (usually glargine) 2 hrs before stopping insulin drip

Transitioning IV to SC Insulin

Insulin Discharge Instructions

Order HBA 1 C in Common Lab Tests Menu

Questions?