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Indications for IV Insulin Infusion

Diabetic ketoacidosisNon-ketotic hyperosmolar stateCritical care illness (surgical)Myocardial infarction or cardiogenic shockPost-operative period following heart surgery. Indications for IV Insulin Infusion. Critical care illness (medical)NPO status in type 1 diabetesGeneral pre-, intra- and post- operative careOrgan transplantationTPNExacerbated hyperglycemia during high dose glucocorticoid therapy .

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Indications for IV Insulin Infusion

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    2. Diabetic ketoacidosis Non-ketotic hyperosmolar state Critical care illness (surgical) Myocardial infarction or cardiogenic shock Post-operative period following heart surgery Indications for IV Insulin Infusion

    3. Critical care illness (medical) NPO status in type 1 diabetes General pre-, intra- and post- operative care Organ transplantation TPN Exacerbated hyperglycemia during high dose glucocorticoid therapy Indications for IV Insulin Infusion

    4. Stroke Dose finding strategy, anticipatory to initiation or re-initiation of SC insulin in type 1 or type 2 diabetes Labor and delivery Other acute illness requiring prompt glycemic control Indications for IV Insulin Infusion

    5. Thresholds for Initiation and Targets of IV Insulin Infusion Therapy

    7. Glycemic Threshold in CABG Portland data suggest BG: < 150 mg/dl for mortality < 175 mg/dl for infection < 125 mg/dl for atrial fibrillation

    9. Reduction of mortality below threshold glucose of 144- 200 mg/dL, with speculative upper limit of target range at about 145 mg/dL

    10. Glycemic threshold in Surgical ICU BG < 110 mg/dl or < 145 mg/dl

    11. What About Medical Patients?

    12. 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

    13. 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

    14. 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)

    16. Glycemic Threshold for Medical Patients < 140 mg/dl if IV Insulin is mandated by condition Acute MI, NPO, Gastroparesis, etc < 180 mg/dl for patients failing SC therapy

    17. 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

    18. Target blood glucose in mg/dL during IV insulin infusion 80 – 110 in Surgical ICU patients 90 – 140 in other Surgical and Medical Patients 70 – 100 in Pregnancy

    19. Methods For Managing Hospitalized Persons with Diabetes Take Diabetes out of the equation. Control glucose!!!

    20. Diabetes in Hospitalized Patients . Psychology Patients expect good glycemic control as part of hospital care They strive for recommended goals at home Difficult to understand staff’s casual approach to BG’s >150

    21. Methods For Managing Hospitalized Persons with Diabetes Continuous Variable Rate IV Insulin Drip Major Surgery, NPO, ICU, Unstable, MI, DKA, Hyperglycemia, Steroids, Gastroparesis, Delivery, etc Basal / Bolus Therapy (MDI) GIK (Reserved for euglycemic patients)

    22. 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

    23. Components of IV Insulin Therapy IV line with minimal flow (> 40 ml/l) Glucose inflow kept constant Potassium must be given Regular insulin in a 1 U/ml or 0.5 U/ml concentration Infusion controller adjustable in 0.1 U doses Accurate bedside BG monitoring done hourly (and if stable, every 2 hours)

    24. 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

    27. ICU Survival Blood glucose control in Intensive Group: Mean AM 103 mg/dl BG < 40 mg/dl 5.2% (39)

    29. Two Specific IV Insulin Infusion Algorithms Markovitz, Braithwaite and colleagues - Tabular form Davidson, Steed and Bode - Computerized system called “Glucommander”

    30. Protocol of Markovitz and colleagues, as modified

    31. Formula for Markovitz Protocol Hourly insulin rate = hourly maintenance rate + ( BG – 150 ) / ISF

    32. Formula for Markovitz Protocol Hourly insulin rate = hourly maintenance rate + ( BG – 150 ) / ISF To create a table, the upper target of 150 can be replaced with any upper target, and the insulin sensitivity factor ( ISF ) may be calculated by a rule of 1500 or 1700. The hourly maintenance rate for target range control for a given patient is discovered during treatment by response to column assignments .

    34. < 100 off 100-109 0.5 110-129 1.0 130-149 1.5 150-169 2.0 170-189 2.5 190-209 3.0 210-254 4.0 255-299 5.0 etc.

    35. < 100 off 100-109 0.5 110-129 1.0 130-149 1.5 150-169 2.0 170-189 2.5 190-209 3.0 210-254 4.0 255-299 5.0 etc.

    36. 80- 89 off < 100 off 90- 99 0.5 100-109 0.5 100-109 1.0 110-129 1.0 110-129 1.5 130-149 1.5 130-149 2.0 150-169 2.0 150-179 3.0 170-189 2.5 180-209 4.0 190-209 3.0 210-239 5.0 210-254 4.0 240-269 6.0 255-299 5.0 270-299 7.0

    37. Instructions about modified Markovitz protocol Default: start with column 2; use priming bolus Switch to next higher column if: BG ? 200 x 1h, falling < 30 mg/dL over the past 1h BG ? 150 x 2h, falling < 60 mg/dL over the past 2h Test BG q 1h if drip turned off by protocol After drip interruption for low BG, resume when BG > 109 Switch to next lower column if: interrupted for low BG, but now resuming on column 4, 5 or 6 for past 8 hr and within target

    39. Historical Perspective IV Insulin Algorithm Insulin (u/h) = (BG-60) x Multiplier “White’s” Multiplier Not Applicable for Majority Based on Type 1 Pediatric Pump Patients IV Insulin Used Frequently in Stressed Type 2 Only 14% Stabilized at 0.02

    40. Continuous Variable Rate IV Insulin Drip (Davidson 1982) 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)

    41. Continuous Variable Rate IV Insulin Drip (Davidson 1982) Adjust Multiplier (initially 0.02) to obtain glucose in target range If BG > 140 mg/dL and not falling by 50mg/dl, increase by 0.01 If BG < 100 mg/dL, decrease by 0.01 If BG 100 to 140 mg/dL, no change in current multiplier If BG is < 80 mg/dL, Give IV D50 cc = (100 – BG) x 0.3 Give continuous rate of Glucose in IVF’s Once eating, continue drip till 2 hour post SQ insulin

    42. Glucommander AN ADAPTIVE, COMPUTER-DIRECTED SYSTEM FOR IV INSULIN, SHOWN TO BE SAFE, SIMPLE, AND EFFECTIVE IN 120,618 HOURS OF OPERATION Invented in 1984 Davidson and Steed 19 Years Experience with this Computer Based Algorithm for the Administration of IV Insulin Currently used as a software program housed in lap top computer in over 60 U.S. hospitals

    43. Glucommander

    45. Glucommander Principles

    47. Glucose Management System (GMS) In 1997, MiniMed and Roche purchased the marketing rights to the Glucommander Changed the name to GMS Multicenter U.S. trials done for FDA approval Useful and Safe for Any Application of IV Insulin Shelved Pending FDA Approval of IV Use of Insulin

    48. Glucose Management System

    49. Glucommander . Complete Data Set 1985 to 1998 Beyond Data Analyzed by Boehringer Manheim/MiniMed in 1995 13 years of data from Glucommander. 5802 Runs over 120,618 hours. Correction of hyperglycemia: Mean starting BG=259 mg/dL (SD 127). Mean stable <150 after three hours. Subsequent stability in target range for 60 hrs. Hypoglycemia: BG’s <50 were 0.6% of total BG’s. 2.6% all runs had one BG <40. All were immediately corrected to 100 with IV glucose No severe hypoglycemia.

    55. Protocol for Insulin in Hospitalized Patient Treatment of Hypoglycemia Any BG <80 mg/dl: D50 = (100-BG) x 0.4 ml IV Do not treat with oral CHO Do Not Hold Insulin When BG Normal

    56. Correction of Hypoglycemia with Glucose 100-BG X 0.2 Grams

    57. Glucommander Similar Systems

    60. How has the Glucommander been used? Treatment of ketoacidosis Hyperosmolar non-ketotic state Perioperative glucose management Labor and delivery Myocardial infarction Critically ill patients in ICU Hyperalimentation Gastroparesis with intractable nausea and vomiting Estimating a patient’s insulin sensitivity A guide for dosing insulin Estimating total insulin dose, correction factor, CHO/Ins

    61. Clinical Experience with Glucommander Simple, safe, and effective method for maintaining glycemic control thru out the hospital Extensively studied Standardized treatment method applicable in a wide variety of conditions Available for review, www.glucommander.com

    62. Transitioning off IV Insulin Infusion Therapy

    63. Converting to SC insulin If More than 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

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

    65. A nurse-managed overnight insulin infusion predicts insulin dose requirement in a wide range of otherwise well patients having poorly controlled diabetes

    66. 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 Supplement All BG >140 mg/dl (BG-100)/(1700/Daily Insulin Requirement)

    69. Questions that need further study What is the glucose threshold and target glucose for IV insulin in acute MI, pre-CABG, other states, etc? <110 mg/dl or <140 mg/dl ? What is the best IV insulin infusion protocol? What is the best way to transition to SC?

    70. Conclusion All hospital patients should have normal glucose

    71. The Paradigm for the Millenium Hyperglycemia: A “Mortal” Sin A blood glucose over 110 in a hospitalized patient causes increased morbidity and mortality. In the 21st Century Neglecting BG >200 Is Malpractice

    72. For a copy or viewing of these slides Contact www.adaendo.com How can I get use of Glucommander? Available for review on internet, www.glucommander.com Contact us: Glucommander@adaendo.com

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